The Role of Mobile Health Technology in Perioperative Spinal Care: A Systematic Scoping Review and Narrative Synthesis

Smartphone applications play a crucial role in contemporary healthcare by aiming to enhance patient care through technology. Mobile health (mHealth) applications have proven to have transformative potential in enhancing patients' outcomes in candidates undergoing orthopedic and spinal surgery. In the context of the pervasive use of smartphones and the exponential growth of mHealth apps, totaling over 99,000 in 2021, the applications had a significant impact on lifestyle management, supporting initiatives like smoking cessation with motivational reminders and progress tracking. Patient compliance is significantly enhanced, reducing surgery cancellations and improving outcomes through effective adherence to pre-operative treatments and instructions. Physiotherapy receives a substantial boost as mHealth facilitates video-guided exercises, potentially improving compliance and treatment outcomes. Data collection takes on innovative dimensions, with mHealth apps capturing post-operative metrics like physical activity, offering valuable insights into patient recovery trends. Remote care is streamlined through features like photo uploads and direct messaging, proving especially beneficial in times of crises such as the COVID-19 pandemic. Despite these merits, challenges emerge, including issues related to technological literacy, potential discrimination due to paywalls, and concerns about patient data confidentiality. Overcoming these challenges requires standardized approaches, legislative measures, and ongoing research to refine and optimize mHealth applications for diverse healthcare settings.


Introduction And Background
Smartphones have become an omnipresent tool in the majority of people's lives since their inception in the early 21st century.With an exponential rate of growth in the past decade, and there being over 99,000 mobile health (mHealth) applications as of 2021 [1], it is only rational that there be an assessment and understanding of the medical, legal, and social implications of their use in healthcare [2].These applications exist to facilitate many aspects of medical practice including health record maintenance and access, communication and consulting, reference and information gathering, patient management and monitoring, as well as clinical decision-making, medical education and training.This positively impacts patients' outcomes, but also improves healthcare services efficiency and reduces their costs over an extended period of time [3][4][5][6][7][8][9][10][11].The role of mHealth apps also extends into the entirety of the perioperative landscape, including the process before, during, and after surgery [12].These applications also help enhance the quality of perioperative outcomes such as pain, wound healing, and recovery, tackling factors that lead to increased delays [13,14], morbidity, and mortality in surgery [15,16].There are a multitude of spine conditions including spinal fractures, scoliosis, and degenerative cervical myelopathy that require extended postoperative follow-up which can be facilitated by mHealth [17,18].This review aims to highlight the benefits and the potential limitations of mobile health applications, based on the current literature, in managing patients undergoing orthopedic and spinal surgery.

Search Strategy
We systematically searched the databases PubMed, EMBASE, and Web of Science under PRISMA guidelines looking for observational studies that assess the role of mHealth applications on perioperative spine patients.The search terms used included: "mobile" and "mHealth" and "Spine" and "Phone" and "App" and "Application" and "Tele" and "Telephone".The review period was restricted from January 1, 1930, to June 30, 2023.

Eligibility criteria and study selection Inclusion Criteria
Inclusion criteria were all levels of scientific evidence, any treatment option, human studies, both genders and any age group.

Exclusion Criteria
The following criteria were used for exclusion: articles of unrelated diagnosis, articles available in abstract form only and non-English articles.

Data extraction
Each abstract was screened for possible inclusion by two reviewers (JH, AN) independently.If a consensus was not reached, a third author (MR) was consulted.Two authors (AF, AN) performed data extraction.

Primary Outcomes
Studies were required to have used mHealth applications and record outcomes in their respective observational cohorts.Ideally, studies used a validated metric through the use of PROMs (patientreported outcome measures).

Secondary Outcomes
We also extracted data on the reported limitations of the available studies, focusing on elements that may make results challenging to repeat.

Intervention
The use of mHealth applications in any form on the outcomes of spine patients perioperatively.

Comparator/control
No comparison or control group was required for inclusion in this review.

Results
The literature search identified 642 studies and after a thorough screening of the retrieved articles, a total of seven studies met the eligibility criteria (Figure 1).

FIGURE 1: Screening and extraction process of the review
Numerous studies probing the role of mHealth in perioperative spine patients unveil valuable insights (Table 1).Ponder et al. revealed the beneficial impact of mHealth on pre-and post-operative patient adherence, leading to a reduction in last-minute surgery cancellations due to a decreased likelihood of misunderstanding instructions on patients undergoing spine surgery [19].

Advantages of mHealth
Mobile health (mHealth) has proven to be highly beneficial through various approaches in enhancing the health status of patients and improving clinical outcomes, as listed in Figure 2 below.The multifaceted advantages offered by mHealth highlight its transformative impact on healthcare delivery.Below are detailed insights into the diverse modalities by which mHealth contributes to positive healthcare outcomes:

FIGURE 2: Summary list of pros and cons of implementing mHealth applications
This figure is the original work of the authors

Lifestyle management
Improving patient lifestyle is imperative in improving health outcomes.One example is via smoking cessation support, with reminders being sent to patients to support motivation, in addition to a platform for tracking their progress in quitting [26][27].Patients smoking prior to surgery could lead to being unfit for surgery, causing delays and possible excess burden on the healthcare system.Additionally, smoking has been associated with a significant reduction in wound healing which could delay progress and worsen patients' outcomes.Spinal surgery patients may particularly benefit from this, with specific conditions like scoliosis being managed by sending reminders for posture improvement as part of management.Interventions using SMS messages have also been used to influence BMI, associated with osteoarthritis and the need for surgery, which, if reduced, will again reduce the burden on both patients and the healthcare system [27].

Compliance
Adherence to pre-operative medical regimen and instructions could dictate whether a surgery can proceed.
A study investigating the effect of mHealth apps on adherence to treatment and instructions involved a cohort of 85 individuals using a mobile application and 89 individuals not using an application, investigating their adherence to medication.All application users were found to be compliant, with five recipients from the control group lost to follow-up.Non-adherence led to the cancellation of surgery, and hence worsening of outcomes for patients, as well as increased cost on the healthcare system [28].Larger scale trials are required to further investigate this effect.Orthopedic patients commonly receive extensive analgesic regimens post-operatively, with some struggling to comprehend the instructions of use effectively [29].mHealth applications have facilitated the provision of an easy-to-access platform to provide them with reminders such as detailing when to take vitamin D and bisphosphonates.Patient satisfaction has been increasing with the evolution of mobile health applications where spinal surgery recipients provided a 96% approval rate when rating the benefits of a mobile health application during the course of their treatment [19], with another application receiving an approval from 40 out of 49 patients [20].

Physiotherapy
Physiotherapy is a vital stage of recovery in patients undergoing spinal and orthopedic surgery.Physical therapy may last several months due to fragility fractures [30], and with most of the patients' demographic being frail, optimizing treatment is imperative.Mobile health applications have shown efficacy in improving patient compliance with physiotherapy [31].It provides a platform with detailed videos of the exercise programs, which saves the time, effort and costs of traveling to see a physiotherapist.This also improves compliance and may potentially enhance their clinical and health-related quality of life outcomes.The use of mobile health applications to treat back pain was investigated in trials and has displayed a short-term improvement at three months, when compared to conventional treatment without an application [22,32].However, further larger-scale trials with increased power are required to establish statistical significance.
Additionally, there has been evidence of short-term improvement for hip and knee osteoarthritis patients [33].Moreover, patients with spinal cord injury benefit as they undergo physiotherapy to preserve and improve their neuromuscular function [34][35].

Data collection
Mobile health applications bring an innovative approach in gauging patient recovery post-operatively.Apple's 'Health' application on iOS was studied in 2020, collecting metrics within the smartphone of 41 patients who underwent trans-foraminal lumbar interbody fusion (TLIF).The metrics included total steps and distance traveled [21,36].Patient smartphones were also used in another study conducted in 2022, to measure the 6-minute walking test (6-MWT), as well as survey patient-reported outcomes (PROMs) after degenerative lumbar disease surgery [23].Collecting metrics of physical activity has been found effective in monitoring recovery trends of patients by assessing the post-operative progress, which is displayed in terms of an increase in daily steps or distance traveled [23].Another study discussed the use of global positioning system data for an array of spinal conditions including herniated discs, spondylosis, and central canal stenosis, to monitor patients' activity, post-operatively [24].This is increasingly beneficial for patients and healthcare professionals to monitor progress and assess procedural success and room for improving management.

Remote care
Smartphone applications could implement a platform to upload progress photos of patients when required, assisting remote monitoring post-operatively [37].Regular progress pictures can assist scoliosis patients monitor their posture, which could be processed in an application to track progression over time and assess for improvement, to guide future direction of management.Applications may also implement a direct messaging system between patient and clinicians, further strengthening means of communication.These options proved significantly advantageous in the context of COVID-19 [37].The benefits may be similar to those noted with remote rehabilitation/physiotherapy: saving clinic slots for more acute cases, and reducing patient effort and costs in attending follow-up appointments.Disadvantages that arise from the use of mobile health applications include the difficulty of relying on photos for diagnosis, the loss of physical examinations when using remote care, discriminating patients who have no access to smartphones and the overall market regulation.

Obstacles in the implementation of mHealth
While mHealth applications can be advantageous, there exists a handful of disadvantages that may compromise the quality of care provided, as detailed in Figure 2. The introduction of novel products inevitably brings forth unique challenges that may impede their expansion, utilization, and overall effectiveness.In the context of healthcare services, the development and adoption of applications present various obstacles.Mobile health applications rely on technological literacy.Certain demographics may lack familiarity with the use of the technology, particularly those who may be more elderly which is the same demographic more likely to be vulnerable to spine diseases [20,32,33,37].Developing applications with a user-friendly interface could help resolve this issue, with some studies attempting to word questionnaires on the application to match sixth-grade reading levels [19].Additionally, discrimination amongst patients based on financial background and access to healthcare is an issue, because mHealth applications vary in pricing, and some patients would have no access to care.This could leave patients of lower socio-economic status lacking access [20,32,38].It is imperative to intervene and make the applications accessible to people of all ages and socio-economic statuses to ensure that there exists no discrimination against different population demographics.
Confidentiality stands as a paramount principle in the medical profession, and any compromise in patients' information integrity poses a potential threat.Such breaches can impede the adoption of mHealth applications as a standard of care [37].To address this concern, it is crucial to implement robust encryption and security measures for application data.However, the current market saturation of mHealth applications presents a dual challenge.Firstly, the sheer number of available options may confuse patients, making it difficult to discern quality products from subpar ones.Consequently, this dilutes the capability of highquality applications to stand out [24].Secondly, the absence of stringent regulations in the market heightens the risk of misinformation, potentially compromising patient safety [27,38].Furthermore, it is essential to acknowledge the limitations of mHealth applications.While they offer a valuable adjunct to healthcare delivery, they cannot fully replace the benefits derived from face-to-face physical examinations -a cornerstone of clinical assessments.Therefore, the optimal approach involves considering mHealth applications as complementary tools that enhance the capabilities of healthcare professionals rather than as complete replacements.
Costs are a big limitation to the implementation of mHealth applications.Even for relatively modest health applications, the investment required can exceed $150,000, dissuading financially constrained practices from considering their implementation [39].While the long-term benefits may be promising, these initial costs pose a formidable barrier to entry.The ongoing maintenance of healthcare applications also poses financial burdens, particularly for smaller providers.Approximately 90% of software life costs are attributed to the maintenance phase [40].Addressing this challenge could involve leveraging standardized application builders or no-code software development platforms, which could significantly reduce costs at the expense of relinquishing some control over the frontend of the platform [41,42].
Another critical concern revolves around patient privacy and ethical considerations.The collection of data, such as patient geolocation and actigraphy, often occurs without participants' full awareness.This raises issues related to informed consent, transparency, and voluntary participation, along with safeguarding data in the event of breaches [43].While this is a broader issue applicable to all applications, specific legislation focusing on health data privacy, security, and breach notification may be necessary [44,45].The integration of mobile health applications into healthcare systems faces technical and individual barriers.Challenges include the lack of existing technology infrastructure, interoperability issues, and concerns regarding userfriendliness [46].Overcoming technological illiteracy and providing adequate training for both staff and patients are additional hurdles [47,48].Notably, the elderly population may face challenges due to a lack of familiarity with mobile applications, emphasizing the need for simplified interfaces and literacy promotion [49].
While these obstacles warrant careful consideration by healthcare providers, maintaining a positive outlook on the potential utility of mHealth applications in the future is rational.Addressing these challenges through thoughtful solutions, such as standardized development platforms, legislative measures, and userfriendly interfaces, can pave the way for the effective integration of these applications into healthcare services.

Future considerations
Envisioning a multitude of forthcoming advancements, the continual development of technology and its myriad innovations stands out.In the context of mHealth applications, anticipations of improved cost efficiency [50] and enhanced user-friendliness [51] are on the horizon.As technological literacy grows and the ubiquity of devices facilitating access to these applications increases [52], the prospect of heightened reach and accessibility to the population becomes apparent.Areas of development encompass enhanced accessibility for the visually impaired [53] and cognitively impaired [54], coupled with the standardization of application templates for cost-effectiveness, particularly beneficial for smaller organizations.
Standardization not only bolsters security against hijacking but also streamlines overall application usage [55].
Despite existing imperfections, the substantial potential of these applications in advancing the healthcare industry endures.Opinions from literature reviews strongly indicate the resilience and probable ascent of mHealth applications as a major healthcare factor in the upcoming decades [56].Future research should hone in on addressing application weaknesses and offering pragmatic solutions.Notably, the identified flaw of low sample sizes in existing studies is anticipated to ameliorate as organizations embracing mHealth applications continue their adoption [57].

Conclusions
The efficacy of mHealth apps in supporting the management of orthopedic and spinal surgery patients is evident.These applications offer a myriad of benefits, ranging from enhancing convenience for both patients and medical teams to mitigating biases in patient data collection, thereby contributing to future research endeavors.However, it is crucial to acknowledge and address potential drawbacks.One significant concern revolves around health inequities, particularly for technologically illiterate or lower socio-economic populations.Ensuring the accessibility and user-friendliness of these applications for diverse demographics is essential to prevent disparities in healthcare access.Additionally, addressing security concerns, such as the potential for breaches in confidential patient data, is paramount for maintaining trust in these digital healthcare tools.Moreover, the absence of a physical element in healthcare delivery through mHealth apps poses a challenge.The value of in-person interactions and physical examinations cannot be entirely replaced, emphasizing the need for a balanced approach that integrates these applications without compromising the essential aspects of traditional healthcare.To enhance the overall efficacy of mHealth applications, further research is recommended.This research should focus on improving patient accessibility, fortifying security measures, and expanding the reach of these applications.By addressing these areas, the potential benefits of mHealth apps can be maximized while minimizing potential drawbacks.
patient data in comparison to traditional means; improved convenience; well received by patients.15 patients were not able to communicate in English from the sample size, and not all data acquired was usable by the teamwho did not own a smartphone were a priori excluded, potentially inserting a selection bias towards specific groups, for example, older patients.Similarly, non-English speaking patients were excluded as well.In terms of spine diseases and type of surgical intervention, the population was quite heterogeneous, and our analysis did not take into consideration disease or treatment-specific features.Effectiveness of App-Delivered, Tailored To investigate the effectiveness Among adults who sought care for LBP, those who were randomized to receive selfBACK, an evidence-based First, the participants were not blinded.Second, healthcare use was not monitored during the follow-up.Third, the stepdetecting wristband worn by participants in the intervention 2024 Hayat et al.Cureus 16(2): e54254.DOI 10.7759/cureus.anevidence-based, individually tailored selfmanagement support system delivered through an app as an adjunct to usual care for adults with LBP-related disability.delivered through an AI-based app as an adjunct to usual care, showed reduced pain-related disability at 3 months compared with those who were randomized to receive usual care alone.group may have introduced an additional benefit that is independent of using the selfBACK app.Fourth, the perprotocol analyses could be biased if participants who engaged with the app during the follow-up period had a different prognosis from those who had little app usage.

TABLE 1 : Table of observational studies in available literature of mHealth on spine patients
[25]ova et al.showcased the superiority of mHealth applications over paper-based methods in terms of adherence and convenience, resulting in heightened patient compliance in lumbar degenerative spinal disorder patients[20].Sprau et al. underscored the positive reception of smartphone-based applications by spinal fusion patients, suggesting their potential as objective operative metrics[21].Sandal et al. indicated that AI-based mHealth systems, as an adjunct to usual care, mitigated lower back pain-related disability at three months, with this improvement sustained at nine months for lower back pain patients[22].Voglis et al. demonstrated postoperative improvement in daily physical performance using mHealth applications for degenerative lumbar disease patients, acknowledging challenges in accurate activity monitoring[23].Boaro et al.showcased smartphone-derived GPS features accurately characterizing perioperative mobility trends and improved data collection capabilities post-operatively using mHealth applications for spine surgery patients[24].Stewart et al. observed increased adherence among patients using mHealth applications in following pre-operative instructions, correlating with a decrease in lastminute surgery cancellations for spine surgery patients[25].