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106 Usability of paper and electronic pain drawings in assessing musculoskeletal pain: a scoping review
  1. Jordan Smitham1,
  2. Benjamin Bowling1,
  3. Cabella Lowe1,
  4. Shellie Boudreau2,
  5. Matt Morrissey3,
  6. Dylan Morrissey1
  1. 1Sports and Exercise Medicine, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
  2. 2Department of Health Science and Technology, Aalborg University, Denmark
  3. 3The Faculty of Life Sciences and Medicine, Kings College London, UK


Background COVID-19 has accelerated the implementation of online consultations thus creating the need to assess usability of electronic-pain-annotation tools. We aimed to learn from the pandemic and generate practice recommendations from assessing electronic-pain-annotation and pen-to-paper-annotation by producing a detailed usability framework.

Materials and Methods This study followed the PRISMA scoping review guidelines. Online databases were searched from January 2015 to February 2021 for studies evaluating pain diagram usability in adults with musculoskeletal pain. Study quality was assessed using STROBE. An evidence gap map, framework and infographic were constructed.

Results 22 observational studies, 1 systematic review and 1 app review were included; of which 9 were high quality, 13 medium and 1 low (App review not assessed). 9 studies reviewed pen-to-paper-annotation, 14 reviewed electronic-pain-annotation and 1 both. Pen-to-paper-annotation and electronic-pain-annotations were found to be highly reliable (ICC 0.81–0.998), valid, and successful communication tools. Both had a positive relationship with outcome measures assessing psychological comorbidities, such as the widespread pain index. Gender specific electronic-pain-annotations enable better identification with the diagram and enhance communication about pain. Barriers involved lack of technology, interpretation, age, and pain experience. Automated weekly reminders were a completion facilitator. There were no studies directly comparing electronic-pain-annotation to pen-to-paper-annotation.

Conclusion Electronic-pain-annotation and pen-to-paper-annotation were both effective at communicating pain with electronic-pain-annotation allowing for more accurate quantification of pain extent. Gender specific electronic-pain-annotation allowed for better reporting of pain. Gaps included responsiveness in both modes and usability in electronic-pain-annotations which needs to be addressed to optimise integration into electronic health records.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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