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Addiction to opiates and synthetic opioids poses a major threat to public health worldwide, with pharmaceutical opioids prescribed to manage pain constituting the main problem. To counteract this threat, suitable pain management strategies should be implemented in health care. Monitoring pain management seems to be feasible using telemedicine with a certain degree of resource intensity and digitization. As a communication channel for this type of monitoring, SMS appears to be a valid alternative.
The aim of this systematic literature review was to (1) provide information on the state of research regarding postoperative pain management via SMS, (2) establish a basic understanding of SMS-based pain management, and (3) provide insight into the feasibility of these management strategies. The research question was as follows: Is postoperative pain management feasible and effective utilizing SMS?
A systematic literature review was performed mainly following the PRISMA guidelines and another guide on performing a systematic literature review for information systems–related research. A search string was developed based on the objectives and research question, and eight databases were searched.
The initial search resulted in 2083 records, which could be narrowed down by applying various exclusion criteria. Thereby, 11 articles were identified as relevant, which were accordingly analyzed and evaluated by full-text screening. In all articles, pain management interventions were performed using SMS communication between health care professionals and patients or their legal guardians. A prospective approach was predominantly chosen as the study design (91%) with the leading research objective of determining the intervention’s feasibility (73%). The primary reason for sending SMS messages was to monitor patients (64%). Overall, the use of SMS improved adherence, acceptance, and satisfaction regarding postoperative pain management. With an average response rate of approximately 89.5% (SD 3.8%), the reliability of SMS as a communication and monitoring tool was further emphasized. This response rate is significantly higher than that for email interventions (66.63%,
This study provides a comprehensive picture of the current status on postoperative pain management by SMS. Communication via SMS was beneficial in all interventions, even preoperative. Six SMS interventions could be certified by the respective institutional review board and three were Health Insurance Portability and Accountability Act–compliant. Therefore, the results of this study could be leveraged to address the opioid epidemic. Overall, the research question could be confirmed. Future research should extend this systematic literature review regarding preoperative pain management. Based on these findings, a pre- and postoperative communication model should be developed to address the opioid epidemic effectively.
Globally, the increasing use of opiates and synthetic opioids poses a major threat to public health [
Almost every aspect of these pain management strategies, and the efficiency and quality of health care rely on effective communication [
Mobile health, delivered through mobile instant messaging apps or SMS texting, has particular potential in this regard. SMS is utilized more frequently [
To address the ongoing opioid epidemic, pain management combined with SMS as a communication medium appears to be very viable, whereby the postoperative phase seems to be unusually decisive. Therefore, the aim of this study was to structure the current state of the literature regarding postoperative pain management via SMS. To our knowledge, there is currently no specific literature review on SMS-based pain management and no synthesized results. Accordingly, this study examined the following research question: Is postoperative pain management feasible and effective utilizing SMS? By answering the research question through a systematic literature review, a conceptual framework for future research is provided.
To gain a valid answer to the research question, the paper is structured as follows. In the Methods, we describe the process of performing the systematic literature review, along with a detailed description of the specific selection and exclusion criteria. The results of the selected literature are compiled accordingly in the Results. The Discussion explains the principal insights from the included studies, along with the limitations of this review. Finally, we provide recommendations for action based on the conclusions, and highlight research gaps for researchers, clinicians, and other health care professionals.
The goal of this literature review was to provide comprehensive insight into postoperative management via SMS. The review should (1) provide information on the state of research, (2) establish a basic understanding of SMS-based pain management, and (3) provide deep insight into the feasibility of these management strategies. To ensure completeness and transparency, a systematic literature review process was followed in all stages of the study. The methodology is mainly based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [
In consideration of the research question, a search string was designed using Boolean operators (AND, OR) for the selection of relevant literature. Various keywords connected the decisive aspects regarding text messages, postoperative care, and pain management. The conclusive search string is documented in the protocol (
Systematic literature review flowchart. PM: pain management; PT: postoperative treatment.
The initial search in the eight databases resulted in 2083 matches. The screening process narrowed down this result by applying a variety of exclusion criteria. Initially, only articles that were published in academic journals or conferences were considered. Further, all non-English articles were excluded. By applying these two criteria, 1305 articles were already excluded. Next, all duplicates were identified by DOI or title alignment and deleted for the next steps (n=143). The remaining 635 articles were screened by title, abstract, and keywords for their relevance to the research question. Accordingly, the papers needed to describe and analyze pain management, and to clearly emphasize postoperative care and SMS. Articles that interpreted abbreviations such as SMS differently or focused on issues not relevant to the review were further excluded. During this screening process, a total of 382 articles could be identified as irrelevant, as these articles neither focused on pain management, postoperative treatment, nor SMS. Only two of these three issues were addressed in 73 articles and one of the three was addressed in 163 articles. As a result of this process, 618 articles were classified as irrelevant, leaving a total of 17 articles eligible for further review.
Full-text screening was performed to comprehensively analyze the remaining 17 articles, and an additional 7 articles were excluded due to thematic deviations or the secondary research method. Based on the remaining 10 articles, a forward and backward search was executed. The backward search revealed no new articles. The forward search resulted in a total of 64 matches for the eight databases. After applying the exclusion criteria, one additional article could be included for analysis, leaving 11 articles in the final pool for review (
Of the 635 articles analyzed in the screening process, 554 (87.2%) were published in the last 5 years, since 2014. This reflects the increasing relevance of digitalized postoperative pain management in recent years. Correspondingly, this is apparent in the final pool of 11 articles, with 45% (n=5) published in 2018 and 36% (n=4) published in 2019. Three articles were published in the journal
Ten of these 11 (91%) studies adopted a prospective design to investigate postoperative pain management in conjunction with SMS. Patients were grouped as cohorts, and investigated for pain and similar outcomes. One study was a nonblinded randomized control trial [
Characteristics of the 11 studies.
Reference | Study design | Research aim | Automation | Age (years), mean (SD) | Surgical procedure |
Anthony et al [ |
Prospective multicenter cohort | Feasibility | yes | 49.6 (13.7) | Hand surgery |
Anthony et al [ |
Prospective cohort | Feasibility | yes | 46.0 (22.0) | Lower extremity fracture |
Booth et al [ |
Prospective cohort | Feasibility | n/aa | 30.7 (5.5) | Caesarean section |
Brix et al [ |
Nonblinded randomized control trial | Feasibility | yes | 47.5 (16.5) | Knee arthroplasty |
Carrier et al [ |
Prospective multicenter cohort | Validation | yes | 57.0 (n/a) | Colorectal surgery |
Chen et al [ |
Prospective cohort | Feasibility | yes | 8.5 (n/a) | Tonsillectomy |
Day et al [ |
Prospective cohort | Feasibility | yes | n/a | Total hip or knee arthroplasty |
Nelson et al [ |
Prospective cohort | Feasibility | yes | 6.1 (2.1) | Humeral fractures |
Newton and Sulman [ |
Prospective cohort | Feasibility | n/a | n/a | Tonsillectomy |
Premkumar et al [ |
Prospective cohort | Validation | yes | 59.4 (10.9) | Total hip or knee arthroplasty |
Yahanda et al [ |
Prospective cohort | Validation | yes | n/a | Total hip or knee arthroplasty |
a n/a: not available; the article did not provide corresponding information.
Overall, 4195 patients were supported by a pain management system tailored to the surgery performed and to the patients’ characteristics such as age or physical condition. The number of study participants ranged from 21 to 3049, with a mean of 381 participants and a median of 85. To select these patients, the researchers applied various selection criteria. For instance, 9 of the 11 (82%) research teams excluded patients without a mobile phone, 6 (55%) excluded patients who could not communicate via SMS, and 5 (45%) excluded patients with a language barrier. At the beginning of the intervention, the sex and age, and other demographic data of all participants were determined in 8 of 11 (73%) studies. The percentage of female participants ranged between 33% and 100%. The intervention was directed at adult patients with a mean age between 30.7 and 59.4 years in 6 of 8 (75%) studies. The other 2 studies analyzed pain management in children between 6.1 and 8.2 years of age (
Nine of the 11 studies used automated pain management systems for their interventions and the other 2 studies did not provide any relevant information on this aspect [
Overview of the interventions.
Study | Message purpose | Time (postoperative days) | Opioids | Pain scale | Alerts | Reminders |
Anthony et al [ |
Monitoring | 7 | yesa | 0-10 | no | yes |
Anthony et al [ |
Monitoring | 14 | yes | 0-10 | no | no |
Booth et al [ |
Monitoring | 60 | yes | 0-10 | yes | no |
Brix et al [ |
Adherence/monitoring | 4 | no | 0-10 | yes | no |
Carrier et al [ |
Monitoring | 7 | yesa | 0-10 | no | yes |
Chen et al [ |
Monitoring | 14 | yesa | 0-10 | no | yes |
Day et al [ |
Education/adherence | 14 | yesa | no | yes | no |
Nelson et al [ |
Monitoring | 21 | yes | 0-10 | no | no |
Newton and Sulman [ |
Education/adherence | 9 | yesa | no | yes | no |
Premkumar et al [ |
Monitoring | 42 | yesa | 0-10 | no | no |
Yahanda et al [ |
Adherence/monitoring | 15 | yesa | 0-9 | no | yes |
aNo specific information about the type of opioid used given.
Whether the goal of the intervention was for patient monitoring or to analyze the adherence to pain management, the studies defined different timeframes. With 60 intervention days, one study was distinctly longer than the others [
For 7 of the 11 (64%) studies, the message blocks’ primary outcome was the monitoring of the postsurgical pain level of the investigated patients. However, 3 of the 11 (27%) studies focused primarily on adherence to the treatment [
Four out of the 11 (36%) interventions sent additional reminders to patients, and 4 interventions (36%) also sent alerts to patients and physicians (
All studies identified a positive effect of SMS on pain management, thereby indirectly providing various recommendations for action. First, 7 interventions measured response rates, each with concrete results. Overall, between 8 and approximately 400 messages were sent to patients or legal guardians. With an average response rate of approximately 89.5% (SD 3.8%), the reliability of SMS as a communication and monitoring tool is evident, especially in comparison to conventional communication methods (
Further, the response rate was confirmed to decrease steadily over the intervention duration, and the majority of unanswered messages occurred within the last postoperative days [
Summary of systematic literature review results.
Reference | Outcome | Results | SMS messages sent, N | Response rate (%) | Compliance |
Anthony et al [ |
Effective | Highest pain level within first 48 h; average use of 15.9 prescription opioids | ~19 | 88.3 | IRBa/HIPAAb |
Anthony et al [ |
Effective | Response rate, pain, and medication intake decline over time | ~22 | 87.5 | IRB/HIPAA |
Booth et al [ |
Positive impact | Rate especially powerful compared to traditional methods | ~400 | 82.0 | IRB |
Brix et al [ |
Positive and efficient | Nonsignificant trend for better adherence | ~8 | n/ac | n/a |
Carrier et al [ |
Positive impact | Intervention led to earlier detection | 16 | 89.5 | n/a |
Chen et al [ |
Positive impact | Real-time monitoring possible | 14 | 88.0 | n/a |
Day et al [ |
Positive impact | High satisfaction rate, high adherence and acceptance among patients | ~18 | n/a | IRB |
Nelson et al [ |
Positive impact | Less medication intake, pain decreased daily | ~20 | 88.4 | IRB/HIPAA |
Newton and Sulman [ |
Positive impact | Improved adherence and communication quality, less anxiety, positive educational effect | 12 | n/a | n/a |
Premkumar et al [ |
Positive impact | Real-time, highly accepted, and available data collection method | ~80 | 96.1 | n/a |
Yahanda et al [ |
Positive impact | Improved adherence and satisfaction | ~18 | n/a | IRB |
aIRB: institutional review board.
bHIPAA: Health Insurance Portability and Accountability Act.
cn/a: not available; the article does not provide corresponding information.
SMS-based pain management is highly applicable and efficient for postoperative communication between health care professionals and patients or legal guardians. Furthermore, alarms and reminders via SMS can improve and maintain communication, while supporting patients or their legal guardians. This support function is desirable for effective pain management [
SMS technology was associated with positive results for all studies. The ubiquity of SMS makes it a cost-effective and straightforward method for pain management that is valid and less intrusive [
Furthermore, the use of SMS can prevent potential bias, and ensure the consistency and timeliness of messaging to patients [
SMS-based pain management allows for simple pre- and postoperative extensions such as easily integrable and more specific questions about the operation and possible symptoms. In addition, reminders and alerts can be triggered automatically by SMS systems. Nevertheless, the response rate was confirmed to decrease steadily over the intervention duration, and the majority of unanswered SMS messages occurred within the last postoperative days [
This study is subject to various limitations. First, only a basic quality analysis of the identified studies was applied. A more detailed analysis could clarify whether the final pool is rigorous, relevant, and credible. However, demand for high-quality research approaches such as randomized control studies is identified, as only one study was a nonblinded randomized control trial [
This study provides a comprehensive review of the current status of the literature on postoperative pain management by SMS. SMS utilization as a communication channel appeared to be favorable and feasible in pain management in the postoperative phase. According to three studies, SMS also seems to be useful for preoperative pain management, especially for additional information on medication or schedules, or as reminders. SMS resulted in excellent patient response rates, better adherence to pain treatment, higher patient satisfaction, and less medication intake. Six SMS interventions were certified by the respective IRBs and three were HIPAA-compliant. This indicates that SMS is capable of meeting health care requirements and is suitable for a health care–specific application. All of these benefits could be leveraged to address the opioid epidemic directly, effectively, and efficiently. The ability to create efficient pain management via SMS ensures comprehensive monitoring and communication. Key drivers of the opioid epidemic, such as medication abuse, shifted patient expectations, inadequate medical education, or inadequate guidelines, could be adequately addressed. In conclusion, the research question could be confirmed: SMS is effective, very well-suited, and feasible for postoperative pain management.
Future research should extend this systematic literature review regarding preoperative pain management. Based on this, a pre- and postoperative communication model should be developed to address the opioid epidemic effectively. This model should be generally applicable and adaptable to the individual clinical situation.
Systematic review protocol.
Health Insurance Portability and Accountability Act
institutional review board
None declared.