The feasibility of M-health for people with chronic low back pain in Shanghai, China: A qualitative study

Introduction

Low back pain (LBP) is a common musculoskeletal disorder worldwide, affecting people in all age groups.¹ LBP has been reported to be the leading cause of disability.² The medical expenses, compensation and lost productivity associated with LBP has imposed a considerable burden on the medical and social systems.^1,3 It has been reported that around 34% of people with LBP suffered from LBP for more than 3 months and then was diagnosed to have chronic low back pain (CLBP).^4,5 CLBP is the second leading cause of disability in China and the management of CLBP is a challenging issue given the size of its population.⁶

Health education and exercise have proven to be effective interventions for CLBP and are recommended as the first-line care for CLBP in clinical guidelines.⁷ However, their clinical application may be limited by the traditional face-to-face physiotherapy model due to time consuming, high cost and lack of tailored exercise programs.⁸ In China, the clinical application of health education and exercise is even limited due to the uneven distribution of professional rehabilitation resources.^9,10 For example, most physiotherapists in China are working in East China and South China leading to very limited access to professional physiotherapy for people living in the less-developed areas.¹¹ A more efficient management method is therefore needed to maximise the benefit of health education and exercise for people with CLBP in China.^12,13

Mobile health (M-health) is a new management method which delivers health care by using applications on electronic devices.^14,15,16 This new healthcare method has been shown to be clinically significant as it could address the inadequacy of health care resources and decrease the cost of healthcare for the community.^15,17 Existing evidence has demonstrated that M-health is effective in improving chronic pain.^18,19,20 A recent systematic review investigating the efficacy of M-health in people with LBP reported that compared with usual care alone, the combination of M-health and usual care was superior in reducing pain intensity and disability in people with LBP.²¹

However, the delivery of health care is complex and the acceptance of any new intervention will be influenced by multiple factors, such as cultural values and social frameworks.²² The application of new intervention could be challenging in regions with large number of populations, uneven distribution of medical resources and various needs of residents.^23,24 Although M-health has been shown to have many promising effects for the management of LBP,^21,25,26 little is known about whether M-health is feasible for the management of CLBP in China. It is reported that, as of August 2023, the online population in China has reached 1.079 billion with an internet penetration rate of 76.4%, providing a strong foundation for the application of M-health in the management of CLBP.²⁷ Investigation of the feasibility of M-health for people with CLBP in China may provide evidence for effective management of CLBP.

Therefore, the purpose of this study was to investigate the feasibility of M-health for people with CLBP in Shanghai, China and associated influencing factors. The research questions were:

Methods

Research design

This qualitative study used focus group and semi-structured interviews to explore the feasibility of M-health through the lens of people with CLBP and physiotherapists. A post-positivist research paradigm was used to construct a social theory for the feasibility of applying M-health to people with CLBP in Shanghai. This study was approved by the Medical Ethics Committee of Shanghai Yangzhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center) (Approval number: 2022/023) and reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ).²⁸

Participants

Participants were recruited at Shanghai Yangzhi Rehabilitation Hospital using purposive sampling method, including oral invitation, advertisement posters and WeChat tweets, from November 2022 to March 2023. This study aimed to recruit 30 participants with LBP and 20 physiotherapists. The sample size would be estimated to be sufficient if no new themes emerged according to the principle of theoretical saturation.

To be eligible for this study, people with CLBP should be 18 years of age or older, have suffered from non-specific LBP for more than 3 months, use a smartphone, have normal cognitive function and be able to understand the questions asked during the interview. People with LBP were excluded from this study if they were suspected of having serious pathologies including cancer, fracture and infection, or were diagnosed to have cognitive dysfunction. Physiotherapists were eligible if they were doing clinical practice and had experience in treating LBP.

Data collection

All subjects signed informed consent forms before data collection. Focus group and individual interviews were employed in this study. All interviews were conducted jointly by two trained researchers in a meeting room at Shanghai Yangzhi Rehabilitation Hospital. The researchers are physiotherapists with extensive experience in clinical management of LBP but they were not directly involved in the treatment of the participants with CLBP. Before the interview, demographic information of participants, including age, gender, pain level, length of LBP, and index of dysfunction were collected. The pain level was assessed using numerical pain rating scale (NPRS) and the disability was measured with the Oswestry Disability Index (ODI).

Semi-structured questions (see Appendix A) were utilised in interviews to allow for more flexibility in the exploration of participants’ experiences and perspectives relating to M-health. Open-ended questions and probing questions were combined to create an interview guide that would target the barriers and facilitators to the acceptance of M-health.

At the beginning of the interview, the aims of this study and topics of LBP were introduced. Participants with CLBP were encouraged to share their experience of LBP freely. The M-health was then introduced via an edited video which showcased the functions of the M-health, including the training regimes and individualised exercise videos for people with chronic pain, and the teleconferencing between patients and healthcare professionals. Finally, questions were asked about their willingness to accept M-health, the strengths and weaknesses of M-health, as well as the barriers to its implementation. A total of 31 interviews, consisting of 5 group interviews and 26 individual interviews. Among these, 27 face-to-face interviews and 4Tencent meetings were conducted by both researchers. The interviews were recorded, transcribed verbatim, and de-identified for analysis.

Data analysis

Data collection and analysis were performed simultaneously. The collected data was sorted using thematic analysis method, which allows for identification, examination and reporting of key patterns or themes of participants’ perspectives. The raw data was sifted through by both researchers before further analysis. Initial codes about each category were descriptive and then themes and sub-themes emerged through a process of ongoing analysis, discussion, and iterative refinement. Themes were identified utilising a six-stage strategy and common threads were extracted from coded data entries. The themes were recorded with vivid quotes to illustrate their meaning. Two researchers (W.X. and G.H.) analysed the data independently. Cross-coding was regularly performed to ensure the consistency of theme identification. Any disagreements would be discussed and consulted with other authors to reach consensuses. The data was processed using NVivo software (QSR International, version 11). The demographic characteristics of participants were described in the form of $\mathrm{\text{mean}}\pm \mathrm{\text{standard}}$ deviation. Additionally, the number of subjects who expressed acceptance, resistance, or neutrality towards the utilisation of M-health was recorded and presented as percentages.

Results

This study recruited 25 patients with CLBP and 20 physiotherapists. The characteristics of the participants were summarised in Tables 1 and 2. The CLBP group has balanced gender distribution (M/F: 12/13) with an average age of $38.1\pm 11.8$ years. The duration of the LBP, pain level and disability were $56.2\pm 57.9$ months, $4.2\pm 1.0$ and $22.1\pm 9.9$, respectively. The age of physiotherapist group (M/F: 14/6) was $29.9\pm 4.1$ years and their clinical experience in managing LBP was $6.0\pm 4.8$ years.

In the CLBP group, 72% of participants accepted the treatment delivered via M-health, 4% did not accept M-health, and the remaining 24% found it acceptable under specific situations. In the physiotherapist group, 90% of participants considered M-health acceptable under specific situations, while the remaining 10% did not accept M-health. Descriptive characteristics are reported in Fig. 1.

Three overarching themes were identified from the data using methodical thematic analysis: (1) Reasons for embracing M-health; (2) Reasons for resisting M-health; (3) Recommendations to enhance the feasibility of M-health (Table 3).

Reasons for embracing M-health

This theme summarises the perceived benefits of using M-health in the management of LBP from both groups. The subthemes are related to specific reasons that make M-health acceptable to most of the participants.

It is convenient and time-saving

Many participants expressed that the most obvious advantage of M-health was its convenience as it enables the healthcare providers to perform assessment, consultation and follow-up via cellphone applications. This approach greatly reduces the time patients with LBP spend on travelling and waiting in the hospital. Patients with LBP also noted that using M-health to manage LBP could minimise the need to reschedule their daily work.

Many participants with LBP and physiotherapists considered the M-health very convenient for storing patient’s medical information including past medical history, drug use, health examination reports and other relevant medical records.

M-health can improve intervention compliance

Many participants thought the M-health was superior in improving patient’s compliance compared to conventional health education approach. This is because the M-health applications could provide exercise videos with detailed instructions which are helpful to patients to exercise properly. Furthermore, the exercise videos can be paused and played repeatedly at any time, which is convenient for patients to keep reviewing the exercise and consolidate their knowledge about the exercise.

Physiotherapists thought the M-health can facilitate the monitoring of the progress of patient’s treatment.

M-health enhances access to rehabilitation resources for patients in need

Some participants with LBP and physiotherapists expressed that M-health could provide more practical options for patients who are living in remote areas or the areas where professional physiotherapy is not available. Usually, patients need to go to hospitals or clinics for face-to-face examination and treatment, which may cause inconvenience to those patients who live in remote areas. With M-health technology, people in different geographical locations can easily access medical services.

Reasons for resisting M-health

This theme describes the reasons why some patients with LBP and physiotherapists did not like or accept M-health approach in the management of LBP.

Comprehensive assessment and treatment limited via M-health

Both participants with LBP and physiotherapists expressed their concerns about the limited functions of M-health approach. They pointed out that the assessment via M-health did not involve important physical examinations, such as palpation, sensation testing and auscultation. Also, healthcare providers could only provide health education and exercise advice via M-health which will limit the treatment effect if passive interventions like manual therapy and ultrasound are indicated. The functional shortcomings of M-health in assessment and treatment made some participants with LBP and physiotherapists reluctant to use M-health approach.

Some participants were also concerned about the lack of real-time feedback of M-health. They thought that, compared to face-to-face treatment, M-health approach does not allow physiotherapists to provide timely and accurate feedback to patient. This will definitely increase the concerns of both patients and physiotherapists about the quality of the exercise.

Laws and regulations of M-health are lacking

Many patients with LBP and physiotherapists expressed their concerns about the lack of relevant laws and regulations of M-health in China which may lead to harms to the rights and interests of both parties. For example, the potential risks include but are not limited to the injury during exercise, information leakage, misdiagnosis due to lack of adequate assessment and testing.

Many participants also mentioned that the M-health is not covered by medical insurance in China which may hinder its clinical application. It will increase the financial burden of patients if M-health is not covered by other commercial insurances.

Physiotherapist-patient estrangement

Some participants considered that M-health may lead to patient’s feeling of a lack of attention and care from their physiotherapists and thus resulted in an estrangement between physiotherapists and patients. Participants explained that the communication and interaction between patients and physiotherapists are limited when the treatment is delivered via M-health, and therefore it is difficult to build a good physiotherapist–patient relationship as to the face-to-face treatment.

M-health approach may also cause inconvenience in certain scenarios

Some physiotherapists thought that M-health may also be time consuming if patients keep raising questions about the use of applications, especially for elderly who are not good at exploring new technologies.

There were also participants who considered the exercise should be performed in places with appropriate equipment. Some participants did not accept the M-health because there were no such places in their living environment.

Recommendations to enhance the feasibility of M-health

This theme summarises suggestions from both participants with LBP and physiotherapists on how to increase the feasibility of M-health. The subthemes include selecting appropriate patients, integrating M-health with face-to-face treatment, enhancing the functions of M-health application and increasing the operability of application.

Selecting appropriate patients

Some physiotherapists suggested that it is important to develop criteria to select appropriate patients with LBP to maximise the effects of M-health.

Integrating M-health with face-to-face treatment

Both participants with LBP and physiotherapists suggested that integrating M-health into the management of LBP could maximise the effectiveness of the intervention. During the face-to-face treatment, physiotherapists can conduct comprehensive assessment, diagnosis and provide individualised treatment while the M-health can be used as a supplement to provide continuous guidance on exercises.

Enhancing the functions of M-health application

Many patients expected the M-health application could provide instant feedback on their performance to improve the quality of exercise.

Participants also suggested that the M-health application may set a patient communication module where patients can interact with each other to enable peer support which can increase patients’ motivation and compliance to the treatment.

Many patients with LBP and physiotherapists suggested that the M-health application should provide more information about LBP which could include knowledge about the causes and potential mechanisms of LBP, skills and tips to do exercise under various circumstances, or advise on the prevention of recurrence and chronicity of LBP.

Enhancing the operability of M-health application

Participants suggested that the operation page of M-health application should be concise, clear and easy to use, so that users can quickly find the functions and information.

Discussion

This study aimed to examine the feasibility of M-health in the management of LBP in Shanghai, China and to explore its advantages and disadvantages from the perspectives of people with CLBP and physiotherapists. The findings revealed that M-health is highly acceptable to both patients with CLBP and physiotherapists as it possesses multiple advantages, such as convenience and efficiency. The M-health was also found to be limited in clinical application for shortcomings in clinical assessment, insurance support, instant feedback, etc. Suggestions for improving the feasibility of M-health in the management of CLBP were also offered by the participants.

M-health seems to be feasible in Shanghai, China as both the patients with CLBP and physiotherapists showed high level of acceptance of this approach. The main reason for the high level of acceptance among people with CLBP and physiotherapists is its convenience which has been demonstrated in previous studies among various populations.^29,30 The M-health was also accepted for its advantage in improving patient’s compliance to the prescribed treatment plan as expressed by participants in this study. This is in line with findings in previous studies in which the functions of M-health such as detailed instructions of exercise, live demonstration and timed reminder were considered to be effective in improving patient’s adherence and empower patients to take an active role in their self-management.^31,32,33 Furthermore, M-health is found to be a critical way to improving access of professional rehabilitation service to people in remote or less developed areas where professional physiotherapists are lacking.^34,35

Establishing M-health laws and support from medical insurance may be the key measures to promote the clinical application of M-health in China. It has been reported that the lack of applicable policies, laws and regulations for potential risks associated with M-health were the main challenges to its clinical application.³⁶ For example, patients with CLBP may worry about the security of their privacy,³⁷ while health practitioners may concern about the risk of being identified as conducting illegal practice, as well as the potential risk of misdiagnosis and mistreatment due to limited assessments.^38,39 In addition, lack of coverage by health insurance was considered another important barrier to the clinical application of M-health.⁴⁰ Currently, the medical insurance in China does not cover the physiotherapy delivered via M-health. If the treatment via M-health could be covered by medical insurance, patient’s willingness to use this service will be increased.⁴¹

Rational integration of M-health and traditional face-to-face model may be an important strategy to improve the feasibility of M-health in China. Although patients agreed that health care delivered via M-health is convenient, they always thought that face-to-face treatment were more favourable and reliable.^42,43 On one hand, integration of two methods could address patient’s concerns about the accuracy of the physical diagnosis and the appropriateness of the treatment plan. On the other hand, development of a stratified management strategy for patients with CLBP may enhance the clinical feasibility of M-health. This means to apply the M-health in the treatment for appropriately selected patients. For example, using valid and stratified care approaches, such as the STarT Back Tool, could match patients to treatments based on prognosis or risk of poor clinical outcome. If patients with CLBP were classified to have high risk of poor outcome, the combination of M-health and face-to-face treatment should be adopted, while for the patients with low risk, they may be just managed with M-health. It has been shown that risk-based stratified care could maximise the treatment benefit and reduce the potential harm, unnecessary interventions and cost.⁴⁴

Offering valuable functions to meet the users’ demands may increase the acceptance of M-health for both patients and physiotherapists. As aforementioned, patients with CLBP were in great need of instant feedback on their exercise performance and individualised health education information. Patients also expressed the need to interact with their physiotherapists or other patients. If the M-health applications could provide such an interaction channel, timed follow-up of patient’s progress and peer support will be enabled to improve the effects of M-health.⁴⁵ Additionally, an increase in the ease of use and user-friendliness of M-health is important as this plays a significant role in determining the acceptability of M-health.^46,47,48

This study investigated the perspectives of M-health from both patients with CLBP and physiotherapists and the findings of this triangulation approach could provide more comprehensive insights into the feasibility of M-health in the management of CLBP in Shanghai, China. However, there are also some weaknesses in this study that may limit the strength of the findings. For example, participants were recruited from outpatient clinics at Shanghai, the perspectives reported here may not represent that of people in remote areas or less developed areas in China. The participants in this study had different levels of experience in using M-health which limits their perspectives on M-health. In addition, this study excluded patients with serious pathologies and acute/subacute LBP which may lead to significant influence on their perspectives on the acceptance of M-health. Further study that involves participants from more regions and participants with various stages of LBP is recommended to provide more insights regarding the feasibility of M-health for people with LBP in China.

Conclusions

This study found that M-health may be acceptable for both people with CLBP and physiotherapists in Shanghai, China as this approach has multiple advantages. Efforts to promote the establishment of M-health policy or laws, rationally integrate M-health with face-to-face treatment and improve the functions of M-health applications may increase its feasibility in China.

Conflict of Interest

The author(s) have no conflicts of interest relevant to this paper.

Funding/Support

This study has received the funding from the Shanghai Municipal Health Commission’s Health Sector Research Program under Grant No. 202240206. Jianhua Lin was supported by the “Outstanding Talent Program” from Shanghai Yangzhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center).

Author Contributions

Conceptualisation and methodology: W.X., J.L., L.L.; Data collection and analysis: W.X., X.L., Y.W., G.H.; Draft preparation: W.X., Review and editing: J.L., A.F., Supervision: J.L. G.H.

ORCID

Waner Xie  https://orcid.org/0009-0006-2265-9422

Guojiong Hu  https://orcid.org/0009-0003-6920-0967

Yijin Wang  https://orcid.org/0009-0007-9259-7551

Xiaoquan Luo  https://orcid.org/0000-0002-4908-8045

Linrong Liao  https://orcid.org/0000-0002-7661-870X

Allan C. L. Fu  https://orcid.org/0000-0002-9894-2367

Jianhua Lin  https://orcid.org/0000-0002-6842-9466