Pain Squad app helps sick kids track pain as a game

A new iPhone app developed for the Hospital for Sick Children in Toronto is giving kids some degree of control over their treatment. The concept behind Pain Squad: Special Police Unit is that patients are recruited by an investigative force that hunts down pain. According to Jennifer Stinson, it’s a way of getting kids to regularly complete entries in a pain diary—not an easy task when a child is weak and discouraged because of their illness and treatment regimens.

“We really need to understand what their pain is like in order to best treat it,” said Stinson, a clinical researcher in the chronic pain program at SickKids, on the line from a Calgary hotel room. According to her, kids with chronic pain say it’s difficult for them to describe in words. “Having an app like this allows them to honestly talk about their pain in a way that they like,” she said.

Twice a day, patients are reminded to complete a pain-reporting mission, answering questions about pain intensity and location using a simple touchscreen interface. Filling out three reports in a row earns them a promotion to the next rank in the squad. The promotions are delivered in the form of short videos featuring the stars of Canadian-filmed TV shows Flashpoint and Rookie Blue.

Back in 2004, Stinson piloted one of the first electronic pain diaries for kids using the Palm Tungsten PDA, and noticed that kids loved using the technology but that they tended to stop filling out the assessments after a week. Rather than pay a nominal fee to encourage them—something that’s done in some institutions—she put out a call to outside companies for ideas on how to internally motivate kids.

Toronto ad agency Cundari won the contract. “We took the pain diary concept and turned it into a bit of a game,” said the company’s Mike Orr, project manager on the app’s development.

The decision to develop Pain Squad for Apple’s iPhone was simple, Orr said. “It needed to do things like run this thing offline and in a secure way that stored the responses and then synchronized them with the server when connectivity was available,” he explained. “And iOS is the most stable and reliable platform for doing that.” (iPhones were preloaded with the app and provided to patients.)

While not a game in the strict sense—Pain Squad doesn’t have rules or objectives beyond participation—the software uses features of games: rewards and achievements, for example. The challenge, Orr said, was to design something engaging enough to keep kids coming back to use the app.

The biggest constraint, according to Orr, was that the questions the patients needed to be asked were set in stone—understandable, given the clinical requirements of the responses. “You can’t play with the formal structure of the survey,” Orr said, “but the environment the survey is delivered in, that’s where you have the opportunity to get a little creative.”

The app is easy to use, so it’s not a burden for a low-energy child to fill out the survey. And Pain Squad gives a person more than just a chance to record their experience of pain. “To have something that gives them a sense of controlling their own destiny and controlling their own care is pretty empowering,” Orr said.

And Pain Squad seems to be working. Stinson has completed two studies on its effectiveness and found that patients are 90-percent compliant, compared to as low as 72 percent with other tools. “These are kids that are having chemotherapy and other treatments. They feel unwell,” she said. “They were asked to complete it twice a day for two weeks, and the majority of them completed every entry.”

The program is now being rolled out at SickKids after the completion of a testing phase. This month, three other Canadian hospitals—McMaster Children’s Hospital in Hamilton, Ottawa’s Children’s Hospital of Eastern Ontario, and B.C. Children’s Hospital in Vancouver—will begin using Pain Squad with their patients. It’s not available to the public, but Orr said SickKids is considering making it available.

An expanded version, Orr added, could become a clinical tool to help patients manage their pain, beyond just recording their experience of it. And Stinson said her eyes have been opened to the effectiveness of games in clinical settings. “Kids with pain don’t want to move,” she said. “So if we can have an app that tracks their pain and mobility, and then provides them with some sort of game to increase their activity despite the fact that they have pain, that would be awesome.”