Smartphone applications are used for self-management, telerehabilitation, evaluation and data collection in low back pain healthcare: a scoping review

Background Smartphone use has grown in providing healthcare for patients with low back pain (LBP), but the literature lacks an analysis of the use of smartphone apps. This scoping review aimed to identify current areas of smartphone apps use for managing LBP. We also aimed to evaluate the current status of the effectiveness or scientific validity of such use and determine perspectives for their potential development. Methods We searched PubMed, PEDro and Embase for articles published in English up to May 3 rd, 2021 that investigated smartphone use for LBP healthcare and their purpose. All types of study design were accepted. Studies concerning telemedicine or telerehabilitation but without use of a smartphone were not included. The same search strategy was performed by two researchers independently and a third researcher validated the synthesis of the included studies. Results We included 43 articles: randomised controlled trials (RCTs) (n=12), study protocols (n=6), reliability/validity studies (n=6), systematic reviews (n=7), cohort studies (n=4), qualitative studies (n=6), and case series (n=1). The purposes of the smartphone app were for 1) evaluation, 2) telerehabilitation, 3) self-management, and 4) data collection. Self-management was the most-studied use, showing promising results derived from moderate- to good-quality RCTs for patients with chronic LBP and patients after spinal surgery. Promising results exist regarding evaluation and data collection use and contradictory results regarding measurement use. Conclusions This scoping review revealed a notable interest in the scientific literatures regarding the use of smartphone apps for LBP patients. The identified purposes point to current scientific status and perspectives for further studies including RCTs and systematic reviews targeting specific usage.


Introduction
Technological development has accelerated notably in the field of telecommunication in the last few decades.Since the introduction of the first mobile phones, the number of users has continued to grow and is now estimated at 6.8 billion worldwide. 1Mobile phones have gained new capabilities such as better Internet connection, allowing them to substitute for personal computers to a large extent.This new generation of mobile phones, called smartphones, has changed a lot of human activity.The number of smartphone users worldwide has surpassed three billion and is forecast to further grow. 2xtensive software of smartphones has permitted the development of new applications, allowing video communication, social media consulting, gaming, and navigation.The potentially inexhaustible use of the smartphones cannot be ignored in any human activity including healthcare.
The dynamic technological development has been accompanied by a less spectacular increase in life expectancy.However, simultaneously, the rate of years living with disability (YLD) has stagnated or even increased for some diseases.The last estimations of the YLD positioned low back pain (LBP) as a leading cause of handicap worldwide. 3esides the obvious healthcare problem, the economic impact of LBP is serious, with the total mean cost per patient over six months estimated at EUR 715.6 in France. 4 One of the aspects of this problem is that LBP could be chronic or recurrent in nature and affects middle-aged, professionally active adults.Chronic LBP concerns less than 10% of cases but 85% of the costs. 5A further problem is that in most cases, physicians are unable to reliably identify the cause of the LBP symptoms, so they classify them as non-specific.
When nonspecific LBP persists and becomes chronic, it becomes increasingly complex and challenging to manage due to its multifactorial nature. 6Failure of the purely biomedical approaches targeting only pathoanatomical nociceptive aspects has led to the development of the more exhaustive bio-psycho-social model.This multidimensional approach encompasses psychological, biological, social, and environmental aspects. 7Current guidelines for management of chronic LBP include psychosocial interventions along with exercise therapy, medications, multidisciplinary rehabilitation and spinal manipulation. 8Completing the context of LBP, some authors highlight the problem of overtreating.Expanding testing and treatment by using therapies and diagnostic tools with weak scientific validity can drive increasing complication rates, marketing abuse and patients' confusion. 9The widespread occurrence of LBP self-management strategies seems appropriate to target economic and healthcare accessibility problems. 10artphone applications (apps) for this purpose appear to be promising tools, giving a wide range of possibilities for use, replacing education booklets, proposing and supervising exercise therapy (telerehabilitation), and stimulating adherence for self-management programs.Using smartphone apps are the most accessible way to provide rehabilitation services and to collect outcomes remotely as smartphones are personal and always available to patients. 11,12Such a new model makes health services more accessible and enhances patient participation and their engagement in selfmanagement. 11Compared to face-to-face treatment smartphone apps could potentially be more cost-effective and could help to overcome the problem of healthcare accessibility.This idea has been developed in other healthcare intents such as diabetes, 13 chronic obstructive pulmonary disease, 14 and osteoarthritis. 15However, smartphones equipped with multiple sensors, cameras, gyroscopes, accelerometers, and magnetometers could also be used as tools for range-of-motion (ROM) measurement 16 or could be simply used with the phone camera for clinical evaluation at a distance. 17Another feature is that smartphone apps could be used for surveying large population samples, allowing to create a database for more sophisticated analyses including case-based reasoning systems. 18Moreover, the need for healthcare management at a distance (telemedicine) has become crucial in the recent situation requiring confinement due to the coronavirus disease 2019 (COVID-19) pandemic.Without the possibility to access conventional healthcare face-to-face with providers, numerous clinicians were challenged to provide telemedicine in order to substitute conventional healthcare in nonessential services. 19,20Smartphone applications have become highly pertinent tools for this purpose.
Indeed, the use of smartphone apps has increased for LBP patients.However, there is a lack of synthesis of the scientific literature in the areas of smartphone app use.Moreover, it is not clear in what purpose using smartphone apps are pertinent and if such use is supported by the scientific studies.Giving a large range of area of interest and the fact that it is a new dynamically developing subject we believe that performing a scoping review will clarify these questions.

REVISED Amendments from Version 1
The article has been modified according to reviewers' comments.This includes some clarifications and sentence reformulations.We hope that the changes made improve the readability of the article.
The objective of this scoping review is to identify current areas of smartphone app use for managing LBP.It also aimed to evaluate the current status of the effectiveness or scientific validity of smartphone app use and to determine perspectives for their potential development.

Protocol and registration
Review protocol presenting search strategy was established without a registration number.

Information sources and search strategy
The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist was used to guide the present study. 21,63Two researchers (LD and JBL) independently searched for articles in PubMed (RRID:SCR_004846), PEDro and EMBASE (RRID:SCR_001650) by using MeSH keywords.The search strategy phrase for PubMed database was ("smartphone application" OR "smartphone app" OR "smartphone" OR "telerehabilitation" OR "telemedicine" OR "mhealth" OR "ehealth") AND ("low back pain" OR "back pain").Corresponding research was realized in PEDro and EMBASE by using the same keywords.Only English language and time frame filters were used for our research.The articles were screened and assessed for eligibility regarding the objective of the study.Articles published between January 1st 2005 and May 3rd 2021 were considered.This time frame includes the emergence of the new generation of mobile phones.

Eligibility criteria
Only studies of smartphone use in LBP adult patient healthcare were included.We excluded studies concerning telemedicine or telerehabilitation but without use of a smartphone.Similarly, we excluded studies in which the smartphone use involved healthy individuals for preventing LBP or promoting physical activity or a healthy lifestyle in healthy individuals.To broaden our review, all qualitative and quantitative studies were accepted, including randomised controlled trials (RCTs) and non-randomized studies, cohort studies, case-control studies, systematic reviews, reliability and validity studies, and study protocols.In cases where both the protocol and the completed study article were published, we included both to ensure comprehensive content analysis of the literature on the subject.Only studies accepted for publication, written in English were considered.

Selection of sources of evidence
Study inclusion was discussed to reach agreement or in cases where a consensus could not be reached, we consulted with a third researcher (EC).Then studies were classified according to the purpose of the smartphone app.The type of study design was also used to classify studies in terms of its objective: effectiveness of the smartphone use, reliability of the smartphone measures, or other type of evaluation and data collection.

Data charting process
Search strategy was prepared and validated with the participation of all authors of the present review.The same search strategy was realized by two researchers (LD and JBL) independently.A third researcher (EC) participated in the synthesis data charting.Then, additional articles were identified throughout citation matching.

Data items
We extracted data concerning smartphone app utilisation.We focused on the purpose of smartphone app utilisation, study design, date of publication, number of participants who completed the study, main outcomes, results and authors conclusions.

Critical appraisal of individual sources of evidence
The quality of selected RCTs was estimated by using the PEDro scale. 22

Synthesis of results
We categorized included studies by the purpose of smartphone app utilisation.The synthesis of the included studies was also done by study design, both were presented in a narrative format and in a synthesis table.

E, DC
Lee, 2016 28 RCT To evaluate the effects of the Graston technique and general exercise on pain and range of motion in patients with chronic LBP.

E
Ross, 2020 26 Retrospective cohort study To identify factors that predicted the benefits and future use of a smartphone pain app among patients with chronic pain.

Qualitative feasibility and quantitative pilot study
To evaluate the feasibility and acceptance of orthopaedists prescribing individualized therapeutic exercises via a smartphone app to patients suffering from non-specific LBP.

TR, SM
Corrêa, 2020 23 Reliability, validity study To test the inter-and intra-rater reliabilities and concurrent validity of smartphone app for quantification of pain drawings in patients with LBP.

Reliability, validity study
To evaluate the concurrent validity and the intra-rater reliability of thoracolumbar range of motion measurement using a mobile application and a digital inclinometer in individuals with and without back pain.

E
Yang, 2019 57 RCT -pilot study To evaluate the additional effect of selfmanagement on physiotherapy via the use of smartphone app on management of chronic LBP.

SM
We identified the following purposes of the smartphone apps: 1) evaluation, 2) telerehabilitation, 3) self-management or 4) data collection.We distinguished telerehabilitation and self-management because of a difference when the remote interaction between healthcare professional and patients occurred for LBP management (telerehabilitation).By contrast, some smartphone apps provide instructions for LBP management without giving feedback from a healthcare professional (self-management).Furthermore, the data collection use in most smartphone apps was coupled with other employmentlike evaluations or self-management, but in some studies, the smartphone app was mainly dedicated to collecting information for further analysis.

Use of smartphone apps for evaluation
3][34] Considering pain evaluation, PainMAP showed excellent intra-and inter-rater reliability and good validity for quantifying the number of pain sites and pain area. 23This application allows patients to mark their pain on digital body charts and automatically quantifies such self-assessment.Furthermore, another smartphone app could effectively evaluate pain changes after transcutaneous electrical nerve stimulation. 25However, Ross et al., reported that patients with chronic pain who appeared to manage their pain better were less likely to report benefits of a smartphone pain app designed for daily pain management and evaluation. 26artphone apps were used to measure lumbar spine ROM and lordosis but showed insufficient reliability and validity as compared with a gravity-based inclinometer. 27By contrast, de Brito Macedo et al., reported good concurrent validity and intra-rater reliability of smartphone thoracolumbar ROM measurements versus a digital inclinometer. 29Lumbar ROM measurement with a smartphone detected a significant difference due to manual therapy and exercise intervention in another study. 28Similar findings were further summarized in systematic review showing contradictory results of psychometric properties of the lumbar spine ROM and lordosis measurements with a smartphone app. 30her examples of smartphone use included clinical and functional evaluation.Peterson et al., suggested that a modified treatment-based classification system for subgrouping patients with LBP could direct treatment in telerehabilitation settings (smartphone app) because the overall rate of percentage agreement with face-to-face assessments was between 48.9% and 59.6%. 17The McKenzie classification and therapy applied with a smartphone app showed comparable clinical outcomes with the traditional clinic-based McKenzie therapy. 32The 6-min walk test performed with a smartphone app and using a GPS system could be reliable but needed to be performed avoiding indoors and city environments with high buildings and rectangular walking curses. 31However, in a scoping review of outcomes with smartphone apps used for LBP management, authors showed the problem of low quality of the outcome measures to monitor the treatment effect.Indeed, only a few smartphone apps offered to monitor their effectiveness in the management of LBP. 33Other examples of smartphone use for clinical evaluation is the use of the Backache Disability Index.Such evaluation includes rating five trunk movements in the erect position and scoring morning back stiffness.Performed remotely with a smartphone app, the index showed good reliability and validity. 34e of smartphone apps for telerehabilitation A total of 12 studies presented smartphone apps as a tool for providing rehabilitation interventions at a distance (telerehabilitation). 17,32,[35][36][37][38][39][40][41][42][43][44] Despite different designs and aims, most of the studies evaluated the effectiveness of the smartphone app use in telerehabilitation on pain and disability.Dario et al., performed a systematic review with metaanalysis to evaluate the effectiveness of the intervention based on any form of telerehabilitation, phone calls, emailing, and web-based chats but also smartphone apps.On the basis of data from 11 included studies, the authors concluded moderate evidence that current telerehabilitation interventions are not more effective than minimal interventions on pain and disability outcomes.Their study also revealed that the effectiveness of such interventions remains understudied. 40ndeed, only three RCTs evaluated the effectiveness of the smartphone apps use to provide telerehabilitation in LBP patients.Hou et al., evaluated a system of telerehabilitation based on a smartphone app interface for patients after lumbar surgery for LBP and a web-based interface for physicians providing and surveying rehabilitation and communicating with the patient.The authors demonstrated that the intervention was more effective than usual care regarding disability and pain status (Ostwestry Disability Index, pain visual analogue scale) at 24-month follow-up. 38Mbada et al., in their RCT, compared telerehabilitation-based McKenzie therapy versus the same treatment but provided in the traditional faceto-face setting.The smartphone app interface was used to introduce the treatment and was supported by phone calls and text messages in the experimental group.In this study, clinical improvement was noted at 4-and 8-week follow-ups, but no difference was found between the two groups in pain intensity, back muscle endurance and activity limitation.Thus, the authors concluded that smartphone app-based McKenzie telerehabilitation can be successfully used especially to bridge the gap in the non-availability of clinic-based therapy. 32Toelle et al., investigated the effect of a multidisciplinary smartphone app (Kaia App) on pain intensity at 12-week follow-ups in an RCT design.The experimental group received multidisciplinary self-management treatment based on current guidelines and supported by a chat with a healthcare professional via the app.The experimental group showed significantly lower pain intensity than the group receiving physiotherapy with on-line education. 41The Kaia App was evaluated previously in a retrospective cohort study and showed good effect on pain intensity reduction, 43 and the analysis of the updated version of Kaia App revealed improvement in treatment adherence. 42One more pilot RCT confirmed the feasibility and preliminary effectiveness of a physical activity intervention supported by a smartphone app on pain and disability.At the same time, patient acceptance and reduced care-seeking were observed. 36The protocol of this study is detailed in a separate article. 45Other studies focused on qualitative analysis of the patient's preferences and compliance in the smartphone app use 35,39 and case series analysis of feasibility, effectiveness on pain and exercices adherence, and patient satisfaction with the telerehabilitation booster session. 37Selter et al., in their pilot study, assessed the validity of an image-based quantification of pain-related disability as well as patient compliance and patient-perceived utility of the smartphone app (Limbr). 44The results showed good compliance and patient-perceived utility.In addition, the authors noted good validity of an image-based quantification of pain-related disability. 44

Use of smartphone apps for self-management
The most-studied use of the smartphone app in LBP patients was for self-management.We identified 29 articles focused on self-management of LBP via a smartphone app: four systematic reviews, 10,33,46,47 five RCTs, 11,38,41,48,49 five study protocols, 18,45,[50][51][52] six qualitative studies, 35,39,[53][54][55][56] three retrospective cohort studies, 26,42,43 five pilot RCTs, 36,44,57,58 and one case series. 37Many of the studies coupled the self-management and telerehabilitation in the same app or in the same study intervention.6][37][38][39][40][41][42][43][44][45] In a scoping review of the outcome used in the smartphone apps for self-management of LBP, Coe-O'Brien et al., found 74 apps; only four used the outcome measure that could be linked to the International Classification of Functioning, Disability and Health System (ICF) core set for LBP.Furthermore, they concluded that most of the apps were of low quality, indicating the lack of outcome evaluation in the apps. 33Machado et al., performed a systematic review of smartphone apps for self-management of LBP.Similarly, they analysed 61 apps and found overall low quality of the apps, pointing to the lack of studies evaluating their effectiveness, presentation of the questionable information, and unattractive layouts.They also recommend that app developers collaborate with healthcare professionals and researchers to ensure the benefit for LBP patients. 10A recent systematic review with meta-analysis analysed eHealth based self-management for chronic LBP.The term eHealth encompassed the interventions based on smartphone apps (m-Health) or on traditional Internet (web-Health) use, so studies included in this meta-analysis were not all based on smartphone apps.Nevertheless, the authors concluded low to moderate evidence of a positive impact on pain and disability of this type of self-management. 46Previously Nicholl et al., performed a systematic review of digital support interventions for the self-management of LBP.They revealed heterogeneity and low quality of the studies, which could not support the utility of digital based interventions for LBP. 47summary of the RCTs focused on effectiveness of smartphone apps targeting self-management for LBP is presented in Table 2 as is the quality evaluation using the PEDRO score.Chhabra et al., evaluated the effect of the self-management app Snapcare.A control group of LBP patients received a written prescription of medication and home exercises and were compared to a self-management group focusing on physical activity improvement based on Snapcare.The results at 12 weeks showed a similar improvement in pain in both groups and greater improvement in function in the Snapcare than control group.The authors concluded that such results support the utility of Snapcare for LBP patients. 11Suman et al., performed a cluster RCT evaluating the effectiveness and cost-utility of a multifaceted eHealth intervention based on websites and social media platforms but also including a mobile version, adaptable to a smartphone.The intervention was inspired by the Australian mass media campaign promoting physical activity, positive back beliefs and coping with LBP.The control group received a digital patient information letter.The presented eHealth strategy was not effective in improving patients' back pain beliefs or decreasing disability or absenteeism, but the study provided a favourable costutility analysis. 48Irvine et al., showed that their mobile app FitBack was effective in improving physical, behavioural and worksite outcomes.FitBack was based on a self-tailored cognitive-behavioural approach and used the American Pain Society recommendations. 49Almhdawi et al., also reported that use of their app called Relieve my back is efficient in pain and disability self-management. 58 also found several articles presenting study protocols for smartphone apps used by LBP patients.Sandal et al., presented the protocol of an RCT comparing the effect of usual care supported by the selfBACK app versus usual care only.Tailored self-management plans were provided by the selfBACK app consisting of advice on physical activity, physical exercises, and educational content.Self-management plans were prepared by using case-based reasoning methodology, a branch of artificial intelligence. 50Mork et al., presented complementary information regarding the implementation of the methodology used in the selfBACK protocol. 18One RCT protocol aimed to evaluate the effectiveness of Relaxback, focusing on relaxation for LBP patients in reducing pain.Autogenic training, mindfulness meditation and guided imagery is used in the app and will be compared to usual care. 51Another RCT protocol is for MIMate, designed to support motivational interviewing performed by a physical therapist and targeting behavioural changes regarding physical activity.MIMate is used between face-to-face physical therapy sessions and is compared to usual physical therapy sessions. 52o qualitative studies coupled telerehabilitation and self-management interventions and were mentioned in the previous section. 32,36Nevertheless, four other qualitative studies investigated the preference in content of an app improving selfmanagement 53,55 or the feasibility/utility of an app providing educational videos focused on self-management, postoperative protocols, or tailored self-management plans. 54,56Three retrospective cohort studies using smartphone apps for self-management of LBP were coupled with telerehabilitation, evaluation or data collection and were mentioned in the previous sections. 26,42,43Similarly, in two pilot studies, self-management was coupled with telerehabilitation; these articles were presented in the previous section. 36,44However, another pilot RCT, used a smartphone app to enhance selfmanagement between physical therapy sessions and compared it to physical therapy only.The Pain Care app provided self-management based on home exercises.The authors concluded that a more powerful study needed to be conducted considering their promising results. 57e of smartphone apps for data collection Some studies used smartphone apps for LBP patients to collect medical information.One study protocol presented a smartphone app to collect timely data in ecological situations, including pain intensity, physical function, analgesic use and adherence to auricular point acupressure treatment. 59Similarly, in a study that aimed to evaluate relations between opioid use and pain intensity, a smartphone app was used exclusively to collect information about pain intensity multiple times daily. 6043,50,54

Discussion
The aim of this scoping review was to identify the current fields of employment of smartphone apps for LBP patients.
Although the use of smartphone apps for LBP patients is relatively recent, the scope of our review appears to be large, with 43 articles meeting our inclusion criteria.Emerging uses of the smartphone apps are self-management, telerehabilitation, evaluation and data collection.The present review did not aim to firmly classify use of the smartphone apps, as their multiple uses can be controversial.Rather we aimed at investigating what could be the utility of the apps for LBP patients, the current scientific knowledge and perspectives that are worthy of study and development.
We observed a notable interest in scientific literature regarding the utilization of smartphone apps for patients with LBP.Self-management is a field of smartphone app use that has gained the most attention.Telerehabilitation is often coupled with self-management, and data collection is usually integrated with evaluation.The evidence of effectiveness of smartphone apps in self-management of LBP derived from RCTs are favourable on pain and disability for patients with chronic LBP 11,32,41,49,57 and patients after spinal surgery for LBP. 38However, one RCT reported no effect of such interventions on pain, disability and beliefs of LBP patients but showed promising cost-utility results. 48erall, the quality of the analysed RCTs was moderate to good as assessed by the PEDro score.Indeed, the content of the interventions varied between the studies, and different apps presented differences in providing self-management.Nevertheless, improving physical activity level and providing education about LBP were the common components of the interventions.Self-management with a smartphone app was frequently used together with other interventions including face-to-face physical therapy, web-based education or email reminders.The systematic reviews focused on self-management actually reviewed app stores to find existing self-management apps rather than screening the scientific literature data 10,33 or included the studies focused more largely on eHealth interventions. 46,47The effectiveness of the telerehabilitation interventions including smartphone apps evaluated by Dario et al., in a 2017 systematic review showed moderate evidence that telerehabilitation is not more effective than minimal interventions for pain and disability outcomes. 40However, since then, new RTCs have shown more optimistic results. 32,38,41Telerehabilitation and selfmanagement of LBP are in a phase of dynamic development; possibly favourable results in recent studies correspond to improvements in providing such interventions.
8][29] Indeed, technical aspects of such measurement are complicated: controlling all potential error sources in a multi-segmental movement is challenging.This observation is consistent with other spinal ROM measurement studies also indicating contradictory results. 61,62Using the therapist's personal smartphone to perform measurements on patients may not be practical.However, remote clinical evaluation using a smartphone app should be developed regarding the consistent results between remote and face-to-face subgrouping of patients by treatment-based classification, the McKenzie system and the Backache Disability Index. 17,32,34e of smartphone apps for data collection seems highly useful and effective.Smartphones are personal and easily accessible to collect data.Many of the studies we found used smartphone apps to collect information, even if the main use was self-management, telerehabilitation, or evaluation.It seems pertinent to develop this branch of smartphone use.At the same time, it's important to respect data security considerations.Yet, our review also reveals development in data treatment.A recently started study implements machine learning technology to provide a personal adapted selfmanagement strategy. 50For this form of analysis, a large amount of data needs to be collected and smartphones perfectly fit this goal.
Limitations Some articles could have been missed in our search strategy as we only used three databases.However, based on a large problem of our review, identifying the current fields of the smartphone apps use for LBP patients' points out perspectives for further studies including perspectives for a more specific systematic review.Also, the highly heterogenic terminology regarding smartphone apps use could have resulted in some omissions.Several studies using eHealth strategy (e.g., tablet apps) were not included if there was no clear information about the smartphone app use.

Conclusions
The present scoping review revealed that the scientific literature interest in the utilization of smartphone apps for patients with LBP is notable.The main uses are for self-management, telerehabilitation, evaluation and data collection.Selfmanagement is the most used in LBP and showed moderate-to good-quality evidence for effectiveness on pain and disability.Regarding technological and socio-cultural development, new fields of use may arise.

Data availability
Underlying data All data underlying the results are available as part of the article and no additional source data are required.

Reporting guidelines
Figshare: PRISMA-ScR checklist for 'Smartphone applications are used for self-management, telerehabilitation, evaluation and data collection in low back pain healthcare: a scoping review', https://doi.org/10.6084/m9.figshare.20555802.v1. 63ta are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).
The rationale and objectives of the study are clear for me.The introduction gives good context on the topic.
The methods used are quite clear and repeatable, but with some remarks: -In the exclusion criteria, it's not fully clear if you also excluded physical activity promotion or lifestyle advise for people with low back pain (or only for healthy people).
- Reviewer Expertise: Shoulder and trunk kinematics, development and assessment of innovative tools to assess and treat people whith chronic musculoskeletic disease, adhesion to treatment based on physical activity.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
The benefits of publishing with F1000Research: Your article is published within days, with no editorial bias • You can publish traditional articles, null/negative results, case reports, data notes and more • The peer review process is transparent and collaborative • Your article is indexed in PubMed after passing peer review • Dedicated customer support at every stage • For pre-submission enquiries, contact research@f1000.com

Figure 1 .
Figure 1.Flow diagram of studies selection.

Table 1 .
List of articles included in the scoping review.

Table 1 .
Continued 17, SMPeterson, 201917Validity study To evaluate the agreement between telerehabilitation and face-to-face assessments of patients with acute and subacute LBP using a modified treatmentbased classification system, and patient satisfaction.E, TR

Table 2 .
Summary of randomized controlled trials evaluating smartphone app-based self-management interventions for patients with low back pain (LBP).

the rationale for, and objectives of, the Systematic Review clearly stated? Yes Are sufficient details of the methods and analysis provided to allow replication by others? Yes Is the statistical analysis and its interpretation appropriate? Not applicable Are the conclusions drawn adequately supported by the results presented in the review? Yes If this is a Living Systematic Review, is the 'living' method appropriate and is the search schedule clearly defined and justified? ('Living Systematic Review' or a variation of this term should be included in the title.) Yes
You included study protocols, but what did you do when those studies were performed and published?Since they can describe the exact same study, can you mention if you excluded protocols when the article of the finished study was published for example.Or any other way of handling them if you included them both.-In the synthesis, can you explain how you drew conclusions like 'promising'.Did you draw those conclusions yourselves or did you take (copy-paste) these conclusions from the included article (like you do mention in table 2 under 'author's conclusion')?This last point applies for the results and discussion/conclusion as well.Quite often you use conclusions like 'promising'.To me, it's too subjective (and perhaps biased).It would be nice if you can give some clarity on that.I understand it's not the main goal like in a systematic review or meta-analysis.
Competing Interests: No competing interests were disclosed.