key: cord-0847132-i37suecf
authors: Burns, Suzanne P.; Terblanche, Madeleine; Perea, Jaimee; Lillard, Hannah; DeLaPena, Catalina; Grinage, Noelle; MacKinen, Ashley; Cox, Ella Elaine
title: mHealth Intervention Applications for Adults Living With the Effects of Stroke: A Scoping Review
date: 2020-12-16
journal: Arch Rehabil Res Clin Transl
DOI: 10.1016/j.arrct.2020.100095
sha: 966af2508ae08a3488f5a9ef5d1755a89e495c5b
doc_id: 847132
cord_uid: i37suecf

OBJECTIVE: To conduct a scoping review of mobile health (mHealth) application (app) interventions to support needs of adults living with the effects of stroke reported in the literature. DATA SOURCES: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus were systematically searched for peer-reviewed publications. Articles were published between January 2007 and September 2020 and met predefined inclusion and exclusion criteria. STUDY SELECTION: Articles included were written in English language, involved adults older than 18 years, and described an mHealth app specifically tested and/or developed as an intervention for someone with stroke to be used remotely and/or independently without constant provider supervision or assistance. Articles were excluded if they focused on acute management of stroke only, focused on primary prevention, were animal studies, were not an app for smartphone or tablet, and did not describe an empirical study. DATA EXTRACTION: Two researchers independently screened titles and abstracts for inclusion. The full-text articles were then reviewed for eligibility by the research team. Data were extracted and verified by a third reviewer. DATA SYNTHESIS: The search yielded 2123 studies and 49 were included for data extraction. The findings reveal that a global surge of studies on mHealth apps for people with stroke have emerged within the past 2 years. Most studies were developed for persons with stroke in the United States and the primary content foci included upper extremity function (31.5%); lower extremity function (5.3%); general exercise, physical activity, and/or functional mobility (23.7%); trunk control (5.3%); medical management and secondary prevention (26.3%); language and speech skills (20.5%); cognitive skills (7.9%); general disability and activities of daily living (5.3%); and home safety (2.6%). Of the included studies, a majority were preliminary in nature, with 36.7% being categorized as pilot or feasibility trials and 24.4% discussing initial design, development, and/or refinement. CONCLUSIONS: Results from this study reveal that the number of apps specifically developed for people with stroke and described in the scientific literature are growing exponentially. The apps have widely varied content to meet the needs of persons with stroke; however, the studies are generally preliminary in nature, focusing on development, usability, and initial pilot testing. This review highlights the need for additional research and development of mHealth apps targeted for adults with stroke. Development should consider the various and complex needs of people living with the effects of chronic stroke, while large-scale trials are needed to build on the existing evidence.

extremity function (5.3%); general exercise, physical activity, and/or functional mobility (23.7%); trunk control (5.3%); medical management and secondary prevention (26.3%); language and speech skills (20.5%); cognitive skills (7.9%); general disability and activities of daily living (5.3%); and home safety (2.6%). Of the included studies, a majority were preliminary in nature, with 36.7% being categorized as pilot or feasibility trials and 24.4% discussing initial design, development, and/or refinement. Conclusions: Results from this study reveal that the number of apps specifically developed for people with stroke and described in the scientific literature are growing exponentially. The apps have widely varied content to meet the needs of persons with stroke; however, the studies are generally preliminary in nature, focusing on development, usability, and initial pilot testing. This review highlights the need for additional research and development of mHealth apps targeted for adults with stroke. Development should consider the various and complex needs of people living with the effects of chronic stroke, while large-scale trials are needed to build on the existing evidence. Stroke is a chronic health condition, and survivors have persistent unmet needs after hospitalization. 1 Poststroke functioning and disability are dynamic, complex, and influenced by impairments and contextual factors. 2 People living with the effects of stroke may have challenges managing their day-to-day lives, and oftentimes this burden falls on both the survivors and their families and care partners. 3 Furthermore, people living with the effects of stroke are at risk for health-related decline, hospital readmission, and an overall reduction in quality of life. 4, 5 Adults with stroke describe feeling abandoned and marginalized by health care services and report lacking knowledge and skills to meet their long-term needs. 5 In fact, nearly 40% of people with stroke do not receive services needed to support long-term needs. 6 Some people with stroke are discharged home immediately after stabilization in the acute hospital, while others receive postacute care services such as inpatient rehabilitation prior to transitioning to life in the community. Nonetheless, it is widely agreed on that services are needed that extend beyond current health care delivery systems to meet population needs. 4 Mobile devices, such as smartphones and tablets, are becoming increasingly embedded in peoples' everyday lives. 7 mHealth applications (apps) have the potential to transform health care delivery and may be particularly useful in the effective management of chronic disease and comorbidities. Although they are not without limitations, mHealth apps are becoming increasingly popular. Adults with stroke are frequently downloading and using apps to support everyday life tasks 7 ; however, a residual knowledge gap exists about the role of mHealth apps supporting selfmanagement of health and function among survivors. Therefore, the purpose of this study is to summarize current literature about interventions delivered via mHealth apps for use by persons living with the effects of stroke. Given the wide adoption and popularity of smartphones and tablets, it is anticipated that these findings will guide future research and development to optimize improved long-term health and functional outcomes.

A scoping review was conducted by systematically searching the literature for eligible studies, extracting relevant data, and qualitatively summarizing the results. Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews was used to guide this current review. 8 A review protocol does not exist for this study.

The lead author and research librarian developed a systematic search strategy that was conducted in October 2018 and September 2020. The search was limited to studies written in English language and in adults older than 18 years. It was conducted within PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus and was composed of Medical Subject Headings of the National Library of Medicine and natural language terms. The search terms included stroke, cerebral vascular accident, recovery, rehabilitation, smartphone, mobile applications, mHealth, telerehabilitation, and telemedicine.

The search included articles beginning in 2007, which was when smartphones and apps began to be generally available. All article titles and abstracts were uploaded to Rayyan web and mobile app a for data management. Two authors independently screened titles and abstracts for inclusion and exclusion. A dichotomous "no" or "maybe" scoring system was used for initial article exclusion. When disagreement on article inclusion occurred, a different author would review to make a final decision on inclusion for full-text review. The authors engaged in hand searching, which involved probing reference lists of review articles, included manuscripts, and first author names of included studies in Google Scholar. Articles included were written in English language, involved adults older than 18 years, and described an mHealth app specifically tested and/or developed as an intervention for someone with a stroke to be used remotely and/or independently without constant provider supervision or assistance. Articles were excluded if they (1) focused on acute management of stroke only (eg, alteplase administration), (2) focused on primary prevention, (3) were animal studies, (4) were not an app for smartphone or tablet, or (5) did not describe an empirical study. Review papers were excluded; however, reference lists were reviewed through hand searching.

Once all of the publications that met inclusion criteria were identified, the researchers extracted and recorded relevant information that matched the aims of the study (i.e., study design, app name, content, quoted study aims, quoted author conclusions). Content foci categories were coded by the first, second, and third authors. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram (fig 1) illustrates the identification, inclusion, and exclusion of articles leading to the final selection of studies for data extraction.

A total of 2123 articles were retrieved from database and hand searching. After removing duplicates and screening for eligibility, 49 articles remained and underwent data extraction. Refer to table 1 for detailed information about included studies.

Overall, the literature described 38 mobile apps, which involved a variety of aims and objectives ranging from describing development to trials examining effectiveness. A majority of the apps examined elements such as usability; operational issues; descriptions of use for continued development and refinement; and pilot, feasibility, proof of concept, and initial study to examine preliminary outcomes such as signals of improvement or efficacy. Eighteen studies (36.7%) were categorized as pilot, feasibility, or proof-ofconcept trials. 9, 10, [12] [13] [14] 17, 24, 30, 33, [36] [37] [38] 42, 45, 47, 52, 56, 57 In general, the studies had relatively small sample sizes, where 23 studies (46.9%) had 20 participants, [9] [10] [11] [12] 15, 16, 22, [25] [26] [27] [28] 32, [34] [35] [36] 38, 41, [43] [44] [45] 47, 50, 57 22 studies (44.9%) had between 21 and 100 participants, 13,14,17-21,23,24,29,30,31,33,40,42,46,49,51-54 and 4 studies (8.2%) had >100 participants (see table 1 ). 20, 39, 48, 56 Content foci

The 49 articles described 38 apps with content that varied in focus. The apps focused on upper extremity function (nZ12; 31.5%) [9] [10] [11] [12] 17, 18, 23, 24, [27] [28] [29] 36, 43, 44, 49, 50, 51, 55 ; lower extremity function (nZ2; 5.3%) 12, 51 ; general exercise, physical activity, and/or functional mobility (nZ9; 23.7%) 12, 31, 37, 39, 41, 42, 46, 47, 51, 54 ; trunk control (nZ2; 5.3%) 51, 53 ; medical management and secondary prevention (nZ10; 26.3%) [13] [14] [15] [16] 33, 39, 40, 43, 44, 48, 51, 52, 54, 56 ; language and speech skills (nZ8; 20.5%) [19] [20] [21] [22] [23] [24] [25] 34, 35, 38, 45 ; cognitive skills (nZ3; 7.9%) 23, 24, 26 ; general disability and activities of daily living (ADL) (nZ2; 5.3%) 30, 32 ; and home safety (nZ1; 2.6%) (fig 2) . 57 

The included studies represented various countries throughout the world. The primary author's location or described target population contributed to data in this section. Of the identified apps in the literature, 17 countries were identified. The United States had the highest frequency, which included 10 total apps. [9] [10] [11] 16, [19] [20] [21] [22] [26] [27] [28] 44, 50, 52, 55 Refer to fig 3 for a depiction of representation by country for each app identified in the literature.

In recent years mHealth apps for people living with the effects of stroke have gained significant traction. The earliest study included in this review was from 2014. 22 This number has grown substantially, with 15 of the included studies 14, 15, 20, [23] [24] [25] [26] [27] [37] [38] [39] [40] 42, 43, 45 

This scoping review identified 49 articles describing 38 mHealth apps for use by individuals after stroke. Our study revealed (1) the studies were generally describing development and refinement, pilot/feasibility trials, and included small sample sizes; (2) the studies and apps covered a range of foci but seemed to neglect to focus on It is feasible to conduct an mHealthbased, nurse-guided blood pressure control intervention among patients with recent stroke in sub-Saharan Africa. We observed a potential signal of efficacy with the intervention, which will need to be tested in a future large definitive study. Sarfo To explore postintervention perspectives and gather in-depth insight into the experiences of survivors of stroke and their caregivers after participation in a larger interventional arm of an mHealth blood pressure management study. The study also sought to assess the contextual and organizational facilitators and barriers encountered in the implementation of the intervention within an operational setting.

Four major themes emerged highlighting the ability to selfmonitor, the use of technology as an interventional tool, training and support, and postintervention adherence. Overwhelming receptivity toward home blood pressure monitoring and the use of mHealth was noted. Feedback indicated benefits in having access to equipment and that message prompts facilitated adherence. Postintervention adherence declined after study intervention, indicating a need for increased exposure to facilitate long-term behavioral change, although participants conveyed a heightened awareness of the importance of blood pressure monitoring and lifestyle changes needed.

(continued on next page) mHealth app interventions for stroke To examine the clinical effectiveness of using iPads to deliver personalized therapy to individuals with aphasia, to determine if a structured iPadbased therapy program that includes homework practice results in significant gains in overall communication and how individual severity profiles affect therapy outcomes.

Participants did not differ in the duration of the therapy. and both groups of participants showed improvement over time in the tasks used for therapy. However, experimental participants used the application more often and showed greater changes in accuracy and latency on the tasks than the control participants; experimental participants' severity level at baseline as measured by standardized tests of language and cognitive skills were a factor in improvement on the tasks. Subgroups of task coimprovement appear to occur between different language tasks, between different cognitive tasks, and across both domains. Finally, experimental participants showed more significant and positive changes because of therapy in their standardized tests than control participants. These results provide preliminary evidence for the usefulness of a tablet-based platform to deliver tailored language and cognitive therapy to individuals with aphasia. Godlove et al 20 Outcomes of treatment are similar for home users and clinic patients, indicating the potential usability of a home-based treatment program for rehabilitation for poststroke aphasia.

(continued on next page) mHealth app interventions for stroke This study provides some preliminary data on talk time in people with aphasia, suggesting that talk time is an indicator of participation.

(continued on next page) mHealth app interventions for stroke To conduct usability testing of the current outREACH telerehabilitation system and to determine the acceptance of the mobile app and its features in Ethiopian rehabilitation clinicians, patients with stroke, and patient caregivers.

Overall, the results of usability testing were promising, and all participants rated the app as easy to use and a useful tool to supplement in-clinic rehabilitation of poststroke upper limb dysfunction. The majority of respondents could successfully navigate through the system modules, found the aesthetics to be visually appealing, and expressed a strong desire to use the system. This innovative care strategy has the potential to change how stroke rehabilitation is delivered in countries such as Ethiopia where a large proportion of the population lives in rural areas and experience a deficit of experienced health professionals.

(continued on next page) mHealth app interventions for stroke Two main usability issues in round 1 were identified with the scheduler module and the similarities between the Home screen and the My Care Plan screen. After applying modifications for the second iteration, there was a significant increase in the average usability score (43%-88%) and a reduction in both the number of errors and the time taken to complete each task. The results of the present study will be integrated into the development, integration, and evaluation of the outREACH system that supports stroke telerehabilitation in underserved populations.

Feasibility trial Australia The Word Trainer

Language/speech skills To evaluate an iPad-based speech therapy app that uses ASR software to provide feedback on speech accuracy to determine the ASR's accuracy against human judgment and whether participants' speech improved with this ASR-based feedback.

For these participants with apraxia of speech plus aphasia due to stroke, satisfactory gains were made in word production accuracy with an appbased therapy program providing ASR-based feedback on accuracy. Findings support further testing of this ASR-based approach as a supplement to clinician-run sessions to assist clients with similar profiles in achieving higher amount and intensity of practice as well as empowering them to manage their own therapy program. Costa et al 46 (1) develop an HBR to recognize and record type and frequency of rehabilitation exercises using a smartwatch and smartphone app and (2) evaluate the efficacy of the HBR system.

This study found that a home care system using a commercial smartwatch and machine learning model can facilitate participation in home training and improve the functional score of the Wolf Motor Function Test and shoulder range of motion of flexion and internal rotation in the treatment of patients with chronic stroke. This strategy can possibly be a cost-effective tool for the home care treatment of survivors of stroke in the future.

(continued on next page) mHealth app interventions for stroke Most literature supporting mHealth apps present only emergent evidence, lower-power designs such as pilot and feasibility studies, and case series, 58 which is consistent with the findings of this study. The vast majority of included articles discuss design and development, are pilot/feasibility studies, and examine outcomes such as usability and acceptability. Most of the articles concluded that additional trials with larger sample sizes are warranted. As more people continue to survive after acute stroke, 59 systems must be in place to support long-term needs.

Long-term needs are diverse after stroke, and we discovered a variety of content foci to support these needs. People with stroke must engage in the day-to-day management of living with a chronic condition, and mHealth apps may be particularly useful in supporting this. For instance, some people may be seeking mHealth apps to continue working toward progress in cognitive function, while others may be more focused on learning approaches for recurrent stroke prevention. Of the identified apps, 79.6% focused on either upper extremity function, language/speech skills, medical management/ secondary prevention, or exercise/physical activity/ functional mobility. Although this finding is generally positive, several content areas need further study. We found that 20.4% of the studies focused on either lower extremity function, trunk control, cognitive function, disability/ADL, and home safety. Furthermore, people living with the effects of stroke have a vast range of needs beyond the content foci identified in this study. For instance, poststroke depression and fatigue are major problem areas that influence health and function. Although we did not identify any apps targeting these topics, it is possible that apps are available for general users or conditions other than stroke.

Interestingly, the increasing rate of stroke among adults younger than 55 years and the rising number of years lived with poststroke disability are pressing the need for alternatives to hospital and institutionalized care. 58 Use of devices to manage various aspects of health care after stroke is gaining traction and popularity to increase long-term self-management of stroke and to help offset reduced accessibility to skilled care. Leveraging mobile technologies has great potential for supporting the long-term needs of people with stroke. With smartphone ownership increasing globally, 60 mHealth apps can provide innovative solutions that are scalable to reach populations with limited access to services after stroke despite geographic location.

The global demand for mHealth apps to support outcomes in persons with stroke is high. Our study discovered a wide representation of countries and populations testing apps for people with stroke to meet health and rehabilitation demands, although most of the research on mHealth apps for persons with stroke is being conducted in the United States. Currently, the severe acute respiratory syndrome coronavirus 2 pandemic is having an effect on health care and service delivery globally. We expect to see a greater surge of mHealth apps to support long-term needs of people living with the effects of stroke to emerge in the near future.

In addition to this scoping review emphasizing the need for additional large-scale trials, it is essential that studies continue to use iterative approaches to design and development. Several of the studies we reviewed described co-design and participatory design approaches to improve overall acceptance of the targeted end user. Engaging people living with the effects of stroke at multiple time points throughout the developmental process is an essential consideration for developing products that are valued and used.

Despite a comprehensive search strategy, this study is not without limitations. The primary limitation of this review is that some published articles may have been missed that met inclusion criteria because they did not emerge in the databases we selected. This study also only included studies that examined mHealth apps as an independent intervention or as an adjunct to traditional therapy with minimal involvement from a health care provider. This decision was guided by our inquiry of how mHealth can support individuals living with disability as a result of stroke but limited the articles included in this study. We also did not include non-English articles, which may have limited the diversity of articles included in our search; however, our search did capture articles from 13 different countries.

The purpose of this study was to systematically identify the literature on mHealth app interventions to support the selfmanagement of adults living with the effects of stroke. The results of this study suggest that there is growing global interest in mHealth apps for this population but that many gaps persist. Although the literature discovered with the search strategy primarily consisted of development, pilot, and feasibility studies, it is promising that most of the articles describe next steps to examine efficacy with larger sample sizes. Continued research and development are critical in this area to best meet the needs of the growing population who are surviving and living with the long-term effects of stroke. Future studies should also involve longitudinal designs to examine long-term engagement and mHealth app effect on health and functional outcomes. 

Doctor's follow-up after stroke in the south of Sweden: an observational study from the Swedish stroke register (Riksstroke)

International classification of functioning, disability, and health: ICF

Timing it right': needs of African American adults with stroke and their caregivers across the care continuum

Interdisciplinary approaches to facilitate return to driving and return to work in mild stroke: a position paper

Stroke survivors' and informal caregivers' experiences of primary care and community healthcare servicesea systematic review and meta-ethnography

Contemporary trends and predictors of postacute service use and routine discharge home after stroke

Popular mHealth apps for adults living with stroke: review and content analysis

PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation

Supporting stroke motor recovery through a mobile application: a pilot study

Preliminary evaluation of a mobile app for everyday stroke rehabilitation. In: RESNA's 2016 annual conference

ARM-Strokes: a mobile app for everyday stroke rehabilitation

Pilot trial of a tele-rehab intervention to improve outcomes after stroke in Ghana: a feasibility and user satisfaction study

PINGS (phone-based intervention under nurse guidance after stroke) interim results of a pilot randomized controlled trial

Phone-based intervention for blood pressure control among Ghanaian stroke survivors: a pilot randomized controlled trial

Assessing mobile health capacity and task shifting strategies to improve hypertension among Ghanaian stroke survivors

A feasibility pilot using a mobile personal health assistant (PHA) app to assist stroke patient and caregiver communication after hospital discharge

Mobile game-based virtual reality rehabilitation program for upper limb dysfunction after ischemic stroke

Mobile game-based virtual reality program for upper extremity stroke rehabilitation

Effectiveness of an impairment-based individualized rehabilitation program using an iPad-based software platform

Comparison of therapy practice at home and in the clinic: a retrospective analysis of the Constant Therapy platform data set

Effects of a tablet-based home practice program with telepractice on treatment outcomes in chronic aphasia

iPractice: piloting the effectiveness of a tablet-based home practice program in aphasia treatment

RecoverNow: a patient perspective on the delivery of mobile tablet-based stroke rehabilitation in the acute care setting

RecoverNow: a mobile tablet-based therapy platform for early stroke rehabilitation

Therapist-guided tabletbased telerehabilitation for patients with aphasia: proof-ofconcept and usability study

Feasibility of an iterative rehabilitation intervention for stroke delivered remotely using mobile health technology

Harnessing smartphone technology and three dimensional printing to create a mobile rehabilitation system, mRehab: assessment of usability and consistency in measurement

In-home rehabilitation using a smartphone app coupled with 3D printed functional objects: single-subject design study

The effect of a finger training application using a tablet PC in chronic hemiparetic stroke patients

Evaluation of the feasibility and acceptability of the 'Care for Stroke' intervention in India, a smartphone-enabled, carer-supported, educational intervention for management of disability following stroke

Increasing physical activity in stroke survivors using STARFISH, an interactive mobile phone application: a pilot study

From conception to evaluation of mobile services for people with head injury: a participatory design perspective

Feasibility of using a mobile application for the monitoring and management of strokeassociated risk factors

Barriers and facilitators to using the CommFitä smart phone app to measure talk time for people with aphasia

An exploratory investigation of the daily talk time of people with nonfluent aphasia and non-aphasic peers

Tablet apps and dexterity: comparison between 3 age groups and proof of concept for stroke rehabilitation

Impact of mHealth technology on adherence to healthy PA after stroke: a randomized study

A speech therapy game application for aphasia patient neurorehabilitationea pilot study of an mHealth app

FARMALARM: application for mobile devices improves risk factor control after stroke

Does a mobile app improve patients' knowledge of stroke risk factors and health-related quality of life in patients with stroke? A randomized controlled trial

Description of the CARE4STROKE programme: a caregiver-mediated exercises intervention with e-health support for stroke patients

Caregiver-mediated exercises with e-health support for early supported discharge after stroke (CARE4STROKE): a randomized controlled trial

Development of an upper extremity stroke rehabilitation mHealth application for sub-Saharan Africa: a usability study

Development of a mHealth system for post-stroke upper limb rehabilitation in medically underserved populations: an iterative usability study

Feasibility of automatic speech recognition for providing feedback during tablet-based treatment for apraxia of speech plus aphasia

An investigation into the validity and reliability of mHealth devices for counting steps in chronic stroke survivors

Connecting patients and therapists remotely using technology is feasible and facilitates exercise adherence after stroke

Effect of 5-minute movies shown via a mobile phone app on risk factors and mortality after stroke in a low-to middle-income country: randomized controlled trial for the stroke caregiver dyad education intervention (Movies4Stroke)

Development and clinical evaluation of a web-based upper limb home rehabilitation system using a smartwatch and machine learning model for chronic stroke survivors: prospective comparative study

Acceptability of a mobile phone-based augmented reality game for rehabilitation of patients with upper limb deficits from stroke: case study

Pilot study on comparisons between the effectiveness of mobile video-guided and paper-based home exercise programs on improving exercise adherence, self-efficacy for exercise and functional outcomes of patients with stroke with 3-month follow-up: a single-blind randomized controlled trial. Hong Kong Physiother

Use of a smartphone-based mobile app for weight management in obese minority stroke survivors: pilot randomized controlled trial with open blinded end point

Smartphone-based visual feedback trunk control training for gait ability in stroke patients: a single-blind randomized controlled trial

Remote management of poststroke patients with a smartphone-based management system integrated in clinical care: prospective, nonrandomized, interventional study

RehabPhone: a softwaredefined tool using 3D printing and smartphones for personalized home-based rehabilitation

Treatment adherence and secondary prevention of ischemic stroke among discharged patients using mobile phone-and WeChat-based improvement services: cohort study

The feasibility and acceptability of smart home technology using the Howz system for people with stroke

Designing, implementing, and evaluating mobile health technologies for managing chronic conditions in older adults: a scoping review

More people are surviving after acute stroke

Majorities in sub-Saharan Africa own mobile phones, but smartphone adoption is modest