Stefan Elbers

209 General discussion ecological validity of the measurements, but also has the potential to provide insight in the dynamic interplay of individual symptoms and to provide continuous feedback on treatment processes (Doherty et al., 2020). In the context of preventing relapse, EMA may also be interesting as a form of remote screening at follow-up that monitors the change over time. mHealth Applications in Interdisciplinary Pain Treatment The decision to develop the paper workbook into anmHealth intervention reflects increased interest in digital applications in rehabilitation care. Several authors suggest that second line treatment services are likely to be transformed into some form of blended care in the coming years, suggesting an important role for evidence-based digital applications to support self-management and maintenance (de Biase et al., 2020; Eccleston et al., 2021; van Ommen et al., 2018). Restrictions on direct patient contact as a result of COVID-19 have further catalysed this development (Eccleston et al., 2020; Emerick et al., 2020). In response to this growth, expert recommendations have been developed to critically monitor implementation of these applications in rehabilitation and ensure appropriate usage. For clinicians, it is important to weigh the potential benefits and limitations for individual patients and always allow for the possibility of non-digital alternatives (Eccleston et al., 2020; Emerick et al., 2020), while improving the accessibility of the application for all patients. This is of particular importance for patients with low health literacy who often have difficulties understanding instruction texts and navigating through the interface (Kim & Xie, 2017), threatening low adaptation and adherence. Ways of increasing accessibility include the use of videos and combining formal with informal teaching methods (Conard, 2019). Although we did not explicitly design the application for patients with low health literacy, we included a feature for various forms of educational materials and videos. Furthermore, the guideline for health care providers includes a stage in which they carefully consider the appropriateness of the intervention for the patient at that time. IMPLICATIONS FOR RESEARCH In the following section, we have organized the implications for research, comparisons with other studies, and future directions of this project in three main themes: 1. towards a living evidence ecosystem; 2. the role of self-management interventions in chronic pain treatment; 3. co-design methodology in the development of health care interventions. 1. Towards a Living Evidence Ecosystem According to Chambers (2018), an important challenge for the field of pain research is to decrease the time before research findings are disseminated to clinical practice. By means