Date Published: January 25, 2019
Publisher: Public Library of Science
Author(s): Michael Pugliese, Tim Ramsay, Rany Shamloul, Karen Mallet, Lise Zakutney, Dale Corbett, Sean Dukelow, Grant Stotts, Michel Shamy, Kumanan Wilson, Julien Guerinet, Dar Dowlatshahi, Andrew Soundy.
Stroke survivors frequently experience a range of post-stroke deficits. Specialized stroke rehabilitation improves recovery, especially if it is started early post-stroke. However, resource limitations often preclude early rehabilitation. Mobile technologies may provide a platform for stroke survivors to begin recovery when they might not be able to otherwise. The study objective was to demonstrate the feasibility of RecoverNow, a tablet-based stroke recovery platform aimed at delivering speech and cognitive therapy.
We recruited a convenience sample of 30 acute stroke patients to use RecoverNow for up to 3 months. Allied health professionals assigned specific applications based on standard of care assessments. Participants were encouraged to take home the RecoverNow tablets upon discharge from acute care. The study team contacted participants to return for a follow-up interview 3 months after enrollment. The primary outcome of interest was feasibility, defined using 5 facets: recruitment rate, adherence rate, retention rate, the proportion of successful follow-up interventions, and protocol deviations. We tracked barriers to tablet-based care as a secondary outcome.
We successfully recruited 30 of 62 eligible patients in 15 weeks (48% recruitment rate). Participants were non-adherent to tablet-based therapy inside and outside of acute care, using RecoverNow for a median of 12 minutes a day. Retention was high with 23 of 30 patients participating in follow-up interviews (77% retention rate) and all but 3 of the 23 interviews (87%) were successfully completed. Only 2 major protocol deviations occurred: one enrollment failure and one therapy protocol violation. Barriers to tablet-based care were frequently encountered by study participants with many expressing the assigned applications were either too easy or too difficult.
Acute stroke patients are interested in attempting tablet-based stroke rehabilitation and are easily recruited early post-stroke. However, tablet-based therapy may be challenging due to patient, device and system-related barriers. Reducing the frequency of common barriers will be essential to keeping patients engaged in tablet-based therapy.
Stroke survivors frequently experience one or more of a broad range of deficits (eg. aphasia, weakness, sensory loss, cognitive impairment) requiring post-stroke rehabilitation. Globally, it is estimated that around one-third of survivors experience communication deficits , up to two-thirds experience cognitive deficits , another two-thirds experience upper limb impairments , and around one-third experience post-stroke depression . Stroke rehabilitation improves these deficits with more intense therapy and earlier therapy initiation being associated with better recovery [5–9]. However, an optimal window for initiating rehabilitative therapies has not been established . Although current guidelines recommend that stroke survivors begin rehabilitation within 5–7 days post-stroke , this goal is not met in many jurisdictions due to a lack of therapists with expertise in stroke recovery and challenges in accessing rehabilitation facilities [10–13]. While waiting in acute care to begin rehabilitation, patients spend little to no time engaging in activities to promote recovery .
This study determined that while RecoverNow use was feasible, few patients completed the target rehabilitation time. The recruitment of 30 patients was completed in 15 weeks with few patients being missed or declining to participate. Despite initial interest in using tablet technology for therapeutic purposes, therapy adherence was low, likely due to the barriers to care identified throughout follow-up. Most participants were retained for a follow-up interview and were able to complete an in-person or telephone interview. The study implications and limitations are discussed below.
Acute stroke patients are interested in attempting mobile tablet-based stroke rehabilitation and are easily recruited into tablet-based therapy studies early post-stroke. However, consistently engaging in tablet-based therapy from acute care to discharge destination may be challenging due to barriers to care. The reported findings can be used to help guide others interested in developing and providing tablet-based stroke therapy interventions. A few key points in particular are worth reiterating: