ACTwithpain - Building an online platform for helping Chronic Pain Patients

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IACTWITHPAIN - Building an online platform for
helping Chronic Pain Patients
Maria Rita Nogueira∗, Paulo Menezes∗, S´
ergio Carvalho†, Paula Castilo Freitas†
∗Institute of Systems and Robotics - Dept. Electrical and Computer Eng. - University of Coimbra, Portugal
†Center for Research in Neuropsychology and Cognitive Behavioral Intervention - University of Coimbra, Portugal
Abstract—The main objective of this multidisciplinary project
is to think up and build a digital application that joins health to
engineering and design. IACT WITHPAIN is a web-platform and
mobile application which aims to help chronic pain patients, by
providing tools to improve their life quality. The platform will
make it available a set of different digital tools and exercise plans
inspired on pain self-management strategies. As IACTWITHPAIN
is targeted to a specific range of people which are commonly
anxious and more vulnerable to stress, the application should be
dynamic and have particular attention to User Experience details.
Consequently will require a whole array of specific functionalities
as a chronic patient needing as an end-user. For this reason, the
aim of this article is to disclose the research concept as the core
focus to provide a personalized user experience design in an
intuitive and user-friendly environment. The platform and this
research project are being developed in ISR - Institute of Systems
and Robotics of Coimbra and CINEICC - Centre for Research
in Neuropsychology and Cognitive Behavioral Intervention of
Coimbra.
Index Terms—Psychotherapy, Online Health support, User
Experience, Usability, Mindfullness, Chronic Pain
I. INTRODUCTION
The experience of pain has always a strong impact on dif-
ferent aspects of the people’s lives by negatively affecting their
daily activities, physical and mental health, family and social
relationships, and even social activity and productivity in the
workplace [1]. Chronic Pain (CP) generally defined as various
occurrences of pain in specific body parts, constant or sporadic
pain of at least 3 months [2]. Chronic Pain is a prevalent health
problem worldwide, and naturally including Portugal, where
it affects around 30% of population, and placing a significant
economic burden on health-care systems [3].
The IACTWITHPAIN project emerged from an idea of
providing custom support to the Portuguese speaking chronic
pain patients, through non-pharmacological mechanisms, but
instead by a set of interventions aiming to reduce suffering
impact and thus improve well-being. This internet-delivered
psychological intervention will help Chronic Pain patients
develop a more accepting, present-focused and non-judgmental
stage towards their chronic illness. Also, patients will learn
how to tackle difficult thoughts and emotions related to living
This work was developed within project ”iACT com a Dor: uma intervenc¸˜
ao
online para autogest˜
ao da dor cr´
onica” - POCI-01-0145-FEDER- 028829
— PTDC/PSI-GER/28829/2017, and has also been by Institute of Systems
and Robotics (ISR) – University of Coimbra via OE - national funds of
FCT/MCTES (PIDDAC) under project UID/EEA/00048/2019.
Fig. 1. A view of the IACTWITH PAIN portal front page.
with Chronic Pain, and to be commited to taking action guided
by their personal values and towards a vital and meaningful
life, despite their pain experience. It is expected that this
will not only benefit patient’s abilities to navigate difficult
emotional experiences, but will also positive impact their
interpersonal relationships, including relatives and friends.
To reach a wider base of chronic pain patients, the choice
was to provide such support through an online application,
accessible via both personal computers and mobile hand-held
platforms (figure 1). As for the creation of any interactive
system, the design phase has a major role as it will be reflected,
more than on the functionalities themselves, but in particular
on the user interface, supporting the construction of intuitive
and easy-to-use applications. In particular for the current case,
it should reflect on the way that information is presented to
the users and guides them through the exercises, which include
breathing exercises, mindfulness practice and muscle relaxing.
It is important to take into account the objective of providing
the patient with a new tool to handle situations which may
trigger pain episodes, and deal with them. It is expected that
through an appropriate interaction system and adequate data
presentation, the platform will stimulate the patients execute
the suggested actions. This includes taking microcopy into
account as well, e.g. below a form field to support a back-and-
forth conversation [4]. Microcopy can be defined as the tiny
elements that included on some interface will guide the users
and alleviate users’ concerns or doubts about proper usage of
some device or system [5].

For the user application development, it means that nav-
igation scheme, interaction and usability support must be
considered as a main part of the system. In fact user experience
is a very dynamic, complex and subjective phenomenon [6]
that must be always at the centre of the design objectives. In
this respect it is crucial to be aware of what is, and what is
not “natural” for the final users.
In the current context, we may expect Chronic Pain patients
to be more likely to exhibit impatient behavior, thus non-
intuitive options will probably make users to prematurely
abandon the application usage. On another side, clinical
psychologists state that these users tend to exhibit patient
behaviours when searching for something they believe will
be beneficial to their condition.
In any case, it is well accepted that a proper design
conception is, most of the time, a key factor to engage users in
the use of the application [7]. To this end in IAC TWITHPAIN
, the inclusion of end-users in the development process was
considered as a very important point, as they will provide
critical views on the app tool regarding its usefulness, user-
friendliness, and how well adapted is the application to be
used by someone suffering from chronic pain.
To achieve the best results an heterogeneous team composed
of clinical psychologists, pain specialists medical doctors, de-
signers and engineers tries to cover all aspects from interaction
design, interaction evaluation, clinical content, and assessment
of intervention results. These aspects will be described in the
remaining of this article after a short review similar existing
products.
A. State of art
In recent years the maturation of a number of technolo-
gies, in particular those that support online applications, have
attracted the attention of professionals from all areas to the
possibility of providing information and access to their ser-
vices remotely via personal computers and hand-held devices.
Rapidly the number of applications developed to give access to
online services like booking, education, entertainment, among
others has exploded. Health was not an exception, and multiple
types of services started to be offered through online platforms
and applications. Some of these services provide information
about the most varied aspects of health from prevention to
care.
Chronic pain is one of the most prominent health problems
in our society [1], and as such the evolution towards use of
interactive and digital media for helping patients can be seen
as a natural step, resulting in the release of several applications
in the recent years [8], [9]. Willing to address this problem
with a new therapeutic solution two questions emerge: 1)
Which works have been proposed to tackle this specific health
problem? 2) How does IACTWIT HPAI N stand out above all
the other works, and which are the user needs that must be
taken into account, for this platform to become really helpful
to the patient?
In fact different chronic pain-related applications with dif-
ferent features and targets are currently available: Catch my
pain [10], My pain diary [11] , Pain scale [12], Manage
my pain [13], Chronic pain tracker [14], Flaredown [15],
Curable [16], Pain Relief Revolution [17], My Chronic pain
team [18]. Starting from the last aforementioned applica-
tion [18] and Pain Scale [12], these two applications have
the feature to ask user to evaluate his pain throughout the day.
In a general way, most of these applications are conceived
by teams with no in-depth experience in this specific health
topic [19], which in turns means a weak input from Health-
care professionals [20]. On the other side, regarding to My
Pain Diary [11] was created by a team composed of multiple
professionals from health and psychology areas [21]. In this
sense, the users can add detailed records about pain intensity,
providing a feature to export detailed reports that can be
further used by doctors in order to guide the treatment.
These applications have usually some limitations in developing
actions to promote some customization of user experience.
Some applications are not free and both camera and GPS are
required: camera to photograph body parts when injured and
GPS to track information about weather (e.g. My Pain Diary:
Chronic Pain Management [11], Flaredown [15]). On other
hand, My Chronic pain team [18] introduces a component
of social networking that provides an interactive way to
share personal experiences with other users. In the same line
(social component), Pain Relief Revolution [17] allows to
share user experience among different social networks, being
available both to web platforms, Android and iOS; however,
a lack of interactions between the user and application is
observed, mainly due to this platform focusing on content,
such as articles describing different categories of chronic pain
and treatment methods. Catch my pain (a) and Manage my
pain [13] are two applications that adopt a full customized
approach and at the same time providing a social component.
Chronic patients who have an active social activity are usually
less subject to depressive behaviour, which in turn leads to a
decreasing on pain intensity when compared against patients
who show low social activity [19].
These social applications, that allow systems to interact
with the user through health surveys, which include pain
level assessment, also allow the user to share this information
with other users (e.g. private groups in social networks).
Curable [16] is one of the applications which stands out above
the others by interacting with user from the outset through an
animated bot called Clara. The bot tries to speak with the
patient, suggesting helpful exercises and other recommenda-
tions. From our experience on using Curable, the application
is continually providing too much information that in long-
term makes the user to loose focus. This application has two
different actions to the users, Podcasts and Recovery Stories,
which in turn are unfiltered stories of chronic pain patients.
Similarly to the Catch my pain (a) and Manage my pain [13],
Curable [16] provides reviews and real testimonials from other
patients, offering to the user an upwelling current of empathy,
compassion for others and even for himself. Another platform,
Flaredown [15], has an interesting and novel visual interaction,
which is very unique because it converts the information

provided by the patient into graphical elements, providing a
different interaction layout with information about his pain
in an intuitive way. As patients need to feel that pain will
become less prominent in their lives, graphical animations
were included in this application as a way to help and motivate
them.
From the above analysis it was possible to identify both
positive and negative aspects of some of the existing appli-
cations for chronic pain management. These results will be
used throughout the development of IACTWIT HPAIN plat-
form, which aims at reaching a considerable fraction of the
Portuguese (and eventually Portuguese speaking) patients.
Included on a project that proposes a non-pharmacological
approach and perform its clinical validation, this application
should help clinicians to collect the necessary data to sup-
port those studies. In parallel with clinical data acquisition,
behavioural, and usability-related data will be acquired, upon
informed consent of the users, to support the evaluation and
improvement of the interaction aspects of this application.
This will help also in understanding how does pain influence
interface usage, and which aspects, if any, must be taken into
account in order to improve the acceptance by these user
groups, or to improve their experience towards this or other
applications.
II. IACTWITHPAIN :GOALS AND US ERS
People with chronic pain rely heavily on the doctors
consultation and drugs prescription in looking for ways to
relieve their suffering. Online interventions have been recently
explored with clear advantages to patients, such as reducing
doctor time and waiting lists, increased cost-effectiveness,
adaptation to the patients’ own paces, and accessibility to
large clinical samples, including rural and remote cohorts.
IACTWIT HPAI N , as an online platform, intends to provide one
viable alternative for teaching patients to deal with pain, which
contrary to the general trends, does not prescribe ignoring the
pain, but rather taking the patient to accept it. It can be said
that it will support a targeted intervention, in which patients
will learn a set of psychological, emotional and pain-coping
skills, that will help them cope with pain in their daily lives.
This is expected to contribute to patient’s autonomy and reduce
the burden in health care systems, as it will empower patients
to better manage their health and pain.
To correctly design any interactive system, one should start
by answering some questions: Who are the end-users? What
are their needs? Do they have specific characteristics that
should be taken into account? How does the pain affect the
cognitive and emotional support of the patient-user?
Our end-users are primarily adults with permanent/frequent
pain conditions which makes them more vulnerable than other
users, and their principal need is basically the one of finding
mechanisms to that enable them to feel better. Knowing that
this search may be done during periods of suffering, it is
important to give them access to simple processes and tasks
that may be completed through intuitive decisions.
One important question to ask is: Should these applications
systematically ask the patients if they have any pain, knowing
that this will eventually recall them of it? Contrary to many
of the analyzed applications, direct pain assessment will be
reduced to the minimum needed. Though users will have
always access to a scale where they may report how they
are feeling at any time. We expect that patients with no
pain, lower pain levels or that ”have accepted the pain” will
tend to not search this reporting feature. Conversely, suffering
people will tend to report it during the critical moments.
Through a continuous data collection we expect to be able
to establish pain usability-related measures on a per individual
level. Besides that, information about how the patient performs
the different actions on the application, will be helpful for
improving the application itself.
III. IMPLEMENTATION
The IACTWIT HPAI N application is currently under devel-
opment for web platforms and mobile devices. It is majorly
targeted to anyone who experiences chronic pain, providing
tools which may help them targeted to anyone who expe-
riences chronic pain, and provides tools which may help
patients cope with illness-related symptoms and limitations.
Throughout the intervention implementation, iACTwithPain
will offer educational activities and experiential exercises,
through which patient’s well-being as a whole is expected
to increase. The application includes a set of modules, each
one composed of explanations, video animations, experimental
exercises, supplementary texts, support material, daily tasks,
audio mediation and other practices.
To support the clinical analysis of the proposed program,
the IACTWIT HPAI N platform will include the following dis-
tinctive characteristics:
1) Detailed health data about the patient is collected when
the patient starts the application.
2) A pre-filtering of the users is performed based on
personal information provided in the signup stage.
3) Classification of users into categories, according to a set
of selected types of Chronic pain (i.e. Chronic Primary
Pain, Postsurgical and Posttraumatic pain, Neuropathic
Pain, Headache and Orofacial pain, Visceral pain, Mus-
culoskeletal pain) *Chronic Cancer Pain shall has not
been included of the ICD category for Chronic Pain;
4) A wide range of mindfulness and compassion-based
exercises, such as ”body-scan”, ”breathing meditation”,
”soothing rhythm breathing”, ”loving-kindness”, etc,
which aim to increase: exercises will be available, sup-
porting the intervention that addresses the following core
themes:
a) Pain acceptance - psychological flexibility (partic-
ularly pain acceptance and values-based commited
action) in the presence of thoughts, feelings and be-
haviors associated with pain through mindfulness
and acceptance practices;
b) Values-based action - promotion of behaviors con-
sistent with personal goals, despite pain symptoms;

c) Self-compassion - fostering a compassionate stance
towards one´s struggles and sufferings, which will
only be incorporated in the intervention for exper-
imental condition.
These themes will be delivered through 8 modules that
will be available to participants throughout an 8-week period;
Each week, users will receive a notification prompting them to
access the application and complete the a new module; Contact
with the research team will be made available to users during
the intervention period through both email/chat supports.
IACTWIT HPAI N differs from other platforms as its inter-
action is inspired by the digital treatment process includes
methods in the follow-up of both successful and unsuccessful
results, goals to be achieved over in use of the application. As
the platform promotes patients self-management, the chronic
pain condition will be better monitored and managed which
in turn may prevent the aggravation of the clinical condition.
The IACTWIT HPAI N will make the difference in health tech-
nologies for teaching the end-users (patients) how to deal with
respective chronic pain(s). Any particular aspects from each
patient will have consequence and a different customization in
user experience design of platform.
To address the user experience concerns and support the
intended user-adaptation, the platform will also include the
following characteristics:
1) Usage data will be collected including: usage frequency,
type of device used (handheld or PC), time between
selections, fast backward steps or UNDOs, and explicit
feedback.
2) The above data will be jointly analized reported chronic
pain types to try to establish any possible correlations
with those types, or reported pain intensity.
3) The above data will be used to refine the interaction
mechanisms and thus expected to improve the attained
user experience.
4) High interactivity of the IACTWI THPAIN tool providing
real-time feedback and prompts, is expected to con-
tribute to promote user adherence and engagement;
IV. USE R EXPERIENCE DESIGN CONSIDERATIONS
User Experience (UX) is gaining more and more adepts
in both industry and academia, used frequently without a
clear definition of what it means [22]. Its introduction came
from researchers finding limitations of the traditional usability
frameworks, where focus tend to be mainly on user cognition
and user performance. In contrast, User Experience highlights
non-utilitarian features of such interactions shifting the focus
to user emotions and sensations, and to the meaning and value
of those interactions in everyday life [23].
In the current work the concerns are on providing the
best possible experience to chronic patients, always focusing
on the user side, feelings and emotions. To that end, the
IACTWIT HPAI N platform being developed upon the following
principles or guidelines:
1) The User is not taught. Give him the basics [23] such as
adding patient notes and tracking his health status since
the first day.
2) Help people to perform fast. The application and actions
performance has a significant impact on continuous use
of platform.
3) Help the user to make decisions. Even if the applica-
tion is providing easy-to-use tools, the user experience
designer must remember that patients, the users, are
humans. As such, they make decisions steered by logic
and emotions [24].
4) To understand better user experience it is crucial to
collect usability related data (e.g. number of “clicks”
before each selection or navigation pattern). In this case
it will serve to identify interaction aspects which need
to be improved, and, by correlating with health data,
how adapted is the system to be used by chronic pain
patients.
5) Similarly, health and pain information will be collected
aiming to perform an evaluation of the success or failure
of the platform to the improve the life quality of the
addressed patients.
6) An eHealth platform always needs to be configured in
order to support the end-user both as a patient and as a
user. This duality of requirements needs special attention
to detect any conflicts may arise during the design of the
central body of the platform.
To improve the tools provided to the final users and the
related user experience, it is important to take into consider-
ation all inputs and ideas by psychologists, doctors, testers,
end-users and all parties involved in the project [24], [25].
This brings to the design stage brainstorming sessions and
prototyping processes, which includes user flow development
and creating wireframe sketches, as shown in figure 2 and
figure 3), respectively.
A main goal of prototyping can be thought of as risk
reduction, as an effective prototyping process can reduce costs
and improve customer review quality [26]. Some of the issues
concerned are crucial to start linking the assignment lines
of user flow scheme to high fidelity prototypes or at least
computer made prototypes which are interactive.
Following the recommendations of Will Evans, we opted
to use wireframes as they support the design decisions via
a search in a problem space of alternatives; After the low-
fidelity prototyping phase, a further stage is needed to enable
us to find the best way forward in user actions along the
platform. Figure 3 shows some examples in more detail of
the individual preliminary screen prototypes which include the
navigation system. There are some cautions that must be kept
in mind: This medium-fidelity prototype has the main objective
of exploring scheme navigation and running usability tests.
Therefore a wireframe prototype needs an interaction between
user-testers and system.
In the current case we achieved a preliminary prototype
which is subject to further adjustments guided by feedback
from potential users, psychologists and other experts in this

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Fig. 2. IACT WITHPAIN user flow, low-fidelity prototype
field of research. It includes a 3D human character which at
the moment is static, although it is planned an active character
representation with the patient specific characteristics and with
progressive physical evolution. This web application is under
development and will be available to mobile platforms, though
some of the technological details are not yet totally defined
as well as the strategy to approach the mobile devices. So far
there are two strategies in line: a) a responsive webApp; b)
an application in the hybrid model (for example by resorting
to ReactNative framework); c) create native apps. The choice
will depend on the inclusion of new requirements in future
definitions, such as the need for localization and/or access to
device peripherals like the camera or Location services. The
webApp is clearly more flexible in terms of development, as it
will follow the developments for the non-mobile site, but has
restricted or no access to those peripheral devices and services.
V. CONCLUSION
Chronic pain is a major challenge for health-care systems
given its prevalence and direct and indirect costs. Also, there’s
a lack of widespread and cost-effective approaches to chronic
pain, particularly non-pharmacological, patient-centred care
and self-management of symptoms. Thus, the use of ICT’s,
innovative information and communication technologies, self-
management solutions may be crucial to reduce symptoms of
chronic pain and improve general well-being. For that prob-
lem, IACTWIT HPAI N will develop and deliver an ICT solution,
through a software platform tailored to chronic patients, for
self-management of pain and improvement of overall well-
being. The intervention contents will be delivered using cre-
ative and innovative therapeutic resources that will be adapted
to chronic pain. There will be a straight interconnectivity
and interactivity between the patient and the IACTWITH-
PAIN tool, providing real-time feedback and prompts that
are expected to promote user adherence and engagement.
This will contribute to improve patients’ autonomy and also
reduce the burden in health-care systems, as it will empower
patients to manage their health and pain. Also, by promoting
patients self-management, the chronic pain condition will be
better monitored and managed, which in turn may prevent
the aggravation of the clinical condition, including depressive
states. In addition, an effective management of chronic pain
will promote long-term health and quality of life in subsequent
stages of life. As the aim is to have people learning how to
deal with pain, through mindfulness-like exercises and collect
the associated performance and interaction data, this can be
seen as the development of a particular case of an e-learning
platform.
VI. ETH ICS A ND INFORMED CON SEN T
The authors state that current project development has
been approved by the appropriate Ethics Commission and all
data acquisition will only be performed based on Informed
User/Patient Consent.
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