The Dis-Engaged Patient? Chronic Interfacing in a Regime of Digital Health Convenience.

Benjamin Lipp: conceptualization, investigation, funding acquisition, writing – original draft, methodology, validation, visualization, writing – review and editing, project administration, formal analysis.

As mentioned above, chronic pain is an experience that can feel out of control. Here, the Quell engenders a sense of predictability, where knowledge about triggers can help anticipate a flare‐up. ‘[I]t puts me in control psychologically’, one user describes it. However, in my interviews it becomes clear that the Quell is not just a ‘neutral’ tool to control pain but an active counterpart that itself can take control of the user. To illustrate this, I first turn to the Quell's interface design. As described above, users can adjust the Quell's intensity manually via a plus‐minus interface on the app's home screen. This number represents the device's electric output measured in milliamps ranging from 0 to 100. When asking users about intensity, they usually respond with these numbers. For example, one user quantifies the limit he can tolerate at ‘a pretty high number, like a 40 or a 45’ (06‐F). Here, some participants told me during the interviews that they noticed a change. While in the beginning the interface did not feature a number, later it changed to displaying the number by default. This too is the case for the latest version, the Quell fibromyalgia. Asking the CEO, it turns out that these changes are the result of a longstanding debate within the company: So, when we started out, we just wanted people to titrate based on what they were feeling . (…) But, as we learned over the years, people like numbers . It gives them comfort and it gives them sort of a sense and kinda it anchors what they’re doing , I guess. (…) So, over time, we’ve finally decided people like the number. It can be a little bit— it can lead people astray . If they’re tuning the intensity to a number as opposed to what they’re feeling, that could be problematic. Because if they have a friend that says, ‘I’m getting great results with 10’, and they go, ‘Cool. I’ll use 10’. But 10 may not be sufficient for you. You need 20. You’re not gonna get a therapeutic response. And that was a concern, but ultimately decided on balance. It was better to show the numbers. (Neurometrix CEO) So, when we started out, we just wanted people to titrate based on what they were feeling . (…) But, as we learned over the years, people like numbers . It gives them comfort and it gives them sort of a sense and kinda it anchors what they’re doing , I guess. (…) So, over time, we’ve finally decided people like the number. It can be a little bit— it can lead people astray . If they’re tuning the intensity to a number as opposed to what they’re feeling, that could be problematic. Because if they have a friend that says, ‘I’m getting great results with 10’, and they go, ‘Cool. I’ll use 10’. But 10 may not be sufficient for you. You need 20. You’re not gonna get a therapeutic response. And that was a concern, but ultimately decided on balance. It was better to show the numbers. The Quell's display of numbers is controversial because its interface turns out to be stickier than intended. It harbours unintended affordances that shape user behaviour in undesirable ways. This renders visible a contradiction in ‘smart’ pain management: On the one hand, the interface should function as an ‘anchor’ to provide the user with some guidance in the absence of a clear standard. On the other hand, managing pain presupposes an active user, one who applies themselves to understanding their pain and developing strategies to cope with it, incl. fine‐tuning the Quell's intensity based on what they are feeling not based on what the interface (or a friend) tells them. However, we can see how the promise of automation, that is, entrusting the device with managing pain, creates the risk of people relying too much on it. This becomes apparent in the way some ‘heavy’ users of Quell make sense of the usage statistics the device provides. Re‐telling an incident during the diary study, one user reflects on what it felt like to not have the device available for a day: But, it’s interesting. You sent me your questions on the Quell, and when I was down in Florida, I didn’t wear it for a day. Yeah. One day I missed, and I didn’t notice any differences . So, is it psychosomatic now that I have to wear it? ‘Cause I’m averaging, I think, over 12 sessions a day. But, m entally it’s like something I rely on now , I think. I’m disappointed if I wake up in the morning and the electrodes disconnected from it or something, or it’s time to air your skin out or whatever, and I didn’t get enough in . (Quell user, 01‐M) But, it’s interesting. You sent me your questions on the Quell, and when I was down in Florida, I didn’t wear it for a day. Yeah. One day I missed, and I didn’t notice any differences . So, is it psychosomatic now that I have to wear it? ‘Cause I’m averaging, I think, over 12 sessions a day. But, m entally it’s like something I rely on now , I think. I’m disappointed if I wake up in the morning and the electrodes disconnected from it or something, or it’s time to air your skin out or whatever, and I didn’t get enough in . Being reminded of situations where he does not have the device available makes this participant reflect on his reliance on the device. This issue of reliance was a pervasive concern in my interviews, and it was often connected to the opioid epidemic. In this context, people are looking for alternatives that do not require them to ‘take a pill’ (06‐F). This refusal of reliance and simultaneous valuation of independence spills over to the Quell sometimes. Not in the sense that it would cause addiction or serious side effects but in that it is something that they nevertheless are dependent on. This dependence materialises as an interfacial relationship that does not necessarily relate to an experience of pain. Rather, the quote above suggests that what is described as ‘getting enough in’ denotes a corridor of pain care that emerges from the continuous interaction of user and device. The user realises that this engagement changes him in a ‘mental’ way, where he feels disappointed when a certain expectation (i.e., 12 sessions a day) could not be reached. Interfacing becomes apparent as a process of reconfiguring users, their relationship to themselves and their pain (Barad  2007 ; Suchman  2007 , 285–286). In other words, users develop a relationship with the device that does not leave them untouched. This ‘touch’ can take different forms: it can be experienced as gaining control over pain, it can be experienced as loss of control over oneself, but it can also give rise to new affective relationships between user and device. One participant describes this, albeit hesitantly, in terms of a friendship: ‘I hate to say the word; it feels more “human” interaction with a device, which is crazy. But it does feel that way to me. “My friend”, I would say. Funny, you know’. (04‐M). I find here the ambivalence of managing pain with a device that is not a mere tool to be tinkered with nor one that simply enables chronic living but rather one that also profoundly changes the user, their experience, agency and perception of themselves as well as their pain.

The Quell represents a yet understudied case of digital health technology: smart technologies aim to shift illness work away from the user to data‐driven devices. However, my analysis shows that instead of fully delegating pain care, the interaction with the device changes the nature and target of users' care practices. Rather than only for themselves, they have to care about the human–machine interface. Put differently, to care for themselves through the Quell users have to engage in constant interfacing work (Lipp  2023 ), that is, establishing, configuring and maintaining interfacial relations between the self, body and device. This analytical framework challenges a too naïve view of healthcare automation, which takes the promise of digital health convenience (‘wear it and forget it’) for granted. Instead, this very promise intensifies people's responsibility to maintain, tune and monitor the device, for example, caring for one's skin in relation to constant transcutaneous stimulation, or regular calibration and tuning of the device to establish an interference‐free feedback loop between the user's behavioural data and the device's algorithmic calculations. In fact, Quell's ‘auto‐pilot’ requires the user to precisely not forget it but to tinker with and supervise it. At the same time, the device does indeed increasingly participate in pain care, namely, through continuous stimulation, data analytics and visualisation. On the one hand, this is enabled through the company's data infrastructures and growing capabilities to develop new functions and personalise treatment. On the other hand, it is related to the specific interfacial relations users develop with the Quell. Here, an analytics of interfacing shows that users re‐work themselves over time, that is, their experience and expectation of pain care become increasingly mediated and inflected through the Quell's interface collecting and visualising symptom and usage data. For one, users develop their pain management strategies while integrated within the continuous loop of data collection and modulatory intervention. For instance, the aforementioned ‘awareness’ for pain triggers is the product of ‘substantiating’ the users' sensory perception and the device's constant feedback. Furthermore, users also depend on the device for a sense of accomplishment, often absent when self‐managing highly uncertain trajectories of chronic conditions (Denny  2009 ). This becomes particularly clear when looking at the device's tracking of usage. Through interaction with these statistics users develop a sense of what is ‘enough’, which relieves them from the uncertainty of what to do when in pain but can also exert pressure to conform to that benchmark. The device becomes a normative authority that nudges the user into certain corridors of therapy (Schüll  2016 ). However, this is not simply achieved by addressing the user's agency and will but rather through a mechanism of automaticity that is increasingly driven by the device (Lindner  2020 ). Nowhere is this more visible than in the device's weather function, which addresses users by way of anticipatory notifications. In these instances, although re‐engaged by the device, the role of the user becomes a different one: from manager of the self to a supervisor of interfacial relations. The analysis shows that a focus on interfacing processes is able to carve out the specific activities performed by users and devices that make care with the Quell practically possible. In particular, such a perspective is able to trace the formation of situated ‘corridors of interaction’ (Lipp  2023 , 677) that are not pre‐determined by digital health technology nor purely an attribute of creative agency. Rather, it is enacted in practices of interfacing that ‘iteratively reconfigure what is possible and what is impossible’ (Barad  2007 , 234). In the case of pain care with the Quell this means that design and use practices co‐evolve over time (see also Oudshoorn and Pinch  2005 ), as exemplified by the ongoing debate about interface design at Neurometrix and users' differential ways of working through the interface. This co‐evolution entails specific types of work afforded by the increasing ubiquity of interfacial relations in digital health: of maintaining, tuning, deciphering and tracking devices. Hence, such an analytics helps capture the processes by which this type of work is enacted while at the same time paying close attention to how it becomes re‐distributed and reconfigured through the proliferation of those very devices. Conversely, studying how people manage chronic illness this way offers important insights for further developing our understanding of interfacial relations. In particular, this diary study has shown how interfacing itself becomes chronic , that is, it is not merely a finite process of domesticating or taming a certain technology once and for all (Fox  2019 ) nor a process of mundanisation, where technologies completely disappear from users' attention (Willim  2024 ). Rather, users of the Quell can plausibly describe the Quell as convenient or invisible while at the same time having to engage in an extensive range of practices that make its use seemingly convenient in the first place. As Quell becomes ‘second nature’ to users, the nature of what managing pain means and entails has profoundly changed. This ambivalence raises an important new issue in the sociology of digital health, namely, to account for an emerging regime of digital health convenience . Common critiques of digital health mobilise a notion of neo‐liberalism that, among other things, seeks to responsibilise individuals expecting them to stay continuously engaged (Lupton  2018 ; for the case of chronic pain, see Charette  2024a ). To be sure, there are clear continuities, but I maintain that digital health convenience functions differently in at least one crucial aspect. Applying Rogers Brubaker's argument to the domain of digital health, caring for the self is ‘… not only a reflexive practice, a way in which the self is known from within; it is a computational process, a way in which the self is known from without’ (Brubaker  2023 , 35), that is, via a plethora of algorithmically governed processes that manifest in the subject ‘automatically’ over time (Lindner  2020 , 88). Hence, the individual is not fully responsibilised in the traditional sense of needing to constantly attend to its own constitution as a responsible subject. Rather it is also partly relieved from same responsibility (Schüll  2016 , 328). The promise, and to some extent, the actual practice of devices such as the Quell is to dis‐engage the user from the chore of leading a good and healthy life while at the same time re‐engaging them in managing the technological milieu required for this very delegation thus re‐introducing responsibility at the level of interfacial supervision. Future work should further investigate this emerging regime and account for how smart technology re‐shapes the work, experience and responsibility of digital healthcare. This paper demonstrates that a sociology of interfacing can move this discussion forward in productive directions.

Maintaining effective pain modulation also requires finding the right level of stimulation intensity, which is enough to alleviate pain while not causing pain itself. In neuromodulation, this is called the ‘therapeutic window’ (S. N. Gozani et al. 2017 , 18), which is usually described in relation to the user's experience as a sensation that feels ‘strong but comfortable’ (Vance et al.  2014 , Quell Manual, p. 8). However, rather than solely relying on the user's experience, the Quell algorithmically calculates the optimal dose based on input from the user and passively collected data. Hence, automating pain management presupposes a process of tuning that involves activities by both user and device. When using the Quell for the first time, the device has to be calibrated to the user's so‐called ‘electrotactile sensation threshold’, the intensity at which they start to feel the stimulation (S. N. Gozani et al. 2017 , 18). During calibration, the device gradually increases the stimulation level from zero. The user then taps a button when they first feel the stimulation, and repeats this several times (Quell Manual, p. 8). However, this does not yet define the therapeutic window itself but only the basis for its calculation by the device, which adds a so‐called ‘intensity offset’ (S. N. Gozani et al. 2017 , 18). At the start, this value is assumed to be constant across all users but it is automatically adjusted over time based on the user's usage. Hence, although they are told to mostly leave this to the device, it depends on continuous feedback by the user. In practice, users change the intensity by hand all the time. For this, the device provides a simple graphical plus–minus interface, which allows the user to increase or decrease the intensity. For users to figure out the ‘right’ intensity they need to tune the intensity in such a way that the pain is gradually replaced or masked by paraesthesia , a sensation participants call ‘prickly’ or ‘tingling’. So, I would knock it down one or two notches until I find the sweet spot of—because it’s like a tingling sensation. It’s like I can feel the tingling sensation but it doesn’t feel like I’m being electrocuted, somewhere in between that. Just enough so that, basically, I can tune out the sensation . It’s not distracting. But it still has some sort of pain relief element to it. So, first using it was just figuring out how to find that good middle spot . (Quell user, 13‐F) So, I would knock it down one or two notches until I find the sweet spot of—because it’s like a tingling sensation. It’s like I can feel the tingling sensation but it doesn’t feel like I’m being electrocuted, somewhere in between that. Just enough so that, basically, I can tune out the sensation . It’s not distracting. But it still has some sort of pain relief element to it. So, first using it was just figuring out how to find that good middle spot . Figuring out that ‘middle spot’ can last ‘many, many months of playing with it’, as another user says (08‐M). Hence, pain relief does not mean that pain would simply go away. Rather it is about tuning it out like a melody, a process which requires not just electrical stimulation but also a refocusing of attention: ‘[i]nstead of concentrating on the pain …, I'm concentrating on stimulation that I'm feeling on the leg’, the same user puts it (08‐M). Relieving pain denotes a process of reorienting one's sensory perception and attention while at the same time continuously tuning the device to support that reorientation. In other words, pain relief is a relational accomplishment that requires one to work on the interface between body, device and perception (Middleton  2022 ). How people get to that point differs vastly: Some regulate the intensity following a ‘the less is better’ approach (e.g., 08‐M), because they want to save battery life, prevent skin irritation or are generally vigilant towards any medical intervention. Others aim to gradually increase the intensity ‘to get up to those higher intensity levels … [and] continue to have a sustaining effect’ (13‐F). At these higher intensities the sensation of the stimulation becomes ‘buzzing’, which some prefer over ‘stinging’ pain. People following this approach usually go through phases of elevated pain or expect more pain due to certain activities (e.g., working around the house or taking a plane). Hence, what constitutes a stimulation ‘middle spot’ is heavily dependent on the person's approach to managing pain, whether it is understood as a matter of dietetics (something to be tempered) or endurance (something to be intensified). So, is the Quell purely disengaging the user? My analysis suggests otherwise. Rather, configuring the Quell involves processes of tuning, calibration, algorithmic calculation and embodied sensing, which are running in parallel, sometimes supporting and sometimes interfering with one another. In the words of one of the participants, the Quell self‐adjusts to a specific level. And, after time of me adjusting, and it adjusting itself, I think that’s where both myself and the device came to a happy agreement that, that’s a good setting. (Quell user, 08‐M) self‐adjusts to a specific level. And, after time of me adjusting, and it adjusting itself, I think that’s where both myself and the device came to a happy agreement that, that’s a good setting. Hence, it is not just the device adjusting itself, nor the user simply controlling the device. Rather, we can observe a continuous process of interfacing, which tunes the user's preferences and embodied perception to the manifold algorithmic processes in and electrical output from the device—and vice versa. This changes the task of treating pain from one that requires active participation by a patient at all times (Baszanger  1989 ) to one where users become shifted in and out of an arrangement in which they rely, to a considerable degree, on activities by the device.

The author gratefully acknowledges support by the European Union's Horizon 2020 research and innovation programme under Marie Skłodowska‐Curie Actions Grant No. 101031798.

Chronic pain is an elusive experience. It ‘comes and goes mysteriously’, as one user notes (04‐M). Here, the Quell, and in particular its tracking capabilities and graphical user interface, offers ways to render pain more ‘transparent’ by monitoring different symptoms and visualising ‘insights’ ‘to help optimise treatment and improve overall health’ (Quell Fibromyalgia Website). Although this is common in many digital health apps, the Quell also aims to lower the need to act on those triggers by adjusting the stimulation intensity automatically. People living with chronic pain work to develop a sense of when and how pain impacts their life, a way to cut through the seeming unpredictability of pain (Charmaz  1997 ). Many participants use the Quell's user interface to achieve this, based on data the device tracks manually, for example, pain diaries and passively, for example, activity levels and sleep tracking. It’s more just like an awareness . If I see that there’s a lot of days where the numbers are higher, it’s more of me thinking like what has been going on in my life that could be contributing to that. Because usually, it’s something stressful or something where I’m doing a lot of physical activity and not anything that I could fix. But it’s more just to be aware of it and how it’s impacting my pain levels. So, if I have other things going on in my life in the future that are similar, I can know . This is probably gonna cause me to have days that are gonna be worse. And just be aware of that so I can make adjustments to my schedule when necessary . (Quell user, 13‐F) It’s more just like an awareness . If I see that there’s a lot of days where the numbers are higher, it’s more of me thinking like what has been going on in my life that could be contributing to that. Because usually, it’s something stressful or something where I’m doing a lot of physical activity and not anything that I could fix. But it’s more just to be aware of it and how it’s impacting my pain levels. So, if I have other things going on in my life in the future that are similar, I can know . This is probably gonna cause me to have days that are gonna be worse. And just be aware of that so I can make adjustments to my schedule when necessary . Tracking and letting the Quell monitor one's body and daily life can amount to an ‘awareness’ about the kinds of activities and situations that may cause pain. This mediation of bodily experience is a phenomenon often described in relation to the quantified self movement (Nafus and Sherman 2014 ). However, in the case of Quell users, this is less experimental and more goal‐oriented towards managing pain, and, once they feel like this process of figuring out how pain impacts their life does not yield any new insights, they stop tracking after a while. This awareness requires ‘checking in with your body’, as another user puts it (15‐F), that is, realising that pain is somehow worse than usual. However, this sense of pain is not purely about the body but also one that is validated through the Quell. On rare occasions, it can even result in the discovery of an entirely new diagnosis, as one participant found that he had restless leg syndrome after examining his sleep data form the Quell (09‐M). Hence, people do not fully rely on their ‘subjective, qualitative feeling’ but use the device as a memory support to contextualise daily form within a longer period of time and to pinpoint certain activities that may have caused a bad day. This is needed, ‘“cause sometimes, they [bad days] all just blend together’ (13‐F). Practices of tracking pain transform chronic experience from a persistent state of suffering into a more regular epistemic object that can be acted on and anticipated. Hence, the Quell shapes how chronicity is experienced, namely as characterised by trends, patterns, fluctuations, exacerbations and more or less preventable triggers. The Quell assists users in this process of deciphering pain but it also tries to do more. Namely, it increasingly makes connections for the user about when and where to change stimulation intensity. Neurometrix’ CEO sketches this vision out as follows: So, we’d like to look at your pain patterns over the course—because this is very well known. People have more pain on certain times of the week based on what they do . They don’t often pay attention to that . Sometimes it’s because their sleep patterns change on the weekends versus during the week and things like that. Or their activity levels go up and they have pain the next day. We can monitor all that and start to build models for individuals that suggest days that they’re gonna have exasperations of their conditions and then pre‐emptively suggest tuning of Quell or schedules of Quell use that will help address that . That’s the vision. We’ve only scratched the surface so far. Weather being one of the examples. So, it’s very much of a data— it’s sort of a big data kind of analysis challenge that we have . (Neurometrix CEO) So, we’d like to look at your pain patterns over the course—because this is very well known. People have more pain on certain times of the week based on what they do . They don’t often pay attention to that . Sometimes it’s because their sleep patterns change on the weekends versus during the week and things like that. Or their activity levels go up and they have pain the next day. We can monitor all that and start to build models for individuals that suggest days that they’re gonna have exasperations of their conditions and then pre‐emptively suggest tuning of Quell or schedules of Quell use that will help address that . That’s the vision. We’ve only scratched the surface so far. Weather being one of the examples. So, it’s very much of a data— it’s sort of a big data kind of analysis challenge that we have . The impact of (especially humid) weather on pain is an increasingly debated topic in pain medicine, especially regarding conditions such as fibromyalgia (Fagerlund et al.  2019 ) and osteoarthritis (Dorleijn et al.  2014 ), both of which are well represented in my sample. 3 Neurometrix is part of that discourse as it conducts research on this using data from its Quell Health Cloud (S. Gozani and Kong  2017 ). Based on this linkage, the user's preferences, location and weather forecast data, the Quell identifies triggers and sends a notification asking whether the device should increase stimulation intensity to pre‐empt pain. In its current state, the system re‐engages the user by bringing a possible trigger to their attention. At the same time, Neurometrix at least plans to do more of this ‘offloading’, as the CEO calls it, by anticipating possible triggers and acting on them automatically. Whereas traditionally people living with chronic pain are understood as active observers of their pain (Baszanger  1992 ), Quell users are invoked in a different role, namely, as supervisors of their therapy. They do not need to be aware of triggers anymore but only confirm or reject suggestions by the device. Although the CEO assures that he ‘wouldn't wanna be doing things blindly without the user knowing’, this vision clearly toys with the idea of bypassing the user entirely, at least if they want that. What is at stake here goes beyond simply the question of consent. Rather, it relates to what Scott Graham has observed with regard to neural imaging and pain medicine: in the quest of understanding and managing pain, smart pain technology seeks to bypass the subject‐in‐pain ‘by detouring through and enlisting a more authoritative ontology’ (Graham  2015 , 119), in this case, one of big data analytics that can anticipate triggers before the user can feel them. This vision of convenience resonates a more widely shared discontent among pain physicians and tech companies with the subjectivity of pain and the quest for finding ‘objective’ data‐driven solutions to it (see Lipp and Hilgartner  2025 ).

Managing chronic pain requires constant attention. Here, the Quell holds a unique promise: ‘Like cruise control on your car, this technology automatically manages stimulation intensity while allowing the user to take manual control at any time’ (Quell Manual). Instead of being constantly reminded of their ‘pain‐full world’ (Jackson  2000 , 164), managing it should become effortless according to Neurometrix. In the words of the CEO: … in a very simple term what we want this to be is wear and forget . 1 In a way what we set out to do was to try to achieve a level of simplicity comparable to taking a pill . The reason pills are so popular in a way, if that’s the right word, is their convenience , even though people still forget to take them. But you take the pill twice a day, and that’s the extent of your engagement in your healthcare. The rest of it is kinda taken care of for you by your physiology. If you have to fuss with something on a very regular basis it’s gonna be—in people’s complicated lives, it’s gonna be difficult . (Neurometrix CEO) … in a very simple term what we want this to be is wear and forget . 1 In a way what we set out to do was to try to achieve a level of simplicity comparable to taking a pill . The reason pills are so popular in a way, if that’s the right word, is their convenience , even though people still forget to take them. But you take the pill twice a day, and that’s the extent of your engagement in your healthcare. The rest of it is kinda taken care of for you by your physiology. If you have to fuss with something on a very regular basis it’s gonna be—in people’s complicated lives, it’s gonna be difficult . The slogan of ‘wear it and forget it’, inspired by telemarketing, 2 denotes a common mantra in the domain of smart pain technology (see also Lipp and Hilgartner  2025 ). The Quell is presented as a tool that takes care of people's pain that fits neatly into their lives. Indeed, many users note that, unlike traditional TENS units, which they describe as ‘complicated’ with ‘wires coming out of it’, to them the Quell is ‘effortless’ and can be worn ‘pretty much anywhere’. Participants describe it as ‘second nature’, so much so that they forget they are wearing it, for example, while showering or passing through airport security. Others value its invisibility for aesthetic reasons. Because of its slimness, it can be tucked under clothes hiding not only the device but also the fact that its wearer suffers pain. This is especially attractive to women in my sample, who, exposed to gendered beauty standards and ageism, prefer to keep themselves ‘neat’ (see also Dalibert  2016 , 651–653). Hence, the device's promise of convenience is attractive to users and for most of them realised in its wearability, small size and ease of use. However, although participants say that they barely interact with the device my interviewees describe many incidents where convenience breaks down and the Quell causes friction. A considerable part of these episodes happen during sleep, where the device loosens or falls off the calf completely. This can cause the user to wake up either because the device electrocutes the user, or because of pain coming back. One former yoga teacher describes this as follows: … what I learnt was that if I wear it on my left side, my left leg, it's not as quick to trigger. But if I've been wearing my Quell on my left side for hours during the day, the skin does need to air out, and I do need to move it to the other leg. And so, there's a sense of a little bit of defeat, frustration when I wake up because I know that it's gonna take me some time to get back to sleep again, whether it's just because of the pain or just because I've woken myself up and had to re‐maneuver everything so that I can get some relief again. (Quell user, 06‐F) … what I learnt was that if I wear it on my left side, my left leg, it's not as quick to trigger. But if I've been wearing my Quell on my left side for hours during the day, the skin does need to air out, and I do need to move it to the other leg. And so, there's a sense of a little bit of defeat, frustration when I wake up because I know that it's gonna take me some time to get back to sleep again, whether it's just because of the pain or just because I've woken myself up and had to re‐maneuver everything so that I can get some relief again. This quote shows two aspects of digital health convenience: that it is permeated with moments of breakdown, with feelings of ‘defeat’ and ‘frustration’, but also that it requires work to maintain Quell's operation. This is especially true because the Quell recommends continuous use at least three times a day in order to achieve a therapeutic effect. With the promise of wearability comes the obligation of adequate dosage, that is, to wear the device as much as possible. In the episode described above, this means to ‘re‐maneuver’ ad hoc. But it may also mean to prepare and anticipate breakdown in the first place. For instance, the user above wears it on her left calf as she realised during use that she is a right‐side sleeper. Hence, wearing it on the right leg would cause the Quell to rub off against the mattress more often. This, however, restricts wearability during the day as users should not wear it in the same location for too long. This is because continuous use of the electrodes may cause skin irritation—the most common side effect. The resulting redness, itching or even burning sensation then means that users need to switch legs or consider entirely different locations such as the thigh or arm. Furthermore, users engage in tactics to prevent said skin irritation, for example, by regularly airing out the skin or using different types of creams to moisturise and treat the skin. All this is to ensure conductivity at the skin‐electrode interface, that is, allowing electrical current to pass through and stimulate the nerves properly. This can be difficult to achieve. One user says that due to dry climate she had to continuously lotion her skin to ensure conductivity and adhesiveness of the electrodes. Others struggle with the opposite problem of too much moisture due to sweating, which deteriorates the electrodes more quickly. The device too participates in this by reminding users to take it off after 5 hours of use. From this, we can see that the promise of convenience is one that needs to be maintained constantly. Even more so, the promise of automation intensifies interfacing work, because breaking the cycle of use may hamper dosing and thus the effectiveness of the device. Hence, rather than completely receding into the background, the Quell regularly comes to the fore through electrocution, irritated skin or breakdown. Although intuitive and easy to wear most of the time, the Quell can never be fully forgotten.

The following analysis is based on a qualitative study of how people ( n  = 11) use this device. Although both past and present users were included, the sampling strategy paid special attention to balancing gender, age and duration of usage (see Table  1 ). The sample features a range of conditions, which is not surprising as the Quell has until recently been available over the counter without need for prescription. Contact to participants was facilitated through the company, which informed them through their mailing list. Interested users then emailed the author directly via email. For reference, participants are identified by a code consisting of a number and abbreviated gender, for example, 07‐F. Overview of participants in the study of Quell. The research design combines the diary method (Hyers  2018 ) with semi‐structured interviews. Eight participants went through the whole procedure incl. a briefing, a 1st interview, the diary study (usually lasting between three and 5 weeks, with daily engagement except weekends) and a final 2nd interview. Three users only took part in the 1st interview. These were mostly ex‐users, which had stopped for different reasons. This particular group was important to uncover critical issues of non‐use (Oudshoorn and Pinch  2005 ). The 1st interview focused on the users' journey with pain and the specific reasons for purchasing the Quell. The diary study consisted of daily prompts followed by interaction via the Telegram messenger app. Next to written texts, users shared screenshots of their Quell interface, photos and videos to describe their interactions with the device as well as general episodes of chronic living. The 2nd interview created an occasion for asking further questions that had remained unanswered or that came up with other participants, as well as an in‐depth reflection of unusual events reported during the diary study. Hence, the goal of this study was to uncover chronic use of technology, that is, the dynamically evolving patterns of using technology in relation to chronic illness that also develops in more or less unpredictable ways. The particular challenge here is to render visible aspects that are ‘second nature’ to participants. For this, the diary method allowed to track ‘mundane’ longer term use patterns, which may go unnoticed by conventional interview methods (Willim  2024 ). Prompts and interview questions then ensured to elicit reflection in users about those use patterns through verbalisation and illustration. Beyond users of the Quell, the study also analysed a wide range of company and regulatory documents, incl. the company's investor news, website content, user manuals, patents, scientific publications and U.S. Security and Exchange Commission filings. These were vital to understand the Quell's technical functioning as well as the company's evolving business operations. To contextualise this, I also interviewed the company's CEO, Shai Gozani, in a semi‐structured interview to, on one hand, confirm some of the open questions around the document analysis and to get insight into the backend of the device, for example, how the company processes user data and how they feed back into the device (or not). The following analysis will alternate between users' narratives about their interaction with the device and the company's position. I present my findings through four sets of interfacing practices: maintaining, tuning, deciphering and tracking. These reveal how Quell users shift in and out of engagement with their pain care. Yet this is not merely a matter of (in)complete automation. In interfacing with the device, also people's sense of their illness and care changes, reconfiguring their role and responsibilities. As self‐care requires attending to the device users have to rework themselves in new ways.

In the case of ‘smart’ pain technology, users are confronted with specific processes of interfacing. ‘Smartness’ here denotes a field term to distinguish between devices whose interfacing is data‐driven (so‐called closed‐loop) and those that are not (open‐loop). Elsewhere (Lipp and Hilgartner  2025 ), I have analysed this distinction as mobilising a specifically cybernetic rationality (Halpern  2014 ) in pain management while at the same time serving strategic purposes to capture and valorise user data within the field of neuromodulation. For the purpose of this article, it is sufficient to note that ‘smartness’ has emerged as an important quality of medical devices. These devices are invoked as tackling what has been dubbed the ‘crisis’ of chronic pain in the United States (Institute of Medicine of the National Academies  2011 ). Chronic pain is estimated to affect one in five Americans (Zelaya et al.  2020 ) and is widely recognised as a leading cause of disability across the globe (Cohen et al.  2021 ). Yet, the principal treatment for chronic pain, opioid medication, has proven insufficient in curbing this growing public health issue. On the contrary, the surge in opioid prescriptions during the 1990s and 2000s is now regarded as a key driver of the U.S. opioid epidemic, marked by sharp increases in addiction and overdose deaths. In response, the United States entered a phase of ‘opioid pharmacovigilance’ (Knight et al.  2017 ), during which federal authorities have sought to reduce opioid prescribing rates (CDC  2016 ; Dowell et al. 2022 ) and to expand access to non‐addictive non‐pharmacological alternatives (Institute of Medicine of the National Academies  2011 ). Neuro‐modulatory methods, both invasive and non‐invasive, have gained momentum in this context (Knotkova et al.  2021 ). Neurometrix Inc., a Massachusetts‐based company, entered this market in the early 2010s with its wearable neuromodulation device, Quell. Initially sold over the counter (for $299), the device was indicated for local chronic intractable pain (Food and Drug Administration  2016 ). However, a lawsuit regarding Neurometrix’ claim that the device could relieve pain beyond the lower limbs ended in a settlement of $4 million in 2020 (Federal Trade Commission  2020 ). Neurometrix shifted to a reimbursement‐based model in 2023, requiring a prescription for insurance‐covered purchase. This transition marks a strategic move towards medical validation of specific chronic pain conditions, starting with an FDA approval for fibromyalgia in 2021. The company was recently acquired by neuromodulation company electroCore. The Quell device uses transcutaneous electrical nerve stimulation (TENS) to relieve pain non‐invasively. TENS, widely used since the 1960s for home and clinical treatment, typically requires the user to remain stationary. Quell, by contrast, is a wearable and designed for continuous use—even during sleep, and is considerably more expensive (about 10 times a regular TENS unit). Worn on the upper calf, it delivers clinical‐grade stimulation at higher intensities (up to 120 V) than standard TENS units (typically 40–60 V), operating at high frequencies. It also features personalisation and automation tools via a companion app. The device passively gathers data (e.g., sleep quality) and supports active input (e.g., pain diary), storing these in the company's Quell Health Cloud with data from nearly 100,000 users. These data are used to tune the stimulation intensity in the background, if personalisation features are activated. These include adjustments at particular times of the day (e.g., afternoons), during sleep and based on weather. Collected data are also analysed for research and for developing new features using machine learning. Quell algorithmically calculates the individual therapeutic window of each user, which is continuously attuned over time according to user behaviour (i.e., the way they adjust stimulation intensity).

Living with chronic illness is hard work. Digital health technologies have been promoted as tools to ease this burden, offering features such as symptom tracking, medication reminders or educational resources. However, rather than reducing the work of managing illness, these technologies often increase patient responsibility, reinforcing neoliberal imperatives of self‐care (Lupton  2018 ). Patients are expected to self‐monitor, interpret health data and adjust behaviours to lead a good and healthy life (Lindner  2020 ), which can be overwhelming rather than liberating (Bagge‐Petersen  2023 ). A growing subset of digital health technology now promises not just efficacy but convenience. These ‘smart’ devices claim to delegate aspects of illness management to algorithmic systems, reducing the need for patient control. Examples include automated insulin pumps (Jansky  2024 ), cardiac pacemakers (Oudshoorn  2020 ) and, in this paper, neurostimulation devices for chronic pain (Lipp and Hilgartner  2025 ). Such technologies suggest a future where patients rely on automation to manage their health with minimal involvement. Rather than simply being about new technology, I argue following Brubaker ( 2023 ) that this gives rise to a regime of digital health convenience , which establishes new human‐machine relations, re‐distributes responsibility and reconfigures illness work changing the position of the patient in relation to their illness. I critically examine this emerging regime through an empirical study of the Quell, a neuromodulation wearable marketed for chronic pain relief in the United States. By analysing user diaries, in‐depth interviews and company documents, I investigate the interface of people's lived experience and smart technology. Specifically, I ask: As automated functions are introduced, how is work re‐distributed between user and device? Which activities are necessary to calibrate and maintain these relations? How does this change the way people relate to their illness and care? And how does this reconfigure the role and responsibility of users? My analysis reveals that, rather than fully relinquishing control to automation, users remain engaged in a process of human‐machine interfacing (Lipp and Dickel  2023 ). Despite its marketed promise, ‘wear it and forget it’, managing pain with Quell requires maintaining contact between device and the skin, tuning the stimulation intensity and developing an awareness for pain triggers. However, rather than being only a user‐driven process, the device actively participates in these processes in manifold ways. While this potentially disburdens the user from self‐managing some aspects of their illness, it also binds them to this technology in new ways. This approach adds a new lens to existing scholarship on digital health emphasising the ongoing relational labour required to sustain human‐machine interaction. Ultimately, I argue that the proliferation of chronic interfacing portends a shift in digital health politics, from a neoliberal model of self‐care towards a regime of digital health convenience. Rather than freeing users up completely, this shift restructures self‐care, requiring people living with chronic illness to become supervisors of their care with digital devices. To examine these dynamics, I first situate smart pain technologies within existing sociological debates on chronic illness, digital health and automation. Second, I introduce the analytical lens of human‐machine interfacing, which allows me to capture the relational labour involved in making automation work. Third, I outline my methodological approach, based on interviews, online diaries and company documentation. The core of the paper presents an analysis of four interfacing practices—maintaining, tuning, deciphering and tracking—through which users become dis‐ and re‐engaged. These practices not only shape how pain is managed but reconfigure the nature and target of pain care. I conclude by discussing how these findings invite a rethinking of sociological critiques of digital health under the conditions of digital health convenience.

Sociological scholarship has long studied the way users cope with and work through chronic illness (Corbin and Strauss  1985 ). Research in this vein emphasises the active role patients take in managing their conditions, including navigating healthcare systems, adhering to treatment regimens and negotiating their identities in the face of chronic illness (Jackson  2000 ; Jowsey et al.  2016 ). This is complicated by the fact that chronic illness often develops in unpredictable ways (Charmaz  1997 ). In the absence of a cure, people find creative and experimental ways to live with disruptive illnesses (Bury  1982 ; Wahlberg and et al.  2021 ). This is especially true for chronic pain (Denny  2009 ) a condition notoriously difficult to diagnose (Baszanger  1992 ) and treat (Grol‐Prokopczyk  2025 ). Chronic pain and its experience is often contested (Barker  2009 ), disregarded by health professionals (Johannessen  2019 ) and stigmatised (Jackson  2005 ), which, in turn, can cause more suffering (Brown et al.  2018 ; Manderson and Warren  2016 ). Although technology has long played a role in the management of chronic pain (Baszanger  1998 ; Corbin and Strauss  1985 , 224–225), more recently, it has become a target for digital health technology. There is an increasing repertoire of apps and devices that promise to provide data‐driven guidance, education and personalised treatment to users, some of whom have become the object of sociological research. For example, scholars have investigated tracking apps (Christiansen et al.  2024 ), VR headsets (Charette  2024a ) and neuro‐modulatory devices (Dalibert  2016 ). Although these technologies are positioned as a way to help manage, and thus better live with pain anywhere at any time, in practice these promises turn out to be far more ambivalent (Charette  2024b ). On the one hand, digital technologies can help make time to manage disease in the context of other temporal demands (Christiansen et al.  2024 ). On the other hand, this can become an additional burden as pain and other symptoms of chronic illness get in the way of using the very technologies promoted to help them (Charette  2024a ). In this context, technologies that automate these interventions are an interesting case, because they seem to tackle exactly that problem: to relieve users from the chores of at least some aspects of chronic living. However, social studies of healthcare automation have shown that this promise, too, is to be treated with caution. For example, Dalibert's ( 2016 ) analysis of spinal cord stimulation for chronic pain shows how the use of these implanted devices involves practices of embodiment and incorporation that go beyond simply their use. Oudshoorn ( 2020 ) illustrates how users of closed‐loop defibrillators and pacemakers far from being completely disengaged develop a sense for anticipating irregular shocks by the device. Finally, Jansky ( 2024 ) shows for the case of closed‐loop insulin pumps that DIY communities rather than simply delegating illness work to devices have to invest considerable work and expertise into building and improving these systems. How do we account for this constitutive ambivalence between the increasing delegation of (aspects of) chronic care to technology and the concomitant intensification of relational labour by users that enables that very delegation? In other words, how to think the simultaneous dis‐ and re‐engagement of users in technologically mediated care? To resolve this issue, I propose to make use of recent discussions around a sociology of interfacing (Lipp et al.  2025 ; Black  2014 ; Shah  2019 ; Suchman  2007 ). An interface is commonly understood as a piece of hardware or software, for example, a graphical user interface, a sensor or screen. However, they are more than that. An interface denotes a specific situation where interaction with technology takes place (Suchman  2007 ). Users have to work through interfaces to achieve certain goals, and in doing so become attuned to the standards, formats and affordances inscribed into them (Schüll  2016 ). Hence, an interface is less a thing than a specific relation that governs how human and machine can interact (Hookway  2014 ). They are thus not neutral intermediaries but active mediators of human–technology interactions (Latour  1994 ). Yet, whereas this can be said about almost any technology, the ubiquity of interfaces is a relatively recent phenomenon tied to the proliferation of ‘informatics’ as a way of ordering human life through information systems and devices (Haraway  1990 ). Here, interfaces do something very specific and paradoxical: they interconnect by way of separation (Lipp and Dickel  2023 ). They provide access to computationally mediated worlds while at the same time ‘hiding its mechanisms and materialities’ (Shah  2019 , 257). In turn, they grant computation access to the human and its materiality by flattening it to signals at the surface (Krasmann  2020 ). Importantly, these are processes that cannot be ascribed either to interface design or to the activities of use alone (Helm and Matzner  2024 ). Rather, it is better thought of as the co‐evolving interplay of different processes of human‐machine interfacing (Lipp and Dickel 2023 ) that involve devices and their designers, the idiosyncrasies of human bodies, as well as the social milieu in which they are embedded. The product of such processes is thus not a situation of either discipline or openness but rather the ongoing formation of situated ‘corridors of interaction’ (Lipp  2023 , 677) sustained by activities from users, devices and designers.