Data from the two qualitative studies and the systematic review of measurement properties informed the content of the PROM app. The app development was based on a ‘Software as a Service’ (SaaS) model. A staged process was followed including defining the app objective, designing the content, development of the app by, testing of the app and disseminating the app into clinical practice. The software release cycle for apps includes a series of stages from initial development to its eventual release:

Pre-alpha: all activities performed during the software development but prior to testing;

Alpha: the first phase of software testing using white box techniques [23];

Beta: the phase generally begins when the software feature is complete, and generally incorporates usability testing to address speed and performance issues [24, 25];

Open and closed beta: closed beta versions of software have restricted accessibility based on the decisions of the developers. Open beta versions, by contrast, are tested by a much wider, informal group who are invited to report bugs [26, 27];

Full release of the ‘stable’ or final user version.

The initial version of the PROM app underwent α- and β-testing, and data security assessment. The pre-alpha and alpha testing stages were undertaken by A closed beta version was created and tested by a convenience sample of patients from different age groups and technical capabilities who were asked to provide feedback on their experience. During the pilot data collection phase using the app patients were asked to provide any feedback on access, speed issues, and usability of the app. These were fed back to who addressed some minor issues prior to the release of the ‘stable’ or final user version of the software for this study.

The pilot testing of the app involved three separate data collection streams to assess the feasibility of using the app, its responsiveness, and test-retest reliability of the PROMs [28]. Volunteer osteopaths recruited patients on a consecutive basis. Patients with symptoms of low back pain of duration 0–6 weeks were included in the responsiveness arm of the study (R), patients with chronic, stable (unchanging) symptoms of low back pain of duration 13 weeks or more were included in the test-retest arm of the study (T), and patients with chronic changeable or subacute symptoms were included in the feasibility arm of the study (F). Patients accessed the data collection system by i) visiting the PROM app weblink to submit their details directly online, or ii) by downloading the app directly on to their mobile phone or tablet device. The patients received automated emails /”push notifications” and email/push notification reminders to their device via the app asking them to complete the follow up questionnaires at one and six weeks post-baseline.

Thirty osteopaths participated in the pilot study and they recruited 257 patients. The pilot process took place between September, 2014 and June, 2015.

Responsiveness data indicated that all of the PROMS were responsive, had good test-re-test reliability and were feasible [28]. The RMDQ was poorly completed and was removed from the final version of the app. The Bournemouth Questionnaire (BQ) includes a question about patients’ which duplicated the VAS information, therefore the VAS was removed from the final version of the app.

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