Developing an mHealth app for post-stroke upper limb rehabilitation: Feedback from US and Ethiopian rehabilitation clinicians

Mobile mental health application use, and app feature preferences among individuals with mental disorders in Ethiopia: A cross-sectional survey

BACKGROUND

Mobile health applications have been shown to assist in the treatment of mental illnesses, yet their potential remains underutilized. As supportive care, mental health applications use may be useful tools in improving mental health literacy and treatment outcomes, but patients' use of and interest in using these apps have not been studied in low-income countries like Ethiopia. This study explores the determinants of patients' mental health app use interests and app feature preferences.

METHODS

A cross-sectional study was conducted with 419 outpatient individuals with mental health disorders at Amanuel Mental Specialized Hospital, Ethiopia, between October and November 2023, using a convenience sampling method. Patients' self-reported mental health app use, interests, attitudes, and app feature preferences were collected. A multivariate logistic regression model was used to identify the associated factors.

RESULTS

Overall prevalence of not interested, somewhat interested, interested, and extremely interested in mental health app use was 5.3 %, 16.9 %, 27.7 %, and 50.1 % respectively. The proportion of current mental health apps use was low (21.2 %). Current mental health app use is associated with living in an urban area (AOR = 6.69, CI: 3.19-14) and having a higher education level (4.12 (2.02-8.04). Furthermore, app features such as psychoeducation, symptom tracking, and self-management techniques ranked as the most preferred app features.

CONCLUSIONS

Most study participants were interested in using mental health apps, but only about one in four were using mental health apps. This suggests promise for their utility in the Ethiopian context. App developers and policymakers should consider rural residents', lower educational levels, and patient app preferences when developing these applications.

Current Status of Barriers to mHealth Access Among Patients With Stroke and Steps Toward the Digital Health Era: Systematic Review

BACKGROUND

Mobile health (mHealth) offers significant benefits for patients with stroke, facilitating remote monitoring and personalized health care solutions beyond traditional settings. However, there is a dearth of comprehensive data, particularly qualitative insights, on the barriers to mHealth access. Understanding these barriers is crucial for devising strategies to enhance mHealth use among patients with stroke.

OBJECTIVE

This study aims to examine the recent literature focusing on barriers to mHealth access among patients with stroke.

METHODS

A systematic search of PubMed, MEDLINE, Web of Science, and CINAHL Plus Full Text was conducted for literature published between 2017 and 2023. Abstracts and full texts were independently screened based on predetermined inclusion and exclusion criteria. Data synthesis was performed using the convergent integrated analysis framework recommended by the Joanna Briggs Institute.

RESULTS

A total of 12 studies met the inclusion criteria. The majority were qualitative studies (about 42%), followed by mixed methods (25%), pilot studies (about 17%), nonrandomized controlled trials (about 8%), and observational studies (about 8%). Participants included patients with stroke, caregivers, and various health care professionals. The most common mHealth practices were home-based telerehabilitation (30%) and poststroke mHealth and telecare services (20%). Identified barriers were categorized into two primary themes: (1) at the patient level and (2) at the health provider-patient-device interaction level. The first theme includes 2 subthemes: health-related issues and patient acceptability. The second theme encompassed 3 subthemes: infrastructure challenges (including software, networking, and hardware), support system deficiencies, and time constraints.

CONCLUSIONS

This systematic review underscores significant barriers to mHealth adoption among patients with stroke. Addressing these barriers in future research is imperative to ensure that mHealth solutions effectively meet patients' needs.

Clinicians' perspectives and usage of rehabilitation technology: a survey

PURPOSE

The aim of this study was to investigate clinicians' perspectives regarding their usage of rehabilitation technology in their day-to-day practice and uncover the factors that impact clinicians' use of rehabilitation technology in their daily practice.

MATERIALS AND METHODS

An online survey was used to gather cross-sectional data from American occupational therapists, occupational therapy assistants, physical therapists, physical therapy assistants, and speech language pathologists. This survey used Likert-scale, multiple choice, and free-response questions.

RESULTS

Approximately half (n = 56/105, 53.3%) of our clinicians reported using rehabilitation in their daily practice. Less than 20% (n = 18/105, 17.1%) of the respondents strongly agreed that they felt comfortable implementing new rehabilitation technology, and few reported that their workplace encouraged (n = 16/85, 18.8%) or strongly encouraged (n = 14/85, 16.5%) the use of rehabilitation technology in practice. Additionally, excluding the 2011-2020 graduate clinicians that reported that they had not learned about rehabilitation technology in school or fieldwork, few reported feeling prepared (n = 14/97, 14.4%) or very prepared (n = 4/97, 4.1%) to use rehabilitation technology after graduation.

CONCLUSIONS

Our findings have revealed a sizable knowledge-to-practice gap in regard to clinicians' preparedness to engage with and advocate for rehabilitation technology in their day-to-day practice.

Using experience-based co-design to develop mobile/tablet applications to support a person-centred and empowering stroke rehabilitation

AIM

To investigate and describe the process of using experience-based co-design (EBCD) to develop mobile/tablet applications to support a person-centred and empowering stroke rehabilitation.

SETTING

Two cross-sectoral stroke rehabilitation settings in Denmark comprising six rehabilitation units.

PARTICIPANTS

Stroke survivors (n = 23), significant others (n = 18), occupational therapists (n = 12), physiotherapists (n = 9), representative of a patient organization (n = 1), application developers (n = 3) and researchers (n = 2).

METHOD

A structured, facilitated EBCD approach comprising six stages was used to co-design a service that aimed to address the priorities and needs of all relevant end-users. Data were collected by interviews, participant observations, notes on "flip sheets" and written feedback on the content in the apps and on the instruction pages. Data were analyzed descriptively and with a constructivist grounded theory analysis.

RESULTS

The content in the application solutions "Mit Sygehus" and "Genoptræn.dk" were co-designed to support the needs identified by all end-users. Relevant evidence-based knowledge, person-centred exercises and guidelines using video recordings were the most important among the developed content in the applications to support person-centred and empowering stroke rehabilitation. Furthermore, easy, and seamless communication were considered important.

CONCLUSIONS

EBCD facilitated the development of content in the applications to support a person-centred and empowering stroke rehabilitation. Participants experienced that their contribution was considered important and valued.

Computer-assisted approaches for measuring, segmenting, and analyzing functional upper extremity movement: a narrative review of the current state, limitations, and future directions

The analysis of functional upper extremity (UE) movement kinematics has implications across domains such as rehabilitation and evaluating job-related skills. Using movement kinematics to quantify movement quality and skill is a promising area of research but is currently not being used widely due to issues associated with cost and the need for further methodological validation. Recent developments by computationally-oriented research communities have resulted in potentially useful methods for evaluating UE function that may make kinematic analyses easier to perform, generally more accessible, and provide more objective information about movement quality, the importance of which has been highlighted during the COVID-19 pandemic. This narrative review provides an interdisciplinary perspective on the current state of computer-assisted methods for analyzing UE kinematics with a specific focus on how to make kinematic analyses more accessible to domain experts. We find that a variety of methods exist to more easily measure and segment functional UE movement, with a subset of those methods being validated for specific applications. Future directions include developing more robust methods for measurement and segmentation, validating these methods in conjunction with proposed kinematic outcome measures, and studying how to integrate kinematic analyses into domain expert workflows in a way that improves outcomes.

Accuracy and Validity of a Single Inertial Measurement Unit-Based System to Determine Upper Limb Kinematics for Medically Underserved Populations

Stroke is one of the leading causes of death and disability worldwide, with a disproportionate burden represented by low- and middle-income countries (LMICs). To improve post-stroke outcomes in LMICs, researchers have sought to leverage emerging technologies that overcome traditional barriers associated with stroke management. One such technology, inertial measurement units (IMUs), exhibit great potential as a low-cost, portable means to evaluate and monitor patient progress during decentralized rehabilitation protocols. As such, the aim of the present study was to determine the ability of a low-cost single IMU sensor-based wearable system (named the T’ena sensor) to reliably and accurately assess movement quality and efficiency in physically and neurologically healthy adults. Upper limb movement kinematics measured by the T’ena sensor were compared to the gold standard reference system during three functional tasks, and root mean square errors, Pearson’s correlation coefficients, intraclass correlation coefficients, and the Bland Altman method were used to compare kinematic variables of interest between the two systems for absolute accuracy and equivalency. The T’ena sensor and the gold standard reference system were significantly correlated for all tasks and measures (r range = 0.648—0.947), although less so for the Finger to Nose task (r range = 0.648—0.894). Results demonstrate that single IMU systems are a valid, reliable, and objective method by which to measure movement kinematics during functional tasks. Context-appropriate enabling technologies specifically designed to address barriers to quality health services in LMICs can accelerate progress towards the United Nations Sustainable Development Goal 3.

Methods for Human-Centered eHealth Development: Narrative Scoping Review

Background

Thorough holistic development of eHealth can contribute to a good fit among the technology, its users, and the context. However, despite the availability of frameworks, not much is known about specific research activities for different aims, phases, and settings. This results in researchers having to reinvent the wheel. Consequently, there is a need to synthesize existing knowledge on research activities for participatory eHealth development processes.

Objective

The 3 main goals of this review are to create an overview of the development strategies used in studies based on the CeHRes (Center for eHealth Research) Roadmap, create an overview of the goals for which these methods can be used, and provide insight into the lessons learned about these methods.

Methods

We included eHealth development studies that were based on the phases and/or principles of the CeHRes Roadmap. This framework was selected because of its focus on participatory, iterative eHealth design in context and to limit the scope of this review. Data were extracted about the type of strategy used, rationale for using the strategy, research questions, and reported information on lessons learned. The most frequently mentioned lessons learned were summarized using a narrative, inductive approach.

Results

In the included 160 papers, a distinction was made between overarching development methods (n=10) and products (n=7). Methods are used to gather new data, whereas products can be used to synthesize previously collected data and support the collection of new data. The identified methods were focus groups, interviews, questionnaires, usability tests, literature studies, desk research, log data analyses, card sorting, Delphi studies, and experience sampling. The identified products were prototypes, requirements, stakeholder maps, values, behavior change strategies, personas, and business models. Examples of how these methods and products were applied in the development process and information about lessons learned were provided.

Conclusions

This study shows that there is a plethora of methods and products that can be used at different points in the development process and in different settings. To do justice to the complexity of eHealth development, it seems that multiple strategies should be combined. In addition, we found no evidence for an optimal single step-by-step approach to develop eHealth. Rather, researchers need to select the most suitable research methods for their research objectives, the context in which data are collected, and the characteristics of the participants. This study serves as a first step toward creating a toolkit to support researchers in applying the CeHRes Roadmap to practice. In this way, they can shape the most suitable and efficient eHealth development process.

Physiotherapists' and occupational therapists' perspectives on information and communication technology in stroke rehabilitation

Aim

The aim of this study was to explore the current and potential use of information and communication technology (ICT) to enhance coherent person-centred rehabilitation after stroke, from the perspectives of physiotherapists and occupational therapists.

Method

Five occupational therapists and four physiotherapists from different phases of the Danish stroke rehabilitation process were included and two focus group interviews were carried out. A grounded theory approach was used throughout the study and a constant comparative method was used in the analysis.

Results

Three subcategories were identified from the analysis of interviews with participants: 1) ICT and apps as meaningful and supportive in the rehabilitation process, 2) ICT as a tool in communication and documentation and 3) Barriers to the integration of ICT and apps in the rehabilitation process. From these categories one core category emerged: The potential of a personalized app solution to facilitate coherent person-centred rehabilitation.

Conclusion

ICT was perceived as important to integrate in stroke rehabilitation both for assessment, training and to compensate for remaining deficits. The development of a personalized app solution could accommodate stroke survivors’ and significant others’ need for insight into and overview over the rehabilitation process as well as access to relevant information, which would thereby empower them. Furthermore, a personalized app solution could also facilitate follow-up after discharge and was perceived to ease the communication and documentation within and between sectors, as well as communication with both stroke survivors and significant others.

Stroke Characteristics and Outcomes of Adult Patients in Northwest Ethiopia

Stroke is becoming one of the leading causes of adult disability and death in sub-Saharan African countries. The aim of the present study is to provide an up-to-date account of the clinical and demographic characteristics of patients with stroke admitted to the University of Gondar College of Medicine and Health Science Comprehensive Specialized Hospital (CMHS). A hospital based retrospective study design was used to analyze the medical records of all patients with stroke admitted to CMHS from June 20th 2012 and April 30th 2018. Data were cleaned and entered into SPSS for analysis. Among the 448 patients with stroke admitted to CMHS, 58.0% (n = 260) of patients were female, and 42.0% (n = 188) were male. In the present sample, 141 (31.5%) had an ischemic stroke confirmed by neuroimaging, 82 (18.3%) had a hemorrhagic stroke confirmed by neuroimaging, and 252 (50.2%) had a stroke with undetermined type. The mean age of stroke was 63.9 years (range = 18–100, SD: 15.1 years), with no differences observed between stroke subtypes. The most common symptoms that led to patients seeking medical intervention were hemiparesis (67.4%), communication difficulties (56.0%), facial deviation (37.3%), and globalized headache (36.4%). Hypertension was the most commonly reported risk factor (37.1%), which was more prevalent in hemorrhagic (n = 37, 45.1%) than ischemic stroke patients (n = 53, 37.6%), stroke with undetermined type (n = 76, 33.8%). Stroke places a significant burden on sub-Saharan African countries. Results of the current study highlight the need to develop programs that educate the Ethiopian populace about the risk factors and symptoms of stroke, the importance of seeking medical care within the golden window, and the benefits of neuroimaging to accurately diagnose stroke subtype. In addition, the current study provides hospital administrators with empirical data that they can use to form an interdisciplinary stroke rehabilitation team capable of improving outcomes of Ethiopian patients with stroke.

Quantitative Assessment of Upper Limb Motor Function in Ethiopian Acquired Brain Injured Patients Using a Low-Cost Wearable Sensor

Acquired brain injuries place a significant burden on sub-Saharan African rehabilitation clinicians and health care facilities. While wearable sensors have the potential to alleviate these issues, many are beyond the financial capabilities of the majority of African persons and clinics. To bridge this gap, we have developed a low-cost wrist-worn sensor (the outREACH sensor) capable of accurately measuring upper limb movement kinematics. In this study we evaluated the extent to which the outREACH sensor is sensitive to the hand performing the task (unimpaired, impaired) and level of impairment (mild, moderate) in 14 Ethiopian persons with acquired brain injury (mean age = 51.6 ± 12.2 years, 1 female, 13 male). Participants performed an object manipulation task with both the impaired and the unimpaired limb, and reaching performance was measured using standard kinematic measures (i.e., movement time, spectral arc length, peak velocity, peak acceleration, mean velocity, mean acceleration). Overall, movements were smoother and faster when performed by the patient's unimpaired limb. In contrast, maximum velocity did not differ between the two limbs. Moreover, the outREACH sensor was sensitive to differences in performance-based upper limb impairment. Fugl-Meyer assessment for upper extremity scores were significantly correlated with movement time, spectral arc length, and peak velocity. Upper limb movement kinematics can be accurately measured using the outREACH sensor. The outREACH sensor can be a valuable addition to standardized clinical measures that provides rehabilitation clinicians with information regarding initial upper limb impairment level and changes in function across the rehabilitation lifespan.

Development of a Post-stroke Upper Limb Rehabilitation Wearable Sensor for Use in Sub-Saharan Africa: A Pilot Validation Study

The development of context-appropriate sensor technologies could alleviate the significant burden of stroke in Sub-Saharan African rehabilitation clinicians and health care facilities. However, many commercially available wearable sensors are beyond the financial capabilities of the majority of African persons. In this study, we evaluated the concurrent validity of a low-cost wearable sensor (i.e., the outREACH sensor) to measure upper limb movement kinematics of 31 healthy persons, using an 8-camera Vicon motion capture system as the reference standard. The outREACH sensor showed high correlation (r range: 0.808-0.990) and agreement (mean difference range: -1.60 to 1.10) with the reference system regardless of task or kinematic parameter. Moreover, Bland-Altman analyses indicated that there were no significant systematic errors present. This study indicates that upper limb movement kinematics can be accurately measured using the outREACH sensor, and have the potential to enhance stroke evaluation and rehabilitation in sub-Saharan Africa.