Evaluating musculoskeletal digital health apps

A woman massages her sore back

About the author: Dr. Liz Kwo is currently the staff VP of clinical data analytics at Anthem and a faculty lecturer at Harvard Medical School who previously cofounded and served as CEO of telemedicine second opinion company InfiniteMD. She received an MD from Harvard Medical School, an MBA from Harvard Business School and an MPH from the Harvard T.H. Chan School of Public Health.
Digital health has been highly adopted in recent years by both healthcare providers and consumers. This increased use has led to development of multiple digital apps dedicated to health purposes. Among the affections tracked and treated by these apps, musculoskeletal-focused digital apps (MDAs) started to be frequently used for physical therapy and rehabilitation, pain management, and behavioral health.
Before choosing the type of MDAs to use, it’s crucial for clinicians to properly assess the evidence base of these apps and to be correctly informed in regards to existing payer reimbursement models.

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Digital health numbers
Digital health has been on an ascending trend for years now and COVID-19 outbreak has accelerated its adoption even more. At the beginning of 2019, the number of smartphone digital health applications available in various app stores used by consumers for health management purposes doubled compared to 2015, reaching a total of 318,000.
In 2018, 90% of physicians used smartphone applications for securely handling EHRs, communicating between staff and accessing clinical content. As of 2018, more than 75% of the biggest health systems provided mobile applications focused on patient engagement.
Moreover, we expect to see a growth of global mobile health of up to $111 billion by 2025, with the COVID-19 pandemic accelerating the adoption of mobile health tools. This expectation is highly supported by the increase of telehealth use, which was 46% in May 2020, compared to only 11% in May 2019.
Start-ups that are changing pain management in mobile health world
Many startups engaged in health app development have quickly realized that pain management is a segment where investments would pay off. One in three to one in five people (including children) are affected worldwide by musculoskeletal (MSK) pain conditions.
Many of the people affected by chronic pain conditions cannot see their doctor on a regular basis, either because of limited mobility reasons or access. Startups in mobile health have set an objective to alleviate some of the pain experienced by these patients and to facilitate the communication between them and their caregivers in real time with the help of the latest digital technologies. Several startups provide patients affected by chronic pain with an assistant for therapy and neuro-stimulating devices.
Examples of MDAs
The number of existing mobile health apps for MSK conditions and injury management has increased at a rapid pace, because more organizational health and wellness initiatives are focusing on pain management and holistic care. The general purpose of these different MSK apps is to provide therapy for patients with MSK issues. 
They can be used by large companies to improve their employees’ health, to prevent injuries and to make recovery more effective, while keeping track of users’ progress. MSK injuries represent 28% of all work injuries, so many apps focus on reducing injuries occurred in muscles, ligaments nerves, joints and tendons in order to improve the health and productivity of employees.
Some MDAs are equipped with physical or mental exercise programs, behavioral interventions such as mindfulness practice, and learning modules to teach consumers how to preserve their state of health and avoid further problems.
Apps currently on the market use several approaches to decrease pain, including making the connection between the mind and the body more powerful in order to alleviate pain; customizing face-to-face treatment programs; and providing treatment with the use of sensors that can be placed on affected areas of the body to monitor the pain and the progress of the applied therapy. There are also applications that feature hardware such as ECG and heart rate sensors that track movement in order to register the progress made by consumers.
Many digital health apps rely on evidence-based exercise-therapy and provide their users with customized guidance and exercise based on the movement, activity and progress made by these users. Other digital health solutions aim to prevent escalation of MSK conditions and focus on preserving MSK health by facilitating the access of users to a wide library of prevention exercises such as yoga, Pilates and stretching.
For example, one app acts as a virtual physiotherapist and enables users to conduct, from home, self-assessment and self-management of common MSK conditions.
Current impact of MSK conditions and injuries
The incidence and prevalence of MSK conditions continue to grow due to:
Increased aging population.
Unaddressed ergonomic problems of daily living, such as excessive sitting.
Although they are frequently encountered, MSK disorders are often wrongly addressed and expensive. MSK injuries cost employers a lot of money, as they are causing more spending and more workdays lost than any other chronic condition. I
n the U.S. alone, this translates into more than 260 million workdays lost every year, which can seriously affect insurance costs. In 2012, one in two adults has been diagnosed with a MSK condition and yet 80% of patients are not provided with evidence-based care.
In many cases, MSK conditions are treated with opioid analgesics and avoidable surgery instead of physical therapy and recovery. Due to this, direct medical costs for imaging, diagnosing and treating MSK disorders are $20 billion per year and continue to grow.
Need for critical assessment of digital apps
The rising adoption of digital health apps requires trained providers to recommend and use MDAs appropriately, whilst avoiding dangers and downsides. There is an ever-growing pool of apps that promise to address MSK conditions.
That is why it’s vital for clinicians to asses correctly the clinical effectiveness, the functionality and the reliability of digital health apps if considering an app for clinical use or recommending an app to their patients.
In this process, clinicians are guided by types of study designs used to generate evidence of effectiveness. The clinical evidence with the highest quality is often provided by large, well-structured observational studies such as cross-sectional, observational and case-control studies.
These studies offer proof of clinical effectiveness under real-world conditions, in contrast with randomized trials. Although considered the gold standard in evidence of effectiveness, randomized trials present some limitations such as inclusion and exclusion criteria.
Next in line in terms of clinical effectiveness evidence are the descriptive studies (surveys, surveillance, case reports). The Cochrane Collaboration’s GRADE approach is a system frequently used to assess the quality of evidence resulting from medical studies.
Currently, 40% of all mobile applications are dedicated to healthcare, which makes the checking and validation of their accuracy for clinical purposes highly important and difficult. Hence, it’s important to review the evidence with which apps support their claims of efficiency.
Assessment of MSK digital apps
In 2011, Rosser and Eccleston identified 111 apps (mostly with Apple’s iOS operating system) which featured options involving training of education skills (56 apps), self-tracking of pain episodes (26 apps) and relaxation techniques (24 apps). Ninety-five of the 111 apps studied did not include any involvement from a healthcare professional in their evaluation of content or design configuration. Most important, none of these apps addressed postoperative pain.
As time passed, a new type of MDAs emerged – one that allows tracking of post-operative pains and contributes to the improvement of self-care of post-operative pain by providing real-time monitoring and symptom management. Several apps have been recently approved by the FDA with an iOS-compatible application enabling patients affected by chronic pain and neurologic disorders to receive customized therapy on mobile devices.
Patients can perform the programs prescribed by their caregivers at their most convenient moment. In addition, Bluetooth technology is built in to these apps to allow for instantaneous communication between the app and an implanted pain management stimulator.
Although many types of MDAs offer users distraction and relaxation tools in order to divert their attention from pain, the evidence shows (as detailed above) that some tools do not provide any type of social support or do not have at least one specialized care provider involved in the process, in case patient pain escalates. All these studies show how important is to develop customized, AI-driven, evidence-based solutions for self-management of pain.
The critical assessment of MDAs should necessarily include evaluation of key elements such as usability, technical content, health content, security and transparency, as follows:
Usability features functionality includes visualization, facility of installation and use, multi-language support and options for customizing.
Technical content refers to performance, portability stability, interoperability capacity, bandwidth and size of application.
Health content features such as quality, literacy level, measuring and interpreting information.
Security/privacy includes data authentication, token options, signalization of data breach.
Transparency functions, including member consent, cost of the applications and precision of the description available in the app stores.
Employer and payer reimbursement
Prior to COVID-19 pandemic, Decision Resources Group indicated that 25% of executives from integrated health networks, from companies with Medicaid care and pharmacy benefits managers, stated their companies were already providing coverage for digital therapies, whilst 45% of them said their companies were interested in providing this type of coverage.
The COVID-19 pandemic triggered an accelerated adoption of digital health (including telehealth), with government and payers changing provisions and reimbursements to incentivize telehealth use in responses to the public health emergency. This encourages more patients and caregivers to connect using digital health, prompting employers and payers to find and implement innovative methods for reimbursing telehealth services provided via digital health applications.
As U.S. healthcare continues to adopt more virtual care models and opportunities, we could see additional coverage or reimbursement for certain apps.
Conclusion
Consumer-focused healthcare is already a reality, with the digital health environment adjusting fast to meet the requirements of this new reality. Medical applications that have proved their efficiency and have been approved by the FDA are already reimbursed by payers.
Yet, the clinical efficiency and the functionality of MDAs are very different, which means that care providers need to properly assess evidence effectiveness before choosing the MDAs they will use. A proper understanding of MDAs environment would enable care providers to use digital health tools to offer high-quality care to individual patients and to prevent or alleviate complications from MSK injuries and issues.

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