Chronic musculoskeletal pain has vast global prevalence [1] and annual costs in the hundreds of billions of dollars in the United States [2,3]. Musculoskeletal disorders are debilitating and may contribute to the opioid epidemic, as they are the most common noncancer indication for an opioid prescription in the United States [4-6]. Nonsurgical care, including exercise, education, and behavioral health, is universally recommended as the first-line treatment for the majority of chronic musculoskeletal conditions [7] given that it can achieve similar outcomes to surgery with reduced cost and lower risk [8,9]. However, conservative care has significant barriers to effective implementation and requires higher patient engagement to be successful [10,11]. Notably, conservative care administered in a clinical setting is also costly, and ongoing monitoring is often infeasible. Given the growing burden of chronic musculoskeletal pain, a scalable and effective mode of conservative care delivery is needed.

Digital health interventions have the potential to improve conservative care outcomes for chronic musculoskeletal pain by increasing patient engagement through electronic delivery of interventions. This approach can better enable patients to take a proactive role in their treatment and learn to self-manage their chronic pain symptoms. With the ubiquity of smartphones, low-cost sensor technology, and advanced analytical approaches to assess complex health care data, the prospect of digital technology for improved patient care is apparent and is reflected in the growing number of clinical trial protocols and review papers on the topic [12]. Digital therapies are shown to be effective for improving outcomes associated with conditions requiring self-management and behavioral change, such as type 2 diabetes [13], hypertension [14], and insomnia [15]. In addition, patient willingness to seek surgical treatment is shown to decrease following participation in a digital care program (DCP) [16]. Chronic pain, although often difficult to diagnose and treat clinically, is also shown to improve with the aid of digital therapy [10]. For chronic musculoskeletal pain specifically, the DCP in this study was previously evaluated in two randomized control trials and demonstrated effectiveness for improving pain and disability associated with knee pain [17] and low back pain [18]. Although these previous musculoskeletal pain studies show potential for a digital therapeutic approach to improve outcomes, they are limited in sample size (less than 200 subjects) and real-world effectiveness has yet to be shown. In this study, we assessed engagement and subject-reported outcomes over a 12-week period following enrollment in the DCP in a sample of over 10,000 users with chronic knee or back pain.