Mobile tablet-based therapies following stroke: a systematic scoping review protocol of attempted interventions and the challenges encountered
Pugliese et al. Systematic Reviews
Mobile tablet-based therapies following stroke: a systematic scoping review protocol of attempted interventions and the challenges encountered
Michael Pugliese 0
Dylan Johnson 0
Dar Dowlatshahi 2
Tim Ramsay 1
0 School of Epidemiology, Public Health, and Preventive Medicine, University of Ottawa , Alta Vista Campus, Room 101, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 , Canada
1 Ottawa Hospital Research Institute and Scientific Director at the Ottawa Methods Centre, University of Ottawa , Alta Vista Campus, 501 Smyth Rd, Ottawa, ON K1H 8L6 , Canada
2 Department of Medicine (Neurology), University of Ottawa Brain and Mind Research Institute, and Ottawa Hospital Research Institute, C2182 Ottawa Hospital Civic Campus , 1053 Carling Avenue, Ottawa, ON K1Y 4E9 , Canada
Background: Stroke is a growing global epidemic limiting the ability of millions to function independently due to post-stroke deficits and complications. Although specialized stroke rehabilitation improves the recovery of functional abilities, accessing rehabilitation services has become increasingly challenging as the number of stroke survivors continues to increase and rehabilitation resources remain scarce. Mobile tablet-based therapies (MTBTs) may be a resource-efficient platform for providing stroke rehabilitation services. The feasibility and challenges of offering MTBTs to stroke survivors should be well understood before expensive, large-scale clinical trials are undertaken to study treatment efficacy. Method: A systematic scoping review will be conducted to describe attempted MTBTs following stroke and the challenges encountered by survivors and study staff. Studies of interest will evaluate MTBTs offered to adult stroke patients in response to post-stroke complications or deficits. Journal databases, gray literature sources, clinical trial registries, relevant organizational websites, and reference lists of eligible studies will be searched to identify suitable studies. Study characteristics, barriers to care, methodological challenges, patient-reported outcomes, and health outcomes will be extracted to describe MTBTs and understand the challenges encountered in context. Results will be presented using descriptive statistics, tables, figures, and narrative description to summarize the scope of the field. Discussion: Trends in MTBT feasibility and common challenges will be discussed to summarize major findings and highlight research gaps. Solutions to common challenges experienced by intervention participants and study staff will be proposed. Implications for the conduct of randomized clinical trials of MTBT efficacy and the appropriateness of a systematic review and meta-analysis of completed trials will be discussed. Systematic review registration: uO Research (http://hdl.handle.net/10393/35696).
Stroke rehabilitation; mHealth; iPad; Tablet computer; CVA; Disability
The growing burden of stroke
Stroke is a global epidemic affecting millions worldwide.
It is the second leading cause of death [
] and the third
leading cause of disability globally [
]. The financial
impact is also immense, incurring billions of dollars in
healthcare costs annually [
]. This enormous burden has
continued to increase with a reported 68% rise in the
absolute number of first-time incidences of strokes and
an 84% increase in stroke survivors worldwide in 2010
when compared to 1990 [
]. Disability and massive
healthcare costs are caused by the wide range of
poststroke impairments and complications experienced by
stroke survivors. Specialized stroke rehabilitation
effectively improves recovery following stroke [
the greatest improvements occurring when therapy
begins early post-stroke and is performed intensely [
Best practice recommends timely transfer of stroke
survivors to well-staffed, specialized inpatient
rehabilitation units with sufficient resources to offer the variety
and intensity of therapy needed to reduce chances of
death and improve functionality.
Accessing stroke rehabilitation services
Accessing early and intensive stroke rehabilitation is
challenging. Rehabilitation is not consistently initiated in
the acute setting [
], and only 16% of stroke survivors in
Canada are transferred to inpatient rehabilitation centers
when estimates suggest 40% of survivors would benefit
]. In the USA, only 24% of patients are transferred to
inpatient services and only after waiting an average of
27 days post-stroke [
]. Accessing outpatient and
community care is also difficult [
] with not all patients
having immediate access to outpatient and community
rehabilitation services [
]. The poor availability of
stroke rehabilitation services is thought to be due to a
lack of therapists with expertise in stroke [
Additionally, therapists reported being assigned between
10.5 and 56 beds per therapist in Ontario rehabilitation
centers  suggesting current therapists are already
overburdened and unable to provide the intensive
therapy needed for improving recovery.
Improving the accessibility of stroke rehabilitation using mobile tablets
Over the past decade, there has been growing interest in
harnessing technology to support stroke rehabilitation
and provide adjunctive therapy. There is growing
research suggesting the positive effects of gaming on
neurological outcomes following stroke with home video
game consoles and virtual reality in particular have been
shown to improve upper limb function and performance
on activities of daily living [
]. Mobile video games
have become available for mobile tablets in the form of
software applications (apps), and there has been growing
interest in mobile tablet-based therapies (MTBTs)
following stroke. MTBTs use apps running on mobile
tablet computers to provide interventions to patients.
MTBTs are separate from and do not include therapies
delivered via smartphone, mobile phone, or non-mobile
touchscreen tablet technologies which are considered
different therapeutic platforms. There are a variety of
apps either explicitly designed to offer therapy (Constant
Therapy© for aphasia and cognitive impairments) or
involving activities analogous to scenarios often used
in stroke rehabilitation (memory and attention games,
etc.). Survivors could use MTBTs to either
supplement therapist-led rehabilitation or begin engaging
early rehabilitation until therapist-led services are
Why is it important to do a review now?
Despite their wide availability, relatively low cost, and
technological power, much remains unknown about
MTBTs including treatment efficacy. However, before
attempting small- or large-scale randomized controlled
trials (RCTs) of treatment efficacy, the feasibility and
challenges of offering MTBTs following stroke should be
well understood in order to improve the chances of
conducting successful studies. The study of MTBTs
following stroke is still relatively new, and to the best of
our knowledge, there is no systematic review
summarizing attempted MTBTs. This systematic scoping review
will be the first in the topic area and can provide
answers to key questions regarding the feasibility and
challenges of MTBTs following stroke while also
describing the breadth of the field, identifying gaps in research,
and informing the conduct of future RCTs and the
appropriateness of meta-analysis of completed RCTs.
The objective of the study protocol is to review the
evidence for mobile tablet-based therapies (MTBTs)
1. What are the characteristics of attempted MTBTs
following stroke in terms of targeted deficits and
method of administration?
2. What barriers or adverse events related to the
administration of MTBTs following stroke have been
encountered by researchers, clinicians, caregivers, or
3. What methodological challenges have been faced by
studies of MTBTs following stroke?
This protocol was developed primarily with the
assistance of a published guideline for scoping reviews
] and with PRISMA-P (Additional file 1) when
necessary and appropriate [
Inclusion criteria (must meet all):
1. Adult stroke survivors (18 years or older) of any
type (ischemic/hemorrhagic) or stage (acute/
chronic) in any setting.
2. Stroke survivors interacting with a mobile tablet
(not a smartphone, mobile phone, or non-mobile
touchscreen tablet) in response to a post-stroke
deficit or complication for therapeutic purposes.
Exclusion criteria (exclude if meet one or more):
1. The mobile tablet is primarily used by someone
other than the stroke survivor for purposes
unrelated to tablet-based therapy support.
2. The mobile tablet is used primarily for purposes
other than therapy.
Criteria explanation and elaboration
Only studies involving adult stroke survivors will be
included; children are a separate population outside of the
scope of the proposed review. There are no restrictions
with regard to stroke type or stage as the field is
expected to be heterogeneous in this regard. Studies
involving a mixture of stroke and non-stroke participants
will be included only if they have separately reported
data about stroke participants.
We define MTBTs as patient-driven therapies in which
participants interact via touch, speech, or movement
with mobile tablet devices in response to a deficit or
complication. The tablet device should be the primary
method of therapy delivery; however, therapies involving
peripheral devices (devices other than the core tablet
unit itself including smartphone, robotics, sensors, etc.)
will be included if the mobile tablet is clearly the
primary platform for delivering therapy. MTBTs do not
include smartphones, mobile phones, or non-mobile
touchscreen tablets. This distinction has been because
mobile tablets offer the unique benefit of having a large
touchscreen interface that is likely easier for stroke
survivors, who often suffer from motor and cognitive
deficits, to manipulate while still remaining easily
portable. This portability could allow survivors to bring their
MTBT with them across their continuum of care from
the acute hospital setting shortly after their stroke to
their discharge destination. The use of tablets as assistive
devices by clinicians for the administration of therapy,
or by patients for the primary purpose of screening,
assessment, or data collection does not constitute a
MTBT. Tele-rehab programs using tablets solely as a
method of videoconferencing with participants will not
be included as the therapy is not truly mobile
tabletbased; the tablet is simply acting as a means of providing
traditional therapist-driven treatment.
There are no restrictions related to context as we are
interested in interventions performed in all settings and
geographical locations, administered in all languages,
and delivered by all types of therapists or non-therapists.
However, only English-language publications will be
considered due to expensive translation costs.
There are no restrictions related to comparators
(standard treatment, workbooks, desktop or laptop
computers, smartphones, etc.) as we are interested in
describing all attempted MTBTs following stroke
regardless of comparisons to other therapies.
There are no restrictions with regard to study outcomes
as we are primarily interested in attempted
interventions, therapy barriers, and research challenges.
However, considering the study goals and research questions,
we are interested in study outcomes including but not
limited to barriers to care, adverse events, protocol
deviations, Research Ethics Board issues, recruitment rate,
adherence rate, retention rate, and patient evaluations of
There are no restrictions with regard to study design:
case studies/series, prospective and retrospective cohort
studies, and randomized or non-randomized controlled
trials of all designs will be included. There will be no
restrictions with regard to study timing as it is expected
that studies will substantially vary in length and timing.
Study protocols and conference abstracts will only be
included if they contain pilot or preliminary results from
a study whose data are otherwise unavailable from a
fullstudy manuscript. Included studies will be clearly
marked as full-text articles, protocols, and abstracts,
As mentioned above, the included studies will be
restricted to those written in English. Although the
first modern tablet computers were introduced in the
early 2000s, the surge in popularity of tablet
computers with the release of the first Apple iPad© in
2010 is well known. Additionally, the mobile tablet
computers which will eventually be included in future
randomized controlled trials will likely continue to
improve upon the capabilities of their counterparts
presented in this review. Therefore, in order to collect
information that will be most relevant to information
future RCTs, searches will be restricted to include
studies between 2010 to present.
A preliminary search of the literature using key terms
related to stroke and mobile devices in MEDLINE
(OVID interface) yielded a number of studies meeting
our inclusion criteria. These articles were used to
identify key words and build a search strategy with
the aid of a health information librarian. One study
author (MP) piloted the search strategy in MEDLINE
to ensure the strategy successfully re-identified the
studies used to build the search. The search strategy
successfully identified these papers, and no further
modifications were made to the strategy except those
necessary to adapt the strategy to different database
The following six databases will be searched:
MEDLINE (OVID interface), EMBASE (OVID
interface), PsycINFO (OVID interface), CINAHL,
Cochrane Database, and Web of Science.
Additional information sources
1. A snowball search of relevant articles and reviews
identified by the database search.
2. Organizational websites: Aphasia.org, American
Stroke Association webpage, Heart and Stroke
Foundation webpage, and Stroke Engine.
3. Clinical trial databases will also be searched for
completed and ongoing studies: ClinialTrials.gov, the
WHO International Clinical Trials Registry Platform,
EU clinical trials database, and ISRCTN.
Gray literature search
A gray literature search will also be performed in order
to find unpublished material using Google Scholar, the
ProQuest Dissertation and Theses Database (Global and
UK & Ireland), and the OpenGrey European gray
literature database. After a preliminary search of Google
Scholar and ProQuest Dissertation Global, it was
decided searches would be limited to the first 200 results
as a compromise between conducting a robust search
and exhausting resources as search results beyond the
first 200 results appeared to be irrelevant [
Database search strategy
The search strategy presented in Table 1 will be used to
search databases with Ovid interfaces and adapted to
search databases using other search interfaces. All index
database searches were restricted to between the years
2010 and present and English language.
Database search results will be downloaded and
imported to reference management software (Endnote™
X8) in order to search for duplicates [
duplicates have been removed using software and manual
identification, the database results will be uploaded into
Covidence©, an online systematic review manager, where
all title/abstract and full-text screening will take place
Two authors (MP and DJ) will independently screen
collected articles in a two-stage process with the assistance
of an article screening form (Table 2): co-screeners will
(1) screen study titles and abstracts returned by database
searches for potentially eligible studies and (2) screen
full-text manuscripts to confirm eligibility. The
screening form will be piloted on batches of 30 title/abstract
pairings and refined until an inter-rater agreement, as
measured by the Kappa statistic, of 0.80 or above is
]. Screening conflicts will be resolved
through discussion between screeners or resolved by a
third party (DD) if necessary during both stages of
screening. Reasons for full-text study exclusion will be
tracked and listed. Screeners will not be blinded to study
authors, affiliated institutions, or journal titles.
Data collection process
Two authors (MP and DJ) will independently extract key
data items needed to describe the included studies and
to answer the research questions stated above. A data
extraction form (Additional file 2) will be used to guide
data collection. Authors will compare and consolidate
extracted information regularly to create a final data
extraction form for each study. As the extraction process
progresses, the data extraction form will be refined as
necessary and any new pieces of information not
collected in studies screened before changes occurred
will be obtained by one of the study authors (MP or DJ).
Study outcomes will be classified into one of three
categories: barriers and adverse events, methodological
challenges, and patient-reported outcomes. An assistive
document (Table 3) will be used to help with the
categorization of outcomes. Data extraction conflicts will
exp cerebrovascular disorders/
(stroke* or cerebrovascular* or cerebral vascular or CVA*).tw.
((cerebr* or brain) adj3 infarct*).tw.
1 or 2 or 3 or 4
(mobile device* or mobile computer* or handheld computer*
(ipad* or galaxy tab* or surface pro*).tw.
6 or 7
be resolved through discussion between screeners or
resolved by a third party (DD) if necessary. No effort will
be made to collect missing information from study
authors due to time constraints.
A wide variety of data items are needed to adequately
answer the proposed research questions in context.
Although every effort has been made to anticipate the
broad extent of variables which will be collected,
refinements to collected information will be made as the data
collection process progresses if deemed necessary. Data
items of interest fall into six categories: general study
information, participant characteristics, intervention
details, comparator details, outcomes, and setting and
context. A full list of variables and clarifications where
necessary can be found in Additional file 2.
Outcomes and prioritization
There is no need to prioritize outcomes to
accomplish the objective of the review. All data items and
outcomes of interest will be collected and discussed
and holistically answer research questions and meet
the study objective.
Risk of bias in individual studies
As per current scoping review guidelines, no formal risk
of bias assessment will be performed for the included
]. However, the potential impact of study
Ratings of perceived usefulness of intervention,
ratings of intervention likability,
other patient opinions.
design on individual study results will be discussed as the
collected data items allow for an informed commentary.
Development of outcome themes
The categories and sub-categories listed above
(Table 3) will serve to guide the thematic
development of qualitative outcome information relevant to
the three research questions. Relevant qualitative
information (patient/caregiver/physician interviews,
reaction, options, etc.) will be entered into
spreadsheet software by one reviewer (MP) and grouped
into an appropriate outcome category and
subcategory (Table 3) after final consolidated data
extraction sheets for each study have been approved by
both extractors (MP and DJ). The frequency of
encountered themes will be noted in the presentation
of the final results.
Presentation of the final results
Determining how to best present the results of a
scoping review is an iterative process where the most
logical approach becomes clearer as the data
collection process comes closer to completion. Therefore,
the following results outline is expected to be refined
throughout the data extraction process. Search results
will be summarized narratively and using the PRISMA
flow diagram (Fig. 1) [
], and the characteristics of
the final included studies will be summarized. The
characteristics of the attempted intervention and
administrative methods (therapy target, whether or not
the therapy was performed with assistance, therapy
setting, and whether the therapy was personalized)
will be presented first to answer the first research
question. This will be followed by lists of encountered
barriers to care, adverse events, and other
patientreported outcomes organized by categories listed
above (Table 3) to answer the second research
question. A list of methodological challenges reported by
the included studies will follow answering the third
and final research question.
Meta-bias(es) and confidence in the cumulative evidence
There is no planned formal assessment of meta-biases
or the confidence in the accumulated body of evidence.
Instead, the impact of bias and strength of the evidence
will be discussed based on the collected data points.
More specifically, the strength of evidence supporting
the feasibility of MTBTs following stroke will be covered
in the discussion section of the final manuscript.
Answers to review questions will be proposed based on the
accumulated evidence. Solutions to common challenges
faced by patients and researchers will be proposed, and if
appropriate, recommendations will be made to evaluate
these solutions. Limitations of the reviewed studies will be
discussed, and recommendations for improving the design
of observational studies of MTBTs will be made. Gaps in
research in terms of under-studied patient populations,
interventional areas, and settings will be addressed.
Recommendations will be made for small- and large-scale
randomized controlled trials of MTBTs, and comments will
be made on the appropriateness of conducting a systematic
review and meta-analysis of completed MTBT trials.
Additional file 1: PRISMA-P checklist. (DOCX 28 kb)
Additional file 2: Data extraction form. (DOCX 13 kb)
App(s): Application(s); MTBT: Mobile tablet-based therapy; RCT: Randomized
The authors would like to thank Mish Boutlet of the University of Ottawa
Health Sciences library for assisting with the refinement of the database
This protocol is for an original systematic scoping review, not an update to a
Amendment to protocol previously registered on January 11, 2017 (http://
hdl.handle.net/10393/35696). uO Research does not allow authors to host
updated protocols. Protocol changes will be tracked and described in the
final study manuscript along with justifications.
Mr. Pugliese is supported by an Ontario Graduate Scholarship and Canadian
Institutes of Health Research Graduate Scholarship.
Dr. Dowlatshahi is supported by a Heart and Stroke Foundation New
Investigator Award and a University of Ottawa Department of Medicine
No other sources of funding nor sponsors supported the current review. The
funding sources had no involvement in developing the study protocol.
Availability of data and materials
All data generated or analyzed during this study will be reported in the final
published manuscript and its supplementary information files.
MP developed study protocol and performed preliminary searches. DJ
developed the study protocol. DD developed the study protocol. TR
developed the study protocol. All authors read and approved the final
Ethics approval and consent to participate
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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