Disability and Rehabilitation

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Mobile health applications for improving physical

function, physical activity, and quality of life in
stroke survivors: a systematic review

A. Rintala, O. Kossi, B. Bonnechère, L. Evers, E. Printemps & P. Feys

To cite this article: A. Rintala, O. Kossi, B. Bonnechère, L. Evers, E. Printemps & P. Feys (2023)
Mobile health applications for improving physical function, physical activity, and quality of life
in stroke survivors: a systematic review, Disability and Rehabilitation, 45:24, 4001-4015, DOI:
10.1080/09638288.2022.2140844

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DISABILITY AND REHABILITATION
2023, VOL. 45, NO. 24, 4001–4015
https://doi.org/10.1080/09638288.2022.2140844

REVIEW

Mobile health applications for improving physical function, physical activity, and
quality of life in stroke survivors: a systematic review
A. Rintalaa,b , O. Kossia,c , B. Bonnech�erea , L. Eversa, E. Printempsa and P. Feysa
a
REVAL Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium; bFaculty of Social Services
and Health Care, LAB University of Applied Sciences, Lahti, Finland; cENATSE, National School of Public Health and Epidemiology, University of
Parakou, Parakou, Benin

ABSTRACT ARTICLE HISTORY

Purpose: To evaluate the effectiveness of mobile health applications (mHealth apps) containing a phys­ Received 15 February 2022
ical training component on physical function and physical activity in stroke rehabilitation. Revised 20 October 2022
Materials and methods: A systematic literature search was conducted in three databases for studies Accepted 23 October 2022
published from inception to 12 July 2022. Clinical trials including mHealth apps with a physical training
KEYWORDS
component were included using outcomes of physical function and physical activity. Quality of life was Stroke; mobile health;
extracted as a secondary outcome. mHealth; rehabilitation;
Results: Five RCTs, two non-RCTs, and four uncontrolled clinical trials were included with a total of 264 physical function; physical
stroke survivors. Eleven apps were identified with a physical training component using features of gamifi­ activity; quality of life
cation (six apps), exercise prescription (three apps), and physical activity (two apps). Six out of seven stud­
ies reported statistically significant improvements in physical function in favor of the experimental group,
with the most robust findings for upper extremity function. For physical activity, statistically significant
improvements were seen in the experimental groups. Only one study showed significant improvement in
quality of life. Overall study quality was fair.
Conclusions: mHealth apps containing a physical training component are promising for physical function
and physical activity in stroke rehabilitation. Further research is warranted to confirm these conclusions.

� IMPLICATIONS FOR REHABILITATION

� Design content of mobile apps with a physical training component were focused on gamification,
exercise prescription, and physical activity
� Using mobile app-delivered therapy seem promising for improving upper extremity function in stroke
rehabilitation
� Using mobile apps also supported an increase of physical activity in people with stroke
� Studies using mobile apps should report more specifically the dosage of physical training
and adherence
� Using mobile apps seems promising as an additional tool for clinical work, however, more studies are
required to understand their effectiveness in stroke rehabilitation.

Introduction survivors are still moderately or severely disabled and more than
half of the stroke survivors are inactive [7]. Moreover, people with
Stroke is one of the leading causes of death and long-term dis­
stroke throughout all stages have lower physical activity (PA)
ability worldwide, accounting for approximately 12% of total
levels compared to healthy age-matched individuals [8].
deaths [1]. The absolute number of stroke deaths has increased
Furthermore, physical inactivity is associated with lower chances
by 43% in the last 30 years and stroke was the third most com­ of independence in activities of daily living [9]. Also, stroke survi­
mon cause of disability worldwide in 2019 [1]. At stroke onset, vors have reported a decline in QoL [3,10].
stroke survivors suffer from very heterogeneous symptoms and To reduce disability after stroke, physiotherapy plays an
signs. Symptoms of stroke vary individually with a wide range of important role in rehabilitation and the amount of time spent in
motoric, mental, lingual, sensory, and cognitive impairments that therapy is highly correlated with functional recovery after stroke
cause functional challenges in daily life and decrease the quality [11,12]. In the recent decade, more attention has been given to
of life (QoL) [2–5]. The most common impairments are paresis telerehabilitation, mobile health applications (mHealth apps), or
experienced in upper (69%) and lower (61%) extremities in the other technological therapy modalities in stroke rehabilitation
acute stage of stroke [6]. At three years post-stroke, 26% of stroke [13–16]. Due to the rapid increase of smartphone and tablet apps

CONTACT Aki Rintala [email protected] Faculty of Social Services and Health Care, LAB University of Applied Sciences, Mukkulankatu 19, Lahti 15210, Finland
Supplemental data for this article can be accessed online at https://doi.org/10.1080/09638288.2022.2140844
� 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in
any way.
4002 A. RINTALA ET AL.

in common daily life, interest in using a mHealth app has also mobility (24%) [16]. Other previous scoping or systematic reviews
increased in healthcare and rehabilitation services [17]. mHealth have also indicated similar directions where mHealth apps have
app is defined as a health and well-being mobile service delivered been implemented in stroke rehabilitation, namely physical, cog­
using a mobile app or other wireless technology in medical care, nitive, and language rehabilitation [22,23]. These previous reviews
which enables two-way health-related information delivery and show that mHealth apps are becoming an interest of study in
communication [18]. Interest has grown mainly with the assump­ stroke rehabilitation and their findings show its potential where
tion that mHealth apps support specific rehabilitation goals, such apps have been targeted in stroke rehabilitation [24].
promote self-management, and increase adherence to home- However, previous reviews have not yet focused on particular out­
rehabilitation exercises [19]. Moreover, one systematic review comes such as PF, PA, or QoL. Nor there has not been an over­
concluded that mHealth apps have the potential to facilitate view of mHealth apps that can be targeted to physical training at
adherence to chronic disease management in diabetes mellitus, home settings [23].
cardiovascular diseases, and chronic lung diseases, but the current The aim of this systematic review is to evaluate the effective­
evidence of the association between mHealth apps and adher­ ness of mHealth apps containing a physical training component
ence to disease management is still rather mixed [20]. For on PF, PA, and QoL in stroke rehabilitation. Moreover, this review
instance, only 58% of the studies reported usability, feasibility, or includes apps that have the potential to be applied independ­
acceptability of mHealth apps in the previous review [20]. ently of the therapist.
Moreover, the usefulness of mHealth apps in stroke rehabilitation
is still unclear. Another review provided an overview of the num­ Methods
ber of commercially available mHealth apps in stroke rehabilita­
tion to offer a low-cost strategy and utility in the rehabilitation of Search strategy
stroke survivors in everyday life [21]. However, the mHealth apps A systematic literature search was conducted using three data­
were not reviewed for its scientific evidence on particular out­ bases: Pubmed, Web of Science, and Scopus for studies published
comes of interest in stroke rehabilitation, such as physical func­ from inception to 16 April 2021. An updated search was con­
tion (PF), PA, and QoL. ducted from the same databases from studies published between
Another topic related to the growth of mHealth apps is the 17 April 2021 and 12 July 2022. A combined flow chart of the
various content that the apps can provide for stroke rehabilita­ study selection is presented in Figure 1. Inclusion criteria were
tion. A previous scoping review listed 39 mHealth apps with a designed according to the PICOS (patient, intervention, compari­
vast heterogeneity in the content of apps, of which the most son, outcome, study designs) framework as follows: P) adult post-
common focuses were upper extremity function (32%), medical stroke survivors in any stages who experienced an ischemic or
management and secondary prevention (26%), exercises, PA, or hemorrhagic stroke. Post-stroke was defined in four stages (acute:

Figure 1. Flow chart of study selection.

 MHEALTH APPLICATIONS IN STROKE REHABILITATION 4003

< 2 weeks; subacute: 3 weeks to 11 weeks; early chronic: Data extraction and statistical synthesis
12–24 weeks; chronic: > 24 weeks [25–27]), I) intervention using a
The characteristics concerning study methods, participants, type
mHealth app on a smartphone or a tablet containing any type of
of intervention, name of the mHealth apps, delivery method of
physical training component (e.g., physical exercises, physical
the app (mobile phone or tablet), and results were extracted from
therapy, or physical activity) for the person to use the app inde­ the included articles and analyzed descriptively. For mHealth
pendently of a therapist but the help of a caregiver was allowed, apps, we derived the findings into categories based on their con­
C) any type of control group (if applicable), O) any type of out­ tent design if possible (e.g., gamification, exercise prescription, or
come measures of PF or PA. A secondary outcome related to QoL another type). To determine the effectiveness of mHealth apps
was extracted if QoL was a subject of investigation in studies using a physical training component in stroke rehabilitation on
including PF or PA, S) randomized controlled trials (RCTs), non- the selected outcomes, we performed a vote counting analysis for
randomized clinical trials (non-RCTs), or uncontrolled clinical trials RCTs and non-RCTs to compare the number of studies reporting
published in English. Articles were excluded if the intervention statistically significant findings between experimental and control
used stationary technological devices such as computers, televi­ groups [33].
sion screens, or robotics, the mHealth apps were used for assess­
ment, medication control, education, cognitive, or speech
rehabilitation, or the mHealth app was only used by a therapist
Results
during training. Furthermore, systematic reviews, discussion or The literature search identified 975 studies after the duplicate
short reports, abstracts, qualitative studies, non-clinical trials, and articles were manually removed. Screening of 53 full-text studies
study protocols were excluded from the review. revealed 11 studies that fulfilled the inclusion criteria [34–44]. No
Two researchers (LE and EP) performed the searches in the relevant articles were identified in the additional manual search.
selected databases. Search terms included keywords describing Overall seven (63.6%) controlled clinical trials (five RCTs and
the technology, rehabilitation, and outcomes of PF, PA, and QoL. two non-RCTs) and four (36.4%) uncontrolled clinical trials were
An example of original search strategies is described in included (Table 1). A flow chart of the screening process is pre­
Supplementary File 1. The search strategy used a medical subject sented in Figure 1. Extracted data are presented in Tables 1 and
or keyword headings. An additional manual search was conducted 2. Five studies were conducted in Europe (United Kingdom, Spain,
using references mentioned in the retrieved studies. the Netherlands, and Israel) [34,38,40,42,44] and three in Asia
Two reviewers (LE and EP) independently screened the titles (South Korea and the Philippines) [36,37,39]. Other studies were
and abstracts of the articles in line with the Preferred Reporting conducted in North America (the United States) [41], South
Items for Systematic Reviews and Meta-analysis guidelines using America (Chile) [35], and Africa (Ghana) [43].
the PICOS criteria [28]. In case of doubt, the article was kept and
chosen to be screened during the full-text screening. Then, Description of the participants
articles were independently evaluated for full-text assessment by
two reviewers (LE and EP). A third reviewer (PF or AR) evaluated The selected studies included a total of 264 stroke survivors of
the studies in case of a disagreement. If needed, corresponding which 215 reported in the controlled clinical trials and 49
reported in the uncontrolled clinical trials. Of the 215 stroke survi­
authors of the included studies were contacted for obtaining add­
vors in the controlled clinical trials, 114 were reported in the
itional information.
experimental group and 101 in the control group. From the total
sample, the median (IQR) age of the participants was 59.3 (55.3 to
Methodological quality of the studies 61.0) years and 41.7% were women. The median (IQR) disease
duration was 18.9 (14.8 to 45.6) months. Seven studies (63.6%)
Study quality assessment was performed independently by two
included stroke survivors in the chronic stage, two (18.2%) studies
reviewers (LE and EP), and in case of uncertainty, a third reviewer
subacute stage, one (9.1%) subacute and chronic stages, and one
(PF or AR) was consulted.
(9.1%) combination of acute, subacute, early chronic, and
For RCTs, methodological quality was assessed using the
chronic stages.
PEDro scale [29,30]. The scale consists of 11 items and each item
Individual studies used different main inclusion criteria for eli­
is rated (yes or no). If the study met the criterion, the item was
gibility to participate in an mHealth intervention study. These
rated “yes.” Points were given if a criterion was reported, except
were defined with measurements of upper extremity impairments
for item 1. Therefore, a total score of 10 points was derived where [37], ability to move wrist and fingers [36,39,40], functional ambu­
the higher score indicated a higher level of quality. A score below lation classification (FAC) score between 3 and 5 points [38,42],
4 points was considered as “poor,” a score from 4 to 5 as “fair,” a able to use a mobile app independently [41], independent walk
score between 6 and 8 as “good,” and a score between 9 and 10 with or without using an aid or orthosis [34], balance (e.g., Berg
as “excellent” [29]. Balance Scale < 50 points out of 56) [35], the level of ADL (e.g.,
For non-RCTs and uncontrolled clinical trials, we used the modified Rankin score of 1 to 4) [43], or a score equal to or less
modified Downs and Black checklist [31,32]. The checklist consists than 10 in the Trunk Impairment Scale (TIS) [44]. Hence, measure­
of 27 items and includes domains for study reporting (10 items), ments of impairment levels varied across studies; however, overall
external validity (3 items), internal validity (bias and confounding) synthesis indicated that most participants had either mild or mod­
(13 items), and power (1 item) [31,32], with a total possible score erate symptoms of stroke (Table 1).
of 28 for randomized and 25 for non-RCTs [31]. An item was
scored 1 (Yes) if the criterion was fulfilled or 0 if inadequately
Methodological quality
reported, unable to determine, or not applicable. Overall quality
rating per study was assessed using the corresponding quality The overall methodological quality of the studies was fair when
levels as previously reported [31]: excellent (26–28); good (20–25); taking into account results taken from the PEDro scale and the
fair (15–19); and poor (� 14). modified Downs and Black checklist (Table 3). For RCTs, a general
 4004

Table 1. Study design and methods of interventions using a smartphone- or tablet-based mHealth application containing a physical training component (11 studies).
N Age (years) Stroke Impairment level
A. RINTALA ET AL.

Studies Country Design (EXP/CON) EXP/CON stage EXP/CON Aim Application Device Setting
Burgos Chile CCT 10 (6/4) 57.0/65.3 Subacute BBS (max. 56): 35.0/35.8 Postural control Android app Smartphone þ Home
et al. [35] 2 IMU sensors
Carabeo Philippines UCT 3 56.0 Chronic Capable to do most household Fine finger dexterity FINDEX Tablet PC Inpatient
et al. [36] chores with the affected hand
Choi et al. [37] South Korea RCT 24 (12/12) 61.0/72.1 Early chronic/ FMA-UE (max. 66): 24.5/21.5 Upper extremity MoU-Rehab Smartphone þ Inpatient
chronic motor function tablet PC
R
V
Grau-Pellicer Spain RCT 41 (24/17) 63.0/68.5 Chronic 10 MWT comfort (m/s): 0.8/0.6 Physical activity Fitlab Training þ Smartphone þ Home
R
et al. [38] FitlabV Test pedometer
Jang and South Korea RCT 21 (10/11) 39.3/49.3 Chronic MFT (max. 32): 8.1/7.3 Finger motor function Finger training Tablet PC Inpatient
Jang [39] application
Kizony Israel UCT 15 63.1 Subacute/ FMA-UE (/60): 54 Hand dexterity Tap-it Tablet PC Inpatient
et al. [40] chronic
Lawson United States UCT 6 53.3 Chronic ARAT (/57): 9–57 (range) Upper extremity ARMStrokes Smartphone Home
et al. [41] motor function
Paul et al. [34] UK CCT 23 (15/8) 56.3/55.3 Chronic 10 MWT (m/s): 0.4/0.4 Physical activity and STARFISH Smartphone Home
well-being
Salgueiro Spain RCT 30 (15/15) 57.3/64.5 Chronic TIS 2.0: 7.6/7.3 Trunk control, balance, Farmalarm Smartphone Home
et al. [44] and gait
Sarfo et al. [43] Ghana UCT 20 54.6 Acute/subacute/ SLS (/15): 7.5 Motor function 9zest Stroke Smartphone Home
early chronic Rehab App
Vloothuis The Netherlands RCT 66 (32/34) 60.5/59.3 Subacute SIS-mobility (max. 100): Mobility CARE4STROKE Smartphone Inpatient or
et al. [42] 49.9/41.4 home
EXP: experimental group; CON: control group; CCT: non-randomized controlled clinical trial; BBS: Berg Balance Scale; IMU: inertial measurement unit; UCT: uncontrolled clinical trial; PC: personal computer; RCT: random­
ized clinical trial; FMA-UE: Fugl-Meyer Assessment – upper extremity; 10MWT: 10-Meter Walking Test; MFT: Manual Function Test; SIS: Stroke Impact Scale; ARAT: Action Research Arm Test; SLS: Stroke Levity Scale.
Table 2. Intervention details and results of studies using a smartphone- or tablet-based mHealth application containing a physical training component (11 studies).
Results between groups (pre-post);
Studies Intervention EXP Intervention CON Training volume Personalized Outcomes vote-countinga Conclusion
Randomized and non-randomized controlled clinical trials
Burgos et al. [35] Six exergames: (1) anteroposterior Usual care EXP: nine sessions of 300 , Yes, the ability to BBS, BBS: significant higher improvement Significant greater
stability limits, (2) mediolateral four weeks þ usual modify own MBT, in EXP with 20.20% vs. 12.50% improvement of
stability limits, (3) sit-to-stand care difficulty level BI (p ¼ 0.019); þ postural control in EXP
transfer, (4) standing, (5) reactive CON: three sessions of MBT: higher improvement in EXP in comparison to CON
balance, and (6) postural control (IMU 400 , four weeks with 29.70% vs. 16.96%, but NS
at lumbar level and anterior thigh of (p ¼ 0.245); 0
paretic side) þ usual care BI: significant higher improvement
in EXP with 17.50% vs. 3.75%
(p ¼ 0.025); þ
Choi et al. [37] Four game applications to improve Usual care of ROM, 10 sessions of Yes, the ability to MMT-UE, MMT-UE (wrist): significant higher Greater improvement of
strength, endurance, ROM, control, strengthening, and 1 h, two weeks adjust difficulty FMA-UE, improvement in EXP (p < 0.05); þ upper limb motor
speed, and accuracy of UE functional levels individually B-stage-UE, MMT-UE (shoulder and elbow): function in EXP in
(smartphone attached to patients’ exercises (1 h) MBI, higher improvement in EXP, but comparison to CON
arm) (300 ) þ usual care (300 ) EQ-5D NS (p > 0.05); 0
FMA-UE: significant higher
improvement in EXP (p < 0.05); þ
B-stage-UE: significant higher
improvement for arm and hand
in EXP (p < 0.05); þ
MBI & EQ-5D: higher improvement
in EXP, but NS (p > 0.05); 0
Grau-Pellicer Inpatient: supervised aerobic, task- Trunk, strengthening EXP: 16 sessions of 1 h, Not reported Outdoors walking Outdoors walking time (minutes/ Significant greater
et al. [38] oriented training, balance, and exercises, gait eight weeks (inpatient) time, sitting time, day): significant higher improvement of
stretching exercises training, and þ usual care 10MWT, improvement in EXP with an physical activity in EXP
þ home: progressive daily ambulation occupational CON: the daily program 6MWT, increase of 56.85 vs. 9.47 in comparison to CON
program (150’/week of moderate therapy for three months TUG, (p ¼ 0.034); þ
physical activity), monitored with app BI, Sitting time (minutes/day):
and pedometer (monitor walking EQ-5D-5L significant higher improvement in
distance, walking speed, and amount EXP with a decrease of 2.96 vs.
of steps/day) 0.53 (p ¼ 0.012); þ
10MWT comfort (m/s): significant
higher improvement in EXP with
an increase of 0.49 vs. 0,12
(p ¼ 0.002); þ
10MWT fast (m/s): significant higher
improvement in EXP with an
increase of 0.67 vs. 0,06
(p ¼ 0.002); þ
6MWT (m): significant higher
improvement in EXP with an
increase of 142.28 vs. 19.79
(p ¼ 0.04); þ
TUG (s): higher improvement in EXP
with a decrease of 14.83 vs. an
increase of 4.67, but NS
(p ¼ 0.057); 0
BI: significant higher improvement
in EXP (p ¼ 0.013); þ
MHEALTH APPLICATIONS IN STROKE REHABILITATION

EQ-5D-5L: significant higher

improvement in EXP
(p ¼ 0.002); þ
(continued)
4005
Table 2. Continued.
4006

Results between groups (pre-post);

Studies Intervention EXP Intervention CON Training volume Personalized Outcomes vote-countinga Conclusion
Jang & Jang, [39] Five finger games with progression: (1) No training EXP: No MMT-wrist, MMT-wrist flexion: higher Significant greater
stretching, (2) flexion, (3) extension, 24 sessions of MMT-fingers, improvement in EXP with an improvement of finger
(4) opposition, and (5) 310 , four weeks MFT, increase of 0.20 vs. 0.00, but NS motor function in EXP
thumb abduction PPT (p > 0.05); 0 in comparison to CON
MMT-wrist extension: significant
higher improvement in EXP with
an increase of 0.40 vs. 0.00
A. RINTALA ET AL.

(p < 0.05); þ
MMT-finger flexion: higher
improvement in EXP with an
increase of 0.30 vs. a decrease of
0.04, but NS (p > 0.05); 0
MMT-finger extension: significant
higher improvement in EXP with
an increase of 0.40 vs. 0.00
(p < 0.05); þ
MFT: significant higher improvement
in EXP with an increase of 2.00
vs. 0.76 (p < 0.05); þ
PPT: significant higher improvement
in EXP with an increase of 1.60
vs. a decrease 0.09 (p < 0.05); þ
Paul et al. [34] Virtual groups of four people are No active six weeks Yes, the ability to set Number of steps/ Number of steps/days: significant Significant greater
represented by colored fish within a rehabilitation, individualized days, sedentary higher improvement in EXP with improvement of
fish tank, when the participant is appointments with step goals time, walking time, an increase of 39.3% vs. a physical activity in EXP
active their fish swims and blows health care SS-QOL, decrease of 20.2% (p ¼ 0.005); þ in comparison to CON
bubbles which they, and other professionals 10MWT Sedentary time: higher improvement
0
participants can see. in EXP with a decrease of 55 vs.
340 , but NS (p ¼ 0.705); 0
Walking time: significant higher
improvement in EXP with an
increase of 200 /day vs. a decrease
of 140 /day (p ¼ 0.002); þ
SS-QOL: higher improvement in EXP
with an increase of 14.1 vs. 7.8
points, but NS (p ¼ 0.313); 0
10MWT (m/s): higher improvement
in EXP with an increase of 0.06
vs. 0.04, but NS (p ¼ 0.967); 0
Salgueiro Core-stability exercises in supine and Usual care EXP: No TIS TIS-balance: significant increase of Significant greater
et al. [44] sitting positions / surfaces on 10 exercises per day, FIST balance in EXP with a change of improvement in TIS-
app þ usual care five days a week, PASS 1.86 vs. 0.23 (p ¼ 0.007); þ balance and TIS-total
12 weeks þ usual care BBS TIS-coordination: increased in EXP in comparison
CON: coordination with a change of to CON
12 weeks 0.71 vs. 0.08, but NS (p ¼ 0.424); 0
TIS-total: significant higher
improvement in EXP with a
change of 2.57 vs. 0.31
(p ¼ 0.032); þ
FIST: higher function in EXP with an
increase of 2.36 vs. 1.15, but NS
(p ¼ 0.574); 0
PASS-mobility: better mobility in EXP
with an increase of 1.43 vs. 0.15,
(continued)
Table 2. Continued.
Results between groups (pre-post);
Studies Intervention EXP Intervention CON Training volume Personalized Outcomes vote-countinga Conclusion
but NS (p ¼ 0.208); 0
PASS-balance: improved balance in
EXP with a change of 0.29 vs.
0.08, but NS (p ¼ 0.532); 0
PASS-total: better posture score in
EXP with a change of 1.71 vs.
0.08, but NS (p ¼ 0.633); 0
BBS: lower balance increase in EXP
with a change of 1.93 vs. 2.46,
but NS (p ¼ 0.647); 0
Vloothuis Set of standardized mobility exercises Usual care EXP: Yes, exercises related SIS, SIS-mobility: lower improvement in No significant differences
et al. [42] on app executed with a caregiver (KNGF-guideline) 40 sessions of 300 , to patient goals FMA-LE, EXP with an increase of 25.00 vs. in mobility in EXP in
þ usual care eight weeks þ usual RMI-LE, 31.95 points, but NS (p ¼ 0.229); 0 comparison to CON
care 6MWT, SIS-emotion: higher improvement in
CON: eight weeks 10MWT, EXP with an increase of 1.50 vs. a
TUG, decrease of 0.84 points, but NS
BBS, (p ¼ 0.652); 0
BI FMA-LE: higher improvement in EXP
with an increase of 5.63 vs. 4.55
points, but NS (p ¼ 0.251); 0
RMI-LE: higher improvement in EXP
with an increase of 14.65 vs.
12.52 points, but NS (p ¼ 0.396); 0
6MWT (m): lower improvement in
EXP with an increase of 73.54 vs.
106.74, but NS (p ¼ 0.946); 0
10MWT (m/s): lower improvement in
EXP with an increase of 0.30 vs.
0.39, but NS
(p ¼ 0.780); 0
TUG (s): higher improvement in EXP
with a decrease of 11.65 vs.
10.91, but NS (p ¼ 0.484); 0
BBS: higher improvement in EXP
with an increase of 14.12 vs.
13.35 points, but NS (p ¼ 0.344); 0
BI: higher improvement in EXP with
an increase of 4.41 vs. 3.57
points, but NS (p ¼ 0.251); 0
Uncontrolled clinical trials
Studies Intervention Training volume Personalized Outcomes Results (pre-post) Conclusion
Carabeo et al. [36] Game-based on everyday functional activities: Nine sessions of max. No Accuracy (percentage Dragging task: no improvement FINDEX may be effective
Dragging task (finger control): place pizza toppings in 300 , six weeks of success), (0.0%) of accuracy, 30.8% to improve fine finger
corresponding places Time taken improvement of time taken dexterity after stroke
Tapping task (finger isolation, coordination): tap piano keys using Tapping task: 24.0% improvement of
particular fingers accuracy
Stretching task (finger ROM): water flower plots by keeping a Stretching task: 31.7% improvement
thumb on a watering can and tapping plot area that of time taken
needs water
Kizony et al. [40] Tap-it game: hold thumb on anchor shape while using One session (two trials) No Accuracy (percentage 73.3% improvement of accuracy Tablet apps may provide
MHEALTH APPLICATIONS IN STROKE REHABILITATION

different fingers to tap on colored shapes that appear of success) a way to improve
and disappear hand dexterity and
function after a stroke
(continued)
4007
4008 A. RINTALA ET AL.

defect of the methodological quality was blinding procedures.

EXP: experimental group: CON: control group; IMU: inertial measurement unit; BBS: Berg Balance Scale; MBT: Mini-BESTest; BI: Barthel Index; NS: not significant; ROM: range of motion; MMT-UE: Manual Muscle Testing –

Sitting Test; PASS: Postural Assessment Scale for Stroke Patients; KNGF: Koninklijk Nederlands Genootschap voor fysiotherapie; SIS: Stroke Impact Scale; FMA-LE: Fugl-Meyer Assessment – lower extremity: RMI-LE:
om stage – Upper Extremity; MBI: Modified Barthel Index; EQ-5D: EuroQol-5 Dimensions- 5 Levels; 10MWT: 10-Meter Walking
Test; 6MWT: 6-Minute Walking Test; TUG: Timed Up and Go Test; MFT: Manual Function Test; PPT: Purdue Pegboard Test; SS-QOL: Stroke Specific Quality of Life Scale; TIS: Trunk Impairment Scale; FIST: Function in
SLS: significant improvement with 9zest Stroke Rehab App
was associated with
Other single issues related to methodological quality was random

improvements in

improvements in
allocation [37], concealed allocation [39,44], baseline comparability

upper extremity
Conclusion

motor function
demonstrated
[37], adequate follow-up (> 85%) [38], and reporting of point
measures and measures of variability [37]. For two non-RCTs and
ARMStrokes

recovery
four uncontrolled clinical trials, low external validity was observed

Vote counting: þ ¼ significant positive results in favor for the experimental group; - ¼ significant negative results in favor for the control group, and 0 ¼ non-significant results between the groups.
where the source population was not adequately reported. Other
main methodological defects were made concerning internal val­

BI: improvement with an increase of

mRS: improvement with a decrease
Results between groups (pre-post);

idity, of which most issues were related to blinding, randomiza­

an increase of 4.7 (p < 0.0001)
tion, and concealment of allocation. Moreover, none of the six

1.7 (p value not reported)

studies reported sufficient power to detect the treatment effect at
vote-countinga
Accuracy (percentage 176.7% improvement of

the significance level of 0.05.

movements captured

VAS pain: no change

NIHSS: no change
0.4 (p ¼ 0.06)

Interventions in the experimental groups and control groups

Interventions in the experimental groups
Of the total 11 mHealth apps, eight apps were delivered using a
mobile phone and three apps were delivered using a tablet
(Table 1). The sample size in the interventions ranged from 3 to
66 participants. The training volume ranged between one single
Outcomes

Rivermead Mobility Index – Lower Extremity; mRS: Modified Rankin Scale; NIHSS: National Institutes of Health Stroke Scale; VAS: Visual Analog Scale.
of success )

session and 12 weeks (median of 5 weeks). Seven (63.6%) out of

11 studies used a smartphone-based mHealth solution in their
SLS, mRS,

VAS pain

interventions [34,35,37,38,41–44], of which three studies used

NIHSS,

apps in a combination with other devices such as inertial move­

BI,

ment unit (IMU) sensors [35], tablet [37], and pedometer [38].
movement ability

exercise program
calibrated to the

Three (27.3%) studies used a tablet-based mHealth solution only

Yes, exercises are
Personalized

individualized,
Yes, progressive,

goal-targeted
of each user

[36,39,40] and one (9.1%) study used either an app or a tablet

ROM and

[44]. Concerning the content of mHealth apps in the experimental

groups, three main categories were classified (Figure 2): gaming,
exercise prescription, and monitoring. Six (54.5%) out of 11 stud­
ies used a gaming app where the intervention was given in a vir­
tual environment either in a hospital setting [36,37,39,40] or at
Multiple daily sessions
Training volume

30–600 , 12 weeks

home [35,41]. Three (27.3%) studies used the mHealth app as an

of 300 , six weeks

exercise prescription (e.g., mobility, upper and lower limb

Four categories of exercise program on the app: (1) mobility, 70 sessions of

strengthening, sitting, standing balance, walking endurance, and

core exercises) which were implemented either completely at
Upper Extremity; FMA-UE: Fugl-Meyer Assessment – upper extremity; B-stage-UE: Brunnstr€

home or combination of inpatient and home settings [42–44].

Two (18.2%) studies used a monitoring app registering the levels
where the monkey/astronaut perform a specific action (picking

of PA which both were applied at home [34,38].

bananas/exploring space), repetitions within 300 is tracked to

upper and lower limb strengthening, (2) dexterity, (3) seated

extremity (holding phone in the hand to detect movements)
Intervention CON

motivate to complete more repetitions, auditory/ vibration/

Lawson et al. [41] Climbing Monkey þ Astronaut game: 8 exercises for upper

Six (54.5%) out of 11 mHealth apps were personalized to the

individual needs of the participants, namely, to modify gaming
difficulty level [35,37], set individualized step goals [34], build
and standing balance, and (4) walking endurance

exercises based on patient goals [42,43], or generate exercises

based on the findings of the range of motion and move­
ment [41].
In addition to what other treatments the experimental groups
received with the apps, five controlled clinical trials provided
usual care consisting of supervised aerobic exercises, task-orien­
Intervention EXP

tated training, balance training, muscle training, gait and posture

visual feedback provided

training, or stretching exercises [35,37,38,42,44].

Six (54.5%) out of 11 studies reported no adverse events from
using the apps during the intervention [34,35,37–39,42]. Five
(45.5%) studies did not report whether or not adverse events
occurred while using the apps [36,40,41,43,44].

Interventions in the control groups

Table 2. Continued.

In five (71.4%) out of seven controlled clinical trials, the control

Sarfo et al. [43]

group received usual care given by a trained therapist in clinical

settings. Usual care was mainly focused on improving range of
motion, muscle strength, gait, trunk stability, and daily life func­
Studies

tioning. Two (28.6%) studies did not include any active rehabilita­
tion for the control group [34,39].
a
 MHEALTH APPLICATIONS IN STROKE REHABILITATION 4009

Table 3. Methodological quality assessment of studies including mHealth applications containing a physical training component in stroke rehabilitation (11 studies).
RCTs (PEDro scale)
Choi et al. Grau-Pellicer Jang and Salgueiro Vloothuis
Criteria [37] et al. [38] Jang [39] et al. [36] et al. [42]
1. Eligibility criteria Yes Yes Yes Yes Yes
2. Random allocation No Yes Yes Yes Yes
3. Concealed allocation Yes Yes No No Yes
4. Baseline comparability No Yes Yes Yes Yes
5. Blinding of participants Yes No No No No
6. Blinding of therapists No No No No No
7. Blinding of assessors Yes No Yes Yes Yes
8. Adequate follow-up (> 85%) Yes No Yes Yes Yes
9. Intention-to-treat analysis Yes Yes Yes Yes Yes
10. Between-group statistical comparisons Yes Yes Yes Yes Yes
11. Reporting of point measures and measures of variability No Yes Yes Yes Yes
Total score (/10) 6/10 6/10 7/10 7/10 8/10
Non-RCT and uncontrolled trials (modified Downs and Black Checklist)
Burgos Carabeo Kizony Lawson Paul Sarfo
et al. et al. et al. et al. et al. et al.
Criteria [35] [36] [40] [41] [34] [43]
Reporting
1. Hypothesis/aim/objective clearly described Yes Yes Yes Yes Yes Yes
2. Main outcomes clearly described in introduction or methods section Yes Yes Yes Yes Yes Yes
3. Patient characteristics clearly described Yes Yes Yes Yes Yes Yes
4. Interventions of interest clearly described Yes Yes Yes Yes Yes Yes
5. Principal confounders clearly described Yes Yes Yes Yes Yes Yes
6. Main findings clearly described Yes Yes Yes Yes Yes Yes
7. Estimates of random variability provided for main outcomes Yes No Yes No Yes Yes
8. All adverse events of intervention reported Yes No No No Yes No
9. Characteristics of patients lost to follow up described No No Yes Yes Yes Yes
10. Probability values reported for main outcomes Yes No Yes No Yes Yes
External validity
11. Subjects asked to participate were representative of the source population UTD UTD UTD UTD No UTD
12. Subjects prepared to participate were representative of the source population No No UTD UTD No Yes
13. Location and delivery of study treatment was representative of the source population Yes UTD UTD Yes Yes Yes
Internal validity – bias
14. Study participants blinded to treatment UTD No No No UTD No
15. Blinded outcome assessment UTD No No No No No
16. Any data dredging clearly described Yes Yes Yes Yes Yes Yes
17. Analyses adjust for differing lengths of follow-up Yes Yes Yes Yes Yes Yes
18. Appropriate statistical tests performed Yes Yes Yes Yes Yes Yes
19. Compliance with interventions was reliable Yes Yes Yes Yes Yes Yes
20. Outcome measures were reliable and valid No Yes Yes Yes Yes No
Internal validity – confounding (selection bias)
21. All participants recruited over the same source population Yes Yes UTD UTD Yes Yes
22. All participants recruited over the same time period Yes UTD UTD UTD UTD UTD
23. Participants randomized to treatment(s) Yes No No No No No
24. Allocation of treatment concealed from investigators and participants UTD No No No No No
25. Adequate adjustment for confounding No No Yes No Yes No
26. Losses to follow up taken into account UTD No Yes UTD Yes Yes
Power
27. Sufficient power to detect treatment effect at the significance level of 0.05 UTD UTD UTD UTD No UTD
Total score (/28) 18 13 17 14 20 18
UTD: unable to determine.

Content of mHealth apps containing a physical training Gaming apps

component Six (54.5%) out of 11 mHealth apps targeted PF related to the
upper extremity and postural control. Only two studies reported
The content design of the mHealth apps in the experimental or visualized a stationary sitting/standing position of the
groups was heterogeneous. We identified three categories: gam­ patient [37,41].
ing apps, exercise prescription apps, and monitoring apps (Figure MoU-Rehab app included a mobile upper extremity rehabili­
2). mHealth apps related to gaming were mostly related to PF for tation program containing exercises to improve upper extremity
upper extremity (MoU-Rehab, unnamed finger training app, FINDEX, strength, endurance, range of motion, control, speed, and accur­
Tap-it, and ARMStrokes) and postural control (unnamed Android acy [37]. The MoU-rehab app contained four mobile game apps.
app). Exercise prescription apps were related to mobility While playing the games viewed on the tablet PC, the smart­
(CARE4STROKE) and motor function (9zest Stroke Rehab and phone was attached to the patient’s arm to detect upper
Farmalarm). Monitoring apps focused on physical activity extremity movements. In this way, participants acquired visual
(FitlabV and STARFISH). Below we have described the apps more
R
and auditory feedback on their movements. Participants were
in detail. encouraged to use the app for 30 min five times a week for two
4010 A. RINTALA ET AL.

Figure 2. Overview of categories for mHealth applications in studies using a smartphone- or tablet-based mHealth application containing a physical training compo­
nent (11 studies).

weeks alongside traditional occupational therapy of 30 min and “Astronaut” [41]. A participant could perform eight exercises
per week. for the upper extremity by holding the smartphone in their hand
An unnamed finger tapping app was built to improve finger to detect upper extremity movements. In the game, a monkey or
motor function [39]. The app consisted of five games containing an astronaut performed a specific task that the participant com­
finger stretching, flexion, extension, opposition, or thumb abduc­ pleted with a correct movement. The goal in the “Climbing
tion exercises. Depending on the game, participants had to place, Monkey” game was to pick bananas from a tree. The goal of the
click, lift, or move their fingertips on the tablet screen. One ses­ “Astronaut” game was to explore space. Both games included
sion was programmed six times a week (31 min per session) for auditory and vibration feedback when the monkey or the astro­
four weeks. naut accomplished the task goal. The amount of training was not
Findex app aimed to improve fine finger dexterity based on reported in the study.
activities of daily living [36]. When the participant logs in to the An unnamed android app was developed for the study to
app, a house foyer is viewed. In the house foyer, the participant improve the postural control of the participants [35]. The smart­
can enter three rooms. These rooms represented three games. phone app consisted of six exergames that focused on anterior-
The first game aimed to exercise finger control with a task to posterior stability limits, mediolateral stability limits, sit-to-stand
place pizza toppings on the corresponding spaces within 2 min. transfer, standing, reactive balance, and postural control. Two
The second game targeted finger isolation and coordination wireless IMUs were used where one IMU was positioned at the
where a participant had to tap piano keys using specific fingers. lumbar level and the other IMU was placed at the anterior thigh
Finally, the third game included a stretching task to increase the of the paretic side. IMUs recorded the movements of the partici­
range of motion (ROM) in fingers where a participant had to pant which created the possibility to receive feedback from the
water flower plots by keeping their thumb on the watering can exercises. Remote app training was programmed for 30 min per
and tapping the flowers that needed water. Participants were session and nine times a week (in a total of 4 h 30 min) in add­
asked to use the app for 30 min one to three times a week in ition to usual physiotherapy of 40 min sessions three times a
conjunction with their standard therapy for four weeks. week for four weeks.
Tap-it app aimed to improve hand dexterity [40]. In this
game, a participant had to hold their thumb on an anchor while Exercise prescription apps
using their other fingers to tap on colored shapes that appear Three (27.3%) out of 11 mHealth apps targeted PF on mobility
and disappear. The app was used only for one session including and motor function at home or home/inpatient environment.
two trials. CARE4STROKE app program aimed at improving mobility
ARMStrokes app targeted upper extremity motor function which was built as a tool for therapists [42]. A therapist selected a
which contained two mobile games, namely “Climbing Monkey” set of standardized exercises presented in the smartphone app,
 MHEALTH APPLICATIONS IN STROKE REHABILITATION 4011

which was executed with a caregiver at home. The app was used achieved by using gaming apps [37,39]. Choi et al. [37] reported
at home where the interaction with a therapist was available statistically significant improvements for upper extremity out­
through telephone, video conferencing, or email when appropri­ comes in favor of the experimental group compared to usual care
ate. Participants were asked to use the app five times a week alone and Jang and Jang [39] showed similar results only focusing
(30 min per session) with their caregiver for eight weeks. on finger function using a finger tapping app compared to a con­
9zest Stroke RehabV app was targeted to improve general
R
trol group of no training, except for MMT of the finger and
motor function at home [43]. In the app, a participant received an wrist flexors.
exercise program consisting of four categories, namely (1) mobil­ Lower extremity function was assessed only in one (14.3%) RCT
ity, upper and lower limb strengthening, (2) dexterity, (3) seated study using the Fugl-Meyer Assessment of the lower extremity
and standing balance, and (4) walking endurance. The app was (FMA-LE) and the Motricity Index of the lower extremity leg (MI-
used in combination with supervised inpatient therapy sessions LE) [42]. Statistically significant differences were not observed in
and at home with a caregiver. Participants were encouraged to the experimental group using the mHealth app targeted to exer­
use the app five times a week (one session 30–60 min) cise description for mobility (CARE4STROKE) with usual care com­
for 12 weeks. pared to usual care alone.
Farmalarm app provided overall 32 exercises (description, Balance was assessed in two RCTs and one non-RCT (42.9%)
photo, and video) designed for core-stability training in a supine using the Mini-BESTest (MBT) and/or Berg Balance Scale (BBS)
position, sitting positing, or sitting on an unstable surface [44]. [35,42,44]. Only Burgos et al. [35] observed a statistically signifi­
Exercises were provided in order of difficulty and the participants cant improvement in BBS scales in the experimental group com­
had the possibility to navigate and choose freely the exercises pared to usual care when the experimental group used a gaming
with an encouragement to perform 10 repetitions of each exercise app targeted to postural control [35]. For other studies or other
five days a week for 12 weeks. The app was used at home with a balance outcomes, statistically significant between-group differen­
combination of maintaining their usual dose of treatment during ces were not reported.
the study. Walking speed was assessed in two RCTs and one non-RCT
(42.9%) using the 10-Meter Walking Test (10MWT) [34,38,42].
Monitoring apps
Walking endurance was assessed in only two clinical trials using
Two (18.2%) out of 11 mHealth apps monitored PA using the
the 6-Minute Walking Test (6MWT) [38,42]. For both outcome
number of steps per day and/or walking and sitting time at
measures, contradictory results were observed, namely, only one
home (Figure 2).
study reported statistically significant improvements for both
FitlabV app aimed to supervise adherence to PA and to reach
R

walking outcomes in favor of the experimental group using a

a moderate-intensity PA level (150 min) per week in addition to
mHealth app for PA monitoring when compared to usual care
twice a week of 1 h exercise program session and regular daily
[38]. Vloothuis et al. [42] and Paul et al. [34] did not observe stat­
walking for eight weeks [38]. This daily ambulation progressive
istically significant differences between the groups on walking
program at home was monitored with an app and a pedometer
outcomes (mHealth apps targeted to exercise prescription and
was used to register walking distance and walking speed.
STARFISH app was designed as a behavioral change interven­ PA monitoring).
Functional mobility and risk of falling were assessed using the
tion to encourage the participant to become more physically
active [34]. The app used a metaphor of a fish tank and virtual Timed Up and Go (TUG) test in two RCTs (28.6%) [38,42]. Neither
groups of four people were represented by colored fish within studies did not report statistically significant improvements in
the fish tank. Real-time feedback was provided in the app. A fish functional mobility between the groups where experimental
swam and blew bubbles in the virtual fish tank when the corre­ groups received mHealth interventions targeted to either PA
sponding participant was physically active. Each participant had a monitoring [38] or exercise prescription for mobility [42].
step count target for five days per week which participants were Activities of daily living were assessed in three RCTs and one
asked to follow for six weeks. non-RCT (57.1%) using Barthel Index (BI), modified Barthel Index
(MBI), or Stroke Impact Scale-mobility (SIS-mobility) [35,37,38,42].
Two studies reported statistically significant improvement in the
Effectiveness of mHealth apps on physical function, physical levels of BI in favor of the experimental groups compared to usual
activity, and quality of life in RCTs and non-RCTs care where the experimental group used a mHealth app targeted
PF to gaming and postural control [35] and PA monitoring [38]. The
Outcomes of PF were assessed in all controlled clinical trials (five other two studies did not find statistically significant differences
RCTs and two non-RCTs). Overall, five RCTs and one non-RCT between the experimental group using a mHealth app content of
reported statistically significant improvement in PF outcomes in gaming and upper extremity exercises [37] and exercise prescrip­
favor of the experimental group compared to control groups of tion for mobility [42] and usual care.
usual care or no rehabilitation (Table 2). In the next paragraphs, Core stability was assessed in one (14.3%) RCT using TIS [44].
we provide more detailed results on each outcome (percentages Statistically significant improvements in TIS-balance and TIS-total
are reported from the total of seven controlled clinical trials were observed in favor of the experimental group compared to
included in this review). usual care when the experimental group used an exercise pre­
Upper extremity function was assessed using five different out­ scription app targeted to core-stability training.
comes in two (28.6%) RCTs, namely the manual muscle testing Function in sitting and postural assessment were assessed also
(MMT) of the upper extremity or wrist and fingers, Fugl-Meyer in one RCT (14.3%) using the Function in Sitting Test (FIST) and
Assessment of the upper extremity (FMA-UE), Bru €nnstrom stage the Postural Assessment Scale for Stroke Patients (PASS) [44]. Both
(B-stage) for the arm and hand, Manual Function Test (MFT), and outcomes and PASS subscales (mobility and balance) improved in
Purdue Pegboard Test (PPT) [37,39]. In both studies, statistically the experimental group but the group difference was not statistic­
significant improvements in upper extremity function were ally significant.
4012 A. RINTALA ET AL.

PA monitoring. Although mostly our findings were heterogeneous in

The level of PA was assessed in two (28.6%) controlled clinical tri­ terms of the content of the apps, duration of the interventions,
als (one RCT and one non-RCT) out of seven controlled clinical tri­ and sample sizes, findings of this review representing 163 stroke
als at home settings [34,38]. PA was measured by the number of survivors who used a mHealth app containing a physical training
steps per day and/or walking and sitting time. Both trials showed component indicated either statistically significant, a similar effect,
a significantly higher walking time in the experimental group in or a slightly positive trend (improvement but not statistically sig­
comparison to the control group consisting of either no active nificant findings) on PF, PA, and QoL. Our results confirm previous
rehabilitation [34] or usual care [38]. Both studies also used a systematic reviews that assessed the effects of mobile tablet- and
mHealth app targeted to PA monitoring. Paul et al. [34] reported computer-based therapies on physical function in stroke survivors
a statistically significant increase in the number of steps per day [22,23]. However, previous reviews did not narrow their inclusion
and a higher decrease in sitting time in the experimental group to apps including a physical training component. Furthermore,
compared to a control group with no rehabilitation. Grau-Pellicer our review focused on interventional studies and non-stationary
et al. [38] reported a statistically significant difference in sitting devices (i.e., portable and remote to be used also in home set­
time in favour of the experimental group compared to usual care. tings if possible), whereas previous reviews included other study
methods and rehabilitation technology that was not clearly
QoL defined as remote or portable (i.e., computer-based) [22,23],
As a secondary outcome of mHealth interventions reporting PF or which could therefore potentially decrease their translation to
PA outcomes, 4 (36.4%) clinical trials (3 RCTs and 1 non-RCT) out daily rehabilitation in a home environment.
of 11 clinical trials assessed the level of QoL [34,37,38,42]. Health- The most promising evidence was found for upper extremity
related QoL was measured by EuroQol-5 Dimensions (EQ-5D), function in the mHealth app designed for gaming, where both
Stroke Specific Quality of Life Scale (SS-QOL), or Stroke Impact included studies reported statistically significant differences in
Scale-emotion (SIS-emotion). Only one out of four studies favor of the experimental group when compared to usual care
reported a statistically significant improvement in QoL (EQ-5D) in [37] and no training [39]. Similar findings were also demonstrated
the experimental group using an app for PA monitoring com­ in a review by Pugliese et al. [22], where one of the most com­
pared to a control group of usual care [38] whereas the other mon therapeutic interventions was targeted to fine motor skills
three studies did not find differences between the groups when for people with chronic stroke including also studies other than
comparing mHealth app intervention to usual care [37,42] and no interventional studies (e.g., cohort studies). The difference to our
active rehabilitation [34]. current review is that our inclusion criteria focused on targeted
rehabilitation outcomes (i.e., PF) with providing an overview of
existing evidence from clinical trials. For other PF outcomes, two
Effectiveness of mHealth apps on physical function, physical
out of four studies found statistically significant improvements in
activity, and quality of life in uncontrolled clinical trials
activities of daily living in favor of the experimental group com­
All four uncontrolled clinical trials included only PF outcomes pared to usual care when mHealth apps were designed for gam­
(Table 2). In three (75.0%) out of four uncontrolled clinical trials, ing (postural control) or PA monitoring [35,38]. The other two
upper extremity function was assessed using the general perform­ found no differences between experimental groups and usual
ance levels achieved on the mHealth app. The performance was care [37,42] which may indicate a similar effect between the
measured by time taken and/or accuracy (percentage of success­ groups. These findings are in line with a previous systematic
ful performance of the app). Overall, higher improvements in per­ review with a meta-analysis of six RCT studies investigating any
formance on the mHealth apps were achieved in all three studies type of technology in distance physical rehabilitation interven­
using apps developed for gaming [36,40,41]. Only one study tions, where the authors found a similar effect on activities of
including the mHealth app targeted to exercise prescription daily living compared to traditional treatments [13]. The difference
reported a statistically significant change within the group after in our review was that our review targeted only to mHealth tech­
70 sessions on motor function [43]. nology. These findings indicate that rehabilitation technology,
including mHealth apps, may have its benefits as an additional
treatment strategy to improve activities in daily living in people
Adherence to the use of mHealth apps
with stroke [13], but more robust evidence is needed. Continuing
Only 4 (36.4%) clinical trials out of 11 studies reported some type with other PF outcomes, our review also found positive trends in
of adherence to the use of mHealth apps with very heteroge­ walking, balance, and lower extremity function for both groups,
neous findings [38,40,43,44]. Only one of these studies reported a which can be viewed as a positive note to continue to develop
high level of adherence (an average of 5.7 sessions per week of mHealth apps targeted to people with stroke. Although only a
motor function exercises with a program of 5 sessions per week) few of the studies reported statistically significant differences in
[43]. Other two studies reported adherence of 50.0% consisting of favor of mHealth interventions, other studies found no differences
daily walking and 150 min per week of moderate physical activity between mHealth app interventions and usual care. These find­
[38] and 14.0% including core-stability exercises five days a week ings encourage us to further research mHealth app interventions
[44]. Also, one study reported that 15 (75.0%) out of 20 partici­ targeted to PF to increase more robust evidence. Similar promis­
pants were able to complete the two trials of the tapping task in ing findings were reported in Zhou et al. [23] review for mHealth
the app [40]. interventions improving physical function in stroke survivors, but
the lack of studies challenges further clear recommendations. For
instance, our review provided an overview of outcomes in PF only
Discussion
in interventional studies, which on the other hand makes it closer
Our findings from the 11 included studies contained 11 different to the rehabilitation settings, but also the observed heterogeneity
mHealth apps in stroke rehabilitation. Of those apps, the most of the content of the interventions makes it difficult to conclude
key features in the mHealth apps were gaming, exercise, and more precise clinical implications.
 MHEALTH APPLICATIONS IN STROKE REHABILITATION 4013

Our review also extracted PA outcomes which were measured considered a confounding factor to conclude the robust effective­
in two studies using mHealth apps designed for monitoring PA. ness of mHealth apps in stroke rehabilitation.
The level of PA was improved in both experimental groups when Studies in our review included mostly participants with chronic
the app was applied at home, and when the effect was compared stroke and mild or moderate disability of stroke with the ability to
to either no active rehabilitation [34] or usual care [38]. This is function independently from most of the daily life activities or
also in line with previous systematic reviews that have similar were independently ambulatory. Also, when we look at the find­
improvements in PA in interventions targeted to all types of tech­ ings from the eligibility criteria of participants included in the
nology-based distance rehabilitation compared to usual care and selected studies, 8 out of 11 clinical trials reported an inclusion
other treatments in stroke and MS rehabilitation [13,45]. It is criterion of no severe cognitive impairment at baseline, and three
worthwhile to continue to explore and investigate the use of included studies excluded stroke survivors with visual disturban­
mHealth apps to target changes and monitor the levels of PA, as ces. These aspects suggest that mHealth solutions may not be
PA has been one of the most studied outcomes in stroke rehabili­ suitable for a proportion of stroke survivors and this aspect is
tation with shown benefits. However, it is still less investigated required to take into account when designing such rehabilitation
using a mHealth app in a home environment [14,46]. interventions. For instance, up to one-third of stroke survivors
This systematic review demonstrated that it is still too early to develop some form of cognitive impairment and up to 65%
make any firm suggestions on the usefulness of mHealth apps develop visual impairment early after stroke [49,50]. However, one
using a physical training component in outcomes of QoL positive note was that mHealth apps may be opted for many pur­
although some positive trends were seen in our overview that poses for people with chronic stroke and can be also applied in a
mHealth apps may improve QoL. Discrepancies between the home setting.
included studies may be due to the inability to detect a change The strength of this systematic review is its focus on mHealth
in QoL surveys for a short clinical trial period, and therefore, may applications including a physical training component, which gives
require more longitudinal use of mHealth apps in a research set­ the first-in-kind overview of such mHealth applications in stroke
ting. However, this is still early speculation and more research on rehabilitation. Also, this review followed the guidelines of the
this aspect is required. Preferred Reporting Items for Systematic Reviews and Meta-ana­
When we view the findings of this review from the key fea­ lysis (PRISMA) using a pre-defined PICOS strategy [28]. However,
tures and training dosages in the apps, we see that the current this systematic review also contains some limitations. First, a
state of such apps in stroke rehabilitation has been mostly selection bias cannot be ruled out during the literature screening
designed for gaming, exercises, or monitoring with a high variety of this systematic review. When studies did not explicitly report
of training dosages reported in the study protocols. Such features that the interventions applied an mHealth app-delivered therapy,
are expected to increase in the near future due to the develop­ these studies were excluded. It may be plausible that some stud­
ments of mobile networks and mobile phones, especially when ies were not screened due to a lack of reporting in the abstract
the technology provides more features and higher sophisticated of the published article. Second, the results of this systematic
designs to be included in future apps, such as augmented reality review are weakened due to a lack of included high-evidence
[47]. However, our findings on reported levels of adherence indi­ research and a low sample size of individual studies. Lastly, the
cate that we cannot confirm whether the features and training generalizability of the results is also limited due to most studies
dosages presented in our review are meaningful. While only four published in developed countries and the small number of
(36%) studies reported any level of adherence with two studies included trials with heterogeneity in the content of mHealth apps
reporting low levels of adherence, there are risks that the apps and therapy modalities. Once more studies are published, these
may not be used as expected. These examples may confound our factors can be analyzed using meta-analysis or metaregression to
findings in this review, especially when most of the studies did identify the underlying mechanisms of the effects. These aspects
not report the level of adherence to the use of the app. diminish a firm conclusion of the benefits of mHealth apps in
Reporting adherence in future studies is crucial to understand to stroke rehabilitation.
whom such mHealth apps are more feasible and whether such Current research supports the use of mHealth as an additional
apps are needed to target some specific content and training dos­ tool alongside traditional care on physical function and physical
ages. Also, involving key stakeholders (e.g., stroke survivors and activity for stroke survivors. However, this review was limited to
health care professionals) in the development process of mHealth the information provided in each study, especially adherence was
features are strongly recommended to take into account the voice poorly reported in the included studies. Also, the content and
of the users. availability of these apps for commercial use may have changed
The overall methodological quality of the included trials was during or after this review. Other aspects that may increase the
fair. The included controlled clinical trials had mainly inadequate challenges of using mHealth apps in clinical care are possible add­
quality for selection bias, performance bias, and co-intervention itional costs to use the app and sufficient mobile or internet con­
bias. Concerning selection bias, the majority of included con­ nectivity in the patient’s living environment. Future studies are
trolled clinical trials had a limited sample size (ranging from 3 to encouraged to report more specific details such as adherence,
66 participants) which lowers the statistical power. This may partly availability of the app, costs of the apps, and the feasibility of the
explain also the null findings of several included studies, as a low app to be used in clinical care.
sample size study has the risk to miss a significant effect [48].
Regarding performance bias, 7 out of 11 studies did not apply or
Conclusion
reported blinding of participants and/or therapists. Given the type
of the interventions, the difficulty of blinding participants or The use of mHealth apps containing a physical training compo­
therapists is comprehensible. Lastly, participants in four studies nent on physical function and physical activity is promising in
simultaneously received also usual care as a standard treatment stroke rehabilitation and can be considered as additional support
alongside the mHealth app (co-intervention bias) which can be for post-stroke care. Further high-quality RCT studies are needed
4014 A. RINTALA ET AL.

to determine the benefits of mHealth-only interventions and their [13] Rintala A, P€aiv€arinne V, Hakala S, et al. Effectiveness of
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Disclosure statement tematic review and meta-analysis of randomized controlled
trials. Arch Phys Med Rehabil. 2019;100(7):1339–1358.
No potential conflict of interest was reported by the author(s). [14] Thilarajah S, Clark RA, Williams G. Wearable sensors and
mobile health (mHealth) technologies to assess and pro­
Funding mote physical activity in stroke: a narrative review. Brain
Impair. 2016;17(1):34–42.
The author(s) reported there is no funding associated with the [15] Dicianno BE, Parmanto B, Fairman AD, et al. Perspectives
work featured in this article. on the evolution of mobile (mHealth) technologies and
application to rehabilitation. Phys Ther. 2015;95(3):136–139.
ORCID [16] Burns SP, Terblanche M, Perea J, et al. mHealth intervention
applications for adults living with the effects of stroke: a scop­
A. Rintala http://orcid.org/0000-0002-0066-4697 ing review. Arch Rehabil Res Clin Transl. 2021;3(1):100095.
O. Kossi http://orcid.org/0000-0001-9117-7191 [17] Istepanian RS, Lacal JC. Emerging mobile communication
B. Bonnech�ere http://orcid.org/0000-0002-7729-4700
technologies for health: some imperative notes on m-health.
P. Feys http://orcid.org/0000-0002-5680-5495
In: Proceedings of the 25th Annual International Conference
of the IEEE Engineering in Medicine and Biology Society
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