FormalPara Key Summary Points

Why carry out this study?

Introducing the concept of telemedicine and digital health and highlighting their significance in healthcare.

Briefly explain what telemedicine is and how it has evolved after the COVID-19 pandemic.

Introducing the different modalities of telecommunications in pain managements (Tele-pain).

Analyzing existing research on the use of telemedicine and digital health in pain management.

Summarize the key findings in the field telemedicine and digital health in pain management.

What was learned from the study?

Telemedicine and digital health allow long-distance patient and clinician contact for remote assessment, monitoring, medical care, education, and timely interventions.

They enhance rapid access to medical care, reduce the need for frequent in-person visits.

Telemedicine and digital health increase access to care, especially for those who face geographical or transportation barriers, very sick patients, or those who have limited mobility.

Telemedicine can be particularly beneficial for patients with chronic pain or limited mobility.

Additionally, telemedicine and digital health improve patient outcomes through regular follow-up and remote support when needed.

Introduction

The term telemedicine originated in 1977 [1]. Telemedicine is a subset of Telehealth and is just one element of Digital Health (Fig. 1) [2]. Telemedicine refers to the provision of remote clinical services for patients and/or informal nurses through information and communication technologies [3]. The application of digital health technology to measure, diagnose, and guide managements and to aid in the prevention of pain has gained much attention in recent years particularly in light of the COVID-19 pandemic [5,6,7,8]. As a consequence of the pandemic, there was exacerbation of chronic pain conditions due to the associated emotional distress, increased social isolation, limited physical activities, and other restrictions. Furthermore, uncertainty surrounding healthcare access and availability during the pandemic added more stress to the patients [9]. During the COVID-19 pandemic with the associated restrictions, telemedicine has become an effective way of communications for providing the required services for patients with chronic pain. Implementation of telemedicine has brought several advantages to pain management during and after the pandemic with improved access to healthcare facilities [10]. With the use of telecommunications, patients can receive continuous care while remaining in their homes, and patients with chronic pain can be regularly monitored [11, 12]. Telemedicine allows patients to receive specialized pain management expertise remotely, reducing the need for travel and saving time and costs. Additionally, telemedicine promotes patient empowerment and engagement by enabling patients to actively participate in managing their pain, monitoring progress, and receiving education or counseling remotely. It is recommended that the first consultation with the pain clinic should be conducted in person, with the possibility of subsequent follow-up visits being performed remotely [13]. Most international pain societies, such as the International Association for the Study of Pain and the American and European Associations of Regional Anesthesia and Pain Medicine, recommended the rapid introduction of eHealth services and the integration of telemedicine consultations into routine clinical care to meet the challenges for patients with chronic pain during the COVID-19 pandemic [14, 15]. The aim of this article is to explore the different modes, clinical applications, benefits, and limitations related to the delivery of telemedicine and digital health for patients with chronic pain. The manuscript is centered around key themes identified during the literature review. We begin by highlighting various definitions for telemedicine offered by international and national organizations, followed by a detailed overview of the critical domains addressed in the published literature: telemedicine delivery modalities, models of implementation, scope of service, locations of service, advantages, limitations, and challenges. We also highlight security, ethical, and legal considerations.

Fig. 1
figure 1

Categories of Digital Health, Telehealth, and Telemedicine, Software as a Medical Device (SaMD), Artificial Intelligence and Machine Learning (AI/ML), information technology (IT)

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Methods

An extensive computer search was conducted including literature from PubMed, MEDLINE, Scopus, Web of Science, and Google Scholar. In addition, other references were included after a manual scanning of references from pertinent websites. The search strategy included articles that were published during the last ten years (from January 2014 to March 2024). The search strategy included the following keywords: pain management, telemedicine in pain management, digital health in pain management, artificial intelligence in pain management, pain during COVID-19, post-COVID pain, and virtual reality for pain management. Articles that met the inclusion criteria, such as articles published in the English language relevant to the condition, presented information on the use of telemedicine, telehealth, or digital health in pain management, were included. Searching approach included observational, cross-sectional, cohort, longitudinal studies, systematic reviews, and meta-analyses. Articles written in languages other than English, case reports, editorials, conference papers, and expert comments were excluded from this search. Additionally, studies that did not test telemedicine or digital health were also excluded. The selected articles were screened by two independent reviewers using the same method of evaluation. The final reviewing strategy of the literature search results in a total of 38 articles were included in this review. The SANRA (Scale for the Assessment of Narrative Review Articles) format for reporting narrative review has been used to evaluate the quality of the manuscript [16]. Table 1 provides glossary definitions for terms used throughout this article. This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

Table 1 Glossary definitions of terminology used in included literature
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Telemedicine, Telehealth, and Digital Health

Here are the main subcategories of digital health: remote sensing and wearables, telemedicine, data analytics and intelligence, predictive modeling, health and behavior modification tools, bioinformatics tools, medical social media, digitized health record platforms, do-it-yourself (DIY) diagnostics, compliance, and treatments [17]. Various US national agencies have also offered their definitions for telehealth and telemedicine, most notably the American Medical Association (AMA), the American Telehealth Association (ATA), and the Centers for Medicare and Medicaid Services (CMS). As outlined by the (AMA), “telehealth, telemedicine and related terms generally refer to the exchange of medical information from one site to another through electronic communication.” [21]. Telemedicine, and digital health technology have emerged to facilitate efficient communication and to provide essential health care services during and after the COVID-19 pandemic. The role of telemedicine has declined somewhat after the pandemic but is still used by some health institutes for selected patients [25].

We can safely refer to the implementation of telecommunications for pain management as “tele-pain.” This newly introduced term like the other terms comes from tele-radiology, tele-mental health care, tele-dermatology, tele-rehabilitation, and home tele-care.

Telemedicine is a subset of telehealth, and is a communication tool conducted remotely with an audio-visual device [14]. Telemedicine is the older term and refers to the remote diagnosis and treatment of patients using telecommunications technology, while telehealth is a more modern term referring to all health and social care uses of technology, including digital communication technology, live video conferencing, mobile apps, and Internet of Things (IoT) devices, which has emerged in recent years as a new treatment model in most fields of medicine [26,27,28]. Although the terms "telemedicine" and "digital health" have different meanings, they are frequently used synonymously [13]. Telemedicine is merely one aspect of digital health, which incorporates everything related to the digitization of healthcare and medicine (Fig. 1.

Modes of Telemedicine and Digital Health

There are several modes of telemedicine that can be used in pain management (tele-pain). Each mode of tele-pain has its own benefits and limitations, and the choice of mode depends on the specific needs and preferences of the patient and healthcare provider. It's important to ensure that patient privacy and security are maintained when utilizing any telemedicine mode, following relevant regulations and guidelines [29,30,31,32]. Clinical studies have shown that telemedicine interventions were more effective in reducing pain intensity compared to interventions based on web pages, telephone, and video conferences. Moreover, the application of telemedicine ensures high-quality assistance comparable to traditional medicine [27, 28]. Methods for the delivery of this technology include synchronous (e.g., live video conferencing), asynchronous (e.g., store-and-forward transmission of photographs, images, vital signs, and video clips for later review), mobile health (mHealth) (e.g., remote patient monitoring and patient reported outcomes), and electronic health (eHealth) (e.g., live or recorded educational presentations to geographically disparate groups of patients or healthcare professionals) [28, 29]. However, a recent meta-analysis showed no significant difference between synchronous and asynchronous telemedicine interventions in terms of pain management effectiveness [2].

  • Telephone Consultation may be a preferable mode for some patients. Telephone consultation lacks the visual aspect of video consultations, but it can be a more convenient and accessible option for patients who have limited access to video technology, or reside in remote or rural areas with limited internet connectivity. It can be used to assess pain scores, gather valuable information, discuss treatment options, and offer guidance for self-care as well as education. A skilled healthcare provider can provide appropriate guidance over the phone [33, 34].

  • Video Consultations involves conducting virtual visits using video conferencing platforms. Patients and healthcare providers can see and interact with each other in real time [35]. This virtual tool allows for a comprehensive assessment of the patient's condition including the ability to observe facial expressions, movements, range of motion, physical signs, and body language as well as provide recommendations for pain management in real time [33, 36]. Video consultations enable physicians to visually assess pain symptoms with more effective communication between patients and healthcare providers. This direct communication is very important in pain assessment and management [37].

  • Remote Monitoring involves using technology to collect and transmit patient data for healthcare providers outside of traditional clinical settings. This mode enables patients to track their pain levels and to share the data with healthcare providers remotely. Remote monitoring allows for ongoing assessment and adjustment of pain management strategies, without the need for in-person visits. Also, it allows healthcare providers to track the effectiveness of the pain management options, make the required modifications, and provide feedback to the patient. In pain management, wearable devices, pain diaries, and specialized pain monitoring tools can provide continuous data on the pain levels, activities, sleep patterns, or medication adherence [38, 39].

  • Store-and-Forward This mode involves patients capturing and sending images, videos, or other relevant data to healthcare providers for review and analysis at a later time. In pain management, this could include photographs or videos of painful areas, scans or X-rays, or even electronic pain diaries. For example, patients can capture images or videos of their painful areas and send them to their healthcare provider for evaluation. The healthcare provider can review the submitted information at their convenience, analyze it, and provide feedback, recommendations, or treatment plans based on their assessment [40, 41].

  • Mobile Device-Based Interventions (mHealth) Applications mHealth can be divided into 3 broad categories according to their goal in chronic pain management: (1) patient education, (2) monitoring of symptoms and medication use, and (3) delivery of treatment or self-management skills [42,43,44].

  • Digital Biomarkers is a term recently defined to mean the “objective, quantifiable, physiological and behavioral measures collected using digital devices that are portable, wearable, implantable or digestible” [5, 22]. The use of digital devices like smartphones facilitates communication and offers a huge number of applications to track physical activity, check blood pressure, record blood sugar, and ensure medication compliance [17]. Utilizing digital biomarkers in pain management, such as data collected from wearable devices or mobile apps, can provide objective measures of pain intensity, frequency, and impact on daily activities. They can supplement traditional subjective pain assessments and offer a more comprehensive view of the patient's condition [6, 45].

  • Digital Therapeutics Digital therapeutics, such as mobile apps or online programs, can provide interactive tools for pain assessment and self-management. These platforms may include symptom tracking, pain diary features, educational resources, and cognitive–behavioral interventions to support patients in managing their pain effectively [46].

  • Integration with Electronic Health Records (EHR) Digital health technologies can integrate with EHR systems to streamline pain assessment processes, ensure data accuracy, and facilitate communication between healthcare providers. By incorporating these digital health tools and technologies into pain assessment and diagnosis practices, healthcare providers can improve the accuracy, efficiency, and effectiveness of pain management for their patients [45, 46].

  • Data-Driven Decision Making Digital health technologies provide healthcare providers with access to comprehensive data on patient pain symptoms, treatment history, and outcomes. These data can inform evidence-based decision-making, improve clinical assessments, and support research efforts in pain management [46, 47].

  • Online Health Communities Unlike telehealth solutions, which provide closed communication between providers and patients, other providers who are visible only to participants, or both, such as online health communities, provide more scalable avenues for open communication that are visible to any that enter a website or application [23]. These have been applied to various conditions and indications, including patient peer-to-peer support, to share coping strategies and health advice related to their condition [48].

  • Virtual Reality (VR) This offers opportunities to personalize pain management interventions for individuals with chronic pain [13, 49]. VR-based interventions have shown promise in enhancing asynchronous remote management of chronic pain. Furthermore, wearable monitoring technologies and VR-assisted biofeedback present prospects for simultaneous, distant patient–physician interactions [13, 42]. VR uses 2-dimensional or 3-dimensional technology, allowing patients and providers to access and interact within a “virtual world.” VR requires multisensory input to create this world. Existing studies have shown promising results of implementing VR in reducing pain intensity and distress, but more evidence is needed to understand the sustained impact of VR interventions on chronic pain management [13, 49]. Recently, the US Food and Drug Administration (FDA) has approved an applied VR app called RelieVR for treating back pain [50, 51]. Further research is needed to establish the long-term effectiveness of VR in managing chronic pain [45].

  • Conversational Artificial Intelligence Another category of potentially relevant digital health solutions for patients with chronic pain in the context of COVID-19 is artificial intelligence (AI)-based conversational applications [6, 52]. Recent advances in AI employing deep learning have resulted in a paradigm shift in advanced medical care. Telemedicine platforms that can be coupled with automated algorithms incorporating AI and big data analytics will further revolutionize the growing field of pain diagnosis and treatment [49, 53].

  • Chat Bots ‘Chat bots’ are computer programs that simulate human conversation, written or spoken. Chat bots have been applied to patient support, collection of patient-reported questionnaires, and triage through symptom checkers. Numerous pilot studies have demonstrated the potential benefit of these automated chat bots to enhance medical care and improve psychological support for patients with mental health disorders [54, 55]. Numerous symptom checkers have also emerged to help triage patients in the ongoing crisis, such as Babylon [56]. Results from a pilot trial of an AI chat bot to promote self-management of chronic pain showed encouraging results [57]. This can help in predicting pain episodes, optimizing treatment strategies, and improving overall patient outcomes [45].

  • Multi-Agent Systems (MAS) MAS are well-established modalities to create communication and cooperation between agents. They are generally considered computerized intelligent autonomous factors to solve various problems [58]. MAS involve many telecommunication applications, such as the internet, robotics, and medical applications [58, 59]. MAS can create a virtual world connecting healthcare providers, social assistants, patients, and relatives to ensure optimal treatment plans [60]. Additionally, MAS can be integrated with technologies such as wearable body sensors and wireless sensor networks to provide continuous monitoring, detect abnormalities, offer remote assistance, and send feedback to caregivers. Ultimately, MAS improve patient care in chronic pain management [40, 60].

Different Models of Telemedicine Implementation

There are several models of telemedicine implementation in the context of chronic pain management. They include:

  • Standard visits or follow-ups carried out via telemedicine without on-site clinical or technological support to patients [61].

  • Standard visits or follow-ups carried out via telemedicine with on-site clinical or technological support to patients [61].

  • Structured or integrated pain management programs involving a telemedicine intervention with or without on-site support [61, 62].

  • "Hub-and-spoke" approach, where the patient is brought to a satellite site where clinician or technological support is available, allowing for nursing staff to assist with in-person tasks [62, 63].

  • Telemedicine programs involving e-consultation networks, clinician education, multidisciplinary care, educational sessions, and monitoring systems [61, 64].

Scope of the Services by Tele-Technology

The scope of telemedicine includes many aspects. Tele-technology services differ according to the clinical situation, resources, and patient level of education. It can be used to triage the cases according to the urgency of the medical condition, or according to the risk of infection. Also, it can be used to evaluate patient medical condition, to assess pain, to plan the treatment of chronic pain, and to prescribe and refill pain medications including opioids [10, 30]. Additionally, telemedicine can be used to offer patient education, treat emotional distress of patients with chronic pain, and to perform a bio-psychosocial management of pain [31, 65, 66].

Hospital Visit versus Telemedicine

Patients may be stratified, based on the type of pain, underlying medical condition. and pain intensity, in order to distinguish between those who could benefit from telemedicine and those who require in-person consultations. In order to attend to those who require care more urgently, patients are triaged. To lower the danger of withdrawal, stable opioid-tolerant patients have been allowed to receive opioid prescriptions via telemedicine [30, 65], while patients at risk of opioid withdrawal or those who need opioids for longer durations should be scheduled for an in-patient visit to identify patients who might be candidates for opioids or other interventions [67,68,69]. For those patients with severe exacerbation of chronic pain, a short-term electronic prescription after evaluation via telemedicine is reasonable, before arranging for a visit to the pain clinic [68, 70, 71]. Patients with implantable intrathecal or epidural pumps require the arrangement of an inpatient or clinic appointment for checking, follow-up, and pump refill [65].

Advantages of Telemedicine and Digital Health in Pain Management

Telemedicine and digital communication play a crucial role in helping patients with chronic pain connect with their healthcare providers during and post-COVID-19 pandemic in the following ways:

  • Improved Accessibility Digital health technologies can eliminate geographic barriers and increase access to pain management services for patients who may otherwise face challenges in traveling long distances, or living in remote and rural areas, or having limited availability of specialists in their area [72, 73]. Also, it facilitates communications for those with limited mobility and physically unfit patients with multiple comorbidities [65]. Glynn et al. [74] provided evidence that telehealth is a successful tool in delivering treatment, improving access to care, decreasing travel burden and costs, and enhancing ability to participate for patients in rural areas [75].

  • Continuity of Care Telemedicine allowed consistent and ongoing communication between patients and pain management providers during the COVID-19 pandemic. Regular virtual follow-ups and monitoring could be conducted seamlessly, ensuring that patients received continuous care and support for their pain management needs. This continuity of care can improve treatment outcomes and patient satisfaction [76, 77].

  • Maintaining Quality of Care Telemedicine allows pain practitioners to continue maintaining relationships and increases patient access, safe delivery of care, and delivery of medications. Moreover, it allows safe description of controlled medications and enhances the quality of delivered care for patients in pain [9, 30, 75, 78].

  • Improved Efficiency The pandemic resulted in the worsening of underlying pain conditions for many patients, leading to less effective pain management strategies [9, 79]. Telemedicine has been shown to improve medical practice efficiency and patient convenience [80].

  • Remote Consultation Through secure video conference systems, patients can consult with pain management providers remotely, expanding access to care and reducing the need for in-person visits [65, 81, 82].

  • Convenience Telemedicine offers convenience for both patients and healthcare providers. Patients can have virtual consultations from the comfort of their homes, eliminating travel time and costs [83].

  • Time Saving Additionally, telemedicine appointments often have shorter waiting times and facilitate faster access to pain management services. Telemedicine allowing patients to receive timely care and reduces waiting times for appointments and consultations [81, 84]. Additionally, digital health overcomes time and distance barriers and leveraging technology, telemedicine enhances access to care, improves patient engagement, and provides a cost-effective approach to managing pain for many individuals [5].

  • Reduced Costs Telemedicine has the potential to reduce overall healthcare costs for both patients and providers. By eliminating the need for in-person visits, patients can save on travel expenses and associated costs. Providers can also reduce overhead costs associated with maintaining physical clinics or office spaces, which can lead to cost-effective healthcare delivery [81, 82]. Telemedicine can ease the workload on the already burdened healthcare system and exhausted healthcare providers [25, 65].

  • Improved technical performance Digital health technologies, such as wearable devices, computerized decision support systems, and telemedicine improve the technical performance and satisfaction of healthcare employees and demonstrate potential to decrease direct and indirect costs of medical services [85]. Worldwide, using digital solutions in practice seems inevitable, with distinct modality-specific prevalence (e.g., 50.8% for telemedicine, 89.9% for electronic health records, and 91.9% for social media platforms) [86, 87].

  • Enhanced Patient Engagement and Education Through telemedicine, healthcare providers can engage patients in remote educational sessions, providing them with information about pain management techniques, lifestyle modifications, and psychological support. Patients can also actively participate in their own care by accessing educational resources and tools provided by pain management professionals through telemedicine platforms [30, 31, 66].

  • Decreased Risk of Infections Telemedicine reduces the risk of exposure to contagious diseases, such as during outbreaks or pandemics. Patients with chronic pain conditions, who may be more vulnerable, can still receive necessary care without risking exposure to infectious agents in healthcare facilities [65, 84]. Telemedicine reduces the need of personal protective equipment, leading to reduction in resource consumption, improved access to health care and reduce resource use across the already stressed healthcare infrastructure during current pandemic [31, 88].

  • Facilitates Multidisciplinary Collaboration Pain management often involves a multidisciplinary approach, requiring collaboration among various healthcare professionals. Telemedicine and digital health tools enable seamless communication and coordination between different specialists involved in a patient's pain management, ensuring a comprehensive and integrated approach to care [46].

  • Data Collection and Remote Monitoring Telemedicine platforms can integrate with wearable devices or remote monitoring tools, allowing healthcare providers to collect and analyze patient-generated health data. These data can inform treatment decisions, track progress, and provide valuable insights into the effectiveness of pain management interventions [30, 83].

  • Enhanced Data Quality Digital health solutions can help ensure the accuracy and reliability of data collected for research purposes, leading to more robust evidence and informed decision-making in healthcare [72, 89].

  • Facilitation of Clinical Trials and Evidence-Based Practices Digital health technologies have the potential to facilitate traditional randomized clinical trials, and can promote evidence-based practices in healthcare, leading to better-informed clinical decisions and improved patient outcomes [72, 89].

  • Post-intervention Follow Up Within chronic pain management, one of telemedicine’s most effective utilization is seen via post-injection follow-up and assessment of further necessary interventions in the form of diagnostic and therapeutic injections. Post-injection communication is crucial and particularly critical after a multitude of blocks, including diagnostic injections, sympathetic blocks, and neurolytic blocks [90,91,92]. Telemedicine is effective for post-injection follow-up and assessment of further necessary interventions [9, 78].

  • Enhanced Patient Satisfaction Telehealth services have demonstrated benefits in terms of access to care, improved medical practice, greater efficiency, and better patient satisfaction [78]. Studies have shown that patients are generally satisfied with telemedicine for remote care experiences compared to in-person visits [81].

Limitations and Challenges of Using Telemedicine and Digital Health in Pain Management

While telecommunications offer numerous benefits for pain management, there are several challenges to consider. Telemedicine cannot replace clinical medicine based on in-person consultation and physical examination and chances of misdiagnosis [88].

  • Limited Physical Examination One of the significant challenges of telemedicine in pain management is the limited ability to perform a comprehensive physical examination remotely [78]. Physical examinations, such as palpation, joint mobility assessment, and detailed neurological examination, may be challenging or impossible to conduct through telemedicine [81]. Remote examination may restrict the ability to perform certain steps such as auscultation and percussion, which are essential in a comprehensive assessment [78, 93]. Inadequate assessment may impact the accuracy of diagnosis and treatment planning, as certain findings may be missed or inadequately assessed. Telemedicine restricts the ability of healthcare providers to physically assess the patient. It cannot fully replace an in-person assessment, potentially leading to gaps in the evaluation process [30, 78, 94].

  • Lack of Baseline Physical Examination For new patients in whom a diagnosis has not been established or where it may be necessary to document symptom improvement or undesirable post-procedural neurologic changes, the physical exam for a new patient can enable the physician to establish a set of potential diagnoses, while ruling out others [94, 95].

  • Inability to perform investigations, certain diagnostic tests, laboratory work, or radiological screening for diagnosis add further limitations to telemedicine [88].

  • Barriers related to the healthcare providers such as lack of education, psychological barriers, and workload-related concerns are relevant barriers and may impact the comprehensive and holistical adoption of digital health technologies [85].

  • Technology Barriers Limited or insufficient infrastructure and access to reliable internet connections and appropriate technological devices can be a barrier for both patients and healthcare providers [85]. Some patients might lack access to the necessary technology or have limited access to the necessary devices or reliable internet connections, hindering their ability to engage with telemedicine services [95, 96].

  • Limited Resources Technical problems during telemedicine appointments can disrupt the patient–provider interaction and cause frustration for both parties. Healthcare providers must ensure that their telemedicine platforms are user-friendly, provide clear instructions to patients, and offer technical support when needed [95]. Using small screens for video calls may hinder the visibility of certain anatomical areas, impacting the quality of the examination. Additionally, using different devices for the video call and accessing medical records may cause inconveniences [13].

  • Infrastructure Requirements Telemedicine consultations need a reliable internet connection and a device, such as a computer, smartphone, or tablet, with a camera and microphone [31, 66, 96]. The evidence suggests that healthcare providers predominantly face infrastructure, technical, training, and workload-related barriers to using digital health technologies, regardless of the level of care or digital technology [85].

  • Lack of Standardized Systems across Different Facilities Lack of harmonized data-sharing agreements and transactional standards between institutions hinder effective data sharing and integration in public health [85, 89].

  • Personal and Psychological Barriers Some of the barriers that impact the utilization of digital health technologies include resistance to change, difficulty understanding the technology, fear of using health technology and technophobia, lack of training and education levels [85], professional experience, poor writing skills, personal attitudes and adherence behavior, and fear of using particular health technology [72].

  • Medication Management Prescribing controlled substances via telemedicine may be subject to additional regulations and restrictions. Healthcare providers may face challenges ensuring the safe and secure prescribing of controlled medications using telemedicine prescriptions. This is mainly attributed to the medico-legal concerns for the use of telemedicine in prescribing controlled medications, refill of opioids, and identification of the patient or caregiver, as well as obtaining consent [30,31,32]. Unfortunately, there were increases in opioids-related mortality and illicit drug use during the pandemic, which can further complicate the management of chronic pain [92, 97].

  • Drug Screening Challenges exist in convenient close therapeutic monitoring and drug screening through telemedicine [78].

  • Lack of Hands-on Treatments Many pain management interventions involve hands-on treatments, such as manual therapy, trigger point injections, or nerve blocks. These treatments cannot be performed remotely, limiting the scope of telemedicine in certain situations [31, 66].

  • Lack of Evidence-Based Research and Guidelines There are no updated clinical practice guidelines to accommodate the rapid changes of the healthcare services in response to the pandemic [30, 65]. Barriers to greater implementation of telehealth services include lack of evidence-based research on long-term outcomes and unforeseen harm or consequences [98].

  • Patient Comfort and Engagement Some patients may feel more comfortable with face-to-face consultations, which build up trust, and effective communication with the healthcare providers. Patients may miss the physical presence of healthcare professionals with telemedicine, which can impact their experience, affecting the patient–physician communication and the patient’s overall satisfaction with telemedicine [31, 65]. A study was carried out to evaluate the experiences of front-line clinicians transitioning to telemedicine during the early stages of the COVID-19 pandemic. The researchers encountered several negatives: less structure and accountability, less information to inform clinical decision-making, challenges in establishing a connection, technological issues, and shorter visits [75]. Telemedicine is not suitable for patients with advanced diseases or with rapid changes of the patient’s condition, or those with associated multiple comorbidities [30, 31, 66, 71].

  • Reimbursement As with any emerging healthcare practice, reimbursement policies and legal issues surrounding telemedicine can be complex and vary among authorities. Healthcare providers may encounter difficulties in ensuring appropriate reimbursement for telemedicine services. Before the epidemic, two main obstacles to the adoption of telemedicine were health insurance coverage and payments [9, 78, 99]. In 2015, the American Medical Association (AMA) have found a solution through coding of telehealth services, and it was approved for the audio and video telecommunications. The AMA also, sponsored a digital payment focusing on the integration of coding, coverage, and payment. Then, after the emergence of the COVID-19 pandemic, which resulted in a rapid expansion of the digital health services, telehealth services were covered at rates comparable to in-person visits [9]. CMS influenced continued reimbursement rates, providing incentives for opportune uses of telemedicine [92]. However, insufficient reimbursement remains a common barrier to telehealth expansion.

Security, Ethical and Legal Considerations

All healthcare professionals, including clinicians and researchers, must understand and apply basic ethical principles [100]. The area of pain management raises the problem of ethical and legal considerations in all situations, such as clinical practices, communications, and research settings [101]. One aspect of these considerations has emerged since the pandemic [30]. The COVID-19 pandemic increased the use of telemedicine and digital health-care services all over the world. A new era of online applications has replaced the classical paperwork [102]. This applies to all documentation, appointments, scheduling, and certificates (e.g., medical reports and sick leaves [49].

  • Security and Privacy Telemedicine practices are subject to legal and regulatory considerations that can vary between jurisdictions. Many concerns in digital health interventions are mainly related to the patient privacy, confidentiality, and data security [102]. It is essential for healthcare providers to protect patient information during different modes of telecommunications, such as video consultations, store-and-forward telemedicine, and remote monitoring [104]. Compliance with national legislation and health authority regulation are vital to ensure the confidentiality of patient data and health information [85, 104]. It is necessary to establish ways to comply with the regulations and to provide professional guidelines governing telemedicine in their respective regions.

  • Ethical Considerations The ethical and medico-legal issues for the use of telemedicine and digital health should not be compromised [30, 103]. Ethical considerations, such as identification of the patient or caregiver, description of controlled medications, refill of opioids, and obtaining informed consent for data collection and access, should be applied according to the guidelines (31, 32. 104). Healthcare providers should respect and maintain patient privacy and confidentiality, autonomy, beneficence, non-maleficence, justice and equity must be respected in telemedicine [89, 103, 104].

Autonomy refers to the patient rights to receive all information about the recommended plan of the managements, both via telemedicine and remote consultations, as well as by standard face-to-face visits [103, 105]. The patient's right to refuse the treatment and not to sign the consent must be respected [101].

Beneficence refers to the ethical responsibility to maximize benefit and minimize injury to the patient. As such, the medical professional must have the greatest technical information possible to ensure a beneficial medical act to the patient [103, 106].

Non-Maleficence refers to the medical action of causing the least harm or no harm to the patient’s health [107].

Justice and Equity: The principle of justice has equity as its fundamental condition and treats each patient according to what is morally appropriate, providing to each individual what is due to them. Physicians should be fair and unbiased [100, 103].

  • Legal Considerations: There are several legal and ethical challenges that should be taken into consideration in applying virtual health communications. This includes but is not limited to the licensing and jurisdiction of doctors and providers, the quality of information and informed consent, data bias, privacy and security concerns, and medical liability [103, 108]

Informed Consent: One of the important challenges is related to informed consent. The concept of informed consent must be an essential element in teleconsultation. The telehealth consent guidelines require that medical practitioners obtain and document verbal or written consent, documenting it in the patient’s medical record. Patients must be given accurate and adequate information [108]. Before taking the consent, it is very crucial to know how to deliver the information on a drug, especially opioids, or intervention, its indication, possible risks, accuracy of the prognosis, and the risk of the pain interventions or medications. The same principles are applied either during remote communications or classical visits [101].

Prescribing Medications: Prescribing medications by telecommunications involves the same level of responsibility as face-to-face consultations. Registered medical practitioners can prescribe relatively safe drugs with low abuse potential for first-time treatment. The prescription of controlled medications and opioids must adhere to the standard rules and regulations of the higher health authorities, and the respective national guidelines, which in the United States would include the Drug Enforcement Administration (DEA), jointly with the Department of Health and Human Services (HHS) [109]. The authorized practitioner can prescribe a controlled substance to a patient using telemedicine, even if the patient is not at a hospital or clinic registered with the DEA. Qualifying practitioners can prescribe buprenorphine to new and existing patients with opioid use disorder based on a telephone evaluation [108]. Such prescriptions are restricted to authorized practitioners such as pain physicians. The pain physician must provide scanned and digital copies of a signed prescription or an e-prescription to the patient as well as to the pharmacy [110]. This flexible telemedicine prescription of opioids after the COVID-19 pandemic is to provide maintenance of treatment, and prevent withdrawal management of the opioid.

Medical Certificates: Since the COVID-19 pandemic, most certificates (medical reports, and sick leaves) are issued by the hospital authority electronically, and have a digital signature as well as a QR coding system that can be scanned and verified by the hospital authority or authorized providers to minimize misuse. These e-documents should be handled carefully to ensure confidentiality and privacy of the patient’s data [111], restricting access to, and processing of, personal data on a “need-to-know” and “need-to-use” basis. The medical practitioner has legal responsibilities when issuing medical certificates. The practitioner must be honest and the medical report must be clear and accurate [112, 113].

Multidisciplinary Telemedicine and Digital Health Team

The pandemic has disrupted the delivery of multidisciplinary pain care, leading to challenges in providing comprehensive pain management services [114]. Coordination of multidisciplinary teams involving multiple healthcare professionals from different disciplines, ensuring effective communication, and collaboration on treatment plans among diverse team members can be challenging, especially in virtual settings [115]. Coordinating effective multidisciplinary telehealth pain management care involves coordinating services through regular electronic meetings attended by various professionals involved in pain management [116]. Different members of the pain care team play essential roles in contributing to comprehensive pain management. Through coordinated efforts, they aim to improve pain outcomes, enhance quality of life, and promote overall well-being for individuals living with chronic pain [117]. Here is how each member contributes to the multidisciplinary approach to pain care:

Physicians: Effective communication between patients and healthcare providers is crucial for the provision of patient care and recovery [117]. A multidisciplinary approach for pain management is essential to improve the outcomes, quality of life, and pain management skills. Pain management specialists and the primary team physicians play a crucial role in improving the quality of life for individuals with chronic pain conditions. They are responsible for communicating with the patient and the other managing team members by the available tools to perform patient assessment and to establish a diagnosing and treating plan of the associated pain conditions [118, 119].

Nurses: Nurse practitioners and pain management nurses play important roles in patient monitoring, administering medications, assisting the physician, educating patients, and coordinating care plans [120,121,122]. Nurses can use the technology of telecommunications to improve their pain management skills by recognizing the possible benefits and the associated challenges [123]. According to a new meta-analysis on cancer pain management, multimodal nursing using mobile internet can ensure good online communications between patients and nurses and achieve more effective pain management. Compared to traditional nursing, this type of care is more easily accessible [120,121,122]. Collaboration between the doctors, nurses, and pharmacists has improved the management of cancer pain symptoms [121, 124, 125].

Pharmacy: Pharmacists contribute substantially to chronic pain management, ensuring the quality use of medicine, resulting in reduced pain intensity [126]. Digital therapeutics are rapidly emerging as clinically effective treatments for diverse chronic diseases. For example, the FDA has recently authorized a prescription VR app for treatment of moderate to severe low back pain. The FDA has also approved an adjunct digital therapy in conjunction with buprenorphine for opioid use disorder, further illustrating opportunities to integrate digital therapeutics with pharmacotherapies. VR and mobile apps can be used as adjunct digital therapies for pain management [127].

Physiatrists: The focus here is on restoring function and improving quality of life for patients with pain through physical medicine and rehabilitation techniques [121].

Other Supportive Teams: Social workers can assist patients in navigating social and environmental factors that impact their pain management, such as access to resources, communications, and social support systems.

Practical Tips for Introducing Remotely Supported Pain Management

Before introducing such new technology, it is important to define your resources, including a robust internet connection, technology options (e.g., computers, smartphones, cellular phones, etc.), videoconferencing platforms (such as Zoom, WebEx, Doximity), and electronic medical records [10, 128]. Additionally, it is recommended to plan and use complementary resources [10, 128], problem-solve and integrate self-help activities, and use experiential learning [129]. The appointments should be scheduled when there are no distractions for you or the patient [128]. For successful pain management, it is essential to explore your patients’ living and socioeconomic environment [129]. All tele-technology applications must follow the clinical practice guidelines [5, 10]. Finally, digital health should not substitute the face-to-face visit, but be considered as a component of a multi-agent system of pain interventions [5].

Areas for Improvement and Future Directions:

Telehealth options were not created by the pandemic, but the pandemic created a new window for introducing such new services to reduce the risk of exposure during the pandemic and to facilitate easy communications during and after the pandemic [65, 71]. This newly introduced communication technology needs comprehensive program-directed education and training for both the healthcare providers and the patients to develop the competencies needed to engage with digital tools [65, 66].

  • Program-directed training for self-management, rehabilitation, and physical therapy should be created and available via video tutorials and applications for smartphones [30, 65, 66].

  • Future innovations in digital health technologies are likely to open up new possibilities for personalized medicine, predictive analytics, and preventive care [89].

  • Integration of telemedicine services with electronic health records (HER).

  • Integration of remote monitoring and development of technologies that allow real-time collection of patient data, such as wearable devices, can enhance the effectiveness of telemedicine in pain management [42, 49].

  • VR applications: Exploring the use of VR technology as a non-pharmaceutical approach to pain management shows promise. Immersive experiences can distract patients from pain and improve their overall well-being [42, 49].

  • Enhanced patient–provider communication focuses on improving the patient–physician connection through video consultations, augmented by audio-visual aids and increased attention to communication skills [42, 49].

  • Updated pain assessment tools including simple pain scales, neuropathic pain scales, and the Pain Catastrophizing Scale, should be developed and validated to be implemented for the virtual consultation setting [30, 65, 66].

  • Overall, the integration of digital health technologies in evidence generation holds great promise for transforming healthcare research and practice [89].

  • Further development of quality and safety metrics tailored to measure the impact of telemedicine in pain management, as well as focusing on comparative analysis of short- and long-term outcomes of in person versus telemedicine sessions, could greatly complement the current body of published literature.

  • It would also be beneficial to conduct further research to better understand how emerging and frontier technologies could optimize the impact of telemedicine in pain management. Examples of future studies could include telemedicine platforms enhanced with patient-generated data via wearables, exoskeletons, bio implants, nanotechnology, VR, augmented reality, extended reality, or brain computer interfaces.

Manuscript Limitations

This is a literature review and there are few studies on these new technologies and applications. Our review excludes pediatric patients as well as those with dementia or intellectual disability, who may otherwise be candidates for such approaches. Comparative studies and long-term follow-up studies are likewise not available. There are no evidence-based guidelines for setting up such services, harmonizing practices, or offering effective and safe telemedicine and digital health services. The important aspects of data security, patient privacy, and medical ethics in telehealth exceed the scope of this review, but represent an important topic for consideration. We must also recognize the possibility of publication bias, as well as the significant heterogeneity observed in the studies conducted. We further acknowledge that the lack of standardized telemedicine delivery and customized telemedicine metrics constitute further limitations of the findings based on the literature review. Despite these limitations, this review article highlights several options and opportunities to apply digital health and offers valuable insights into the rapidly growing digital health technology. It also helps as an important source for continued care of patients with chronic pain as well as for further exploration and research in this rapidly growing field.

Conclusion

Telemedicine and digital health can be used for different aspects in pain management, including clinical services, education, and administrative purposes to ensure the important role of telecommunication technology in enhancing pain management and outcomes. This new mode of communication is no longer limited by space, time, and other barriers. Most of the findings from previous publications emphasize the effectiveness of telemedicine in pain management. It provides a cost-effective approach for managing chronic pain and rebuilding medical systems. Digital health technology allows long-distance patient and clinician contact for remote assessment, rapid access to medical care, education, and timely interventions. Moreover, digital health reduces the need for frequent in-person visits. This can be particularly beneficial for those who face geographical or transportation barriers, patients with limited mobility due to chronic pain, or very sick patients. However, there are a few drawbacks of telemedicine consultations, such as lack of hands-on elements of the physical examination, palpation, and detailed neurological examination. Other challenges include technological barriers and decreased patient–physician rapport. Despite these challenges, advancements in technology, ongoing research, and evolving regulations continue to address these concerns and further enhance the use of telemedicine in pain management. Areas of future improvement include enhanced patient–provider communication, integration of telemedicine services with HER, and remote monitoring technologies, and the rapid development of virtual reality for pain management. Further research is necessary to confirm the long-term effects, enhance the advancements in telecommunication technology, and to optimize its use in pain management.