Recently, I talked about PainSquad as an example of gamification for patient care.

This app–created originally for the Kids Hospital in Toronto, Canada–was developed as an interactive pain diary for children with cancer.

I came across this project based upon a poster presented at the 2012 Medicine 2.0 Conference.

Intrigued, I have kept in contact with the developers, and recently conducted an interview with the primary developer. The questions focused on what the barriers were for the implementation of such a feature in a mobile application, and where it can be expanded.


1. How did you get the idea for developing PainSquad? What support did you need to get it going?

In 2004, I developed one of the first electronic pain diaries for adolescents with arthritis called the e-Ouch using a Palm Tungsten. This diary used alarms to remind patients to complete the survey three times a day and the research team offered a small monetary reward to encourage compliance with the daily entries. In this project, average weekly compliance was 76%.

I wanted to use the same concept to better understand pain in children and teens with cancer. This time, I wanted to use the latest in smartphone technology (an iPhone app) to find a better way to internally motivate kids to complete the diary entries. Pain in children with cancer is one of the most distressing symptoms and can be due to the cancer itself, its treatment and/or procedures.

The current tools to assess pain in this population are paper-based and do not allow for real-time assessment. Having a better understanding of the types of pain that children with cancer experience will help clinicians to better manage it.

In order to develop the app, we first applied for funding to develop and evaluate the reliability and validity of this new pain assessment tool for kids –9 to 18 years of age with cancer. We received funding from Children’s Cancers and Blood Disorders to develop and evaluate this new pain assessment tool.

We then needed to find a company to develop this app. We interviewed three companies and decided on using Cundari, which is a communication firm. They developed the app inkind and proposed a gaming element that would spark children’s interest and improve compliance. The gaming element naturally motivated them to record their pain levels twice a day, over a two-to-three week period. I also needed support from my institution to host the database and with commercial development of the app.

2. Can you give an outline of how you will develop an algorithm for pain management using this approach?

Our next step is to develop a clinical decision-making support tool that will help kids with cancer learn how to better manage their own pain in the hospital and/or home setting. This tool will provide “in–the-moment” access to tailor and personalize self-monitoring of pain and other symptoms and pain-coping strategies. We will use a phased approach to build and evaluate this tool.

We recently hosted a two-day consensus meeting with experts in oncology and pediatric pain to develop the key features of this clinical decision-making tool. The next step will involve interviews with teens, their parents and health care providers to refine the features of the app. We will use this information to refine the algorithm. We will then apply for funding to develop the algorithm and evaluate it in a clinical trial.

3. What has been the overall feedback on PainSquad?

The response from patients, their families and clinicians has been overwhelming. Children feel more in control of their cancer pain with the app and enjoy using it. Compliance rates for recording pain twice-a-day jumped to 90% compared to the e-Ouch pain diary.

The only way to explain this increased compliance was the infusion of the creative gaming element. This app has also won numerous media awards including two Gold Cannes Lions in mobile category.

4. What barriers have you faced? How did you overcome them, and what advice do you have for others who may want to do this?

As researchers, we don’t realize how much work and financial support needs to go into launching an app in the Apple Store. We get the grant to fund the development and evaluation of these health apps but don’t give much consideration to the ongoing maintenance and technical support for them.

5. How do you think gamification will fit together with using mobile health technology? Who should healthcare providers partner with?

Gamification is a key ingredient in making mobile health apps stickable–especially for children and youth. Researchers and app developers need to partner with those who have expertise in developing games related to health.The Pain Squad app prompts patients to fill out a police-style report about their pain. After submitting a certain number of reports, patients move up the ranks to the next level of the game.

The Pain Squad app feels like a video game, prompting children to record their pain levels twice-a-day and rewarding them with badges and positive reinforcement. Sixteen videos featuring the casts of Canada’s top police dramas, Flashpoint and Rookie Blue, deliver messages telling the children who complete reports that they are moving up the ranks.

Lasting Thoughts:

I personally think this was a great example of where gamification really brought things together. A great target population, a greatly developed tool, and rewarding perks for users to stay adherent to its ultimate purpose. Further assessment and development by others should be able to capitalize on their success.

Jennifer Stinson, RN-EC, PhD, CPNP