Effectiveness of Digital Health Interventions (DHI) in Chronic Pain Management: A Scoping Review of Current Evidence and Emerging Trends

Within the last decade, the development of medical technology has revolutionized the healthcare landscape at an exponential pace. From imaging studies to expedited billing processes, aspects of medicine that were once monotonous and burdensome are now achievable through a few clicks of a button. The rapid growth of technological advancements in healthcare and the widespread availability of innovative portable electronic devices introduce opportunities to transform the future for all patients [ 1 ]. Chronic pain is a condition estimated to afflict over 50 million Americans (roughly one in five adults) and 1.5 billion individuals worldwide [ 2 ]. Chronic pain is defined by the International Association for the Study of Pain (IASP) as “persistent or recurrent pain lasting longer than 3 months” [ 2 ]. Although pain constitutes only a symptom and is not a formal diagnosis, there are numerous conditions that are intimately entwined with chronic pain, including arthritis, fibromyalgia, migraines and headaches, inflammatory bowel disease (IBD), low back pain (LBP), neuropathy, chronic fatigue syndrome (CFS), endometriosis, and chronic postsurgical pain [ 3 , 4 ]. Arthritis refers to the inflammation and/or degeneration of joints, often caused by autoimmune processes or "wear and tear" [ 5 ]. Fibromyalgia is a chronic neurological disorder characterized by diffuse musculoskeletal pain with associated symptoms of fatigue, sleep disturbances, cognitive difficulties, and heightened sensitivity to pain [ 6 ]. Migraine is a debilitating type of headache characterized by “recurrent attacks of moderate to severe throbbing and pulsating pain on one side of the head” [ 7 ]. IBD is a functional gastrointestinal disorder characterized by recurrent abdominal pain or discomfort and changes in bowel habits such as diarrhea, constipation, or a combination of both [ 8 ]. LBP is defined as “a painful neurological disorder that affects the lower segment of the spine,” and it is one of the most common causes of physician office visits [ 9 , 10 ]. Neuropathies are caused by nerve damage or dysfunction of peripheral nerves, resulting in persistent pain that is often described as burning, tingling, or shooting [ 11 ]. CFS, also known as myalgic encephalomyelitis, is a multifaceted condition characterized by extreme fatigue with associated muscle pain, aches, joint pain, and headaches [ 12 , 13 ]. Endometriosis is a chronic gynecological disorder resulting from extra-uterine proliferation of uterine tissue, causing chronic pelvic pain and impaired fertility [ 14 , 15 ]. Chronic postsurgical pain is “pain persisting at least three months after surgery, that was not present before surgery, or that had different characteristics or increased intensity from preoperative pain, localized to the surgical site or a referred area" [ 16 , 17 ]. Although the underlying causes of these conditions vary, they all share a common thread: persistent pain. Normally, pain serves a crucial protective function, but in the context of certain diseases, chronic pain can significantly impact quality of life [ 18 ]. Chronic pain often arises from immune activation, inflammation, or irritation of nearby tissues, nerves, and organs. Persistent inflammation sensitizes nociceptive and non-nociceptive sensory nerve fibers, leading to a lowered pain threshold-a phenomenon known as peripheral sensitization [ 18 ]. Prolonged exposure to pain can also lead to the brain interpreting pain signals as more intense, a process called central sensitization [ 19 , 20 ]. Most postoperative pain falls under the category of "nociceptive pain," which stems from tissue damage [ 21 ]. Furthermore, chronic pain may have psychological effects such as depression and anxiety, which can heighten pain perception and contribute to a state of heightened sensitivity [ 19 , 22 ]. Treatment and prevention of chronic pain presents a multifaceted challenge due to the complex nature of pain generation and chemical signaling in various disease states [ 23 , 24 ]. Management of chronic pain differs depending on the underlying condition and often encompasses a variety of approaches aimed at mitigating the impact of the pain on an individual’s quality of life. Physicians frequently rely on pharmacologic interventions to manage symptoms, such as over-the-counter nonsteroidal-anti-inflammatory drugs (NSAIDs) and prescription analgesics (including opioids) [ 25 ]. Adjunctive treatments include antidepressants, anticonvulsants, and surgical interventions in refractory cases [ 25 , 26 ]. A challenge with many chronic diseases and associated pain is that appropriate treatment methodologies may be limited by the patient’s memory of their symptoms, pain severity, and frequency of discomfort. Patients often struggle to accurately recall their pain levels and experiences, leading to less effective treatments. Physicians aim to alleviate these discrepancies through the use of self-reported pain scales and questionnaires, but such methods have limitations because they rely on the patient's subjective reporting [ 27 ]. The emergence of modern digital health interventions (DHIs) such as electronic health (eHealth) and mobile health (mHealth) aims to improve this process, which invites opportunity for promising advances in the future of chronic pain management. "eHealth" is a catch-all term referring to the various aspects of healthcare and related technologies that have been advanced through creation of the internet and communication technology [ 28 ]. DHIs and digital health are concepts that fall under the umbrella of eHealth. The World Health Organization defines "digital health" as “the use of information and communication technology in support of health and health-related fields” [ 24 ]. DHIs, a form of digital health, are “discrete functionalit[ies] of digital technology [used] to achieve health-related objectives”. DHIs include mobile applications, virtual reality (VR) programs, artificial intelligence, and wearable devices [ 29 ]. Wearable devices are a type of wearable health technology that provide real-time feedback by continuously collecting data regarding a person’s physical activity, heart rate, sleep patterns, stress indicators, and monitor chronic disease progression [ 29 ]. mHealth is another subset of eHealth defined as the “use of mobile wireless technologies for public health” [ 2 , 24 ]. The use of digital health in the form of telemedicine is well-established and widely utilized in the post-COVID era, particularly for mental health treatment and follow-up. Still, there remains a gap in the established use and success of eHealth and mHealth for chronic pain management [ 30 , 31 ]. Therefore, a comprehensive assessment of the existing knowledge gap is imperative to not only ascertain the potential advantages of emerging DHIs in chronic pain management but also to lay a foundation for future related research. The emergence of eHealth and mHealth offers potential to improve symptom record-keeping and expand accessibility to cost-effective and convenient solutions for patients who are vulnerable to shortcomings of the US healthcare system [ 24 ]. DHIs provide a solution to ensure health objectives are achieved for patients with limited coverage, delayed access to care, or those who are geographically underserved [ 24 ]. DHIs can also prevent reduced quality care through facilitation of more accurate data collection and increased productivity of patient’s scheduled office visits [ 24 ]. Notably, adopting DHIs also offers an opportunity to address the opioid epidemic by improving efficacy of arranged treatments and thus reducing the need for opioid prescriptions. There is a well-established relationship between chronic medical conditions and an overreliance on pharmacological methods of pain management. Despite this notion, the American College of Physicians recommends nonpharmacological modalities as a first-line therapy for pain management in conditions such as chronic low back pain (CLBP) [ 9 ]. Existing literature explores different modes of DHIs in the management of singular chronic pain conditions and their respective management rather than evaluated as a whole, further emphasizing the need for a comprehensive evaluation of these devices. Is there a role for DHIs in monitoring, managing, and optimizing outcomes for chronic pain conditions? Despite an extensive search, no published reviews have comprehensively covered these various medical conditions collectively in the context of therapeutic responses to DHIs, which includes mobile apps, VR, and artificial intelligence. Gaps in research emphasizes the urgency of conducting a scoping review to navigate these growing technologies for the improvement in health outcomes and the reduction of suffering in patients living with chronic pain. As the digital health landscape rapidly expands, it is imperative that healthcare evolves in tandem with emerging technologies to enhance patient care, particularly in the context of chronic pain management. Chronic pain is often associated with debilitating consequences, including self-defeat, depression, and overall lower quality of life [ 32 ]. The primary objective of this scoping review is to examine peer-reviewed studies to investigate the recent advancements in DHIs for chronic pain management. The review seeks to identify conditions that exhibit improved treatment outcomes through the utilization of DHIs, patient groups most likely to benefit from DHIs, and the specific types of DHIs that have the potential to enhance the quality of life for chronic pain patients.

Methods Objective This scoping review methodology was selected to facilitate a thorough synthesis and mapping of current evidence and emergent trends in DHI, such as eHealth and mHealth, to enhance pain management and contribute to shaping the future state of chronic pain research. This scoping review was performed consistent with guidance provided by the Joanna Briggs Institute Review Manual [ 33 ] and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines [ 34 ]. Eligibility Criteria The PCC model was used in which P stands for population, C stands for concept, and C stands for context. The population involved studies on individuals of any age 18+ and any gender, who are diagnosed with a condition associated with chronic pain. The concept focused on the use of DHI for effectively managing conditions frequently linked with chronic pain, as detailed in the background. Studies focused on chronic pain management beyond the specific disorders within the study’s scope were omitted from consideration. DHIs encompass a wide range of technologies and interventions that are delivered through digital platforms. The study focused on mobile apps, web-based tools, and wearable devices designed to manage chronic pain. Chronic pain management pertains to the various strategies, approaches, and interventions aimed at mitigating the impact of chronic pain on individuals' lives. For further identification of the study’s concept, effectiveness was related to the assessment of how well DHIs contributed to managing chronic pain. Effectiveness was identified to encompass various outcomes such as pain reduction, improved quality of life, enhanced functionality, patient satisfaction, improved patient and physician communication, and more. Additionally, current evidence refers to the existing body of research and literature that explored the effects of DHIs on chronic pain management, which included studies that have investigated the outcomes, benefits, and limitations of such interventions. Lastly, emerging trends within the study’s concept involved identifying and discussing new or evolving patterns, technologies, approaches, or strategies within our scope of DHIs for chronic pain management. The context of this review included chronic pain-associated conditions such as musculoskeletal conditions (arthritis, osteoarthritis, LBP), fibromyalgia, migraines and headaches, endometriosis, IBD, and CFS. Additionally, the types of DHIs will specifically relate to mHealth and eHealth, such as wearable devices, VR, mobile apps, and artificial intelligence. Information Sources and Search Strategy This scoping review included experimental and quasi-experimental study designs, comprising randomized controlled trials, nonrandomized controlled trials, and studies conducted before and after interventions. Additionally, analytical observational studies, such as prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies, were incorporated. The review also considered the inclusion of descriptive observational study designs, such as case series, individual case reports, and descriptive cross-sectional studies. This scoping review utilized EMBASE, Ovid MEDLINE, Cumulated Index in Nursing and Allied Health Literature (CINAHL), Web of Science, and Cochrane Central. The key search terms included “chronic pain manage” OR “long-term pain relief” OR “sustained pain alleviation” OR “pain control for chronic conditions” OR “chronic pain” AND “ehealth interventions” OR “mobile health interventions” OR “digital therapy” OR “health informatic solutions” OR “digital health intervention.” Databases were accessed on October 6, 2023. Studies were included in this review if they were original, published works focusing on chronic pain patients with one of the named conditions using DHIs as an adjunct of management. Additionally, studies that focused on trends of DHIs in pain management were included. Studies outside the English language, systemic reviews, books, or opinion pieces were excluded. Additionally, studies that did not primarily address the management of chronic pain conditions or did not investigate DHIs in patients with chronic pain will be excluded. Only studies published between 2013 and 2023, provided they are available in full text and have been formally published, will be considered for inclusion. Data Analysis For managing records and data throughout the review, JBI Sumari (https://sumari.jbi.global/) and MS Excel (Microsoft Corporation, Redmond, Washington, United States) software programs were utilized. Data was extracted from papers included in the scoping review by two or more independent reviewers. Extracted data included participant information, the core concept, context, study methods, and any other pertinent key findings. Data extraction was facilitated using an Excel spreadsheet. After conducting the data analysis, a PRISMA flow chart was utilized to present the steps followed in the search strategy. Quality Assessment The 34 articles selected from the full-text reviews were evaluated for quality using the JBI critical appraisal tools. Each article was evaluated by each author, and discrepancies between the scoring of the evaluators were discussed and resolved, with three authors ultimately agreeing upon a checklist score. Studies were included if they had a low risk of bias or better, defined as a score of 70% or above following JBI critical appraisal method. All 34 were included and had a low risk of bias according to the JBI checklists. Results After searching the databases using the predetermined search terms and applying the inclusion and exclusion criteria, 34 articles were identified as being within the scope of this review (Figure 1 ). All studies included in the review are summarized in Table 1 . The PRISMA flow chart tracks the article selection process leading to the inclusion of 34 articles in this review CLBP: Chronic low back pain; DTxP: digital therapeutics for pain; ITT: intention-to-treat; FM: fibromyalgia; FM-ST: fibromyalgia-symptom tracking; FM-ACT: fibromyalgia-acceptance and commitment therapy; REN: remote electrical neuromodulation; GIER: guided intervention of education and relaxation; TKR: total knee replacement; MCID: minimal clinically important difference; mAPA: mobile auricular point acupressure; PEG tool: pain, enjoyment, and general tool activity From the data extraction list, a breakdown of chronic pain condition type by study was created. The studies included encompassed a variety of chronic pain disorders as shown in Table 1 with a breakdown of included studies by type of chronic pain shown in Table 2 and Figure 2 . The largest proportion of articles that met the inclusion criteria were for musculoskeletal pain. Musculoskeletal pain was further categorized into two categories: back pain and non-back-related musculoskeletal pain. Ultimately, no studies on CFS and neuropathy were identified for inclusion. Among 34 studies, 24 were quantitative [ 37 - 41 , 44 , 45 , 47 - 50 , 54 - 64 , 66 ], four were qualitative [ 36 , 51 , 35 , 68 ], and six used mixed methods [ 42 , 43 , 46 , 52 , 53 , 67 ]. Most studies included used surveys for collecting data [ 37 - 39 , 41 , 43 , 44 , 49 , 52 - 54 , 57 - 60 , 62 , 64 ]. The questionnaires used in surveys were mostly developed by Short Form Health Survey, University of Sydney; Keele University’s Institute for Primary Care and Health Sciences; Patient Health Questionnaire; Roland-Morris Disability Questionnaire; Survey of Pain Attitudes; Coping Strategies Questionnaire; Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire; Knee Injury and Osteoarthritis Outcome Score Pain subscale; Endometriosis Health Profile; Wisconsin Brief Pain Questionnaire; and Pain Self-Efficacy Questionnaire. In the mixed-method studies, most commonly, content or thematic analyses were used. A total of two studies conducted in-depth or semi-structured interviews [ 36 , 62 ]. All 34 studies included had clear ethical statements within the paper either stating ethical board approval or exemption [ 35 - 68 ]. Characteristics of the Reviewed Studies The studies were conducted in 11 countries, the majority being based in the United States (n = 7), the United Kingdom (n = 4), and Australia (n = 3). Other countries with less than three studies were Canada (n = 1), Denmark (n = 1), France (n = 2), India (n = 1), Jordan (n = 1), Netherlands (n = 1), Spain (n = 2), and Switzerland (n = 1) (Figure 3 ). Participants in the reviewed studies were from diverse subsets of conditions associated with chronic pain, which included arthritis (n = 2), fibromyalgia (n = 1), back pain (n = 11), other non-back-related musculoskeletal pain (n = 8), migraines and headaches (n = 1), endometriosis (n = 2), and unspecified chronic pain (n = 9) (Table 2 , Figure 2 ). Significant gender differences were identified in three studies where the participants studied were primarily females [ 51 , 61 , 43 ]. Accessibility of DHIs Subtopics within the realm of DHI accessibility include enhanced patient autonomy and improved patient management of chronic pain conditions [ 44 , 50 , 54 , 60 , 63 ]. Positive pain outcomes were associated with the accessibility of DHIs, suggesting that improved adherence and frequent app usage are linked to better outcomes [ 68 ]. While DHIs simplify pain management and make it more accessible, two studies emphasize that these interventions should complement traditional therapies rather than replace standard care [ 38 , 68 ]. DHIs have also proven to enhance clinician accessibility, enabling providers to better manage patient pain [ 36 , 60 , 66 , 67 ]. Apps have demonstrated capabilities in tracking alarm symptoms (such as chest pain, vomiting, numbness) [ 65 , 66 ] and facilitation of two-way communication between doctors and patients [ 64 ]-features positively received by patients. The utilization of apps for tracking alarm symptoms has been associated with reduced anxiety for both clinicians and patients [ 66 , 67 ]. The underutilization of DHIs by providers was also found to have a negative impact on patient experiences due to unmet expectations of provider responsiveness, emphasizing the importance of clinician involvement in DHI design [ 36 , 64 , 68 ]. Furthermore, DHIs have expanded the accessibility of self-management tools to a broader spectrum of patients [ 41 , 59 ]. Particularly in regions with limited access to healthcare facilities, such as rural areas, DHIs offer easily accessible self-management tools that prove beneficial for patient outcomes [ 58 ]. The studies suggested that there was a decrease in care-seeking activities in groups that used DHI s [ 38 ]. The overarching goal of DHIs is to reduce the number of clinic and emergency room visits, saving patients from unnecessary trips and alleviating the burden on the healthcare system [ 65 ]. Reduced Healthcare Costs Reductions in healthcare costs with DHI use include overall cost reductions, reductions in pharmaceutical-associated costs, and savings resulting from the deferral of invasive procedures. Six studies reported a reduction in healthcare costs associated with the implementation of a DHI in chronic pain management [ 41 , 47 , 54 , 56 , 57 , 60 , 63 ]. Among them, two studies highlighted cost reductions by applications designed to manage different types of LBP [ 47 , 56 ]. The remaining 26 studies either lacked substantial evidence supporting cost reduction or did not use cost reduction/effectiveness as a metric for gauging the success of the management interventions. Notably, no studies reported an increase in associated healthcare costs. Multiple studies evaluated the decrease in healthcare costs achieved through a reduction in pharmaceutical usage, particularly opiate use [ 57 , 60 , 63 ], illustrating overlap between reduction in healthcare costs and accessibility associated with DHI use. The observation of diminished pharmaceutical use suggests potential cost savings linked to the alleviation of dependency [ 57 ]. Another dimension of cost reduction involved the ability of DHIs to defer the need for surgical procedures, specifically over a course of multiple years [ 54 ]. However, challenges in patient adherence underscored the necessity for further adjustments and enhancements needed for DHIs to optimize patient usage and subsequent benefit. A distinct avenue of interest within the realm of cost-effectiveness involved the standardization of strategies disseminated through a large platform, such as a mobile app [ 47 , 56 ]. This approach aimed to educate a broad audience in techniques like self-relaxation, offering convenient at-home interventions, potentially obviating the need for in-person doctor visits, and empowering individuals to manage their health proactively, ultimately alleviating unnecessary short-term and long-term healthcare costs [ 47 , 56 ]. Similarly, the utilization of a mobile-web intervention to reach a diverse population showcased the potential for cost-effectiveness and positive user engagement in a wider array of different socioeconomic demographics [ 41 ]. Reduction in Pain Twenty-one studies reported positive outcomes in pain reduction [ 37 , 39 , 41 , 45 - 51 , 53 , 56 - 59 , 61 , 62 ]. These studies employed diverse interventions, utilizing the DHIs both as primary care and adjuncts, reflecting the complex landscape of chronic pain management. Interventions looking at pain intensity demonstrated statistically significant improvements in pain intensity, disability index scores, and overall quality of life [ 37 ]. These findings underline the potential benefits of personalized approaches to chronic pain management. While over 60% of the articles reported pain reduction, no articles reported an increase with associated pain management techniques. The effectiveness of mHealth interventions, such as applications promoting adherence to physical activity and self-management, showcased positive outcomes in chronic LBP patients [ 39 ]. Several interventions across 17 studies, such as GIER with REN treatments and ACT, reported multifaceted improvements in pain relief, functionality, and return to normalcy [ 37 , 39 , 41 , 45 - 51 , 53 , 56 - 59 , 61 , 62 ]. These technology-based interventions, including applications and virtual training, demonstrated positive impacts on pain outcomes. Mental Health Implications Eleven studies included assessed aspects of mental health in relation to chronic pain [ 37 , 40 , 41 , 43 , 53 , 56 , 58 , 60 , 61 , 65 - 67 ]. Utilizing DHIs was associated with positive mental health outcomes including significantly reduced depression and anxiety [ 58 , 60 , 66 , 67 ], reduced pain-associated fear avoidance [ 40 , 53 ], and improved affect [ 61 ], as well as improved emotional understanding of and overall attitude toward pain [ 41 ]. One study found improvement in lower back pain (LBP) outcomes after utilizing an AI-based smartphone app, even in participants with high baseline levels of depression and stress [ 44 ]. DHIs were also associated with significantly reduced daily opioid use and even complete opioid cessation [ 60 , 63 , 57 ]. Several studies found no positive mental health outcomes after utilizing DHIs [ 37 , 43 , 56 , 64 ]. Some DHIs encompassed additional behavioral features such as relaxation techniques, autogenic training, meditation, guided imagery [ 55 ], mood recording features [ 4 ], and adjunctive behavioral techniques such as cognitive behavioral therapy and guided relaxation [ 51 , 56 ], in addition to daily questionnaires related to anxiety, depression, and pain catastrophizing [ 60 ]. No studies reported negative impacts on mental health. Pain Catastrophizing Eight studies investigated the impact of digital technologies on pain catastrophizing in patients with chronic pain. All assessments of pain catastrophizing were measured using the pain catastrophizing scale (PCS) [ 43 , 46 , 49 , 59 , 60 , 64 , 65 , 66 ]. Among these studies, two focused on VR-based DHIs [ 46 , 49 ], while six investigated DHIs delivered through smartphone apps [ 43 , 59 , 60 , 64 - 66 ]. VR-based DHIs did not yield significant reductions in PCS scores among patients with LBP [ 46 ] or endometriosis [ 49 ]. However, one of these devices demonstrated that patients with higher PCS scores experienced greater pain intensity 60 minutes after undergoing their first VR treatment [ 49 ]. In contrast, app-based devices produced more varied results. Three studies reported significant results in PCS scores for those living with chronic musculoskeletal pain conditions [ 59 , 60 , 65 ]: two of them demonstrating significant reductions in PCS scores [ 59 , 60 ], whereas the remaining study demonstrated that scores increased with a greater number of assessments completed by participants [ 65 ]. Additional app-based DHI studies found no statistically significant reductions in PCS scores for chronic pain [ 43 , 64 ]. Notably, one specific app-based DHI exhibited high levels of construct validity in assessing PCS, serving as a valuable guide for managing interventions in chronic pain treatment [ 66 ]. Discussion The evidence presented in this review underscores the efficacy of DHIs in improving chronic pain management. In the analysis of themes, including pain reduction, accessibility, and cost-effectiveness, DHIs demonstrate promise for enhancing patient outcomes and accessibility to care, particularly for disadvantaged and underserved patient populations. DHIs offer the potential for reducing healthcare expenditures and addressing mental health dimensions such as anxiety, depression, and pain catastrophizing. Reduction in Pain DHIs provide a diverse array of interventions tailored to address chronic pain based on individual patient needs and preferences. The reduction in pain achieved through personalized pain management strategies, coupled with the increased accessibility of pain management services from the convenience of a patient's home, offers an avenue for integrating holistic strategies into clinical practices to effectively address chronic pain. Noteworthy advancements are observed in the realm of mHealth applications. These applications focus on encouraging patients to adhere to physical activity and self-management, showcasing significant efficacy, particularly in conditions such as chronic LBP [ 39 ]. By integrating patient accountability with convenient access to medically approved instructions, mobile applications likely enhance patient adherence, thereby further bolstering the pain reduction potential of DHIs. Guided intervention of education and relaxation (GIER) with remote electrical neuromodulation (REN) treatments and acceptance and commitment therapy (ACT), a form of cognitive behavioral therapy, have exhibited multifaceted enhancements in pain relief, functional capacity, and restoration of normalcy, underscoring the value of taking a holistic approach in the management of chronic pain [ 50 , 51 ]. Virtual training programs and VR have shown positive impacts on pain outcomes, suggesting a complementary role of technological interventions alongside traditional pain management strategies [ 46 , 62 ]. While digital interventions have shown positive impacts for some patients, it’s notable to mention the lack of accessibility to these programs based on cost and access to the applicable technology for patients worldwide. Further research could be conducted to evaluate VR as an adjunct to standard care to weigh the efficacy of these programs with the imposed financial burden to patients. While these findings provide valuable insights, several gaps in knowledge warrant further attention. Firstly, there remains a need for further exploration into the mechanisms underlying the effectiveness of these DHIs. Additionally, the review highlights the need for more studies assessing the long-term efficacy and sustainability of such interventions as well as their scalability and applicability across diverse patient populations such as those in rural areas and low socioeconomic status. While mHealth interventions have shown promise, there is a lack of standardized protocols and guidelines for their development and implementation in chronic pain management. This gap underscores the importance of future research in establishing best practices and ensuring the quality and effectiveness of mHealth interventions. Accessibility Accessibility provided by DHIs is a valuable asset for individuals with chronic pain conditions. DHIs play a pivotal role in streamlining pain management, facilitating ease of access to healthcare for socioeconomically disadvantaged and rural regions [ 41 , 59 ]. This enhanced accessibility can be attributed to the large number of pain management mobile applications, readily available on numerous mobile app platforms that are increasingly offered as a complement to standard care. DHIs not only enhance patient accessibility but also provide healthcare providers with the means to monitor patients and access pertinent pain data [ 64 ]. This data, in turn, can inform care decisions during both in-office and telehealth visits, contributing to higher quality care and more informed decision-making by physicians, ultimately benefiting patient outcomes. The favorability of two-way communication within apps among patients mitigates anxiety associated with chronic conditions, fostering a sense of security through readily available access to healthcare professionals in case of emergencies. Alarm symptom tracking further contributes to anxiety reduction by guiding patients in making informed decisions about whether to seek emergency medical services, thereby reducing unnecessary healthcare facility visits and associated costs [ 38 ]. However, a noteworthy barrier to the wider adoption of DHIs lies in the underutilization of available technology by healthcare providers [ 36 , 64 , 68 ]. Patient reports indicate that a lack of engagement and app usage by physicians dissuades patient engagement, highlighting the importance of physician support to bolster the credibility of DHIs in public perception. Despite their proven effectiveness, DHIs require active endorsement and utilization by physicians to ensure patient adherence. The potential cost associated with monetized applications may still deter some patients, although numerous cost-free applications are currently available. It is also necessary to mention that accessibility to DHIs is largely limited to technology-literate individuals who own a smartphone, VR device, or other wearable device who frequently engage with the user interface to provide accurate health tracking data. Additionally, other DHI interventions, such as VR technology, remain financially prohibitive and are unlikely to be covered by insurance, restricting their usage and potential pain reduction benefits to higher income households. Further research could be conducted to evaluate VR as an adjunct to the standard care to weigh the efficacy of these programs with the imposed financial burden to patients. The escalating prevalence of smartphone ownership is evident in the United States, with 76% of individuals who earn an annual income below $30,000 possessing access to technology. Furthermore, this percentage rises to 87% for those earning between $30,000 and $100,000 annually, underscoring the potential for DHIs to reach a substantial portion of the US populace, surpassing the reach of traditional care methods alone [ 68 ]. Nonetheless, it is imperative to acknowledge existing barriers for individuals from lower socioeconomic strata. A total of 41% of individuals earning less than $30,000 annually report a lack of home broadband access, constraining internet utilization and impeding the full utilization of certain key features inherent to DHIs, such as two-way communication and real-time alarm symptom monitoring by healthcare professionals. Additionally, a quarter of the population in rural and lower-income areas lacks access to smartphones entirely, posing a potential obstacle to the seamless integration of these technologies, warranting attention as a public health concern. These findings reinforce the notion that while DHIs streamline pain management and offer a valuable tool for patients lacking access to traditional healthcare facilities, they should be regarded as complementary to, rather than a replacement for, traditional therapies [ 3 , 18 ]. Kelly et al. advocate for a blended care model that combines technology with face-to-face management to optimize monitoring and care, asserting that DHIs primarily contribute to enhancing self-management. Reduced Healthcare Costs The observed cost reduction associated with DHIs for managing LBP underscores their potential to significantly impact chronic condition care. These findings not only demonstrate the cost-saving capabilities of DHIs in LBP management, but also suggest broader implications for addressing other chronic conditions [ 47 , 56 ]. Understanding how DHIs contribute to cost reduction in LBP care can inform the development of tailored intervention strategies with guidelines for the management of additional chronic conditions, thereby improving patient outcomes and reducing healthcare expenditure on a wider scale. The reduction in pharmaceutical usage, particularly opiates, due to DHI use, is another significant aspect of cost reduction in chronic pain management [ 57 , 60 , 63 ]. By diminishing reliance on medications, DHIs offer a pathway to decreased healthcare expenditures. Furthermore, DHIs demonstrate the potential to defer the need for surgical interventions over extended periods, as indicated by longitudinal studies [ 54 ]. These findings hold promise for guiding future research aimed at understanding the broader impact of DHIs on patient outcomes and healthcare spending, suggesting potential avenues for large-scale cost savings and improved management of chronic pain conditions. Although not consistently emphasized in the literature, some studies reported promising results regarding healthcare cost reduction through the utilization of DHIs for chronic pain management [ 47 , 56 ]. This suggests that cost reduction may be an associated benefit even in studies where it was not explicitly addressed. These findings underscore a need for further research aimed at evaluating the degree of healthcare cost reductions associated with DHI use in chronic pain management. Given the prevalent economic barriers hindering healthcare accessibility for patients with chronic conditions, understanding the nuances of cost reduction associated with digital interventions is imperative for reducing the global economic impact of treating patients living with chronic pain. This endeavor holds the potential to refine digital healthcare interventions to better meet the needs of patients and healthcare systems alike, ultimately fostering improved accessibility and affordability of care for individuals with chronic conditions. The emphasis on cost reduction in DHIs highlights their potential benefits for patients, especially in managing chronic conditions. These findings underscore the capacity of DHIs to revolutionize chronic condition care by offering cost-effective alternatives to traditional treatment methods. Mental Health Implications The utilization of DHIs serves to bolster the efficacy of a multifaceted approach to managing chronic pain conditions, particularly by addressing mental health-associated symptoms. DHIs incorporate a comprehensive array of behavioral components, including relaxation modalities, autogenic training, meditation, guided imagery, mood tracking, CBT, and guided relaxation, among others. Crucially, DHIs integrate daily assessments aimed at targeting anxiety, depression, providing a holistic framework for addressing the complex interplay between mental health and chronic pain management [ 60 ]. By encompassing diverse components, DHIs offer a promising avenue for effectively managing chronic pain conditions while concurrently addressing mental health-related symptoms, thereby enhancing overall patient well-being and treatment outcomes. The adoption of DHIs presents a promising avenue for improving mental health outcomes within the management of chronic pain, as supported by a growing body of empirical research. Studies demonstrate significant reductions in comorbid depression and anxiety, as well as decreases in fear-avoidance behaviors associated with pain, improvements in affect, and enhanced emotional understanding and coping attitudes toward pain [ 40 , 41 , 53 , 58 , 60 , 61 , 66 , 67 ]. Notably, positive outcomes in managing LBP through AI-based smartphone applications, even among participants with elevated levels of depression and stress at baseline, underscore the potential of DHIs to address mental health concerns within chronic pain populations [ 44 ]. Moreover, DHIs have shown efficacy in reducing daily opioid consumption and facilitating opioid cessation [ 57 , 60 , 63 ], suggesting potential benefits in mitigating opioid dependency. However, it is important to note that some investigations have failed to observe significant improvements in mental health parameters following DHI implementation though none saw a deterioration in mental health [ 37 , 43 , 56 , 64 ]. These findings underscore the potential of DHIs as efficacious instruments for enhancing mental well-being among chronic pain sufferers. However, further research is warranted to elucidate the underlying mechanisms driving DHI-mediated effects on mental health outcomes and to identify optimal intervention strategies tailored to individual patient profiles. Additionally, future investigations should explore specific chronic pain syndromes, such as LBP, and vulnerable patient cohorts, particularly those facing socioeconomic barriers to healthcare access. By addressing these gaps, future studies can provide a comprehensive understanding of the landscape of DHIs in chronic pain management, ultimately informing evidence-based practices and promoting holistic well-being for patients. Pain Catastrophizing In this study, the utilization of DHIs for the management of pain catastrophizing demonstrated mixed results. Pain catastrophizing, characterized by distressing cognitive thoughts associated with pain conditions, is quantified based on helplessness, rumination, and magnification scores [ 43 , 46 , 49 , 59 , 60 , 64 - 66 ]. Although pain catastrophizing represents a significant method of quantifying the pain experience, only a limited number of studies evaluated this parameter with DHI use. One smartphone DHI study reported significant reductions in pain catastrophizing scores (PCS) among patients living with osteoarthritis and CLBP [ 46 , 60 ]. However, contrasting results emerged from other studies evaluating DHIs in musculoskeletal conditions, with some demonstrating nonsignificant reductions in chronic musculoskeletal PCS scores [ 59 ], no change in PCS scores in nonspecific chronic pain and LBP, respectively [ 43 , 64 ], or even significantly increased nonspecific chronic pain PCS scores [ 65 ]. The predominant result of these studies suggests that DHIs must be further evaluated to ascertain the true efficacy of DHIs in managing PCS, with a particular focus on their role in the management of musculoskeletal conditions. Notably, one study reported impressive levels of construct validity, which refers to the degree to which a test or instrument accurately measures the theoretical constructs related to the pain experience that it is intended to measure, in a smartphone-based DHI [ 66 ]. This suggests the potential for DHIs to enhance the identification of patients prone to pain catastrophizing and serve as a valuable tool in a provider’s approach to treatment for chronic pain patients [ 66 ]. Consequently, the use of DHIs for accurately identifying pain catastrophizing patients could revolutionize patient-physician interactions especially for individuals who experience heightened distress due to their condition. This presents an opportunity for a more comprehensive assessment and personalized treatment, fostering trust and rapport with patients, aligning with the core values of the osteopathic profession. VR-based DHIs represent a cutting-edge opportunity to address chronic pain patients. Given the interconnectedness of pain catastrophizing with the cognitive process of pain perception, advancements in the immersive VR technology experience offer an increasing opportunity to leverage these technologies to reshape how patients perceive pain [ 46 ]. Through physical engagement with therapeutic exercises and continuous visual feedback offered by VR technologies, patients can potentially restructure their understanding of pain, leading to reduced PCS scores [ 46 ]. Moreover, VR-delivered DHIs demonstrate a favorable safety profile [ 46 , 56 ]. However, the high cost associated with these innovative devices presents an obstacle to wider access and adoption of these devices. Despite the beneficial impacts listed above, further research is needed to understand the underlying mechanisms through which DHIs enhance patient outcomes and accessibility to care, reduce healthcare expenditures, and address mental health dimensions of care, such as anxiety, depression, and pain catastrophizing. Guidelines must be established to optimize intervention strategies using these devices. Additionally, while the study findings did not indicate DHIs as more beneficial for some types of pain than others, this presents a prospective avenue for further research to explore. Limitations Limitations identified in this scoping review encompassed restricting the evaluated conditions to those falling in the most common chronic pain conditions: musculoskeletal conditions (arthritis, osteoarthritis, LBP), fibromyalgia, migraines and headaches, and endometriosis. Additionally, articles were confined to those published in the English language. While there was considerable ethnic diversity in participants, socioeconomic disparities related to the accessibility of these technologies may introduce potential bias. Furthermore, the exclusion of studies involving children and adolescents, who have increasing technological proficiency and accessibility, but who are historically less commonly affected by chronic pain conditions, perpetuates a lack of knowledge regarding the potential impact of DHIs on children and adolescents living with chronic pain conditions. Many of the studies focused on one specific chronic pain condition and/or a lack of randomization/selection bias among patients where participants were non-blind to being in the experimental group or were selected based on having a diagnosis of a particular condition [ 36 , 43 - 45 , 47 , 48 , 55 , 62 , 64 ]. Furthermore, several studies identified additional constraints such as small sample sizes [ 36 , 38 , 39 , 48 , 49 , 52 , 55 , 61 , 62 , 64 ], gender imbalances [ 42 , 55 , 61 , 68 ] lack of generalizability [ 47 , 55 , 61 , 62 , 68 ], patient adherence concerns [ 36 , 39 , 49 , 50 , 64 ], and technical challenges [ 43 , 47 , 64 ]. Some articles also raised concerns about patient self-reporting, which may have impacted the accuracy of the findings without an objective assessment [ 39 , 41 , 42 , 44 , 60 , 62 ]. Additionally, the recent development of many assessed DHI technologies led to concerns about the lack of long-term follow-up in several studies [ 37 - 39 , 45 , 47 , 51 , 53 , 60 , 64 ]. Lastly, only a limited number of databases were utilized in the creation of this scoping review with additional resources also available that could have yielded more information to bolster arguments and examine common themes for the use of DHIs in chronic pain management. The typical limitations of scoping reviews must also be considered as this paper prioritized encompassing data that provided overarching themes of DHIs rather than focusing on the depth of individual chronic pain topics and the efficacy DHIs provide in their management. Future research is needed into individual disorders of chronic pain to establish more nuanced and precise insights into the efficacy of DHIs in their therapeutic interventions.

This scoping review highlights the diverse landscape of interventions targeting pain reduction in chronic pain management with themes of pain reduction, increased accessibility and cost-effectiveness, positive mental health implications, and pain catastrophizing. Despite continued progress, ongoing research is needed to understand the underlying mechanisms of mental health implications and the potential economic benefit posed by DHIs. This is essential for advancing the understanding of effective strategies for managing chronic pain and ultimately enhancing patient outcomes. The findings underscore the importance of tailored approaches and ongoing research efforts to optimize pain management outcomes.