@Article{info:doi/10.2196/65993, author="Wei, Yixin and Chen, Yuan and Ma, Runting and Qiu, Yitong and Su, Wei and Zhang, Li and Gao, Qiang", title="Research Hotspots and Trends of Virtual Reality Intervention for Stroke: Bibliometric Analysis", journal="JMIR Serious Games", year="2025", month="Apr", day="16", volume="13", pages="e65993", keywords="virtual reality", keywords="stroke", keywords="bibliometric analysis", keywords="hotspots", keywords="research trends", abstract="Background: Virtual reality (VR) is a rapidly developing technology that has gained significant traction in the treatment and rehabilitation of individuals with stroke. Research on VR-based stroke treatment has garnered increasing attention. Objective: The aim of this study is to present a bibliometric analysis of VR for stroke studies to identify the application status, research hotspots, and emerging trends and guide future scientific research. Methods: We included studies and reviews on the topic of VR-based stroke treatment and rehabilitation from 1999 to 2023 were retrieved from Web of Science Core Collection database. Citespace 6.3.1 and VOSviewer 1.6.20 software was used for the visual analysis of publications, institutions, authors, journals, citations, and Scimago Graphica software was used for the geographic visualization of published countries or regions. Results: Our study analyzed 1171 papers on VR-based stroke rehabilitation published between 1999 and 2023, revealing a gradual increase in annual publications over the past 2 decades, peaking at 154 in 2022. North America and Western Europe were identified as major contributors, with significant input from their institutions, researchers, and publications. The Journal of NeuroEngineering and Rehabilitation emerged as the leading journal in this field, while Calabr{\`o} Rocco Salvatore was recognized as the most prolific author, focusing on the neurophysiological impacts of VR on patients with stroke. Keywords with notable citation bursts, such as ``environment,'' ``trial,'' ``arm,'' and ``motor learning,'' highlighted the core research themes in this domain. Conclusions: Our study provides valuable insights into the current research hotspots and emerging trends in VR-based stroke treatment and rehabilitation. Current research primarily focuses on evaluating the effectiveness of VR in improving upper limb function and balance in patients with stroke. Future directions are shifting towards integrating VR with rehabilitation techniques, such as physiotherapy and occupational therapy, while advancements in VR technology continue to garner increasing attention. ", doi="10.2196/65993", url="https://games.jmir.org/2025/1/e65993" } @Article{info:doi/10.2196/63064, author="Suzuki, Takuya and Kono, Yuji and Ogasawara, Takayuki and Mukaino, Masahiko and Aoshima, Yasushi and Furuzawa, Shotaro and Fujita, Yurie and Matsuura, Hirotaka and Yamaguchi, Masumi and Tsukada, Shingo and Otaka, Yohei", title="Moving Standard Deviation of Trunk Acceleration as a Quantification Index for Physical Activities: Validation Study", journal="JMIR Form Res", year="2025", month="Apr", day="8", volume="9", pages="e63064", keywords="smart clothing", keywords="step count", keywords="moving standard deviation of acceleration", keywords="MSDA", keywords="wheelchair", keywords="activity quantification", keywords="physical activities", keywords="validation study", keywords="accelerometer", keywords="regular gait patterns", keywords="older people", keywords="aging", keywords="motor impairments", keywords="step detection", keywords="stroke", keywords="hemiparesis", keywords="measurement system", keywords="walking", keywords="mobility", keywords="rehabilitation", abstract="Background: Step count is used to quantify activity in individuals using accelerometers. However, challenges such as difficulty in detecting steps during slow or irregular gait patterns and the inability to apply this method to wheelchair (WC) users limit the broader utility of accelerometers. Alternative device-specific measures of physical activity exist, but their specificity limits cross-applicability between different device sensors. Moving standard deviation of acceleration (MSDA), obtained from truncal acceleration measurements, is proposed as another alternative variable to quantify physical activity in patients. Objective: This study aimed to evaluate the validity and feasibility of MSDA for quantifying physical activity in patients with stroke-induced hemiparesis by comparing it with the traditional step count. Methods: We enrolled 197 consecutive patients with stroke hemiparesis admitted to a convalescent rehabilitation ward. Using the hitoe system, a smart clothing--based physical activity measurement system, we measured the MSDA of trunk movement and step count. The correlation between MSDA and step count was examined in all participants. Based on their daily living mobility levels, measured using the Functional Independence Measure (FIM), participants were categorized into 6 subgroups: FIM1-4, FIM5 (WC), FIM5 (walking), FIM6 (WC), FIM6 (walking), and FIM7 (walking). Intersubgroup differences in MSDA were analyzed. Results: A strong correlation was observed between MSDA and step count (r=0.78; P<.001), with a stronger correlation in the walking group (r=0.79; P<.001) compared with the WC group (r=0.55; P<.001). The Shapiro-Wilk test indicated no significant results for MSDA across all subgroups, supporting a normal distribution within these groups. In contrast, the step count data for the WC subgroups showed significant results, indicating a deviation from a normal distribution. Additionally, 10.2\% (20/197) of participants recorded zero steps, demonstrating a floor effect in the step count data. The median MSDA values for the 6 subgroups (FIM1-4, FIM5 WC, FIM5 walking, FIM6 WC, FIM6 walking, and FIM7) were 0.006, 0.007, 0.010, 0.011, 0.011, and 0.014, respectively, reflecting their levels of independence based on the FIM mobility scores. The median step counts for these subgroups were 68, 233, 1386, 367, 2835, and 4462, respectively. FIM5 participants who walked had higher step counts than FIM6 participants using WCs, though the difference was marginally but not statistically significant (P=.07), highlighting the impact of mobility type (walking vs WC). Conclusions: The results suggest the validity of MSDA as a variable for physical activity in patients with stroke, applicable to patients with stroke irrespective of their mobility measures. This finding highlights the potential of MSDA for use in individuals with motor impairments, including WC users, underscoring its broad utility in rehabilitation clinical practice. ", doi="10.2196/63064", url="https://formative.jmir.org/2025/1/e63064" } @Article{info:doi/10.2196/59172, author="Wr{\'o}bel, Ewa Agata and Cash, Philip and Maier, Anja and Paulin Hansen, John", title="Determining the Prioritization of Behavior Change Techniques for Long-Term Stroke Rehabilitation: Delphi Survey Study", journal="Interact J Med Res", year="2025", month="Apr", day="7", volume="14", pages="e59172", keywords="behavior change", keywords="behavior change techniques", keywords="BCT", keywords="neuroscience", keywords="neurology", keywords="stroke", keywords="rehabilitation", keywords="adherence", keywords="Delphi method", keywords="Delphi", keywords="intervention design", keywords="intervention mapping", abstract="Background: Stroke results in both physical disability and psychological distress. The impact can be minimized through rehabilitation, but it is a long-term process, making it difficult for patients to adhere to treatment. Thus, a better understanding of long-term behavior change interventions for patients with stroke is needed as well as how such interventions can support not only rehabilitation of motoric functions but also mental well-being. Objective: The aim of this study is to understand both the most important behavior change technique (BCT) clusters for long-term stroke rehabilitation in general as well as which are most relevant for each aspect of stroke rehabilitation: behavioral, cognitive, and emotional. Methods: We applied the 16 BCT clusters. The study used a 2-round Delphi survey, as reliable consensus was obtained among a group of 12 international experts. Experts represented three main backgrounds involved in behavioral intervention in the health context: (1) specialists in behavioral science (n=4), (2) behavioral designers (n=4), and (3) expert health care professionals (n=4). Experts were brought together in this way for the first time. In the first round, web-based questionnaires were used to collect data from the experts. This was followed by a personalized second round. Consensus was determined by statistically aggregating the responses and evaluating IQR and percentage consensus. BCT clusters reaching consensus (IQR ?1 and percentage ?50\%) were then ranked. Results: In total, 12 of 16 BCT clusters reached consensus for general importance in stroke rehabilitation, with 11, 9, and 6 BCT clusters achieving consensus for, respectively, the behavioral, cognitive, and emotional aspects of rehabilitation. The overall most relevant BCT clusters were repetition and substitution, social support, feedback and monitoring, and self-belief, with similar outcomes for behavioral and cognitive rehabilitation. For emotional rehabilitation, social support and identity were emphasized. The least relevant BCT clusters were natural consequences, covert learning, and comparison of behavior. Conclusions: This expert panel study using a 2-round Delphi survey ranked the importance of BCT clusters for long-term stroke rehabilitation. The process yielded a number of novel insights highlighting differences in importance between general rehabilitation and that specifically focused on the behavioral, cognitive, and emotional aspects of stroke recovery. This provides a first but important step toward unlocking the prioritization of BCT clusters for long-term intervention contexts such as stroke rehabilitation and enables effective intervention mapping addressing long-term behavior change and treatment adherence. ", doi="10.2196/59172", url="https://www.i-jmr.org/2025/1/e59172" } @Article{info:doi/10.2196/69003, author="Huang, Jiaqi and Wei, Yixi and Zhou, Ping and He, Xiaokuo and Li, Hai and Wei, Xijun", title="Effect of Home-Based Virtual Reality Training on Upper Extremity Recovery in Patients With Stroke: Systematic Review", journal="J Med Internet Res", year="2025", month="Apr", day="4", volume="27", pages="e69003", keywords="stroke", keywords="upper extremity", keywords="virtual reality", keywords="home-based", keywords="rehabilitation", keywords="motor control", keywords="recovery", abstract="Background: Stroke is a leading cause of long-term disability, often resulting in upper extremity dysfunction. Traditional rehabilitation methods often face challenges such as limited patient access to resources and lack of sustained motivation. Home-based virtual reality (VR) training is gaining traction as an innovative, sustainable, and interactive alternative. However, the effect of home-based VR, specifically for upper extremity recovery in patients with stroke, remains insufficiently explored. Objective: This systematic review aims to synthesize existing evidence to evaluate the impact of home-based VR interventions on upper extremity function recovery in patients with stroke. Methods: This systematic review followed the guidelines of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). A comprehensive literature search was conducted across PubMed, Web of Science, Scopus, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) Ultimate databases, targeting English-language randomized controlled trials (RCTs) published up to June 30, 2024. Eligible studies involved patients with stroke with upper extremity dysfunction who received home-based VR interventions. Data extraction was performed by 2 independent reviewers, and study quality was assessed using the Physiotherapy Evidence Database scale. Due to heterogeneity in study designs and outcome measures, a narrative synthesis was performed instead of a meta-analysis. Results: A total of 8 RCTs with 392 participants were included. This review shows that home-based VR training positively affects upper extremity function recovery in patients with stroke, especially in motor control improvement. Customized VR systems were more effective than commercial VR systems in patients with moderate to severe disorders. Although studies generally showed positive results, differences in intervention protocols and small sample sizes limited the validity of results. The effect of VR therapy also varied based on the VR system type, intervention intensity, and the functional level of patients. Conclusions: This systematic review shows that home-based VR training has a positive impact on upper extremity rehabilitation for patients with stroke, particularly in those with varying degrees of dysfunction. However, heterogeneity in study design and differences in outcome measures affect the reliability of the current conclusions. Future studies should include larger, standardized RCTs with long-term follow-up to assess their continued effects. Future research should explore how VR technology can be integrated into comprehensive rehabilitation programs, focusing on patient-centered approaches that incorporate sustainable, personalized technology, and support services to optimize recovery outcomes. Trial Registration: PROSPERO CRD42024526650; https://tinyurl.com/5dny5bhp ", doi="10.2196/69003", url="https://www.jmir.org/2025/1/e69003", url="http://www.ncbi.nlm.nih.gov/pubmed/40074365" } @Article{info:doi/10.2196/64729, author="Sheehy, Lisa and Taillon-Hobson, Anne and Sveistrup, Heidi and Bilodeau, Martin and Yang, Christine and Welch, Vivian and Finestone, Hillel", title="Home-Based Nonimmersive Virtual Reality Training After Discharge From Inpatient or Outpatient Stroke Rehabilitation: Parallel Feasibility Randomized Controlled Trial", journal="JMIR Rehabil Assist Technol", year="2025", month="Mar", day="28", volume="12", pages="e64729", keywords="virtual reality", keywords="telerehabilitation", keywords="stroke", keywords="home", keywords="exercises", keywords="physical activity", keywords="physiotherapy", keywords="exergames", keywords="rehabilitation intensity", keywords="randomized controlled feasibility trial", keywords="motor", keywords="movement", keywords="patient care", keywords="patient engagement", keywords="health intervention", keywords="stroke rehabilitation", keywords="interactive games", keywords="game therapy", keywords="interactive therapy", keywords="rehabilitation", abstract="Background: Nonimmersive virtual reality training (NIVRT) can be used to continue rehabilitative exercise for stroke recovery at home after discharge from inpatient or outpatient therapy. Objective: The objectives of this randomized controlled feasibility trial were to assess home-based NIVRT as telerehabilitation with patients living with stroke, and its potential to improve standing function and gait. Methods: Patients approaching discharge from inpatient or outpatient stroke rehabilitation were randomly allocated to NIVRT or iPad interventions. NIVRT provided interactive games and exercises designed to improve balance, stepping, and aerobic capacity. iPad apps addressed cognition and fine motor skills. Participants were visited in their homes by a physiotherapist, taught to use the program, and asked to do 30 minutes of exercise 5 days a week for 6 weeks, asynchronously. Feasibility was assessed by measuring recruitment, adherence, ability to set up and learn NIVRT, enjoyment, intent to continue, perception of impact, and safety. Participants completed assessments of standing balance, gait, and general function, before and after the intervention, by a blinded assessor. Results: NIVRT participants (n=11; 10 male participants; mean age 64, SD 12 years) did an average of 26 sessions (total 700 minutes), while iPad participants (n=9; 6 male participants; mean age 61, SD 20 years) did an average of 33 sessions (total 1241 minutes). Space was tight in 5 homes. All but 1 participant learned NIVRT and progressed. Most enjoyed it and felt that it improved their recovery. There were no serious adverse events. Most assessments showed improvement over time for both groups. Conclusions: Home-based NIVRT is safe and feasible to continue rehabilitative exercise after discharge. More research on efficacy and effectiveness in this population is required. Trial Registration: ClinicalTrials.gov NCT03261713; https://clinicaltrials.gov/study/NCT03261713 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-019-3438-9 ", doi="10.2196/64729", url="https://rehab.jmir.org/2025/1/e64729" } @Article{info:doi/10.2196/66123, author="Naef, C. Aileen and Duarte, Guichande and Neumann, Saskia and Shala, Migjen and Branscheidt, Meret and Easthope Awai, Chris", title="Toward Unsupervised Capacity Assessments for Gait in Neurorehabilitation: Validation Study", journal="J Med Internet Res", year="2025", month="Mar", day="26", volume="27", pages="e66123", keywords="gait analysis", keywords="gait rehabilitation", keywords="10-meter walk test", keywords="stroke", keywords="unsupervised assessments", keywords="supervised assessments", keywords="sensors", keywords="motivation", keywords="capacity", keywords="monitoring", keywords="wearables", keywords="stroke survivors", keywords="quality of life", abstract="Background: Gait impairments are common in stroke survivors, negatively impacting their overall quality of life. Therefore, gait rehabilitation is often targeted during in-clinic rehabilitation. While standardized assessments are available for inpatient evaluation, the literature often reports variable results when these assessments are conducted in a home environment. Several factors, such as the presence of an observer, the environment itself, or the technology used, may contribute to these differing results. Therefore, it is relevant to establish unsupervised capacity assessments for both in-clinic use and across the continuum of care. Objective: This study aimed to investigate the effect of supervision on the outcomes of a sensor-based 10-meter walk test conducted in a clinical setting, maintaining a controlled environment and setup. Methods: In total, 21 stroke survivors (10 female, 11 male; age: mean 63.9, SD 15.5 years) were assigned alternately to one of two data collection sequences and tested over 4 consecutive days, alternating between supervised test (ST) and unsupervised test (UST) assessments. For both assessments, participants were required to walk a set distance of 10 meters as fast as possible while data were collected using a single wearable sensor (Physilog 5) attached to each shoe. After each walking assessment, the participants completed the Intrinsic Motivation Inventory. Statistical analyses were conducted to examine the mean speed, stride length, and cadence, across repeated measurements and between assessment conditions. Results: The intraclass correlation coefficient indicated good to excellent reliability for speed (ST: $\kappa$=0.93, P<.001; UST: $\kappa$=0.93, P<.001), stride length (ST: $\kappa$=0.92, P<.001; UST: $\kappa$=0.88, P<.001), and cadence (ST: $\kappa$=0.91, P<.001; UST: $\kappa$=0.95, P<.001) across repeated measurements for both ST and UST assessments. There was no significant effect of testing order (ie, sequence A vs B). Comparing ST and UST, there were no significant differences in speed (t39=--0.735, P=.47, 95\% CI 0.06-0.03), stride length (z=0.835, P=.80), or cadence (t39=--0.501, P=.62, 95\% CI 3.38-2.04) between the 2 assessments. The overall motivation did not show any significant differences between the ST and UST conditions (P>.05). However, the self-reported perceived competence increased during the unsupervised assessment from the first to the second measurement. Conclusions: Unsupervised gait capacity assessments offer a reliable alternative to supervised assessments in a clinical environment, showing comparable results for gait speed, stride length, and cadence, with no differences in overall motivation between the two. Future work should build upon these findings to extend unsupervised assessment of both capacity and performance in home environments. Such assessments could allow improved and more specific tracking of rehabilitation progress across the continuum of care. ", doi="10.2196/66123", url="https://www.jmir.org/2025/1/e66123" } @Article{info:doi/10.2196/64591, author="Ye, Qin and Wang, Wei and Zeng, Xuan and Kuang, Yuxian and Geng, Bingbing and Zhou, Song and Liu, Ning", title="Development and Validation of the Digital Health Literacy Questionnaire for Stroke Survivors: Exploratory Sequential Mixed Methods Study", journal="J Med Internet Res", year="2025", month="Mar", day="25", volume="27", pages="e64591", keywords="stroke survivors", keywords="digital health literacy", keywords="validation", keywords="reliability", keywords="mixed methods study", abstract="Background: In China, there is limited research on digital health literacy (DHL) among patients with stroke. This is mainly due to the lack of validated tools, which hinders the precision and sustainability of our country's digital transformation. Objective: This study aimed to develop and validate a DHL scale specifically for stroke survivors in China. Methods: We used a sequential, exploratory, mixed methods approach to develop a DHL questionnaire for stroke survivors. This study comprised 418 patients with stroke aged 18 years and older. To evaluate the questionnaire's psychometric qualities, we randomly assigned individuals to 2 groups (subsample 1: n=118, subsample 2: n=300). Construct validity was evaluated through internal consistency analysis, exploratory and confirmatory factor analyses, hypothesis testing for structural validity, measurement invariance assessments using the eHealth Literacy Scale, and Rasch analyses to determine the questionnaire's validity and reliability. Results: This study underwent 4 stages of systematic development. The initial pool of items contained 25 items, 5 of which were eliminated after content validity testing; 19 items were subsequently retained through cognitive interviews. After an interitem correlation analysis, 2 more items were excluded, leaving 17 items for exploratory factor analysis. Finally, 2 items were excluded by Rasch analysis, resulting in a final version of the questionnaire containing 15 items. The total score range of the scale was 15-75, with higher scores indicating greater DHL competence. Results showed that principal component analysis confirmed the theoretical structure of the questionnaire (69.212\% explained variance). The factor model fit was good with $\chi$24=1.669; root mean square error of approximation=0.047; Tucker-Lewis Index=0.973; and Comparative Fit Index=0.977. In addition, hypothesis-testing construct validity with the eHealth Literacy Scale revealed a strong correlation (r=0.853). The internal consistency (Cronbach $\alpha$) coefficient was 0.937. The retest reliability coefficient was 0.941. Rasch analysis demonstrated the item separation index was 3.81 (reliability 0.94) and the individual separation index was 2.91 (reliability 0.89). Conclusions: The DHL Questionnaire for Stroke Survivors is a reliable and valid measure to assess DHL among stroke survivors in China. ", doi="10.2196/64591", url="https://www.jmir.org/2025/1/e64591" } @Article{info:doi/10.2196/67219, author="Bakas, Tamilyn and Miller, Elaine and Sucharew, Heidi and Kreitzer, Natalie and Israel, Jahmeel and Rota, Matthew and Harnett, Brett and Dunning, Kari and Jones, Holly and McCarthy, Michael and Brehm, Bonnie and Austin, K. Joan and Mitchell, H. Pamela", title="Examining the Efficacy of the Telehealth Assessment and Skill-Building Kit (TASK III) Intervention for Stroke Caregivers: Protocol for a Randomized Controlled Clinical Trial", journal="JMIR Res Protoc", year="2025", month="Mar", day="25", volume="14", pages="e67219", keywords="stroke", keywords="family caregivers", keywords="depressive symptoms", keywords="health-related quality of life", keywords="clinical trial", keywords="intervention study", keywords="protocol", keywords="nursing", abstract="Background: Stroke is a leading cause of serious, long-term disability and has a sudden onset. Upon discharge to the home setting, families are thrust into providing care, often without sufficient training from health care providers. Aligned with current patient and caregiver guidelines, the Telehealth Assessment and Skill-Building Kit (TASK III) is a nurse-led intervention designed to empower caregivers to address their own needs and those of the survivor using innovative skill-building strategies. Objective: This study aims to test the short-term (immediately after the intervention at 8 wk) and long-term (12, 24, and 52 wk) efficacy of the TASK III intervention, compared with an information, support, and referral (ISR) group, to improve caregiver life changes (ie, changes in physical health, physical functioning, emotional well-being, and general health) as a result of providing care. Methods: A randomized controlled clinical trial design will be used with baseline data collection from 296 family caregivers by telephone after the stroke survivor is discharged home. Caregivers randomly assigned to the ISR group (n=148, 50\%) will receive information from the American Heart Association about stroke family caregiving. Caregivers randomly assigned to the TASK III group (n=148, 50\%) will receive a TASK III resource guide and information from the American Heart Association. Both groups will receive 8 weekly calls from a nurse, with a booster call a month later. Outcomes will be assessed by blinded data collectors at 8, 12, 24, and 52 weeks. The primary outcome (at 8 wk) is caregiver life changes measured by the Bakas Caregiving Outcomes Scale. Secondary outcomes are depressive symptoms; other symptoms (eg, stress, fatigue, sleep, pain, and shortness of breath); unhealthy days; diet; exercise; and self-reported health care use. Mediators are task difficulty, threat appraisal, and self-efficacy. Program evaluation outcomes (satisfaction and technology ratings) will also be analyzed. Results: The trial was registered on March 10, 2022. Enrollment and random assignment of the first participant was on November 30, 2022, with an anticipated completion of recruitment by November 30, 2025. Completion of the primary end point data analysis is anticipated by August 31, 2026, with results expected to be reported on ClinicalTrials.gov by April 1, 2027. As of October 9, 2024, a total of 198 (66.9\% of the proposed total sample of 296) family caregivers have been enrolled and randomly assigned to the TASK III group (n=98, 49.5\%) or the ISR group (n=100, 50.5\%). The last update was performed on January 25, 2024. Conclusions: If the TASK III intervention is shown to be efficacious in the proposed randomized controlled clinical trial, our next goal will be to translate TASK III into ongoing stroke systems of care, providing a tremendous public health impact. Trial Registration: ClinicalTrials.gov NCT05304078; https://clinicaltrials.gov/study/NCT05304078 International Registered Report Identifier (IRRID): DERR1-10.2196/67219 ", doi="10.2196/67219", url="https://www.researchprotocols.org/2025/1/e67219", url="http://www.ncbi.nlm.nih.gov/pubmed/39937971" } @Article{info:doi/10.2196/67658, author="Tistad, Malin and Hultman, Lill and Wohlin Wottrich, Annica and von Koch, Lena", title="The Lived Experience of Participating in Online Peer-To-Peer Groups After Acquired Brain Injury: Phenomenological Study", journal="J Med Internet Res", year="2025", month="Mar", day="25", volume="27", pages="e67658", keywords="compassion", keywords="experiential knowledge", keywords="fatigue", keywords="self-compassion", keywords="stroke", keywords="social media", keywords="meaning", keywords="interview", keywords="normalization", abstract="Background: Stroke and other acquired brain injuries (ABIs) can present challenging experiences for individuals, both in recovery of functions affected by visible or invisible impairments and in learning to live with the new situation. Research has shown that sharing experiences face-to-face in peer groups can be beneficial during recovery. However, there is limited knowledge about the lived experiences of people with ABI who participate in online peer-to-peer groups. Objective: The aim of our study was to explore the lived experiences of participating in online peer-to-peer groups for people with ABI, where participants themselves set the agenda. Methods: Members of 2 Facebook groups (FBGs) for people with ABI were invited to participate in this study, and 20 individuals were included (14 women and 6 men; age range 24-74 years). One FBG focused on stroke and the other on fatigue caused by ABI. One group was private, and the other group was public. Data were collected through semistructured interviews, in which participants were encouraged to describe their experiences of engaging in FBGs in detail. The interviews were conducted over telephone or Zoom and digitally recorded. The audio recordings were then transcribed verbatim, resulting in 224 pages of text, and analyzed using the empirical phenomenological psychological method. Results: The analysis presented a common meaning structure with 1 main characteristic that is, ``validating self,'' common for all 20 participants, and 3 subcharacteristics, that is, ``learning---having one's own experiences confirmed,'' ``adjusting self---building competence and self-compassion,'' and ``supporting others---becoming a valued lived-experience expert/authority.'' Together, the subcharacteristics reflected a process of validating self from newcomer to lived-experience expert or authority. In this process, members of FBGs moved from being newcomers with pronounced needs for support and to learn and to have their experiences confirmed by others with similar experiences. Thus, participants were building competence and developing self-compassion. Gradually, they assumed the role of advisors, mentors, or coaches, acknowledging their experiences and competence as valuable to others, thereby validating themselves as compassionate lived-experience experts or authorities in supporting others. Conclusions: Participation in online peer-to-peer groups can offer unique opportunities for individuals with ABI to validate self through processes that involve learning, developing self-compassion and compassion for others, and offering support to others with similar experiences. Given that rehabilitation after an ABI is often of limited duration and that positive experiences can be achieved over time through involvement in digital peer-to-peer support, health care professionals should assist patients by providing information and directing them to digital networks for people with ABI. However, when recommending the use of online peer-to-peer support, impairments and insufficient digital competence that may complicate or prevent the use of social media should be assessed and support provided when relevant. ", doi="10.2196/67658", url="https://www.jmir.org/2025/1/e67658", url="http://www.ncbi.nlm.nih.gov/pubmed/40131323" } @Article{info:doi/10.2196/67779, author="Kanitkar, Anuprita and Sepehri, Nariman and Lezen, Ariel and Parmar, Tejraj Sanjay and Hin, Kit-Fong Cherry and Szturm, Joseph Tony", title="A Game-Based Mechatronic Device for Digital Rehabilitation of Hand Function After a Stroke: Design, Prototyping, and Feasibility Study", journal="JMIR Neurotech", year="2025", month="Mar", day="19", volume="4", pages="e67779", keywords="stroke", keywords="manual dexterity", keywords="hand function", keywords="poststroke", keywords="fine motor", keywords="thumb", keywords="finger", keywords="wrist", keywords="movement", keywords="motor rehabilitation", keywords="assistive technology", keywords="smart monitoring", keywords="pilot", keywords="feasibility", keywords="prototyping", keywords="prototype", keywords="nervous system", keywords="nerve", keywords="motor neuron", abstract="Background: This paper presents an easy-to-use, affordable robotic manipulandum device (RMD) equipped with smart monitoring and assistive technologies to engage in game-based exercise and repetitive task practice. The RMD has been designed to enhance a wide range of fine motor manual dexterity skills, including thumb, finger, and wrist movements. By focusing on finger and hand functions, it extends its utility beyond basic reaching or object transfer movements. Various interchangeable 3D-printed therapy handles of different shapes and sizes can be easily attached to the RMD drive shaft. These handle movements can be used to engage with numerous affordable, commercially available computer games, allowing patients to practice tasks that involve varying movement amplitudes, speeds, precision, and cognitive challenges. Additionally, the device is capable of automatically recording and storing the patient's real-time performance data on any given computer, integrating assessment into treatment. Objective: A pilot study was conducted with 5 patients with stroke to examine the feasibility and benefits of a 6-week game-based exercise program using the proposed device. Methods: A feasibility study was conducted with 5 participants. Data were collected using the computer game--based upper extremity assessment of manual dexterity and Wolf Motor Function Test (WMFT) before and after the intervention lasting 6 weeks. Results: The pilot study demonstrated that clients' expectations related to manual dexterity were met. The average improvement in the functional ability score of the WMFT was 14 (SD 3) points, with all participants exceeding the minimal clinically important difference. The average reduction in total time was 30 (SD 14) seconds, with 4 of 5 participants surpassing the minimal clinically important difference. For the computer game--based upper extremity assessment, the average improvement in success rate was 23\% (SD 12\%), and the average decrease in response time was 105 (SD 44) milliseconds. Conclusions: Findings revealed acceptable, engaging, game-based, and task-oriented training with a high level of compliance. Substantial improvements from pre- to postintervention were observed using the WMFT and assessments of manual dexterity. Trial Registration: ClinicalTrials.gov NCT05071885; https://clinicaltrials.gov/study/NCT05071885 ", doi="10.2196/67779", url="https://neuro.jmir.org/2025/1/e67779" } @Article{info:doi/10.2196/58021, author="Oh, Mi-Young and Kim, Hee-Soo and Jung, Mi Young and Lee, Hyung-Chul and Lee, Seung-Bo and Lee, Mi Seung", title="Machine Learning--Based Explainable Automated Nonlinear Computation Scoring System for Health Score and an Application for Prediction of Perioperative Stroke: Retrospective Study", journal="J Med Internet Res", year="2025", month="Mar", day="19", volume="27", pages="e58021", keywords="machine learning", keywords="explainability", keywords="score", keywords="computation scoring system", keywords="Nonlinear computation", keywords="application", keywords="perioperative stroke", keywords="perioperative", keywords="stroke", keywords="efficiency", keywords="ML-based models", keywords="patient", keywords="noncardiac surgery", keywords="noncardiac", keywords="surgery", keywords="effectiveness", keywords="risk tool", keywords="risk", keywords="tool", keywords="real-world data", abstract="Background: Machine learning (ML) has the potential to enhance performance by capturing nonlinear interactions. However, ML-based models have some limitations in terms of interpretability. Objective: This study aimed to develop and validate a more comprehensible and efficient ML-based scoring system using SHapley Additive exPlanations (SHAP) values. Methods: We developed and validated the Explainable Automated nonlinear Computation scoring system for Health (EACH) framework score. We developed a CatBoost-based prediction model, identified key features, and automatically detected the top 5 steepest slope change points based on SHAP plots. Subsequently, we developed a scoring system (EACH) and normalized the score. Finally, the EACH score was used to predict perioperative stroke. We developed the EACH score using data from the Seoul National University Hospital cohort and validated it using data from the Boramae Medical Center, which was geographically and temporally different from the development set. Results: When applied for perioperative stroke prediction among 38,737 patients undergoing noncardiac surgery, the EACH score achieved an area under the curve (AUC) of 0.829 (95\% CI 0.753-0.892). In the external validation, the EACH score demonstrated superior predictive performance with an AUC of 0.784 (95\% CI 0.694-0.871) compared with a traditional score (AUC=0.528, 95\% CI 0.457-0.619) and another ML-based scoring generator (AUC=0.564, 95\% CI 0.516-0.612). Conclusions: The EACH score is a more precise, explainable ML-based risk tool, proven effective in real-world data. The EACH score outperformed traditional scoring system and other prediction models based on different ML techniques in predicting perioperative stroke. ", doi="10.2196/58021", url="https://www.jmir.org/2025/1/e58021" } @Article{info:doi/10.2196/60391, author="Shmilovitch, Haim Amit and Katson, Mark and Cohen-Shelly, Michal and Peretz, Shlomi and Aran, Dvir and Shelly, Shahar", title="GPT-4 as a Clinical Decision Support Tool in Ischemic Stroke Management: Evaluation Study", journal="JMIR AI", year="2025", month="Mar", day="7", volume="4", pages="e60391", keywords="GPT-4", keywords="ischemic stroke", keywords="clinical decision support", keywords="artificial intelligence", keywords="neurology", abstract="Background: Cerebrovascular diseases are the second most common cause of death worldwide and one of the major causes of disability burden. Advancements in artificial intelligence have the potential to revolutionize health care delivery, particularly in critical decision-making scenarios such as ischemic stroke management. Objective: This study aims to evaluate the effectiveness of GPT-4 in providing clinical support for emergency department neurologists by comparing its recommendations with expert opinions and real-world outcomes in acute ischemic stroke management. Methods: A cohort of 100 patients with acute stroke symptoms was retrospectively reviewed. Data used for decision-making included patients' history, clinical evaluation, imaging study results, and other relevant details. Each case was independently presented to GPT-4, which provided scaled recommendations (1-7) regarding the appropriateness of treatment, the use of tissue plasminogen activator, and the need for endovascular thrombectomy. Additionally, GPT-4 estimated the 90-day mortality probability for each patient and elucidated its reasoning for each recommendation. The recommendations were then compared with a stroke specialist's opinion and actual treatment decisions. Results: In our cohort of 100 patients, treatment recommendations by GPT-4 showed strong agreement with expert opinion (area under the curve [AUC] 0.85, 95\% CI 0.77-0.93) and real-world treatment decisions (AUC 0.80, 95\% CI 0.69-0.91). GPT-4 showed near-perfect agreement with real-world decisions in recommending endovascular thrombectomy (AUC 0.94, 95\% CI 0.89-0.98) and strong agreement for tissue plasminogen activator treatment (AUC 0.77, 95\% CI 0.68-0.86). Notably, in some cases, GPT-4 recommended more aggressive treatment than human experts, with 11 instances where GPT-4 suggested tissue plasminogen activator use against expert opinion. For mortality prediction, GPT-4 accurately identified 10 (77\%) out of 13 deaths within its top 25 high-risk predictions (AUC 0.89, 95\% CI 0.8077-0.9739; hazard ratio 6.98, 95\% CI 2.88-16.9; P<.001), outperforming supervised machine learning models such as PRACTICE (AUC 0.70; log-rank P=.02) and PREMISE (AUC 0.77; P=.07). Conclusions: This study demonstrates the potential of GPT-4 as a viable clinical decision-support tool in the management of acute stroke. Its ability to provide explainable recommendations without requiring structured data input aligns well with the routine workflows of treating physicians. However, the tendency toward more aggressive treatment recommendations highlights the importance of human oversight in clinical decision-making. Future studies should focus on prospective validations and exploring the safe integration of such artificial intelligence tools into clinical practice. ", doi="10.2196/60391", url="https://ai.jmir.org/2025/1/e60391", url="http://www.ncbi.nlm.nih.gov/pubmed/40053715" } @Article{info:doi/10.2196/63136, author="Koka, Avinash and Stuby, Loric and Carrera, Emmanuel and Gabr, Ahmed and O'Connor, Margaret and Missilier Peruzzo, Nathalie and Waeterloot, Olivier and Medlin, Friedrich and Rigolet, Fabien and Schmutz, Thomas and Michel, Patrik and Desmettre, Thibaut and Suppan, M{\'e}lanie and Suppan, Laurent", title="Asynchronous Distance Learning Performance and Knowledge Retention of the National Institutes of Health Stroke Scale Among Health Care Professionals Using Video or e-Learning: Web-based Randomized Controlled Trial", journal="J Med Internet Res", year="2025", month="Mar", day="4", volume="27", pages="e63136", keywords="stroke", keywords="e-learning", keywords="video", keywords="medical education", keywords="randomized controlled trial", keywords="knowledge retention", keywords="knowledge acquisition", keywords="NIHSS", keywords="National Institutes of Health Stroke Scale", keywords="learner satisfaction", abstract="Background: Stroke treatment has significantly improved over the last decades, but the complexity of stroke cases requires specialized care through dedicated teams with specific knowledge and training. The National Institutes of Health Stroke Scale (NIHSS), widely used to assess neurological deficits and make treatment decisions, is reliable but requires specific training and certification. The traditional didactic training method, based on a video, may not adequately address certain NIHSS intricacies nor engage health care professionals (HCPs) in continuous learning, leading to suboptimal proficiency. In the context of time-constrained clinical settings, highly interactive e-learning could be a promising alternative for NIHSS knowledge acquisition and retention. Objective: This study aimed to assess the efficacy of a highly interactive e-learning module compared with a traditional didactic video in improving NIHSS knowledge among previously trained HCPs. Furthermore, its impact on knowledge retention was also assessed. Methods: A prospective, multicentric, triple-blind, and web-based randomized controlled trial was conducted in 3 Swiss university hospitals, involving HCPs previously trained in NIHSS. Invitations were sent through email, and participants were randomized to either the e-learning or traditional didactic video group through a fully automated process upon self-registration on the website. A 50-question quiz was administered before and after exposure to the training method, and scores were compared to assess knowledge acquisition. The quiz was repeated after 1 month to evaluate retention. Subjective assessments of learning methods that is, user satisfaction, probability of recommendation, perceived difficulty, and perception of duration, were also collected through a Likert-scale questionnaire. A sample size of 72 participants were deemed necessary to have an 80\% chance of detecting a difference of 2 points in the postcourse quiz between groups at the 5\% significance level. Results: Invitations to participate were sent through email to an estimated 325 HCPs. 174 HCPs enrolled in the study, of which 97 completed the study course. Both learning methods significantly improved NIHSS knowledge, with an improvement of 3.2 (range 2.0-4.3) points in the e-learning group and of 2.1 (1.2-3.1) points in the video group. However, the e-learning group performed better, with higher scores in knowledge acquisition (median score 39.0, IQR 36.0-41.0 vs 37, IQR 34.0-39.0; P=.03) and in knowledge retention (mean score 38.2, 95\% CI 36.7-39.7 vs 35.8, 95\% CI 34.8-36.8; P=.007). Participants in the e-learning group were more likely to recommend the learning method (77\% vs 49\%, P=.02), while no significant difference was found for satisfaction (P=.17), perceived duration (P=.17), and difficulty (P=.32). Conclusions: A highly interactive e-learning module was found to be an effective asynchronous method for NIHSS knowledge acquisition and retention in previously NIHSS-trained HCPs, and may now be considered for inclusion in NIHSS training programs for HCPs. International Registered Report Identifier (IRRID): RR2-10.3390/healthcare9111460 ", doi="10.2196/63136", url="https://www.jmir.org/2025/1/e63136", url="http://www.ncbi.nlm.nih.gov/pubmed/40053772" } @Article{info:doi/10.2196/57957, author="Rampioni, Margherita and Leonzi, Sara and Antognoli, Luca and Mura, Anna and Stara, Vera", title="Poststroke eHealth Technologies--Based Rehabilitation for Upper Limb Recovery: Systematic Review", journal="J Med Internet Res", year="2025", month="Mar", day="4", volume="27", pages="e57957", keywords="stroke", keywords="rehabilitation", keywords="technology-based interventions", keywords="upper limb", keywords="technologies-based rehabilitation", keywords="limb", keywords="systematic review", keywords="cerebral vascular diseases", keywords="patient", keywords="effectiveness", keywords="database", keywords="therapy", keywords="conventional therapy", keywords="mobile phone", abstract="Background: Stroke is one of the most common cerebral vascular diseases, usually affecting people aged 60 years and older. It leads to a variety of disabilities requiring motor and cognitive rehabilitation. Poststroke rehabilitation is critical for recovery, particularly for upper limb impairments, which affect approximately 80\% of stroke survivors. Conventional rehabilitation often faces barriers such as cost, accessibility, and patient adherence. In contrast, eHealth technologies offer a promising alternative by providing accessible, cost-effective, and engaging rehabilitation solutions. Objective: While numerous systematic reviews have explored various aspects of technology-based rehabilitation for poststroke upper limb recovery, there is a notable lack of comprehensive synthesis of these findings. This gap presents challenges, primarily due to the focus on specific technologies, which complicates understanding the overall effectiveness of these interventions. Consequently, clinicians and researchers may find it difficult to assess the field holistically, potentially hindering informed decision-making in clinical practice. This review synthesizes evidence from systematic reviews evaluating the effectiveness of eHealth technology--based interventions for upper limb recovery in poststroke individuals. Two main questions are examined: (1) Are eHealth technology--based therapies more or equally effective than conventional therapies for stroke rehabilitation? (2) What are the main clinical considerations for low-cost eHealth technology--based rehabilitation? Methods: Comprehensive literature searches were conducted in PubMed, Web of Science, Scopus, Embase, and Google Scholar using predefined inclusion criteria based on the Population, Intervention, Comparison, Outcome, and Study Design (PICOS) framework. Systematic reviews published in English without date restrictions were included. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) flowchart guided study selection. Methodological quality was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR 2) criteria. Results: A total of 1792 records were screened, resulting in 7 systematic reviews published between 2019 and 2023 being included. These reviews encompassed 95 studies involving 2995 participants with a mean age of 58.8 years across acute, subacute, and chronic stroke phases. Interventions included telerehabilitation, mobile health (mHealth) apps, augmented reality (AR), virtual reality (VR), wearable devices, and exergames. While AR and VR demonstrated potential benefits when combined with conventional therapies (eg, AR showing significant improvements in upper limb function with a standardized mean difference 0.657; P<.001), evidence for stand-alone effectiveness remained inconclusive due to heterogeneity in study designs, intervention protocols, and outcome measures. Most reviews were rated as critically low quality due to methodological limitations. Conclusions: eHealth technologies hold promise for enhancing upper limb rehabilitation post stroke by addressing barriers such as cost and accessibility while providing engaging interventions. However, the field remains fragmented with insufficient evidence to establish clear efficacy. Future research should focus on standardizing protocols, optimizing neurorehabilitation principles such as dosage and task specificity, and improving methodological rigor to evaluate these interventions' long-term impact better. ", doi="10.2196/57957", url="https://www.jmir.org/2025/1/e57957", url="http://www.ncbi.nlm.nih.gov/pubmed/40053744" } @Article{info:doi/10.2196/67010, author="Song, Xiaowei and Wang, Jiayi and He, Feifei and Yin, Wei and Ma, Weizhi and Wu, Jian", title="Stroke Diagnosis and Prediction Tool Using ChatGLM: Development and Validation Study", journal="J Med Internet Res", year="2025", month="Feb", day="26", volume="27", pages="e67010", keywords="stroke", keywords="diagnosis", keywords="large language model", keywords="ChatGLM", keywords="generative language model", keywords="primary care", keywords="acute stroke", keywords="prediction tool", keywords="stroke detection", keywords="treatment", keywords="electronic health records", keywords="noncontrast computed tomography", abstract="Background: Stroke is a globally prevalent disease that imposes a significant burden on health care systems and national economies. Accurate and rapid stroke diagnosis can substantially increase reperfusion rates, mitigate disability, and reduce mortality. However, there are considerable discrepancies in the diagnosis and treatment of acute stroke. Objective: The aim of this study is to develop and validate a stroke diagnosis and prediction tool using ChatGLM-6B, which uses free-text information from electronic health records in conjunction with noncontrast computed tomography (NCCT) reports to enhance stroke detection and treatment. Methods: A large language model (LLM) using ChatGLM-6B was proposed to facilitate stroke diagnosis by identifying optimal input combinations, using external tools, and applying instruction tuning and low-rank adaptation (LoRA) techniques. A dataset containing details of 1885 patients with and those without stroke from 2016 to 2024 was used for training and internal validation; another 335 patients from two hospitals were used as an external test set, including 230 patients from the training hospital but admitted at different periods, and 105 patients from another hospital. Results: The LLM, which is based on clinical notes and NCCT, demonstrates exceptionally high accuracy in stroke diagnosis, achieving 99\% in the internal validation dataset and 95.5\% and 79.1\% in two external test cohorts. It effectively distinguishes between ischemia and hemorrhage, with an accuracy of 100\% in the validation dataset and 99.1\% and 97.1\% in the other test cohorts. In addition, it identifies large vessel occlusions (LVO) with an accuracy of 80\% in the validation dataset and 88.6\% and 83.3\% in the other test cohorts. Furthermore, it screens patients eligible for intravenous thrombolysis (IVT) with an accuracy of 89.4\% in the validation dataset and 60\% and 80\% in the other test cohorts. Conclusions: We developed an LLM that leverages clinical text and NCCT to identify strokes and guide recanalization therapy. While our results necessitate validation through widespread deployment, they hold the potential to enhance stroke identification and reduce reperfusion time. ", doi="10.2196/67010", url="https://www.jmir.org/2025/1/e67010" } @Article{info:doi/10.2196/66218, author="Schranz, Madlen and Rupprecht, Mirjam and Aigner, Annette and Benning, Leo and Schlump, Carmen and Charfeddine, Nesrine and Diercke, Michaela and Grabenhenrich, Linus and Ullrich, Alexander and Neuhauser, Hannelore and Maier, Birga and and Hans, Patricius Felix and Blaschke, Sabine", title="Establishing Syndromic Surveillance of Acute Coronary Syndrome, Myocardial Infarction, and Stroke: Registry Study Based on Routine Data From German Emergency Departments", journal="JMIR Public Health Surveill", year="2025", month="Feb", day="25", volume="11", pages="e66218", keywords="emergency medicine", keywords="routinely collected health data", keywords="public health surveillance", keywords="syndromic surveillance", keywords="acute coronary syndrome", keywords="myocardial infarction", keywords="stroke", keywords="routine data", keywords="Germany", keywords="emergency department", keywords="accuracy", keywords="syndrome", keywords="diagnosis", keywords="public health", keywords="health surveillance", abstract="Background: Emergency department (ED) routine data offer a unique opportunity for syndromic surveillance of communicable and noncommunicable diseases (NCDs). In 2020, the Robert Koch Institute established a syndromic surveillance system using ED data from the AKTIN registry. The system provides daily insights into ED utilization for infectious diseases. Adding NCD indicators to the surveillance is of great public health importance, especially during acute events, where timely monitoring enables targeted public health responses and communication. Objective: This study aimed to develop and validate syndrome definitions for the NCD indicators of acute coronary syndrome (ACS), myocardial infarction (MI), and stroke (STR). Methods: First, syndrome definitions were developed with clinical experts combining ED diagnosis, chief complaints, diagnostic certainty, and discharge information. Then, using the multicenter retrospective routine ED data provided by the AKTIN registry, we conducted internal validation by linking ED cases fulfilling the syndrome definition with the hospital discharge diagnoses and calculating sensitivity, specificity, and accuracy. Lastly, external validation comprised the comparison of the ED cases fulfilling the syndrome definition with the federal German hospital diagnosis statistic. Ratios comparing the relative number of cases for all syndrome definitions were calculated and stratified by age and sex. Results: We analyzed data from 9 EDs, totaling 704,797 attendances from January 1, 2019, to March 5, 2021. Syndrome definitions were based on ICD-10 (International Statistical Classification of Diseases and Related Health Problems 10th Revision-German Modification) diagnoses, chief complaints, and discharge information. We identified 4.3\% of all cases as ACS, 0.6\% as MI, and 3.2\% as STR. Patients with ACS and MI were more likely to be male (58.3\% and 64.7\%), compared to the overall attendances (52.7\%). For all syndrome definitions, the prevalence was higher in the older age groups (60?79 years and >80 years), and the highest proportions of cases were assigned an urgency level (3=urgent or 2=very urgent). The internal validation showed accuracy and specificity levels above 96\% for all syndrome definitions. The sensitivity was 85.3\% for ACS, 56.6\% for MI, and 80.5\% for STR. The external validation showed high levels of correspondence between the ED data and the German hospital statistics, with most ratios ranging around 1, indicating congruence, particularly in older age groups. The highest differences were noted in younger age groups, with the highest ratios in women aged between 20 and 39 years (4.57 for MI and 4.17 for ACS). Conclusions: We developed NCD indicators for ACS, MI, and STR that showed high levels of internal and external validity. The integration of these indicators into the syndromic surveillance system for EDs could enable daily monitoring of NCD patterns and trends to enhance timely public health surveillance in Germany. ", doi="10.2196/66218", url="https://publichealth.jmir.org/2025/1/e66218" } @Article{info:doi/10.2196/66802, author="Xu, Shiqi and Xu, Yanwen and Wen, Ruyi and Wang, Jun and Qiu, Yuyu and Chan, CH Chetwyn", title="Virtual Reality Enhanced Exercise Training in Upper Limb Function of Patients With Stroke: Meta-Analytic Study", journal="J Med Internet Res", year="2025", month="Feb", day="19", volume="27", pages="e66802", keywords="virtual reality", keywords="stroke", keywords="upper limb function", keywords="exercise training", keywords="meta-analysis", abstract="Background: Recovery of upper limb function after stroke secondary to ischemia or hemorrhage is crucial for patients' independence in daily living and quality of life. Virtual reality (VR) is a promising computer-based technology designed to enhance the effects of rehabilitation; however, the results of VR-based interventions remain equivocal. Objective: This study aims to review the plausible factors that may have influenced VR's therapeutic effects on improving upper limb function in patients with stroke, with the goal of synthesizing an optimal VR intervention protocol. Methods: The databases PubMed, EMBASE, Web of Science, and Cochrane Library were queried for English-language papers published from May 2022 onward. Two reviewers independently extracted data from the included papers, and discrepancies in their findings were resolved through consensus during joint meetings. The risk of bias was assessed using the Physiotherapy Evidence Database Scale and the Methodological Index for Non-Randomized Studies. Outcome variables included the Action Research Arm Test, Box-Block Test, Functional Independence Measure, Upper Extremity Fugl-Meyer Assessment, and Wolf Motor Function Test. The plausible factors examined were age, total dosage (hours), trial length (weeks), session duration (hours/session), frequency (sessions/week), and VR content design. The Bonferroni adjustment was applied to P values to prevent data from being incorrectly deemed statistically significant. Results: The final sample included 15 articles with a total of 1243 participants (age range 48.6-75.59 years). Participants in the VR therapy (VRT) group (n=455) demonstrated significantly greater improvements in upper limb function and independence in activities of daily living compared with those in the conventional therapy group (n=301). Significant factors contributing to improved outcomes in upper limb function were younger age (mean difference [MD] 5.34, 95\% CI 2.18-8.5, P<.001; I2=0\%), interventions lasting more than 15 hours (MD 9.67, 95\% CI 4.19-15.15, P<.001; I2=0\%), trial lengths exceeding 4 weeks (MD 4.02, 95\% CI 1.39-6.65, P=.003; I2=15\%), and more than 4 sessions per week (MD 3.48, 95\% CI 0.87-6.09, P=.009; I2=0\%). However, the design of the VR content, including factors such as the number of features (eg, offering exercise and functional tasks; individualized goals; activity quantification; consideration of comorbidities and baseline activity level; addressing patient needs; aligning with patient background such as education level; patient-directed goals and interests; goal setting; progressive difficulty levels; and promoting self-efficacy), did not demonstrate significant effects (MD 3.89, 95\% CI --6.40 to 1.09; effect Z=1.36, P=.16). Conclusions: Greater VR effects on improving upper limb function in patients with stroke were associated with higher training doses (exceeding 15 hours) delivered over 4-6 weeks, with shorter sessions (approximately 1 hour) scheduled 4 or more times per week. Additionally, younger patients appeared to benefit more from the VR protocol compared with older patients. ", doi="10.2196/66802", url="https://www.jmir.org/2025/1/e66802", url="http://www.ncbi.nlm.nih.gov/pubmed/39969977" } @Article{info:doi/10.2196/56397, author="Binyamin-Netser, Reut and Handelzalts, Shirley and Goldhamer, Noy and Avni, Inbar and Tayer Yeshurun, Adi and Koren, Yogev and Bibas Levy, Ofri and Kramer, Shilo and Bar Haim, Simona and Shmuelof, Lior", title="Neurotechnology-Based, Intensive, Supplementary Upper-Extremity Training for Inpatients With Subacute Stroke: Feasibility Study", journal="JMIR Serious Games", year="2025", month="Feb", day="13", volume="13", pages="e56397", keywords="stroke", keywords="rehabilitation", keywords="neurotechnology", abstract="Background: Upper-extremity hemiparesis is a common and debilitating impairment after stroke, severely restricting stroke survivors' ability to participate in daily activities and function independently. Alarmingly, only a small percentage of stroke patients fully recover upper extremity function. Animal models indicate that high-dose upper extremity training during the early poststroke phase can significantly enhance motor recovery. However, translating such programs for human patients remains challenging due to resource limitations, patient compliance issues, and administrative constraints. Objective: This study aimed to assess the feasibility and potential efficacy of an intensive, video game--based upper-extremity training protocol designed to improve movement quality during inpatient stroke rehabilitation. Additionally, it evaluated the resources required for this intervention. Specifically, the protocol provides high-intensity, high-dose training to facilitate motor recovery by engaging patients in targeted interactive exercises. Methods: Twelve patients with upper-extremity hemiparesis completed a 4-week intensive training program comprising 40 sessions of 60 minutes; the training was conducted for 2 hours per day, 5 days per week. This was delivered in addition to standard care, which included 3 therapeutic sessions daily. Two video game--based platforms were used: one platform (tech 1) targeted proximal movements involving the shoulder and elbow, while the second platform (tech 2) emphasized distal movements of the wrist and fingers. Feasibility was assessed using the measure of time on task and measures of patients' motivation and engagement. Potential effectiveness was assessed using the Fugl-Meyer Assessment of the upper extremity (FMA-UE) scale, Action Research Arm Test (ARAT), and Stroke Impact Scale (SIS). Results: Of the 12 patients, 8 completed the full protocol, 3 completed 34?38 sessions, and 1 completed 27 sessions. On average, patients actively engaged in exercises for 35 (SD 4) minutes per hour on the proximal platform (tech 1) and 37 (SD 2) minutes on the distal platform (tech 2). Patients reported high motivation and enjoyment throughout the sessions, with an Intrinsic Motivation Inventory enjoyment score of 6.49 (SD 0.66) out of 7. Pain levels were minimal, with a visual analogue scale (VAS) mean score of 2.00 (SD 2.32). Significant improvements were observed in motor function assessments: the mean improvement in FMA-UE score was 16.5 (SD 10.2) points, ARAT scores increased by 22.9 (SD 13.1) points, and the SIS Hand Function and Recovery score showed a mean delta of 1.23 (SD 0.80) points and a 23.33\% (SD 21.5\%) improvement, respectively. Conclusions: These findings demonstrate that a high-dose, high-intensity, video game--based training protocol is feasible and can be successfully integrated into subacute stroke rehabilitation. Additionally, preliminary evidence suggests that this supplementary intervention may be effective in enhancing motor recovery. This approach holds promise for future stroke rehabilitation protocols by offering an engaging, high-dose, and high-intensity program during early recovery. Trial Registration: Clinicaltrials.gov NCT04737395, https://clinicaltrials.gov/study/NCT04737395 ", doi="10.2196/56397", url="https://games.jmir.org/2025/1/e56397" } @Article{info:doi/10.2196/48328, author="Kottlors, Jonathan and Hahnfeldt, Robert and G{\"o}rtz, Lukas and Iuga, Andra-Iza and Fervers, Philipp and Bremm, Johannes and Zopfs, David and Laukamp, R. Kai and Onur, A. Oezguer and Lennartz, Simon and Sch{\"o}nfeld, Michael and Maintz, David and Kabbasch, Christoph and Persigehl, Thorsten and Schlamann, Marc", title="Large Language Models--Supported Thrombectomy Decision-Making in Acute Ischemic Stroke Based on Radiology Reports: Feasibility Qualitative Study", journal="J Med Internet Res", year="2025", month="Feb", day="13", volume="27", pages="e48328", keywords="artificial intelligence", keywords="radiology", keywords="report", keywords="large language model", keywords="text-based augmented supporting system", keywords="mechanical thrombectomy", keywords="GPT", keywords="stroke", keywords="decision-making", keywords="thrombectomy", keywords="imaging", keywords="model", keywords="machine learning", keywords="ischemia", abstract="Background: The latest advancement of artificial intelligence (AI) is generative pretrained transformer large language models (LLMs). They have been trained on massive amounts of text, enabling humanlike and semantical responses to text-based inputs and requests. Foreshadowing numerous possible applications in various fields, the potential of such tools for medical data integration and clinical decision-making is not yet clear. Objective: In this study, we investigate the potential of LLMs in report-based medical decision-making on the example of acute ischemic stroke (AIS), where clinical and image-based information may indicate an immediate need for mechanical thrombectomy (MT). The purpose was to elucidate the feasibility of integrating radiology report data and other clinical information in the context of therapy decision-making using LLMs. Methods: A hundred patients with AIS were retrospectively included, for which 50\% (50/100) was indicated for MT, whereas the other 50\% (50/100) was not. The LLM was provided with the computed tomography report, information on neurological symptoms and onset, and patients' age. The performance of the AI decision-making model was compared with an expert consensus regarding the binary determination of MT indication, for which sensitivity, specificity, and accuracy were calculated. Results: The AI model had an overall accuracy of 88\%, with a specificity of 96\% and a sensitivity of 80\%. The area under the curve for the report-based MT decision was 0.92. Conclusions: The LLM achieved promising accuracy in determining the eligibility of patients with AIS for MT based on radiology reports and clinical information. Our results underscore the potential of LLMs for radiological and medical data integration. This investigation should serve as a stimulus for further clinical applications of LLMs, in which this AI should be used as an augmented supporting system for human decision-making. ", doi="10.2196/48328", url="https://www.jmir.org/2025/1/e48328", url="http://www.ncbi.nlm.nih.gov/pubmed/39946168" } @Article{info:doi/10.2196/56521, author="Allaart, G. Corinne and van Houwelingen, Sanne and Hilkens, HE Pieter and van Halteren, Aart and Biesma, H. Douwe and Dijksman, Lea and van der Nat, B. Paul", title="The Significance of a Cerebrovascular Accident Outcome Prediction Model for Patients, Family Members, and Health Care Professionals: Qualitative Evaluation Study", journal="JMIR Hum Factors", year="2025", month="Jan", day="22", volume="12", pages="e56521", keywords="cerebrovascular accident", keywords="machine learning", keywords="artificial intelligence", keywords="visualization", keywords="focus groups", keywords="questionnaire", keywords="informal caregivers", keywords="health care professionals", abstract="Background: Patients with cerebrovascular accident (CVA) should be involved in setting their rehabilitation goals. A personalized prediction of CVA outcomes would allow care professionals to better inform patients and informal caregivers. Several accurate prediction models have been created, but acceptance and proper implementation of the models are prerequisites for model adoption. Objective: This study aimed to assess the added value of a prediction model for long-term outcomes of rehabilitation after CVA and evaluate how it can best be displayed, implemented, and integrated into the care process. Methods: We designed a mock-up version, including visualizations, based on our recently developed prediction model. We conducted focus groups with CVA patients and informal caregivers, and separate focus groups with health care professionals (HCPs). Their opinions on the current information management and the model were analyzed using a thematic analysis approach. Lastly, a Measurement Instrument for Determinants of Innovations (MIDI) questionnaire was used to collect insights into the prediction model and visualizations with HCPs. Results: The analysis of 6 focus groups, with 9 patients, 4 informal caregivers, and 8 HCPs, resulted in 10 themes in 3 categories: evaluation of the current care process (information absorption, expectations of rehabilitation, prediction of outcomes, and decision aid), content of the prediction model (reliability, relevance, and influence on the care process), and accessibility of the model (ease of understanding, model type preference, and moment of use). We extracted recommendations for the prediction model and visualizations. The results of the questionnaire survey (9 responses, 56\% response rate) underscored the themes of the focus groups. Conclusions: There is a need for the use of a prediction model to assess CVA outcomes, as indicated by the general approval of participants in both the focus groups and the questionnaire survey. We recommend that the prediction model be geared toward HCPs, as they can provide the context necessary for patients and informal caregivers. Good reliability and relevance of the prediction model will be essential for its wide adoption. ", doi="10.2196/56521", url="https://humanfactors.jmir.org/2025/1/e56521" } @Article{info:doi/10.2196/55455, author="Pereira, Polin Amanda and Machado Neto, Jose Olibario and Elui, Carril Valeria Meirelles and Pimentel, Campos Maria da Graca", title="Wearable Smartphone-Based Multisensory Feedback System for Torso Posture Correction: Iterative Design and Within-Subjects Study", journal="JMIR Aging", year="2025", month="Jan", day="22", volume="8", pages="e55455", keywords="stroke rehabilitation", keywords="posture", keywords="postural balance", keywords="wearable technology", keywords="multisensory feedback", keywords="smartphone", keywords="stroke", keywords="mHealth", keywords="mobile health", keywords="digital health", keywords="digital technology", keywords="digital intervention", keywords="gerontology", abstract="Background: The prevalence of stroke is high in both males and females, and it rises with age. Stroke often leads to sensor and motor issues, such as hemiparesis affecting one side of the body. Poststroke patients require torso stabilization exercises, but maintaining proper posture can be challenging due to their condition. Objective: Our goal was to develop the Postural SmartVest, an affordable wearable technology that leverages a smartphone's built-in accelerometer to monitor sagittal and frontal plane changes while providing visual, tactile, and auditory feedback to guide patients in achieving their best-at-the-time posture during rehabilitation. Methods: To design the Postural SmartVest, we conducted brainstorming sessions, therapist interviews, gathered requirements, and developed the first prototype. We used this initial prototype in a feasibility study with individuals without hemiparesis (n=40, average age 28.4). They used the prototype during 1-hour seated sessions. Their feedback led to a second prototype, which we used in a pilot study with a poststroke patient. After adjustments and a kinematic assessment using the Vicon Gait Plug-in system, the third version became the Postural SmartVest. We assessed the Postural SmartVest in a within-subject experiment with poststroke patients (n=40, average age 57.1) and therapists (n=20, average age 31.3) during rehabilitation sessions. Participants engaged in daily activities, including walking and upper limb exercises, without and with app feedback. Results: The Postural SmartVest comprises a modified off-the-shelf athletic lightweight compression tank top with a transparent pocket designed to hold a smartphone running a customizable Android app securely. This app continuously monitors sagittal and frontal plane changes using the built-in accelerometer sensor, providing multisensory feedback through audio, vibration, and color changes. Patients reported high ratings for weight, comfort, dimensions, effectiveness, ease of use, stability, durability, and ease of adjustment. Therapists noted a positive impact on rehabilitation sessions and expressed their willingness to recommend it. A 2-tailed t-test showed a significant difference (P<.001) between the number of the best-at-the-time posture positions patients could maintain in 2 stages, without feedback (mean 13.1, SD 7.12) and with feedback (mean 4.2, SD 3.97), demonstrating the effectiveness of the solution in improving posture awareness. Conclusions: The Postural SmartVest aids therapists during poststroke rehabilitation sessions and assists patients in improving their posture during these sessions. ", doi="10.2196/55455", url="https://aging.jmir.org/2025/1/e55455" } @Article{info:doi/10.2196/54121, author="Zhang, Haofuzi and Zou, Peng and Luo, Peng and Jiang, Xiaofan", title="Machine Learning for the Early Prediction of Delayed Cerebral Ischemia in Patients With Subarachnoid Hemorrhage: Systematic Review and Meta-Analysis", journal="J Med Internet Res", year="2025", month="Jan", day="20", volume="27", pages="e54121", keywords="machine learning", keywords="subarachnoid hemorrhage", keywords="delayed cerebral ischemia", keywords="systematic review", abstract="Background: Delayed cerebral ischemia (DCI) is a primary contributor to death after subarachnoid hemorrhage (SAH), with significant incidence. Therefore, early determination of the risk of DCI is an urgent need. Machine learning (ML) has received much attention in clinical practice. Recently, some studies have attempted to apply ML models for early noninvasive prediction of DCI. However, systematic evidence for its predictive accuracy is still lacking. Objective: The aim of this study was to synthesize the prediction accuracy of ML models for DCI to provide evidence for the development or updating of intelligent detection tools. Methods: PubMed, Cochrane, Embase, and Web of Science databases were systematically searched up to May 18, 2023. The risk of bias in the included studies was assessed using PROBAST (Prediction Model Risk of Bias Assessment Tool). During the analysis, we discussed the performance of different models in the training and validation sets. Results: We finally included 48 studies containing 16,294 patients with SAH and 71 ML models with logistic regression as the main model type. In the training set, the pooled concordance index (C index), sensitivity, and specificity of all the models were 0.786 (95\% CI 0.737-0.835), 0.77 (95\% CI 0.69-0.84), and 0.83 (95\% CI 0.75-0.89), respectively, while those of the logistic regression models were 0.770 (95\% CI 0.724-0.817), 0.75 (95\% CI 0.67-0.82), and 0.71 (95\% CI 0.63-0.78), respectively. In the validation set, the pooled C index, sensitivity, and specificity of all the models were 0.767 (95\% CI 0.741-0.793), 0.66 (95\% CI 0.53-0.77), and 0.78 (95\% CI 0.71-0.84), respectively, while those of the logistic regression models were 0.757 (95\% CI 0.715-0.800), 0.59 (95\% CI 0.57-0.80), and 0.80 (95\% CI 0.71-0.87), respectively. Conclusions: ML models appear to have relatively desirable power for early noninvasive prediction of DCI after SAH. However, enhancing the prediction sensitivity of these models is challenging. Therefore, efficient, noninvasive, or minimally invasive low-cost predictors should be further explored in future studies to improve the prediction accuracy of ML models. Trial Registration: PROSPERO (CRD42023438399); https://tinyurl.com/yfuuudde ", doi="10.2196/54121", url="https://www.jmir.org/2025/1/e54121" } @Article{info:doi/10.2196/56679, author="Zawada, J. Stephanie and Ganjizadeh, Ali and Conte, Marco Gian and Demaerschalk, M. Bart and Erickson, J. Bradley", title="Exploring Remote Monitoring of Poststroke Mood With Digital Sensors by Assessment of Depression Phenotypes and Accelerometer Data in UK Biobank: Cross-Sectional Analysis", journal="JMIR Neurotech", year="2025", month="Jan", day="10", volume="4", pages="e56679", keywords="depression", keywords="cerebrovascular disease", keywords="remote monitoring", keywords="stroke", keywords="accelerometers", keywords="mobile phone", abstract="Background: Interest in using digital sensors to monitor patients with prior stroke for depression, a risk factor for poor outcomes, has grown rapidly; however, little is known about behavioral phenotypes related to future mood symptoms and if patients with and without previously diagnosed depression experience similar phenotypes. Objective: This study aimed to assess the feasibility of using digital sensors to monitor mood in patients with prior stroke with a prestroke depression diagnosis (DD) and controls. We examined relationships between physical activity behaviors and self-reported depression frequency. Methods: In the UK Biobank wearable accelerometer cohort, we retrospectively identified patients who had previously suffered a stroke (N=1603) and conducted cross-sectional analyses with those who completed a subsequent depression survey follow-up. Sensitivity analyses assessed a general population cohort excluding previous stroke participants and 2 incident cohorts: incident stroke (IS) and incident cerebrovascular disease (IC). Results: In controls, the odds of being in a higher depressed mood frequency category decreased by 23\% for each minute spent in moderate?to?vigorous physical activity (odds ratio 0.77, 95\% CI 0.69?0.87; P<.001). This association persisted in both general cohorts and in the IC control cohort. Conclusions: Although moderate?to?vigorous physical activity was linked with less frequent depressed mood in patients with prior stroke without DD, this finding did not persist in DDs. Thus, accelerometer-mood monitoring may provide clinically useful insights about future mood in patients with prior stroke without DDs. Considering the finding in the IC cohort and the lack of findings in the IS cohorts, accelerometer-mood monitoring may also be appropriately applied to observing broader cerebrovascular disease pathogenesis. ", doi="10.2196/56679", url="https://neuro.jmir.org/2025/1/e56679" } @Article{info:doi/10.2196/50627, author="Lolak, Sermkiat and Attia, John and McKay, J. Gareth and Thakkinstian, Ammarin", title="Application of Dragonnet and Conformal Inference for Estimating Individualized Treatment Effects for Personalized Stroke Prevention: Retrospective Cohort Study", journal="JMIR Cardio", year="2025", month="Jan", day="8", volume="9", pages="e50627", keywords="stroke", keywords="causal effect", keywords="ITE", keywords="individual treatment effect", keywords="Dragonnet", keywords="conformal inference", keywords="mortality", keywords="hospital records", keywords="hypertension", keywords="risk factor", keywords="diabetes", keywords="dyslipidemia", keywords="atrial fibrillation", keywords="machine learning", keywords="treatment", abstract="Background: Stroke is a major cause of death and disability worldwide. Identifying individuals who would benefit most from preventative interventions, such as antiplatelet therapy, is critical for personalized stroke prevention. However, traditional methods for estimating treatment effects often focus on the average effect across a population and do not account for individual variations in risk and treatment response. Objective: This study aimed to estimate the individualized treatment effects (ITEs) for stroke prevention using a novel combination of Dragonnet, a causal neural network, and conformal inference. The study also aimed to determine and validate the causal effects of known stroke risk factors---hypertension (HT), diabetes mellitus (DM), dyslipidemia (DLP), and atrial fibrillation (AF)---using both a conventional causal model and machine learning models. Methods: A retrospective cohort study was conducted using data from 275,247 high-risk patients treated at Ramathibodi Hospital, Thailand, between 2010 and 2020. Patients aged >18 years with HT, DM, DLP, or AF were eligible. The main outcome was ischemic or hemorrhagic stroke, identified using International Classification of Diseases, 10th Revision (ICD-10) codes. Causal effects of the risk factors were estimated using a range of methods, including: (1) propensity score--based methods, such as stratified propensity scores, inverse probability weighting, and doubly robust estimation; (2) structural causal models; (3) double machine learning; and (4) Dragonnet, a causal neural network, which was used together with weighted split-conformal quantile regression to estimate ITEs. Results: AF, HT, and DM were identified as significant stroke risk factors. Average causal risk effect estimates for these risk factors ranged from 0.075 to 0.097 for AF, 0.017 to 0.025 for HT, and 0.006 to 0.010 for DM, depending on the method used. Dragonnet yielded causal risk ratios of 4.56 for AF, 2.44 for HT, and 1.41 for DM, which is comparable to other causal models and the standard epidemiological case-control study. Mean ITE analysis indicated that several patients with DM or DM with HT, who were not receiving antiplatelet treatment at the time of data collection, showed reductions in total risk of ?0.015 and ?0.016, respectively. Conclusions: This study provides a comprehensive evaluation of stroke risk factors and demonstrates the feasibility of using Dragonnet and conformal inference to estimate ITEs of antiplatelet therapy for stroke prevention. The mean ITE analysis suggested that those with DM or DM with HT, who were not receiving antiplatelet treatment at the time of data collection, could potentially benefit from this therapy. The findings highlight the potential of these advanced techniques to inform personalized treatment strategies for stroke, enabling clinicians to identify individuals who are most likely to benefit from specific interventions. ", doi="10.2196/50627", url="https://cardio.jmir.org/2025/1/e50627" } @Article{info:doi/10.2196/49847, author="Chen, Jiayin and Or, Kalun Calvin and Li, Zhixian and Yeung, Kwong Eric Hiu and Chen, Tianrong", title="Perceptions of Patients With Stroke Regarding an Immersive Virtual Reality--Based Exercise System for Upper Limb Rehabilitation: Questionnaire and Interview Study", journal="JMIR Serious Games", year="2025", month="Jan", day="1", volume="13", pages="e49847", keywords="virtual reality", keywords="stroke", keywords="perception", keywords="rehabilitation", keywords="questionnaire", keywords="interview", abstract="Background: With substantial resources allocated to develop virtual reality (VR)--based rehabilitation exercise programs for poststroke motor rehabilitation, it is important to understand how patients with stroke perceive these technology-driven approaches, as their perceptions can determine acceptance and adherence. Objective: This study aimed to examine the perceptions of patients with stroke regarding an immersive VR-based exercise system developed to deliver shoulder, elbow, forearm, wrist, and reaching exercises. Methods: A questionnaire was used to assess the perceptions of 21 inpatients who had experienced stroke (mean time from stroke onset: 37.2, SD 25.9 days; Brunnstrom stage of stroke recovery for the arm: 3-5) regarding the perceived usefulness of, ease of use of, attitude toward, intrinsic motivation for, and intention to use the exercise system. The measurement items were rated on a 7-point Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree), with higher values indicating more positive perceptions. Descriptive statistics were used to summarize the responses. Moreover, we conducted semistructured interviews that were audio recorded, transcribed, and subjected to content analysis to identify thematic patterns. Results: The questionnaire results revealed that the patients' perceptions of the exercise system were positive (mean ratings >6). The content analysis revealed 6 positive themes from 73 statements about the exercise system: ease of use, usefulness, enjoyment, motivation, accessibility, and game design. Conversely, 15 statements reflected negative perceptions, which were clustered into 3 themes: difficulty in handling VR devices, uncomfortable experiences when using VR devices, and monotony. Conclusions: Integrating VR technology into poststroke functional exercises holds significant promise based on patient interests. However, patient preferences and adaptability must be considered to promote the technology's success. VR-guided exercises should be user-friendly, health-promoting, engaging, and well-designed. Furthermore, addressing challenges, such as bulkiness, motion sickness, discomfort, and exercise monotony, is crucial for the widespread adoption and diffusion of this technology. ", doi="10.2196/49847", url="https://games.jmir.org/2025/1/e49847" } @Article{info:doi/10.2196/53696, author="Khoshnaw, Sara and Panzarasa, Pietro and De Simoni, Anna", title="Metaphor Diffusion in Online Health Communities: Infodemiology Study in a Stroke Online Health Community", journal="JMIR Cardio", year="2024", month="Dec", day="17", volume="8", pages="e53696", keywords="online health community", keywords="social capital", keywords="metaphor", keywords="stroke", keywords="OHC", keywords="novelty", keywords="passive analysis", keywords="stroke survivor", keywords="self-promotion", keywords="post-stroke", keywords="information diffusion", abstract="Background: Online health communities (OHCs) enable patients to create social ties with people with similar health conditions outside their existing social networks. Harnessing mechanisms of information diffusion in OHCs has attracted attention for its ability to improve illness self-management without the use of health care resources. Objective: We aimed to analyze the novelty of a metaphor used for the first time in an OHC, assess how it can facilitate self-management of post-stroke symptoms, describe its appearance over time, and classify its diffusion mechanisms. Methods: We conducted a passive analysis of posts written by UK stroke survivors and their family members in an online stroke community between 2004 and 2011. Posts including the term ``legacy of stroke'' were identified. Information diffusion was classified according to self-promotion or viral spread mechanisms and diffusion depth (the number of users the information spreads out to). Linguistic analysis was performed through the British National Corpus and the Google search engine. Results: Post-stroke symptoms were referred to as ``legacy of stroke.'' This metaphor was novel and appeared for the first time in the OHC in the second out of a total of 3459 threads. The metaphor was written by user A, who attributed it to a stroke consultant explaining post-stroke fatigue. This user was a ``superuser'' (ie, a user with high posting activity) and self-promoted the metaphor throughout the years in response to posts written by other users, in 51 separate threads. In total, 7 users subsequently used the metaphor, contributing to its viral diffusion, of which 3 were superusers themselves. Superusers achieved the higher diffusion depths (maximum of 3). Of the 7 users, 3 had been part of threads where user A mentioned the metaphor, while 2 users had been part of discussion threads in unrelated conversations. In total, 2 users had not been part of threads with any of the other users, suggesting that the metaphor was acquired through prior lurking activity. Conclusions: Metaphors that are considered helpful by patients with stroke to come to terms with their symptoms can diffuse in OHCs through both self-promotion and social (or viral) spreading, with the main driver of diffusion being the superuser trait. Lurking activity (the most common behavior in OHCs) contributed to the diffusion of information. As an increasing number of patients with long-term conditions join OHCs to find others with similar health-related concerns, improving clinicians' and researchers' awareness of the diffusion of metaphors that facilitate self-management in health social media may be beneficial beyond the individual patient. ", doi="10.2196/53696", url="https://cardio.jmir.org/2024/1/e53696" } @Article{info:doi/10.2196/59136, author="Krohn, Maria and Rintala, Aki and Immonen, Jaakko and Sj{\"o}gren, Tuulikki", title="The Effectiveness of Therapeutic Exercise Interventions With Virtual Reality on Balance and Walking Among Persons With Chronic Stroke: Systematic Review, Meta-Analysis, and Meta-Regression of Randomized Controlled Trials", journal="J Med Internet Res", year="2024", month="Dec", day="2", volume="26", pages="e59136", keywords="stroke", keywords="chronic", keywords="virtual reality", keywords="physiotherapy", keywords="therapeutic exercise", keywords="balance", keywords="walking", abstract="Background: Well-targeted balance, walking, and weight-shift training can improve balance capabilities in the chronic phase of stroke. There is an urgent need for a long-term approach to rehabilitation that extends beyond the acute and subacute phases, supporting participation without increasing the demand for health care staff. Objective: This study aims to evaluate the effectiveness of therapeutic exercise interventions with virtual reality (VR) training on balance and walking at the activity and participation levels in individuals with chronic stroke, compared with control groups receiving no treatment, conventional physical therapy, specific training, similar treatment, or identical treatment without VR. Methods: Studies were searched across 6 databases. The inclusion criteria were as follows: Adults aged 18 years or older with a stroke diagnosis for at least 6 months (population). Therapeutic exercises within a VR environment, using VR glasses or interactive games (intervention). Control groups without the use of VR (including no treatment, conventional physical therapy, specific training, similar treatment without VR, or identical treatment without the additional use of VR; comparison). We evaluated the Berg Balance Scale score, Functional Reach Test performance, Activities-specific Balance Confidence Scale score, Six-minute Walk Test, Two-minute Walk Test, 10-meter Walk Test results, and cadence (outcome measures). We investigated randomized controlled trials (study design). A meta-analysis and a meta-regression analysis were conducted to evaluate whether the content of VR interventions or control groups, as well as the level of VR immersion used, was related to balance or walking outcomes. Results: A total of 43 randomized controlled trials involving 1136 participants were included in this review. The use of VR training in therapeutic exercise interventions had a large effect on balance (standardized mean difference 0.51, 95\% CI 0.29-0.72; P<.001) and a moderate effect on walking (standardized mean difference 0.31, 95\% CI 0.09-0.53; P=.006) in individuals with chronic stroke, compared with pooled control groups (no treatment, conventional physical therapy, specific training, similar treatment, or identical treatment without the use of VR). According to the meta-regression findings, the content of VR interventions (P=.52), the type of control groups (P=.79), and the level of VR immersion (P=.82) were not significantly related to the pooled balance or walking outcomes. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) was moderate for balance and low for walking. Conclusions: Therapeutic exercise training with VR had a positive, albeit moderate, effect on balance and a low impact on walking at the level of activity (capacity), even in the chronic phase of stroke, without serious side effects. The results are applicable to working-aged stroke rehabilitees who are able to walk without assistance. Further research is needed with defined VR methods and outcomes that assess performance at the level of real-life participation. ", doi="10.2196/59136", url="https://www.jmir.org/2024/1/e59136", url="http://www.ncbi.nlm.nih.gov/pubmed/39621381" } @Article{info:doi/10.2196/59749, author="Rose, K. Dorian and Brunetti, Gina and Cavka, Kathryn and Hoisington, Brooke J. and Snyder, Hannah and Xue, Wei and Smith, K. Barbara", title="Respiratory Strength Training Versus Respiratory Relaxation Training in the Rehabilitation of Physical Impairment, Function, and Return to Participation After Stroke: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2024", month="Nov", day="27", volume="13", pages="e59749", keywords="stroke", keywords="rehabilitation", keywords="exercise", keywords="clinical trial", keywords="respiration", keywords="wellness", keywords="community based", abstract="Background: Persistent disability in chronic stroke survivors is often attributed to arm or leg weakness; however, respiratory muscle weakness also impedes poststroke rehabilitation, reduces quality of life, and increases the risk of health complications. Respiratory complications are common after stroke and place patients at risk for both prolonged functional disability and mortality. In addition, stroke survivors face ongoing cardiovascular disease that places them at risk for recurrent stroke. Objective: The study aims to compare the effects of 2 respiratory training programs, paired with individualized flexibility, strengthening, and cardiovascular exercise programs, on physiologic, activity, and societal participation outcomes in chronic stroke survivors. Methods: This study will be a randomized controlled trial. Participants are 80 community-dwelling adults with chronic stroke. In conjunction with a 24-session (3 times/week for 8 weeks), American Heart Association--informed, whole-body exercise program, participants will be randomized to receive either respiratory strength training or respiratory relaxation training. Study intervention will be directed by a physical therapist and take place in a community fitness center. Outcome assessments will occur in a clinical research center. The primary outcome measure is maximal respiratory pressure. Secondary outcome measures include airway clearance, walking endurance, spatial-temporal gait characteristics, community walking, functional strength and fatigue, depression, and societal participation measures. Longer-term societal participation is a complex domain that may be influenced by other factors beyond physical function. Participants' health status will be monitored for 1 year following the intervention for falls, respiratory illness, and hospitalizations. Additional subanalyses will evaluate the effect of smoke exposure on short- and long-term outcomes. Outcome assessors are blinded to group assignments. Respiratory relaxation training is an active comparator, but no pure control group is included. Results: This study was funded in March 2020 with enrollment commencing in November 2020. Completion of enrollment is projected for May 2025 with a study projected end date of April 2026. Published results are anticipated in Fall 2026. Conclusions: Results from this study will improve our understanding of the additive benefits of respiratory exercises on short- and long-term physiologic, functional, and societal gains for these individuals. These data will be instructive to meet a current unmet rehabilitative need to promote patient-centered care and contribute to decreasing morbidity and mortality in chronic stroke survivors. Trial Registration: ClinicalTrials.gov: NCT05819333; https://clinicaltrials.gov/study/NCT05819333 International Registered Report Identifier (IRRID): DERR1-10.2196/59749 ", doi="10.2196/59749", url="https://www.researchprotocols.org/2024/1/e59749" } @Article{info:doi/10.2196/59572, author="Zhou, Wu and Feng, HaiXia and Tao, Hua and Sun, Hui and Zhang, TianTian and Wang, QingXia and Zhang, Li", title="Factors Influencing Poststroke Cognitive Dysfunction: Cross-Sectional Analysis", journal="JMIR Form Res", year="2024", month="Nov", day="19", volume="8", pages="e59572", keywords="stroke", keywords="cognitive dysfunction", keywords="analysis of associated factors", keywords="MMSE", keywords="Mini-Mental State Examination", keywords="status survey", keywords="cognitive", keywords="survey", keywords="cognitive impairment", keywords="cross-sectional study", keywords="cross sectional", keywords="stroke patients", keywords="cognition", keywords="education", abstract="Background: Poststroke cognitive impairment (PSCI) is a common and debilitating complication that affects stroke survivors, impacting memory, attention, and executive function. Despite its prevalence, the factors contributing to PSCI remain unclear, with limited insights into how demographic and clinical variables influence cognitive outcomes. Objective: This study investigates the incidence of cognitive impairment in patients with stroke and examines key demographic and clinical factors, such as age, gender, and education level, which contribute to cognitive decline. The aim is to provide a deeper understanding of PSCI to inform early intervention strategies for improving patient outcomes. Methods: A cross-sectional study was conducted on 305 patients with ischemic stroke admitted to Zhongda Hospital, Southeast University, from January 2019 to September 2022. Cognitive function was assessed using the Mini-Mental State Examination (MMSE) within 72 hours of hospital admission. Demographic information, including age, gender, and education level, were collected. Statistical analyses were performed using chi-square tests, independent t tests, and multivariate regression to assess the relationship between cognitive function and key variables. Pearson correlation analysis explored associations among age, education, and MMSE scores. Results: Among the 305 patients with stroke, 16.7\% (n=51) were diagnosed with cognitive impairment based on MMSE scores. The prevalence of cognitive impairment was slightly higher in males (17.6\%, n=159) than females (15.8\%, n=146), but this difference was not statistically significant. A strong negative correlation was found between MMSE scores and age (r=--0.32; P<.01), indicating that older patients had lower cognitive function. Education level showed a positive correlation with MMSE scores (r=0.41; P<.01), with patients with higher educational attainment demonstrating better cognitive outcomes. Cognitive function showed a marked decline in patients older than 60 years, particularly in domains such as memory, attention, and language skills. Conclusions: This study confirms that age and education are significant factors in determining cognitive outcomes after stroke. The results align with existing literature showing that cognitive function declines with age, while higher educational attainment serves as a protective factor. The findings suggest that individuals with greater cognitive reserve, often linked to higher education, are better equipped to cope with the impact of brain injury. However, the study's reliance on MMSE may have limited its ability to detect domain-specific impairments. Future studies should consider using more sensitive cognitive tools, such as the Montreal Cognitive Assessment (MoCA), to provide a more comprehensive evaluation of PSCI. Cognitive impairment is prevalent among stroke survivors, with age and education level being key factors influencing outcomes. These findings underscore the importance of early detection and targeted interventions to mitigate cognitive decline. Further research with larger samples and more sensitive cognitive assessments is needed to fully understand PSCI and improve rehabilitation strategies for patients with stroke. ", doi="10.2196/59572", url="https://formative.jmir.org/2024/1/e59572" } @Article{info:doi/10.2196/58388, author="Wei, Xijun and Zhou, Ping and Wei, Yixi and Wu, Dashuang and Qin, Ping and Zhang, Yingying and Zhu, Jing and Ren, Zhanbing and Li, Hai and Zhang, Yumei", title="Comparison of Occupational Performance in Immersive Virtual and Real Environments Among Patients With Stroke: Observational Randomized Crossover Pilot Study", journal="JMIR Serious Games", year="2024", month="Nov", day="15", volume="12", pages="e58388", keywords="instrumental activities of daily living", keywords="immersive virtual reality", keywords="occupational performance", keywords="stroke rehabilitation", keywords="occupational therapy", abstract="Background: Conventional rehabilitation approaches involve therapists simulating various occupational tasks in health care settings or recreating real-life situations to assess and train patients in instrumental activities of daily living (IADLs). As an alternative, immersive virtual reality (IVR) has been widely used in stroke rehabilitation for years, but research comparing occupational performance between virtual and real environments is limited. Objective: This study aims to introduce a novel IVR shopping system designed for patients with stroke and to investigate the correlation of occupational performance in virtual and real environments among patients with stroke. Methods: Ten patients with stroke were recruited from the Department of Rehabilitation Medicine, Shenzhen Hospital, Southern Medical University, who met the inclusion and exclusion criteria for this observational, randomized crossover study; the patients were predominantly male (n=7), had experienced ischemic stroke (n=9), were aged 14 to 73 years, and had a time since stroke of 1 to 42 months. All patients attempted shopping tasks in virtual and real environments. The Mini-Mental State Examination (MMSE), Timed Up and Go Test (TUGT), modified Barthel index (MBI), and Lawton index (LI) were used to assess cognition, ambulation, and activities of daily living. Memory capacity and duration in the virtual and real environments were recorded as the primary parameters of occupational performance. The Wilcoxon test and Spearman correlation coefficients were used to analyze the differences and correlations between the 2 environments. Results: The Wilcoxon test showed no significant differences between the virtual and real environments in memory capacity and duration of task completion (P>.99 and P=.99), and memory capacity in both environments correlated with the LI ($\rho$=0.81; P=.005). Memory duration had a relationship with the TUGT in the virtual environment ($\rho$=0.68; P=.03) and a borderline negative correlation with MMSE in the real environment ($\rho$=?0.58; P=.08). Conclusions: Considering the small sample size used in this study and the study's limitations, despite the significant correlation between shopping performance in IVR and the real world, it is still too early to conclude that IVR is a noninferior approach, but it presents the potential to be an alternative for assessment and training in IADLs when resources are limited. However, further research is needed to investigate the psychometric properties, clinical effects, and impact of virtual training on real-world performance. The implications for practice might include the following: (1) occupational performance in virtual shopping might be the same as real-world shopping, and more virtual IADLs could thus be developed; (2) virtual IADL assessment and training systems could be used in remote locations or locations with limited resources; and (3) more objective parameters of IADLs could be extracted from virtual environments. Trial Registration: Chinese Clinical Trial Registry ChiCTR2000041058; https://www.chictr.org.cn/showprojEN.html?proj=65714 ", doi="10.2196/58388", url="https://games.jmir.org/2024/1/e58388" } @Article{info:doi/10.2196/55481, author="Chien, Shih-Ying and Wu, Ching-Yi and Wong, May-Kuen Alice and Chen, Chih-Kuang and Beckman, L. Sara", title="Exploring the Impact of an Interactive Electronic Pegboard on Manual Dexterity and Cognitive Skills of Patients With Stroke: Preliminary Analysis", journal="JMIR Form Res", year="2024", month="Oct", day="24", volume="8", pages="e55481", keywords="interactive electronic pegboard", keywords="stroke", keywords="hand dexterity", keywords="cognitive rehabilitation", keywords="system", abstract="Background: As individuals age, the incidence and mortality rates of cerebrovascular accidents significantly rise, leading to fine motor impairments and cognitive deficits that impact daily life. In modern occupational therapy, assessing manual dexterity and cognitive functions typically involves observation of patients interacting with physical objects. However, this pen-and-paper method is not only time-consuming, relying heavily on therapist involvement, but also often inaccurate. Digital assessment methods, therefore, have the potential to increase the accuracy of diagnosis, as well as decrease the workload of health care professionals. Objective: This study examined the feasibility of an interactive electronic pegboard for the assessment and rehabilitation of patients with stroke. Methods: We explored the pegboard's clinical applicability by examining the relationship among stages, timing, and difficulty settings, as well as their alignment with patient capabilities. In total, 10 participants used a prototype of the pegboard for functional and task assessments; questionnaire interviews were conducted simultaneously to collect user feedback. Results: Patients with stroke consistently required more time to complete tasks than expected, significantly deviating from the initial time frames. Additionally, the participants exhibited a slight reduction in performance levels in both manual dexterity and cognitive abilities. Insights from questionnaire responses revealed that the majority of participants found the prototype interface easy and enjoyable to use, with good functionality. Conclusions: This preliminary investigation supports the efficacy of interactive electronic pegboards for the rehabilitation of the hand functions of patients with stroke, as well as training their attentional and cognitive abilities. This digital technology could potentially alleviate the burden of health care workers, positioning it as a valuable and intelligent precision health care tool. ", doi="10.2196/55481", url="https://formative.jmir.org/2024/1/e55481", url="http://www.ncbi.nlm.nih.gov/pubmed/39446480" } @Article{info:doi/10.2196/58419, author="Pogrebnoy, Dina and Ashton, Lee and Beh, A. Brian and Burke, Meredith and Cullen, Richard and Czerenkowski, Jude and Davey, Julie and Dennett, M. Amy and English, Kevin and Godecke, Erin and Harper, Nicole and Lynch, Elizabeth and MacDonald-Wicks, Lesley and Patterson, Amanda and Ramage, Emily and Schelfhaut, Ben and Simpson, B. Dawn and Zacharia, Karly and English, Coralie", title="Adapting a Telehealth Physical Activity and Diet Intervention to a Co-Designed Website for Self-Management After Stroke: Tutorial", journal="J Med Internet Res", year="2024", month="Oct", day="22", volume="26", pages="e58419", keywords="stroke", keywords="secondary prevention", keywords="co-design", keywords="how-to guide, website development", keywords="accessibility", keywords="navigation", keywords="self-management", doi="10.2196/58419", url="https://www.jmir.org/2024/1/e58419" } @Article{info:doi/10.2196/54827, author="Clancy, Brigid and Bonevski, Billie and English, Coralie and Guillaumier, Ashleigh", title="The Online Health Information--Seeking Behaviors of People Who Have Experienced Stroke: Qualitative Interview Study", journal="JMIR Form Res", year="2024", month="Oct", day="18", volume="8", pages="e54827", keywords="stroke", keywords="online health information seeking", keywords="information-seeking behavior", keywords="consumer health information", keywords="digital health", keywords="eHealth", keywords="long-term care", keywords="health-risk behaviors", keywords="qualitative research", keywords="mobile phone", abstract="Background: Stroke is a leading cause of death and disability worldwide. As health resources become digitized, it is important to understand how people who have experienced stroke engage with online health information. This understanding will aid in guiding the development and dissemination of online resources to support people after stroke. Objective: This study aims to explore the online health information--seeking behaviors of people who have experienced stroke and any related barriers or navigational needs. Methods: Purposeful sampling was used to recruit participants via email between March and November 2022. The sampling was done from an existing cohort of Australian stroke survivors who had previously participated in a randomized controlled trial of an online secondary prevention program. The cohort consisted of people with low levels of disability. Semistructured one-on-one interviews were conducted via phone or video calls. These calls were audio recorded and transcribed verbatim. The data were analyzed by 2 independent coders using a combined inductive--deductive approach. In the deductive analysis, responses were mapped to an online health information--seeking behavior framework. Inductive thematic analysis was used to analyze the remaining raw data that did not fit within the deductive theoretical framework. Results: A sample of 15 relatively independent, high-functioning people who had experienced stroke from 4 Australian states, aged between 29 and 80 years, completed the interview. A broad range of online health information--seeking behaviors were identified, with most relating to participants wanting to be more informed about medical conditions and symptoms of their own or of a family member or a friend. Barriers included limited eHealth literacy and too much generalization of online information. Online resources were described to be more appealing and more accessible if they were high-quality, trustworthy, easy to use, and suggested by health care providers or trusted family members and friends. Across the interviews, there was an underlying theme of disconnection that appeared to impact not only the participants' online health information seeking, but their overall experience after stroke. These responses were grouped into 3 interrelated subthemes: disconnection from conventional stroke narratives and resources, disconnection from the continuing significance of stroke, and disconnection from long-term supports. Conclusions: People who have experienced stroke actively engage with the internet to search for health information with varying levels of confidence. The underlying theme of disconnection identified in the interviews highlights the need for a more comprehensive and sustained framework for support after stroke beyond the initial recovery phase. Future research should explore the development of tailored and relatable internet-based resources, improved communication and education about the diversity of stroke experiences and ongoing risks, and increased opportunities for long-term support. ", doi="10.2196/54827", url="https://formative.jmir.org/2024/1/e54827" } @Article{info:doi/10.2196/56980, author="Jeter, Russell and Greenfield, Raymond and Housley, N. Stephen and Belykh, Igor", title="Classifying Residual Stroke Severity Using Robotics-Assisted Stroke Rehabilitation: Machine Learning Approach", journal="JMIR Biomed Eng", year="2024", month="Oct", day="7", volume="9", pages="e56980", keywords="stroke", keywords="rehabilitation robotics", keywords="machine learning", keywords="artificial intelligence", keywords="physical therapy", keywords="neuroplasticity", abstract="Background: Stroke therapy is essential to reduce impairments and improve motor movements by engaging autogenous neuroplasticity. Traditionally, stroke rehabilitation occurs in inpatient and outpatient rehabilitation facilities. However, recent literature increasingly explores moving the recovery process into the home and integrating technology-based interventions. This study advances this goal by promoting in-home, autonomous recovery for patients who experienced a stroke through robotics-assisted rehabilitation and classifying stroke residual severity using machine learning methods. Objective: Our main objective is to use kinematics data collected during in-home, self-guided therapy sessions to develop supervised machine learning methods, to address a clinician's autonomous classification of stroke residual severity--labeled data toward improving in-home, robotics-assisted stroke rehabilitation. Methods: In total, 33 patients who experienced a stroke participated in in-home therapy sessions using Motus Nova robotics rehabilitation technology to capture upper and lower body motion. During each therapy session, the Motus Hand and Motus Foot devices collected movement data, assistance data, and activity-specific data. We then synthesized, processed, and summarized these data. Next, the therapy session data were paired with clinician-informed, discrete stroke residual severity labels: ``no range of motion (ROM),'' ``low ROM,'' and ``high ROM.'' Afterward, an 80\%:20\% split was performed to divide the dataset into a training set and a holdout test set. We used 4 machine learning algorithms to classify stroke residual severity: light gradient boosting (LGB), extra trees classifier, deep feed-forward neural network, and classical logistic regression. We selected models based on 10-fold cross-validation and measured their performance on a holdout test dataset using F1-score to identify which model maximizes stroke residual severity classification accuracy. Results: We demonstrated that the LGB method provides the most reliable autonomous detection of stroke severity. The trained model is a consensus model that consists of 139 decision trees with up to 115 leaves each. This LGB model boasts a 96.70\% F1-score compared to logistic regression (55.82\%), extra trees classifier (94.81\%), and deep feed-forward neural network (70.11\%). Conclusions: We showed how objectively measured rehabilitation training paired with machine learning methods can be used to identify the residual stroke severity class, with efforts to enhance in-home self-guided, individualized stroke rehabilitation. The model we trained relies only on session summary statistics, meaning it can potentially be integrated into similar settings for real-time classification, such as outpatient rehabilitation facilities. ", doi="10.2196/56980", url="https://biomedeng.jmir.org/2024/1/e56980", url="http://www.ncbi.nlm.nih.gov/pubmed/39374054" } @Article{info:doi/10.2196/60955, author="Eriksson, Gunilla and Kamwesiga, Tunga Julius and Fors, Uno and Oyana, Tonny and von Koch, Lena and Ytterberg, Charlotte and Guidetti, Susanne", title="Implementing and Evaluating a Mobile Phone--Supported and Family-Centered Rehabilitation Program for People With Stroke in Uganda (F@ce 2.0): Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2024", month="Sep", day="25", volume="13", pages="e60955", keywords="information and communication technology", keywords="ICT", keywords="mobile health", keywords="mHealth", keywords="telehealth", keywords="telemedicine", keywords="remote rehabilitation", keywords="activity of daily living", keywords="ADL", keywords="East Africa", keywords="sub-Saharan Africa", keywords="intervention", keywords="occupational therapy", keywords="physiotherapy", abstract="Background: Stroke is a global societal challenge. Annually, 13 million people experience stroke, and the prevalence of stroke is increasing in low-income countries; hence, accessible rehabilitation needs to be developed. Information and communication technology can help by providing access to rehabilitation support through information, self-evaluation, and self-management of rehabilitation. The F@ce 2.0 rehabilitation program provides support in goal-setting and problem-solving strategies through phone calls from the interventionist twice a week and daily SMS text message reminders over 8 weeks to improve performance in valued activities in everyday life. Our hypothesis is that F@ce 2.0 will increase functioning in daily activities and participation in everyday life as well as improve performance and satisfaction in valued daily activities and self-efficacy (ie, confidence in own ability to perform activities) among people living with the consequences of stroke. Objective: This study aims to implement F@ce 2.0, a mobile phone--supported and family-centered rehabilitation program, and evaluate its effects on performance in daily activities and participation in everyday life in comparison to ordinary rehabilitation among persons with stroke and their family members in Uganda. An additional aim is to explore experiences of participating in F@ce 2.0 and plausible mechanisms of impact that might explain the potential effects of F@ce 2.0. Methods: A randomized controlled trial will be conducted to compare the outcomes of the F@ce 2.0 group and a control group receiving ordinary rehabilitation. Health care professionals will recruit 90 clients from both urban and rural areas. The primary outcomes for persons with stroke are perceived performance in daily activities assessed using the Canadian Occupational Performance Measure and self-efficacy assessed using the Self-Efficacy Scale; for family members, the primary outcome is caregiver burden evaluated using the Caregiver Burden Scale. Descriptive statistics will be used to present characteristics and outcomes at 3 and 6 months. All statistical analyses comparing the outcomes at the different time points between the F@ce 2.0 and control groups will be performed using intention-to-treat analysis. Qualitative interviews will be used to explore the experiences of persons with stroke and their family members participating in F@ce 2.0, using a grounded theory approach to data collection and analysis. A process evaluation will be conducted using a single-case study design with mixed methods to explore the implementation process. Results: Recruitment and data collection in the randomized controlled trial were initiated in January 2022 and have been completed. The intervention has been provided to 51 participants in the intervention group. Interviews of persons with stroke, family members, and health care professionals have been conducted. Data analysis will be performed during autumn 2024 and spring 2025. Conclusions: This study will provide evidence of the plausible effects of F@ce 2.0 and the process of implementing the program in low-income countries. International Registered Report Identifier (IRRID): DERR1-10.2196/60955 ", doi="10.2196/60955", url="https://www.researchprotocols.org/2024/1/e60955" } @Article{info:doi/10.2196/59711, author="Wang, Zhaoxin and Yang, Wenwen and Li, Zhengyu and Rong, Ze and Wang, Xing and Han, Jincong and Ma, Lei", title="A 25-Year Retrospective of the Use of AI for Diagnosing Acute Stroke: Systematic Review", journal="J Med Internet Res", year="2024", month="Sep", day="10", volume="26", pages="e59711", keywords="acute stroke", keywords="artificial intelligence", keywords="AI", keywords="machine learning", keywords="deep learning", keywords="stroke lesion segmentation and classification", keywords="stroke prediction", keywords="stroke prognosis", abstract="Background: Stroke is a leading cause of death and disability worldwide. Rapid and accurate diagnosis is crucial for minimizing brain damage and optimizing treatment plans. Objective: This review aims to summarize the methods of artificial intelligence (AI)--assisted stroke diagnosis over the past 25 years, providing an overview of performance metrics and algorithm development trends. It also delves into existing issues and future prospects, intending to offer a comprehensive reference for clinical practice. Methods: A total of 50 representative articles published between 1999 and 2024 on using AI technology for stroke prevention and diagnosis were systematically selected and analyzed in detail. Results: AI-assisted stroke diagnosis has made significant advances in stroke lesion segmentation and classification, stroke risk prediction, and stroke prognosis. Before 2012, research mainly focused on segmentation using traditional thresholding and heuristic techniques. From 2012 to 2016, the focus shifted to machine learning (ML)--based approaches. After 2016, the emphasis moved to deep learning (DL), which brought significant improvements in accuracy. In stroke lesion segmentation and classification as well as stroke risk prediction, DL has shown superiority over ML. In stroke prognosis, both DL and ML have shown good performance. Conclusions: Over the past 25 years, AI technology has shown promising performance in stroke diagnosis. ", doi="10.2196/59711", url="https://www.jmir.org/2024/1/e59711" } @Article{info:doi/10.2196/55852, author="Pohl, Petra and Klerfors, Karoline and Kj{\"o}rk, K. Emma", title="Evaluation of a Digital Previsit Tool for Identifying Stroke-Related Health Problems Before a Follow-Up Visit (Part 1): Survey Study", journal="JMIR Hum Factors", year="2024", month="Sep", day="3", volume="11", pages="e55852", keywords="e-health", keywords="stroke", keywords="Strokeh{\"a}lsa", keywords="follow-up", keywords="previsit", keywords="person-centred care", keywords="health literacy", keywords="digital tool", keywords="shared decision-making", keywords="survey", keywords="mobile phone", abstract="Background: Stroke may lead to various disabilities, and a structured follow-up visit is strongly recommended within a few months after an event. To facilitate this visit, the digital previsit tool ``Strokehealth'' was developed for patients to fill out in advance. The concept Strokeh{\"a}lsa (or Strokehealth) was initially developed in-house as a Windows application, later incorporated in 1177.se. Objective: The study's primary objective was to use a patient satisfaction survey to evaluate the digital previsit tool Strokehealth when used before a follow-up visit, with a focus on feasibility and relevance from the perspective of people with stroke. Our secondary objective was to explore the extent to which the previsit tool identified stroke-related health problems. Methods: Between November 2020 and June 2021, a web-based survey was sent to patients who were scheduled for a follow-up visit after discharge from a stroke unit and had recently filled in the previsit tool. The survey covered demographic characteristics, internet habits, and satisfaction rated using 5 response options. Descriptive statistics were used to present data from both the previsit tool and the survey. We also compared the characteristics of those who completed the previsit tool and those who did not, using nonparametric statistics. Free-text responses were thematically analyzed. Results: All patients filling out the previsit tool (80/171; age: median 67, range 32-91 years) were community-dwelling. Most had experienced a mild stroke and reported a median of 2 stroke-related health problems (range 0-8), and they were significantly younger than nonresponders (P<.001). The survey evaluating the previsit tool was completed by 73\% (58/80; 39 men). The majority (48/58, 83\%) reported using the internet daily. Most respondents (56/58, 97\%) were either satisfied (n=15) or very satisfied (n=41) with how well the previsit tool captured their health problems. The highest level of dissatisfaction was related to the response options in Strokehealth (n=5). Based on the free-text answers to the survey, we developed 4 themes. First, Strokehealth was perceived to provide a structure that ensured that issues would be emphasized and considered. Second, user-friendliness and accessibility were viewed as acceptable, although respondents suggested improvements. Third, participants raised awareness about being approached digitally for communication and highlighted the importance of how to be approached. Fourth, their experiences with Strokehealth were influenced by their perceptions of the explanatory texts, the response options, and the possibility of elaborating on their answers in free text. Conclusions: People with stroke considered the freely available previsit tool Strokehealth feasible for preparing in advance for a follow-up visit. Despite high satisfaction with how well the tool captured their health problems, participants indicated that additional free-text responses and revised information could enhance usability. Improvements need to be considered in parallel with qualitative data to ensure that the tool meets patient needs. Trial Registration: Researchweb 275135; https://www.researchweb.org/is/vgr/project/275135 ", doi="10.2196/55852", url="https://humanfactors.jmir.org/2024/1/e55852" } @Article{info:doi/10.2196/58330, author="Sun, Jia and Ma, Liang and Miao, Xiao and Sun, Hui and Zhu, SuSu and Zhang, Ran and Fan, LeLe and Hu, TingTing", title="Current Status of Outcomes Reported by Patients With Stroke and an Analysis of Influencing Factors: Cross-Sectional Questionnaire Study", journal="JMIR Form Res", year="2024", month="Aug", day="26", volume="8", pages="e58330", keywords="stroke", keywords="patient-reported outcomes", keywords="blood lipids", keywords="influence factor", keywords="correlation analysis", keywords="nursing care", abstract="Background: Stroke is the leading cause of acquired disability and the second leading cause of death worldwide. Its rate of incidence, disability, mortality, and recurrence is high, and the patients experience various symptoms of discomfort, which not only affect their rehabilitation function but also reduce their ability to perform daily activities and their quality of life. Nowadays, with the improvement of China's medical standards, patients are increasingly attentive to their quality of life and health status. However, diagnostic techniques and effective treatments for patients with stroke are still limited but urgently required. Objective: This study aimed to evaluate the quality of life during hospitalization using a stroke patient-reported outcomes (PROs) scale and additionally to recognize potential factors and risk indicators that may impact recurrent events, facilitating early intervention measures. Methods: This is a registry-based, retrospective observational cross-sectional study on patients with stroke. A convenient sampling method was used to select various indicators of patients. The Stroke-PRO scale was then used to assess patients' conditions across physical, psychological, social, and therapeutic domains. Multiple linear regression analysis was applied to identify factors influencing stroke PROs, while correlation analysis was conducted to explore the relationship between these outcomes and blood lipid levels. Results: The mean Stroke-PRO score in this study was 4.09 (SD 0.29) points. By multiple linear regression analysis, residence, occupation, physical exercise, Barthel index, Braden scale, National Institutes of Health Stroke Scale scores at admission, and stroke type were the risk factors for reported outcomes of patients with stroke (P<.05). Correlation analysis showed that serum triglyceride, total cholesterol, and low-density lipoprotein were negatively correlated with Stroke-PRO scores in patients with stroke (P<.05), while high-density lipoprotein was positively correlated with patients with stroke (P<.05). The 95\% CI was --0.31 to --0.03 for triglyceride, 0.17-0.44 for high-density lipoprotein, --0.29 to --0.01 for cholesterol, --0.30 to --0.02 for low-density lipoprotein, and --0.12 to 0.16 for blood glucose. Conclusions: Patients with stroke have a low level of health, and their reported outcomes need to be improved. Accordingly, nursing staff should pay attention to the quality of life and blood lipid indexes of patients with stroke, actively assess their actual health status, and take early intervention measures to promote their recovery. ", doi="10.2196/58330", url="https://formative.jmir.org/2024/1/e58330" } @Article{info:doi/10.2196/54511, author="Niyomyart, Atsadaporn and Ruksakulpiwat, Suebsarn and Benjasirisan, Chitchanok and Phianhasin, Lalipat and Nigussie, Kabtamu and Thorngthip, Sutthinee and Shamita, Gazi and Thampakkul, Jai and Begashaw, Lidya", title="Current Status of Barriers to mHealth Access Among Patients With Stroke and Steps Toward the Digital Health Era: Systematic Review", journal="JMIR Mhealth Uhealth", year="2024", month="Aug", day="22", volume="12", pages="e54511", keywords="digital health", keywords="mHealth", keywords="barrier", keywords="stroke", keywords="systematic review", keywords="mobile phones", abstract="Background: Mobile health (mHealth) offers significant benefits for patients with stroke, facilitating remote monitoring and personalized health care solutions beyond traditional settings. However, there is a dearth of comprehensive data, particularly qualitative insights, on the barriers to mHealth access. Understanding these barriers is crucial for devising strategies to enhance mHealth use among patients with stroke. Objective: This study aims to examine the recent literature focusing on barriers to mHealth access among patients with stroke. Methods: A systematic search of PubMed, MEDLINE, Web of Science, and CINAHL Plus Full Text was conducted for literature published between 2017 and 2023. Abstracts and full texts were independently screened based on predetermined inclusion and exclusion criteria. Data synthesis was performed using the convergent integrated analysis framework recommended by the Joanna Briggs Institute. Results: A total of 12 studies met the inclusion criteria. The majority were qualitative studies (about 42\%), followed by mixed methods (25\%), pilot studies (about 17\%), nonrandomized controlled trials (about 8\%), and observational studies (about 8\%). Participants included patients with stroke, caregivers, and various health care professionals. The most common mHealth practices were home-based telerehabilitation (30\%) and poststroke mHealth and telecare services (20\%). Identified barriers were categorized into two primary themes: (1) at the patient level and (2) at the health provider-patient-device interaction level. The first theme includes 2 subthemes: health-related issues and patient acceptability. The second theme encompassed 3 subthemes: infrastructure challenges (including software, networking, and hardware), support system deficiencies, and time constraints. Conclusions: This systematic review underscores significant barriers to mHealth adoption among patients with stroke. Addressing these barriers in future research is imperative to ensure that mHealth solutions effectively meet patients' needs. ", doi="10.2196/54511", url="https://mhealth.jmir.org/2024/1/e54511" } @Article{info:doi/10.2196/54604, author="Silvera-Tawil, David and Cameron, Jan and Li, Jane and Varnfield, Marlien and Allan, P. Liam and Harris, Mitch and Lannin, A. Natasha and Redd, Christian and Cadilhac, A. Dominique", title="Multicomponent Support Program for Secondary Prevention of Stroke Using Digital Health Technology: Co-Design Study With People Living With Stroke or Transient Ischemic Attack", journal="J Med Internet Res", year="2024", month="Aug", day="22", volume="26", pages="e54604", keywords="mobile app", keywords="stroke", keywords="transient ischemic attack", keywords="health service delivery", keywords="mobile health", keywords="mHealth", keywords="mobile phone", abstract="Background: Few individuals (<2\%) who experience a stroke or transient ischemic attack (TIA) participate in secondary prevention lifestyle programs. Novel approaches that leverage digital health technology may provide a viable alternative to traditional interventions that support secondary prevention in people living with stroke or TIA. To be successful, these strategies should focus on user needs and preferences and be acceptable to clinicians and people living with stroke or TIA. Objective: This study aims to co-design, with people with lived experience of stroke or TIA (referred to as consumers) and clinicians, a multicomponent digital technology support program for secondary prevention of stroke. Methods: A consumer user needs survey (108 items) was distributed through the Australian Stroke Clinical Registry and the Stroke Association of Victoria. An invitation to a user needs survey (135 items) for clinicians was circulated via web-based professional forums and national organizations (eg, the Stroke Telehealth Community of Practice Microsoft Teams Channel) and the authors' research networks using Twitter (subsequently rebranded X, X Corp) and LinkedIn (LinkedIn Corp). Following the surveys, 2 rounds of user experience workshops (design and usability testing workshops) were completed with representatives from each end user group (consumers and clinicians). Feedback gathered after each round informed the final design of the digital health program. Results: Overall, 112 consumers (male individuals: n=63, 56.3\%) and 54 clinicians (female individuals: n=43, 80\%) responded to the survey; all items were completed by 75.8\% (n=85) of consumers and 78\% (n=42) of clinicians. Most clinicians (46/49, 94\%) indicated the importance of monitoring health and lifestyle measures more frequently than current practice, particularly physical activity, weight, and sleep. Most consumers (87/96, 90\%) and clinicians (41/49, 84\%) agreed that providing alerts about potential deterioration in an individual's condition were important functions for a digital program. Intention to use a digital program for stroke prevention and discussing the data collected during face-to-face consultations was high (consumers: 79/99, 80\%; clinicians 36/42, 86\%). In addition, 7 consumers (male individuals: n=5, 71\%) and 9 clinicians (female individuals: n=6, 67\%) took part in the user experience workshops. Participants endorsed using a digital health program to help consumers manage stroke or TIA and discussed preferred functions and health measures in a digital solution for secondary prevention of stroke. They also noted the need for a mobile app that is easy to use. Clinician feedback highlighted the need for a customizable clinician portal that captures individual consumer goals. Conclusions: Following an iterative co-design process, supported by evidence from user needs surveys and user experience workshops, a consumer-facing app that integrates wearable activity trackers and a clinician web portal were designed and developed to support secondary prevention of stroke. Feasibility testing is currently in progress to assess acceptability and use. ", doi="10.2196/54604", url="https://www.jmir.org/2024/1/e54604", url="http://www.ncbi.nlm.nih.gov/pubmed/39172512" } @Article{info:doi/10.2196/56189, author="Barcheus, Ida-Maria and Ranner, Maria and M{\aa}nsson Lexell, Eva and Jacobsson, Lars and Larsson-Lund, Maria", title="The Internet-Based Intervention Strategies for Empowering Activities in Everyday Life: Qualitative Study of Experiences of Clients With Stroke", journal="JMIR Form Res", year="2024", month="Aug", day="15", volume="8", pages="e56189", keywords="internet-based rehabilitation", keywords="occupational therapy intervention", keywords="rehabilitation", keywords="self-management", keywords="stroke", keywords="active everyday life", keywords="activity-based intervention", abstract="Background: There is a need to enhance access to and support for self-management of activities in everyday life after a stroke. Internet-based solutions have the potential to contribute to this development. Consequently, an internet-based intervention called Strategies for Empowering Activities in Everyday Life (SEE) was developed. The intervention aims to assist clients in developing management strategies that promote a healthy distribution and balanced engagement in various activities performed in different places and with other people.?To further support the development and feasibility of this intervention, more knowledge is needed about clients' experiences during the intervention process. Objective: This study aims to explore and describe how clients with stroke experienced the SEE intervention process and whether participation in SEE influenced their experience of everyday life. Methods: Overall, 9 clients with stroke who received SEE participated in the study---4 (44\%) women and 5 (56\%) men aged 37 to 73 years. Qualitative interviews about experiences with SEE were conducted twice during the intervention process with each participant. The data were analyzed using the constant comparative method of grounded theory. Results: The participants' experiences with the intervention process of SEE formed the core category, conceptualized as The relevance of and readiness for entering a change process in activities of everyday life differ among clients, constituting of two main categories: (1) an eye-opener providing agency for a change process and (2) never beginning a change process in activities in everyday life. The results showed that the relevance of and readiness for SEE differed between the participants. The experiences of 78\% (7/9) of the participants reflected that the intervention process provided them with an agency to drive their own change process for activities in everyday life to promote health. Overall, 22\% (2/9) of the participants refrained from entering a change process during SEE as they did not recognize any need for changes in their activities. When SEE was relevant and adopted as expected, the participants described it as an eye-opener for how they can alter their health based on how they distribute and spend their time on various activities. Conclusions: SEE has the potential to support clients' development of self-management and to take an active role in influencing their engagement in activities in everyday life and health. This study identified necessary improvements in the educational program for professionals to enhance delivery and strengthen the therapeutic mechanisms of SEE for future research. To effectively implement internet-based interventions such as SEE, it is crucial to identify clients who express a need for self-management in activities and are ready to invest the effort required to adopt a change process. Furthermore, it is indicated that participants'?self-analysis?of their everyday activities empowers them to adopt new?self-management strategies, which can also benefit other interventions. ", doi="10.2196/56189", url="https://formative.jmir.org/2024/1/e56189" } @Article{info:doi/10.2196/54009, author="Hassan, Ayman and Benlamri, Rachid and Diner, Trina and Cristofaro, Keli and Dillistone, Lucas and Khallouki, Hajar and Ahghari, Mahvareh and Littlefield, Shalyn and Siddiqui, Rabail and MacDonald, Russell and Savage, W. David", title="An App for Navigating Patient Transportation and Acute Stroke Care in Northwestern Ontario Using Machine Learning: Retrospective Study", journal="JMIR Form Res", year="2024", month="Aug", day="1", volume="8", pages="e54009", keywords="stroke care", keywords="acute stroke", keywords="northwestern", keywords="Ontario", keywords="prediction", keywords="models", keywords="machine learning", keywords="stroke", keywords="cardiovascular", keywords="brain", keywords="neuroscience", keywords="TIA", keywords="transient ischemic attack", keywords="coordinated care", keywords="navigation", keywords="navigating", keywords="mHealth", keywords="mobile health", keywords="app", keywords="apps", keywords="applications", keywords="geomapping", keywords="geography", keywords="geographical", keywords="location", keywords="spatial", keywords="predict", keywords="predictions", keywords="predictive", abstract="Background: A coordinated care system helps provide timely access to treatment for suspected acute stroke. In Northwestern Ontario (NWO), Canada, communities are widespread with several hospitals offering various diagnostic equipment and services. Thus, resources are limited, and health care providers must often transfer patients with stroke to different hospital locations to ensure the most appropriate care access within recommended time frames. However, health care providers frequently situated temporarily (locum) in NWO or providing care remotely from other areas of Ontario may lack sufficient information and experience in the region to access care for a patient with a time-sensitive condition. Suboptimal decision-making may lead to multiple transfers before definitive stroke care is obtained, resulting in poor outcomes and additional health care system costs. Objective: We aimed to develop a tool to inform and assist NWO health care providers in determining the best transfer options for patients with stroke to provide the most efficient care access. We aimed to develop an app using a comprehensive geomapping navigation and estimation system based on machine learning algorithms. This app uses key stroke-related timelines including the last time the patient was known to be well, patient location, treatment options, and imaging availability at different health care facilities. Methods: Using historical data (2008-2020), an accurate prediction model using machine learning methods was developed and incorporated into a mobile app. These data contained parameters regarding air (Ornge) and land medical transport (3 services), which were preprocessed and cleaned. For cases in which Ornge air services and land ambulance medical transport were both involved in a patient transport process, data were merged and time intervals of the transport journey were determined. The data were distributed for training (35\%), testing (35\%), and validation (30\%) of the prediction model. Results: In total, 70,623 records were collected in the data set from Ornge and land medical transport services to develop a prediction model. Various learning models were analyzed; all learning models perform better than the simple average of all points in predicting output variables. The decision tree model provided more accurate results than the other models. The decision tree model performed remarkably well, with the values from testing, validation, and the model within a close range. This model was used to develop the ``NWO Navigate Stroke'' system. The system provides accurate results and demonstrates that a mobile app can be a significant tool for health care providers navigating stroke care in NWO, potentially impacting patient care and outcomes. Conclusions: The NWO Navigate Stroke system uses a data-driven, reliable, accurate prediction model while considering all variations and is simultaneously linked to all required acute stroke management pathways and tools. It was tested using historical data, and the next step will to involve usability testing with end users. ", doi="10.2196/54009", url="https://formative.jmir.org/2024/1/e54009" } @Article{info:doi/10.2196/56996, author="Elf, Marie and Norin, Lizette and Meijering, Louise and Pessah-Rasmussen, H{\'e}l{\`e}ne and Suhonen, Riitta and Zingmark, Magnus and Kyl{\'e}n, Maya", title="Rehabilitation at Home With the Development of a Sustainable Model Placing the Person's Needs and Environment at Heart: Protocol for a Multimethod Project", journal="JMIR Res Protoc", year="2024", month="Jul", day="23", volume="13", pages="e56996", keywords="co-design", keywords="early supported discharge", keywords="home", keywords="integrated care", keywords="life space mobility", keywords="multi-methods", keywords="physical environment", keywords="person-centered care", keywords="social environment", keywords="stroke rehabilitation", abstract="Background: Each year, more than 1.5 million people in Europe have a stroke, and many experience disabilities leading to activity and participation restrictions. Home-based rehabilitation is the recommended approach for stroke rehabilitation, in line with the international shift to integrated care. Despite this, rehabilitation often focuses on the person's physical functions, not the whole life situation and opportunities to live an active life. Given that rehabilitation today is often provided in the person's home, there is a need to develop new models that consider the rehabilitation process as situated in the everyday living environment of persons with stroke. This project is grounded in experiences from our ongoing research, where we study the importance of the home environment for health and participation among persons with stroke, rehabilitated at home. This research has shown unmet needs, which lead to suboptimal rehabilitation outcomes. There is a need for studies on how to use environmental resources to optimize stroke rehabilitation in the home setting. Objective: The overarching objective of the project is to develop a new practice model for rehabilitation where the needs of the person are the starting point and where the environment is considered. Methods: The project will be conducted in partnership with persons with stroke, significant others, health care professionals, and care managers. Results from a literature review will form the base for interviews with the stakeholders, followed by co-designing workshops aiming to create a new practice model. Focus groups will be held to refine the outcome of the workshops to a practice model. Results: This 4-year project commenced in January 2023 and will continue until December 2026. The results of the literature review are, as of April 2024, currently being analyzed. The ethics application for the interviews and co-design phase was approved in October 2023 and data collection is ongoing during spring 2024. We aim to develop a practice model with stakeholders and refine it together with care managers and decision makers. The outcome is a new practice model and implementation plan, which will be achieved in autumn 2026. Conclusions: The project contributes with a prominent missing puzzle to optimize the rehabilitation process by adding a strong focus on user engagement combined with integrating different aspects of the environment. The goal is to improve quality of life and increase reintegration in society for the large group of people living with the aftermath of a stroke. By co-designing with multiple stakeholders, we expect the model to be feasible and sustainable. The knowledge from the project will also contribute to an increased awareness of the importance of the physical environment for sustainable health care. The findings will lay the foundation for future upscaling initiatives. International Registered Report Identifier (IRRID): DERR1-10.2196/56996 ", doi="10.2196/56996", url="https://www.researchprotocols.org/2024/1/e56996" } @Article{info:doi/10.2196/59781, author="Sauerzopf, Lena and Luft, Andreas and Maeusli, Valeria and Klamroth-Marganska, Verena and Sy, Michael and Spiess, Rebekka Martina", title="Technology Use for Home-Based Stroke Rehabilitation in Switzerland From the Perspectives of Persons Living With Stroke, Informal Caregivers, and Therapists: Qualitative Interview and Focus Group Study", journal="JMIR Rehabil Assist Technol", year="2024", month="Jul", day="18", volume="11", pages="e59781", keywords="home-based therapy", keywords="technology-based tools", keywords="app", keywords="stroke", keywords="outpatient rehabilitation", keywords="occupational therapy", keywords="physiotherapy", keywords="mobile phone", abstract="Background: Stroke is a leading cause for long-term disability, requiring both inpatient and outpatient rehabilitation and self-training in the home environment. Technology-based tools are gradually gaining acceptance as additional and suitable options for extending the rehabilitation process. While the experiences of persons living with stroke, therapists, and informal caregivers with respect to technology use have already been investigated in other countries, this topic is underexplored in the Swiss context. Objective: We aimed to explore the experiences and needs of persons living with stroke, informal caregivers, and therapists in using technology-based tools in a home environment for stroke rehabilitation in Switzerland. Methods: This study followed a qualitative descriptive methodology, including semistructured interviews and focus group discussions. We applied a deductive template analysis alongside the accessibility, adaptability, accountability, and engagement framework to analyze the qualitative data sets for technology-assisted solutions for poststroke rehabilitation. Results: We collected the experiences and needs of persons living with stroke (7/23, 30\%), informal caregivers (4/23, 17\%), and therapists (occupational and physical therapists; 12/23, 52\%). The 4 categories we used to organize the analysis and results were accessibility to quality rehabilitation, adaptability to patient differences, accountability or compliance with rehabilitation, and engagement with rehabilitation. Persons living with stroke stated that they use various tools within their rehabilitation process depending on their specific needs. They felt that there is a plethora of tools available but sometimes felt overwhelmed with the selection process. Informal caregivers indicated that they generally felt underserved and insufficiently informed throughout the rehabilitation process. They reported that they use technology-based tools to support their relatives affected by stroke in becoming more independent. Therapists appreciate the numerous possible applications of technology-based tools in rehabilitation. At the same time, however, they express dissatisfaction with the lack of clarity in Switzerland regarding cost coverage, recommendations, and training opportunities. Conclusions: Persons living with stroke, informal caregivers, and therapists in Switzerland reported varied and unique experiences and needs with the use of technology-based tools in outpatient stroke rehabilitation. Written recommendations, the assumption of financial costs, and the provision of information and education could foster increased confidence in the use of technology-based tools for patients and therapists. ", doi="10.2196/59781", url="https://rehab.jmir.org/2024/1/e59781" } @Article{info:doi/10.2196/49530, author="Liang, Huey-Wen and Wu, Chueh-Hung and Lin, Chen and Chang, Hsiang-Chih and Lin, Yu-Hsuan and Chen, Shao-Yu and Hsu, Wei-Chen", title="Rest-Activity Rhythm Differences in Acute Rehabilitation Between Poststroke Patients and Non--Brain Disease Controls: Comparative Study", journal="J Med Internet Res", year="2024", month="Jul", day="4", volume="26", pages="e49530", keywords="circadian rhythms", keywords="stroke rehabilitation, rest-activity rhythms, relative amplitude, delirium screening, interdaily stability", abstract="Background: Circadian rhythm disruptions are a common concern for poststroke patients undergoing rehabilitation and might negatively impact their functional outcomes. Objective: Our research aimed to uncover unique patterns and disruptions specific to poststroke rehabilitation patients and identify potential differences in specific rest-activity rhythm indicators when compared to inpatient controls with non--brain-related lesions, such as patients with spinal cord injuries. Methods: We obtained a 7-day recording with a wearable actigraphy device from 25 poststroke patients (n=9, 36\% women; median age 56, IQR 46-71) and 25 age- and gender-matched inpatient control participants (n=15, 60\% women; median age 57, IQR 46.5-68.5). To assess circadian rhythm, we used a nonparametric method to calculate key rest-activity rhythm indicators---relative amplitude, interdaily stability, and intradaily variability. Relative amplitude, quantifying rest-activity rhythm amplitude while considering daily variations and unbalanced amplitudes, was calculated as the ratio of the difference between the most active 10 continuous hours and the least active 5 continuous hours to the sum of these 10 and 5 continuous hours. We also examined the clinical correlations between rest-activity rhythm indicators and delirium screening tools, such as the 4 A's Test and the Barthel Index, which assess delirium and activities of daily living. Results: Patients who had a stroke had higher least active 5-hour values compared to the control group (median 4.29, IQR 2.88-6.49 vs median 1.84, IQR 0.67-4.34; P=.008). The most active 10-hour values showed no significant differences between the groups (stroke group: median 38.92, IQR 14.60-40.87; control group: median 31.18, IQR 18.02-46.84; P=.93). The stroke group presented a lower relative amplitude compared to the control group (median 0.74, IQR 0.57-0.85 vs median 0.88, IQR 0.71-0.96; P=.009). Further analysis revealed no significant differences in other rest-activity rhythm metrics between the two groups. Among the patients who had a stroke, a negative correlation was observed between the 4 A's Test scores and relative amplitude ($\rho$=--0.41; P=.045). Across all participants, positive correlations emerged between the Barthel Index scores and both interdaily stability ($\rho$=0.34; P=.02) and the most active 10-hour value ($\rho$=0.42; P=.002). Conclusions: This study highlights the relevance of circadian rhythm disruptions in poststroke rehabilitation and provides insights into potential diagnostic and prognostic implications for rest-activity rhythm indicators as digital biomarkers. ", doi="10.2196/49530", url="https://www.jmir.org/2024/1/e49530" } @Article{info:doi/10.2196/54159, author="Wodu, Obinuchi Chioma and Sweeney, Gillian and Slachetka, Milena and Kerr, Andrew", title="Stroke Survivors' Interaction With Hand Rehabilitation Devices: Observational Study", journal="JMIR Biomed Eng", year="2024", month="Jun", day="26", volume="9", pages="e54159", keywords="stroke", keywords="rehabilitation", keywords="hand rehabilitation devices", keywords="accessibility", keywords="stroke survivors", keywords="rehabilitation technologies", abstract="Background: The hand is crucial for carrying out activities of daily living as well as social interaction. Functional use of the upper limb is affected in up to 55\% to 75\% of stroke survivors 3 to 6 months after stroke. Rehabilitation can help restore function, and several rehabilitation devices have been designed to improve hand function. However, access to these devices is compromised in people with more severe loss of function. Objective: In this study, we aimed to observe stroke survivors with poor hand function interacting with a range of commonly used hand rehabilitation devices. Methods: Participants were engaged in an 8-week rehabilitation intervention at a technology-enriched rehabilitation gym. The participants spent 50-60 minutes of the 2-hour session in the upper limb section at least twice a week. Each participant communicated their rehabilitation goals, and an Action Research Arm Test (ARAT) was used to measure and categorize hand function as poor (scores of 0-9), moderate (scores of 10-56), or good (score of 57). Participants were observed during their interactions with 3 hand-based rehabilitation devices that focused on hand rehabilitation: the GripAble, NeuroBall, and Semi-Circular Peg Board. Observations of device interactions were recorded for each session. Results: A total of 29 participants were included in this study, of whom 10 (34\%) had poor hand function, 17 (59\%) had moderate hand function, and 2 (7\%) had good hand function. There were no differences in the age and years after stroke among participants with poor hand function and those with moderate (P=.06 and P=.09, respectively) and good (P=.37 and P=.99, respectively) hand function. Regarding the ability of the 10 participants with poor hand function to interact with the 3 hand-based rehabilitation devices, 2 (20\%) participants with an ARAT score greater than 0 were able to interact with the devices, whereas the other 8 (80\%) who had an ARAT score of 0 could not. Their inability to interact with these devices was clinically examined, and the reason was determined to be a result of either the presence of (1) muscle tone or stiffness or (2) muscle weakness. Conclusions: Not all stroke survivors with impairments in their hands can make use of currently available rehabilitation technologies. Those with an ARAT score of 0 cannot actively interact with hand rehabilitation devices, as they cannot carry out the hand movement necessary for such interaction. The design of devices for hand rehabilitation should consider the accessibility needs of those with poor hand function. ", doi="10.2196/54159", url="https://biomedeng.jmir.org/2024/1/e54159", url="http://www.ncbi.nlm.nih.gov/pubmed/38922668" } @Article{info:doi/10.2196/53807, author="Xu, Stanley and Sy, S. Lina and Hong, Vennis and Holmquist, J. Kimberly and Qian, Lei and Farrington, Paddy and Bruxvoort, J. Katia and Klein, P. Nicola and Fireman, Bruce and Han, Bing and Lewin, J. Bruno", title="Ischemic Stroke After Bivalent COVID-19 Vaccination: Self-Controlled Case Series Study", journal="JMIR Public Health Surveill", year="2024", month="Jun", day="25", volume="10", pages="e53807", keywords="ischemic stroke", keywords="bivalent COVID-19 vaccine", keywords="influenza vaccine", keywords="self-controlled case series", keywords="coadministration", keywords="ischemic", keywords="stroke", keywords="TIA", keywords="transient ischemic attack", keywords="ischemia", keywords="cardiovascular", keywords="COVID-19", keywords="SARS-CoV-2", keywords="vaccine", keywords="vaccines", keywords="vaccination", keywords="association", keywords="correlation", keywords="risk", keywords="risks", keywords="adverse", keywords="side effect", keywords="subgroup analyses", keywords="subgroup analysis", keywords="bivalent", keywords="influenza", keywords="infectious", keywords="respiratory", keywords="incidence", keywords="case series", abstract="Background: The potential association between bivalent COVID-19 vaccination and ischemic stroke remains uncertain, despite several studies conducted thus far. Objective: This study aimed to evaluate the risk of ischemic stroke following bivalent COVID-19 vaccination during the 2022-2023 season. Methods: A self-controlled case series study was conducted among members aged 12 years and older who experienced ischemic stroke between September 1, 2022, and March 31, 2023, in a large health care system. Ischemic strokes were identified using International Classification of Diseases, Tenth Revision codes in emergency departments and inpatient settings. Exposures were Pfizer-BioNTech or Moderna bivalent COVID-19 vaccination. Risk intervals were prespecified as 1-21 days and 1-42 days after bivalent vaccination; all non--risk-interval person-time served as the control interval. The incidence of ischemic stroke was compared in the risk interval and control interval using conditional Poisson regression. We conducted overall and subgroup analyses by age, history of SARS-CoV-2 infection, and coadministration of influenza vaccine. When an elevated risk was detected, we performed a chart review of ischemic strokes and analyzed the risk of chart-confirmed ischemic stroke. Results: With 4933 ischemic stroke events, we found no increased risk within the 21-day risk interval for the 2 vaccines and by subgroups. However, risk of ischemic stroke was elevated within the 42-day risk interval among individuals aged younger than 65 years with coadministration of Pfizer-BioNTech bivalent and influenza vaccines on the same day; the relative incidence (RI) was 2.13 (95\% CI 1.01-4.46). Among those who also had a history of SARS-CoV-2 infection, the RI was 3.94 (95\% CI 1.10-14.16). After chart review, the RIs were 2.34 (95\% CI 0.97-5.65) and 4.27 (95\% CI 0.97-18.85), respectively. Among individuals aged younger than 65 years who received Moderna bivalent vaccine and had a history of SARS-CoV-2 infection, the RI was 2.62 (95\% CI 1.13-6.03) before chart review and 2.24 (95\% CI 0.78-6.47) after chart review. Stratified analyses by sex did not show a significantly increased risk of ischemic stroke after bivalent vaccination. Conclusions: While the point estimate for the risk of chart-confirmed ischemic stroke was elevated in a risk interval of 1-42 days among individuals younger than 65 years with coadministration of Pfizer-BioNTech bivalent and influenza vaccines on the same day and among individuals younger than 65 years who received Moderna bivalent vaccine and had a history of SARS-CoV-2 infection, the risk was not statistically significant. The potential association between bivalent vaccination and ischemic stroke in the 1-42--day analysis warrants further investigation among individuals younger than 65 years with influenza vaccine coadministration and prior SARS-CoV-2 infection. Furthermore, the findings on ischemic stroke risk after bivalent COVID-19 vaccination underscore the need to evaluate monovalent COVID-19 vaccine safety during the 2023-2024 season. ", doi="10.2196/53807", url="https://publichealth.jmir.org/2024/1/e53807", url="http://www.ncbi.nlm.nih.gov/pubmed/38916940" } @Article{info:doi/10.2196/56357, author="Chien, Shih-Ying and Wong, MK Alice and Wu, Ching-Yi and Beckman, L. Sara", title="Interactive Electronic Pegboard for Enhancing Manual Dexterity and Cognitive Abilities: Instrument Usability Study", journal="JMIR Hum Factors", year="2024", month="Jun", day="21", volume="11", pages="e56357", keywords="interactive electronic pegboard", keywords="stroke", keywords="hand dexterity", keywords="cognitive rehabilitation", keywords="system", abstract="Background: Strokes pose a substantial health burden, impacting 1 in 6 people globally. One-tenth of patients will endure a second, often more severe, stroke within a year. Alarmingly, a younger demographic is being affected due to recent lifestyle changes. As fine motor and cognitive issues arise, patient disability as well as the strain on caregivers and health care resources is exacerbated. Contemporary occupational therapy assesses manual dexterity and cognitive functions through object manipulation and pen-and-paper recordings. However, these assessments are typically isolated, which makes it challenging for therapists to comprehensively evaluate specific patient conditions. Furthermore, the reliance on one-on-one training and assessment approaches on manual documentation is inefficient and prone to transcription errors. Objective: This study examines the feasibility of using an interactive electronic pegboard for stroke rehabilitation in clinical settings. Methods: A total of 10 patients with a history of stroke and 10 healthy older individuals were recruited. With a limit of 10 minutes, both groups of participants underwent a series of challenges involving tasks related to manual operation, shape recognition, and color discrimination. All participants underwent the Box and Block Test and the Purdue Pegboard Test to assess manual dexterity, as well as an array of cognitive assessments, including the Trail Making Test and the Mini-Mental Status Examination, which served as a basis to quantify participants' attention, executive functioning, and cognitive abilities. Results: The findings validate the potential application of an interactive electronic pegboard for stroke rehabilitation in clinical contexts. Significant statistical differences (P<.01) were observed across all assessed variables, including age, Box and Block Test results, Purdue Pegboard Test outcomes, Trail Making Test-A scores, and Mini-Mental Status Examination performance, between patients with a history of stroke and their healthy older counterparts. Functional and task testing, along with questionnaire interviews, revealed that patients with a history of stroke demonstrated prolonged completion times and slightly inferior performance. Nonetheless, most patients perceived the prototype as user-friendly and engaging. Thus, in the context of patient rehabilitation interventions or the evaluation of patient cognition, physical functioning, or manual dexterity assessments, the developed pegboard could potentially serve as a valuable tool for hand function, attention, and cognitive rehabilitation, thereby mitigating the burden on health care professionals. Conclusions: Health care professionals can use digital electronic pegboards not only as a precise one-on-one training tool but also as a flexible system that can be configured for online or offline, single-player or multiplayer use. Through data analysis, a more informed examination of patients' cognitive and functional issues can be conducted. Importantly, patient records will be fully retained throughout practices, exercises, or tests, and by leveraging the characteristics of big data, patients can receive the most accurate rehabilitation prescriptions, thereby assisting them in obtaining optimal care. ", doi="10.2196/56357", url="https://humanfactors.jmir.org/2024/1/e56357", url="http://www.ncbi.nlm.nih.gov/pubmed/38904991" } @Article{info:doi/10.2196/51546, author="Mizuno, Emi and Ogasawara, Takayuki and Mukaino, Masahiko and Yamaguchi, Masumi and Tsukada, Shingo and Sonoda, Shigeru and Otaka, Yohei", title="Highlighting Unseen Activity Through 48-Hour Continuous Measurement in Subacute Stroke Rehabilitation: Preliminary Cohort Study", journal="JMIR Form Res", year="2024", month="May", day="29", volume="8", pages="e51546", keywords="activity monitoring", keywords="smart clothing system", keywords="stroke", keywords="unseen", keywords="monitoring", keywords="recovery", keywords="physical condition", keywords="deconditioning", keywords="muscle wasting", keywords="wearable technology", keywords="wearable", keywords="activity level", keywords="rehabilitation", keywords="physical therapy", keywords="heart rate", keywords="ADL", keywords="activities of daily living", keywords="training", keywords="older people", keywords="mobile phone", abstract="Background: Motor impairments not only lead to a significant reduction in patient activity levels but also trigger a further deterioration in motor function due to deconditioning, which is an issue that is particularly pronounced during hospitalization. This deconditioning can be countered by sustaining appropriate activity levels. Activities that occur outside of scheduled programs, often overlooked, are critical in this context. Wearable technology, such as smart clothing, provides a means to monitor these activities. Objective: This study aimed to observe activity levels in patients who had strokes during the subacute phase, focusing on both scheduled training sessions and other nontraining times in an inpatient rehabilitation environment. A smart clothing system is used to simultaneously measure heart rate and acceleration, offering insights into both the amount and intensity of the physical activity. Methods: In this preliminary cohort study, 11 individuals undergoing subacute stroke rehabilitation were enrolled. The 48-hour continuous measurement system, deployed at admission and reassessed 4 weeks later, monitored accelerometry data for physical activity (quantified with a moving SD of acceleration [MSDA]) and heart rate for intensity (quantified with percent heart rate reserve). The measurements were performed using a wearable activity monitoring system, the hitoe (NTT Corporation and Toray Industries, Inc) system comprising a measuring garment (wear or strap) with integrated electrodes, a data transmitter, and a smartphone. The Functional Independence Measure was used to assess the patients' daily activity levels. This study explored factors such as differences in activity during training and nontraining periods, correlations with activities of daily living (ADLs) and age, and changes observed after 4 weeks. Results: A significant increase was found in the daily total MSDA after the 4-week program, with the average percent heart rate reserve remaining consistent. Physical activity during training positively correlated with ADL levels both at admission ($\rho$=0.86, P<.001) and 4 weeks post admission ($\rho$=0.96, P<.001), whereas the correlation between age and MSDA was not significant during training periods at admission ($\rho$=--0.41, P=.21) or 4 weeks post admission ($\rho$=--0.25, P=.45). Conversely, nontraining activity showed a negative correlation with age, with significant negative correlations with age at admission ($\rho$=--0.82, P=.002) and 4 weeks post admission ($\rho$=--0.73, P=.01). Conclusions: Inpatient rehabilitation activity levels were positively correlated with ADL levels. Further analysis revealed a strong positive correlation between scheduled training activities and ADL levels, whereas nontraining activities showed no such correlation. Instead, a negative correlation between nontraining activities and age was observed. These observations suggest the importance of providing activity opportunities for older patients, while it may also suggest the need for adjusting the activity amount to accommodate the potentially limited fitness levels of this demographic. Future studies with larger patient groups are warranted to validate and further elucidate these findings. ", doi="10.2196/51546", url="https://formative.jmir.org/2024/1/e51546", url="http://www.ncbi.nlm.nih.gov/pubmed/38809596" } @Article{info:doi/10.2196/54699, author="Rony, Jahangir Rahat and Amir, Shajnush and Ahmed, Nova and Atiba, Samuelson and Verdezoto, Nervo and Sparkes, Valerie and Stawarz, Katarzyna", title="Understanding the Sociocultural Challenges and Opportunities for Affordable Wearables to Support Poststroke Upper-Limb Rehabilitation: Qualitative Study", journal="JMIR Rehabil Assist Technol", year="2024", month="May", day="28", volume="11", pages="e54699", keywords="rehabilitation", keywords="wearables", keywords="upper-limb rehabilitation", keywords="user-centered design", keywords="qualitative", keywords="interviews", keywords="experiences", keywords="attitudes", keywords="perceptions", keywords="digital health", keywords="health technology", keywords="wearable", keywords="user centered design", keywords="design", keywords="home", keywords="stroke", keywords="recovery", keywords="affordable", keywords="low income", keywords="low resource", keywords="Bangladesh", keywords="physiotherapy", abstract="Background: People who survive a stroke in many cases require upper-limb rehabilitation (ULR), which plays a vital role in stroke recovery practices. However, rehabilitation services in the Global South are often not affordable or easily accessible. For example, in Bangladesh, the access to and use of rehabilitation services is limited and influenced by cultural factors and patients' everyday lives. In addition, while wearable devices have been used to enhance ULR exercises to support self-directed home-based rehabilitation, this has primarily been applied in developed regions and is not common in many Global South countries due to potential costs and limited access to technology. Objective: Our goal was to better understand physiotherapists', patients', and caregivers' experiences of rehabilitation in Bangladesh, existing rehabilitation practices, and how they differ from the rehabilitation approach in the United Kingdom. Understanding these differences and experiences would help to identify opportunities and requirements for developing affordable wearable devices that could support ULR in home settings. Methods: We conducted an exploratory study with 14 participants representing key stakeholder groups. We interviewed physiotherapists and patients in Bangladesh to understand their approaches, rehabilitation experiences and challenges, and technology use in this context. We also interviewed UK physiotherapists to explore the similarities and differences between the 2 countries and identify specific contextual and design requirements for low-cost wearables for ULR. Overall, we remotely interviewed 8 physiotherapists (4 in the United Kingdom, 4 in Bangladesh), 3 ULR patients in Bangladesh, and 3 caregivers in Bangladesh. Participants were recruited through formal communications and personal contacts. Each interview was conducted via videoconference, except for 2 interviews, and audio was recorded with consent. A total of 10 hours of discussions were transcribed. The results were analyzed using thematic analysis. Results: We identified several sociocultural factors that affect ULR and should be taken into account when developing technologies for the home: the important role of family, who may influence the treatment based on social and cultural perceptions; the impact of gender norms and their influence on attitudes toward rehabilitation and physiotherapists; and differences in approach to rehabilitation between the United Kingdom and Bangladesh, with Bangladeshi physiotherapists focusing on individual movements that are necessary to build strength in the affected parts and their British counterparts favoring a more holistic approach. We propose practical considerations and design recommendations for developing ULR devices for low-resource settings. Conclusions: Our work shows that while it is possible to build a low-cost wearable device, the difficulty lies in addressing sociotechnical challenges. When developing new health technologies, it is imperative to not only understand how well they could fit into patients', caregivers', and physiotherapists' everyday lives, but also how they may influence any potential tensions concerning culture, religion, and the characteristics of the local health care system. ", doi="10.2196/54699", url="https://rehab.jmir.org/2024/1/e54699" } @Article{info:doi/10.2196/56884, author="Bui, Thu Huong Thi and Nguy?n Th? Ph??ng, Qu?nh and Cam Tu, Ho and Nguyen Phuong, Sinh and Pham, Thi Thuy and Vu, Thu and Nguyen Thi Thu, Huyen and Khanh Ho, Lam and Nguyen Tien, Dung", title="The Roles of NOTCH3 p.R544C and Thrombophilia Genes in Vietnamese Patients With Ischemic Stroke: Study Involving a Hierarchical Cluster Analysis", journal="JMIR Bioinform Biotech", year="2024", month="May", day="7", volume="5", pages="e56884", keywords="Glasgow Coma Scale", keywords="ischemic stroke", keywords="hierarchical cluster analysis", keywords="clustering", keywords="machine learning", keywords="MTHFR", keywords="NOTCH3", keywords="modified Rankin scale", keywords="National Institutes of Health Stroke Scale", keywords="prothrombin", keywords="thrombophilia", keywords="mutations", keywords="genetics", keywords="genomics", keywords="ischemia", keywords="risk", keywords="risk analysis", abstract="Background: The etiology of ischemic stroke is multifactorial. Several gene mutations have been identified as leading causes of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), a hereditary disease that causes stroke and other neurological symptoms. Objective: We aimed to identify the variants of NOTCH3 and thrombophilia genes, and their complex interactions with other factors. Methods: We conducted a hierarchical cluster analysis (HCA) on the data of 100 patients diagnosed with ischemic stroke. The variants of NOTCH3 and thrombophilia genes were identified by polymerase chain reaction with confronting 2-pair primers and real-time polymerase chain reaction. The overall preclinical characteristics, cumulative cutpoint values, and factors associated with these somatic mutations were analyzed in unidimensional and multidimensional scaling models. Results: We identified the following optimal cutpoints: creatinine, 83.67 (SD 9.19) {\textmu}mol/L; age, 54 (SD 5) years; prothrombin (PT) time, 13.25 (SD 0.17) seconds; and international normalized ratio (INR), 1.02 (SD 0.03). Using the Nagelkerke method, cutpoint 50\% values of the Glasgow Coma Scale score; modified Rankin scale score; and National Institutes of Health Stroke Scale scores at admission, after 24 hours, and at discharge were 12.77, 2.86 (SD 1.21), 9.83 (SD 2.85), 7.29 (SD 2.04), and 6.85 (SD 2.90), respectively. Conclusions: The variants of MTHFR (C677T and A1298C) and NOTCH3 p.R544C may influence the stroke severity under specific conditions of PT, creatinine, INR, and BMI, with risk ratios of 4.8 (95\% CI 1.53-15.04) and 3.13 (95\% CI 1.60-6.11), respectively (Pfisher<.05). It is interesting that although there are many genes linked to increased atrial fibrillation risk, not all of them are associated with ischemic stroke risk. With the detection of stroke risk loci, more information can be gained on their impacts and interconnections, especially in young patients. ", doi="10.2196/56884", url="https://bioinform.jmir.org/2024/1/e56884", url="http://www.ncbi.nlm.nih.gov/pubmed/38935968" } @Article{info:doi/10.2196/51526, author="Ruksakulpiwat, Suebsarn and Phianhasin, Lalipat and Benjasirisan, Chitchanok and Ding, Kedong and Ajibade, Anuoluwapo and Kumar, Ayanesh and Stewart, Cassie", title="Assessing the Efficacy of ChatGPT Versus Human Researchers in Identifying Relevant Studies on mHealth Interventions for Improving Medication Adherence in Patients With Ischemic Stroke When Conducting Systematic Reviews: Comparative Analysis", journal="JMIR Mhealth Uhealth", year="2024", month="May", day="6", volume="12", pages="e51526", keywords="ChatGPT", keywords="systematic reviews", keywords="medication adherence", keywords="mobile health", keywords="mHealth", keywords="ischemic stroke", keywords="mobile phone", abstract="Background: ChatGPT by OpenAI emerged as a potential tool for researchers, aiding in various aspects of research. One such application was the identification of relevant studies in systematic reviews. However, a comprehensive comparison of the efficacy of relevant study identification between human researchers and ChatGPT has not been conducted. Objective: This study aims to compare the efficacy of ChatGPT and human researchers in identifying relevant studies on medication adherence improvement using mobile health interventions in patients with ischemic stroke during systematic reviews. Methods: This study used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Four electronic databases, including CINAHL Plus with Full Text, Web of Science, PubMed, and MEDLINE, were searched to identify articles published from inception until 2023 using search terms based on MeSH (Medical Subject Headings) terms generated by human researchers versus ChatGPT. The authors independently screened the titles, abstracts, and full text of the studies identified through separate searches conducted by human researchers and ChatGPT. The comparison encompassed several aspects, including the ability to retrieve relevant studies, accuracy, efficiency, limitations, and challenges associated with each method. Results: A total of 6 articles identified through search terms generated by human researchers were included in the final analysis, of which 4 (67\%) reported improvements in medication adherence after the intervention. However, 33\% (2/6) of the included studies did not clearly state whether medication adherence improved after the intervention. A total of 10 studies were included based on search terms generated by ChatGPT, of which 6 (60\%) overlapped with studies identified by human researchers. Regarding the impact of mobile health interventions on medication adherence, most included studies (8/10, 80\%) based on search terms generated by ChatGPT reported improvements in medication adherence after the intervention. However, 20\% (2/10) of the studies did not clearly state whether medication adherence improved after the intervention. The precision in accurately identifying relevant studies was higher in human researchers (0.86) than in ChatGPT (0.77). This is consistent with the percentage of relevance, where human researchers (9.8\%) demonstrated a higher percentage of relevance than ChatGPT (3\%). However, when considering the time required for both humans and ChatGPT to identify relevant studies, ChatGPT substantially outperformed human researchers as it took less time to identify relevant studies. Conclusions: Our comparative analysis highlighted the strengths and limitations of both approaches. Ultimately, the choice between human researchers and ChatGPT depends on the specific requirements and objectives of each review, but the collaborative synergy of both approaches holds the potential to advance evidence-based research and decision-making in the health care field. ", doi="10.2196/51526", url="https://mhealth.jmir.org/2024/1/e51526", url="http://www.ncbi.nlm.nih.gov/pubmed/38710069" } @Article{info:doi/10.2196/56417, author="Kim, Yuyoung and Kim, Minjung and Kim, Jinwoo and Song, Tae-Jin", title="Smartphone-Based Speech Therapy for Poststroke Dysarthria: Pilot Randomized Controlled Trial Evaluating Efficacy and Feasibility", journal="J Med Internet Res", year="2024", month="Apr", day="25", volume="26", pages="e56417", keywords="dysarthria", keywords="stroke", keywords="smartphone", keywords="speech therapy", keywords="app", keywords="acute and early subacute", keywords="feasibility", keywords="mobile phone", abstract="Background: Dysarthria is a common poststroke speech disorder affecting communication and psychological well-being. Traditional speech therapy is effective but often poses challenges in terms of accessibility and patient adherence. Emerging smartphone-based therapies may offer promising alternatives for the treatment of poststroke dysarthria. Objective: This study aimed to assess the efficacy and feasibility of smartphone-based speech therapy for improving speech intelligibility in patients with acute and early subacute poststroke dysarthria. This study also explored the impact of the intervention on psychological well-being, user experience, and overall feasibility in a clinical setting. Methods: Participants were divided into 2 groups for this randomized, evaluator-blinded trial. The intervention group used a smartphone-based speech therapy app for 1 hour per day, 5 days per week, for 4 weeks, with guideline-based standard stroke care. The control group received standard guideline-based stroke care and rehabilitation. Speech intelligibility, psychological well-being, quality of life, and user acceptance were assessed using repeated measures ANOVA. Results: In this study, 40 patients with poststroke dysarthria were enrolled, 32 of whom completed the trial (16 in each group). The intervention group showed significant improvements in speech intelligibility compared with the control group. This was evidenced by improvements from baseline (F1,30=34.35; P<.001), between-group differences (F1,30=6.18; P=.02), and notable time-by-group interactions (F1,30=6.91; P=.01). Regarding secondary outcomes, the intervention led to improvements in the percentage of correct consonants over time (F1,30=5.57; P=.03). In addition, significant reductions were noted in the severity of dysarthria in the intervention group over time (F1,30=21.18; P<.001), with a pronounced group effect (F1,30=5.52; P=.03) and time-by-group interaction (F1,30=5.29; P=.03). Regarding quality of life, significant improvements were observed as measured by the EQ-5D-3L questionnaire (F1,30=13.25; P<.001) and EQ-VAS (F1,30=7.74; P=.009) over time. The adherence rate to the smartphone-based app was 64\%, with over half of the participants completing all the sessions. The usability of the app was rated high (system usability score 80.78). In addition, the intervention group reported increased self-efficacy in using the app compared with the control group (F1,30=10.81; P=.003). Conclusions: The smartphone-based speech therapy app significantly improved speech intelligibility, articulation, and quality of life in patients with poststroke dysarthria. These findings indicate that smartphone-based speech therapy can be a useful assistant device in the management of poststroke dysarthria, particularly in the acute and early subacute stroke stages. Trial Registration: ClinicalTrials.gov NCT05146765; https://clinicaltrials.gov/ct2/show/NCT05146765 ", doi="10.2196/56417", url="https://www.jmir.org/2024/1/e56417", url="http://www.ncbi.nlm.nih.gov/pubmed/38509662" } @Article{info:doi/10.2196/44463, author="Liu, Zhuo and Sun, Xin and Guo, Zhen-Ni and Sun, Ye and Yang, Yi and Yan, Xiuli", title="Effects of a Planned Web-Based Educational Intervention Based on the Health Belief Model for Patients With Ischemic Stroke in Promoting Secondary Prevention During the COVID-19 Lockdown in China: Quasi-Experimental Study", journal="JMIR Mhealth Uhealth", year="2024", month="Apr", day="24", volume="12", pages="e44463", keywords="health belief model", keywords="health education", keywords="secondary prevention", keywords="stroke", keywords="medication adherence", keywords="patient education", keywords="web-based education", keywords="digital intervention", keywords="promotion", keywords="stroke patients", keywords="ischemic", keywords="prevention", keywords="quasi-experimental study", keywords="education", keywords="control group", keywords="health management", keywords="management", keywords="systolic blood pressure", keywords="blood pressure", keywords="effectiveness", abstract="Background: Some common modified vascular risk factors remain poorly controlled among stroke survivors, and educational programs may help improve these conditions. Objective: This study aimed to evaluate the effect of a planned web-based educational intervention based on the health belief model (HBM) in promoting secondary prevention among patients with ischemic stroke. Methods: An evaluation-blinded quasi-experimental trial with a historical control group was conducted. Patients admitted from March to June 2020 were assigned to the historical control group, and patients admitted from July to October 2020 were assigned to the intervention group. The control group received routine health management. The intervention group received 6 additional sessions based on the HBM via Tencent Meeting, an audio and video conferencing application, within 3 months after discharge. Sessions were held every 2 weeks, with each session lasting approximately 40 minutes. These sessions were conducted in small groups, with about 8 to 10 people in each group. The primary outcomes were changes in blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), hemoglobin A1c (HbA1c), and the proportion of patients achieving the treatment target. The secondary outcomes were medication adherence, assessed with the Morisky Medicine Adherence Scale (MMAS), and disability, assessed with the modified Rankin scale. Results: In total, 315 patients experiencing their first-ever stroke were analyzed. More patients in the intervention group had controlled BP (41.9\% vs 28.4\%; adjusted odds ratio [aOR] 1.93; P=.01), LDL-C (83.1\% vs 67.7\%; aOR 2.66; P=.001), and HbA1c (91.9\% vs 83.9\%; aOR: 3.37; P=.04) levels as well as a significant postintervention decrease in the systolic BP (adjusted $\beta$ ?3.94; P=.02), LDL-C (adjusted $\beta$ ?0.21; P=.008), and HbA1c (adjusted $\beta$ ?0.27; P<.001), compared with control groups. Significant between-group differences were observed in medication adherence (79.4\% vs 63.2\%; aOR 2.31; P=.002) but not in favorable functional outcomes. Conclusions: A web-based education program based on the HBM may be more effective than current methods used to educate patients having strokes on optimal vascular risk factors and medication adherence. Trial Registration: Chinese Clinical Trial Registry ChiCTR2000040804; https://www.chictr.org.cn/showproj.html?proj=62431 ", doi="10.2196/44463", url="https://mhealth.jmir.org/2024/1/e44463" } @Article{info:doi/10.2196/48725, author="Gooch, J. Helen and Jarvis, A. Kathryn and Stockley, C. Rachel", title="Behavior Change Approaches in Digital Technology--Based Physical Rehabilitation Interventions Following Stroke: Scoping Review", journal="J Med Internet Res", year="2024", month="Apr", day="24", volume="26", pages="e48725", keywords="behavior change", keywords="behavior therapy", keywords="digital health technology", keywords="digital health", keywords="digital technology", keywords="health behavior", keywords="physical and rehabilitation medicine", keywords="scoping review", keywords="stroke rehabilitation", abstract="Background: Digital health technologies (DHTs) are increasingly used in physical stroke rehabilitation to support individuals in successfully engaging with the frequent, intensive, and lengthy activities required to optimize recovery. Despite this, little is known about behavior change within these interventions. Objective: This scoping review aimed to identify if and how behavior change approaches (ie, theories, models, frameworks, and techniques to influence behavior) are incorporated within physical stroke rehabilitation interventions that include a DHT. Methods: Databases (Embase, MEDLINE, PsycINFO, CINAHL, Cochrane Library, and AMED) were searched using keywords relating to behavior change, DHT, physical rehabilitation, and stroke. The results were independently screened by 2 reviewers. Sources were included if they reported a completed primary research study in which a behavior change approach could be identified within a physical stroke rehabilitation intervention that included a DHT. Data, including the study design, DHT used, and behavior change approaches, were charted. Specific behavior change techniques were coded to the behavior change technique taxonomy version 1 (BCTTv1). Results: From a total of 1973 identified sources, 103 (5\%) studies were included for data charting. The most common reason for exclusion at full-text screening was the absence of an explicit approach to behavior change (165/245, 67\%). Almost half (45/103, 44\%) of the included studies were described as pilot or feasibility studies. Virtual reality was the most frequently identified DHT type (58/103, 56\%), and almost two-thirds (65/103, 63\%) of studies focused on upper limb rehabilitation. Only a limited number of studies (18/103, 17\%) included a theory, model, or framework for behavior change. The most frequently used BCTTv1 clusters were feedback and monitoring (88/103, 85\%), reward and threat (56/103, 54\%), goals and planning (33/103, 32\%), and shaping knowledge (33/103, 32\%). Relationships between feedback and monitoring and reward and threat were identified using a relationship map, with prominent use of both of these clusters in interventions that included virtual reality. Conclusions: Despite an assumption that DHTs can promote engagement in rehabilitation, this scoping review demonstrates that very few studies of physical stroke rehabilitation that include a DHT overtly used any form of behavior change approach. From those studies that did consider behavior change, most did not report a robust underpinning theory. Future development and research need to explicitly articulate how including DHTs within an intervention may support the behavior change required for optimal engagement in physical rehabilitation following stroke, as well as establish their effectiveness. This understanding is likely to support the realization of the transformative potential of DHTs in stroke rehabilitation. ", doi="10.2196/48725", url="https://www.jmir.org/2024/1/e48725" } @Article{info:doi/10.2196/47600, author="Lee, J. Edmund W. and Tan, W. Warrick and Pham, Phat Ben Tan and Kawaja, Ariffin and Theng, Yin-Leng", title="Addressing Data Absenteeism and Technology Chauvinism in the Use of Gamified Wearable Gloves Among Older Adults: Moderated Usability Study", journal="JMIR Serious Games", year="2024", month="Apr", day="24", volume="12", pages="e47600", keywords="wearables", keywords="exergames", keywords="older adults", keywords="active aging", keywords="rehabilitation", keywords="stroke", abstract="Background: Digital health technologies have the potential to improve health outcomes for older adults, especially for those recovering from stroke. However, there are challenges to developing these technologies, such as data absenteeism (where older adults' views are often underrepresented in research and development) and technology chauvinism (the belief that sophisticated technology alone is the panacea to addressing health problems), which hinder their effectiveness. Objective: In this study, we aimed to address these challenges by developing a wearable glove integrated with culturally relevant exergames to motivate older adults to exercise and, for those recovering from stroke, to adhere to rehabilitation. Methods: We conducted a moderated usability study with 19 older adults, of which 11 (58\%) had a history of stroke. Our participants engaged in a 30-minute gameplay session with the wearable glove integrated with exergames, followed by a quantitative survey and an in-depth interview. We used descriptive analysis to compare responses to the System Usability Scale between those who had a history of stroke and those who did not. In addition, we analyzed the qualitative interviews using a bottom-up thematic analysis to identify key themes related to the motivations and barriers regarding the use of wearable gloves for rehabilitation and exercise. Results: Our study generated several key insights. First, making the exergames exciting and challenging could improve exercise and rehabilitation motivation, but it could also have a boomerang effect, where participants may become demotivated if the games were very challenging. Second, the comfort and ease of use of the wearable gloves were important for older adults, regardless of their stroke history. Third, for older adults with a history of stroke, the functionality and purpose of the wearable glove were important in helping them with specific exercise movements. Conclusions: Our findings highlight the importance of providing contextual support for the effective use of digital technologies, particularly for older adults recovering from stroke. In addition to technology and usability factors, other contextual factors such as gamification and social support (from occupational therapists or caregivers) should be considered to provide a comprehensive approach to addressing health problems. To overcome data absenteeism and technology chauvinism, it is important to develop digital health technologies that are tailored to the needs of underserved communities. Our study provides valuable insights for the development of digital health technologies that can motivate older adults recovering from stroke to exercise and adhere to rehabilitation. ", doi="10.2196/47600", url="https://games.jmir.org/2024/1/e47600", url="http://www.ncbi.nlm.nih.gov/pubmed/38656778" } @Article{info:doi/10.2196/49409, author="Howdle, Charlotte and Wright, Alexander William James and Mant, Jonathan and De Simoni, Anna", title="Factors Influencing Recovery From Pediatric Stroke Based on Discussions From a UK-Based Online Stroke Community: Qualitative Thematic Study", journal="J Med Internet Res", year="2024", month="Apr", day="16", volume="26", pages="e49409", keywords="child", keywords="stroke", keywords="rehabilitation", keywords="barriers", keywords="facilitators", keywords="internet-based intervention", keywords="self-help group", keywords="thematic analysis", abstract="Background: The incidence of stroke in children is low, and pediatric stroke rehabilitation services are less developed than adult ones. Survivors of pediatric stroke have a long poststroke life expectancy and therefore have the potential to experience impairments from their stroke for many years. However, there are relatively few studies characterizing these impairments and what factors facilitate or counteract recovery. Objective: This study aims to characterize the main barriers to and facilitators of recovery from pediatric stroke. A secondary aim was to explore whether these factors last into adulthood, whether they change, or if new factors impacting recovery emerge in adulthood. Methods: We performed a qualitative thematic analysis based on posts from a population of participants from a UK-based online stroke community, active between 2004 and 2011. The analysis focused on users who talked about their experiences with pediatric stroke, as identified by a previous study. The posts were read by 3 authors, and factors influencing recovery from pediatric stroke were mapped into 4 areas: medical, physical, emotional, and social. Factors influencing recovery were divided into short-term and long-term factors. Results: There were 425 posts relating to 52 survivors of pediatric stroke. Some survivors of stroke posted for themselves, while others were talked about by a third party (mostly parents; 31/35, 89\% mothers). In total, 79\% (41/52) of survivors of stroke were aged ?18 years and 21\% (11/52) were aged >18 years at the time of posting. Medical factors included comorbidities as a barrier to recovery. Medical interventions, such as speech and language therapy and physiotherapy, were also deemed useful. Exercise, particularly swimming, was deemed a facilitator. Among physical factors, fatigue and chronic pain could persist decades after a stroke, with both reported as a barrier to feeling fully recovered. Tiredness could worsen existing stroke-related impairments. Other long-standing impairments were memory loss, confusion, and dizziness. Among emotional factors, fear and uncertainty were short-term barriers, while positivity was a major facilitator in both short- and long-term recovery. Anxiety, grief, and behavioral problems hindered recovery. The social barriers were loneliness, exclusion, and hidden disabilities not being acknowledged by third parties. A good support network and third-party support facilitated recovery. Educational services were important in reintegrating survivors into society. Participants reported that worrying about losing financial support, such as disability allowances, and difficulties in obtaining travel insurance and driving licenses impacted recovery. Conclusions: The lived experience of survivors of pediatric stroke includes long-term hidden disabilities and barriers to rehabilitation. These are present in different settings, such as health care, schools, workplaces, and driving centers. Greater awareness of these issues by relevant professional groups may help ameliorate them. ", doi="10.2196/49409", url="https://www.jmir.org/2024/1/e49409", url="http://www.ncbi.nlm.nih.gov/pubmed/38625726" } @Article{info:doi/10.2196/55432, author="Regan, Wherley Elizabeth and Toto, Pamela and Brach, Jennifer", title="A Community Needs Assessment and Implementation Planning for a Community Exercise Program for Survivors of Stroke: Protocol for a Pilot Hybrid Type I Clinical Effectiveness and Implementation Study", journal="JMIR Res Protoc", year="2024", month="Apr", day="11", volume="13", pages="e55432", keywords="community participatory research", keywords="need assessment", keywords="exercise", keywords="survivors of stroke", keywords="community", keywords="community need", keywords="exercise program", keywords="stroke", keywords="physical activity", keywords="PA", keywords="mobility impairments", keywords="impairment", keywords="mobility", keywords="health decline", keywords="group activity", keywords="group exercise", abstract="Background: Physical activity and exercise are important aspects of maintaining health. People with mobility impairments, including survivors of stroke, are less likely to exercise and at greater risk of developing or worsening chronic health conditions. Increasing accessible, desired options for exercise may address the gap in available physical activity programs, provide an opportunity for continued services after rehabilitation, and cultivate social connections for people after stroke and others with mobility impairments. Existing evidence-based community programs for people after stroke target cardiovascular endurance, mobility, walking ability, balance, and education. While much is known about the effectiveness of these programs, it is important to understand the local environment as implementation and sustainment strategies are context-specific. Objective: This study protocol aims to evaluate community needs and resources for exercise for adults living with mobility impairments with initial emphasis on survivors of stroke in Richland County, South Carolina. Results will inform a hybrid type I effectiveness and implementation pilot of an evidence-based group exercise program for survivors of stroke. Methods: The exploration and preparation phases of the EPIS (Exploration, Preparation, Implementation, and Sustainment) implementation model guide the study. A community needs assessment will evaluate the needs and desires of survivors of stroke through qualitative semistructured interviews with survivors of stroke, rehabilitation professionals, and fitness trainers serving people with mobility impairments. Additional data will be collected from survivors of stroke through a survey. Fitness center sites will be assessed through interviews and the Accessibility Instrument Measuring Fitness and Recreation Environments inventory. Qualitative data will be evaluated using content analysis and supported by mean survey results. Data will be categorized by the community (outer context), potential participants (outer context), and fitness center (inner context) and evaluate needs, resources, barriers, and facilitators. Results will inform evidence-based exercise program selection, adaptations, and specific local implementation strategies to influence success. Pilot outcome measures for participants (clinical effectiveness), process, and program delivery levels will be identified. An implementation logic model for interventions will be created to reflect the design elements for the pilot and their complex interactions. Results: The study was reviewed by the institutional review board and exempt approved on December 19, 2023. The study data collection began in January 2024 and is projected to be completed in June 2024. A total of 17 participants have been interviewed as of manuscript submission. Results are expected to be published in early 2025. Conclusions: Performing a needs assessment before implementing it in the community allows for early identification of complex relationships and preplanning to address problems that cannot be anticipated in controlled effectiveness research. Evaluation and preparation prior to implementation of a community exercise program enhance the potential to be successful, valued, and sustained in the community. International Registered Report Identifier (IRRID): DERR1-10.2196/55432 ", doi="10.2196/55432", url="https://www.researchprotocols.org/2024/1/e55432", url="http://www.ncbi.nlm.nih.gov/pubmed/38603776" } @Article{info:doi/10.2196/49440, author="Wright, A. William J. and Howdle, Charlotte and Coulson, S. Neil and De Simoni, Anna", title="Exploring the Types of Social Support Exchanged by Survivors of Pediatric Stroke and Their Families in an Online Peer Support Community: Qualitative Thematic Analysis", journal="J Med Internet Res", year="2024", month="Mar", day="15", volume="26", pages="e49440", keywords="child", keywords="internet-based intervention", keywords="online health communities", keywords="peer support", keywords="qualitative analysis", keywords="rehabilitation", keywords="self-help group", keywords="self-help", keywords="social support", keywords="stroke", keywords="support groups", keywords="thematic analysis", abstract="Background: Pediatric stroke is relatively rare and underresearched, and there is little awareness of its occurrence in wider society. There is a paucity of literature on the effectiveness of interventions to improve rehabilitation and the services available to survivors. Access to online health communities through the internet may be a means of support for patients with pediatric stroke and their families during recovery; however, little research has been done in this area. Objective: This study aims to identify the types of social support provided by an online peer support group to survivors of pediatric stroke and their families. Methods: This was a qualitative thematic analysis of posts from a pediatric stroke population on a UK online stroke community active between 2004 and 2011. The population was split into 2 groups based on whether stroke survivors were aged ?18 years or aged >18 years at the time of posting. The posts were read by 2 authors who used the adapted Social Support Behavior Code to analyze the types of social support exchanged. Results: A total of 52 participants who experienced a pediatric stroke were identified, who posted a total of 425 messages to the community. About 41 survivors were aged ?18 years at the time of posting and were written about by others (31/35 were mothers), while 11 were aged >18 years and were writing about themselves. Survivors and their families joined together in discussion threads. Support was offered and received by all participants, regardless of age. Of all 425 posts, 193 (45.4\%) contained at least 1 instance of social support. All 5 types of social support were identified: informational, emotional, network, esteem support, and tangible aid. Informational and emotional support were most commonly exchanged. Emotional support was offered more often than informational support among participants aged ?18 years at the time of posting; this finding was reversed in the group aged >18 years. Network support and esteem support were less commonly exchanged. Notably, the access subcategory of network support was not exchanged with the community. Tangible aid was the least commonly offered type of support. The exchanged social support provided insight into rehabilitation interventions and the unmet needs of pediatric stroke survivors. Conclusions: We found evidence of engagement of childhood stroke survivors and their families in an online stroke community, with peer support being exchanged between both long- and short-term survivors of pediatric stroke. Engagement of long-term survivors of pediatric stroke through the online community was key, as they were able to offer informational support from lived experience. Further interventional research is needed to assess health and rehabilitation outcomes from engagement with online support groups. Research is also needed to ensure safe, nurturing online communities. ", doi="10.2196/49440", url="https://www.jmir.org/2024/1/e49440", url="http://www.ncbi.nlm.nih.gov/pubmed/38488858" } @Article{info:doi/10.2196/50647, author="Fernandez, L. Laura and Griswold, Dylan and Khun, Isla and Rodriguez De Francisco, Victoria Diana", title="Innovative Solutions for Patients Who Undergo Craniectomy: Protocol for a Scoping Review", journal="JMIR Res Protoc", year="2024", month="Mar", day="7", volume="13", pages="e50647", keywords="cranioplasty", keywords="decompressive craniectomy", keywords="global neurosurgery", keywords="intellectual property", keywords="stroke", keywords="traumatic brain injury", keywords="innovative", keywords="innovative solutions", keywords="craniectomy", keywords="increased intracranial pressure", keywords="intracranial pressure", keywords="prototypes", keywords="medical devices", keywords="middle-income countries", keywords="low-income countries", keywords="noninvasive", abstract="Background: Decompressive craniectomy (DC) is a widely used procedure to alleviate high intracranial pressure. Multidisciplinary teams have designed and implemented external medical prototypes to improve patient life quality and avoid complications following DC in patients awaiting cranioplasty (CP), including 3D printing and plaster prototypes when available. Objective: This scoping review aims to understand the extent and type of evidence about innovative external prototypes for patients who undergo DC while awaiting CP. Methods: This scoping review will use the Joanna Briggs Institute methodology for scoping reviews. This scoping review will include noninvasive medical devices for adult patients who undergo DC while waiting for CP. The search strategy will be implemented in MEDLINE, Embase, Web of Science, Scielo, Scopus, and the World Health Organization (WHO) Global Health Index Medicus. Patent documents were also allocated in Espacenet, Google Patents, and the World Intellectual Property Organization (WIPO) database. Results: This scoping review is not subject to ethical approval as there will be no involvement of patients. The dissemination plan includes publishing the review findings in a peer-reviewed journal and presenting results at conferences that engage the most pertinent stakeholders in innovation and neurosurgery. Conclusions: This scoping review will serve as a baseline to provide evidence for multidisciplinary teams currently designing these noninvasive innovations to reduce the risk of associated complications after DC, hoping that more cost-effective models can be implemented, especially in low- and middle-income countries. International Registered Report Identifier (IRRID): DERR1-10.2196/50647 ", doi="10.2196/50647", url="https://www.researchprotocols.org/2024/1/e50647", url="http://www.ncbi.nlm.nih.gov/pubmed/38451601" } @Article{info:doi/10.2196/50863, author="Li, Zhaoying and Lei, Yating and Bui, Quoc and DePaul, Olivia and Nicol, E. Ginger and Mohr, C. David and Lee, I. Sunghoon and Fong, M. Mandy W. and Metts, L. Christopher and Tomazin, E. Stephanie and Wong, K. Alex W.", title="A Digital Intervention to Promote Self-Management Self-Efficacy Among Community-Dwelling Individuals With Stroke: Pilot Randomized Controlled Trial", journal="JMIR Rehabil Assist Technol", year="2024", month="Feb", day="19", volume="11", pages="e50863", keywords="digital intervention", keywords="feasibility", keywords="mobile health", keywords="participation", keywords="rehabilitation", keywords="self-efficacy", keywords="self-management", keywords="stroke", keywords="technology", keywords="telehealth", keywords="telemedicine", keywords="text messaging", abstract="Background: Digital interventions provided through smartphones or the internet that are guided by a coach have been proposed as promising solutions to support the self-management of chronic conditions. However, digital intervention for poststroke self-management is limited; we developed the interactive Self-Management Augmented by Rehabilitation Technologies (iSMART) intervention to address this gap. Objective: This study aimed to examine the feasibility and initial effects of the iSMART intervention to improve self-management self-efficacy in people with stroke. Methods: A parallel, 2-arm, nonblinded, randomized controlled trial of 12-week duration was conducted. A total of 24 participants with mild-to-moderate chronic stroke were randomized to receive either the iSMART intervention or a manual of stroke rehabilitation (attention control). iSMART was a coach-guided, technology-supported self-management intervention designed to support people managing chronic conditions and maintaining active participation in daily life after stroke. Feasibility measures included retention and engagement rates in the iSMART group. For both the iSMART intervention and active control groups, we used the Feasibility of Intervention Measure, Acceptability of Intervention Measure, and Intervention Appropriateness Measure to assess the feasibility, acceptability, and appropriateness, respectively. Health measures included the Participation Strategies Self-Efficacy Scale and the Patient-Reported Outcomes Measurement Information System's Self-Efficacy for Managing Chronic Conditions. Results: The retention rate was 82\% (9/11), and the engagement (SMS text message response) rate was 78\% for the iSMART group. Mean scores of the Feasibility of Intervention Measure, Acceptability of Intervention Measure, and Intervention Appropriateness Measure were 4.11 (SD 0.61), 4.44 (SD 0.73), and 4.36 (SD 0.70), respectively, which exceeded our benchmark (4 out of 5), suggesting high feasibility, acceptability, and appropriateness of iSMART. The iSMART group showed moderate-to-large effects in improving self-efficacy in managing emotions (r=0.494), symptoms (r=0.514), daily activities (r=0.593), and treatments and medications (r=0.870), but the control group showed negligible-to-small effects in decreasing self-efficacy in managing emotions (r=0.252), symptoms (r=0.262), daily activities (r=0.136), and treatments and medications (r=0.049). In addition, the iSMART group showed moderate-to-large effects of increasing the use of participation strategies for management in the home (r=0.554), work (r=0.633), community (r=0.673), and communication activities (r=0.476). In contrast, the control group showed small-to-large effects of decreasing the use of participation strategies for management in the home (r=0.567), work (r=0.342, community (r=0.215), and communication activities (r=0.379). Conclusions: Our findings support the idea that iSMART was feasible to improve poststroke self-management self-efficacy. Our results also support using a low-cost solution, such as SMS text messaging, to supplement traditional therapeutic patient education interventions. Further evaluation with a larger sample of participants is still needed. Trial Registration: ClinicalTrials.gov 202004137; https://clinicaltrials.gov/study/NCT04743037?id=202004137\&rank=1 ", doi="10.2196/50863", url="https://rehab.jmir.org/2024/1/e50863", url="http://www.ncbi.nlm.nih.gov/pubmed/38373029" } @Article{info:doi/10.2196/48900, author="Villada Castillo, Felipe Julian and Montoya Vega, Fernanda Maria and Mu{\~n}oz Cardona, Edison John and Lopez, David and Qui{\~n}ones, Leonardo and Henao Gallo, Alberto Oscar and Lopez, Fernando Jose", title="Design of Virtual Reality Exergames for Upper Limb Stroke Rehabilitation Following Iterative Design Methods: Usability Study", journal="JMIR Serious Games", year="2024", month="Jan", day="11", volume="12", pages="e48900", keywords="stroke", keywords="user-centered design", keywords="exergame", keywords="design", keywords="virtual reality", keywords="playtest", keywords="upper limb rehabilitation", abstract="Background: Since the early 2000s, there has been a growing interest in using exercise video games (exergames) and virtual reality (VR)--based interventions as innovative methods to enhance physical rehabilitation for individuals with multiple disabilities. Over the past decade, researchers and exercise professionals have focused on developing specialized immersive exercise video games for various populations, including those who have experienced a stroke, revealing tangible benefits for upper limb rehabilitation. However, it is necessary to develop highly engaging, personalized games that can facilitate the creation of experiences aligned with the preferences, motivations, and challenges communicated by people who have had an episode of stroke. Objective: This study seeks to explore the customization potential of an exergame for individuals who have undergone a stroke, concurrently evaluating its usability as a technological tool in the realm of physical therapy and rehabilitation. Methods: We introduce a playtest methodology to enhance the design of a VR exergame developed using a user-centered approach for upper limb rehabilitation in stroke survivors. Over 4 playtesting sessions, stroke survivors interacted with initial game versions using VR headsets, providing essential feedback for refining game content and mechanics. Additionally, a pilot study involving 10 stroke survivors collected data through VR-related questionnaires to assess game design aspects such as mechanics, assistance, experience, motion sickness, and immersion. Results: The playtest methodology was beneficial for improving the exergame to align with user needs, consistently incorporating their perspectives and achieving noteworthy results. The pilot study revealed that users had a positive response. In the first scenario, a carpenter presents a game based on the flexion-extension movement of the elbow; the second scenario includes a tejo game (a traditional Colombian throwing game) designed around game mechanics related to the flexion-extension movement of the shoulder; and in the third scenario, a farmer challenges the player to perform a movement combining elbow flexion and extension with internal and external rotation of the shoulder. These findings suggest the potential of the studied exergame as a tool for the upper limb rehabilitation of individuals who have experienced a stroke. Conclusions: The inclusion of exergames in rehabilitation for stroke-induced hemiparesis has significantly benefited the recovery process by focusing on essential shoulder and elbow movements. These interactive games play a crucial role in helping users regain mobility and restore practical use of affected limbs. They also serve as valuable data sources for researchers, improving the system's responsiveness. This iterative approach enhances game design and markedly boosts user satisfaction, suggesting exergames have promising potential as adjunctive elements in traditional therapeutic approaches. ", doi="10.2196/48900", url="https://games.jmir.org/2024/1/e48900", url="http://www.ncbi.nlm.nih.gov/pubmed/38206670" } @Article{info:doi/10.2196/52447, author="Che, Qianzi and Song, Tian and Liang, Ning and Guo, Jing and Chen, Zhao and Liu, Xiaoyu and Yang, Lu and Jiang, Yin and Wang, Yanping and Shi, Nannan", title="Dazhu Hongjingtian Injection for Ischemic Stroke: Protocol for a Prospective, Multicenter Observational Study", journal="JMIR Res Protoc", year="2023", month="Dec", day="22", volume="12", pages="e52447", keywords="ischemic stroke", keywords="study protocol", keywords="complementary and alternative therapies", keywords="prospective study", keywords="stroke", keywords="observational study", keywords="effectiveness", keywords="treatment", keywords="optimal treatment", keywords="medication", keywords="DZHJTI treatment", keywords="clinical setting", keywords="therapy", keywords="cohort study", keywords="androgen syndrome", keywords="patients with AIS", keywords="patient with AIS", keywords="China", keywords="stroke recurrence", keywords="traditional medicine", keywords="laboratory parameters", keywords="health", keywords="tissue plasminogen activator (tPA)", keywords="tPA", keywords="stroke treatment", keywords="plasminogen", abstract="Background: Although results from in vitro studies and small randomized controlled trials have shown positive effects of Dazhu hongjingtian injection (DZHJTI) on acute ischemic stroke (AIS), their generalizability to routine clinical practice remains to be established. Objective: The primary aim of this study is to evaluate the effectiveness of DZHJTI treatment for AIS with regard to changes in the stroke-related neurological deficit from baseline to outpatient follow-up, mortality, subsequent vascular events, disability, and traditional Chinese medicine syndrome in real-world clinical settings. By monitoring for adverse events or significant changes in vital signs and laboratory parameters, we also aim to assess the safety of DZHJTI. Methods: This prospective, multicenter cohort study plans to enroll 2000 patients with AIS within 14 days of symptom onset from 30 hospitals across China. Eligible patients will be followed up for 6 months after initiating medication treatments. The primary outcome will be the change in the National Institute of Health Stroke Scale score from baseline to outpatient follow-up. The secondary outcomes include overall mortality, stroke recurrence, new-onset major vascular events, global disability, and improvement of traditional Chinese medicine syndrome in 6 months. Adverse events or clinically significant changes in vital signs and laboratory parameters, regardless of the severity, will be recorded during the trial to assess the safety of DZHJTI. An augmented inverse propensity weighted estimator will be used to reduce variability and improve accuracy in average treatment effects estimation. Results: The clinical trial registration was approved in October 2022, and the recruitment and enrollment of participants started in November 2022. The study's outcomes are expected to be published in 2025 in reputable, peer-reviewed health-related research journals. Conclusions: This real-world cohort study is the first to assess the effectiveness and safety of DZHJTI in treating AIS. It may provide additional clinical evidence, including the duration of response, long-term drug effectiveness, and subgroup efficacy data. The study results will be valuable for clinicians and patients seeking optimal treatment for AIS and could lead to better use of DZHJTI and improved patient outcomes. Trial Registration: ITMCTR ITMCTR2022000005; http://tinyurl.com/554ns8m5 International Registered Report Identifier (IRRID): DERR1-10.2196/52447 ", doi="10.2196/52447", url="https://www.researchprotocols.org/2023/1/e52447", url="http://www.ncbi.nlm.nih.gov/pubmed/38133909" } @Article{info:doi/10.2196/51178, author="Afrin, Mahabuba and Khan, Uddin Sharif and Das, Chandra Subir and Huq, Ehsanul K. A. T. M. and Moriyama, Michiko", title="Effectiveness of a Health Education Program for Patients Who Had a Stroke and Their Caregivers by Controlling Modifiable Risk Factors to Reduce Stroke Recurrence in a Tertiary Hospital in Bangladesh: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2023", month="Dec", day="15", volume="12", pages="e51178", keywords="stroke", keywords="caregiver", keywords="recurrence of stroke", keywords="health education", keywords="Bangladesh", keywords="modifiable risk factor", keywords="recurrence", keywords="hospital", keywords="disability", keywords="lifestyle change", keywords="behavioral change", keywords="risk factor", keywords="quality of life", keywords="tertiary", abstract="Background: Stroke is a significant public health concern that causes severe and long-lasting disability. The recurrence of stroke is increasing due to lack of patients' knowledge and compliance with treatment to control modifiable risk factors and lifestyle changes. Health education can be an effective way to increase knowledge about behavioral changes in patients who had a stroke. Objective: The aim of this study is to evaluate the effectiveness of a health education program in Bangladesh for patients who had their first stroke and their family caregivers in order to reduce the recurrence of stroke by controlling modifiable risk factors. Methods: This is a parallel, open-label, prospective randomized controlled trial conducted at the National Institute of Neurosciences \& Hospital in Dhaka, Bangladesh. We enrolled ?18-year-old patients of both sexes who had a history of first stroke attack (transient ischemic attack, hemorrhagic stroke, lacunar stroke, atherothrombotic stroke, or cardioembolic stroke). We stratified patients into those aged <65 years and those aged ?65 years and according to types of strokes for randomization. Our estimated sample size was 432. The intervention group receives face-to-face counseling on lifestyle modifications, blood pressure monitoring, and medication compliance--related health education during enrollment and monthly follow-ups. However, the control group receives only usual care from the hospital. The primary end point of this study is the reduction in the stroke recurrence rates at the end of the 12-month follow-up period. The secondary end points are to (1) assess the occurrence of all adverse events such as other cardiac events and all-cause mortality, (2) evaluate the status of the controlling modifiable risk factors such as blood pressure, glycated hemoglobin, and non--high-density lipoprotein cholesterol, (3) assess the knowledge related to stroke by using the investigator-developed questionnaire, (4) evaluate the lifestyle behavior related to stroke by using the investigator-developed questionnaire, (5) assess medication adherence, and (6) evaluate the quality of life of patients who had a stroke and their family caregivers. The evaluation points will be at baseline, 6 months, and 12 months for both groups. Results: Patients' enrollment started on October 2022, and follow-up will be completed in March 2024. A total of 432 participants were included in both the intervention (n=216) and control groups (n=216). This study was approved by the institutional review board and the ethics review board of the National Institute of Neurosciences \& Hospital (IRB/NINSH/2022/151) on August 30, 2022. Conclusions: Our health education program is expected to reduce the recurrence of stroke and improve the quality of life of patients who have had the first stroke. The results of this study will provide insights into the importance of health education for (self)-management and prevention of stroke. Trial Registration: ClinicalTrials.gov NCT05520034; https://clinicaltrials.gov/ct2/show/NCT05520034 International Registered Report Identifier (IRRID): DERR1-10.2196/51178 ", doi="10.2196/51178", url="https://www.researchprotocols.org/2023/1/e51178", url="http://www.ncbi.nlm.nih.gov/pubmed/38100172" } @Article{info:doi/10.2196/49702, author="Alder, Gemma and Taylor, Denise and Rashid, Usman and Olsen, Sharon and Brooks, Thonia and Terry, Gareth and Niazi, Khan Imran and Signal, Nada", title="A Brain Computer Interface Neuromodulatory Device for Stroke Rehabilitation: Iterative User-Centered Design Approach", journal="JMIR Rehabil Assist Technol", year="2023", month="Dec", day="11", volume="10", pages="e49702", keywords="user-centered design", keywords="stroke", keywords="rehabilitation technology", keywords="wearable technology", keywords="brain computer interface", keywords="BCI", keywords="mobile app", keywords="think-aloud", keywords="near live", keywords="semistructured interviews", abstract="Background: Rehabilitation technologies for people with stroke are rapidly evolving. These technologies have the potential to support higher volumes of rehabilitation to improve outcomes for people with stroke. Despite growing evidence of their efficacy, there is a lack of uptake and sustained use in stroke rehabilitation and a call for user-centered design approaches during technology design and development. This study focuses on a novel rehabilitation technology called exciteBCI, a complex neuromodulatory wearable technology in the prototype stage that augments locomotor rehabilitation for people with stroke. The exciteBCI consists of a brain computer interface, a muscle electrical stimulator, and a mobile app. Objective: This study presents the evaluation phase of an iterative user-centered design approach supported by a qualitative descriptive methodology that sought to (1) explore users' perspectives and experiences of exciteBCI and how well it fits with rehabilitation, and (2) facilitate modifications to exciteBCI design features. Methods: The iterative usability evaluation of exciteBCI was conducted in 2 phases. Phase 1 consisted of 3 sprint cycles consisting of single usability sessions with people with stroke (n=4) and physiotherapists (n=4). During their interactions with exciteBCI, participants used a ``think-aloud'' approach, followed by a semistructured interview. At the end of each sprint cycle, device requirements were gathered and the device was modified in preparation for the next cycle. Phase 2 focused on a ``near-live'' approach in which 2 people with stroke and 1 physiotherapist participated in a 3-week program of rehabilitation augmented by exciteBCI (n=3). Participants completed a semistructured interview at the end of the program. Data were analyzed from both phases using conventional content analysis. Results: Overall, participants perceived and experienced exciteBCI positively, while providing guidance for iterative changes. Five interrelated themes were identified from the data: (1) ``This is rehab'' illustrated that participants viewed exciteBCI as having a good fit with rehabilitation practice; (2) ``Getting the most out of rehab'' highlighted that exciteBCI was perceived as a means to enhance rehabilitation through increased engagement and challenge; (3) ``It is a tool not a therapist,'' revealed views that the technology could either enhance or disrupt the therapeutic relationship; and (4) ``Weighing up the benefits versus the burden'' and (5) ``Don't make me look different'' emphasized important design considerations related to device set-up, use, and social acceptability. Conclusions: This study offers several important findings that can inform the design and implementation of rehabilitation technologies. These include (1) the design of rehabilitation technology should support the therapeutic relationship between the patient and therapist, (2) social acceptability is a design priority in rehabilitation technology but its importance varies depending on the use context, and (3) there is value in using design research methods that support understanding usability in the context of sustained use. ", doi="10.2196/49702", url="https://rehab.jmir.org/2023/1/e49702", url="http://www.ncbi.nlm.nih.gov/pubmed/38079202" } @Article{info:doi/10.2196/43416, author="Maltby, Steven and Garcia-Esperon, Carlos and Jackson, Kate and Butcher, Ken and Evans, W. James and O'Brien, William and Dixon, Courtney and Russell, Skye and Wilson, Natalie and Kluge, G. Murielle and Ryan, Annika and Paul, L. Christine and Spratt, J. Neil and Levi, R. Christopher and Walker, Rohan Frederick", title="TACTICS VR Stroke Telehealth Virtual Reality Training for Health Care Professionals Involved in Stroke Management at Telestroke Spoke Hospitals: Module Design and Implementation Study", journal="JMIR Serious Games", year="2023", month="Dec", day="7", volume="11", pages="e43416", keywords="virtual reality", keywords="technology", keywords="medical education", keywords="telehealth", keywords="stroke management", keywords="stroke workflow", abstract="Background: Stroke management in rural areas is more variable and there is less access to reperfusion therapies, when compared with metropolitan areas. Delays in treatment contribute to worse patient outcomes. To improve stroke management in rural areas, health districts are implementing telestroke networks. The New South Wales Telestroke Service provides neurologist-led telehealth to 23 rural spoke hospitals aiming to improve treatment delivery and patient outcomes. The training of clinical staff was identified as a critical aspect for the successful implementation of this service. Virtual reality (VR) training has not previously been used in this context. Objective: We sought to develop an evidence-based VR training module specifically tailored for stroke telehealth. During implementation, we aimed to assess the feasibility of workplace deployment and collected feedback from spoke hospital staff involved in stroke management on training acceptability and usability as well as perceived training impact. Methods: The TACTICS VR Stroke Telehealth application was developed with subject matter experts. During implementation, both quantitative and qualitative data were documented, including VR use and survey feedback. VR hardware was deployed to 23 rural hospitals, and use data were captured via automated Wi-Fi transfer. At 7 hospitals in a single local health district, staff using TACTICS VR were invited to complete surveys before and after training. Results: TACTICS VR Stroke Telehealth was deployed to rural New South Wales hospitals starting on April 14, 2021. Through August 20, 2023, a total of 177 VR sessions were completed. Survey respondents (n=20) indicated a high level of acceptability, usability, and perceived training impact (eg, accuracy and knowledge transfer; mean scores 3.8-4.4; 5=strongly agree). Furthermore, respondents agreed that TACTICS VR increased confidence (13/18, 72\%), improved understanding (16/18, 89\%), and improved awareness (17/18, 94\%) regarding stroke telehealth. A comparison of matched pre- and posttraining responses revealed that training improved the understanding of telehealth workflow practices (after training: mean 4.2, SD 0.6; before training: mean 3.2, SD 0.9; P<.001), knowledge on accessing stroke telehealth (mean 4.1, SD 0.6 vs mean 3.1, SD 1.0; P=.001), the awareness of stroke telehealth (mean 4.1, SD 0.6 vs mean 3.4, SD 0.9; P=.03), ability to optimally communicate with colleagues (mean 4.2, SD 0.6 vs mean 3.7, SD 0.9; P=.02), and ability to make improvements (mean 4.0, SD 0.6 vs mean 3.5, SD 0.9; P=.03). Remote training and deployment were feasible, and limited issues were identified, although uptake varied widely (0-66 sessions/site). Conclusions: TACTICS VR Stroke Telehealth is a new VR application specifically tailored for stroke telehealth workflow training at spoke hospitals. Training was considered acceptable, usable, and useful and had positive perceived training impacts in a real-world clinical implementation context. Additional work is required to optimize training uptake and integrate training into existing education pathways. ", doi="10.2196/43416", url="https://games.jmir.org/2023/1/e43416", url="http://www.ncbi.nlm.nih.gov/pubmed/38060297" } @Article{info:doi/10.2196/49412, author="Chen, Yu-Shiue and Sung, Pi-Shan and Lai, Ming-Chi and Huang, Chin-Wei", title="The Primary Prevention of Poststroke Epilepsy in Patients With Middle Cerebral Artery Infarct: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2023", month="Nov", day="24", volume="12", pages="e49412", keywords="poststroke epilepsy", keywords="middle cerebral artery infarct", keywords="seizure", keywords="randomized control trial", keywords="epilepsy", keywords="stroke", keywords="stroke survivor", keywords="prognosis", keywords="mortality", keywords="drug therapy", keywords="development", keywords="seizure severity", keywords="efficacy", keywords="heart attack", keywords="angina", keywords="cardiovascular", keywords="cardiology", keywords="cardiologist", abstract="Background: Poststroke epilepsy poses a significant clinical challenge for individuals recovering from strokes, leading to a less favorable long-term outlook and increased mortality rates. Existing studies have primarily concentrated on administering antiseizure or anticonvulsant treatments only after the onset of late-onset seizures, without intervening during the epileptogenesis phase following a stroke. Objective: This research protocol is designed to conduct a randomized controlled trial to assess whether the early, preventive introduction of low-dose antiepileptic drug therapy (levetiracetam [LEV] or perampanel [PER]) in patients who have experienced middle cerebral artery (MCA) infarction can reduce the risk of developing poststroke epilepsy (primary prevention). Methods: Participants with MCA infarction, either with or without reperfusion treatments, will be recruited and promptly receive preventive intervention within 72 hours of the stroke occurrence. These participants will be randomly assigned to receive either PER (4 mg per day), LEV (1000 mg per day), or a placebo that matches the active drugs. This treatment will continue for 12 weeks after allocation. Brain magnetic resonance imaging will be used to confirm the presence of MCA territory infarction, and an electroencephalography will be used to ensure the absence of epileptiform discharges or electrographic seizures at the time of the stroke. All participants will undergo follow-up assessments for 72 weeks after allocation. Results: The primary outcome under evaluation will be the incidence of poststroke epilepsy in the 3 groups following the 18-month study period. Secondary outcomes will encompass the time to the occurrence of the first seizure, the severity of seizures, any treatment-related adverse events, and the modified Rankin scale score at 3 and 18 months. Exploratory outcomes will involve comparing the effectiveness and safety of PER and LEV. Conclusions: We anticipate that the intervention groups will experience a lower incidence and reduced severity of poststroke epilepsy compared to the control group after 18 months. We aim to establish evidence supporting the potential preventive effects of LEV and PER on poststroke seizures and epilepsy in patients with MCA infarction, as well as to explore the antiepileptogenic potential of both LEV and PER in patients with major ischemic strokes. Trial Registration: ClinicalTrials.gov NCT04858841; https://clinicaltrials.gov/study/NCT04858841 International Registered Report Identifier (IRRID): DERR1-10.2196/49412 ", doi="10.2196/49412", url="https://www.researchprotocols.org/2023/1/e49412", url="http://www.ncbi.nlm.nih.gov/pubmed/37999939" } @Article{info:doi/10.2196/50438, author="Smayda, Elisabeth Kirsten and Cooper, Hodsdon Sarah and Leyden, Katie and Ulaszek, Jackie and Ferko, Nicole and Dobrin, Annamaria", title="Validating the Safe and Effective Use of a Neurorehabilitation System (InTandem) to Improve Walking in the Chronic Stroke Population: Usability Study", journal="JMIR Rehabil Assist Technol", year="2023", month="Nov", day="20", volume="10", pages="e50438", keywords="chronic stroke", keywords="walking", keywords="InTandem", keywords="MR-001", keywords="neurorehabilitation", keywords="human factors engineering", keywords="usability", keywords="rhythmic auditory stimulation", keywords="validation", keywords="neurotherapeutic", abstract="Background: Persistent walking impairment following a stroke is common. Although rehabilitative interventions exist, few exist for use at home in the chronic phase of stroke recovery. InTandem (MedRhythms, Inc) is a neurorehabilitation system intended to improve walking and community ambulation in adults with chronic stroke walking impairment. Objective: Using design best practices and human factors engineering principles, the research presented here was conducted to validate the safe and effective use of InTandem. Methods: In total, 15 participants in the chronic phase of stroke recovery (?6 months after stroke) participated in this validation study. Participants were scored on 8 simulated use tasks, 4 knowledge assessments, and 7 comprehension assessments in a simulated home environment. The number and types of use errors, close calls, and operational difficulties were evaluated. Analyses of task performances, participant behaviors, and follow-up interviews were conducted to determine the root cause of use errors and difficulties. Results: During this validation study, 93\% (14/15) of participants were able to successfully complete the critical tasks associated with the simulated use of the InTandem system. Following simulated use task assessments, participants' knowledge and comprehension of the instructions for use and key safety information were evaluated. Overall, participants were able to find and correctly interpret information in the materials in order to answer the knowledge assessment questions. During the comprehension assessment, participants understood warning statements associated with critical tasks presented in the instructions for use. Across the entire study, 3 ``use errors'' and 1 ``success with difficulty'' were recorded. No adverse events, including slips, trips, or falls, occurred in this study. Conclusions: In this validation study, people in the chronic phase of stroke recovery were able to safely and effectively use InTandem in the intended use environment. This validation study contributes to the overall understanding of residual use--related risks of InTandem in consideration of the established benefits. ", doi="10.2196/50438", url="https://rehab.jmir.org/2023/1/e50438", url="http://www.ncbi.nlm.nih.gov/pubmed/37983080" } @Article{info:doi/10.2196/46056, author="Fischer, Ann-Kathrin and M{\"u}hlbacher, C. Axel", title="Patient and Public Acceptance of Digital Technologies in Health Care: Protocol for a Discrete Choice Experiment", journal="JMIR Res Protoc", year="2023", month="Aug", day="10", volume="12", pages="e46056", keywords="health preference research", keywords="stated preference survey", keywords="discrete choice experiment", keywords="study protocol", keywords="digital transformation", keywords="digital technologies", keywords="digital interventions", keywords="health care", keywords="rehabilitation", keywords="stroke", keywords="mobile phone", abstract="Background: Strokes pose a particular challenge to the health care system. Although stroke-related mortality has declined in recent decades, the absolute number of new strokes (incidence), stroke deaths, and survivors of stroke has increased. With the increasing need of neurorehabilitation and the decreasing number of professionals, innovations are needed to ensure adequate care. Digital technologies are increasingly used to meet patients' unfilled needs during their patient journey. Patients must adhere to unfamiliar digital technologies to engage in health interventions. Therefore, the acceptance of the benefits and burdens of digital technologies in health interventions is a key factor in implementing these innovations. Objective: This study aims to describe the development of a discrete choice experiment (DCE) to weigh criteria that impact patient and public acceptance. Secondary study objectives are a benefit-burden assessment (estimation of the maximum acceptable burden of technical features and therapy-related characteristics for the patient or individual, eg, no human contact), overall comparison (assessment of the relative importance of attributes for comparing digital technologies), and adherence (identification of key attributes that influence patient adherence). The exploratory objectives include heterogeneity assessment and subgroup analysis. The methodological aims are to investigate the use of DCE. Methods: To obtain information on the criteria impacting acceptance, a DCE will be conducted including 7 attributes based on formative qualitative research. Patients with stroke (experimental group) and the general population (control group) are surveyed. The final instrument includes 6 best-best choice tasks in partial design. The experimental design is a fractional-factorial efficient Bayesian design (D-error). A conditional logit regression model and mixed logistic regression models will be used for analysis. To consider the heterogeneity of subgroups, a latent class analysis and an analysis of heteroscedasticity will be performed. Results: The literature review, qualitative preliminary study, survey development, and pretesting were completed. Data collection and analysis will be completed in the last quarter of 2023. Conclusions: Our results will inform decision makers about patients' and publics' acceptance of digital technologies used in innovative interventions. The patient preference information will improve decisions regarding the development, adoption, and pricing of innovative interventions. The behavioral changes in the choice of digital intervention alternatives are observable and can therefore be statistically analyzed. They can be translated into preferences, which define the value. This study will investigate the influences on the acceptance of digital interventions and thus support decisions and future research. International Registered Report Identifier (IRRID): DERR1-10.2196/46056 ", doi="10.2196/46056", url="https://www.researchprotocols.org/2023/1/e46056", url="http://www.ncbi.nlm.nih.gov/pubmed/37561559" } @Article{info:doi/10.2196/47736, author="Lolak, Sermkiat and Attia, John and McKay, J. Gareth and Thakkinstian, Ammarin", title="Comparing Explainable Machine Learning Approaches With Traditional Statistical Methods for Evaluating Stroke Risk Models: Retrospective Cohort Study", journal="JMIR Cardio", year="2023", month="Jul", day="26", volume="7", pages="e47736", keywords="stroke", keywords="machine learning", keywords="risk prediction model", keywords="explainable artificial Intelligence", keywords="risk factor", keywords="cohort study", keywords="high-risk patient", keywords="hypertension", abstract="Background: Stroke has multiple modifiable and nonmodifiable risk factors and represents a leading cause of death globally. Understanding the complex interplay of stroke risk factors is thus not only a scientific necessity but a critical step toward improving global health outcomes. Objective: We aim to assess the performance of explainable machine learning models in predicting stroke risk factors using real-world cohort data by comparing explainable machine learning models with conventional statistical methods. Methods: This retrospective cohort included high-risk patients from Ramathibodi Hospital in Thailand between January 2010 and December 2020. We compared the performance and explainability of logistic regression (LR), Cox proportional hazard, Bayesian network (BN), tree-augmented Na{\"i}ve Bayes (TAN), extreme gradient boosting (XGBoost), and explainable boosting machine (EBM) models. We used multiple imputation by chained equations for missing data and discretized continuous variables as needed. Models were evaluated using C-statistics and F1-scores. Results: Out of 275,247 high-risk patients, 9659 (3.5\%) experienced a stroke. XGBoost demonstrated the highest performance with a C-statistic of 0.89 and an F1-score of 0.80 followed by EBM and TAN with C-statistics of 0.87 and 0.83, respectively; LR and BN had similar C-statistics of 0.80. Significant factors associated with stroke included atrial fibrillation (AF), hypertension (HT), antiplatelets, HDL, and age. AF, HT, and antihypertensive medication were common significant factors across most models, with AF being the strongest factor in LR, XGBoost, BN, and TAN models. Conclusions: Our study developed stroke prediction models to identify crucial predictive factors such as AF, HT, or systolic blood pressure or antihypertensive medication, anticoagulant medication, HDL, age, and statin use in high-risk patients. The explainable XGBoost was the best model in predicting stroke risk, followed by EBM. ", doi="10.2196/47736", url="https://cardio.jmir.org/2023/1/e47736", url="http://www.ncbi.nlm.nih.gov/pubmed/37494080" } @Article{info:doi/10.2196/45816, author="Specht, Julian and Stegmann, Barbara and Gross, Hanna and Krakow, Karsten", title="Cognitive Training With Head-Mounted Display Virtual Reality in Neurorehabilitation: Pilot Randomized Controlled Trial", journal="JMIR Serious Games", year="2023", month="Jul", day="21", volume="11", pages="e45816", keywords="cognitive rehabilitation", keywords="virtual reality", keywords="neurorehabilitation", keywords="psychology", keywords="stroke", abstract="Background: Neurological rehabilitation is technologically evolving rapidly, resulting in new treatments for patients. Stroke, one of the most prevalent conditions in neurorehabilitation, has been a particular focus in recent years. However, patients often need help with physical and cognitive constraints, whereby the cognitive domain in neurorehabilitation does not technologically exploit existing potential. Usually, cognitive rehabilitation is performed with pen and paper or on a computer, which leads to limitations in preparation for activities of daily living. Technologies such as virtual reality (VR) can bridge this gap. Objective: This pilot study investigated the use of immersive VR in cognitive rehabilitation for patients undergoing inpatient neurorehabilitation. The goal was to determine the difference in rehabilitation effectiveness between a VR serious game that combines everyday activities with cognitive paradigms and conventional computerized cognitive training. We hypothesized the superiority of the VR serious game regarding cognitive abilities and patient-reported outcomes as well as transfer to daily life. Methods: We recruited 42 patients with acute brain affection from a German neurorehabilitation clinic in inpatient care with a Mini Mental Status Test score >20 to participate in this randomized controlled trial. Participants were randomly assigned to 2 groups, with 1 receiving the experimental VR treatment (n=21). VR training consisted of daily life scenarios, for example, in a kitchen, focusing on treating executive functions such as planning and problem-solving. The control group (n=21) received conventional computerized cognitive training. Each participant received a minimum of 18 treatment sessions in their respective group. Patients were tested for cognitive status, subjective health, and quality of life before and after the intervention (Alters-Konzentrations-Test, Wechsler Memory Scale---Revised, Trail Making Test A and B, Tower of London---German version, Short Form 36, European Quality of Life 5 Dimensions visual analog scale, and Fragebogen zur Erfassung der Performance in VR). Results: Repeated-measures ANOVA revealed several significant main effects in the cognitive tests: Tower of London---German version (P=.046), Trail Making Test A (P=.01), and Wechsler Memory Scale---Revised (P=.006). However, post hoc tests revealed that the VR group showed significant improvement in the planning, executive control, and problem-solving domains (P=.046, Bonferroni P=.02). In contrast, no significant improvement in the control group between t0 and t1 was detected (all P>.05). Furthermore, a nonsignificant trend was observed in visual speed in the VR group (P=.09, Bonferroni P=.02). Conclusions: The results of this pilot randomized controlled trial showed that immersive VR training in cognitive rehabilitation had greater effectiveness than the standard of care in treating patients experiencing stroke in some cognitive domains . These findings support the further use and study of VR training incorporating activities of daily living in other neurological disorders involving cognitive dysfunction. Trial Registration: Federal Registry of Clinical Trials of Germany (DRKS) DRKS00023605; https://drks.de/search/de/trial/DRKS00023605 ", doi="10.2196/45816", url="https://games.jmir.org/2023/1/e45816", url="http://www.ncbi.nlm.nih.gov/pubmed/37477957" } @Article{info:doi/10.2196/40639, author="Potter, H. Thomas B. and Pratap, Sharmila and Nicolas, Carlos Juan and Khan, S. Osman and Pan, P. Alan and Bako, T. Abdulaziz and Hsu, Enshuo and Johnson, Carnayla and Jefferson, N. Imory and Adegbindin, K. Sofiat and Baig, Eman and Kelly, R. Hannah and Jones, L. Stephen and Britz, W. Gavin and Tannous, Jonika and Vahidy, S. Farhaan", title="A Neuro-Informatics Pipeline for Cerebrovascular Disease: Research Registry Development", journal="JMIR Form Res", year="2023", month="Jul", day="21", volume="7", pages="e40639", keywords="clinical outcome", keywords="intracerebral hemorrhage", keywords="acute ischemic stroke", keywords="transient ischemic attack", keywords="subarachnoid hemorrhage", keywords="cerebral amyloid angiopathy", keywords="learning health system", keywords="electronic health record", keywords="data curation", keywords="database", abstract="Background: Although stroke is well recognized as a critical disease, treatment options are often limited. Inpatient stroke encounters carry critical information regarding the mechanisms of stroke and patient outcomes; however, these data are typically formatted to support administrative functions instead of research. To support improvements in the care of patients with stroke, a substantive research data platform is needed. Objective: To advance a stroke-oriented learning health care system, we sought to establish a comprehensive research repository of stroke data using the Houston Methodist electronic health record (EHR) system. Methods: Dedicated processes were developed to import EHR data of patients with primary acute ischemic stroke, intracerebral hemorrhage (ICH), transient ischemic attack, and subarachnoid hemorrhage under a review board--approved protocol. Relevant patients were identified from discharge diagnosis codes and assigned registry patient identification numbers. For identified patients, extract, transform, and load processes imported EHR data of primary cerebrovascular disease admissions and available data from any previous or subsequent admissions. Data were loaded into patient-focused SQL objects to enable cross-sectional and longitudinal analyses. Primary data domains (admission details, comorbidities, laboratory data, medications, imaging data, and discharge characteristics) were loaded into separate relational tables unified by patient and encounter identification numbers. Computed tomography, magnetic resonance, and angiography images were retrieved. Imaging data from patients with ICH were assessed for hemorrhage characteristics and cerebral small vessel disease markers. Patient information needed to interface with other local and national databases was retained. Prospective patient outreach was established, with patients contacted via telephone to assess functional outcomes 30, 90, 180, and 365 days after discharge. Dashboards were constructed to provide investigators with data summaries to support access. Results: The Registry of Neurological Endpoint Assessments among Patients with Ischemic and Hemorrhagic Stroke (REINAH) database was constructed as a series of relational category-specific SQL objects. Encounter summaries and dashboards were constructed to draw from these objects, providing visual data summaries for investigators seeking to build studies based on REINAH data. As of June 2022, the database contains 18,061 total patients, including 1809 (10.02\%) with ICH, 13,444 (74.43\%) with acute ischemic stroke, 1221 (6.76\%) with subarachnoid hemorrhage, and 3165 (17.52\%) with transient ischemic attack. Depending on the cohort, imaging data from computed tomography are available for 85.83\% (1048/1221) to 98.4\% (1780/1809) of patients, with magnetic resonance imaging available for 27.85\% (340/1221) to 85.54\% (11,500/13,444) of patients. Outcome assessment has successfully contacted 56.1\% (240/428) of patients after ICH, with 71.3\% (171/240) of responders providing consent for assessment. Responders reported a median modified Rankin Scale score of 3 at 90 days after discharge. Conclusions: A highly curated and clinically focused research platform for stroke data will establish a foundation for future research that may fundamentally improve poststroke patient care and outcomes. ", doi="10.2196/40639", url="https://formative.jmir.org/2023/1/e40639", url="http://www.ncbi.nlm.nih.gov/pubmed/37477961" } @Article{info:doi/10.2196/42094, author="Tropea, Peppino and Infarinato, Francesco and Sterpi, Irma and Ottaviani, Marco and Antoniotti, Paola and Romano, Paola and Picardi, Michela and Goffredo, Michela and Re, Riccardo and Pournajaf, Sanaz and Seregni, Agnese and Caronni, Antonio and Franceschini, Marco and Corbo, Massimo", title="Action Observation Treatment for Upper Limb Rehabilitation in Patients With Stroke: Protocol for a Multicenter Randomized Controlled Trial", journal="JMIR Res Protoc", year="2023", month="Apr", day="20", volume="12", pages="e42094", keywords="action observation treatment", keywords="stroke rehabilitation", keywords="upper limb kinematics", keywords="EEG", keywords="electroencephalography", keywords="qEEG", keywords="quantitative electroencephalography", abstract="Background: In the last few years, new noninvasive strategies have emerged as rehabilitative treatments for patients with stroke. Action observation treatment (AOT) is a rehabilitation approach based on the properties of the mirror neuron system with a positive impact on modifying cortical activation patterns and improving the upper limb kinematics. AOT involves the dynamic process of observing purposeful actions with the intention of imitating and then practicing those actions. In recent years, several clinical studies suggested the effectiveness of AOT in patients with stroke to improve motor recovery and autonomy in activities of daily living. However, a deeper knowledge of the behavior of the sensorimotor cortex during AOT seems to be essential. Objective: The aim of this clinical trial, conducted in 2 neurorehabilitation centers and in patients' homes, is to investigate the effectiveness of AOT in patients with stroke, confirming the translational power of a tailored treatment. Particular emphasis will be placed on the predictive value of neurophysiological biomarkers. In addition, the feasibility and impact of a home-based AOT program will be investigated. Methods: A 3-arm, assessor-blinded, randomized controlled trial will be performed by enrolling patients with stroke in the chronic stage. A total of 60 participants will be randomly allocated to receive 15 sessions of AOT with different protocols (AOT at the hospital, AOT at home, and sham AOT), 3 sessions per week. The primary outcome will be assessed using the Fugl-Meyer Assessment-Upper Extremity scores. Secondary outcomes will be clinical, biomechanical, and neurophysiological assessment. Results: The study protocol is part of a project (project code GR-2016--02361678) approved and funded by the Italian Ministry of Health. The study began with the recruitment phase in January 2022, and enrollment was expected to end in October 2022. Recruitment is now closed (December 2022). The results of this study are expected to be published in spring 2023. Upon completion of the analyses, we will examine the preliminary effectiveness of the intervention and neurophysiological outcomes. Conclusions: This study will be used to evaluate the effectiveness of 2 different AOT scenarios (ie, AOT at the hospital and AOT at home) in patients with chronic stroke and to assess the predictive value of neurophysiological biomarkers. Specifically, we will attempt to induce the functional modification of the cortical components by exploiting the features of the mirror neuron system, demonstrating relevant clinical, kinematic, and neurophysiological changes after AOT. With our study, we also want to provide, for the first time in Italy, the AOT home-based program while assessing its feasibility and impact. Trial Registration: ClinicalTrials.gov NCT04047134; https://clinicaltrials.gov/ct2/show/NCT04047134 International Registered Report Identifier (IRRID): DERR1-10.2196/42094 ", doi="10.2196/42094", url="https://www.researchprotocols.org/2023/1/e42094", url="http://www.ncbi.nlm.nih.gov/pubmed/37079364" } @Article{info:doi/10.2196/43861, author="Davoody, Nadia and Eghdam, Aboozar and Koch, Sabine and H{\"a}gglund, Maria", title="Evaluation of an Electronic Care and Rehabilitation Planning Tool With Stroke Survivors With Aphasia: Usability Study", journal="JMIR Hum Factors", year="2023", month="Apr", day="17", volume="10", pages="e43861", keywords="usability testing", keywords="stroke", keywords="aphasia", keywords="eHealth", keywords="rehabilitation", keywords="co-design", keywords="evaluation", keywords="user-centered design", keywords="effectiveness", keywords="user satisfaction", keywords="mobile phone", abstract="Background: Patients with chronic illnesses with physical and cognitive disabilities, particularly stroke survivors with aphasia, are often not involved in design and evaluation processes. As a consequence, existing eHealth services often do not meet the needs of this group of patients, which has resulted in a digital divide. Objective: The aim of this study was to examine the effectiveness and user satisfaction of an electronic care and rehabilitation planning tool from the perspective of stroke survivors with aphasia. This would help us gain knowledge on how such a tool would need to be adapted for these patients for further development. Methods: Usability tests were conducted with 9 postdischarge stroke survivors with aphasia. Effectiveness was measured using task-based tests, and user satisfaction was studied through qualitative interviews at the end of each test. All tests were audio recorded, and each test lasted approximately 1 hour. The data were analyzed using qualitative content analysis. As the tool can be used by stroke survivors either independently or with some support from their next of kin or care professionals, the research group decided to divide the participants into 2 groups. Group 1 did not receive any support during the tests, and group 2 received some minor support from the moderator. Results: The results showed that the care and rehabilitation planning tool was not effective for stroke survivors with aphasia, as many participants in group 1 did not accomplish the tasks successfully. Despite several usability problems and challenges in using the tool because of patients' disabilities, the participants were positive toward using the tool and found it useful for their care and rehabilitation journey. Conclusions: There is a need to involve patients with chronic illnesses more in the design and evaluation processes of health information systems and eHealth services. eHealth services and health information systems designed for this group of patients should be more adaptable and flexible to provide them with appropriate functionalities and features, meet their needs, and be useful and easy to use. In addition, the design and evaluation processes should be adapted, considering the challenges of this patient group. ", doi="10.2196/43861", url="https://humanfactors.jmir.org/2023/1/e43861", url="http://www.ncbi.nlm.nih.gov/pubmed/37067848" } @Article{info:doi/10.2196/37442, author="Mee, Harry and Casta{\~n}o-Leon, M. Ana and Timofeev, Ivan and Adeleye, Amos and Devi Bhagavatula, Indira and Marklund, Niklas and Muehlschlegel, Susanne and Bond, Katie and Clement, Clare and Grieve, Kirsty and Owen, Nicola and Whiting, Gemma and Turner, Carole and Rubiano Escobar, Mariano Andres and Shukla, Dhaval and Paul, Maria and Allanson, Judith and Pomeroy, Valerie and Viaroli, Edoardo and Warburton, Elizabeth and Wells, Adam and Hawryluk, Gregory and Helmy, Adel and Anwar, Fahim and Honeybul, Stephen and Hutchinson, Peter and Kolias, Angelos", title="Standardizing Cranioplasty Outcomes Following Stroke or Traumatic Brain Injury: Protocol for the Development of a Core Outcome Set", journal="JMIR Res Protoc", year="2023", month="Apr", day="17", volume="12", pages="e37442", keywords="cranioplasty", keywords="TBI", keywords="stroke", keywords="core outcome set", keywords="domains", keywords="COMET", keywords="health Interventions", keywords="recovery", keywords="traumatic brain injury", keywords="neurological", keywords="neurology", keywords="reporting", keywords="outcome", abstract="Background: Core outcome sets (COSs) are important and necessary as they help standardize reporting in research studies. Cranioplasty following traumatic brain injury (TBI) or stroke is becoming increasingly common, leading to an ever-growing clinical and research interest, especially regarding the optimal material, cost-effectiveness, and timing of cranioplasty concerning neurological recovery and complications. Consequently, heterogeneous reporting of outcomes from such diverse studies has led to limited meta-analysis ability and an ongoing risk of outcome reporting bias. This study aims to define a standardized COS for reporting in all future TBI and stroke cranioplasty studies. Objective: This study has four aims: (1) undertake a systematic review to collate the most current outcome measures used within the cranioplasty literature; (2) undertake a qualitative study to understand better the views of clinicians, patients' relatives, and allied health professionals regarding clinical outcomes following cranioplasty; (3) undertake a Delphi survey as part of the process of gaining consensus for the COS; and (4) finalize consensus through a consensus meeting resulting in the COS. Methods: An international steering committee has been formed to guide the development of the COS. In addition, recommendations from other clinical initiatives such as COMET (Core Outcomes and Effectiveness Trials) and OMERACT (Outcome Measures in Rheumatology) have been adhered to. Phase 1 is data collection through a systematic review and qualitative study. Phase 2 is the COS development through a Delphi survey and consensus meetings with consensus definitions decided and agreed upon before the Delphi survey begins to avoid bias. Results: Phase 1 started at the end of 2019, following ethical approval in December 2019, and the project completion date is planned for the end of 2022 or beginning of 2023. Conclusions: This study should result in a consensus on a COS for cranioplasty, following TBI or stroke, to help standardize outcome reporting for future studies, which can be applied to future research and clinical services, help align future studies, build an increased understanding of cranioplasty and its impact on a patient's function and recovery, and help standardize the evidence base. International Registered Report Identifier (IRRID): DERR1-10.2196/37442 ", doi="10.2196/37442", url="https://www.researchprotocols.org/2023/1/e37442", url="http://www.ncbi.nlm.nih.gov/pubmed/35759752" } @Article{info:doi/10.2196/44285, author="Epalte, Klinta and Grjadovojs, Aleksandrs and B?rzi?a, Guna", title="Use of the Digital Assistant Vigo in the Home Environment for Stroke Recovery: Focus Group Discussion With Specialists Working in Neurorehabilitation", journal="JMIR Rehabil Assist Technol", year="2023", month="Apr", day="14", volume="10", pages="e44285", keywords="stroke", keywords="rehabilitation", keywords="digital therapeutic", keywords="focus group", keywords="home-based rehabilitation", keywords="recovery", keywords="efficacy", keywords="application", keywords="rehabilitation program", keywords="functionality", keywords="usability", keywords="development", abstract="Background: There is a lack of resources for the provision of adequate rehabilitation after a stroke, thus creating a challenge to provide the necessary high-quality, patient-centered, and cost-efficient rehabilitation services at a time when they are needed the most. Tablet-based therapeutic programs present an alternative way to access rehabilitation services and show a new paradigm for providing therapeutic interventions following a stroke anytime and anywhere. The digital assistant Vigo is an artificial intelligence--based app that provides an opportunity for a new, more integrative way of carrying out a home-based rehabilitation program. Considering the complexity of the stroke recovery process, factors such as a suitable population, appropriate timing, setting, and the necessary patient-specialist support structure need to be thoroughly researched. There is a lack of qualitative research exploring the perspectives of professionals working in neurorehabilitation of the content and usability of the digital tool for the recovery of patients after a stroke. Objective: The aim of this study is to identify the requirements for a tablet-based home rehabilitation program for stroke recovery from the perspective of a specialist working in stroke rehabilitation. Methods: The focus group study method was chosen to explore specialists' attitudes, experience, and expectations related to the use of the digital assistant Vigo as a home-based rehabilitation program for stroke recovery in domains of the app's functionality, compliance, usability, and content. Results: In total, 3 focus groups were conducted with a participant count of 5-6 per group and the duration of the discussion ranging from 70 to 80 minutes. In total, 17 health care professionals participated in the focus group discussions. The participants represented physiotherapists (n=7, 41.2\%), occupational therapists (n=7, 41.2\%), speech and language therapists (n=2, 11.8\%), and physical medicine and rehabilitation physicians (n=1, 5.9\%). Audio and video recordings of each discussion were created for further transcription and analysis. In total, 4 themes were identified: (1) the clinician's views on using Vigo as a home-based rehabilitation system, (2) patient-related circumstances facilitating and limiting the use of Vigo; (3) Vigo's functionality and use process (program creation, individual use, remote support); and (4) complementary and alternative Vigo use perspectives. The last 3 themes were divided further into 10 subthemes, and 2 subthemes had 2 sub-subthemes each. Conclusions: Health care professionals expressed a positive attitude toward the usability of the Vigo app. It is important that the content and use of the app be coherent with the aim to avoid (1) misunderstanding its practical use and the need for integration in practice and (2) misusing the app. In all focus groups, the importance of close involvement of rehabilitation specialists in the process of app development and research was highlighted. ", doi="10.2196/44285", url="https://rehab.jmir.org/2023/1/e44285", url="http://www.ncbi.nlm.nih.gov/pubmed/37058334" } @Article{info:doi/10.2196/39307, author="Suda, Satoshi and Katano, Takehiro and Kitagawa, Kazuo and Iguchi, Yasuyuki and Fujimoto, Shigeru and Ono, Kenjiro and Kano, Osamu and Takekawa, Hidehiro and Koga, Masatoshi and Ihara, Masafumi and Morimoto, Masafumi and Yamagami, Hiroshi and Terasaki, Tadashi and Yamaguchi, Keiji and Okubo, Seiji and Ueno, Yuji and Ohara, Nobuyuki and Kamiya, Yuki and Takeuchi, Masataka and Yazawa, Yukako and Terasawa, Yuka and Doijiri, Ryosuke and Tsuboi, Yoshifumi and Sonoda, Kazutaka and Nomura, Koichi and Shimoyama, Takashi and Kutsuna, Akihito and Kimura, Kazumi", title="Detection of Atrial Fibrillation Using Insertable Cardiac Monitors in Patients With Cryptogenic Stroke in Japan (the LOOK Study): Protocol for a Prospective Multicenter Observational Study", journal="JMIR Res Protoc", year="2023", month="Apr", day="13", volume="12", pages="e39307", keywords="atrial cardiomyopathy", keywords="atrial fibrillation", keywords="biomarker", keywords="cryptogenic stroke", keywords="insertable cardiac monitor", abstract="Background: Paroxysmal atrial fibrillation (AF) is a probable cause of cryptogenic stroke (CS), and its detection and treatment are important for the secondary prevention of stroke. Insertable cardiac monitors (ICMs) are clinically effective in screening for AF and are superior to conventional short-term cardiac monitoring. Japanese guidelines for determining clinical indications for ICMs in CS are stricter than those in Western countries. Differences between Japanese and Western guidelines may impact the detection rate and prediction of AF via ICMs in patients with CS. Available data on Japanese patients are limited to small retrospective studies. Furthermore, additional information about AF detection, including the number of episodes, cumulative episode duration, anticoagulation initiation (type and dose of regimen and time of initiation), rate of catheter ablation, role of atrial cardiomyopathy, and stroke recurrence (time of recurrence and cause of the recurrent event), was not provided in the vast majority of previously published studies. Objective: In this study, we aim to identify the proportion and timing of AF detection and risk stratification criteria in patients with CS in real-world settings in Japan. Methods: This is a multicenter, prospective, observational study that aims to use ICMs to evaluate the proportion, timing, and characteristics of AF detection in patients diagnosed with CS. We will investigate the first detection of AF within the initial 6, 12, and 24 months of follow-up after ICM implantation. Patient characteristics, laboratory data, atrial cardiomyopathy markers, serial magnetic resonance imaging findings at baseline, 6, 12, and 24 months after ICM implantation, electrocardiogram readings, transesophageal echocardiography findings, cognitive status, stroke recurrence, and functional outcomes will be compared between patients with AF and patients without AF. Furthermore, we will obtain additional information regarding the number of AF episodes, duration of cumulative AF episodes, and time of anticoagulation initiation. Results: Study recruitment began in February 2020, and thus far, 213 patients have provided written informed consent and are currently in the follow-up phase. The last recruited participant (May 2021) will have completed the 24-month follow-up in May 2023. The main results are expected to be submitted for publication in 2023. Conclusions: The findings of this study will help identify AF markers and generate a risk scoring system with a novel and superior screening algorithm for occult AF detection while identifying candidates for ICM implantation and aiding the development of diagnostic criteria for CS in Japan. Trial Registration: UMIN Clinical Trial Registry UMIN000039809; https://tinyurl.com/3jaewe6a International Registered Report Identifier (IRRID): DERR1-10.2196/39307 ", doi="10.2196/39307", url="https://www.researchprotocols.org/2023/1/e39307", url="http://www.ncbi.nlm.nih.gov/pubmed/37052993" } @Article{info:doi/10.2196/42556, author="Bally, S. Esmee L. and Cheng, Demi and van Grieken, Amy and Ferri Sanz, Mireia and Zanutto, Oscar and Carroll, Aine and Darley, Andrew and Roozenbeek, Bob and Dippel, J. Diederik W. and Raat, Hein", title="Patients' Perspectives Regarding Digital Health Technology to Support Self-management and Improve Integrated Stroke Care: Qualitative Interview Study", journal="J Med Internet Res", year="2023", month="Apr", day="4", volume="25", pages="e42556", keywords="stroke patients", keywords="digital health technology", keywords="self-management", keywords="co-design", keywords="user-requirements", keywords="user-centered design", keywords="qualitative research", abstract="Background: Digital technologies such as mobile apps and robotics have the potential to involve stroke patients better in the care process and to promote self-management. However, barriers exist that constrain the adoption and acceptance of technology in clinical practice. Examples of barriers are privacy concerns, challenges regarding usability, and the perception that there is no need for health-related technology. To address these barriers, co-design can be used to enable patients to reflect on their experiences of a service and to tailor digital technologies to the needs and preferences of end users regarding content and usability. Objective: This study aims to explore the perspectives of stroke patients toward how digital health technology could support self-management regarding health and well-being, as well as integrated stroke care. Methods: A qualitative study was conducted to understand patient perspectives. Data were collected in co-design sessions during the ValueCare study. Patients from a Dutch hospital who experienced an ischemic stroke (n=36) within the past 18 months were invited to participate. Data collection took place between December 2020 and April 2021 via one-to-one telephone interviews. A short self-report questionnaire was used to collect data on sociodemographics, disease-specific information, and technology use. All interviews were audio-taped and transcribed verbatim. The interview data were analyzed using a thematic approach. Results: Patients held mixed attitudes toward digital health technologies. Some patients viewed digital technology as a convenient product or service, while others expressed no desire or need to use technology for self-management or care. Digital features suggested by stroke patients included (1) information about the causes of stroke, medication, prognosis, and follow-up care; (2) an online library with information regarding stroke-related health and care issues; (3) a personal health record by which patients can retrieve and manage their own health information; and (4) online rehabilitation support to empower patients to exercise at home. Regarding the user interface of future digital health technology, patients emphasized the need for easy-to-use and simple designs. Conclusions: Stroke patients mentioned credible health information, an online library with stroke-related health and care information, a personal health record, and online rehabilitation support as the main features to include in future digital health technologies. We recommend that developers and designers of digital health for stroke care listen to the ``voice of the stroke patients'' regarding both functionality and the characteristics of the interface. International Registered Report Identifier (IRRID): RR2-10.1186/s12877-022-03333-8 ", doi="10.2196/42556", url="https://www.jmir.org/2023/1/e42556", url="http://www.ncbi.nlm.nih.gov/pubmed/37014677" } @Article{info:doi/10.2196/40651, author="Stammler, Britta and Flammer, Kathrin and Schuster, Thomas and Lambert, Marian and Karnath, Hans-Otto", title="Negami: An Augmented Reality App for the Treatment of Spatial Neglect After Stroke", journal="JMIR Serious Games", year="2023", month="Feb", day="27", volume="11", pages="e40651", keywords="spatial neglect", keywords="gamification", keywords="augmented reality", keywords="visual exploration training", keywords="stroke rehabilitation", keywords="serious games", keywords="rehabilitation", keywords="stroke", abstract="Background: A widely applied and effective rehabilitation method for patients experiencing spatial neglect after a stroke is ``visual exploration training.'' Patients improve their ipsilesional bias of attention and orientation by training exploration movements and search strategies toward the contralesional side of space. In this context, gamification can have a positive influence on motivation for treatment and thus on the success of treatment. In contrast to virtual reality applications, treatment enhancements through augmented reality (AR) have not yet been investigated, although they offer some advantages over virtual reality. Objective: This study aimed to develop an AR-based app (Negami) for the treatment of spatial neglect that combines visual exploration training with active, contralesionally oriented rotation of the eyes, head, and trunk. Methods: The app inserts a virtual element (origami bird) into the real space surrounding the patient, which the patient explores with the camera of a tablet. Subjective reports from healthy elderly participants (n=10) and patients with spatial neglect after stroke (n=10) who trained with the new Negami app were analyzed. Usability, side effects, and game experience were assessed by various questionnaires. Results: Training at the highest defined difficulty level was perceived as differently challenging but not as frustrating by the group of healthy elderly participants. The app was rated with high usability, hardly any side effects, high motivation, and entertainment. The group of patients with spatial neglect after stroke consistently evaluated the app positively on the dimensions of motivation, satisfaction, and fun. Conclusions: The Negami app represents a promising extension by adding AR to traditional exploration training for spatial neglect. Through participants' natural interaction with the physical surrounding environment during playful tasks, side effects as symptoms of cybersickness are minimized and patients' motivation appeared to markedly increase. The use of AR in cognitive rehabilitation programs and the treatment of spatial neglect seems promising and should receive further investigation. ", doi="10.2196/40651", url="https://games.jmir.org/2023/1/e40651", url="http://www.ncbi.nlm.nih.gov/pubmed/36848215" } @Article{info:doi/10.2196/40416, author="Guo, Liquan and Wang, Jiping and Wu, Qunqiang and Li, Xinming and Zhang, Bochao and Zhou, Linfu and Xiong, Daxi", title="Clinical Study of a Wearable Remote Rehabilitation Training System for Patients With Stroke: Randomized Controlled Pilot Trial", journal="JMIR Mhealth Uhealth", year="2023", month="Feb", day="23", volume="11", pages="e40416", keywords="remote rehabilitation", keywords="wearable devices", keywords="human-computer interaction", keywords="rehabilitation training", keywords="stroke", abstract="Background: In contrast to the large and increasing number of patients with stroke, clinical rehabilitation resources cannot meet their rehabilitation needs. Especially for those discharged, ways to carry out effective rehabilitation training without the supervision of physicians and receive guidance from physicians remain urgent problems to be solved in clinical rehabilitation and have become a research hot spot at home and abroad. At present, there are many studies on home rehabilitation training based on wearable devices, Kinect, among others, but these have disadvantages (eg, complex systems, high price, and unsatisfactory rehabilitation effects). Objective: This study aims to design a remote intelligent rehabilitation training system based on wearable devices and human-computer interaction training tasks, and to evaluate the effectiveness and safety of the remote rehabilitation training system for nonphysician-supervised motor rehabilitation training of patients with stroke through a clinical trial study. Methods: A total of 120 inpatients with stroke having limb motor dysfunction were enrolled via a randomized, parallel-controlled method in the rehabilitation institutions, and a 3-week clinical trial was conducted in the rehabilitation hall with 60 patients in the experimental group and 60 in the control group. The patients in the experimental group used the remote rehabilitation training system for rehabilitation training and routine clinical physical therapy (PT) training and received routine drug treatment every day. The patients in the control group received routine clinical occupational therapy (OT) training and routine clinical PT training and routine drug treatment every day. At the beginning of the training (baseline) and after 3 weeks, the Fugl-Meyer Motor Function Rating scale was scored by rehabilitation physicians, and the results were compared and analyzed. Results: Statistics were performed using SAS software (version 9.4). The total mean Fugl-Meyer score improved by 11.98 (SD 8.46; 95\% CI 9.69-14.27) in the control group and 17.56 (SD 11.65; 95\% CI 14.37-20.74) in the experimental group, and the difference between the 2 groups was statistically significant (P=.005). Among them, the mean Fugl-Meyer upper extremity score improved by 7.45 (SD 7.24; 95\% CI 5.50-9.41) in the control group and 11.28 (SD 8.59; 95\% CI 8.93-13.62) in the experimental group, and the difference between the 2 groups was statistically significant (P=.01). The mean Fugl-Meyer lower extremity score improved by 4.53 (SD 4.42; 95\% CI 3.33-5.72) in the control group and 6.28 (SD 5.28; 95\% CI 4.84-7.72) in the experimental group, and there was no significant difference between the 2 groups (P=.06). The test results showed that the experimental group was better than the control group, and that the patients' motor ability was improved. Conclusions: The remote rehabilitation training system designed based on wearable devices and human-computer interaction training tasks can replace routine clinical OT training. In the future, through medical device registration certification, the system will be used without the participation of physicians or therapists, such as in rehabilitation training halls, and in remote environments, such as communities and homes. Trial Registration: Chinese Clinical Trial Registry ChiCTR2200061310; https://tinyurl.com/34ka2725 ", doi="10.2196/40416", url="https://mhealth.jmir.org/2023/1/e40416", url="http://www.ncbi.nlm.nih.gov/pubmed/36821348" } @Article{info:doi/10.2196/41691, author="Han, Dong and Ding, Y. Eric and Cho, Chaeho and Jung, Haewook and Dickson, L. Emily and Mohagheghian, Fahimeh and Peitzsch, G. Andrew and DiMezza, Danielle and Tran, Khanh-Van and McManus, D. David and Chon, H. Ki", title="A Smartwatch System for Continuous Monitoring of Atrial Fibrillation in Older Adults After Stroke or Transient Ischemic Attack: Application Design Study", journal="JMIR Cardio", year="2023", month="Feb", day="13", volume="7", pages="e41691", keywords="atrial fibrillation", keywords="stroke", keywords="smartwatch app", keywords="smartphone apps", keywords="wearable devices", keywords="user experience", keywords="older adults", keywords="mobile phone", abstract="Background: The prevalence of atrial fibrillation (AF) increases with age and can lead to stroke. Therefore, older adults may benefit the most from AF screening. However, older adult populations tend to lag more than younger groups in the adoption of, and comfort with, the use of mobile health (mHealth) apps. Furthermore, although mobile apps that can detect AF are available to the public, most are designed for intermittent AF detection and for younger users. No app designed for long-term AF monitoring has released detailed system design specifications that can handle large data collections, especially in this age group. Objective: This study aimed to design an innovative smartwatch-based AF monitoring mHealth solution in collaboration with older adult participants and clinicians. Methods: The Pulsewatch system is designed to link smartwatches and smartphone apps, a website for data verification, and user data organization on a cloud server. The smartwatch in the Pulsewatch system is designed to continuously monitor the pulse rate with embedded AF detection algorithms, and the smartphone in the Pulsewatch system is designed to serve as the data-transferring hub to the cloud storage server. Results: We implemented the Pulsewatch system based on the functionality that patients and caregivers recommended. The user interfaces of the smartwatch and smartphone apps were specifically designed for older adults at risk for AF. We improved our Pulsewatch system based on feedback from focus groups consisting of patients with stroke and clinicians. The Pulsewatch system was used by the intervention group for up to 6 weeks in the 2 phases of our randomized clinical trial. At the conclusion of phase 1, 90 trial participants who had used the Pulsewatch app and smartwatch for 14 days completed a System Usability Scale to assess the usability of the Pulsewatch system; of 88 participants, 56 (64\%) endorsed that the smartwatch app is ``easy to use.'' For phases 1 and 2 of the study, we collected 9224.4 hours of smartwatch recordings from the participants. The longest recording streak in phase 2 was 21 days of consecutive recordings out of the 30 days of data collection. Conclusions: This is one of the first studies to provide a detailed design for a smartphone-smartwatch dyad for ambulatory AF monitoring. In this paper, we report on the system's usability and opportunities to increase the acceptability of mHealth solutions among older patients with cognitive impairment. Trial Registration: ClinicalTrials.gov NCT03761394; https://www.clinicaltrials.gov/ct2/show/NCT03761394 International Registered Report Identifier (IRRID): RR2-10.1016/j.cvdhj.2021.07.002 ", doi="10.2196/41691", url="https://cardio.jmir.org/2023/1/e41691", url="http://www.ncbi.nlm.nih.gov/pubmed/36780211" } @Article{info:doi/10.2196/36477, author="Chen, Min and Tan, Xuan and Padman, Rema", title="A Machine Learning Approach to Support Urgent Stroke Triage Using Administrative Data and Social Determinants of Health at Hospital Presentation: Retrospective Study", journal="J Med Internet Res", year="2023", month="Jan", day="30", volume="25", pages="e36477", keywords="stroke", keywords="diagnosis", keywords="triage", keywords="decision support", keywords="social determinants of health", keywords="prediction", keywords="machine learning", keywords="interpretability", keywords="medical decision-making", keywords="retrospective study", keywords="claims data", abstract="Background: The key to effective stroke management is timely diagnosis and triage. Machine learning (ML) methods developed to assist in detecting stroke have focused on interpreting detailed clinical data such as clinical notes and diagnostic imaging results. However, such information may not be readily available when patients are initially triaged, particularly in rural and underserved communities. Objective: This study aimed to develop an ML stroke prediction algorithm based on data widely available at the time of patients' hospital presentations and assess the added value of social determinants of health (SDoH) in stroke prediction. Methods: We conducted a retrospective study of the emergency department and hospitalization records from 2012 to 2014 from all the acute care hospitals in the state of Florida, merged with the SDoH data from the American Community Survey. A case-control design was adopted to construct stroke and stroke mimic cohorts. We compared the algorithm performance and feature importance measures of the ML models (ie, gradient boosting machine and random forest) with those of the logistic regression model based on 3 sets of predictors. To provide insights into the prediction and ultimately assist care providers in decision-making, we used TreeSHAP for tree-based ML models to explain the stroke prediction. Results: Our analysis included 143,203 hospital visits of unique patients, and it was confirmed based on the principal diagnosis at discharge that 73\% (n=104,662) of these patients had a stroke. The approach proposed in this study has high sensitivity and is particularly effective at reducing the misdiagnosis of dangerous stroke chameleons (false-negative rate <4\%). ML classifiers consistently outperformed the benchmark logistic regression in all 3 input combinations. We found significant consistency across the models in the features that explain their performance. The most important features are age, the number of chronic conditions on admission, and primary payer (eg, Medicare or private insurance). Although both the individual- and community-level SDoH features helped improve the predictive performance of the models, the inclusion of the individual-level SDoH features led to a much larger improvement (area under the receiver operating characteristic curve increased from 0.694 to 0.823) than the inclusion of the community-level SDoH features (area under the receiver operating characteristic curve increased from 0.823 to 0.829). Conclusions: Using data widely available at the time of patients' hospital presentations, we developed a stroke prediction model with high sensitivity and reasonable specificity. The prediction algorithm uses variables that are routinely collected by providers and payers and might be useful in underresourced hospitals with limited availability of sensitive diagnostic tools or incomplete data-gathering capabilities. ", doi="10.2196/36477", url="https://www.jmir.org/2023/1/e36477", url="http://www.ncbi.nlm.nih.gov/pubmed/36716097" } @Article{info:doi/10.2196/31903, author="Denny, Carter Mary and Ancer Leal, Andrea and Montiel, Casameni Tahani and Wynne, J. Keona and Edquilang, Gabrielle and Vu, Thi Kim Yen and Vahidy, Farhaan and Savitz, I. Sean and Beauchamp, ES Jennifer and Sharrief, Anjail", title="An Intervention Mapping Approach to Developing a Stroke Literacy Video for Recent Stroke Survivors: Development and Usability Study", journal="JMIR Form Res", year="2023", month="Jan", day="4", volume="7", pages="e31903", keywords="stroke", keywords="stroke prevention", keywords="health literacy", keywords="stroke literacy", keywords="patient education", keywords="transition of care", keywords="risk factors", keywords="cardiac", keywords="digital health", abstract="Background: Most vascular events after stroke may be prevented by modifying vascular risk factors through medical and behavioral interventions. Stroke literacy---an understanding of stroke symptoms, risk factors, and treatment---likely contributes to vascular risk factor control and in turn stroke recurrence risk. Stroke literacy is the lowest among adults belonging to racial and ethnic minority populations in the United States. Video-based interventions targeting stroke literacy may help acute stroke survivors understand stroke and subsequently reduce the risk of stroke recurrence. However, the failure of prior stroke literacy interventions may be due in part to the fact that the interventions were not theory-driven. Intervention mapping (IM) provides a framework for use in the development, implementation, and evaluation of evidence-informed, health-related interventions. Objective: We aimed to develop a video-based educational intervention to improve stroke literacy in hospitalized patients with acute stroke. Methods: The 6-step iterative process of IM was used to develop a video-based educational intervention and related implementation and evaluation plans. The six steps included a needs assessment, the identification of outcomes and change objectives, the selection of theory- and video-based intervention methods and practical applications, the development of a video-based stroke educational intervention, plans for implementation, and evaluation strategies. Results: A 5-minute video-based educational intervention was developed. The IM approach led to successful intervention development by emphasizing stakeholder involvement, generation and adoption, and information retainment in the planning phase of the intervention. A planned approach to video adoption, implementation, and evaluation was also developed. Conclusions: An IM approach guided the development of a 5-minute video-based educational intervention to promote stroke literacy among acute stroke survivors. Future studies are needed to assess the use of technology and digital media to support widespread access and participation in video-based health literacy interventions for populations with acute and chronic stroke. Studies are needed to assess the impact of video-based educational interventions that are paired with stroke systems of care optimization to reduce the risk of stroke recurrence. Furthermore, studies on culturally and linguistically sensitive video-based stroke literacy interventions are needed to address known racial and ethnic disparities in stroke literacy. International Registered Report Identifier (IRRID): RR2-10.1371/journal.pone.0171952 ", doi="10.2196/31903", url="https://formative.jmir.org/2023/1/e31903", url="http://www.ncbi.nlm.nih.gov/pubmed/35972729" } @Article{info:doi/10.2196/40166, author="Morgan, A. Kerri and Wong, K. Alex W. and Walker, Kim and Desai, Heeb Rachel and Knepper, M. Tina and Newland, K. Pamela", title="A Mobile Phone Text Messaging Intervention to Manage Fatigue for People With Multiple Sclerosis, Spinal Cord Injury, and Stroke: Development and Usability Testing", journal="JMIR Form Res", year="2022", month="Dec", day="21", volume="6", number="12", pages="e40166", keywords="fatigue", keywords="disability", keywords="mobile health", keywords="mHealth", keywords="patient activation", abstract="Background: Fatigue significantly affects daily functioning in persons with disabilities. Fatigue management can be challenging, and the information provided during routine physician visits to manage fatigue can be overwhelming. One way to address fatigue is to increase knowledge, skills, and confidence for self-management (ie, patient activation). Self-management programs have shown promising effects in targeting fatigue in persons with disabilities. However, satisfaction with self-management programs is low for persons with disabilities, and tailoring interventions to personalized needs has been recommended. SMS text messaging is increasingly being used to implement health behavior change interventions in a person's natural environment. Little has been done to link mobile health approaches with patient activation and self-management to address fatigue in persons with disabilities. Objective: This study aimed to develop and test a mobile phone--based fatigue self-management SMS text messaging intervention targeting patient activation in 3 groups of persons with disabilities: persons with multiple sclerosis, persons who had a stroke, and persons with a spinal cord injury. Methods: We used evidence-based resources and input from a consumer advisory board (CAB; composed of 2 participants from each of the 3 disability groups) and a neurologist to develop the intervention. The study was conducted using a 4-step process: development of the initial SMS text messaging library and categorization of the content into 9 content areas, review and modification of the SMS text messages by the neurologist and CAB, integration of the content library into a digital platform, and utility testing by CAB members. Results: A total of 6 CAB participants rated SMS text messages covering 9 domain areas of fatigue self-management with good clarity (mean ratings=3.5-5.0 out of 5) and relevance (mean ratings=3.2-5.0 out of 5). Overall, SMS text messaging content was reported by CAB participants as helpful, clear, and well suited for a mobile health intervention. The CAB reached consensus on the time of day that SMS text messages should be sent (morning) and their frequency (once per day). This feedback led the research team to narrow down the program to deliver 48 SMS text messages, 1 per day, Monday through Thursday only, a total of 4 SMS text messages per week, over a 12-week period. The final set of SMS text messages was programmed into a digital platform with a predefined delivery schedule. The usability of the intervention was high, with 55 (83\%) out of 66 responses endorsing the highest rating. Conclusions: This study demonstrates a step-by-step process for developing a fatigue self-management SMS text messaging intervention for persons with disabilities. For this population, whose access to health services is often limited, this intervention provides an alternative delivery model to increase access to fatigue information and deliver content that aligns with the person's needs. ", doi="10.2196/40166", url="https://formative.jmir.org/2022/12/e40166", url="http://www.ncbi.nlm.nih.gov/pubmed/36542466" } @Article{info:doi/10.2196/40374, author="Kamalakannan, Sureshkumar and Karunakaran, Vijay and Kaliappan, Balaji Ashwin and Nagarajan, Ramakumar", title="Systematic Development of the ReWin Application: A Digital Therapeutic Rehabilitation Innovation for People With Stroke-related Disabilities in India", journal="JMIR Rehabil Assist Technol", year="2022", month="Nov", day="24", volume="9", number="4", pages="e40374", keywords="stroke", keywords="telerehabilitation", keywords="neurological rehabilitation", keywords="disability", keywords="India", keywords="rehabilitation", keywords="recovery", keywords="stroke care", keywords="patient care", keywords="digital technology", keywords="feasibility", keywords="acceptability", keywords="digital therapy", doi="10.2196/40374", url="https://rehab.jmir.org/2022/4/e40374", url="http://www.ncbi.nlm.nih.gov/pubmed/36422867" } @Article{info:doi/10.2196/40548, author="O'Keefe, Sophie and Radford, Kathryn and Farrin, Amanda and Oakman, Jodi and Alves-Stein, Serena and Cloud, Geoffrey and Douglas, Jacinta and Stanley, Mandy and Lannin, A. Natasha", title="A Tailored Occupational Therapist--Led Vocational Intervention for People With Stroke: Protocol for a Pilot Randomized Controlled Trial", journal="JMIR Res Protoc", year="2022", month="Oct", day="31", volume="11", number="10", pages="e40548", keywords="return to work", keywords="vocational rehabilitation", keywords="acquired brain injury", keywords="stroke", keywords="traumatic brain injury", keywords="neuroscience", keywords="rehabilitation", keywords="intervention", keywords="feasibility", keywords="stroke recovery", keywords="resume work", abstract="Background: Resuming work after stroke is a common goal of working-age adults, yet there are few vocational rehabilitation programs designed to address the unique challenges faced following stroke. The Work intervention was developed to address these gaps. Objective: This paper presents a protocol that outlines the steps that will be undertaken to pilot both the intervention and trial processes for the Work trial. Methods: The Work trial is a 2-arm, prospective, randomized, blinded-assessor study with intention-to-treat analysis. A total of 54 adults of working age who have experienced a stroke <4 months prior will be randomized 1:1 to either (1) an experimental group who will receive a 12-week early vocational intervention (Work intervention) plus usual clinical rehabilitation or (2) a control group who will receive only their usual clinical rehabilitation. Results: Outcomes include study and intervention feasibility and intervention benefit. In addition to evaluating the feasibility of delivering vocational intervention early after stroke, benefit will be assessed by measuring rates of vocational participation and quality-of-life improvements at the 3- and 6-month follow-ups. Process evaluation using data collected during the study, as well as postintervention individual interviews with participants and surveys with trial therapists, will complement quantitative data. Conclusions: The results of the trial will provide details on the feasibility of delivering the Work intervention embedded within the clinical rehabilitation context and inform future trial processes. Pilot data will enable a future definitive trial to determine the clinical effectiveness of vocational rehabilitation when delivered in the early subacute phase of stroke recovery. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12619001164189; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378112\&isReview=true International Registered Report Identifier (IRRID): DERR1-10.2196/40548 ", doi="10.2196/40548", url="https://www.researchprotocols.org/2022/10/e40548", url="http://www.ncbi.nlm.nih.gov/pubmed/36315220" } @Article{info:doi/10.2196/39855, author="Langford, Tom and Fleming, Victoria and Upton, Emily and Doogan, Catherine and Leff, Alexander and Romano, M. Daniela", title="Design Innovation for Engaging and Accessible Digital Aphasia Therapies: Framework Analysis of the iReadMore App Co-Design Process", journal="JMIR Neurotech", year="2022", month="Oct", day="18", volume="1", number="1", pages="e39855", keywords="aphasia", keywords="reading impairment", keywords="co-design", keywords="framework analysis", keywords="speech and language therapy", keywords="digital health", keywords="accessibility", abstract="Background: iReadMore is a digital therapy for people with acquired reading impairments (known as alexia) caused by brain injury or neurodegeneration. A phase II clinical trial demonstrated the efficacy of the digital therapy research prototype for improving reading speed and accuracy in people with poststroke aphasia (acquired language impairment) and alexia. However, it also highlighted the complexities and barriers to delivering self-managed therapies at home. Therefore, in order to translate the positive study results into real-world benefits, iReadMore required subsequent design innovation. Here, we present qualitative findings from the co-design process as well as the methodology. Objective: We aimed to present a methodology for inclusive co-design in the redesign of a digital therapy prototype, focusing on elements of accessibility and user engagement. We used framework analysis to explore the themes of the communications and interactions from the co-design process. Methods: This study included 2 stages. In the first stage, 5 in-person co-design sessions were held with participants living with poststroke aphasia (n=22) and their carers (n=3), and in the second stage, remote one-to-one beta-testing sessions were held with participants with aphasia (n=20) and their carers (n=5) to test and refine the final design. Data collection included video recordings of the co-design sessions in addition to participants' written notes and drawings. Framework analysis was used to identify themes within the data relevant to the design of digital aphasia therapies in general. Results: From a qualitative framework analysis of the data generated in the co-design process, 7 key areas of consideration for digital aphasia therapies have been proposed and discussed in context. The themes generated were agency, intuitive design, motivation, personal trajectory, recognizable and relatable content, social and sharing, and widening participation. This study enabled the deployment of the iReadMore app in an accessible and engaging format. Conclusions: Co-design is a valuable strategy for innovating beyond traditional therapy designs to utilize what is achievable with technology-based therapies in user-centered design. The co-designed iReadMore app has been publicly released for use in the rehabilitation of acquired reading impairments. This paper details the co-design process for the iReadMore therapy app and provides a methodology for how inclusive co-design can be conducted with people with aphasia. The findings of the framework analysis offer insights into design considerations for digital therapies that are important to people living with aphasia. ", doi="10.2196/39855", url="https://neuro.jmir.org/2022/1/e39855" } @Article{info:doi/10.2196/35637, author="Newcomer, Valerie and Metzinger, Megan and Vick, Sydney and Robertson, Caroline and Lawrence, Taylor and Glass, Amanda and Elliott, Lauren and Williams, Ansleigh", title="A Stroke Rehabilitation Educational Program for Occupational Therapy Students and Practitioners: Usability Study", journal="JMIR Med Educ", year="2022", month="Sep", day="30", volume="8", number="3", pages="e35637", keywords="knowledge translation", keywords="task-oriented training", keywords="stroke assessments", keywords="telerehabilitation", keywords="occupational therapy", keywords="students", keywords="practitioners", keywords="educational program", abstract="Background: There are gaps in knowledge translation (KT) of current evidence-based practices regarding stroke assessment and rehabilitation delivered through teletherapy. A lack of this knowledge can prevent occupational therapy (OT) students and practitioners from implementing current research findings. Objective: The aim of this pilot study was to create an educational program to translate knowledge into practice regarding the remote delivery of stroke assessment and rehabilitation to OT students and practitioners. Four areas of focus were addressed in the educational program, including KT, task-oriented training, stroke assessments, and telerehabilitation. Methods: Two pilot studies were conducted to assess the knowledge gained via pretests and posttests of knowledge, followed by a System Usability Scale and general feedback questionnaire. Participants in study 1 were 5 OT practitioners and 1 OT assistant. Participants in study 2 were 9 current OT students. Four 1-hour modules were emailed weekly to participants over the course of 4 weeks, with each module covering a different topic (KT, task-oriented training, stroke assessments, and telerehabilitation). Preliminary results were reviewed using descriptive statistics. Results: Statistically significant results were found with increased scores of knowledge for both students and practitioners. Most of the educational modules had an above-average score regarding value and positive feedback for the educational program as a whole from the participants. Conclusions: Overall, the results of this pilot study indicate that a web-based educational program is a valuable, informational method of increasing the translation of knowledge in the remote delivery of stroke assessment and rehabilitation. OT students and practitioners found the information presented to be valuable and relevant to their future profession and current practice. ", doi="10.2196/35637", url="https://mededu.jmir.org/2022/3/e35637", url="http://www.ncbi.nlm.nih.gov/pubmed/36178717" } @Article{info:doi/10.2196/37506, author="Hernandez, Alejandro and Bubyr, Liudmila and Archambault, S. Philippe and Higgins, Johanne and Levin, F. Mindy and Kairy, Dahlia", title="Virtual Reality--Based Rehabilitation as a Feasible and Engaging Tool for the Management of Chronic Poststroke Upper-Extremity Function Recovery: Randomized Controlled Trial", journal="JMIR Serious Games", year="2022", month="Sep", day="27", volume="10", number="3", pages="e37506", keywords="rehabilitation", keywords="serious game", keywords="stroke", keywords="telerehabilitation", keywords="upper extremity", keywords="virtual reality--based rehabilitation", keywords="virtual reality", keywords="virtual care", abstract="Background: A growing number of stroke survivors are left with little to no rehabilitation services upon discharge from stroke rehabilitation, although arm deficits may persist or develop from disuse once rehabilitation services have ceased. Virtual reality (VR)--based rehabilitation, combined with new technologies such as telerehabilitation, including serious games using VR environments that encourage users to practice functional movements from home with minimal supervision, may have an important role to play in optimizing and maintaining upper extremity (UE) function. Objective: The primary objective of this study is to determine the extent to which a 1-month intervention using a VR-based serious game is effective in improving UE function compared with an evidence-based home exercise program. A secondary objective is to assess the feasibility of implementing the intervention for chronic stroke rehabilitation in participants' homes. Methods: A total of 51 chronic stroke participants were randomized to treatment (n=26, 51\%; Jintronix system) or standard care (n=25, 49\%; standardized Graded Repetitive Arm Supplementary Program kit home program) groups. The participants were evaluated at baseline (before), immediately after the intervention (after), and at follow-up (4 weeks). The primary outcome measure was the Fugl-Meyer Assessment for UE (FMA-UE). Secondary outcome measures included the Stroke Impact Scale and an abridged version of the Motor Activity Log-14. Self-reported number of sessions was logged for the standard care group. Results: No statistically significant differences between groups were found across measures. Overall time effects were found for the FMA-UE (P=.045), specifically between preintervention and postintervention time points for both groups (P=.03). A total of 9 participants in the treatment group reached or surpassed the minimal clinically important difference in scores for the FMA-UE, with 7 (78\%) of them having baseline low or moderate arm function, compared with 3 (33\%) participants in the standard care group. Furthermore, 56\% (9/16) of the participants in the treatment group who actively engaged with the system reached the minimal clinically important difference for the FMA-UE, compared with none for the 0\% (0/10) less-active participants. Conclusions: These findings suggest that UE training for chronic stroke survivors using virtual rehabilitation in their home may be as effective as a gold standard home exercise program and that those who used the system the most achieved the greatest improvement in UE function, indicating its relevance to being included as part of ongoing rehabilitation services. Trial Registration: ClinicalTrials.gov NCT02491203; https://clinicaltrials.gov/ct2/show/NCT02491203 International Registered Report Identifier (IRRID): RR2-10.1016/j.cct.2015.12.006 ", doi="10.2196/37506", url="https://games.jmir.org/2022/3/e37506", url="http://www.ncbi.nlm.nih.gov/pubmed/36166289" } @Article{info:doi/10.2196/38489, author="Murakami, Tatsunori and Higuchi, Yumi and Ueda, Tetsuya and Kozuki, Wataru and Gen, Aki", title="Internet-Based Information Sharing With Families of Patients With Stroke in a Rehabilitation Hospital During the COVID-19 Pandemic: Case-Control Study", journal="JMIR Rehabil Assist Technol", year="2022", month="Sep", day="20", volume="9", number="3", pages="e38489", keywords="COVID-19", keywords="internet-based", keywords="health information", keywords="stroke", keywords="family", keywords="rehabilitation", keywords="case-control", keywords="activities of daily living", keywords="information communication technology", keywords="physical function", keywords="recovery", abstract="Background: The spread of COVID-19 has affected stroke rehabilitation. Given that inpatient visits are restricted in most institutions, alternative ways of providing information to family members are imperative. Informing families about patients' rehabilitation progress via the web may help involve families in the rehabilitation process, enhance patients' motivation to continue rehabilitation, and contribute overall to patients' improvement in activities of daily living (ADL). Objective: We aimed to investigate the feasibility of the Internet-Based Rehabilitation Information Sharing (IRIS) intervention for families of patients with stroke at a rehabilitation hospital and examine the effect of IRIS on patients' ADL improvement. Methods: In this case-control study, participants were inpatients at a rehabilitation hospital between March 2020 and April 2021. The intervention group (information and communication technology [ICT] group) included patients and families who requested IRIS, which consisted of a progress report on patients' rehabilitation using text, photos, and videos. Those who did not receive internet-based information were included in the non-ICT group. The control group, matched with the ICT group based on a 1:1 propensity score, was selected from the non-ICT group. The covariates for calculating the propensity score were patients' age, sex, and motor and cognitive scores on the Functional Independence Measure at admission. The main outcome was the degree of ADL improvement during hospitalization. Multiple regression analysis (forced entry method) was performed to confirm the impact of ICT use on ADL improvement. The independent variables were the presence of intervention, length of hospital stay, and number of days from onset to hospitalization. Results: In total, 16 groups of patients and families participated in the IRIS. The mean age of patients was 78.6 (SD 7.2) and 78.6 (SD 8.2) years in the ICT and control groups, respectively. The median total Functional Independence Measure difference was 28.5 (IQR 20.3-53.0) and 11.0 (IQR 2.8-30.0) in the ICT and control groups, respectively, and the ICT group showed significant improvement in ADL function (P=.02). In the multiple regression analysis of the ICT and control groups, the unstandardized regression coefficient was 11.97 (95\% CI 0.09-23.84) for ICT use. These results indicate that ICT use was independently and significantly associated with improvement in ADL. Conclusions: This study examined the effect of IRIS on family members to improve ADL in patients with stroke who are hospitalized. The results showed that IRIS promotes the improvement of patients' ADL regardless of age, sex, motor and cognitive functions at admission, and the length of hospital stay. ", doi="10.2196/38489", url="https://rehab.jmir.org/2022/3/e38489", url="http://www.ncbi.nlm.nih.gov/pubmed/35960841" } @Article{info:doi/10.2196/31305, author="Allegue, Rakia Dorra and Sweet, Norman Shane and Higgins, Johanne and Archambault, S. Philippe and Michaud, Francois and Miller, C. William and Tousignant, Michel and Kairy, Dahlia", title="Lessons Learned From Clinicians and Stroke Survivors About Using Telerehabilitation Combined With Exergames: Multiple Case Study", journal="JMIR Rehabil Assist Technol", year="2022", month="Sep", day="15", volume="9", number="3", pages="e31305", keywords="stroke", keywords="rehabilitation", keywords="virtual reality", keywords="video games", keywords="telerehabilitation", keywords="upper extremity", keywords="motivation", abstract="Background: In Canada, stroke survivors have difficulty accessing community-based rehabilitation services because of a lack of resources. VirTele, a personalized remote rehabilitation program combining virtual reality exergames and telerehabilitation, was developed to provide stroke survivors an opportunity to pursue rehabilitation of their chronic upper extremity (UE) deficits at home while receiving ongoing follow-up from a clinician. Objective: We aimed to identify the behavioral and motivational techniques used by clinicians during the VirTele intervention, explore the indicators of empowerment among stroke survivors, and investigate the determinants of VirTele use among stroke survivors and clinicians. Methods: This multiple case study involved 3 stroke survivors with chronic UE deficits and their respective clinicians (physiotherapists) who participated in the VirTele intervention, a 2-month remote rehabilitation intervention that uses nonimmersive virtual reality exergames and telerehabilitation aimed at improving UE deficits in stroke survivors. Study participants had autonomous access to Jintronix exergames and were asked to use them for 30 minutes, 5 times a week. The VirTele intervention included 1-hour videoconference sessions with a clinician 1 to 3 times a week, during which the clinician engaged in motivational interviewing, supervised the stroke survivors' use of the exergames, and monitored their use of the affected UE through activities of daily living. Semidirected interviews were conducted with the clinicians and stroke survivors 4 to 5 weeks after the end of the VirTele intervention. All interviews were audiorecorded and transcribed verbatim. An abductive thematic analysis was conducted to generate new ideas through a dynamic interaction between data and theory. Results: Three stroke survivors (n=2, 67\%, women and n=1, 33\%, man), with a mean age of 58.8 (SD 19.4) years, and 2 physiotherapists participated in the study. Five major determinants of VirTele use emerged from the qualitative analyses, namely technology performance (usefulness and perception of exergames), effort (ease of use), family support (encouragement), facilitators (considerations of the stroke survivors' safety as well as trust and understanding of instructions), and challenges (miscommunication and exergame limits). During the VirTele intervention, both clinicians used motivational and behavioral techniques to support autonomy, competence, and connectivity. All these attributes were reflected as empowerment indicators in the stroke survivors. Lessons learned from using telerehabilitation combined with exergames are provided, which will be relevant to other researchers and contexts. Conclusions: This multiple case study provides a first glimpse into the impact that motivational interviewing can have on adherence to exergames and changes in behavior in the use of the affected UE in stroke survivors. Lessons learned regarding the supportive role caregivers play and the new responsibilities clinicians have when using the VirTele intervention may inform the use of exergames via telerehabilitation. These lessons will also serve as a model to guide the implementation of similar interventions. International Registered Report Identifier (IRRID): RR2-10.2196/14629 ", doi="10.2196/31305", url="https://rehab.jmir.org/2022/3/e31305", url="http://www.ncbi.nlm.nih.gov/pubmed/36107484" } @Article{info:doi/10.2196/38956, author="Seid, Alebachew Abubeker and Moloro, Hassen Abdulkerim", title="Effectiveness of Neurodynamic Interventions in Patients With Stroke: Protocol for a Systematic Review and Meta-analysis", journal="JMIR Res Protoc", year="2022", month="Sep", day="7", volume="11", number="9", pages="e38956", keywords="stroke", keywords="neurodynamic", keywords="neurological", keywords="physiotherapy", keywords="physiotherapist", keywords="neural mobilization", keywords="review", keywords="intervention", keywords="search strategy", keywords="search strategies", keywords="library science", keywords="information science", keywords="librarian", keywords="pain", keywords="quality of life", keywords="disability", keywords="disabilities", keywords="physical function", abstract="Background: Stroke is the most common and serious neurological condition, which can lead to death, limited functionality, and reduced quality of life. Studies with conflicting results and various methodological limitations have been conducted to assess the effectiveness of neurodynamic interventions for patients with stroke. Objective: This systematic review and meta-analysis aimed to investigate the pooled effectiveness of different neurodynamic interventions on patients with stroke. Methods: The PubMed, PEDro, and Google Scholar databases will be searched for studies published with full text in the English language from inception to date. Randomized controlled trials evaluating the effect of different neurodynamic techniques on patients with stroke will be included. The primary outcome measures will include pain, disability/function, and quality of life. Secondary outcome measures will include physical performance measures such as balance, range of motion, muscle strength, and specific diagnostic and neurodynamic test outcomes. The screening, data extraction, and methodological quality assessment will be performed by two independent reviewers. The PEDro scale will be used to systematically appraise the methodological quality. Review Manager V.5.4 software will be used for statistical analysis. Weighted mean difference or standardized mean difference with 95\% CIs and P values will be used to calculate the treatment effect for each outcome variable. Results: Search terms and search databases have been identified. The data extraction sheet has also been developed. This study is expected to be completed by the end of 2022. Conclusions: This study will provide up-to-date evidence on the effectiveness and use of neurodynamic interventions for patients with stroke in clinical practice. Trial Registration: PROSPERO CRD42022319972; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=319972 International Registered Report Identifier (IRRID): PRR1-10.2196/38956 ", doi="10.2196/38956", url="https://www.researchprotocols.org/2022/9/e38956", url="http://www.ncbi.nlm.nih.gov/pubmed/36069824" } @Article{info:doi/10.2196/39444, author="Guterud, Mona and Bugge, Fagerheim Helge and R{\o}islien, Jo and Larsen, Karianne and Eriksen, Erik and Ingebretsen, H{\aa}kon Svein and Mikkelsen, Lerstang Martin and Kramer-Johansen, Jo and Bache, G. Kristi and Sandset, Charlotte Else and Hov, Ranhoff Maren", title="Interrater Agreement on National Institutes of Health Stroke Scale Between Paramedics and Stroke Physicians: Validation Study for the Digital Training Model in the Paramedic Norwegian Acute Stroke Prehospital Project", journal="JMIR Neurotech", year="2022", month="Aug", day="11", volume="1", number="1", pages="e39444", keywords="paramedic", keywords="stroke", keywords="ambulance", keywords="National Institutes of Health Stroke Scale", keywords="NIHSS", keywords="training", keywords="digital", keywords="interrater", keywords="agreement", keywords="Norway", keywords="acute", keywords="treatment", keywords="hospital", keywords="time", keywords="communication", keywords="mobile application", keywords="clinical trial", keywords="physician", keywords="simulation", abstract="Background: Time spent in the prehospital phase of acute stroke care is multifactorial and has an effect on the possibilities for acute treatment. Communication between paramedics and the in-hospital stroke team directly affects time to treatment. A mutual stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) may improve communication quality. The Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) was a stepped-wedge, randomized trial of stroke screening using NIHSS in the ambulance where the intervention was training paramedics in stroke and the NIHSS, with the use of NIHSS made into a mobile app to guide the examination and facilitate communication with the in-hospital stroke team. Objective: The aim of this study was to validate the digital training model from the ParaNASPP clinical trial. Methods: In total, 24 paramedics were recruited from Oslo University Hospital in Norway to complete the ParaNASPP training model; 20 exclusive videos with predefined NIHSS scores were recorded; and 4 stroke physicians from Oslo University Hospital were included for reference. Bland-Altman plots with 95\% limits of agreement (LoA) were calculated---first comparing paramedics and stroke physicians to the predefined scores and then with each other. The predefined LoA were set to 3 points. To align with clinical practice, NIHSS scores were also dichotomized into 2 categories: from 0-5 (minor stroke) or ?6 (moderate and major stroke), and agreement was calculated using Cohen $\kappa$. Results: The videos (n=20) had a median (range) NIHSS score of 7 (0-31). The paramedics' scores were slightly higher than the predefined scores with a mean difference of --0.38 and the LoA ranging from --4.04 to 3.29. The paramedics scored higher than the stroke physicians with a mean difference of --0.39, with the LoA ranging from --4.58 to 3.80. When the NIHSS scores were dichotomized, Cohen $\kappa$ was 0.89 between the predefined scores and paramedics, 0.92 between the predefined scores and stroke physicians, and 0.81 between the paramedics and stroke physicians, all indicating very good agreement. Conclusions: The paramedics scored higher than both the predefined scores and stroke physicians' scores, hence the predefined LoA were not met. However, the width of the LoA was smaller than seen when experienced neurologists are compared. When the NIHSS scores were dichotomized, the paramedics achieved very good agreement with both the predefined scores and stroke physicians' scores. This study demonstrates the possibilities for the transfer of clinical competence in digital simulation training. ", doi="10.2196/39444", url="https://neuro.jmir.org/2022/1/e39444" } @Article{info:doi/10.2196/38704, author="Hu, Xiaolei and Jonz{\'e}n, Karolina and Lindahl, A. Olof and Karlsson, Marcus and Norstr{\"o}m, Fredrik and Lundstr{\"o}m, Erik and Sunnerhagen, Stibrant Katharina", title="Digital Graphic Follow-up Tool (Rehabkompassen) for Identifying Rehabilitation Needs Among People After Stroke: Randomized Clinical Feasibility Study", journal="JMIR Hum Factors", year="2022", month="Jul", day="29", volume="9", number="3", pages="e38704", keywords="stroke", keywords="rehabilitation", keywords="needs assessment", keywords="outcome assessment", keywords="structured follow-up: follow-up", keywords="digital tool", keywords="digital health", keywords="eHealth", keywords="feasibility", keywords="randomized controlled trial", keywords="RCT", keywords="adherence", keywords="acceptability", keywords="clinical setting", keywords="Rankin scale", keywords="outpatient", abstract="Background: Stroke is a leading cause of disability among adults, with heavy social and economic burden worldwide. A cost-effective solution is urgently needed to facilitate the identification of individual rehabilitation needs and thereby provide tailored rehabilitations to reduce disability among people who have had a stroke. A novel digital graphic follow-up tool Rehabkompassen has recently been developed to facilitate capturing the multidimensional rehabilitation needs of people who have had a stroke. Objective: The aim of this study was to evaluate the feasibility and acceptability of conducting a definitive trial to evaluate Rehabkompassen as a digital follow-up tool among people who have had a stroke in outpatient clinical settings. Methods: This pilot study of Rehabkompassen was a parallel, open-label, 2-arm prospective, proof-of-concept randomized controlled trial (RCT) with an allocation ratio of 1:1 in a single outpatient clinic. Patients who have had a stroke within the 3 previous months, aged ?18 years, and living in the community were included. The trial compared usual outpatient visits with Rehabkompassen (intervention group) and without Rehabkompassen (control group) at the 3-month follow-up as well as usual outpatient visit with Rehabkompassen at the 12-month follow-up. Information on the recruitment rate, delivery, and uptake of Rehabkompassen; assessment and outcome measures completion rates; the frequency of withdrawals; the loss of follow-up; and satisfaction scores were obtained. The key outcomes were evaluated in both groups. Results: In total, 28 patients (14 control, 14 Rehabkompassen) participated in this study, with 100 patients screened. The overall recruitment rate was 28\% (28/100). Retention in the trial was 86\% (24/28) at the 12-month follow-up. All participants used the tool as planned during their follow-ups, which provided a 100\% (24/24) task completion rate of using Rehabkompassen and suggested excellent feasibility. Both patient- and physician-participants reported satisfaction with the instrument (19/24, 79\% and 2/2, 100\%, respectively). In all, 2 (N=2, 100\%) physicians and 18 (N=24, 75\%) patients were willing to use the tool in the future. Furthermore, modified Rankin Scale as the primary outcome and various stroke impacts as secondary outcomes were both successfully collected and compared in this study. Conclusions: This study demonstrated the high feasibility and adherence of the study protocol as well as the high acceptability of Rehabkompassen among patients who have had a stroke and physicians in an outpatient setting in comparison to the predefined criterion. The information collected in this feasibility study combined with the amendments of the study protocol may improve the future definitive RCT. The results of this trial support the feasibility and acceptability of conducting a large definitive RCT. Trial Registration: ClinicalTrials.gov NCT04915027; https://clinicaltrials.gov/ct2/show/NCT04915027 ", doi="10.2196/38704", url="https://humanfactors.jmir.org/2022/3/e38704", url="http://www.ncbi.nlm.nih.gov/pubmed/35904867" } @Article{info:doi/10.2196/37243, author="Reszel, Jessica and van den Hoek, Joan and Nguyen, Tram and Aravind, Gayatri and Bayley, T. Mark and Bird, Marie-Louise and Edwards, Kate and Eng, J. Janice and Moore, L. Jennifer and Nelson, A. Michelle L. and Ploughman, Michelle and Richardson, Julie and Salbach, M. Nancy and Tang, Ada and Graham, D. Ian", title="How Community-Based Teams Use the Stroke Recovery in Motion Implementation Planner: Longitudinal Qualitative Field Test Study", journal="JMIR Form Res", year="2022", month="Jul", day="29", volume="6", number="7", pages="e37243", keywords="knowledge translation", keywords="knowledge mobilization", keywords="implementation science", keywords="implementation planning", keywords="stroke", keywords="rehabilitation", keywords="capacity building", keywords="community-based exercise programs", abstract="Background: The Stroke Recovery in Motion Implementation Planner guides teams through the process of planning for the implementation of community-based exercise programs for people with stroke, in alignment with implementation science frameworks. Objective: The purpose of this study was to conduct a field test with end users to describe how teams used the Planner in real-world conditions; describe the effects of Planner use on participants' implementation-planning knowledge, attitudes, and activities; and identify factors influencing the use of the Planner. Methods: This field test study used a longitudinal qualitative design. We recruited teams across Canada who intended to implement a community-based exercise program for people with stroke in the next 6 to 12 months and were willing to use the Planner to guide their work. We completed semistructured interviews at the time of enrollment, monitoring calls every 1 to 2 months, and at the end of the study to learn about implementation-planning work completed and Planner use. The interviews were analyzed using conventional content analysis. Completed Planner steps were plotted onto a timeline for comparison across teams. Results: We enrolled 12 participants (program managers and coordinators, rehabilitation professionals, and fitness professionals) from 5 planning teams. The teams were enrolled in the study between 4 and 14 months, and we conducted 25 interviews. We observed that the teams worked through the planning process in diverse and nonlinear ways, adapted to their context. All teams provided examples of how using the Planner changed their implementation-planning knowledge (eg, knowing the steps), attitudes (eg, valuing community engagement), and activities (eg, hosting stakeholder meetings).?We identified team, organizational, and broader contextual factors that hindered and facilitated uptake of the Planner. Participants shared valuable tips from the field to help future teams optimize use of the Planner. Conclusions: The Stroke Recovery in Motion Implementation Planner is an adaptable resource that may be used in diverse settings to plan community-based exercise programs for people with stroke. These findings may be informative to others who are developing resources to build the capacity of those working in community-based settings to implement new programs and practices. Future work is needed to monitor the use and understand the effect of using the Planner on exercise program implementation and sustainability.? ", doi="10.2196/37243", url="https://formative.jmir.org/2022/7/e37243", url="http://www.ncbi.nlm.nih.gov/pubmed/35904855" } @Article{info:doi/10.2196/37189, author="Reszel, Jessica and van den Hoek, Joan and Nguyen, Tram and Aravind, Gayatri and Bayley, T. Mark and Bird, Marie-Louise and Edwards, Kate and Eng, J. Janice and Moore, L. Jennifer and Nelson, A. Michelle L. and Ploughman, Michelle and Richardson, Julie and Salbach, M. Nancy and Tang, Ada and Graham, D. Ian", title="The Stroke Recovery in Motion Implementation Planner: Mixed Methods User Evaluation", journal="JMIR Form Res", year="2022", month="Jul", day="29", volume="6", number="7", pages="e37189", keywords="stroke", keywords="rehabilitation", keywords="community-based exercise programs", keywords="knowledge translation", keywords="knowledge mobilization", keywords="implementation science", abstract="Background: As more people are surviving stroke, there is a growing need for services and programs that support the long-term needs of people living with the effects of stroke. Exercise has many benefits; however, most people with stroke do not have access to specialized exercise programs that meet their needs in their communities. To catalyze the implementation of these programs, our team developed the Stroke Recovery in Motion Implementation Planner, an evidence-informed implementation guide for teams planning a community-based exercise program for people with stroke. Objective: This study aimed to conduct a user evaluation to elicit user perceptions of the usefulness and acceptability of the Planner to inform revisions. Methods: This mixed methods study used a concurrent triangulation design. We used purposive sampling to enroll a diverse sample of end users (program managers and coordinators, rehabilitation health partners, and fitness professionals) from three main groups: those who are currently planning a program, those who intend to plan a program in the future, and those who had previously planned a program. Participants reviewed the Planner and completed a questionnaire and interviews to identify positive features, areas of improvement, value, and feasibility. We used descriptive statistics for quantitative data and content analysis for qualitative data. We triangulated the data sources to identify Planner modifications. Results: A total of 39 people participated in this study. Overall, the feedback was positive, highlighting the value of the Planner's comprehensiveness, tools and templates, and real-world examples. The identified areas for improvement included clarifying the need for specific steps, refining navigation, and creating more action-oriented content. Most participants reported an increase in knowledge and confidence after reading the Planner and reported that using the resource would improve their planning approach. Conclusions: We used a rigorous and user-centered process to develop and evaluate the Planner. End users indicated that it is a valuable resource and identified specific changes for improvement. The Planner was subsequently updated and is now publicly available for community planning teams to use in the planning and delivery of evidence-informed, sustainable, community-based exercise programs for people with stroke. ", doi="10.2196/37189", url="https://formative.jmir.org/2022/7/e37189", url="http://www.ncbi.nlm.nih.gov/pubmed/35904870" } @Article{info:doi/10.2196/33755, author="Leng, Yan and Lo, Ambrose Wai Leung and Mao, Rong Yu and Bian, Ruihao and Zhao, Li Jiang and Xu, Zhiqin and Li, Le and Huang, Feng Dong", title="The Impact of Cognitive Function on Virtual Reality Intervention for Upper Extremity Rehabilitation of Patients With Subacute Stroke: Prospective Randomized Controlled Trial With 6-Month Follow-up", journal="JMIR Serious Games", year="2022", month="Jul", day="8", volume="10", number="3", pages="e33755", keywords="stroke", keywords="motor function of upper extremity", keywords="virtual reality", keywords="cognitive function", abstract="Background: Stroke is among the leading causes of long-term disability worldwide. Motor impairments after stroke not only impact the individuals quality of life but also lay substantial burdens on the society. Motor planning is a key component of cognitive function that impacts motor control. Hand movements such as grasping or reaching to grasp require the application of correct force and the coordination of multiple limb segments. Successful completion of hand motor task requires a certain degree of cognitive function to anticipate the requirement of the task. Cognitive function may thus be a confounding factor to rehabilitation outcomes. Objective: This study aims to explore the impact of cognitive function on functional outcomes in people with subacute stroke after VR intervention. Methods: Patients with stroke were first stratified into cognitively normal (CN) and cognitively impaired (CI), followed by allocation to the VR or control group (CG). Fugl-Meyer Assessment for Upper Extremity (FMA-UE), Barthel Index (BI), and Instrumental Activities of Daily Living (IADL) were recorded at baseline, 3 weeks after the intervention, and 3 and 6 months after the intervention. The between-group and within-group differences were assessed by repeated-measures analysis of variance (ANOVA). Results: The between-group comparison indicated that FMA-UE, BI, and IADL (time effect P<.001 for all) scores improved significantly in both groups after the intervention. Repeated-measures ANOVA indicated that FMA-UE, BI, and IADL (time effect P<.001 for all) were significantly different in each subgroup after the intervention. For BI score, the ANOVA results showed obvious interaction effects (treatment {\texttimes} time {\texttimes} cognitive effect, P=.04). Conclusions: VR intervention was as effective as traditional conventional therapy in improving upper limb function regardless of the cognitive functional level. Patients with stroke with impaired cognitive function may gain more improvement in upper limb function and independency in performing activities of daily living after a VR-based intervention. Trial Registration: Chinese Clinical Trial Registry ChiCTR-IOC-15006064; https://tinyurl.com/4c9vkrrn ", doi="10.2196/33755", url="https://games.jmir.org/2022/3/e33755", url="http://www.ncbi.nlm.nih.gov/pubmed/35802415" } @Article{info:doi/10.2196/33745, author="Allegue, Rakia Dorra and Higgins, Johanne and Sweet, N. Shane and Archambault, S. Philippe and Michaud, Francois and Miller, William and Tousignant, Michel and Kairy, Dahlia", title="Rehabilitation of Upper Extremity by Telerehabilitation Combined With Exergames in Survivors of Chronic Stroke: Preliminary Findings From a Feasibility Clinical Trial", journal="JMIR Rehabil Assist Technol", year="2022", month="Jun", day="22", volume="9", number="2", pages="e33745", keywords="stroke", keywords="rehabilitation", keywords="virtual reality", keywords="video games", keywords="telerehabilitation", keywords="upper extremity", keywords="motivation", keywords="mHealth", keywords="mobile health", keywords="personalized care", keywords="stroke rehabilitation", abstract="Background: Exergames are increasingly being used among survivors of stroke with chronic upper extremity (UE) sequelae to continue exercising at home after discharge and maintain activity levels. The use of virtual reality exergames combined with a telerehabilitation app (VirTele) may be an interesting alternative to rehabilitate the UE sequelae in survivors of chronic stroke while allowing for ongoing monitoring with a clinician. Objective: This study aimed to determine the feasibility of using VirTele in survivors of chronic stroke at home and explore the impact of VirTele on UE motor function, quantity and quality of use, quality of life, and motivation in survivors of chronic stroke compared with conventional therapy. Methods: This study was a 2-arm feasibility clinical trial. Eligible participants were randomly allocated to an experimental group (receiving VirTele for 8 weeks) or a control group (receiving conventional therapy for 8 weeks). Feasibility was measured from the exergame and intervention logs completed by the clinician. Outcome measurements included the Fugl-Meyer Assessment-UE, Motor Activity Log-30, Stroke Impact Scale-16, and Treatment Self-Regulation Questionnaire-15, which were administered to both groups at four time points: time point 1 (T1; before starting the intervention), time point 2 (after the intervention), time point 3 (1 month after the intervention), and time point 4 (T4; 2 months after the intervention). Results: A total of 11 survivors of stroke were randomized and allocated to an experimental or a control group. At the onset of the COVID-19 pandemic, participants pursued the allocated treatment for 3 months instead of 8 weeks. VirTele intervention dose was captured in terms of time spent on exergames, frequency of use of exergames, total number of successful repetitions, and frequency of videoconference sessions. Technical issues included the loss of passwords, internet issues, updates of the system, and problems with the avatar. Overall, most survivors of stroke found the technology easy to use and useful, except for 9\% (1/11) of participants. For the Fugl-Meyer Assessment-UE and Motor Activity Log-30, both groups exhibited an improvement in >50\% of the participants, which was maintained over time (from time point 3 to T4). Regarding Stroke Impact Scale-16 scores, the control group reported improvement in activities of daily life (3/5, 60\%), hand function (5/5, 100\%), and mobility (2/5, 40\%), whereas the experimental group reported varied and inconclusive results (from T1 to T4). For the Treatment Self-Regulation Questionnaire-15, 75\% (3/4) of the experimental group demonstrated an increase in the autonomous motivation score (from T1 to time point 2), whereas, in the control group, this improvement was observed in only 9\% (1/11) of participants. Conclusions: The VirTele intervention constitutes another therapeutic alternative, in addition to conventional therapy, to deliver an intense personalized rehabilitation program for survivors of chronic stroke with UE sequelae. International Registered Report Identifier (IRRID): RR2-10.2196/14629 ", doi="10.2196/33745", url="https://rehab.jmir.org/2022/2/e33745", url="http://www.ncbi.nlm.nih.gov/pubmed/35731560" } @Article{info:doi/10.2196/33981, author="Zachrison, S. Kori and Hayden, M. Emily and Boggs, M. Krislyn and Boyle, P. Tehnaz and Gao, Jingya and Samuels-Kalow, E. Margaret and Marcin, P. James and Camargo Jr, A. Carlos", title="Emergency Departments' Uptake of Telehealth for Stroke Versus Pediatric Care: Observational Study", journal="J Med Internet Res", year="2022", month="Jun", day="20", volume="24", number="6", pages="e33981", keywords="telehealth", keywords="telemedicine", keywords="emergency care", keywords="stroke", keywords="pediatric care", abstract="Background: Telehealth for emergency stroke care delivery (telestroke) has had widespread adoption, enabling many hospitals to obtain stroke center certification. Telehealth for pediatric emergency care has been less widely adopted. Objective: Our primary objective was to determine whether differences in policy or certification requirements contributed to differential uptake of telestroke versus pediatric telehealth. We hypothesized that differences in financial incentives, based on differences in patient volume, prehospital routing policy, and certification requirements, contributed to differential emergency department (ED) adoption of telestroke versus pediatric telehealth. Methods: We used the 2016 National Emergency Department Inventory--USA to identify EDs that were using telestroke and pediatric telehealth services. We surveyed all EDs using pediatric telehealth services (n=339) and a convenience sample of the 1758 EDs with telestroke services (n=366). The surveys characterized ED staffing, transfer patterns, reasons for adoption, and frequency of use. We used bivariate comparisons to examine differences in reasons for adoption and use between EDs with only telestroke services, only pediatric telehealth services, or both. Results: Of the 442 EDs surveyed, 378 (85.5\%) indicated use of telestroke, pediatric telehealth, or both. EDs with both services were smaller in bed size, volume, and ED attending coverage than those with only telestroke services or only pediatric telehealth services. EDs with telestroke services reported more frequent use, overall, than EDs with pediatric telehealth services: 14.1\% (45/320) of EDs with telestroke services reported weekly use versus 2.9\% (8/272) of EDs with pediatric telehealth services (P<.001). In addition, 37 out of 272 (13.6\%) EDs with pediatric telehealth services reported no consults in the past year. Across applications, the most frequently selected reason for adoption was ``improving level of clinical care.'' Policy-related reasons (ie, for compliance with outside certification or standards or for improving ED performance on quality metrics) were rarely indicated as the most important, but these reasons were indicated slightly more often for telestroke adoption (12/320, 3.8\%) than for pediatric telehealth adoption (1/272, 0.4\%; P=.003). Conclusions: In 2016, more US EDs had telestroke services than pediatric telehealth services; among EDs with the technology, consults were more frequently made for stroke than for pediatric patients. The most frequently indicated reason for adoption among all EDs was related to clinical care. ", doi="10.2196/33981", url="https://www.jmir.org/2022/6/e33981", url="http://www.ncbi.nlm.nih.gov/pubmed/35723927" } @Article{info:doi/10.2196/24111, author="Chen, Jiayin and Or, Kalun Calvin and Chen, Tianrong", title="Effectiveness of Using Virtual Reality--Supported Exercise Therapy for Upper Extremity Motor Rehabilitation in Patients With Stroke: Systematic Review and Meta-analysis of Randomized Controlled Trials", journal="J Med Internet Res", year="2022", month="Jun", day="20", volume="24", number="6", pages="e24111", keywords="virtual reality", keywords="stroke", keywords="rehabilitation", keywords="upper extremity", keywords="meta-analysis", abstract="Background: In recent years, efforts have been made to implement virtual reality (VR) to support the delivery of poststroke upper extremity motor rehabilitation exercises. Therefore, it is important to review and analyze the existing research evidence of its effectiveness. Objective: Through a systematic review and meta-analysis of randomized controlled trials, this study examined the effectiveness of using VR-supported exercise therapy for upper extremity motor rehabilitation in patients with stroke. Methods: This study followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The CINAHL Plus, MEDLINE, Web of Science, Embase, and Cochrane Library databases were searched on December 31, 2021. Changes in outcomes related to impairments in upper extremity functions and structures, activity limitations, and participation restrictions in life situations from baseline to after intervention, after intervention to follow-up assessment, and baseline to follow-up assessment were examined. Standardized mean differences (SMDs) were calculated using a random-effects model. Subgroup analyses were performed to determine whether the differences in treatment outcomes depended on age, stroke recovery stage, VR program type, therapy delivery format, similarities in intervention duration between study groups, intervention duration in VR groups, and trial length. Results: A total of 42 publications representing 43 trials (aggregated sample size=1893) were analyzed. Compared with the control groups that used either conventional therapy or no therapy, the intervention groups that used VR to support exercise therapy showed significant improvements in upper extremity motor function (Fugl-Meyer Assessment-Upper Extremity; SMD 0.45, 95\% CI 0.21-0.68; P<.001), range of motion (goniometer; SMD 1.01, 95\% CI 0.50-1.52; P<.001), muscle strength (Manual Muscle Testing; SMD 0.79, 95\% CI 0.28-1.30; P=.002), and independence in day-to-day activities (Functional Independence Measure; SMD 0.23, 95\% CI 0.06-0.40; P=.01, and modified Rankin Scale; SMD 0.57, 95\% CI 0.01-1.12; P=.046). Significant subgroup differences were observed in hand dexterity (Box and Block Test), spasticity (Ashworth Scale or modified Ashworth Scale), arm and hand motor ability (Wolf Motor Function Test and Manual Function Test), hand motor ability (Jebsen Hand Function Test), and quality of life (Stroke Impact Scale). There was no evidence that the benefits of VR-supported exercise therapy were maintained after the intervention ended. Conclusions: VR-supported upper extremity exercise therapy can be effective in improving motor rehabilitation results. Our review showed that of the 12 rehabilitation outcomes examined during the course of VR-based therapy, significant improvements were detected in 2 (upper extremity motor function and range of motion), and both significant and nonsignificant improvements were observed in another 2 (muscle strength and independence in day-to-day activities), depending on the measurement tools or methods used. Trial Registration: PROSPERO CRD42021256826; https://tinyurl.com/2uarftbh ", doi="10.2196/24111", url="https://www.jmir.org/2022/6/e24111", url="http://www.ncbi.nlm.nih.gov/pubmed/35723907" } @Article{info:doi/10.2196/34307, author="Wang, Xiaoyi and Fu, Yan and Ye, Bing and Babineau, Jessica and Ding, Yong and Mihailidis, Alex", title="Technology-Based Compensation Assessment and Detection of Upper Extremity Activities of Stroke Survivors: Systematic Review", journal="J Med Internet Res", year="2022", month="Jun", day="13", volume="24", number="6", pages="e34307", keywords="stroke", keywords="upper extremity rehabilitation", keywords="UE rehabilitation", keywords="compensation", keywords="assessment", keywords="technology", keywords="sensor", keywords="artificial intelligence", keywords="AI", abstract="Background: Upper extremity (UE) impairment affects up to 80\% of stroke survivors and accounts for most of the rehabilitation after discharge from the hospital release. Compensation, commonly used by stroke survivors during UE rehabilitation, is applied to adapt to the loss of motor function and may impede the rehabilitation process in the long term and lead to new orthopedic problems. Intensive monitoring of compensatory movements is critical for improving the functional outcomes during rehabilitation. Objective: This review analyzes how technology-based methods have been applied to assess and detect compensation during stroke UE rehabilitation. Methods: We conducted a wide database search. All studies were independently screened by 2 reviewers (XW and YF), with a third reviewer (BY) involved in resolving discrepancies. The final included studies were rated according to their level of clinical evidence based on their correlation with clinical scales (with the same tasks or the same evaluation criteria). One reviewer (XW) extracted data on publication, demographic information, compensation types, sensors used for compensation assessment, compensation measurements, and statistical or artificial intelligence methods. Accuracy was checked by another reviewer (YF). Four research questions were presented. For each question, the data were synthesized and tabulated, and a descriptive summary of the findings was provided. The data were synthesized and tabulated based on each research question. Results: A total of 72 studies were included in this review. In all, 2 types of compensation were identified: disuse of the affected upper limb and awkward use of the affected upper limb to adjust for limited strength, mobility, and motor control. Various models and quantitative measurements have been proposed to characterize compensation. Body-worn technology (25/72, 35\% studies) was the most used sensor technology to assess compensation, followed by marker-based motion capture system (24/72, 33\% studies) and marker-free vision sensor technology (16/72, 22\% studies). Most studies (56/72, 78\% studies) used statistical methods for compensation assessment, whereas heterogeneous machine learning algorithms (15/72, 21\% studies) were also applied for automatic detection of compensatory movements and postures. Conclusions: This systematic review provides insights for future research on technology-based compensation assessment and detection in stroke UE rehabilitation. Technology-based compensation assessment and detection have the capacity to augment rehabilitation independent of the constant care of therapists. The drawbacks of each sensor in compensation assessment and detection are discussed, and future research could focus on methods to overcome these disadvantages. It is advised that open data together with multilabel classification algorithms or deep learning algorithms could benefit from automatic real time compensation detection. It is also recommended that technology-based compensation predictions be explored. ", doi="10.2196/34307", url="https://www.jmir.org/2022/6/e34307", url="http://www.ncbi.nlm.nih.gov/pubmed/35699982" } @Article{info:doi/10.2196/37927, author="Bello-Manga, Halima and Haliru, Lawal and Ahmed, Abdulkareem Kudrat and Tabari, Musa Abdulkadir and Farouk, Usman Bilkisu and Bahago, Yimi Gloria and Kazaure, Shuaibu Aisha and Muhammad, Sani Abdulrasheed and Gwarzo, Abubakar Samira and Baumann, A. Ana and DeBaun, R. Michael and King, A. Allison", title="Primary Prevention of Stroke in Children With Sickle Cell Anemia in Nigeria: Protocol for a Mixed Methods Implementation Study in a Community Hospital", journal="JMIR Res Protoc", year="2022", month="Jun", day="13", volume="11", number="6", pages="e37927", keywords="sickle cell anemia", keywords="stroke prevention", keywords="transcranial Doppler ultrasonography", abstract="Background: In Nigeria, approximately 150,000 children with sickle cell anemia (SCA) are born annually, accounting for more than half of all SCA births worldwide. Without intervention, about 11\% of children with SCA will develop a stroke before their 20th birthday. Evidence-based practices for primary stroke prevention include screening for abnormal transcranial Doppler (TCD) measurements coupled with regular blood transfusion therapy for at least one year, followed by hydroxyurea (HU) therapy indefinitely. In high-resource countries, this strategy contributes to a 92\% decrease in stroke incidence rates. In 2016, as part of a capacity building objective of the Stroke Prevention Trial in Nigeria (1R01NS094041: SPRING), TCD screening was adopted as standard care at Barau Dikko Teaching Hospital in Kaduna. However, with just 70 radiologists and only 3 certified in TCD screening in the state, just 5.49\% (1101/20,040) of eligible children with SCA were screened. Thus, there is a need to explore alternate implementation strategies to ensure children with SCA receive standard care TCD screening to decrease stroke incidence. Objective: This protocol describes a study to create a stroke prevention program in a community hospital in Kaduna through task shifting TCD screening to nurses and training medical officers to initiate and monitor HU utilization for stroke prevention. Methods: This study will be conducted at 2 sites (teaching hospital and community hospital) over a period of 3 years (November 2020 to November 2023), in 3 phases using both quasi-experimental and effectiveness-implementation study designs. In the needs assessment phase, focus groups and structured interviews will be conducted with health care providers and hospital administrators to identify barriers and facilitators to evidence-based stroke prevention practices. Results from the needs assessment will inform intervention strategies and a process plan to fit the needs of the community hospital. In the capacity building phase, nurses and medical officers at the community hospital will be trained on TCD screening and HU initiation and monitoring. In the implementation phase, children with SCA aged 2-16 years will be recruited into a nonrandomized single-arm prospective trial to determine the feasibility of initiating a task-shifted stroke prevention program by recording recruitment, retention, and adherence rates. The Reach and Effectiveness components of the RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework will be used to evaluate implementation outcomes between the community and teaching hospitals. Results: The needs assessment phase of the study was completed in February 2021. Manuscript on findings is currently in preparation. Capacity building is ongoing with TCD training and sickle cell disease and stroke education sessions for nurses and doctors in the community hospital. Recruitment for the implementation trial is expected to commence in July 2022. Conclusions: This study proposes a structured, theory-driven approach to create a stroke prevention program in a community hospital in Kaduna, Nigeria, to decrease stroke incidence among children with SCA. Results will provide preliminary data for a definitive randomized clinical trial in implementation science. International Registered Report Identifier (IRRID): PRR1-10.2196/37927 ", doi="10.2196/37927", url="https://www.researchprotocols.org/2022/6/e37927", url="http://www.ncbi.nlm.nih.gov/pubmed/35700018" } @Article{info:doi/10.2196/35478, author="Kj{\"o}rk, K. Emma and Sunnerhagen, S. Katharina and Lundgren-Nilsson, {\AA}sa and Andersson, K. Anders and Carlsson, Gunnel", title="Development of a Digital Tool for People With a Long-Term Condition Using Stroke as a Case Example: Participatory Design Approach", journal="JMIR Hum Factors", year="2022", month="Jun", day="3", volume="9", number="2", pages="e35478", keywords="eHealth", keywords="digital tool", keywords="Strokeh{\"a}lsa", keywords="follow-up", keywords="chronic care", keywords="stroke", keywords="Post-Stroke Checklist", keywords="health literacy", keywords="co-design", keywords="shared decision making", abstract="Background: In patient care, demand is growing for digital health tools to enable remote services and enhance patient involvement. People with chronic conditions often have multiple health problems, and long-term follow-up is recommended to meet their needs and enable access to appropriate support. A digital tool for previsit preparation could enhance time efficiency and guide the conversation during the visit toward the patient's priorities. Objective: This study aims to develop a digital previsit tool and explore potential end user's perceptions, using a participatory approach with stroke as a case example. Methods: The digital tool was developed and prototyped according to service design principles, informed by qualitative participant data and feedback from an expert panel. All features were processed in workshops with a team that included a patient partner. The resulting tool presented questions about health problems and health information. Study participants were people with stroke recruited from an outpatient clinic and patient organizations in Sweden. Development and data collection were conducted in parallel. For conceptualization, the initial prototype was based on the Post-Stroke Checklist and research. Needs and relevance were explored in focus groups, and we used a web survey and individual interviews to explore perceived utility, ease of use, and acceptance. Data were thematically analyzed following the Framework Method. Results: The development process included 22 participants (9 women) with a median age of 59 (range 42-83) years and a median of 51 (range 4-228) months since stroke. Participants were satisfied or very satisfied with using the tool and recommended its use in clinical practice. Three main themes were constructed based on focus group data (n=12) and interviews (n=10). First, valuable accessible information illuminated the need for information to confirm experiences, facilitate responses, and invite engagement in their care. Amendments to the information in turn reconfigured their expectations. Second, utility and complexity in answering confirmed that the questions were relevant and comprehensible. Some participants perceived the answer options as limiting and suggested additional space for free text. Third, capturing needs and value of the tool highlighted the tool's potential to identify health problems and the importance of encouraging further dialog. The resulting digital tool, Strokeh{\"a}lsa [Strokehealth] version 1.0, is now incorporated into a national health platform. Conclusions: The participatory approach to tool development yielded a previsit digital tool that the study group perceived as useful. The holistic development process used here, which integrated health information, validated questions, and digital functionality, offers an example that could be applicable in the context of other long-term conditions. Beyond its potential to identify care needs, the tool offers information that confirms experiences and supports answering the questions in the tool. The tool is freely shared for adaptation in different contexts. Trial Registration: researchweb 236341; https://www.researchweb.org/is/vgr/project/236341 ", doi="10.2196/35478", url="https://humanfactors.jmir.org/2022/2/e35478", url="http://www.ncbi.nlm.nih.gov/pubmed/35657650" } @Article{info:doi/10.2196/33291, author="Clancy, Brigid and Bonevski, Billie and English, Coralie and Baker, L. Amanda and Turner, Alyna and Magin, Parker and Pollack, Michael and Callister, Robin and Guillaumier, Ashleigh", title="Access to and Use of Internet and Social Media by Low-Morbidity Stroke Survivors Participating in a National Web-Based Secondary Stroke Prevention Trial: Cross-sectional Survey", journal="J Med Internet Res", year="2022", month="May", day="30", volume="24", number="5", pages="e33291", keywords="stroke", keywords="stroke survivor", keywords="recurrent stroke", keywords="digital health", keywords="social media", keywords="internet use", keywords="eHealth", keywords="information-seeking behavior", keywords="web-based", keywords="mobile phone", abstract="Background: eHealth applications for stroke are a growing area of research that has yielded promising results. However, little is known about how stroke survivors engage with the internet, social media, and other digital technologies on a day-to-day basis. Objective: This study had three main objectives: to describe the type, frequency, and purpose of technology use among a cohort of low-morbidity stroke survivors; to investigate associations between social media use and participant factors, including sociodemographics, physical function, and independence in activities of daily living; and to investigate associations between stroke-related health risk factors and the use of the internet to search for health and medical information. Methods: This study is a secondary analysis of data obtained during a national randomized controlled trial---Prevent 2nd Stroke. The participants were stroke survivors recruited from 2 Australian stroke registries who completed 2 telephone-administered surveys to collect data on demographics and stroke characteristics; health risk factors (diet quality, physical activity, blood pressure medication, alcohol intake, anxiety and depression, and smoking status); physical functioning; independence in activities of daily living; and questions about what technology they had access to, how often they used it, and for what purposes. Participants were eligible if they had no more than a moderate level of disability (modified Rankin score ?3) and had access to the internet. Multivariable logistic regression was used to assess the associations between social media use and sociodemographics, physical function, and independence in activities of daily living as well as associations between stroke-related health risk factors and the use of the internet to search for health and medical information. Results: Data from 354 participants were included in the analysis. Approximately 79.1\% (280/354) of participants used the internet at least daily, 40.8\% (118/289) accessed social media on their phone or tablet daily, and 46.4\% (134/289) looked up health and medical information at least monthly. Women were 2.7 times more likely to use social media (adjusted odds ratio 2.65, 95\% CI 1.51-4.72), and people aged >75 years were significantly less likely to use social media compared with those aged <55 years (adjusted odds ratio 0.17, 95\% CI 0.07-0.44). Health risk factors were not found to be associated with searching for health- or medical-related information. Conclusions: The internet appears to be a viable platform to engage with stroke survivors who may not be high-morbidity to conduct research and provide information and health interventions. This is important given that they are at high risk of recurrent stroke regardless of their level of disability. Exploring the technology use behaviors and the possibility of eHealth among survivors who experience higher levels of morbidity or disability because of their stroke is an area of research that warrants further study. ", doi="10.2196/33291", url="https://www.jmir.org/2022/5/e33291", url="http://www.ncbi.nlm.nih.gov/pubmed/35635754" } @Article{info:doi/10.2196/37672, author="Elf, Marie and Klockar, Erika and Kyl{\'e}n, Maya and von Koch, Lena and Ytterberg, Charlotte and Wallin, Lars and Finch, Tracy and Gustavsson, Catharina and Jones, Fiona", title="Tailoring and Evaluating an Intervention to Support Self-management After Stroke: Protocol for a Multi-case, Mixed Methods Comparison Study", journal="JMIR Res Protoc", year="2022", month="May", day="6", volume="11", number="5", pages="e37672", keywords="self-management", keywords="self-management support", keywords="self-efficacy", keywords="stroke rehabilitation", keywords="home rehabilitation", keywords="person-centered care", abstract="Background: Self-management programs are recognized as a valuable approach to supporting people with long-term conditions, such as stroke, in managing their daily lives. Bridges Self-Management (Bridges) focuses on how practitioners interact and support patients' confidence, skills, and knowledge, and it is an example of a complex intervention. Bridges has been developed and used across multiple health care pathways in the United Kingdom and is theoretically informed by social cognition theory and self-efficacy principles. Evidence shows that self-management programs based on the construct of self-efficacy can be effective. There is still much to learn about how health care services or pathways should implement support for self-management in a sustainable way and whether this implementation process is different depending on the context or culture of the team or service provided. Objective: The aim of this study is to tailor and evaluate an intervention (Bridges) to support self-management after stroke in a Swedish context. Methods: We will use a pretest-posttest design with a case study approach to evaluate the feasibility and implementation of self-management support in two stroke settings. This project includes a complex intervention and depends on the actions of individuals, different contexts, and the adaptation of behavior over time. A mixed methods approach was chosen to understand both outcomes and mechanisms of impact. Data collection will comprise outcome measurements and assessment tools as well as qualitative interviews. Data will be collected concurrently and integrated into a mixed methods design. Results: Recruitment and data collection for the first site of the project ran from September 1, 2021, to January 17, 2022. The intervention at the first site was conducted from November 1, 2021, to March 5, 2022. The evaluation will start after the implementation phase. The second site has been recruited, and the baseline data collection will start in spring 2022. The intervention will start in early autumn 2022. Data collection will be completed by the end of 2022. Conclusions: This study represents a unique, highly relevant, and innovative opportunity to maximize knowledge and minimize practice gaps in rehabilitation stroke care. The study will produce robust data on the intervention and in-depth data on the contextual factors and mechanisms related to the feasibility of the intervention and for whom it is feasible. Bridges has been used in the United Kingdom for more than 10 years, and this study will explore its contextualization and implementation within a Swedish stroke environment. The evaluation will study results at the patient, staff, and organizational levels and provide recommendations for the adoption and refinement of future efforts to support self-management. International Registered Report Identifier (IRRID): DERR1-10.2196/37672 ", doi="10.2196/37672", url="https://www.researchprotocols.org/2022/5/e37672", url="http://www.ncbi.nlm.nih.gov/pubmed/35522476" } @Article{info:doi/10.2196/26990, author="Burdea, Grigore and Kim, Nam and Polistico, Kevin and Kadaru, Ashwin and Grampurohit, Namrata and Hundal, Jasdeep and Pollack, Simcha", title="Robotic Table and Serious Games for Integrative Rehabilitation in the Early Poststroke Phase: Two Case Reports", journal="JMIR Rehabil Assist Technol", year="2022", month="Apr", day="13", volume="9", number="2", pages="e26990", keywords="subacute stroke", keywords="virtual reality", keywords="gamification", keywords="therapeutic game controller", keywords="integrative rehabilitation", keywords="BrightArm Duo", keywords="BrightArm Compact", keywords="upper extremity", keywords="cognition", keywords="depression", abstract="Background: BrightArm Compact is a new rehabilitation system for the upper extremities. It provides bimanual training with gradated gravity loading and mediates interactions with cognitively challenging serious games. Objective: The aim of this study is to design and test a robotic rehabilitation table--based virtual rehabilitation system for functional impact of the integrative training in the early poststroke phase. Methods: A new robotic rehabilitation table, controllers, and adaptive games were developed. The 2 participants underwent 12 experimental sessions in addition to the standard of care. Standardized measures of upper extremity function (primary outcome), depression, and cognition were administered before and after the intervention. Nonstandardized measures included game variables and subjective evaluations. Results: The 2 case study participants attained high total arm repetitions per session (504 and 957) and achieved high grasp and finger-extension counts. Training intensity contributed to marked improvements in affected shoulder strength (225\% and 100\% increase), grasp strength (27\% and 16\% increase), and pinch strength (31\% and 15\% increase). The shoulder flexion range increased by 17\% and 18\% and elbow supination range by 75\% and 58\%. Improvements in motor function were at or above minimal clinically important difference for the Fugl-Meyer Assessment (11 and 10 points), Chedoke Arm and Hand Activity Inventory (11 and 14 points), and Upper Extremity Functional Index (19 and 23 points). Cognitive and emotive outcomes were mixed. Subjective rating by participants and training therapists were positive (average 4, SD 0.22, on a 5-point Likert scale). Conclusions: The design of the robotic rehabilitation table was tested on 2 participants in the early poststroke phase, and results are encouraging for upper extremity functional gains and technology acceptance. Trial Registration: ClinicalTrials.gov NCT04252170; https://clinicaltrials.gov/ct2/show/NCT04252170 ", doi="10.2196/26990", url="https://rehab.jmir.org/2022/2/e26990", url="http://www.ncbi.nlm.nih.gov/pubmed/35416787" } @Article{info:doi/10.2196/30196, author="Bu, Xiaofan and Ng, HF Peter and Tong, Ying and Chen, Q. Peter and Fan, Rongrong and Tang, Qingping and Cheng, Qinqin and Li, Shuangshuang and Cheng, SK Andy and Liu, Xiangyu", title="A Mobile-based Virtual Reality Speech Rehabilitation App for Patients With Aphasia After Stroke: Development and Pilot Usability Study", journal="JMIR Serious Games", year="2022", month="Apr", day="7", volume="10", number="2", pages="e30196", keywords="virtual reality", keywords="speech rehabilitation", keywords="stroke", keywords="app", keywords="Delphi", abstract="Background: Stroke has the highest disability-adjusted life-years lost in any disease, and approximately one-third of the patients get aphasia. Computers and tablets are innovative and aid in intensive treatments in speech rehabilitation for patients with aphasia. However, mechanical training limits the help to patients. Objective: This study aims to provide a framework for an integrated virtual reality (VR) app to provide speech rehabilitation for patients with aphasia. Methods: The content was generated through an in-depth literature review and discussion with experienced rehabilitation physicians and occupational therapists. We then conducted a 2-round Delphi study with 15 experts from hospitals and universities to rate the content using a 5-point Likert scale. The app was developed by an interdisciplinary team involving VR, medical science of rehabilitation, and therapeutic rehabilitation. Pilot usability testing of this novel app was conducted among 5 patients with aphasia, 5 healthy volunteers, 5 medical staff, and 2 VR experts. Results: We designed 4 modules of speech rehabilitation: oral expression, auditory comprehension, cognition, and comprehensive application. Our VR-based interactive and intelligent app was developed to provide an alternative option for patients with aphasia. Pilot usability testing revealed user satisfaction with the app. Conclusions: This study designed and tested a novel VR-based app for speech rehabilitation specifically adapted to patients with aphasia. This will guide other studies to develop a similar program or intelligent system in a clinical setting. ", doi="10.2196/30196", url="https://games.jmir.org/2022/2/e30196", url="http://www.ncbi.nlm.nih.gov/pubmed/35389349" } @Article{info:doi/10.2196/30366, author="Wiskerke, Evelyne and Kool, Jan and Hilfiker, Roger and Sattelmayer, Martin Karl and Verheyden, Geert", title="Determining the Optimal Virtual Reality Exergame Approach for Balance Therapy in Persons With Neurological Disorders Using a Rasch Analysis: Longitudinal Observational Study", journal="JMIR Serious Games", year="2022", month="Mar", day="22", volume="10", number="1", pages="e30366", keywords="digital therapeutics", keywords="virtual reality", keywords="exergaming", keywords="balance", keywords="stroke", keywords="multiple sclerosis", keywords="neurorehabilitation", keywords="Rasch analysis", abstract="Background: Virtual reality (VR) exergames have gained popularity in the rehabilitation of persons with neurological disorders as an add-on therapy to increase intensity of training. Intensity is strongly dependent on the motivation of the patient. Motivation can be increased by delivering variation within training and challenging exercises. However, patients are often underchallenged, as exergame difficulty often does not match the patient's ability. A Rasch analysis can establish hierarchy of exergame items in order to assist the delivery of patient-centered therapy. Objective: The aim of this study was to apply the Rasch model to create a hierarchical order of existing VR balance exergames and to relate these exergames to the abilities of persons with neurological disorders, in order to deliver challenge and variation. Methods: A total of 30 persons with stroke and 51 persons with multiple sclerosis (MS) were included in the study. All participants performed a training program, lasting 3 weeks for persons with MS and 4 weeks for persons with stroke, in which they performed VR balance exergames with a movement recognition--based system (MindMotion GO; MindMaze SA). VR exercise scores, Berg Balance Scale scores, and clinical descriptive data were collected. Berg Balance Scale and device scores were analyzed with the Rasch model using a repeated-measures approach to examine whether the distribution of exercise scores fitted the Rasch model. Secondly, a person-item map was created to show the hierarchy of exercise difficulty and person ability. Results: Participants completed a selection of 56 balance exercises (ie, items), which consisted of a combination of various balance tasks and levels (ie, exercises). Using repeated measures, this resulted in a count of 785 observations. Analysis showed strong evidence for unidimensionality of the data. A total of 47 exercises (ie, items) had a sufficiently good fit to the Rasch model. Six items showed underfit, with outfit mean square values above 1.5. One item showed underfit but was kept in the analysis. Three items had negative point-biserial correlations. The final model consisted of 47 exercises, which were provided for persons with low to moderate balance ability. Conclusions: The VR exercises sufficiently fitted the Rasch model and resulted in a hierarchical order of VR balance exercises for persons with stroke and MS with low to moderate balance ability. In combination with the Berg Balance Scale, the results can guide clinical decision-making in the selection of patient-focused VR balance exercises. Trial Registration: ClinicalTrials.gov NCT03993275; https://clinicaltrials.gov/ct2/show/NCT03993275 ", doi="10.2196/30366", url="https://games.jmir.org/2022/1/e30366", url="http://www.ncbi.nlm.nih.gov/pubmed/35315785" } @Article{info:doi/10.2196/34537, author="Bernaerts, Sylvie and De Witte, J. Nele A. and Van der Auwera, Vicky and Bonroy, Bert and Muraru, Luiza and Bamidis, Panagiotis and Frantzidis, Christos and Kourtidou-Papadeli, Chrysoula and Azevedo, Nancy and Garatea, Jokin and Mu{\~n}oz, Idoia and Almeida, Rosa and Losada, Raquel and Fung, Joyce and Kehayia, Eva and Lamontagne, Anouk and de Guise, Elaine and Duclos, Cyril and Higgins, Johanne and Nadeau, Sylvie and Beaudry, Lucie and Konstantinidis, Evdokimos", title="Rehabilitation Supported by Technology: Protocol for an International Cocreation and User Experience Study", journal="JMIR Res Protoc", year="2022", month="Mar", day="10", volume="11", number="3", pages="e34537", keywords="cocreation", keywords="harmonization", keywords="living lab", keywords="rehabilitation", keywords="small-scale real-life testing", keywords="technology", abstract="Background: Living labs in the health and well-being domain have become increasingly common over the past decade but vary in available infrastructure, implemented study designs, and outcome measures. The Horizon 2020 Project Virtual Health and Wellbeing Living Lab Infrastructure aims to harmonize living lab procedures and open living lab infrastructures to facilitate and promote research activities in the health and well-being domain in Europe and beyond. This protocol will describe the design of a joint research activity, focusing on the use of innovative technology for both rehabilitation interventions and data collection in a rehabilitation context. Objective: With this joint research activity, this study primarily aims to gain insight into each living lab's infrastructure and procedures to harmonize health and well-being living lab procedures and infrastructures in Europe and beyond, particularly in the context of rehabilitation. Secondarily, this study aims to investigate the potential of innovative technologies for rehabilitation through living lab methodologies. Methods: This study has a mixed methods design comprising multiple phases. There are two main phases of data collection: cocreation (phase 1) and small-scale pilot studies (phase 2), which are preceded by a preliminary harmonization of procedures among the different international living labs. An intermediate phase further allows the implementation of minor adjustments to the intervention or protocol depending on the input that was obtained in the cocreation phase. A total of 6 small-scale pilot studies using innovative technologies for intervention or data collection will be performed across 4 countries. The target study sample comprises patients with stroke and older adults with mild cognitive impairment. The third and final phases involve Delphi procedures to reach a consensus on harmonized procedures and protocols. Results: Phase 1 data collection will begin in March 2022, and phase 2 data collection will begin in June 2022. Results will include the output of the cocreation sessions, small-scale pilot studies, and advice on harmonizing procedures and protocols for health and well-being living labs focusing on rehabilitation. Conclusions: The knowledge gained by the execution of this research will lead to harmonized procedures and protocols in a rehabilitation context for health and well-being living labs in Europe and beyond. In addition to the harmonized procedures and protocols in rehabilitation, we will also be able to provide new insights for improving the implementation of innovative technologies in rehabilitation. International Registered Report Identifier (IRRID): PRR1-10.2196/34537 ", doi="10.2196/34537", url="https://www.researchprotocols.org/2022/3/e34537", url="http://www.ncbi.nlm.nih.gov/pubmed/35266874" } @Article{info:doi/10.2196/31504, author="Meyer, Amanda and Hrdlicka, Charles Henry and Cutler, Erica and Hellstrand, Jill and Meise, Emily and Rudolf, Kaitlyn and Grevelding, Pete and Nankin, Matthew", title="A Novel Body Weight--Supported Postural Perturbation Module for Gait and Balance Rehabilitation After Stroke: Preliminary Evaluation Study", journal="JMIR Rehabil Assist Technol", year="2022", month="Mar", day="1", volume="9", number="1", pages="e31504", keywords="stroke rehabilitation", keywords="postural balance", keywords="gait and ambulation", keywords="balance perturbation", keywords="postural perturbation", keywords="body weight support system", keywords="occupational therapy", keywords="physical therapy", keywords="long-term acute care hospital, Berg Balance Scale", keywords="Activities-Specific Balance Confidence Scale", abstract="Background: Impaired balance regulation after stroke puts patients and therapists at risk of injury during rehabilitation. Body weight support systems (BWSSs) minimize this risk and allow patients to safely practice balance activities during therapy. Treadmill-based balance perturbation systems with BWSSs are known to improve balance in patients with age- or disease-related impairments. However, these stationary systems are unable to accommodate complex exercises that require more freedom of movement. Objective: This study aims to evaluate the effect of a new balance perturbation module, which is directly integrated into a track-mounted BWSS, on balance impairments secondary to acute stroke. Methods: This unblinded quasi-randomized controlled preliminary study was conducted in a rehabilitation-focused long-term acute care hospital. Participants were recruited from stroke rehabilitation inpatients with an admission Berg Balance Scale (BBS) score of 21 (out of 56) or greater. Over a 2-week period, consented participants completed 8 BWSS or BWSS with perturbation (BWSS-P) treatment sessions; study activities were incorporated into regular treatment to avoid disruption of their normal care. Although both groups conducted the same balance and gait activities during their treatment sessions, the BWSS-P sessions included lateral, anterior, and posterior balance perturbations. Pre- and postintervention BBS and Activities-Specific Balance Confidence (ABC) assessments were the primary outcome measures collected. Institutional BBS data from the year before installation of the track-mounted BWSS were retrospectively included as a post hoc historical standard of care comparison. Results: The improved postintervention BBS and ABC assessment scores showed that all participants benefited from therapy (P<.001 for all pre- and postintervention comparisons). The average BBS percent change for the BWSS-P sample (n=14) was 66.95\% (SD 43.78\%) and that for the BWSS control sample (n=15) was 53.29\% (SD 24.13\%). These values were greater than those for the standard of care group (n=30; mean 28.31\%, SD 17.25\%; P=.02 and P=.005 respectively), with no difference among the BWSS groups (P=.67). ABC score changes were also similar among the preintervention and postintervention BWSS groups (P=.94 and P=.92, respectively). Conclusions: Both BWSS groups demonstrated similar BBS and ABC score improvements, indicating that balance perturbations were not detrimental to postacute stroke rehabilitation and were safe to use. These data provide strong rationale and baseline data for conducting a larger follow-up study to further assess if this new perturbation system provides additional benefit to the rehabilitation of gait and balance impairments following stroke. Trial Registration: ClinicalTrials.gov NCT04919161; https://clinicaltrials.gov/ct2/show/NCT04919161 ", doi="10.2196/31504", url="https://rehab.jmir.org/2022/1/e31504", url="http://www.ncbi.nlm.nih.gov/pubmed/35080495" } @Article{info:doi/10.2196/29806, author="Sung, Sheng-Feng and Hsieh, Cheng-Yang and Hu, Ya-Han", title="Early Prediction of Functional Outcomes After Acute Ischemic Stroke Using Unstructured Clinical Text: Retrospective Cohort Study", journal="JMIR Med Inform", year="2022", month="Feb", day="17", volume="10", number="2", pages="e29806", keywords="acute ischemic stroke", keywords="bag-of-words", keywords="extreme gradient boosting", keywords="machine learning", keywords="MetaMap", keywords="natural language processing", keywords="outcome prediction", keywords="text classification", keywords="unstructured clinical text", abstract="Background: Several prognostic scores have been proposed to predict functional outcomes after an acute ischemic stroke (AIS). Most of these scores are based on structured information and have been used to develop prediction models via the logistic regression method. With the increased use of electronic health records and the progress in computational power, data-driven predictive modeling by using machine learning techniques is gaining popularity in clinical decision-making. Objective: We aimed to investigate whether machine learning models created by using unstructured text could improve the prediction of functional outcomes at an early stage after AIS. Methods: We identified all consecutive patients who were hospitalized for the first time for AIS from October 2007 to December 2019 by using a hospital stroke registry. The study population was randomly split into a training (n=2885) and test set (n=962). Free text in histories of present illness and computed tomography reports was transformed into input variables via natural language processing. Models were trained by using the extreme gradient boosting technique to predict a poor functional outcome at 90 days poststroke. Model performance on the test set was evaluated by using the area under the receiver operating characteristic curve (AUC). Results: The AUCs of text-only models ranged from 0.768 to 0.807 and were comparable to that of the model using National Institutes of Health Stroke Scale (NIHSS) scores (0.811). Models using both patient age and text achieved AUCs of 0.823 and 0.825, which were similar to those of the model containing age and NIHSS scores (0.841); the model containing preadmission comorbidities, level of consciousness, age, and neurological deficit (PLAN) scores (0.837); and the model containing Acute Stroke Registry and Analysis of Lausanne (ASTRAL) scores (0.840). Adding variables from clinical text improved the predictive performance of the model containing age and NIHSS scores, the model containing PLAN scores, and the model containing ASTRAL scores (the AUC increased from 0.841 to 0.861, from 0.837 to 0.856, and from 0.840 to 0.860, respectively). Conclusions: Unstructured clinical text can be used to improve the performance of existing models for predicting poststroke functional outcomes. However, considering the different terminologies that are used across health systems, each individual health system may consider using the proposed methods to develop and validate its own models. ", doi="10.2196/29806", url="https://medinform.jmir.org/2022/2/e29806", url="http://www.ncbi.nlm.nih.gov/pubmed/35175201" } @Article{info:doi/10.2196/27597, author="Barak Ventura, Roni and Stewart Hughes, Kora and Nov, Oded and Raghavan, Preeti and Ruiz Mar{\'i}n, Manuel and Porfiri, Maurizio", title="Data-Driven Classification of Human Movements in Virtual Reality--Based Serious Games: Preclinical Rehabilitation Study in Citizen Science", journal="JMIR Serious Games", year="2022", month="Feb", day="10", volume="10", number="1", pages="e27597", keywords="motion analysis", keywords="principal component analysis", keywords="telerehabilitation", keywords="virtual reality", abstract="Background: Sustained engagement is essential for the success of telerehabilitation programs. However, patients' lack of motivation and adherence could undermine these goals. To overcome this challenge, physical exercises have often been gamified. Building on the advantages of serious games, we propose a citizen science--based approach in which patients perform scientific tasks by using interactive interfaces and help advance scientific causes of their choice. This approach capitalizes on human intellect and benevolence while promoting learning. To further enhance engagement, we propose performing citizen science activities in immersive media, such as virtual reality (VR). Objective: This study aims to present a novel methodology to facilitate the remote identification and classification of human movements for the automatic assessment of motor performance in telerehabilitation. The data-driven approach is presented in the context of a citizen science software dedicated to bimanual training in VR. Specifically, users interact with the interface and make contributions to an environmental citizen science project while moving both arms in concert. Methods: In all, 9 healthy individuals interacted with the citizen science software by using a commercial VR gaming device. The software included a calibration phase to evaluate the users' range of motion along the 3 anatomical planes of motion and to adapt the sensitivity of the software's response to their movements. During calibration, the time series of the users' movements were recorded by the sensors embedded in the device. We performed principal component analysis to identify salient features of movements and then applied a bagged trees ensemble classifier to classify the movements. Results: The classification achieved high performance, reaching 99.9\% accuracy. Among the movements, elbow flexion was the most accurately classified movement (99.2\%), and horizontal shoulder abduction to the right side of the body was the most misclassified movement (98.8\%). Conclusions: Coordinated bimanual movements in VR can be classified with high accuracy. Our findings lay the foundation for the development of motion analysis algorithms in VR-mediated telerehabilitation. ", doi="10.2196/27597", url="https://games.jmir.org/2022/1/e27597", url="http://www.ncbi.nlm.nih.gov/pubmed/35142629" } @Article{info:doi/10.2196/27935, author="Ahmedy, Fatimah and Mohamad Hashim, Natiara and Lago, Herwansyah and Plijoly, Protasius Leonard and Ahmedy, Ismail and Idna Idris, Yamani Mohd and Gani, Abdullah and Sybil Shah, Syahiskandar and Chia, Kang Yuen", title="Comparing Neuroplasticity Changes Between High and Low Frequency Gait Training in Subacute Stroke: Protocol for a Randomized, Single-Blinded, Controlled Study", journal="JMIR Res Protoc", year="2022", month="Jan", day="28", volume="11", number="1", pages="e27935", keywords="neuroplasticity", keywords="gait training", keywords="stroke rehabilitation", keywords="electroencephalogram signals", abstract="Background: Walking recovery post stroke can be slow and incomplete. Determining effective stroke rehabilitation frequency requires the assessment of neuroplasticity changes. Neurobiological signals from electroencephalogram (EEG) can measure neuroplasticity through incremental changes of these signals after rehabilitation. However, changes seen with a different frequency of rehabilitation require further investigation. It is hypothesized that the association between the incremental changes from EEG signals and the improved functional outcome measure scores are greater in higher rehabilitation frequency, implying enhanced neuroplasticity changes. Objective: The purpose of this study is to identify the changes in the neurobiological signals from EEG, to associate these with functional outcome measures scores, and to compare their associations in different therapy frequency for gait rehabilitation among subacute stroke individuals. Methods: A randomized, single-blinded, controlled study among patients with subacute stroke will be conducted with two groups: an intervention group (IG) and a control group (CG). Each participant in the IG and CG will receive therapy sessions three times a week (high frequency) and once a week (low frequency), respectively, for a total of 12 consecutive weeks. Each session will last for an hour with strengthening, balance, and gait training. The main variables to be assessed are the 6-Minute Walk Test (6MWT), Motor Assessment Scale (MAS), Berg Balance Scale (BBS), Modified Barthel Index (MBI), and quantitative EEG indices in the form of delta to alpha ratio (DAR) and delta-plus-theta to alpha-plus-beta ratio (DTABR). These will be measured at preintervention (R0) and postintervention (R1). Key analyses are to determine the changes in the 6MWT, MAS, BBS, MBI, DAR, and DTABR at R0 and R1 for the CG and IG. The changes in the DAR and DTABR will be analyzed for association with the changes in the 6MWT, MAS, BBS, and MBI to measure neuroplasticity changes for both the CG and IG. Results: We have recruited 18 participants so far. We expect to publish our results in early 2023. Conclusions: These associations are expected to be positive in both groups, with a higher correlation in the IG compared to the CG, reflecting enhanced neuroplasticity changes and objective evaluation on the dose-response relationship. International Registered Report Identifier (IRRID): DERR1-10.2196/27935 ", doi="10.2196/27935", url="https://www.researchprotocols.org/2022/1/e27935", url="http://www.ncbi.nlm.nih.gov/pubmed/35089146" } @Article{info:doi/10.2196/27805, author="Taira, Kazuya and Fujita, Sumio", title="Prediction of Age-Adjusted Mortality From Stroke in Japanese Prefectures: Ecological Study Using Search Engine Queries", journal="JMIR Form Res", year="2022", month="Jan", day="20", volume="6", number="1", pages="e27805", keywords="stroke", keywords="age-adjusted mortality", keywords="search engine query", keywords="Japan", keywords="random forest", keywords="generalized linear mixed model", keywords="search engine", keywords="GLMM", keywords="information-seeking behavior", abstract="Background: Stroke is a major cause of death and the need for nursing care in Japan, with large regional disparities. Objective: The purpose of this study was to clarify the association between stroke-related information retrieval behavior and age-adjusted mortality in each prefecture in Japan. Methods: Age-adjusted mortality from stroke and aging rates were obtained from publicly available Japanese government statistics. A total of 9476 abstracts of Japanese articles related to symptoms and signs of stroke were identified in Ichushi-Web, a Japanese web-based database of biomedical articles, and 100 highly frequent words (hereafter referred to as the Stroke 100) were extracted. Using data from 2014 to 2019, a random forest analysis was carried out using the age-adjusted mortality from stroke in 47 prefectures as the outcome variable and the standardized retrieval numbers of the Stroke 100 words in the log data of Yahoo! JAPAN Search as predictive variables. Regression analysis was performed using a generalized linear mixed model (GLMM) with the number of standardized searches for Stroke 100 words with high importance scores in the random forest model as the predictive variable. In the GLMM, the aging rate and data year were used as control variables, and the random slope of data year and random intercept were calculated by prefecture. Results: The mean age-adjusted mortality from stroke was 28.07 (SD 4.55) deaths per 100,000 for all prefectures in all data years. The accuracy score of the random forest analysis was 89.94\%, the average error was 2.79 degrees, and the mean squared error was 13.57 degrees. The following 9 variables with high importance scores in the random forest analysis were selected as predictive variables for the regression analysis: male, age, hospitalization, enforcement, progress, stroke, abnormal, use, and change. As a result of the regression analysis with GLMM, the standardized partial regression coefficients ($\beta$) and 95\% confidence intervals showed that the following internet search terms were significantly associated with age-adjusted mortality from stroke: male ($\beta$=?5.83, 95\% CI ?8.67 to ?3.29), age ($\beta$=?5.83, 95\% CI ?8.67 to ?3.29), hospitalization ($\beta$=?5.83, 95\% CI ?8.67 to ?3.29), and abnormal ($\beta$=3.83, 95\% CI 1.14 to 6.56). Conclusions: Stroke-related search behavior was associated with age-adjusted mortality from stroke in each prefecture in Japan. Query terms that were strongly associated with age-adjusted mortality rates of stroke suggested the possibility that individual characteristics, such as sex and age, have an impact on stroke-associated mortality and that it is important to receive medical care early after stroke onset. Further studies on the criteria and timing of alerting are needed by monitoring information-seeking behavior to identify queries that are strongly associated with stroke mortality. ", doi="10.2196/27805", url="https://formative.jmir.org/2022/1/e27805", url="http://www.ncbi.nlm.nih.gov/pubmed/35049512" } @Article{info:doi/10.2196/32566, author="He, Fan and Blackberry, Irene and Yao, Liqing and Xie, Haiyan and Mnatzaganian, George", title="Geographical Disparities in Pooled Stroke Incidence and Case Fatality in Mainland China, Hong Kong, and Macao: Protocol for a Systematic Review and Meta-analysis", journal="JMIR Res Protoc", year="2022", month="Jan", day="18", volume="11", number="1", pages="e32566", keywords="case fatality", keywords="Hong Kong", keywords="incidence", keywords="Mainland China", keywords="Macao", keywords="meta-analysis", keywords="stroke", keywords="systematic review", keywords="stroke incidence", keywords="mortality rates", keywords="epidemiology", abstract="Background: Geographical variations in stroke incidence and case fatality in China have been reported. Nonetheless, pooled estimates in major Chinese regions are unknown. Objective: This systematic review and meta-analysis aims to investigate pooled estimates of incidence and short-term case fatality of stroke in Mainland China, Hong Kong, and Macao. Methods: Longitudinal studies published in English and indexed in PubMed/MEDLINE, Embase, CINAHL, and Web of Science, or in Chinese and indexed in SinoMed and CQVIP will be targeted. Articles reporting on adults living in China who experience first-ever stroke or die within 1 year from newly onset stroke will be included. The 95\% confidence intervals of the event will be estimated using the exact method based on the Poisson distribution. The log incidence rates together with their corresponding log standard errors will be meta-analyzed using DerSimonian and Laird random effects models. Pooled case fatality rates will also be estimated using a random effect model. Time trends in pooled age-standardized stroke incidence and case fatality will be estimated. The heterogeneity of the included studies will be measured using the I2 statistic and meta-regressions will be run to analyze the effect of reported covariates on found heterogeneity. Risk of bias will be examined using the Newcastle-Ottawa Scale. Publication bias will be tested using funnel plots and Egger tests. Sensitivity analysis will be run by risk of bias. Results: This study was funded and registered in 2020. The systematic searches, study selections, and quality assessments were completed in July 2021. Data extraction and analysis and manuscript writing are scheduled to be completed by December 2021. Conclusions: This will be the first study to provide regional differences in pooled estimates of stroke incidence with case fatality in Mainland China, Hong Kong, and Macao. This study will assist in addressing inequalities in stroke care across China. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42020170724; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=170724 International Registered Report Identifier (IRRID): PRR1-10.2196/32566 ", doi="10.2196/32566", url="https://www.researchprotocols.org/2022/1/e32566", url="http://www.ncbi.nlm.nih.gov/pubmed/35040797" } @Article{info:doi/10.2196/23440, author="Alanazi, M. Eman and Abdou, Aalaa and Luo, Jake", title="Predicting Risk of Stroke From Lab Tests Using Machine Learning Algorithms: Development and Evaluation of Prediction Models", journal="JMIR Form Res", year="2021", month="Dec", day="2", volume="5", number="12", pages="e23440", keywords="stroke", keywords="lab tests", keywords="machine learning technology", keywords="predictive analytics", abstract="Background: Stroke, a cerebrovascular disease, is one of the major causes of death. It causes significant health and financial burdens for both patients and health care systems. One of the important risk factors for stroke is health-related behavior, which is becoming an increasingly important focus of prevention. Many machine learning models have been built to predict the risk of stroke or to automatically diagnose stroke, using predictors such as lifestyle factors or radiological imaging. However, there have been no models built using data from lab tests. Objective: The aim of this study was to apply computational methods using machine learning techniques to predict stroke from lab test data. Methods: We used the National Health and Nutrition Examination Survey data sets with three different data selection methods (ie, without data resampling, with data imputation, and with data resampling) to develop predictive models. We used four machine learning classifiers and six performance measures to evaluate the performance of the models. Results: We found that accurate and sensitive machine learning models can be created to predict stroke from lab test data. Our results show that the data resampling approach performed the best compared to the other two data selection techniques. Prediction with the random forest algorithm, which was the best algorithm tested, achieved an accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and area under the curve of 0.96, 0.97, 0.96, 0.75, 0.99, and 0.97, respectively, when all of the attributes were used. Conclusions: The predictive model, built using data from lab tests, was easy to use and had high accuracy. In future studies, we aim to use data that reflect different types of stroke and to explore the data to build a prediction model for each type. ", doi="10.2196/23440", url="https://formative.jmir.org/2021/12/e23440", url="http://www.ncbi.nlm.nih.gov/pubmed/34860663" } @Article{info:doi/10.2196/30184, author="Li, Chong and Song, Xinyu and Chen, Shugeng and Wang, Chuankai and He, Jieying and Zhang, Yongli and Xu, Shuo and Yan, Zhijie and Jia, Jie and Shull, Peter", title="Long-term Effectiveness and Adoption of a Cellphone Augmented Reality System on Patients with Stroke: Randomized Controlled Trial", journal="JMIR Serious Games", year="2021", month="Nov", day="23", volume="9", number="4", pages="e30184", keywords="stroke", keywords="augmented reality", keywords="serious game", keywords="upper limb motor function", keywords="cognitive function", keywords="home-based rehabilitation", abstract="Background: A serious game--based cellphone augmented reality system (CARS) was developed for rehabilitation of stroke survivors, which is portable, convenient, and suitable for self-training. Objective: This study aims to examine the effectiveness of CARS in improving upper limb motor function and cognitive function of stroke survivors via conducting a long-term randomized controlled trial and analyze the patient's acceptance of the proposed system. Methods: A double-blind randomized controlled trial was performed with 30 poststroke, subacute phase patients. All patients in both the experimental group (n=15) and the control group (n=15) performed a 1-hour session of therapy each day, 5 days per week for 2 weeks. Patients in the experimental group received 30 minutes of rehabilitation training with CARS and 30 minutes of conventional occupational therapy (OT) each session, while patients in the control group received conventional OT for the full 1 hour each session. The Fugl-Meyer Assessment of Upper Extremity (FMA-UE) subscale, Action Research Arm Test (ARAT), manual muscle test and Brunnstrom stage were used to assess motor function; the Mini-Mental State Examination, Add VS Sub, and Stroop Game were used to assess cognitive function; and the Barthel index was used to assess activities of daily living before and after the 2-week treatment period. In addition, the User Satisfaction Evaluation Questionnaire was used to reflect the patients' adoption of the system in the experimental group after the final intervention. Results: All the assessment scores of the experimental group and control group were significantly improved after intervention. After the intervention. The experimental group's FMA-UE and ARAT scores increased by 11.47 and 5.86, respectively, and were both significantly higher than the increase of the control group. Similarly, the score of the Add VS Sub and Stroop Game in the experimental group increased by 7.53 and 6.83, respectively, after the intervention, which also represented a higher increase than that in the control group. The evaluation of the adoption of this system had 3 sub-dimensions. In terms of accessibility, the patients reported a mean score of 4.27 (SD 0.704) for the enjoyment of their experience with the system, a mean 4.33 (SD 0.816) for success in using the system, and a mean 4.67 (SD 0.617) for the ability to control the system. In terms of comfort, the patients reported a mean 4.40 (SD 0.737) for the clarity of information provided by the system and a mean 4.40 (SD 0.632) for comfort. In terms of acceptability, the patients reported a mean 4.27 (SD 0.884) for usefulness in their rehabilitation and a mean 4.67 (0.617) in agreeing that CARS is a suitable tool for home-based rehabilitation. Conclusions: The rehabilitation based on combined CARS and conventional OT was more effective in improving both upper limb motor function and cognitive function than was conventional OT. Due to the low cost and ease of use, CARS is also potentially suitable for home-based rehabilitation. Trial Registration: Chinese Clinical Trial Registry ChiCTR1800017568; https://tinyurl.com/xbkkyfyz ", doi="10.2196/30184", url="https://games.jmir.org/2021/4/e30184", url="http://www.ncbi.nlm.nih.gov/pubmed/34817390" } @Article{info:doi/10.2196/31007, author="Zhang, Qi and Fu, Yu and Lu, Yanhui and Zhang, Yating and Huang, Qifang and Yang, Yajie and Zhang, Ke and Li, Mingzi", title="Impact of Virtual Reality-Based Therapies on Cognition and Mental Health of Stroke Patients: Systematic Review and Meta-analysis", journal="J Med Internet Res", year="2021", month="Nov", day="17", volume="23", number="11", pages="e31007", keywords="virtual reality", keywords="stroke", keywords="cognition", keywords="depression", keywords="mental health", abstract="Background: Stroke remains one of the major chronic illnesses worldwide that health care organizations will need to address for the next several decades. Individuals poststroke are subject to levels of cognitive impairment and mental health problems. Virtual reality (VR)-based therapies are new technologies used for cognitive rehabilitation and the management of psychological outcomes. Objective: This study performed a meta-analysis to evaluate the effects of VR-based therapies on cognitive function and mental health in patients with stroke. Methods: A comprehensive database search was performed using PubMed, MEDLINE (Ovid), Embase, Cochrane Library, and APA PsycINFO databases for randomized controlled trials (RCTs) that studied the effects of VR on patients with stroke. We included trials published up to April 15, 2021, that fulfilled our inclusion and exclusion criteria. The literature was screened, data were extracted, and the methodological quality of the included trials was assessed. Meta-analysis was performed using RevMan 5.3 software. Results: A total of 894 patients from 23 RCTs were included in our meta-analysis. Compared to traditional rehabilitation therapies, the executive function (standard mean difference [SMD]=0.88, 95\% confidence interval [CI]=0.06-1.70, P=.03), memory (SMD=1.44, 95\% CI=0.21-2.68, P=.02), and visuospatial function (SMD=0.78, 95\% CI=0.23-1.33, P=.006) significantly improved among patients after VR intervention. However, there were no significant differences observed in global cognitive function, attention, verbal fluency, depression, and the quality of life (QoL). Conclusions: The findings of our meta-analysis showed that VR-based therapies are efficacious in improving executive function, memory, and visuospatial function in patients with stroke. For global cognitive function, attention, verbal fluency, depression, and the QoL, further research is required. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021252788; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=252788 ", doi="10.2196/31007", url="https://www.jmir.org/2021/11/e31007", url="http://www.ncbi.nlm.nih.gov/pubmed/34787571" } @Article{info:doi/10.2196/30277, author="Yang, Yujie and Zheng, Jing and Du, Zhenzhen and Li, Ye and Cai, Yunpeng", title="Accurate Prediction of Stroke for Hypertensive Patients Based on Medical Big Data and Machine Learning Algorithms: Retrospective Study", journal="JMIR Med Inform", year="2021", month="Nov", day="10", volume="9", number="11", pages="e30277", keywords="stroke", keywords="medical big data", keywords="electronic health records", keywords="machine learning", keywords="risk prediction", keywords="hypertension", abstract="Background: Stroke risk assessment is an important means of primary prevention, but the applicability of existing stroke risk assessment scales in the Chinese population has always been controversial. A prospective study is a common method of medical research, but it is time-consuming and labor-intensive. Medical big data has been demonstrated to promote disease risk factor discovery and prognosis, attracting broad research interest. Objective: We aimed to establish a high-precision stroke risk prediction model for hypertensive patients based on historical electronic medical record data and machine learning algorithms. Methods: Based on the Shenzhen Health Information Big Data Platform, a total of 57,671 patients were screened from 250,788 registered patients with hypertension, of whom 9421 had stroke onset during the 3-year follow-up. In addition to baseline characteristics and historical symptoms, we constructed some trend characteristics from multitemporal medical records. Stratified sampling according to gender ratio and age stratification was implemented to balance the positive and negative cases, and the final 19,953 samples were randomly divided into a training set and test set according to a ratio of 7:3. We used 4 machine learning algorithms for modeling, and the risk prediction performance was compared with the traditional risk scales. We also analyzed the nonlinear effect of continuous characteristics on stroke onset. Results: The tree-based integration algorithm extreme gradient boosting achieved the optimal performance with an area under the receiver operating characteristic curve of 0.9220, surpassing the other 3 traditional machine learning algorithms. Compared with 2 traditional risk scales, the Framingham stroke risk profiles and the Chinese Multiprovincial Cohort Study, our proposed model achieved better performance on the independent validation set, and the area under the receiver operating characteristic value increased by 0.17. Further nonlinear effect analysis revealed the importance of multitemporal trend characteristics in stroke risk prediction, which will benefit the standardized management of hypertensive patients. Conclusions: A high-precision 3-year stroke risk prediction model for hypertensive patients was established, and the model's performance was verified by comparing it with the traditional risk scales. Multitemporal trend characteristics played an important role in stroke onset, and thus the model could be deployed to electronic health record systems to assist in more pervasive, preemptive stroke risk screening, enabling higher efficiency of early disease prevention and intervention. ", doi="10.2196/30277", url="https://medinform.jmir.org/2021/11/e30277", url="http://www.ncbi.nlm.nih.gov/pubmed/34757322" } @Article{info:doi/10.2196/28090, author="Garcia-Rudolph, Alejandro and Opisso, Eloy and Tormos, M. Jose and Madai, Istvan Vince and Frey, Dietmar and Becerra, Helard and Kelleher, D. John and Bernabeu Guitart, Montserrat and L{\'o}pez, Jaume", title="Toward Personalized Web-Based Cognitive Rehabilitation for Patients With Ischemic Stroke: Elo Rating Approach", journal="JMIR Med Inform", year="2021", month="Nov", day="10", volume="9", number="11", pages="e28090", keywords="cognitive rehabilitation", keywords="Elo rating", keywords="predictors", keywords="stroke rehabilitation", keywords="web-based tasks", abstract="Background: Stroke is a worldwide cause of disability; 40\% of stroke survivors sustain cognitive impairments, most of them following inpatient rehabilitation at specialized clinical centers. Web-based cognitive rehabilitation tasks are extensively used in clinical settings. The impact of task execution depends on the ratio between the skills of the treated patient and the challenges imposed by the task itself. Thus, treatment personalization requires a trade-off between patients' skills and task difficulties, which is still an open issue. In this study, we propose Elo ratings to support clinicians in tasks assignations and representing patients' skills to optimize rehabilitation outcomes. Objective: This study aims to stratify patients with ischemic stroke at an early stage of rehabilitation into three levels according to their Elo rating; to show the relationships between the Elo rating levels, task difficulty levels, and rehabilitation outcomes; and to determine if the Elo rating obtained at early stages of rehabilitation is a significant predictor of rehabilitation outcomes. Methods: The PlayerRatings R library was used to obtain the Elo rating for each patient. Working memory was assessed using the DIGITS subtest of the Barcelona test, and the Rey Auditory Verbal Memory Test (RAVLT) was used to assess verbal memory. Three subtests of RAVLT were used: RAVLT learning (RAVLT075), free-recall memory (RAVLT015), and recognition (RAVLT015R). Memory predictors were identified using forward stepwise selection to add covariates to the models, which were evaluated by assessing discrimination using the area under the receiver operating characteristic curve (AUC) for logistic regressions and adjusted R2 for linear regressions. Results: Three Elo levels (low, middle, and high) with the same number of patients (n=96) in each Elo group were obtained using the 50 initial task executions (from a total of 38,177) for N=288 adult patients consecutively admitted for inpatient rehabilitation in a clinical setting. The mid-Elo level showed the highest proportions of patients that improved in all four memory items: 56\% (54/96) of them improved in DIGITS, 67\% (64/96) in RAVLT075, 58\% (56/96) in RAVLT015, and 53\% (51/96) in RAVLT015R (P<.001). The proportions of patients from the mid-Elo level that performed tasks at difficulty levels 1, 2, and 3 were 32.1\% (3997/12,449), 31.\% (3997/12,449), and 36.9\% (4595/12,449), respectively (P<.001), showing the highest match between skills (represented by Elo level) and task difficulties, considering the set of 38,177 task executions. Elo ratings were significant predictors in three of the four models and quasi-significant in the fourth. When predicting RAVLT075 and DIGITS at discharge, we obtained R2=0.54 and 0.43, respectively; meanwhile, we obtained AUC=0.73 (95\% CI 0.64-0.82) and AUC=0.81 (95\% CI 0.72-0.89) in RAVLT075 and DIGITS improvement predictions, respectively. Conclusions: Elo ratings can support clinicians in early rehabilitation stages in identifying cognitive profiles to be used for assigning task difficulty levels. ", doi="10.2196/28090", url="https://medinform.jmir.org/2021/11/e28090", url="http://www.ncbi.nlm.nih.gov/pubmed/34757325" } @Article{info:doi/10.2196/28946, author="Elkin, L. Peter and Mullin, Sarah and Mardekian, Jack and Crowner, Christopher and Sakilay, Sylvester and Sinha, Shyamashree and Brady, Gary and Wright, Marcia and Nolen, Kimberly and Trainer, JoAnn and Koppel, Ross and Schlegel, Daniel and Kaushik, Sashank and Zhao, Jane and Song, Buer and Anand, Edwin", title="Using Artificial Intelligence With Natural Language Processing to Combine Electronic Health Record's Structured and Free Text Data to Identify Nonvalvular Atrial Fibrillation to Decrease Strokes and Death: Evaluation and Case-Control Study", journal="J Med Internet Res", year="2021", month="Nov", day="9", volume="23", number="11", pages="e28946", keywords="afib", keywords="atrial fibrillation", keywords="artificial intelligence", keywords="NVAF", keywords="natural language processing", keywords="stroke risk", keywords="bleed risk", keywords="CHA2DS2-VASc", keywords="HAS-BLED", keywords="bio-surveillance", abstract="Background: Nonvalvular atrial fibrillation (NVAF) affects almost 6 million Americans and is a major contributor to stroke but is significantly undiagnosed and undertreated despite explicit guidelines for oral anticoagulation. Objective: The aim of this study is to investigate whether the use of semisupervised natural language processing (NLP) of electronic health record's (EHR) free-text information combined with structured EHR data improves NVAF discovery and treatment and perhaps offers a method to prevent thousands of deaths and save billions of dollars. Methods: We abstracted 96,681 participants from the University of Buffalo faculty practice's EHR. NLP was used to index the notes and compare the ability to identify NVAF, congestive heart failure, hypertension, age ?75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, sex category (CHA2DS2-VASc), and Hypertension,?Abnormal liver/renal function,?Stroke history,?Bleeding history or predisposition,?Labile INR,?Elderly,?Drug/alcohol usage (HAS-BLED) scores using unstructured data (International Classification of Diseases codes) versus structured and unstructured data from clinical notes. In addition, we analyzed data from 63,296,120 participants in the Optum and Truven databases to determine the NVAF frequency, rates of CHA2DS2?VASc ?2, and no contraindications to oral anticoagulants, rates of stroke and death in the untreated population, and first year's costs after stroke. Results: The structured-plus-unstructured method would have identified 3,976,056 additional true NVAF cases (P<.001) and improved sensitivity for CHA2DS2-VASc and HAS-BLED scores compared with the structured data alone (P=.002 and P<.001, respectively), causing a 32.1\% improvement. For the United States, this method would prevent an estimated 176,537 strokes, save 10,575 lives, and save >US \$13.5 billion. Conclusions: Artificial intelligence--informed bio-surveillance combining NLP of free-text information with structured EHR data improves data completeness, prevents thousands of strokes, and saves lives and funds. This method is applicable to many disorders with profound public health consequences. ", doi="10.2196/28946", url="https://www.jmir.org/2021/11/e28946", url="http://www.ncbi.nlm.nih.gov/pubmed/34751659" } @Article{info:doi/10.2196/29120, author="Zanotto, Stella Bruna and Beck da Silva Etges, Paula Ana and dal Bosco, Avner and Cortes, Gabriel Eduardo and Ruschel, Renata and De Souza, Claudia Ana and Andrade, V. Claudio M. and Viegas, Felipe and Canuto, Sergio and Luiz, Washington and Ouriques Martins, Sheila and Vieira, Renata and Polanczyk, Carisi and Andr{\'e} Gon{\c{c}}alves, Marcos", title="Stroke Outcome Measurements From Electronic Medical Records: Cross-sectional Study on the Effectiveness of Neural and Nonneural Classifiers", journal="JMIR Med Inform", year="2021", month="Nov", day="1", volume="9", number="11", pages="e29120", keywords="natural language processing", keywords="stroke", keywords="outcomes", keywords="electronic medical records", keywords="EHR", keywords="electronic health records", keywords="text processing", keywords="data mining", keywords="text classification", keywords="patient outcomes", abstract="Background: With the rapid adoption of electronic medical records (EMRs), there is an ever-increasing opportunity to collect data and extract knowledge from EMRs to support patient-centered stroke management. Objective: This study aims to compare the effectiveness of state-of-the-art automatic text classification methods in classifying data to support the prediction of clinical patient outcomes and the extraction of patient characteristics from EMRs. Methods: Our study addressed the computational problems of information extraction and automatic text classification. We identified essential tasks to be considered in an ischemic stroke value-based program. The 30 selected tasks were classified (manually labeled by specialists) according to the following value agenda: tier 1 (achieved health care status), tier 2 (recovery process), care related (clinical management and risk scores), and baseline characteristics. The analyzed data set was retrospectively extracted from the EMRs of patients with stroke from a private Brazilian hospital between 2018 and 2019. A total of 44,206 sentences from free-text medical records in Portuguese were used to train and develop 10 supervised computational machine learning methods, including state-of-the-art neural and nonneural methods, along with ontological rules. As an experimental protocol, we used a 5-fold cross-validation procedure repeated 6 times, along with subject-wise sampling. A heatmap was used to display comparative result analyses according to the best algorithmic effectiveness (F1 score), supported by statistical significance tests. A feature importance analysis was conducted to provide insights into the results. Results: The top-performing models were support vector machines trained with lexical and semantic textual features, showing the importance of dealing with noise in EMR textual representations. The support vector machine models produced statistically superior results in 71\% (17/24) of tasks, with an F1 score >80\% regarding care-related tasks (patient treatment location, fall risk, thrombolytic therapy, and pressure ulcer risk), the process of recovery (ability to feed orally or ambulate and communicate), health care status achieved (mortality), and baseline characteristics (diabetes, obesity, dyslipidemia, and smoking status). Neural methods were largely outperformed by more traditional nonneural methods, given the characteristics of the data set. Ontological rules were also effective in tasks such as baseline characteristics (alcoholism, atrial fibrillation, and coronary artery disease) and the Rankin scale. The complementarity in effectiveness among models suggests that a combination of models could enhance the results and cover more tasks in the future. Conclusions: Advances in information technology capacity are essential for scalability and agility in measuring health status outcomes. This study allowed us to measure effectiveness and identify opportunities for automating the classification of outcomes of specific tasks related to clinical conditions of stroke victims, and thus ultimately assess the possibility of proactively using these machine learning techniques in real-world situations. ", doi="10.2196/29120", url="https://medinform.jmir.org/2021/11/e29120", url="http://www.ncbi.nlm.nih.gov/pubmed/34723829" } @Article{info:doi/10.2196/32134, author="Gaboury, Isabelle and Tousignant, Michel and Corriveau, H{\'e}l{\`e}ne and Menear, Matthew and Le Dorze, Guylaine and Rochefort, Christian and Vachon, Brigitte and Rochette, Annie and Gosselin, Sylvie and Michaud, Fran{\c{c}}ois and Bollen, Jessica and Dean, Sarah", title="Effects of Telerehabilitation on Patient Adherence to a Rehabilitation Plan: Protocol for a Mixed Methods Trial", journal="JMIR Res Protoc", year="2021", month="Oct", day="28", volume="10", number="10", pages="e32134", keywords="adherence", keywords="interprofessional shared decision making", keywords="rehabilitation", keywords="stroke", keywords="telerehabilitation", abstract="Background: Strong evidence supports beginning stroke rehabilitation as soon as the patient's medical status has stabilized and continuing following discharge from acute care. However, adherence to rehabilitation treatments over the rehabilitation phase has been shown to be suboptimal. Objective: The aim of this study is to assess the impact of a telerehabilitation platform on stroke patients' adherence to a rehabilitation plan and on their level of reintegration into normal social activities, in comparison with usual care. The primary outcome is patient adherence to stroke rehabilitation (up to 12 weeks), which is hypothesized to influence reintegration into normal living. Secondary outcomes for patients include functional recovery and independence, depression, adverse events related to telerehabilitation, use of services (up to 6 months), perception of interprofessional shared decision making, and quality of services received. Interprofessional collaboration as well as quality of interprofessional shared decision making will be measured with clinicians. Methods: In this interrupted time series with a convergent qualitative component, rehabilitation teams will be trained to develop rehabilitation treatment plans that engage the patient and family, while taking advantage of a telerehabilitation platform to deliver the treatment. The intervention will be comprised of 220 patients who will take part in stroke telerehabilitation with an interdisciplinary group of clinicians (telerehabilitation group) versus face-to-face standard of care (control group: n=110 patients). Results: Our Research Ethics Board approved the study in June 2020. Data collection for the control group is underway, with another year planned before we begin the intervention phase. Conclusions: This study will contribute to the minimization of both knowledge and practice gaps, while producing robust, in-depth data on the factors related to the effectiveness of telerehabilitation in a stroke rehabilitation continuum. Findings will inform best practice guidelines regarding telecare services and the provision of telerehabilitation, including recommendations for effective interdisciplinary collaboration regarding stroke rehabilitation. Trial Registration: ClinicalTrials.gov NCT04440215; https://clinicaltrials.gov/ct2/show/NCT04440215 International Registered Report Identifier (IRRID): DERR1-10.2196/32134 ", doi="10.2196/32134", url="https://www.researchprotocols.org/2021/10/e32134", url="http://www.ncbi.nlm.nih.gov/pubmed/34709196" } @Article{info:doi/10.2196/28923, author="Reuter, Katja and Liu, Chang and Le, NamQuyen and Angyan, Praveen and Finley, M. James", title="General Practice and Digital Methods to Recruit Stroke Survivors to a Clinical Mobility Study: Comparative Analysis", journal="J Med Internet Res", year="2021", month="Oct", day="13", volume="23", number="10", pages="e28923", keywords="clinical trial", keywords="stroke", keywords="falls", keywords="digital media", keywords="social media", keywords="advertising", keywords="participant recruitment", keywords="Facebook", keywords="Google", keywords="clinical research", keywords="research methods", keywords="recruitment practices", keywords="enrollment", abstract="Background: Participant recruitment remains a barrier to conducting clinical research. The disabling nature of a stroke, which often includes functional and cognitive impairments, and the acute stage of illness at which patients are appropriate for many trials make recruiting patients particularly complex and challenging. In addition, people aged 65 years and older, which includes most stroke survivors, have been identified as a group that is difficult to reach and is commonly underrepresented in health research, particularly clinical trials. Digital media may provide effective tools to support enrollment efforts of stroke survivors in clinical trials. Objective: The objective of this study was to compare the effectiveness of general practice (traditional) and digital (online) methods of recruiting stroke survivors to a clinical mobility study. Methods: Recruitment for a clinical mobility study began in July 2018. Eligible study participants included individuals 18 years and older who had a single stroke and were currently ambulatory in the community. General recruiting practice included calling individuals listed in a stroke registry, contacting local physical therapists, and placing study flyers throughout a university campus. Between May 21, 2019, and June 26, 2019, the study was also promoted digitally using the social network Facebook and the search engine marketing tool Google AdWords. The recruitment advertisements (ads) included a link to the study page to which users who clicked were referred. Primary outcomes of interest for both general practice and digital methods included recruitment speed (enrollment rate) and sample characteristics. The data were analyzed using the Lilliefors test, the Welch two-sample t test, and the Mann-Whitney test. Significance was set at P=.05. All statistical analyses were performed in MATLAB 2019b. Results: Our results indicate that digital recruitment methods can address recruitment challenges regarding stroke survivors. Digital recruitment methods allowed us to enroll study participants at a faster rate (1.8 participants/week) compared to using general practice methods (0.57 participants/week). Our findings also demonstrate that digital and general recruitment practices can achieve an equivalent level of sample representativeness. The characteristics of the enrolled stroke survivors did not differ significantly by age (P=.95) or clinical scores (P=.22; P=.82). Comparing the cost-effectiveness of Facebook and Google, we found that the use of Facebook resulted in a lower cost per click and cost per enrollee per ad. Conclusions: Digital recruitment can be used to expedite participant recruitment of stroke survivors compared to more traditional recruitment practices, while also achieving equivalent sample representativeness. Both general practice and digital recruitment methods will be important to the successful recruitment of stroke survivors. Future studies could focus on testing the effectiveness of additional general practice and digital media approaches and include robust cost-effectiveness analyses. Examining the effectiveness of different messaging and visual approaches tailored to culturally diverse and underrepresented target subgroups could provide further data to move toward evidence-based recruitment strategies. ", doi="10.2196/28923", url="https://www.jmir.org/2021/10/e28923", url="http://www.ncbi.nlm.nih.gov/pubmed/34643544" } @Article{info:doi/10.2196/27396, author="Berensp{\"o}hler, Sarah and Minnerup, Jens and Dugas, Martin and Varghese, Julian", title="Common Data Elements for Meaningful Stroke Documentation in Routine Care and Clinical Research: Retrospective Data Analysis", journal="JMIR Med Inform", year="2021", month="Oct", day="12", volume="9", number="10", pages="e27396", keywords="common data elements", keywords="stroke", keywords="documentation", abstract="Background: Medical information management for stroke patients is currently a very time-consuming endeavor. There are clear guidelines and procedures to treat patients having acute stroke, but it is not known how well these established practices are reflected in patient documentation. Objective: This study compares a variety of documentation processes regarding stroke. The main objective of this work is to provide an overview of the most commonly occurring medical concepts in stroke documentation and identify overlaps between different documentation contexts to allow for the definition of a core data set that could be used in potential data interfaces. Methods: Medical source documentation forms from different documentation contexts, including hospitals, clinical trials, registries, and international standards, regarding stroke treatment followed by rehabilitation were digitized in the operational data model. Each source data element was semantically annotated using the Unified Medical Language System. The concept codes were analyzed for semantic overlaps. A concept was considered common if it appeared in at least two documentation contexts. The resulting common concepts were extended with implementation details, including data types and permissible values based on frequent patterns of source data elements, using an established expert-based and semiautomatic approach. Results: In total, 3287 data elements were identified, and 1051 of these emerged as unique medical concepts. The 100 most frequent medical concepts cover 9.51\% (100/1051) of all concept occurrences in stroke documentation, and the 50 most frequent concepts cover 4.75\% (50/1051). A list of common data elements was implemented in different standardized machine-readable formats on a public metadata repository for interoperable reuse. Conclusions: Standardization of medical documentation is a prerequisite for data exchange as well as the transferability and reuse of data. In the long run, standardization would save time and money and extend the capabilities for which such data could be used. In the context of this work, a lack of standardization was observed regarding current information management. Free-form text fields and intricate questions complicate automated data access and transfer between institutions. This work also revealed the potential of a unified documentation process as a core data set of the 50 most frequent common data elements, accounting for 34\% of the documentation in medical information management. Such a data set offers a starting point for standardized and interoperable data collection in routine care, quality management, and clinical research. ", doi="10.2196/27396", url="https://medinform.jmir.org/2021/10/e27396", url="http://www.ncbi.nlm.nih.gov/pubmed/34636733" } @Article{info:doi/10.2196/20066, author="Vieira, Catarina and Ferreira da Silva Pais-Vieira, Carla and Novais, Jo{\~a}o and Perrotta, Andr{\'e}", title="Serious Game Design and Clinical Improvement in Physical Rehabilitation: Systematic Review", journal="JMIR Serious Games", year="2021", month="Sep", day="23", volume="9", number="3", pages="e20066", keywords="serious games", keywords="physical rehabilitation", keywords="systematic review", keywords="physical impairment", keywords="game design", keywords="game characteristics", keywords="stroke", keywords="multiple sclerosis", keywords="cerebral palsy", abstract="Background: Serious video games have now been used and assessed in clinical protocols, with several studies reporting patient improvement and engagement with this type of therapy. Even though some literature reviews have approached this topic from a game perspective and presented a broad overview of the types of video games that have been used in this context, there is still a need to better understand how different game characteristics and development strategies might impact and relate to clinical outcomes. Objective: This review assessed the relationship between the characteristics of serious games (SGs) and their relationship with the clinical outcomes of studies that use this type of therapy in motor impairment rehabilitation of patients with stroke, multiple sclerosis, or cerebral palsy. The purpose was to take a closer look at video game design features described in the literature (game genre [GG], game nature [GN], and game development strategy [GDS]) and assess how they may contribute toward improving health outcomes. Additionally, this review attempted to bring together medical and game development perspectives to facilitate communication between clinicians and game developers, therefore easing the process of choosing the video games to be used for physical rehabilitation. Methods: We analyzed the main features of SG design to obtain significant clinical outcomes when applied to physical rehabilitation of patients recovering from motor impairments resulting from stroke, multiple sclerosis, and cerebral palsy. We implemented a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) database-adjusted electronic search strategy for the PubMed, IEEE Xplore, and Cochrane databases. Results: We screened 623 related papers from 2010-2021 and identified 12 that presented results compatible with our inclusion criteria. A total of 512 participants with stroke (8 studies, 417 participants), cerebral palsy (1 study, 8 participants), and multiple sclerosis (2 studies, 46 participants) were included; 1 study targeting the elderly (41 participants) was also included. All studies assessed motor, sensory, and functional functions, while some also measured general health outcomes. Interventions with games were used for upper-limb motor rehabilitation. Of the 12 studies, 8 presented significant improvements in at least one clinical measurement, of which 6 presented games from the casual GG, 1 combined the casual, simulation, and exergaming GGs, and 2 combined the sports and simulation GGs. Conclusions: Of the possible combinations of game design features (GG, GN, and GDS) described, custom-made casual games that resort to the first-person perspective, do not feature a visible player character, are played in single-player mode, and use nonimmersive virtual reality attain the best results in terms of positive clinical outcomes. In addition, the use of custom-made games versus commercial off-the-shelf games tends to give better clinical results, although the latter are perceived as more motivating and engaging. ", doi="10.2196/20066", url="https://games.jmir.org/2021/3/e20066", url="http://www.ncbi.nlm.nih.gov/pubmed/34554102" } @Article{info:doi/10.2196/26153, author="Allegue, Rakia Dorra and Kairy, Dahlia and Higgins, Johanne and Archambault, S. Philippe and Michaud, Francois and Miller, C. William and Sweet, N. Shane and Tousignant, Michel", title="A Personalized Home-Based Rehabilitation Program Using Exergames Combined With a Telerehabilitation App in a Chronic Stroke Survivor: Mixed Methods Case Study", journal="JMIR Serious Games", year="2021", month="Aug", day="31", volume="9", number="3", pages="e26153", keywords="stroke", keywords="rehabilitation", keywords="virtual reality", keywords="video games", keywords="telerehabilitation", keywords="upper extremity", keywords="motivation", abstract="Background: In Canada, only 11\% of stroke survivors have access to outpatient and community-based rehabilitation after discharge from inpatient rehabilitation. Hence, innovative community-based strategies are needed to provide adequate postrehabilitation services. The VirTele program, which combines virtual reality exergames and a telerehabilitation app, was developed to provide stroke survivors with residual upper extremity deficits, the opportunity to participate in a personalized home rehabilitation program. Objective: This study aims to determine the feasibility of VirTele for remote upper extremity rehabilitation in a chronic stroke survivor; explore the preliminary efficacy of VirTele on upper extremity motor function, the amount and quality of upper extremity use, and impact on quality of life and motivation; and explore the determinants of behavioral intention and use behavior of VirTele along with indicators of empowerment. Methods: A 63-year-old male stroke survivor (3 years) with moderate upper extremity impairment participated in a 2-month VirTele intervention. He was instructed to use exergames (5 games for upper extremity) for 30 minutes, 5 times per week, and conduct videoconference sessions with a clinician at least once per week. Motivational interviewing was incorporated into VirTele to empower the participant to continue exercising and use his upper extremities in everyday activities. Upper extremity motor function (Fugl-Meyer Assessment--upper extremity), amount and quality of upper extremity use (Motor Activity Log-30), and impact on quality of life (Stroke Impact Scale-16) and motivation (Treatment Self-Regulation Questionnaire-15) were measured before (T1), after (T2) VirTele intervention, and during a 1- (T3) and 2-month (T4) follow-up period. Qualitative data were collected through logs and semistructured interviews. Feasibility data (eg, number and duration of videoconference sessions and adherence) were documented at the end of each week. Results: The participant completed 48 exergame sessions (33 hours) and 8 videoconference sessions. Results suggest that the VirTele intervention and the study protocol could be feasible for stroke survivors. The participant exhibited clinically meaningful improvements at T2 on the Fugl-Meyer and Stroke Impact Scale-16 and maintained these gains at T3 and T4. During the follow-up periods, the amount and quality of upper extremity use showed meaningful changes, suggesting more involvement of the affected upper extremity in daily activities. The participant demonstrated a high level of autonomous motivation, which may explain his adherence. Performance, effort, and social influence have meaningful weights in the behavioral intention of using VirTele. However, the lack of control of technical and organizational infrastructures may influence the long-term use of technology. At the end of the intervention, the participant demonstrated considerable empowerment at both the behavioral and capacity levels. Conclusions: VirTele was shown to be feasible for use in chronic stroke survivors for remote upper extremity rehabilitation. Meaningful determinants of behavioral intention and use behavior of VirTele were identified, and preliminary efficacy results are promising. International Registered Report Identifier (IRRID): RR2-10.2196/14629 ", doi="10.2196/26153", url="https://games.jmir.org/2021/3/e26153", url="http://www.ncbi.nlm.nih.gov/pubmed/34132649" } @Article{info:doi/10.2196/28192, author="Komatsu, Teppei and Sakai, Kenichiro and Iguchi, Yasuyuki and Takao, Hiroyuki and Ishibashi, Toshihiro and Murayama, Yuichi", title="Using a Smartphone Application for the Accurate and Rapid Diagnosis of Acute Anterior Intracranial Arterial Occlusion: Usability Study", journal="J Med Internet Res", year="2021", month="Aug", day="27", volume="23", number="8", pages="e28192", keywords="stroke", keywords="infarction", keywords="teleradiology", keywords="smartphone", keywords="telehealth", keywords="reperfusion", keywords="neurology", keywords="mHealth", keywords="application", keywords="mobile health", keywords="mobile applications", keywords="diagnosis", keywords="diagnostics", abstract="Background: Telestroke has developed rapidly as an assessment tool for patients eligible for reperfusion therapy. Objective: To investigate whether vascular neurologists can diagnose intracranial large vessel occlusion (LVO) as quickly and accurately using a smartphone application compared to a hospital-based desktop PC monitor. Methods: We retrospectively enrolled 108 consecutive patients with acute ischemic stroke in the middle cerebral artery territory who underwent magnetic resonance imaging (MRI) within 24 hours of their stroke onset. Two vascular neurologists, blinded to all clinical information, independently evaluated magnetic resonance angiography and fluid-attenuated inversion recovery images for the presence or absence of LVO in the internal carotid artery and middle cerebral artery (M1, M2, or M3) on both a smartphone application (Smartphone-LVO) and a hospital-based desktop PC monitor (PC-LVO). To evaluate the accuracy of an arterial occlusion diagnosis, interdevice variability between Smartphone-LVO and PC-LVO was analyzed using $\kappa$ statistics, and image interpretation time was compared between Smartphone-LVO and PC-LVO. Results: There was broad agreement between Smartphone-LVO and PC-LVO evaluations regarding the presence or absence of arterial occlusion (Reader 1: $\kappa$=0.94; P<.001 vs Reader 2: $\kappa$=0.89; P<.001), and interpretation times were similar between Smartphone-LVO and PC-LVO. Conclusions: The results indicate the evaluation of neuroimages using a smartphone application can provide an accurate and timely diagnosis of anterior intracranial arterial occlusion that can be shared immediately with members of the stroke team to support the management of patients with hyperacute ischemic stroke. ", doi="10.2196/28192", url="https://www.jmir.org/2021/8/e28192", url="http://www.ncbi.nlm.nih.gov/pubmed/34448716" } @Article{info:doi/10.2196/28748, author="Noser, Anne Elizabeth and Zhang, Jing and Rahbar, Hossein Mohammad and Sharrief, Zarinah Anjail and Barreto, David Andrew and Shaw, Sandi and Grotta, Charles James and Savitz, Isaac Sean and Ifejika, Lotea Nneka", title="Leveraging Multimedia Patient Engagement to Address Minority Cerebrovascular Health Needs: Prospective Observational Study", journal="J Med Internet Res", year="2021", month="Aug", day="13", volume="23", number="8", pages="e28748", keywords="environmental justice", keywords="urban flooding", keywords="stroke", keywords="community engagement", keywords="education", keywords="health disparities", abstract="Background: Social inequities affecting minority populations after Hurricane Katrina led to an expansion of environmental justice literature. In August 2017, Hurricane Harvey rainfall was estimated as a 3000- to 20,000-year flood event, further affecting minority populations with disproportionate stroke prevalence. The Stomp Out Stroke initiative leveraged multimedia engagement, creating a patient-centered cerebrovascular health intervention. Objective: This study aims to address social inequities in cerebrovascular health through the identification of race- or ethnicity-specific health needs and the provision of in-person stroke prevention screening during two community events (May 2018 and May 2019). Methods: Stomp Out Stroke recruitment took place through internet-based channels (websites and social networking). Exclusively through web registration, Stomp Out Stroke participants (aged >18 years) detailed sociodemographic characteristics, family history of stroke, and stroke survivorship. Participant health interests were compared by race or ethnicity using Kruskal-Wallis or chi-square test at an $\alpha$=.05. A Bonferroni-corrected P value of .0083 was used for multiple comparisons. Results: Stomp Out Stroke registrants (N=1401) were 70\% (973/1390) female (median age 45 years) and largely self-identified as members of minority groups: 32.05\% (449/1401) Hispanic, 25.62\% (359/1401) African American, 13.63\% (191/1401) Asian compared with 23.63\% (331/1401) non-Hispanic White. Stroke survivors comprised 11.55\% (155/1401) of our population. A total of 124 stroke caregivers participated. Approximately 36.81\% (493/1339) of participants had a family history of stroke. African American participants were most likely to have Medicare or Medicaid insurance (84/341, 24.6\%), whereas Hispanic participants were most likely to be uninsured (127/435, 29.2\%). Hispanic participants were more likely than non-Hispanic White participants to obtain health screenings (282/449, 62.8\% vs 175/331, 52.9\%; P=.03). Asian (105/191, 54.9\%) and African American (201/359, 55.9\%) participants were more likely to request stroke education than non-Hispanic White (138/331, 41.6\%) or Hispanic participants (193/449, 42.9\%). African American participants were more likely to seek overall health education than non-Hispanic White participants (166/359, 46.2\% vs 108/331, 32.6\%; P=.002). Non-Hispanic White participants (48/331, 14.5\%) were less likely to speak to health care providers than African American (91/359, 25.3\%) or Asian participants (54/191, 28.3\%). During the 2018 and 2019 events, 2774 health screenings were completed across 12 hours, averaging four health screenings per minute. These included blood pressure (1031/2774, 37.16\%), stroke risk assessment (496/2774, 17.88\%), bone density (426/2774, 15.35\%), carotid ultrasound (380/2774, 13.69\%), BMI (182/2774, 6.56\%), serum lipids (157/2774, 5.65\%), and hemoglobin A1c (102/2774, 3.67\%). Twenty multimedia placements using the Stomp Out Stroke webpage, social media, \#stompoutstroke, television, iQ radio, and web-based news reached approximately 849,731 people in the Houston area. Conclusions: Using a combination of internet-based recruitment, registration, and in-person assessments, Stomp Out Stroke identified race- or ethnicity-specific health care needs and provided appropriate screenings to minority populations at increased risk of urban flooding and stroke. This protocol can be replicated in Southern US Stroke Belt cities with similar flood risks. ", doi="10.2196/28748", url="https://www.jmir.org/2021/8/e28748", url="http://www.ncbi.nlm.nih.gov/pubmed/34397385" } @Article{info:doi/10.2196/23464, author="de Castro, Paul Kim and Chiu, Henrison Harold and De Leon-Yao, Cheska Ronna and Almelor-Sembrana, Lorraine and Dans, Miguel Antonio", title="A Patient Decision Aid for Anticoagulation Therapy in Patients With Nonvalvular Atrial Fibrillation: Development and Pilot Study", journal="JMIR Cardio", year="2021", month="Aug", day="12", volume="5", number="2", pages="e23464", keywords="shared decision-making", keywords="patient decision aid", keywords="atrial fibrillation", keywords="anticoagulation", keywords="stroke prevention", keywords="mHealth", keywords="mobile health", abstract="Background: Atrial fibrillation (AF) is one of the most common predisposing factors for ischemic stroke worldwide. Because of this, patients with AF are prescribed anticoagulant medications to decrease the risk. The availability of different options for oral anticoagulation makes it difficult for some patients to decide a preferred choice of medication. Clinical guidelines often recommend enhancing the decision-making process of patients by increasing their involvement in health decisions. In particular, the use of patient decision aids (PDAs) in patients with AF was associated with increased knowledge and increased likelihood of making a choice. However, the majority of available PDAs are from Western countries. Objective: We aimed to develop and pilot test a PDA to help patients with nonvalvular AF choose an oral anticoagulant for stroke prevention in the local setting. Outcomes were (1) reduction in patient decisional conflict, (2) improvement in patient knowledge, and (3) patient and physician acceptability. Methods: We followed the International Patient Decision Aid Standards (IPDAS) to develop a mobile app--based PDA for anticoagulation therapy in patients with nonvalvular AF. Focus group discussions identified decisional needs, which were subsequently incorporated into the PDA to compare choices for anticoagulation. Based on recommendations, the prototype PDA was rendered by at least 30 patients and 30 physicians. Decisional conflict and patient knowledge were tested before and after the PDA was implemented. Patient acceptability and physician acceptability were measured after each encounter. Results: Anticoagulant options were compared by the PDA using three factors that were identified (impact on stroke and bleeding risk, and price). The comparisons were presented as tables and graphs. The prototype PDA was rendered by 30 doctors and 37 patients for pilot testing. The mean duration of the encounters was 15 minutes. The decisional conflict score reduced by 35 points (100-point scale; P<.001). The AF knowledge score improved from 10 to 15 (P<.001). The PDA was acceptable for both patients and doctors. Conclusions: Our study showed that an app-based PDA for anticoagulation therapy in patients with nonvalvular AF (1) reduced patient decisional conflict, (2) improved patient knowledge, and (3) was acceptable to patients and physicians. A PDA is potentially acceptable and useful in our setting. A randomized controlled trial is warranted to test its effectiveness compared to usual care. PDAs for other conditions should also be developed. ", doi="10.2196/23464", url="https://cardio.jmir.org/2021/2/e23464", url="http://www.ncbi.nlm.nih.gov/pubmed/34385138" } @Article{info:doi/10.2196/28266, author="Kummer, Benjamin and Shakir, Lubaina and Kwon, Rachel and Habboushe, Joseph and Jett{\'e}, Nathalie", title="Usage Patterns of Web-Based Stroke Calculators in Clinical Decision Support: Retrospective Analysis", journal="JMIR Med Inform", year="2021", month="Aug", day="2", volume="9", number="8", pages="e28266", keywords="medical informatics", keywords="clinical informatics", keywords="mhealth", keywords="digital health", keywords="cerebrovascular disease", keywords="medical calculators", keywords="health information", keywords="health information technology", keywords="information technology", keywords="economic health", keywords="clinical health", keywords="electronic health records", abstract="Background: Clinical scores are frequently used in the diagnosis and management of stroke. While medical calculators are increasingly important support tools for clinical decisions, the uptake and use of common medical calculators for stroke remain poorly characterized. Objective: We aimed to describe use patterns in frequently used stroke-related medical calculators for clinical decisions from a web-based support system. Methods: We conducted a retrospective study of calculators from MDCalc, a web-based and mobile app--based medical calculator platform based in the United States. We analyzed metadata tags from MDCalc's calculator use data to identify all calculators related to stroke. Using relative page views as a measure of calculator use, we determined the 5 most frequently used stroke-related calculators between January 2016 and December 2018. For all 5 calculators, we determined cumulative and quarterly use, mode of access (eg, app or web browser), and both US and international distributions of use. We compared cumulative use in the 2016-2018 period with use from January 2011 to December 2015. Results: Over the study period, we identified 454 MDCalc calculators, of which 48 (10.6\%) were related to stroke. Of these, the 5 most frequently used calculators were the CHA2DS2-VASc score for atrial fibrillation stroke risk calculator (5.5\% of total and 32\% of stroke-related page views), the Mean Arterial Pressure calculator (2.4\% of total and 14.0\% of stroke-related page views), the HAS-BLED score for major bleeding risk (1.9\% of total and 11.4\% of stroke-related page views), the National Institutes of Health Stroke Scale (NIHSS) score calculator (1.7\% of total and 10.1\% of stroke-related page views), and the CHADS2 score for atrial fibrillation stroke risk calculator (1.4\% of total and 8.1\% of stroke-related page views). Web browser was the most common mode of access, accounting for 82.7\%-91.2\% of individual stroke calculator page views. Access originated most frequently from the most populated regions within the United States. Internationally, use originated mostly from English-language countries. The NIHSS score calculator demonstrated the greatest increase in page views (238.1\% increase) between the first and last quarters of the study period. Conclusions: The most frequently used stroke calculators were the CHA2DS2-VASc, Mean Arterial Pressure, HAS-BLED, NIHSS, and CHADS2. These were mainly accessed by web browser, from English-speaking countries, and from highly populated areas. Further studies should investigate barriers to stroke calculator adoption and the effect of calculator use on the application of best practices in cerebrovascular disease. ", doi="10.2196/28266", url="https://medinform.jmir.org/2021/8/e28266", url="http://www.ncbi.nlm.nih.gov/pubmed/34338647" } @Article{info:doi/10.2196/19905, author="Huang, Yanqun and Wang, Ni and Zhang, Zhiqiang and Liu, Honglei and Fei, Xiaolu and Wei, Lan and Chen, Hui", title="Patient Representation From Structured Electronic Medical Records Based on Embedding Technique: Development and Validation Study", journal="JMIR Med Inform", year="2021", month="Jul", day="23", volume="9", number="7", pages="e19905", keywords="electronic medical records", keywords="Skip-gram", keywords="feature representation", keywords="patient representation", keywords="stroke", abstract="Background: The secondary use of structured electronic medical record (sEMR) data has become a challenge due to the diversity, sparsity, and high dimensionality of the data representation. Constructing an effective representation for sEMR data is becoming more and more crucial for subsequent data applications. Objective: We aimed to apply the embedding technique used in the natural language processing domain for the sEMR data representation and to explore the feasibility and superiority of the embedding-based feature and patient representations in clinical application. Methods: The entire training corpus consisted of records of 104,752 hospitalized patients with 13,757 medical concepts of disease diagnoses, physical examinations and procedures, laboratory tests, medications, etc. Each medical concept was embedded into a 200-dimensional real number vector using the Skip-gram algorithm with some adaptive changes from shuffling the medical concepts in a record 20 times. The average of vectors for all medical concepts in a patient record represented the patient. For embedding-based feature representation evaluation, we used the cosine similarities among the medical concept vectors to capture the latent clinical associations among the medical concepts. We further conducted a clustering analysis on stroke patients to evaluate and compare the embedding-based patient representations. The Hopkins statistic, Silhouette index (SI), and Davies-Bouldin index were used for the unsupervised evaluation, and the precision, recall, and F1 score were used for the supervised evaluation. Results: The dimension of patient representation was reduced from 13,757 to 200 using the embedding-based representation. The average cosine similarity of the selected disease (subarachnoid hemorrhage) and its 15 clinically relevant medical concepts was 0.973. Stroke patients were clustered into two clusters with the highest SI (0.852). Clustering analyses conducted on patients with the embedding representations showed higher applicability (Hopkins statistic 0.931), higher aggregation (SI 0.862), and lower dispersion (Davies-Bouldin index 0.551) than those conducted on patients with reference representation methods. The clustering solutions for patients with the embedding-based representation achieved the highest F1 scores of 0.944 and 0.717 for two clusters. Conclusions: The feature-level embedding-based representations can reflect the potential clinical associations among medical concepts effectively. The patient-level embedding-based representation is easy to use as continuous input to standard machine learning algorithms and can bring performance improvements. It is expected that the embedding-based representation will be helpful in a wide range of secondary uses of sEMR data. ", doi="10.2196/19905", url="https://medinform.jmir.org/2021/7/e19905", url="http://www.ncbi.nlm.nih.gov/pubmed/34297000" } @Article{info:doi/10.2196/23174, author="Inglis-Jassiem, Gakeemah and Grimmer, Karen and Conradie, Thandi and Louw, Quinette", title="Descriptive Review of Online Information Resources for People With Stroke: Protocol for a Scoping Review", journal="JMIR Res Protoc", year="2021", month="Jul", day="13", volume="10", number="7", pages="e23174", keywords="stroke", keywords="online resources", keywords="content", keywords="readability", keywords="design", abstract="Background: People with stroke and their caregivers experience numerous information needs; internet-based resources may offer cost-effective ways to improve access to information about this condition and its management, including the availability of resources and support. The quality of online health information is, therefore, an important consideration for both developers and consumers of these online resources. Objective: This study aims to map and evaluate the content, readability, understandability, design, and quality characteristics of freely available online information resources (ie, websites) that empower people with stroke and their caregivers with information and self-help strategies poststroke. Methods: This descriptive review will follow the five systematic and rigorous methodological steps that are recommended for scoping reviews, which include the following: (1) identifying the research question, (2) identifying relevant studies, (3) selecting the studies, (4) charting the data, and (5) collating, summarizing, and reporting the results. Data will then be synthesized and analyzed thematically. Results: As of February 2021, the scoping review is in the data extraction stage. Data will be synthesized, and the first results are expected to be submitted for publication in an open-access peer-reviewed journal in August 2021. In addition, we will develop an accessible summary of the results for stakeholder meetings. Ethical approval is not required for this review, as it will only include publicly available information. Conclusions: This study is novel and will evaluate the typology, content, and design-related criteria, including accessibility, aesthetics, navigability, interactivity, privacy, and data protection, of online information resources for stroke. The review will be limited to online resources published in English. International Registered Report Identifier (IRRID): DERR1-10.2196/23174 ", doi="10.2196/23174", url="https://www.researchprotocols.org/2021/7/e23174", url="http://www.ncbi.nlm.nih.gov/pubmed/34255721" } @Article{info:doi/10.2196/29182, author="Knobel, Johannes Samuel Elia and Kaufmann, Charlotte Brigitte and Gerber, Moreno Stephan and Urwyler, Prabitha and Cazzoli, Dario and M{\"u}ri, M. Ren{\'e} and Nef, Tobias and Nyffeler, Thomas", title="Development of a Search Task Using Immersive Virtual Reality: Proof-of-Concept Study", journal="JMIR Serious Games", year="2021", month="Jul", day="2", volume="9", number="3", pages="e29182", keywords="virtual reality", keywords="serious game", keywords="search task", keywords="stroke", keywords="neglect", keywords="usability", keywords="development", keywords="immersion", keywords="concept", keywords="gaming", abstract="Background: Serious games are gaining increasing importance in neurorehabilitation since they increase motivation and adherence to therapy, thereby potentially improving its outcome. The benefits of serious games, such as the possibility to implement adaptive feedback and the calculation of comparable performance measures, can be even further improved by using immersive virtual reality (iVR), allowing a more intuitive interaction with training devices and higher ecological validity. Objective: This study aimed to develop a visual search task embedded in a serious game setting for iVR, including self-adapting difficulty scaling, thus being able to adjust to the needs and ability levels of different groups of individuals. Methods: In a two-step process, a serious game in iVR (bird search task) was developed and tested in healthy young (n=21) and elderly (n=23) participants and in a group of patients with impaired visual exploration behavior (ie, patients with hemispatial neglect after right-hemispheric stroke; n=11). Usability, side effects, game experience, immersion, and presence of the iVR serious game were assessed by validated questionnaires. Moreover, in the group of stroke patients, the performance in the iVR serious game was also considered with respect to hemispatial neglect severity, as assessed by established objective hemispatial neglect measures. Results: In all 3 groups, reported usability of the iVR serious game was above 4.5 (on a Likert scale with scores ranging from 1 to 5) and reported side effects were infrequent and of low intensity (below 1.5 on a Likert scale with scores ranging from 1 to 4). All 3 groups equally judged the iVR serious game as highly motivating and entertaining. Performance in the game (in terms of mean search time) showed a lateralized increase in search time in patients with hemispatial neglect that varied strongly as a function of objective hemispatial neglect severity. Conclusions: The developed iVR serious game, ``bird search task,'' was a motivating, entertaining, and immersive task, which can, due to its adaptive difficulty scaling, adjust and be played by different populations with different levels of skills, including individuals with cognitive impairments. As a complementary finding, it seems that performance in the game is able to capture typical patterns of impaired visual exploration behavior in hemispatial neglect, as there is a high correlation between performance and neglect severity as assessed with a cancellation task. ", doi="10.2196/29182", url="https://games.jmir.org/2021/3/e29182", url="http://www.ncbi.nlm.nih.gov/pubmed/34255653" } @Article{info:doi/10.2196/30621, author="Kim, S. Esther and Laird, Laura and Wilson, Carlee and Bieg, Till and Mildner, Philip and M{\"o}ller, Sebastian and Schatz, Raimund and Schwarz, Stephanie and Spang, Robert and Voigt-Antons, Jan-Niklas and Rochon, Elizabeth", title="Implementation and Effects of an Information Technology--Based Intervention to Support Speech and Language Therapy Among Stroke Patients With Aphasia: Protocol for a Virtual Randomized Controlled Trial", journal="JMIR Res Protoc", year="2021", month="Jul", day="2", volume="10", number="7", pages="e30621", keywords="aphasia", keywords="rehabilitation", keywords="speech-language pathology", keywords="app-based therapy", keywords="user-centered design", keywords="mHealth", keywords="adaptive software", abstract="Background: Mobile app--based therapies are increasingly being employed by speech-language pathologists in the rehabilitation of people with aphasia as adjuncts or substitutes for traditional in-person therapy approaches. These apps can increase the intensity of treatment and have resulted in meaningful outcomes across several domains. Objective: VoiceAdapt is a mobile therapy app designed with user and stakeholder feedback within a user-centered design framework. VoiceAdapt uses two evidence-based lexical retrieval treatments to help people with aphasia in improving their naming abilities through interactions with the app. The purpose of the randomized controlled trial (RCT) proposed here is to examine the feasibility and clinical efficacy of training with VoiceAdapt on the language and communication outcomes of people with aphasia. Methods: A multicenter RCT is being conducted at two locations within Canada. A total of 80 people with aphasia will be recruited to participate in a two-arm, waitlist-controlled, crossover group RCT. After baseline assessment, participants will be randomized into an intervention group or a waitlist control group. The intervention group participants will engage in 5 weeks of training with the app, followed by posttreatment and follow-up assessments after an additional 5 weeks. Those in the waitlist control group will have no training for 5 weeks; this is followed by pretreatment assessment, training for 5 weeks, and posttreatment assessment. All trial procedures are being conducted remotely given the COVID-19 pandemic. Results: Recruitment of participants started in September 2020, and the study is expected to be completed by March 2022. Publication of results is expected within 6 months of study completion. Conclusions: The results of the RCT will provide information on evidence-based practice using technology-based solutions to treat aphasia. If positive results are obtained from this RCT, the VoiceAdapt app can be recommended as an efficacious means of improving lexical retrieval and communicative functioning in people with aphasia in an easily accessible and a cost-effective manner. Moreover, the implementation of this RCT through remote assessment and delivery can provide information to therapists on telerehabilitation practices and monitoring of app-based home therapy programs. Trial Registration: ClinicalTrials.gov NCT04108364; https://clinicaltrials.gov/ct2/show/NCT04108364 International Registered Report Identifier (IRRID): DERR1-10.2196/30621 ", doi="10.2196/30621", url="https://www.researchprotocols.org/2021/7/e30621", url="http://www.ncbi.nlm.nih.gov/pubmed/34255727" } @Article{info:doi/10.2196/12029, author="Rennick-Egglestone, Stefan and Mawson, Sue", title="Homes of Stroke Survivors Are a Challenging Environment for Rehabilitation Technologies", journal="JMIR Rehabil Assist Technol", year="2021", month="Jun", day="17", volume="8", number="2", pages="e12029", keywords="domestic rehabilitation technology", keywords="brain injury", keywords="stroke", keywords="research through design", doi="10.2196/12029", url="https://rehab.jmir.org/2021/2/e12029", url="http://www.ncbi.nlm.nih.gov/pubmed/34137728" } @Article{info:doi/10.2196/24116, author="Lv, Meina and Wu, Tingting and Jiang, Shaojun and Chen, Wenjun and Zhang, Jinhua", title="Effects of Telemedicine and mHealth on Systolic Blood Pressure Management in Stroke Patients: Systematic Review and Meta-Analysis of Randomized Controlled Trials", journal="JMIR Mhealth Uhealth", year="2021", month="Jun", day="11", volume="9", number="6", pages="e24116", keywords="stroke", keywords="systolic blood pressure", keywords="mHealth", keywords="telemedicine", keywords="meta-analysis", keywords="self-management", abstract="Background: Stroke is a common, harmful disease with high recurrence and mortality rates. Uncontrolled blood pressure is an important and changeable risk factor for stroke recurrence. Telemedicine and mobile health (mHealth) interventions may have the potential to facilitate the control of blood pressure among stroke survivors, but their effect has not been established. Objective: This systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to estimate the effects of telemedicine and mHealth interventions on the control of systolic blood pressure among stroke survivors. Methods: The research literature published up to June 28, 2020, and consisting of RCTs related to telemedicine and mHealth interventions was searched in PubMed, EMBASE, Web of Science, and the Cochrane Library. The Cochrane risk of bias tool (RoB 2.0) was used to evaluate the quality of the studies. The Cochran Q test and I2 statistic were used to assess heterogeneity. Data were meta-analyzed using a random-effects model. Mean difference (MD) with 95\% CI and 95\% prediction interval (PI) were calculated. Results: In total, 9 RCTs with a total sample size of 1583 stroke survivors met the inclusion criteria. Compared with the usual care, telemedicine and mHealth had a significantly greater impact on the control of systolic blood pressure (MD --5.49; 95\% CI --7.87 to --3.10; P<.001; 95\% PI --10.46 to --0.51). A subgroup analysis showed that the intervention mode of telephone plus SMS text messaging (MD --9.09; 95\% CI --12.71 to --5.46; P<.001) or only telephone (MD --4.34; 95\% CI --6.55 to --2.13; P<.001; 95\% PI --7.24 to --1.45) had a greater impact on the control of systolic blood pressure than usual care. Among the stroke survivors with an intervention interval ?1 week (MD --6.51; 95\% CI --9.36 to --3.66; P<.001; 95\% PI --12.91 to --0.10) or a baseline systolic blood pressure ?140 mm Hg (MD --6.15; 95\% CI --9.44 to --2.86; P<.001; 95\% PI --13.55 to 1.26), the control of systolic blood pressure using telemedicine and mHealth was better than that of usual care. Conclusions: In general, telemedicine and mHealth reduced the systolic blood pressure of stroke survivors by an average of 5.49 mm Hg compared with usual care. Telemedicine and mHealth are a relatively new intervention mode with potential applications for the control of systolic blood pressure among stroke survivors, especially those with hypertensive stroke. ", doi="10.2196/24116", url="https://mhealth.jmir.org/2021/6/e24116", url="http://www.ncbi.nlm.nih.gov/pubmed/34114961" } @Article{info:doi/10.2196/27084, author="Shaklai, Sigal and Gilad-Bachrach, Ran and Yom-Tov, Elad and Stern, Naftali", title="Detecting Impending Stroke From Cognitive Traits Evident in Internet Searches: Analysis of Archival Data", journal="J Med Internet Res", year="2021", month="May", day="28", volume="23", number="5", pages="e27084", keywords="search engines", keywords="diagnosis", keywords="screening", keywords="stroke", keywords="risk", keywords="internet", keywords="trend", keywords="infodemiology", keywords="archive", keywords="prospective", keywords="algorithm", abstract="Background: Cerebrovascular disease is a leading cause of mortality and disability. Common risk assessment tools for stroke are based on the Framingham equation, which relies on traditional cardiovascular risk factors to predict an acute event in the near decade. However, no tools are currently available to predict a near/impending stroke, which might alert patients at risk to seek immediate preventive action (eg, anticoagulants for atrial fibrillation, control of hypertension). Objective: Here, we propose that an algorithm based on internet search queries can identify people at increased risk for a near stroke event. Methods: We analyzed queries submitted to the Bing search engine by 285 people who self-identified as having undergone a stroke event and 1195 controls with regard to attributes previously shown to reflect cognitive function. Controls included random people 60 years and above, or those of similar age who queried for one of nine control conditions. Results: The model performed well against all comparator groups with an area under the receiver operating characteristic curve of 0.985 or higher and a true positive rate (at a 1\% false-positive rate) above 80\% for separating patients from each of the controls. The predictive power rose as the stroke date approached and if data were acquired beginning 120 days prior to the event. Good prediction accuracy was obtained for a prospective cohort of users collected 1 year later. The most predictive attributes of the model were associated with cognitive function, including the use of common queries, repetition of queries, appearance of spelling mistakes, and number of queries per session. Conclusions: The proposed algorithm offers a screening test for a near stroke event. After clinical validation, this algorithm may enable the administration of rapid preventive intervention. Moreover, it could be applied inexpensively, continuously, and on a large scale with the aim of reducing stroke events. ", doi="10.2196/27084", url="https://www.jmir.org/2021/5/e27084", url="http://www.ncbi.nlm.nih.gov/pubmed/34047699" } @Article{info:doi/10.2196/16703, author="Lou, Weiqun Vivian and Tang, Man Jennifer Yee and Lau, Kai Gary Kui and Lum, Sang Terry Yat and Fong, Kenneth and Ko, Tung Rachel Wai and Cheng, Man Clio Yuen and Fu, Yinqi Joyce and Chow, Lun Eddie Siu and Chu, Kwok Angus Chun and Hui, Elsie and Ng, Ling Winnie Wing and Chan, Wai Felix Hon and Luk, C. C. and Kwok, K. T.", title="Effectiveness of a Two-Tier Family-Oriented Intervention in Enhancing the Family Functioning and Care Capacity of the Family Caregivers of Stroke Survivors: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2021", month="May", day="28", volume="10", number="5", pages="e16703", keywords="two-tier family-oriented intervention", keywords="family functioning", keywords="family caregivers", keywords="stroke survivors", keywords="randomized controlled trial", abstract="Background: Stroke has profound impacts on families. Often, family members, including stroke survivors and the person who takes up the role of the primary caregiver, would encounter demands on finances, rehabilitation arrangement, and even conflicts. Hence, a family-oriented intervention is expected to enable families to rebuild internal and external resources to achieve optimal rehabilitation and community reintegration. Objective: This study aims to describe a design of a two-tier family-oriented care management intervention for enhancing the family functioning and care capacity of the caregivers of stroke survivors. Methods: The two-tier care management intervention was guided by a standardized protocol conducted by trained professional care managers (first tier) with the support of trained volunteers (second tier), which lasted for 8-12 weeks. Participants were recruited through collaborating hospitals according to inclusion and exclusion criteria. In order to examine the effectiveness and cost-effectiveness of the two-tier care management intervention, a two-arm randomization multicenter study was designed, including an active comparison group, which was guided by a standardized protocol conducted by trained volunteers. Dyadic participants, including both stroke survivors and their primary caregivers for both groups, were invited to participate in a questionnaire survey using standardized and purposefully developed measures 3 times: before the intervention, immediately after the intervention, and 2 months after the intervention. The primary outcome was family functioning measured by the Family Role Performance Scale and Family Assessment Device-General Functioning Scale. The secondary outcomes included caregiving burden, depressive symptoms, care management strategies, and the incremental cost-effectiveness ratio. Results: Recruitment began in January 2017 and was completed at the end of April 2019. Data collection was completed at the end of March 2020. As of March 2020, enrollment has been completed (n=264 stroke caregivers). A total of 200 participants completed the baseline questionnaires. We aim to publish the results by mid-2021. Conclusions: This study successfully developed a two-tier care management protocol that aims to enhance the family functioning of the caregivers of stroke survivors. Guided by a standardized protocol, this family-oriented two-tier intervention protocol was found to be feasible among Chinese families. Trial Registration: ClinicalTrials.gov NCT03034330; https://ichgcp.net/clinical-trials-registry/NCT03034330 International Registered Report Identifier (IRRID): RR1-10.2196/16703 ", doi="10.2196/16703", url="https://www.researchprotocols.org/2021/5/e16703", url="http://www.ncbi.nlm.nih.gov/pubmed/34047707" } @Article{info:doi/10.2196/24346, author="Lee, Jen-Kuang and Hung, Chi-Sheng and Huang, Ching-Chang and Chen, Ying-Hsien and Wu, Hui-Wen and Chuang, Pao-Yu and Yu, Jiun-Yu and Ho, Yi-Lwun", title="The Costs and Cardiovascular Benefits in Patients With Peripheral Artery Disease From a Fourth-Generation Synchronous Telehealth Program: Retrospective Cohort Study", journal="J Med Internet Res", year="2021", month="May", day="18", volume="23", number="5", pages="e24346", keywords="peripheral artery disease", keywords="fourth-generation synchronous telehealth program", keywords="ischemic stroke", keywords="hospitalization", keywords="cardiovascular disease", keywords="telehealth", keywords="stroke", keywords="cost", keywords="benefit", keywords="heart", abstract="Background: Patients with peripheral artery disease (PAD) are at high risk for major cardiovascular events, including myocardial infarction, stroke, and hospitalization for heart failure. We have previously shown the clinical efficacy of a fourth-generation synchronous telehealth program for some patients, but the costs and cardiovascular benefits of the program for PAD patients remain unknown. Objective: The telehealth program is now widely used by higher-risk cardiovascular patients to prevent further cardiovascular events. This study investigated whether patients with PAD would also have better cardiovascular outcomes after participating in the fourth-generation synchronous telehealth program. Methods: This was a retrospective cohort study. We screened 5062 patients with cardiovascular diseases who were treated at National Taiwan University Hospital and then enrolled 391 patients with a diagnosis of PAD. Of these patients, 162 took part in the telehealth program, while 229 did not and thus served as control patients. Inverse probability of treatment weighting (IPTW) based on the propensity score was used to mitigate possible selection bias. Follow-up outcomes included heart failure hospitalization, acute coronary syndrome, stroke, and all-cause readmission during the 1-year follow-up period and through the last follow-up. Results: The mean follow-up duration was 3.1 (SD 1.8) years for the patients who participated in the telehealth program and 3.2 (SD 1.8) for the control group. The telehealth program patients exhibited lower risk of ischemic stroke than did the control group in the first year after IPTW (0.9\% vs 3.5\%; hazard ratio [HR] 0.24; 95\% CI 0.07-0.80). The 1-year composite endpoint of vascular accident, including acute coronary syndrome and stroke, was also significantly lower in the telehealth program group after IPTW (2.4\% vs 5.2\%; HR 0.46; 95\% CI 0.21-0.997). At the end of the follow-up, the telehealth program group continued to exhibit a significantly lower rate of ischemic stroke than did the control group after IPTW (0.9\% vs 3.5\%; HR 0.52, 95\% CI 0.28-0.93). Furthermore, the medical costs of the telehealth program patients were not higher than those of the control group, whether in terms of outpatient, emergency department, hospitalization, or total costs. Conclusions: The PAD patients who participated in the fourth-generation synchronous telehealth program exhibited lower risk of ischemic stroke events over both mid- and long-term follow-up periods. However, larger-scale and prospective randomized clinical trials are needed to confirm our findings. ", doi="10.2196/24346", url="https://www.jmir.org/2021/5/e24346", url="http://www.ncbi.nlm.nih.gov/pubmed/34003132" } @Article{info:doi/10.2196/26133, author="Tran, E. Johanna and Fowler, A. Christopher and Delikat, Jemy and Kaplan, Howard and Merzier, M. Marie and Schlesinger, R. Michelle and Litzenberger, Stefan and Marszalek, M. Jacob and Scott, Steven and Winkler, L. Sandra", title="Immersive Virtual Reality to Improve Outcomes in Veterans With Stroke: Protocol for a Single-Arm Pilot Study", journal="JMIR Res Protoc", year="2021", month="May", day="10", volume="10", number="5", pages="e26133", keywords="stroke", keywords="immersive virtual reality", keywords="feasibility", keywords="veterans affairs", keywords="veterans", keywords="pilot", keywords="recovery", keywords="upper extremity", abstract="Background: Over the last decade, virtual reality (VR) has emerged as a cutting-edge technology in stroke rehabilitation. VR is defined as a type of computer-user interface that implements real-time simulation of an activity or environment allowing user interaction via multiple sensory modalities. In a stroke population, VR interventions have been shown to enhance motor, cognitive, and psychological recovery when utilized as a rehabilitation adjunct. VR has also demonstrated noninferiority to usual care therapies for stroke rehabilitation. Objective: The proposed pilot study aims to (1) determine the feasibility and tolerability of using a therapeutic VR platform in an inpatient comprehensive stroke rehabilitation program and (2) estimate the initial clinical efficacy (effect size) associated with the VR platform using apps for pain distraction and upper extremity exercise for poststroke neurologic recovery. Methods: This study will be conducted in the Comprehensive Integrated Inpatient Rehabilitation Program at the James A Haley Veterans' Hospital. Qualitative interviews will be conducted with 10 clinical staff members to assess the feasibility of the VR platform from the clinician perspective. A prospective within-subject pretest-posttest pilot design will be used to examine the tolerability of the VR platform and the clinical outcomes (ie, upper extremity neurologic recovery, hand dexterity, pain severity) in 10 veteran inpatients. A VR platform consisting of commercially available pain distraction and upper extremity apps will be available at the participants' bedside for daily use during their inpatient stay (approximately 4-6 weeks). Clinician interviews will be analyzed using qualitative descriptive analysis. Cohen d effect sizes with corresponding 95\% CIs will be calculated for upper extremity neurologic recovery, hand dexterity, and pain. The proportion of participants who achieve minimal clinically important difference after using the VR platform will be calculated for each clinical outcome. Results: This study was selected for funding in August 2020. Institutional review board approval was received in October 2020. The project start date was December 2020. The United States Department has issued a moratorium on in-person research activities secondary to COVID-19. Data collection will commence once this moratorium is lifted. Conclusions: Our next step is to conduct a large multi-site clinical trial that will incorporate the lessons learned from this pilot feasibility study to test the efficacy of a VR intervention in inpatient rehabilitation and transition to home environments. When VR is used in patients' rooms, it serves to provide additional therapy and may reduce clinician burden. VR also presents an opportunity similar to home-based practice exercises. VR can be implemented in both clinical settings and people's own homes, where engagement in ongoing self-management approaches is often most challenging. This unique experience offers the potential for seamless transition from inpatient rehabilitation to the home. International Registered Report Identifier (IRRID): PRR1-10.2196/26133 ", doi="10.2196/26133", url="https://www.researchprotocols.org/2021/5/e26133", url="http://www.ncbi.nlm.nih.gov/pubmed/33970110" } @Article{info:doi/10.2196/24381, author="Yu, X. Amy Y. and Liu, A. Zhongyu and Pou-Prom, Chloe and Lopes, Kaitlyn and Kapral, K. Moira and Aviv, I. Richard and Mamdani, Muhammad", title="Automating Stroke Data Extraction From Free-Text Radiology Reports Using Natural Language Processing: Instrument Validation Study", journal="JMIR Med Inform", year="2021", month="May", day="4", volume="9", number="5", pages="e24381", keywords="stroke", keywords="diagnostic imaging", keywords="data extraction", keywords="natural language processing", keywords="neurovascular", keywords="imaging", keywords="stroke surveillance", keywords="surveillance", abstract="Background: Diagnostic neurovascular imaging data are important in stroke research, but obtaining these data typically requires laborious manual chart reviews. Objective: We aimed to determine the accuracy of a natural language processing (NLP) approach to extract information on the presence and location of vascular occlusions as well as other stroke-related attributes based on free-text reports. Methods: From the full reports of 1320 consecutive computed tomography (CT), CT angiography, and CT perfusion scans of the head and neck performed at a tertiary stroke center between October 2017 and January 2019, we manually extracted data on the presence of proximal large vessel occlusion (primary outcome), as well as distal vessel occlusion, ischemia, hemorrhage, Alberta stroke program early CT score (ASPECTS), and collateral status (secondary outcomes). Reports were randomly split into training (n=921) and validation (n=399) sets, and attributes were extracted using rule-based NLP. We reported the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the overall accuracy of the NLP approach relative to the manually extracted data. Results: The overall prevalence of large vessel occlusion was 12.2\%. In the training sample, the NLP approach identified this attribute with an overall accuracy of 97.3\% (95.5\% sensitivity, 98.1\% specificity, 84.1\% PPV, and 99.4\% NPV). In the validation set, the overall accuracy was 95.2\% (90.0\% sensitivity, 97.4\% specificity, 76.3\% PPV, and 98.5\% NPV). The accuracy of identifying distal or basilar occlusion as well as hemorrhage was also high, but there were limitations in identifying cerebral ischemia, ASPECTS, and collateral status. Conclusions: NLP may improve the efficiency of large-scale imaging data collection for stroke surveillance and research. ", doi="10.2196/24381", url="https://medinform.jmir.org/2021/5/e24381", url="http://www.ncbi.nlm.nih.gov/pubmed/33944791" } @Article{info:doi/10.2196/24323, author="Tran, Kim-Anh and Pollock, William Neal and Rh{\'e}aume, Caroline and Razdan, Sonya Payal and Fortier, F{\'e}lix-Antoine and Dutil-Fafard, Lara and Morin, Camille and Monnot, Pierre-Marie David and Huot-Lavoie, Maxime and Simard-Sauriol, Philippe and Chandavong, Sam and Le Pabic, Genevi{\`e}ve and LeBlanc, Jean-Philippe and Lafond, Daniel and Marion, Andr{\'e}anne and Archambault, Michel Patrick", title="Evidence Supporting the Management of Medical Conditions During Long-Duration Spaceflight: Protocol for a Scoping Review", journal="JMIR Res Protoc", year="2021", month="Mar", day="29", volume="10", number="3", pages="e24323", keywords="spaceflight", keywords="astronauts", keywords="microgravity", keywords="weightlessness", keywords="acute coronary syndrome", keywords="arrhythmia", keywords="atrial fibrillation", keywords="eye penetration", keywords="intraocular foreign body", keywords="herniated disk", keywords="nephrolithiasis", keywords="pulmonary embolism", keywords="retinal detachment", keywords="sepsis", keywords="stroke", keywords="spaceflight associated neuro-ocular syndrome", abstract="Background: Future long-duration space exploration missions, such as traveling to Mars, will create an increase in communication time delays and disruptions and remove the viability of emergency returns to Earth for timely medical treatment. Thus, higher levels of medical autonomy are necessary. Crew selection is proposed as the first line of defense to minimize medical risk for future missions; however, the second proposed line of defense is medical preparedness and crew member autonomy. In an effort to develop a decision support system, the Canadian Space Agency mandated a team of scientists from Thales Research and Technology Canada (Qu{\'e}bec, QC) and Universit{\'e} Laval (Qu{\'e}bec, QC) to create an evidence-based medical condition database linking mission-critical human conditions with key causal factors, diagnostic and treatment information, and probable outcomes. Objective: To complement this database, we are currently conducting a scoping review to better understand the depth and breadth of evidence about managing medical conditions in space. Methods: This scoping review will adhere to quality standards for scoping reviews, employing Levac, Colquhoun, and O'Brien's 6-stage methodology; the reported results will follow the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension for scoping reviews. In stage 1, we identified the research question in collaboration with the Canadian Space Agency (CSA), the main knowledge user. We prioritized 10 medical conditions: (1) acute coronary syndrome, (2) atrial fibrillation, (3) eye penetration, (4) herniated disk, (5) nephrolithiasis, (6) pulmonary embolism, (7) retinal detachment, (8) sepsis, (9) stroke, and (10) spaceflight associated neuro-ocular syndrome. In stage 2, with the help of an information specialist from Cochrane Canada Francophone, papers were identified through searches of the following databases: ARC, Embase, IeeeXplore, Medline Ovid, PsychINFO, and Web of Science. In stage 3, studies will be selected and assessed using a 3-step process and emerging, refined exclusion criteria. In stage 4, the data will be charted in a table based on parameters required by the CSA and developed using Google spreadsheets for shared access. In stage 5, evidence-based descriptive summaries will be produced for each condition, as well as descriptive analyses of collected data. Finally, in stage 6, the findings will be shared with the CSA to guide the completion of this project. Results: This study was planned in December 2018. Stage 1 has been completed. The initial database search strategy with all target conditions combined identified a total of 10,403 citations to review through title and abstract screening and after duplicate removal. We plan to complete stages 2-6 by the beginning of 2021. Conclusions: This scoping review will map the literature on the management of 10 priority medical conditions in space. It will also enable us to identify knowledge gaps that must be addressed in future research, ensuring successful and medically safe future missions as humankind embarks upon new frontiers of space exploration. International Registered Report Identifier (IRRID): DERR1-10.2196/24323 ", doi="10.2196/24323", url="https://www.researchprotocols.org/2021/3/e24323", url="http://www.ncbi.nlm.nih.gov/pubmed/33779571" } @Article{info:doi/10.2196/20916, author="Xu, Yangfan and Tong, Meiqinzi and Ming, Wai-Kit and Lin, Yangyang and Mai, Wangxiang and Huang, Weixin and Chen, Zhuoming", title="A Depth Camera--Based, Task-Specific Virtual Reality Rehabilitation Game for Patients With Stroke: Pilot Usability Study", journal="JMIR Serious Games", year="2021", month="Mar", day="24", volume="9", number="1", pages="e20916", keywords="virtual reality", keywords="rehabilitation", keywords="stroke", keywords="lower extremity", keywords="rehabilitation game", abstract="Background: The use of virtual reality is popular in clinical rehabilitation, but the effects of using commercial virtual reality games in patients with stroke have been mixed. Objective: We developed a depth camera--based, task-specific virtual reality game, Stomp Joy, for poststroke rehabilitation of the lower extremities. This study aims to assess its feasibility and clinical efficacy. Methods: We carried out a feasibility test for Stomp Joy within representative user groups. Then, a clinical efficacy experiment was performed with a randomized controlled trial, in which 22 patients with stroke received 10 sessions (2 weeks) of conventional physical therapy only (control group) or conventional physical therapy plus 30 minutes of the Stomp Joy intervention (experimental group) in the clinic. The Fugl-Meyer Assessment for Lower Extremity (FMA-LE), Modified Barthel Index (MBI), Berg Balance Scale (BBS) score, single-leg stance (SLS) time, dropout rate, and adverse effects were recorded. Results: This feasibility test showed that Stomp Joy improved interest, pressure, perceived competence, value, and effort using the Intrinsic Motivation Inventory. The clinical efficacy trial showed a significant time-group interaction effect for the FMA-LE (P=.006), MBI (P=.001), BBS (P=.004), and SLS time (P=.001). A significant time effect was found for the FMA-LE (P=.001), MBI (P<.001), BBS (P<.001), and SLS time (P=.03). These indicated an improvement in lower extremity motor ability, basic activities of daily living, balance ability, and single-leg stance time in both groups after 2 weeks of the intervention. However, no significant group effects were found for the FMA-LE (P=.06), MBI (P=.76), and BBS (P=.38), while a significant group interaction was detected for SLS time (P<.001). These results indicated that the experimental group significantly improved more in SLS time than did the control group. During the study, 2 dropouts, including 1 participant who fell, were reported. Conclusions: Stomp Joy is an effective depth camera--based virtual reality game for replacing part of conventional physiotherapy, achieving equally effective improvement in lower extremity function among stroke survivors. High-powered randomized controlled studies are now needed before recommending the routine use of Stomp Joy in order to confirm these findings by recruiting a large sample size. ", doi="10.2196/20916", url="https://games.jmir.org/2021/1/e20916", url="http://www.ncbi.nlm.nih.gov/pubmed/33759795" } @Article{info:doi/10.2196/21312, author="Bhattacharjya, Sutanuka and Cavuoto, Anne Lora and Reilly, Brandon and Xu, Wenyao and Subryan, Heamchand and Langan, Jeanne", title="Usability, Usefulness, and Acceptance of a Novel, Portable Rehabilitation System (mRehab) Using Smartphone and 3D Printing Technology: Mixed Methods Study", journal="JMIR Hum Factors", year="2021", month="Mar", day="22", volume="8", number="1", pages="e21312", keywords="stroke", keywords="rehabilitation", keywords="smart technology", keywords="3-dimensional printing", keywords="usability", abstract="Background: Smart technology use in rehabilitation is growing and can be used remotely to assist clients in self-monitoring their performance. With written home exercise programs being the commonly prescribed form of rehabilitation after discharge, mobile health technology coupled with task-oriented programs can enhance self-management of upper extremity training. In the current study, a rehabilitation system, namely mRehab, was designed that included a smartphone app and 3D-printed household items such as mug, bowl, key, and doorknob embedded with a smartphone. The app interface allowed the user to select rehabilitation activities and receive feedback on the number of activity repetitions completed, time to complete each activity, and quality of movement. Objective: This study aimed to assess the usability, perceived usefulness, and acceptance of the mRehab system by individuals with stroke and identify the challenges experienced by them when using the system remotely in a home-based setting. Methods: A mixed-methods approach was used with 11 individuals with chronic stroke. Following training, individuals with stroke used the mRehab system for 6 weeks at home. Each participant completed surveys and engaged in a semistructured interview. Participants' qualitative reports regarding the usability of mRehab were integrated with their survey reports and quantitative performance data. Results: Of the 11 participants, 10 rated the mRehab system between the 67.5th and 97.5th percentile on the System Usability Scale, indicating their satisfaction with the usability of the system. Participants also provided high ratings of perceived usefulness (mean 5.8, SD 0.9) and perceived ease of use (mean 5.3, SD 1.5) on a 7-point scale based on the Technology Acceptance Model. Common themes reported by participants showed a positive response to mRehab with some suggestions for improvements. Participants reported an interest in activities they perceived to be adequately challenging. Some participants indicated a need for customizing the feedback to be more interpretable. Overall, most participants indicated that they would like to continue using the mRehab system at home. Conclusions: Assessing usability in the lived environment over a prolonged duration of time is essential to identify the match between the system and users' needs and preferences. While mRehab was well accepted, further customization is desired for a better fit with the end users. Trial Registration: ClinicalTrials.gov NCT04363944; https://clinicaltrials.gov/ct2/show/NCT04363944 ", doi="10.2196/21312", url="https://humanfactors.jmir.org/2021/1/e21312", url="http://www.ncbi.nlm.nih.gov/pubmed/33749608" } @Article{info:doi/10.2196/22659, author="Van de Winckel, Ann and Nawshin, Tanjila and Byron, Casey", title="Combining a Hudl App With Telehealth to Increase Home Exercise Program Adherence in People With Chronic Diseases Experiencing Financial Distress: Randomized Controlled Trial", journal="JMIR Form Res", year="2021", month="Mar", day="18", volume="5", number="3", pages="e22659", keywords="chronic disease", keywords="spinal cord injury", keywords="stroke", keywords="telehealth", keywords="telemedicine", keywords="traumatic brain injury", abstract="Background: Patients with chronic diseases often need to adhere to long-term individualized home exercise programs (HEPs). Limited adherence to long-term exercise given during physical therapy (PT) visits reduces the capacity of exercise to manage or improve symptoms related to chronic disease. In addition, a lower socioeconomic status negatively impacts exercise adherence. To mitigate this, apps that motivate people to exercise could be a viable option. Using an app through telehealth may help adults with chronic diseases to achieve long-term HEP adherence. However, because apps for rehabilitation are an emerging field, the feasibility of the app needs to be evaluated. Objective: To address HEP adherence in participants with chronic diseases who are experiencing financial distress, we aim to evaluate the feasibility of and satisfaction with the Hudl Technique app and telehealth and satisfaction with PT care and to monitor HEP adherence and compliance (ie, percentage of participant-recorded videos sent) in participants using the app with telehealth compared with those using standard HEPs on paper. Methods: We recruited patients scheduled for outpatient PT. We performed a randomized controlled trial in which the experimental group received weekly HEP demonstrations through app videos on a tablet with feedback on their self-recorded HEP video performance from the telehealth physical therapist. The control group received HEPs on paper without feedback, as is customary in PT practice. Demographic, clinical, and health coverage information was collected for screening and baseline measurements. Adherence and compliance were evaluated. Both groups completed surveys at 8 and 24 weeks on their satisfaction with PT care, and the experimental group also completed a survey on their satisfaction with the app with telehealth use. Descriptive and nonparametric statistics were used for within-group and between-group comparisons and analyzed with JMP, version 13. Results: Overall, 45 adults with chronic diseases who were experiencing financial distress were randomized into experimental (23/45, 51\%) and control (22/45, 49\%) groups, with 74\% (17/23) and 86\% (19/22) participants completing the 24-week HEP, respectively. The experimental group had an HEP adherence frequency of 4 (SD 2) to 5 (SD 2) times per week at 8 and 24 weeks (P=.14), whereas HEP adherence decreased in the control group from 4 (SD 2) to 3 (SD 2) times per week (P=.07), with a significant difference (P=.01) between groups at 24 weeks. Of the total participants, 68\% (15/22) sent videos. They sent 68\% (16/24) of the requested number of videos on average. The average score for PT care satisfaction was maintained at 87\% in the experimental group (P=.99), whereas it decreased from 89\% at 8 weeks to 74\% at 24 weeks (P=.008) in the control group. App-related adverse events were not observed. Conclusions: The Hudl app/telehealth platform is feasible for delivering HEPs and maintaining HEP adherence in participants with chronic diseases who are experiencing financial distress. Trial Registration: ClinicalTrials.gov NCT02659280; https://clinicaltrials.gov/ct2/show/NCT02659280 ", doi="10.2196/22659", url="https://formative.jmir.org/2021/3/e22659", url="http://www.ncbi.nlm.nih.gov/pubmed/33640865" } @Article{info:doi/10.2196/22951, author="Zhao, Yiqing and Fu, Sunyang and Bielinski, J. Suzette and Decker, A. Paul and Chamberlain, M. Alanna and Roger, L. Veronique and Liu, Hongfang and Larson, B. Nicholas", title="Natural Language Processing and Machine Learning for Identifying Incident Stroke From Electronic Health Records: Algorithm Development and Validation", journal="J Med Internet Res", year="2021", month="Mar", day="8", volume="23", number="3", pages="e22951", keywords="stroke", keywords="natural language processing", keywords="electronic health records", keywords="machine learning", abstract="Background: Stroke is an important clinical outcome in cardiovascular research. However, the ascertainment of incident stroke is typically accomplished via time-consuming manual chart abstraction. Current phenotyping efforts using electronic health records for stroke focus on case ascertainment rather than incident disease, which requires knowledge of the temporal sequence of events. Objective: The aim of this study was to develop a machine learning--based phenotyping algorithm for incident stroke ascertainment based on diagnosis codes, procedure codes, and clinical concepts extracted from clinical notes using natural language processing. Methods: The algorithm was trained and validated using an existing epidemiology cohort consisting of 4914 patients with atrial fibrillation (AF) with manually curated incident stroke events. Various combinations of feature sets and machine learning classifiers were compared. Using a heuristic rule based on the composition of concepts and codes, we further detected the stroke subtype (ischemic stroke/transient ischemic attack or hemorrhagic stroke) of each identified stroke. The algorithm was further validated using a cohort (n=150) stratified sampled from a population in Olmsted County, Minnesota (N=74,314). Results: Among the 4914 patients with AF, 740 had validated incident stroke events. The best-performing stroke phenotyping algorithm used clinical concepts, diagnosis codes, and procedure codes as features in a random forest classifier. Among patients with stroke codes in the general population sample, the best-performing model achieved a positive predictive value of 86\% (43/50; 95\% CI 0.74-0.93) and a negative predictive value of 96\% (96/100). For subtype identification, we achieved an accuracy of 83\% in the AF cohort and 80\% in the general population sample. Conclusions: We developed and validated a machine learning--based algorithm that performed well for identifying incident stroke and for determining type of stroke. The algorithm also performed well on a sample from a general population, further demonstrating its generalizability and potential for adoption by other institutions. ", doi="10.2196/22951", url="https://www.jmir.org/2021/3/e22951", url="http://www.ncbi.nlm.nih.gov/pubmed/33683212" } @Article{info:doi/10.2196/25123, author="Naqvi, Ali Imama and Montiel, Casameni Tahani and Bittar, Yazan and Hunter, Norma and Okpala, Munachi and Johnson, Constance and Weiner, G. Mark and Savitz, Sean and Sharrief, Anjail and Beauchamp, Sanner Jennifer Elizabeth", title="Internet Access and Usage Among Stroke Survivors and Their Informal Caregivers: Cross-sectional Study", journal="JMIR Form Res", year="2021", month="Mar", day="8", volume="5", number="3", pages="e25123", keywords="internet access", keywords="stroke", keywords="caregivers", keywords="surveys", keywords="questionnaires", keywords="mobile phone", abstract="Background: Web-based interventions have shown promise for chronic disease management but have not been widely applied to populations with stroke. Existing barriers may inhibit the adoption of web-based interventions among stroke survivors and necessitate the involvement of informal caregivers. However, limited information is available on internet accessibility and usability among stroke survivors and their caregivers. Objective: This study aims to investigate internet access and usage in a cohort of stroke survivors and their caregivers. Methods: A cross-sectional survey was conducted with 375 participants (248 stroke survivors and 127 caregivers). Descriptive statistics were generated using cross-tabulation. Comparisons with categorical data were conducted using the chi-square test, whereas the Mann-Whitney U test was used for comparisons involving ordinal variables. Results: Overall, 86.1\% (323/375) of the participants reported having internet access. Caregivers were more likely than stroke survivors to access the internet (N=375, $\chi$21=18.5, P<.001) and used text messaging (n=321, $\chi$21=14.7, P<.001). Stroke survivors and caregivers with internet access were younger than stroke survivors and caregivers without internet access. The highest number of participants who reported internet access were non-Hispanic White. Smartphones were the most common devices used to access the internet. Email was the most common type of internet usage reported. Patients who survived for >12 months after a stroke reported higher internet access than those who survived <3 months (P<.001). The number of hours per week spent using the internet was higher for caregivers than for stroke survivors (P<.001). Conclusions: Future feasibility and acceptability studies should consider the role of the informal caregiver, participant age, race and ethnicity, the use of smartphone apps, email and text correspondence, and the amount of time elapsed since the stroke event in the design and implementation of web-based interventions for populations with stroke. ", doi="10.2196/25123", url="https://formative.jmir.org/2021/3/e25123", url="http://www.ncbi.nlm.nih.gov/pubmed/33683206" } @Article{info:doi/10.2196/25488, author="Wu, Yiqun and Chen, Fei and Song, Haiqing and Feng, Wuwei and Sun, Jinping and Liu, Ruisen and Li, Dongmei and Liu, Ying", title="Use of a Smartphone Platform to Help With Emergency Management of Acute Ischemic Stroke: Observational Study", journal="JMIR Mhealth Uhealth", year="2021", month="Feb", day="9", volume="9", number="2", pages="e25488", keywords="acute ischemic stroke", keywords="door-to-needle time", keywords="smartphone platform", keywords="emergency management", keywords="smartphone", keywords="mHealth", keywords="stroke", keywords="management", keywords="emergency", keywords="first aid", keywords="utility", keywords="digital health", abstract="Background: To improve the outcomes of acute ischemic stroke (AIS), timely thrombolytic therapy is crucial. Series strategies were recommended to reduce door-to-needle (DTN) time for AIS. Mobile technologies are feasible and have been used in stroke management for various purposes. However, the use of smartphone platforms that integrate series strategies through the entire first aid process to improve emergency management of AIS remains to be verified. Objective: This study aims to describe the utility and application of a smartphone platform in the emergency management of AIS and report the DTN time for patients with AIS during its 2-year application period. Our results are relevant to digital health management. Methods: A smartphone platform named ``Green'' was developed to incorporate the field assessment, hospital recommendation, prehospital notification, real-time communication, clinical records creation, key time-stamping, and quality control to streamline and standardize overall AIS emergency management processes. The emergency medical system (EMS) and all the emergency departments in Beijing have used this platform since 2018. From January 1, 2018, to December 31, 2019, 8457 patients diagnosed with AIS received intravenous tissue-type plasminogen activator therapy. The median DTN time and the proportions of patients with DTN times of ?60 minutes and ?45 minutes were reported. Results: During the 2-year application period of this platform, the median DTN time was 45 minutes, and the proportions of patients with DTN times of ?60 minutes and ?45 minutes were 74.6\% and 50.5\%, respectively. The median DTN time was significantly reduced from 50 minutes in 2018 to 42 minutes in 2019 (P<.001). The proportions of patients with DTN times of ?60 minutes and ?45 minutes increased from 66.1\% and 40.7\%, respectively, in 2018 to 80.7\% and 57.3\%, respectively, in 2019 (both P<.001). Sustained improvement in DTN time was seen during all the observed months. The improvement occurred across all facilities, and the variations among hospitals also decreased. The median DTN time for patients transferred by ambulances (43 minutes) was significantly shorter than those who reached hospitals by themselves (47 minutes; P<.001). Conclusions: Sustained reductions in DTN time reflected the improvement in AIS emergency management processes. The use of a smartphone platform integrating recommended strategies throughout all first aid stages is a practical way to help the emergency management of AIS. ", doi="10.2196/25488", url="http://mhealth.jmir.org/2021/2/e25488/", url="http://www.ncbi.nlm.nih.gov/pubmed/33560236" } @Article{info:doi/10.2196/24186, author="Stengl, Helena and Ganeshan, Ramanan and Hellwig, Simon and Blaszczyk, Edyta and Fiebach, B. Jochen and Nolte, H. Christian and Bauer, Axel and Schulz-Menger, Jeanette and Endres, Matthias and Scheitz, F. Jan", title="Cardiomyocyte Injury Following Acute Ischemic Stroke: Protocol for a Prospective Observational Cohort Study", journal="JMIR Res Protoc", year="2021", month="Feb", day="5", volume="10", number="2", pages="e24186", keywords="ischemic stroke", keywords="troponin T", keywords="myocardial ischemia", keywords="myocardial injury", keywords="stroke-heart syndrome", keywords="cardiac imaging techniques", keywords="magnetic resonance imaging", keywords="Takotsubo syndrome", keywords="autonomic nervous system", abstract="Background: Elevated cardiac troponin, which indicates cardiomyocyte injury, is common after acute ischemic stroke and is associated with poor functional outcome. Myocardial injury is part of a broad spectrum of cardiac complications that may occur after acute ischemic stroke. Previous studies have shown that in most patients, the underlying mechanism of stroke-associated myocardial injury may not be a concomitant acute coronary syndrome. Evidence from animal research and clinical and neuroimaging studies suggest that functional and structural alterations in the central autonomic network leading to stress-mediated neurocardiogenic injury may be a key underlying mechanism (ie, stroke-heart syndrome). However, the exact pathophysiological cascade remains unclear, and the diagnostic and therapeutic implications are unknown. Objective: The aim of this CORONA-IS (Cardiomyocyte injury following Acute Ischemic Stroke) study is to quantify autonomic dysfunction and to decipher downstream cardiac mechanisms leading to myocardial injury after acute ischemic stroke. Methods: In this prospective, observational, single-center cohort study, 300 patients with acute ischemic stroke, confirmed via cerebral magnetic resonance imaging (MRI) and presenting within 48 hours of symptom onset, will be recruited during in-hospital stay. On the basis of high-sensitivity cardiac troponin levels and corresponding to the fourth universal definition of myocardial infarction, 3 groups are defined (ie, no myocardial injury [no cardiac troponin elevation], chronic myocardial injury [stable elevation], and acute myocardial injury [dynamic rise/fall pattern]). Each group will include approximately 100 patients. Study patients will receive routine diagnostic care. In addition, they will receive 3 Tesla cardiovascular MRI and transthoracic echocardiography within 5 days of symptom onset to provide myocardial tissue characterization and assess cardiac function, 20-min high-resolution electrocardiogram for analysis of cardiac autonomic function, and extensive biobanking. A follow-up for cardiovascular events will be conducted 3 and 12 months after inclusion. Results: After a 4-month pilot phase, recruitment began in April 2019. We estimate a recruitment period of approximately 3 years to include 300 patients with a complete cardiovascular MRI protocol. Conclusions: Stroke-associated myocardial injury is a common and relevant complication. Our study has the potential to provide a better mechanistic understanding of heart and brain interactions in the setting of acute stroke. Thus, it is essential to develop algorithms for recognizing patients at risk and to refine diagnostic and therapeutic procedures. Trial Registration: Clinicaltrials.gov NCT03892226; https://www.clinicaltrials.gov/ct2/show/NCT03892226. International Registered Report Identifier (IRRID): DERR1-10.2196/24186 ", doi="10.2196/24186", url="http://www.researchprotocols.org/2021/2/e24186/", url="http://www.ncbi.nlm.nih.gov/pubmed/33544087" } @Article{info:doi/10.2196/22902, author="Marsden, Lesley Dianne and Boyle, Kerry and Jordan, Louise-Anne and Dunne, Anne Judith and Shipp, Jodi and Minett, Fiona and Styles, Amanda and Birnie, Jaclyn and Ormond, Sally and Parrey, Kim and Buzio, Amanda and Lever, Sandra and Paul, Michelle and Hill, Kelvin and Pollack, P. Michael R. and Wiggers, John and Oldmeadow, Christopher and Cadilhac, Ann-Michele Dominique and Duff, Jed and ", title="Improving Assessment, Diagnosis, and Management of Urinary Incontinence and Lower Urinary Tract Symptoms on Acute and Rehabilitation Wards That Admit Adult Patients: Protocol for a Before-and-After Implementation Study", journal="JMIR Res Protoc", year="2021", month="Feb", day="4", volume="10", number="2", pages="e22902", keywords="urinary incontinence", keywords="lower urinary tract symptoms", keywords="inpatient", keywords="practice-gap", keywords="practice improvement", keywords="protocol", abstract="Background: Urinary incontinence (UI) and lower urinary tract symptoms (LUTS) are commonly experienced by adult patients in hospitals (inpatients). Although peak bodies recommend that health services have systems for optimal UI and LUTS care, they are often not delivered. For example, results from the 2017 Australian National Stroke Audit Acute Services indicated that of the one-third of acute stroke inpatients with UI, only 18\% received a management plan. In the 2018 Australian National Stroke Audit Rehabilitation Services, half of the 41\% of patients with UI received a management plan. There is little reporting of effective inpatient interventions to systematically deliver optimal UI/LUTS care. Objective: This study aims to determine whether our UI/LUTS practice-change package is feasible and effective for delivering optimal UI/LUTS care in an inpatient setting. The package includes our intervention that has been synthesized from the best-available evidence on UI/LUTS care and a theoretically informed implementation strategy targeting identified barriers and enablers. The package is targeted at clinicians working in the participating wards. Methods: This is a pragmatic, real-world, before- and after-implementation study conducted at 12 hospitals (15 wards: 7/15, 47\% metropolitan, 8/15, 53\% regional) in Australia. Data will be collected at 3 time points: before implementation (T0), immediately after the 6-month implementation period (T1), and again after a 6-month maintenance period (T2). We will undertake medical record audits to determine any change in the proportion of inpatients receiving optimal UI/LUTS care, including assessment, diagnosis, and management plans. Potential economic implications (cost and consequences) for hospitals implementing our intervention will be determined. Results: This study was approved by the Hunter New England Human Research Ethics Committee (HNEHREC Reference No. 18/10/17/4.02). Preimplementation data collection (T0) was completed in March 2020. As of November 2020, 87\% (13/15) wards have completed implementation and are undertaking postimplementation data collection (T1). Conclusions: Our practice-change package is designed to reduce the current inpatient UI/LUTS evidence-based practice gap, such as those identified through national stroke audits. This study has been designed to provide clinicians, managers, and policy makers with the evidence needed to assess the potential benefit of further wide-scale implementation of our practice-change package. International Registered Report Identifier (IRRID): DERR1-10.2196/22902 ", doi="10.2196/22902", url="https://www.researchprotocols.org/2021/2/e22902", url="http://www.ncbi.nlm.nih.gov/pubmed/33538703" } @Article{info:doi/10.2196/14494, author="Katzan, Irene and Schuster, Andrew and Kinzy, Tyler", title="Physical Activity Monitoring Using a Fitbit Device in Ischemic Stroke Patients: Prospective Cohort Feasibility Study", journal="JMIR Mhealth Uhealth", year="2021", month="Jan", day="19", volume="9", number="1", pages="e14494", keywords="physical activity", keywords="accelerometer", keywords="ischemic stroke", keywords="step activity monitor", abstract="Background: Continuous tracking of ambulatory activity in real-world settings using step activity monitors has many potential uses. However, feasibility, accuracy, and correlation with performance measures in stroke patients have not been well-established. Objective: The primary study objective was to determine adherence with wearing a consumer-grade step activity monitor, the Fitbit Charge HR, in home-going ischemic stroke patients during the first 90 days after hospital discharge. Secondary objectives were to (1) determine accuracy of step counts of the Fitbit Charge HR compared with a manual tally; (2) calculate correlations between the Fitbit step counts and the mobility performance scores at discharge and 30 days after stroke; (3) determine variability and change in weekly step counts over 90 days; and (4) evaluate patient experience with using the Fitbit Charge HR poststroke. Methods: A total of 15 participants with recent mild ischemic stroke wore a Fitbit Charge HR for 90 days after discharge and completed 3 mobility performance tests from the National Institutes of Health Toolbox at discharge and Day 30: (1) Standing Balance Test, (2) 2-Minute Walk Endurance Test, and (3) 4-Meter Walk Gait Speed Test. Accuracy of step activity monitors was assessed by calculating differences in steps recorded on the step activity monitor and a manual tally during 2-minute walk tests. Results: Participants had a mean age of 54 years and a median modified Rankin scale score of 1. Mean daily adherence with step activity monitor use was 83.6\%. Mean daily step count in the first week after discharge was 4376. Daily step counts increased slightly during the first 30 days after discharge (average increase of 52.5 steps/day; 95\% CI 32.2-71.8) and remained stable during the 30-90 day period after discharge. Mean step count difference between step activity monitor and manual tally was --4.8 steps (--1.8\%). Intraclass correlation coefficients for step counts and 2-minute walk, standing balance, and 4-meter gait speed at discharge were 0.41 (95\% CI --0.14 to 0.75), --0.12 (95\% CI --0.67 to 0.64), and 0.17 (95\% CI --0.46 to 0.66), respectively. Values were similarly poor at 30 days. Conclusions: The use of consumer-grade Fitbit Charge HR in patients with recent mild stroke is feasible with reasonable adherence and accuracy. There was poor correlation between step counts and gait speed, balance, and endurance. Further research is needed to evaluate the association between step counts and other outcomes relevant to patients, including patient-reported outcomes and measures of physical function. ", doi="10.2196/14494", url="http://mhealth.jmir.org/2021/1/e14494/", url="http://www.ncbi.nlm.nih.gov/pubmed/33464213" } @Article{info:doi/10.2196/25374, author="Ranta, Annemarei and Thompson, Stephanie and Harwood, Ngarongoa Matire Louise and Cadilhac, Ann-Michele Dominique and Barber, Alan Peter and Davis, John Alan and Gommans, Henry John and Fink, Newton John and McNaughton, Karel Harry and Denison, Hayley and Corbin, Marine and Feigin, Valery and Abernethy, Virginia and Levack, William and Douwes, Jeroen and Girvan, Jacqueline and Wilson, Andrew", title="Reducing Ethnic and Geographic Inequities to Optimise New Zealand Stroke Care (REGIONS Care): Protocol for a Nationwide Observational Study", journal="JMIR Res Protoc", year="2021", month="Jan", day="12", volume="10", number="1", pages="e25374", keywords="stroke", keywords="protocols", keywords="stroke units", keywords="rehabilitation", keywords="M?ori", keywords="Pacific people", keywords="health inequities", keywords="cost-efficacy", keywords="rural", keywords="observational study", abstract="Background: Stroke systems of care differ between larger urban and smaller rural settings and it is unclear to what extent this may impact on patient outcomes. Ethnicity influences stroke risk factors and care delivery as well as patient outcomes in nonstroke settings. Little is known about the impact of ethnicity on poststroke care, especially in M?ori and Pacific populations. Objective: Our goal is to describe the protocol for the Reducing Ethnic and Geographic Inequities to Optimise New Zealand Stroke Care (REGIONS Care) study. Methods: This large, nationwide observational study assesses the impact of rurality and ethnicity on best practice stroke care access and outcomes involving all 28 New Zealand hospitals caring for stroke patients, by capturing every stroke patient admitted to hospital during the 2017-2018 study period. In addition, it explores current access barriers through consumer focus groups and consumer, carer, clinician, manager, and policy-maker surveys. It also assesses the economic impact of care provided at different types of hospitals and to patients of different ethnicities and explores the cost-efficacy of individual interventions and care bundles. Finally, it compares manual data collection to routine health administrative data and explores the feasibility of developing outcome models using only administrative data and the cost-efficacy of using additional manually collected registry data. Regarding sample size estimates, in Part 1, Study A, 2400 participants are needed to identify a 10\% difference between up to four geographic subgroups at 90\% power with an $\alpha$ value of .05 and 10\% to 20\% loss to follow-up. In Part 1, Study B, a sample of 7645 participants was expected to include an estimated 850 M?ori and 419 Pacific patients and to provide over 90\% and over 80\% power, respectively. Regarding Part 2, 50\% of the patient or carer surveys, 40 provider surveys, and 10 focus groups were needed to achieve saturation of themes. The main outcome is the modified Rankin Scale (mRS) score at 3 months. Secondary outcomes include mRS scores; EQ-5D-3L (5-dimension, 3-level EuroQol questionnaire) scores; stroke recurrence; vascular events; death; readmission at 3, 6, and 12 months; cost of care; and themes around access barriers. Results: The study is underway, with national and institutional ethics approvals in place. A total of 2379 patients have been recruited for Part 1, Study A; 6837 patients have been recruited for Part 1, Study B; 10 focus groups have been conducted and 70 surveys have been completed in Part 2. Data collection has essentially been completed, including follow-up assessment; however, primary and secondary analyses, data linkage, data validation, and health economics analysis are still underway. Conclusions: The methods of this study may provide the basis for future epidemiological studies that will guide care improvements in other countries and populations. International Registered Report Identifier (IRRID): DERR1-10.2196/25374 ", doi="10.2196/25374", url="https://www.researchprotocols.org/2021/1/e25374", url="http://www.ncbi.nlm.nih.gov/pubmed/33433396" } @Article{info:doi/10.2196/18649, author="Georgiou, Theodoros and Holland, Simon and van der Linden, Janet", title="Rhythmic Haptic Cueing for Gait Rehabilitation of People With Hemiparesis: Quantitative Gait Study", journal="JMIR Biomed Eng", year="2020", month="Nov", day="24", volume="5", number="1", pages="e18649", keywords="hemiparetic gait", keywords="stroke", keywords="technology assisted rehabilitation", keywords="quantitative study", keywords="gait analysis", keywords="gait asymmetry", keywords="gait", keywords="neurology", keywords="hemiparesis", keywords="rehabilitation", keywords="brain injury", abstract="Background: Rhythm, brain, and body are closely linked. Humans can synchronize their movement to auditory rhythms in ways that can improve the regularity of movement while reducing perceived effort. However, the ability to perform rhythmic movement may be disrupted by various neurological conditions. Many such conditions impair mechanisms that control movement, such as gait, but typically without rhythmic perception being affected. This paper focuses on hemiparetic stroke, a neurological condition that affects one side of the body. Hemiparetic stroke can cause severe asymmetries in gait, leading to numerous physical problems ranging from muscle degeneration to bone fractures. Movement synchronization via entrainment to auditory metronomes is known to improve asymmetry and related gait problems; this paper presents the first systematic study of entrainment for gait rehabilitation via the haptic modality. Objective: This paper explores the gait rehabilitation of people with hemiparesis following a stroke or brain injury, by a process of haptic entrainment to rhythmic cues. Various objective measures, such as stride length and stride time, are considered. Methods: This study is a quantitative gait study combining temporal and spatial data on haptically cued participants with hemiparetic stroke and brain injury. We designed wearable devices to deliver the haptic rhythm, called Haptic Bracelets, which were placed on the leg near the knee. Spatial data were recorded using a Qualisys optical motion capturing system, consisting of 8 optoelectronic cameras, and 20 markers placed on anatomical lower limb landmarks and 4 additional tracking clusters placed on the right and left shank and thigh. Gait characteristics were measured before, during, and after cueing. Results: All 11 successfully screened participants were able to synchronize their steps to a haptically presented rhythm. Specifically, 6 participants demonstrated immediate improvements regarding their temporal gait characteristics, and 3 of the 6 improved their gait in terms of spatial characteristics. Conclusions: Considering the great variability between survivors of stroke and brain injury and the limited number of available participants in our study, there is no claim of statistical evidence that supports a formal experimental result of improved gait. However, viewing this empirical gait investigation as a set of 11 case studies, more modest empirical claims can be made. All participants were able to synchronize their steps to a haptically presented rhythm. For a substantial proportion of participants, an immediate (though not necessarily lasting) improvement of temporal gait characteristics was found during cueing. Some improvements over baseline occurred immediately after, rather than during, haptic cueing. Design issues and trade-offs are identified, and interactions between perception, sensory deficit, attention, memory, cognitive load, and haptic entrainment are noted. ", doi="10.2196/18649", url="http://biomedeng.jmir.org/2020/1/e18649/" } @Article{info:doi/10.2196/21799, author="LeLaurin, H. Jennifer and Lamba, H. Avi and Eliazar-Macke, D. Nathaniel and Schmitzberger, K. Magda and Freytes, Magaly I. and Dang, Stuti and Vogel, Bruce W. and Levy, E. Charles and Klanchar, Angelina S. and Beyth, J. Rebecca and Shorr, I. Ronald and Uphold, R. Constance", title="Postdischarge Intervention for Stroke Caregivers: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2020", month="Nov", day="11", volume="9", number="11", pages="e21799", keywords="COVID-19", keywords="stroke", keywords="caregivers", keywords="depression", keywords="burden", keywords="randomized controlled trial", keywords="web-based intervention", keywords="problem-solving", abstract="Background: The majority of stroke survivors return to their homes and need assistance from family caregivers to perform activities of daily living. These increased demands coupled with the lack of preparedness for their new roles lead to a high risk for caregivers developing depressive symptoms and other negative outcomes. Follow-up home support and problem-solving interventions with caregivers are crucial for maintaining stroke survivors in their homes. Problem-solving interventions are effective but are underused in practice because they require large amounts of staff time to implement and are difficult for caregivers logistically. Objective: The aim of this study is to test a problem-solving intervention for stroke caregivers that can be delivered over the telephone during the patient's transitional care period (time when the stroke survivor is discharged to home) followed by 8 asynchronous online sessions. Methods: The design is a two-arm parallel randomized clinical trial with repeated measures. We will enroll 240 caregivers from eight Veterans Affairs (VA) medical centers. Participants randomized into the intervention arm receive a modified problem-solving intervention that uses telephone and web-based support and training with interactive modules, fact sheets, and tools on the previously developed and nationally available Resources and Education for Stroke Caregivers' Understanding and Empowerment Caregiver website. In the usual care group, no changes are made in the information, discharge planning, or care the patients who have had a stroke normally receive, and caregivers have access to existing VA resources (eg, caregiver support line, self-help materials). The primary outcome is a change in caregiver depressive symptoms at 11 and 19 weeks after baseline data collection. Secondary outcomes include changes in stroke caregivers' burden, knowledge, positive aspects of caregiving, self-efficacy, perceived stress, health-related quality of life, and satisfaction with care and changes in stroke survivors' functional abilities and health care use. The team will also determine the budgetary impact, facilitators, barriers, and best practices for implementing the intervention. Throughout all phases of the study, we will collaborate with members of an advisory panel. Results: Study enrollment began in June 2015 and is ongoing. The first results are expected to be submitted for publication in 2021. Conclusions: This is the first known study to test a transitional care and messaging center intervention combined with technology to decrease caregiver depressive symptoms and to improve the recovery of stroke survivors. If successful, findings will support an evidence-based model that can be transported into clinical practice to improve the quality of caregiving post stroke. Trial Registration: ClinicalTrials.gov NCT01600131; https://www.clinicaltrials.gov/ct2/show/NCT01600131 International Registered Report Identifier (IRRID): DERR1-10.2196/21799 ", doi="10.2196/21799", url="http://www.researchprotocols.org/2020/11/e21799/", url="http://www.ncbi.nlm.nih.gov/pubmed/33174856" } @Article{info:doi/10.2196/19604, author="Dunne, Stephen and Close, Helen and Richards, Nicola and Ellison, Amanda and Lane, R. Alison", title="Maximizing Telerehabilitation for Patients With Visual Loss After Stroke: Interview and Focus Group Study With Stroke Survivors, Carers, and Occupational Therapists", journal="J Med Internet Res", year="2020", month="Oct", day="23", volume="22", number="10", pages="e19604", keywords="telerehabilitation", keywords="vision", keywords="barriers", keywords="facilitators", keywords="technology", abstract="Background: Visual field defects are a common consequence of stroke, and compensatory eye movement strategies have been identified as the most promising rehabilitation option. There has been a move toward compensatory telerehabilitation options, such as the Durham Reading and Exploration (DREX) training app, which significantly improves visual exploration, reading, and self-reported quality of life. Objective: This study details an iterative process of liaising with stroke survivors, carers, and health care professionals to identify barriers and facilitators to using rehabilitation tools, as well as elements of good practice in telerehabilitation, with a focus on how the DREX package can be maximized. Methods: Survey data from 75 stroke survivors informed 12 semistructured engagement activities (7 focus groups and 5 interviews) with 32 stroke survivors, 10 carers, and 24 occupational therapists. Results: Thematic analysis identified key themes within the data. Themes identified problems associated with poststroke health care from both patients' and occupational therapists' perspectives that need to be addressed to improve uptake of this rehabilitation tool and telerehabilitation options generally. This included identifying additional materials or assistance that were required to boost the impact of training packages. The acute rehabilitation setting was an identified barrier, and perceptions of technology were considered a barrier by some but a facilitator by others. In addition, 4 key features of telerehabilitation were identified: additional materials, the importance of goal setting, repetition, and feedback. Conclusions: The data were used to try to overcome some barriers to the DREX training and are further discussed as considerations for telerehabilitation in general moving forward. ", doi="10.2196/19604", url="http://www.jmir.org/2020/10/e19604/", url="http://www.ncbi.nlm.nih.gov/pubmed/33095179" } @Article{info:doi/10.2196/20496, author="Giebel, D. Godwin", title="Use of mHealth Devices to Screen for Atrial Fibrillation: Cost-Effectiveness Analysis", journal="JMIR Mhealth Uhealth", year="2020", month="Oct", day="6", volume="8", number="10", pages="e20496", keywords="mHealth", keywords="atrial fibrillation", keywords="screening devices", keywords="strokes", keywords="cost-effectiveness", keywords="photoplethysmography", abstract="Background: With an estimated prevalence of around 3\% and an about 2.5-fold increased risk of stroke, atrial fibrillation (AF) is a serious threat for patients and a high economic burden for health care systems all over the world. Patients with AF could benefit from screening through mobile health (mHealth) devices. Thus, an early diagnosis is possible with mHealth devices, and the risk for stroke can be markedly reduced by using anticoagulation therapy. Objective: The aim of this work was to assess the cost-effectiveness of algorithm-based screening for AF with the aid of photoplethysmography wrist-worn mHealth devices. Even if prevented strokes and prevented deaths from stroke are the most relevant patient outcomes, direct costs were defined as the primary outcome. Methods: A Monte Carlo simulation was conducted based on a developed state-transition model; 30,000 patients for each CHA2DS2-VASc (Congestive heart failure, Hypertension, Age?75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category [female]) score from 1 to 9 were simulated. The first simulation served to estimate the economic burden of AF without the use of mHealth devices. The second simulation served to simulate the economic burden of AF with the use of mHealth devices. Afterwards, the groups were compared in terms of costs, prevented strokes, and deaths from strokes. Results: The CHA2DS2-VASc score as well as the electrocardiography (ECG) confirmation rate had the biggest impact on costs as well as number of strokes. The higher the risk score, the lower were the costs per prevented stroke. Higher ECG confirmation rates intensified this effect. The effect was not seen in groups with lower risk scores. Over 10 years, the use of mHealth (assuming a 75\% ECG confirmation rate) resulted in additional costs ({\texteuro}1=US \$1.12) of {\texteuro}441, {\texteuro}567, {\texteuro}536, {\texteuro}520, {\texteuro}606, {\texteuro}625, {\texteuro}623, {\texteuro}692, and {\texteuro}847 per patient for a CHA2DS2-VASc score of 1 to 9, respectively. The number of prevented strokes tended to be higher in groups with high risk for stroke. Higher ECG confirmation rates led to higher numbers of prevented strokes. The use of mHealth (assuming a 75\% ECG confirmation rate) resulted in 25 (7), --68 (--54), 98 (--5), 266 (182), 346 (271), 642 (440), 722 (599), 1111 (815), and 1116 (928) prevented strokes (fatal) for CHA2DS2-VASc score of 1 to 9, respectively. Higher device accuracy in terms of sensitivity led to even more prevented fatal strokes. Conclusions: The use of mHealth devices to screen for AF leads to increased costs but also a reduction in the incidence of stroke. In particular, in patients with high CHA2DS2-VASc scores, the risk for stroke and death from stroke can be markedly reduced. ", doi="10.2196/20496", url="http://mhealth.jmir.org/2020/10/e20496/", url="http://www.ncbi.nlm.nih.gov/pubmed/33021489" } @Article{info:doi/10.2196/20641, author="Park, Eunjeong and Lee, Kijeong and Han, Taehwa and Nam, Suk Hyo", title="Automatic Grading of Stroke Symptoms for Rapid Assessment Using Optimized Machine Learning and 4-Limb Kinematics: Clinical Validation Study", journal="J Med Internet Res", year="2020", month="Sep", day="16", volume="22", number="9", pages="e20641", keywords="machine learning", keywords="artificial intelligence", keywords="sensors", keywords="kinematics", keywords="stroke", keywords="telemedicine", abstract="Background: Subtle abnormal motor signs are indications of serious neurological diseases. Although neurological deficits require fast initiation of treatment in a restricted time, it is difficult for nonspecialists to detect and objectively assess the symptoms. In the clinical environment, diagnoses and decisions are based on clinical grading methods, including the National Institutes of Health Stroke Scale (NIHSS) score or the Medical Research Council (MRC) score, which have been used to measure motor weakness. Objective grading in various environments is necessitated for consistent agreement among patients, caregivers, paramedics, and medical staff to facilitate rapid diagnoses and dispatches to appropriate medical centers. Objective: In this study, we aimed to develop an autonomous grading system for stroke patients. We investigated the feasibility of our new system to assess motor weakness and grade NIHSS and MRC scores of 4 limbs, similar to the clinical examinations performed by medical staff. Methods: We implemented an automatic grading system composed of a measuring unit with wearable sensors and a grading unit with optimized machine learning. Inertial sensors were attached to measure subtle weaknesses caused by paralysis of upper and lower limbs. We collected 60 instances of data with kinematic features of motor disorders from neurological examination and demographic information of stroke patients with NIHSS 0 or 1 and MRC 7, 8, or 9 grades in a stroke unit. Training data with 240 instances were generated using a synthetic minority oversampling technique to complement the imbalanced number of data between classes and low number of training data. We trained 2 representative machine learning algorithms, an ensemble and a support vector machine (SVM), to implement auto-NIHSS and auto-MRC grading. The optimized algorithms performed a 5-fold cross-validation and were searched by Bayes optimization in 30 trials. The trained model was tested with the 60 original hold-out instances for performance evaluation in accuracy, sensitivity, specificity, and area under the receiver operating characteristics curve (AUC). Results: The proposed system can grade NIHSS scores with an accuracy of 83.3\% and an AUC of 0.912 using an optimized ensemble algorithm, and it can grade with an accuracy of 80.0\% and an AUC of 0.860 using an optimized SVM algorithm. The auto-MRC grading achieved an accuracy of 76.7\% and a mean AUC of 0.870 in SVM classification and an accuracy of 78.3\% and a mean AUC of 0.877 in ensemble classification. Conclusions: The automatic grading system quantifies proximal weakness in real time and assesses symptoms through automatic grading. The pilot outcomes demonstrated the feasibility of remote monitoring of motor weakness caused by stroke. The system can facilitate consistent grading with instant assessment and expedite dispatches to appropriate hospitals and treatment initiation by sharing auto-MRC and auto-NIHSS scores between prehospital and hospital responses as an objective observation. ", doi="10.2196/20641", url="http://www.jmir.org/2020/9/e20641/", url="http://www.ncbi.nlm.nih.gov/pubmed/32936079" } @Article{info:doi/10.2196/22208, author="Seo, Minseok and Shin, Myung-Jun and Park, Sung Tae and Park, Jong-Hwan", title="Clinometric Gait Analysis Using Smart Insoles in Patients With Hemiplegia After Stroke: Pilot Study", journal="JMIR Mhealth Uhealth", year="2020", month="Sep", day="10", volume="8", number="9", pages="e22208", keywords="stroke", keywords="hemiplegia", keywords="gait", keywords="smart insole", keywords="medical informatics", keywords="rehabilitation", keywords="observational", keywords="wearable", keywords="assessment", abstract="Background: For effective rehabilitation after stroke, it is essential to conduct an objective assessment of the patient's functional status. Several stroke severity scales have been used for this purpose, but such scales have various limitations. Objective: Gait analysis using smart insole technology can be applied continuously, objectively, and quantitatively, thereby overcoming the shortcomings of other assessment tools. Methods: To confirm the reliability of gait analysis using smart insole technology, normal healthy controls wore insoles in their shoes during the Timed Up and Go (TUG) test. The gait parameters were compared with the manually collected data. To determine the gait characteristics of patients with hemiplegia due to stroke, they were asked to wear insoles and take the TUG test; gait parameters were calculated and compared with those of control subjects. To investigate whether the gait analysis accurately reflected the patients' clinical condition, we analyzed the relationships of 22 gait parameters on 4 stroke severity scales. Results: The smart insole gait parameter data were similar to those calculated manually. Among the 18 gait parameters tested, 14 were significantly effective at distinguishing patients from healthy controls. The smart insole data revealed that the stance duration on both sides was longer in patients than controls, which has proven difficult to show using other methods. Furthermore, the sound side in patients showed a markedly longer stance duration. Regarding swing duration, that of the sound side was shorter in patients than controls, whereas that of the hemiplegic side was longer. We identified 10 significantly correlated gait parameters on the stroke severity scales. Notably, the difference in stance duration between the sound and hemiplegic sides was significantly correlated with the Fugl-Meyer Assessment (FMA) lower extremity score. Conclusions: This study confirmed the feasibility and applicability of the smart insole as a device to assess the gait of patients with hemiplegia due to stroke. In addition, we demonstrated that the FMA score was significantly correlated with the smart insole data. Providing an environment where stroke patients can easily measure walking ability helps to maintain chronic functions as well as acute rehabilitation. Trial Registration: UMIN Clinical Trials Registry UMIN000041646, https://upload.umin.ac.jp/cgi-open-bin/ctr\_e/ctr\_view.cgi?recptno=R000047538 ", doi="10.2196/22208", url="http://mhealth.jmir.org/2020/9/e22208/", url="http://www.ncbi.nlm.nih.gov/pubmed/32909949" } @Article{info:doi/10.2196/16180, author="Minen, Tova Mia and Reichel, Frederica Julia and Pemmireddy, Pallavi and Loder, Elizabeth and Torous, John", title="Characteristics of Neuropsychiatric Mobile Health Trials: Cross-Sectional Analysis of Studies Registered on ClinicalTrials.gov", journal="JMIR Mhealth Uhealth", year="2020", month="Aug", day="4", volume="8", number="8", pages="e16180", keywords="smartphones", keywords="mobile phones", keywords="apps", keywords="mental health", keywords="regulation", keywords="stroke", keywords="migraine", keywords="major depressive disorder", keywords="Alzheimer disease", keywords="anxiety disorders", keywords="alcohol use disorders", keywords="opioid use disorders", keywords="epilepsy", keywords="schizophrenia", abstract="Background: The development of mobile health (mHealth) technologies is progressing at a faster pace than that of the science to evaluate their validity and efficacy. Under the International Committee of Journal Medical Editors (ICMJE) guidelines, clinical trials that prospectively assign people to interventions should be registered with a database before the initiation of the study. Objective: The aim of this study was to better understand the smartphone mHealth trials for high-burden neuropsychiatric conditions registered on ClinicalTrials.gov through November 2018, including the number, types, and characteristics of the studies being conducted; the frequency and timing of any outcome changes; and the reporting of results. Methods: We conducted a systematic search of ClinicalTrials.gov for the top 10 most disabling neuropsychiatric conditions and prespecified terms related to mHealth. According to the 2016 World Health Organization Global Burden of Disease Study, the top 10 most disabling neuropsychiatric conditions are (1) stroke, (2) migraine, (3) major depressive disorder, (4) Alzheimer disease and other dementias, (5) anxiety disorders, (6) alcohol use disorders, (7) opioid use disorders, (8) epilepsy, (9) schizophrenia, and (10) other mental and substance use disorders. There were no date, location, or status restrictions. Results: Our search identified 135 studies. A total of 28.9\% (39/135) of studies evaluated interventions for major depressive disorder, 14.1\% (19/135) of studies evaluated interventions for alcohol use disorders, 12.6\% (17/135) of studies evaluated interventions for stroke, 11.1\% (15/135) of studies evaluated interventions for schizophrenia, 8.1\% (11/135) of studies evaluated interventions for anxiety disorders, 8.1\% (11/135) of studies evaluated interventions for other mental and substance use disorders, 7.4\% (10/135) of studies evaluated interventions for opioid use disorders, 3.7\% (5/135) of studies evaluated interventions for Alzheimer disease or other dementias, 3.0\% (4/135) of studies evaluated interventions for epilepsy, and 3.0\% (4/135) of studies evaluated interventions for migraine. The studies were first registered in 2008; more than half of the studies were registered from 2016 to 2018. A total of 18.5\% (25/135) of trials had results reported in some publicly accessible location. Across all the studies, the mean estimated enrollment (reported by the study) was 1078, although the median was only 100. In addition, across all the studies, the actual reported enrollment was lower, with a mean of 249 and a median of 80. Only about a quarter of the studies (35/135, 25.9\%) were funded by the National Institutes of Health. Conclusions: Despite the increasing use of health-based technologies, this analysis of ClinicalTrials.gov suggests that only a few apps for high-burden neuropsychiatric conditions are being clinically evaluated in trials. ", doi="10.2196/16180", url="https://mhealth.jmir.org/2020/8/e16180", url="http://www.ncbi.nlm.nih.gov/pubmed/32749230" } @Article{info:doi/10.2196/17036, author="Signal, June Nada Elizabeth and McLaren, Ruth and Rashid, Usman and Vandal, Alain and King, Marcus and Almesfer, Faisal and Henderson, Jeanette and Taylor, Denise", title="Haptic Nudges Increase Affected Upper Limb Movement During Inpatient Stroke Rehabilitation: Multiple-Period Randomized Crossover Study", journal="JMIR Mhealth Uhealth", year="2020", month="Jul", day="29", volume="8", number="7", pages="e17036", keywords="stroke", keywords="rehabilitation", keywords="physical activity", keywords="movement", keywords="disability", keywords="technology", keywords="upper limb", keywords="wearable", keywords="haptic", keywords="nudge", abstract="Background: As many as 80\% of stroke survivors experience upper limb (UL) disability. The strong relationships between disability, lost productivity, and ongoing health care costs mean reducing disability after stroke is critical at both individual and society levels. Unfortunately, the amount of UL-focused rehabilitation received by people with stroke is extremely low. Activity monitoring and promotion using wearable devices offer a potential technology-based solution to address this gap. Commonly, wearable devices are used to deliver a haptic nudge to the wearer with the aim of promoting a particular behavior. However, little is known about the effectiveness of haptic nudging in promoting behaviors in patient populations. Objective: This study aimed to estimate the effect of haptic nudging delivered via a wrist-worn wearable device on UL movement in people with UL disability following stroke undertaking inpatient rehabilitation. Methods: A multiple-period randomized crossover design was used to measure the association of UL movement with the occurrence of haptic nudge reminders to move the affected UL in 20 people with stroke undertaking inpatient rehabilitation. UL movement was observed and classified using movement taxonomy across 72 one-minute observation periods from 7:00 AM to 7:00 PM on a single weekday. On 36 occasions, a haptic nudge to move the affected UL was provided just before the observation period. On the other 36 occasions, no haptic nudge was given. The timing of the haptic nudge was randomized across the observation period for each participant. Statistical analysis was performed using mixed logistic regression. The effect of a haptic nudge was evaluated from the intention-to-treat dataset as the ratio of the odds of affected UL movement during the observation period following a ``Planned Nudge'' to the odds of affected limb movement during the observation period following ``No Nudge.'' Results: The primary intention-to-treat analysis showed the odds ratio (OR) of affected UL movement following a haptic nudge was 1.44 (95\% CI 1.28-1.63, P<.001). The secondary analysis revealed an increased odds of affected UL movement following a Planned Nudge was predominantly due to increased odds of spontaneous affected UL movement (OR 2.03, 95\% CI 1.65-2.51, P<.001) rather than affected UL movement in conjunction with unaffected UL movement (OR 1.13, 95\% CI 0.99-1.29, P=.07). Conclusions: Haptic nudging delivered via a wrist-worn wearable device increases affected UL movement in people with UL disability following stroke undertaking inpatient rehabilitation. The promoted movement appears to be specific to the instructions given. Trial Registration: Australia New Zealand Clinical Trials Registry 12616000654459; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370687\&isReview=true ", doi="10.2196/17036", url="https://mhealth.jmir.org/2020/7/e17036", url="http://www.ncbi.nlm.nih.gov/pubmed/32723718" } @Article{info:doi/10.2196/17132, author="Dimaguila, Luis Gerardo and Gray, Kathleen and Merolli, Mark", title="Enabling Better Use of Person-Generated Health Data in Stroke Rehabilitation Systems: Systematic Development of Design Heuristics", journal="J Med Internet Res", year="2020", month="Jul", day="28", volume="22", number="7", pages="e17132", keywords="person-generated health data", keywords="patient-reported outcome measures", keywords="heuristics", keywords="stroke rehabilitation", keywords="consumer health informatics", keywords="evidence-based practice", keywords="information technology", abstract="Background: An established and well-known method for usability assessment of various human-computer interaction technologies is called heuristic evaluation (HE). HE has been adopted for evaluations in a wide variety of specialized contexts and with objectives that go beyond usability. A set of heuristics to evaluate how health information technologies (HITs) incorporate features that enable effective patient use of person-generated health data (PGHD) is needed in an era where there is a growing demand and variety of PGHD-enabled technologies in health care and where a number of remote patient-monitoring technologies do not yet enable patient use of PGHD. Such a set of heuristics would improve the likelihood of positive effects from patients' use of PGHD and lower the risk of negative effects. Objective: This study aims to describe the development of a set of heuristics for the design and evaluation of how well remote patient therapeutic technologies enable patients to use PGHD (PGHD enablement). We used the case of Kinect-based stroke rehabilitation systems (K-SRS) in this study. Methods: The development of a set of heuristics to enable better use of PGHD was primarily guided by the R3C methodology. Closer inspection of the methodology reveals that neither its development nor its application to a case study were described in detail. Thus, where relevant, each step was grounded through best practice activities in the literature and by using Nielsen's heuristics as a basis for determining the new set of heuristics. As such, this study builds on the R3C methodology, and the implementation of a mixed process is intended to result in a robust and credible set of heuristics. Results: A total of 8 new heuristics for PGHD enablement in K-SRS were created. A systematic and detailed process was applied in each step of heuristic development, which bridged the gaps described earlier. It is hoped that this would aid future developers of specialized heuristics, who could apply the detailed process of heuristic development for other domains of technology, and additionally for the case of PGHD enablement for other health conditions. The R3C methodology was also augmented through the use of qualitative studies with target users and domain experts, and it is intended to result in a robust and credible set of heuristics, before validation and refinement. Conclusions: This study is the first to develop a new set of specialized heuristics to evaluate how HITs incorporate features that enable effective patient use of PGHD, with K-SRS as a key case study. In addition, it is the first to describe how the identification of initial HIT features and concepts to enable PGHD could lead to the development of a specialized set of heuristics. ", doi="10.2196/17132", url="http://www.jmir.org/2020/7/e17132/", url="http://www.ncbi.nlm.nih.gov/pubmed/32720901" } @Article{info:doi/10.2196/18058, author="Bayona, Hern{\'a}n and Ropero, Brenda and Salazar, Jos{\'e} Antonio and P{\'e}rez, Camilo Juan and Granja, Felipe Manuel and Mart{\'i}nez, Fernando Carlos and Useche, Nicol{\'a}s Juan", title="Comprehensive Telestroke Network to Optimize Health Care Delivery for Cerebrovascular Diseases: Algorithm Development", journal="J Med Internet Res", year="2020", month="Jul", day="27", volume="22", number="7", pages="e18058", keywords="stroke", keywords="telestroke", keywords="cerebrovascular disease", keywords="software", keywords="algorithms", keywords="emergency medicine", keywords="clinical pathways", abstract="Background: Health care delivery for cerebrovascular diseases is a complex process, which may be improved using telestroke networks. Objective: The purpose of this work was to establish and implement a protocol for the management of patients with acute stroke symptoms according to the available treatment alternatives at the initial point of care and the transfer possibilities. Methods: The review board of our institutions approved this work. The protocol was based on the latest guidelines of the American Heart Association and American Stroke Association. Stroke care requires human and technological resources, which may differ according to the patient's point of entry into the health care system. Three health care settings were identified to define the appropriate protocols: primary health care setting, intermediate health care setting, and advanced health care setting. Results: A user-friendly web-based telestroke solution was developed. The predictors, scales, and scores implemented in this system allowed the assessment of the vascular insult severity and neurological status of the patient. The total number of possible pathways implemented was as follows: 10 in the primary health care setting, 39 in the intermediate health care setting, and 1162 in the advanced health care setting. Conclusions: The developed comprehensive telestroke platform is the first stage in optimizing health care delivery for patients with stroke symptoms, regardless of the entry point into the emergency network, in both urban and rural regions. This system supports health care personnel by providing adequate inpatient stroke care and facilitating the prompt transfer of patients to a more appropriate health care setting if necessary, especially for patients with acute ischemic stroke within the therapeutic window who are candidates for reperfusion therapies, ultimately contributing to mitigating the mortality and morbidity associated with stroke. ", doi="10.2196/18058", url="http://www.jmir.org/2020/7/e18058/", url="http://www.ncbi.nlm.nih.gov/pubmed/32716302" } @Article{info:doi/10.2196/19582, author="Langan, Jeanne and Bhattacharjya, Sutanuka and Subryan, Heamchand and Xu, Wenyao and Chen, Baicheng and Li, Zhengxiong and Cavuoto, Lora", title="In-Home Rehabilitation Using a Smartphone App Coupled With 3D Printed Functional Objects: Single-Subject Design Study", journal="JMIR Mhealth Uhealth", year="2020", month="Jul", day="22", volume="8", number="7", pages="e19582", keywords="stroke", keywords="rehabilitation", keywords="smart technology", keywords="3D printing", keywords="usability", abstract="Background: Stroke is a major cause of long-term disability. While there is potential for improvements long after stroke onset, there is little to support functional recovery across the lifespan. mHealth solutions can help fill this gap. mRehab was designed to guide individuals with stroke through a home program and provide performance feedback. Objective: To examine if individuals with chronic stroke can use mRehab at home to improve upper limb mobility. The secondary objective was to examine if changes in limb mobility transferred to standardized clinical assessments. Methods: mRehab consists of a smartphone coupled with 3D printed household items: mug, bowl, key, and doorknob. The smartphone custom app guides task-oriented activities and measures both time to complete an activity and quality of movement (smoothness/accuracy). It also provides performance-based feedback to aid the user in self-monitoring their performance. Task-oriented activities were categorized as (1) object transportation, (2) prehensile grip with supination/pronation, (3) fractionated finger movement, and (4) walking with object. A total of 18 individuals with stroke enrolled in the single-subject experimental design study consisting of pretesting, a 6-week mRehab home program, and posttesting. Pre- and posttesting included both in-laboratory clinical assessments and in-home mRehab recorded samples of task performance. During the home program, mRehab recorded performance data. A System Usability Scale assessed user's perception of mRehab. Results: A total of 16 participants completed the study and their data are presented in the results. The average days of exercise for each mRehab activity ranged from 15.93 to 21.19 days. This level of adherence was sufficient for improvements in time (t15=2.555, P=.02) and smoothness (t15=3.483, P=.003) in object transportation. Clinical assessments indicated improvements in functional performance (t15=2.675, P=.02) and hand dexterity (t15=2.629, P=.02). Participant's perception of mRehab was positive. Conclusions: Despite heterogeneity in participants' use of mRehab, there were improvements in upper limb mobility. Smartphone-based portable technology can support home rehabilitation programs in chronic conditions such as stroke. The ability to record performance data from home rehabilitation offers new insights into the impact of home programs on outcomes. Trial Registration: ClinicalTrials.gov NCT04363944; https://clinicaltrials.gov/ct2/show/NCT04363944 ", doi="10.2196/19582", url="http://mhealth.jmir.org/2020/7/e19582/", url="http://www.ncbi.nlm.nih.gov/pubmed/32706702" } @Article{info:doi/10.2196/18919, author="Bashir, Ayisha", title="Stroke and Telerehabilitation: A Brief Communication", journal="JMIR Rehabil Assist Technol", year="2020", month="Jul", day="17", volume="7", number="2", pages="e18919", keywords="telerehabilitation", keywords="rehabilitation", keywords="nursing", keywords="stroke", keywords="telehealth", doi="10.2196/18919", url="https://rehab.jmir.org/2020/2/e18919", url="http://www.ncbi.nlm.nih.gov/pubmed/32706739" } @Article{info:doi/10.2196/17182, author="Appalasamy, Rani Jamuna and Joseph, Pauline Joyce and Seeta Ramaiah, Siva and Md Zain, Zaini Anuar and Quek, Fatt Kia and Tha, Kyi Kyi", title="Video Narratives Intervention Among Stroke Survivors: Feasibility and Acceptability Study of a Randomized Controlled Trial", journal="JMIR Aging", year="2020", month="Jul", day="10", volume="3", number="2", pages="e17182", keywords="feasibility and acceptability", keywords="medication understanding", keywords="use self-efficacy", keywords="stroke", keywords="video narratives", abstract="Background: A large number of stroke survivors worldwide suffer from moderate to severe disability. In Malaysia, long-term uncontrolled stroke risk factors lead to unforeseen rates of recurrent stroke and a growing incidence of stroke occurrence across ages, predominantly among the elderly population. This situation has motivated research efforts focused on tapping into patient education, especially related to patient self-efficacy of understanding and taking medication appropriately. Video narratives integrated with health belief model constructs have demonstrated potential impacts as an aide to patient education efforts. Objective: The aim of this study was to investigate the feasibility and acceptability of study procedures based on a randomized controlled trial protocol of a video narratives intervention among poststroke patients. We also aimed to obtain preliminary findings of video narratives related to medication understanding and use self-efficacy (MUSE) and blood pressure control. Methods: A parallel group randomized controlled trial including a control group (without video viewing) and an intervention group (with video viewing) was conducted by researchers at a neurology outpatient clinic on poststroke patients (N=54). Baseline data included patients' sociodemographic characteristics, medical information, and all outcome measures. Measurements of MUSE and blood pressure following the trial were taken during a 3-month follow-up period. Feasibility of the trial was assessed based on recruitment and study completion rates along with patients' feedback on the burden of the study procedures and outcome measures. Acceptability of the trial was analyzed qualitatively. Statistical analysis was applied to ascertain the preliminary results of video narratives. Results: The recruitment rate was 60 out of 117 patients (51.3\%). Nevertheless, the dropout rate of 10\% was within the acceptable range. Patients were aged between 21 and 74 years. Nearly 50 of the patients (>85\%) had adequate health literacy and exposure to stroke education. Most of the patients (>80\%) were diagnosed with ischemic stroke, whereby the majority had primary hypertension. The technicalities of randomization and patient approach were carried out with minimal challenge and adequate patient satisfaction. The video contents received good responses with respect to comprehension and simplicity. Moreover, an in-depth phone interview with 8 patients indicated that the video narratives were considered to be useful and inspiring. These findings paralleled the preliminary findings of significant improvement within groups in MUSE (P=.001) and systolic blood pressure control (P=.04). Conclusions: The queries and feedback from each phase in this study have been acknowledged and will be taken forward in the full trial. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN 12618000174280; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373554 ", doi="10.2196/17182", url="https://aging.jmir.org/2020/2/e17182", url="http://www.ncbi.nlm.nih.gov/pubmed/32469839" } @Article{info:doi/10.2196/15851, author="Smith, Alexander and Bains, Natalie and Copeland, Lauren and Pennington, Anna and Carter, Ben and Hewitt, Jonathan", title="Morbidity Prevalence Estimate at 6 Months Following a Stroke: Protocol for a Cohort Study", journal="JMIR Res Protoc", year="2020", month="Jun", day="17", volume="9", number="6", pages="e15851", keywords="stroke", keywords="prevalence estimate", keywords="morbidity", keywords="disability", keywords="PROMs", keywords="outcomes", keywords="quality of life (QoL)", abstract="Background: Knowledge of the prevalence of morbidity secondary to stroke is important for health care professionals, health care commissioners, third sector organizations, and stroke survivors to understand the likely progress of poststroke sequelae and to aid in commissioning decisions, planning care, and adjusting to life after stroke. Objective: The primary aim of the Morbidity PRevalence Estimate In StrokE (MORe PREcISE) study is to determine the prevalence of morbidity secondary to a stroke, predictors of morbidity, and trends in quality of life and functional status using patient-reported outcomes, cognitive and functional assessments. Methods: A total of 500 participants will be recruited across Wales and England within 14 days following an admission to a stroke unit for either an ischemic or hemorrhagic stroke as part of a multicenter cohort study. Participants are assessed at baseline ?14 days poststroke and subsequently at 90 ({\textpm} 14) days and 180 ({\textpm} 14) days poststroke. At each time point, data will be collected relating to the following domains: participant demographics, routine clinical, patient reported, cognitive status, emotional well-being, and functional ability. Results: Recruitment commenced in October 2018 with 20 sites opened as of September 2019 and was closed on October 31, 2019. Conclusions: The primary outcome is the prevalence of morbidity at 6 months secondary to a stroke. Further analysis will consider temporal changes in the health-related domains to describe trends among baseline, 3-, and 6-month time points. Trial Registration: ClinicalTrials.gov NCT03605381; https://clinicaltrials.gov/ct2/show/NCT03605381 International Registered Report Identifier (IRRID): DERR1-10.2196/15851 ", doi="10.2196/15851", url="https://www.researchprotocols.org/2020/6/e15851", url="http://www.ncbi.nlm.nih.gov/pubmed/32512539" } @Article{info:doi/10.2196/15893, author="Sakai, Kenichiro and Komatsu, Teppei and Iguchi, Yasuyuki and Takao, Hiroyuki and Ishibashi, Toshihiro and Murayama, Yuichi", title="Reliability of Smartphone for Diffusion-Weighted Imaging--Alberta Stroke Program Early Computed Tomography Scores in Acute Ischemic Stroke Patients: Diagnostic Test Accuracy Study", journal="J Med Internet Res", year="2020", month="Jun", day="9", volume="22", number="6", pages="e15893", keywords="smartphone app", keywords="DWI", keywords="ASPECTS", abstract="Background: High-quality neuroimages can be viewed using a medical app installed on a smartphone. Although interdevice agreement between smartphone and desktop PC monitor was found to be favorable for evaluating computed tomography images, there are no interdevice agreement data for diffusion-weighted imaging (DWI). Objective: The aim of our study was to compare DWI interpretation using the Join smartphone app with that using a desktop PC monitor, in terms of interdevice and interrater agreement and elapsed interpretation time. Methods: The ischemic change in the DWI of consecutive patients with acute stroke in the middle cerebral artery territory was graded by 2 vascular neurologists using the Join smartphone app and a desktop PC monitor. The vascular neurologists were blinded to all patient information. Each image was categorized as either Diffusion-Weighted Imaging--Alberta Stroke Program Early Computed Tomography Scores (DWI-ASPECTS) ?7 or DWI-ASPECTS <7 according to the Japanese Society for Neuroendovascular Therapy. We analyzed interdevice agreement and interrater agreement with respect to DWI-ASPECTS. Elapsed interpretation time was compared between DWI-ASPECTS evaluated by the Join smartphone app and a desktop PC monitor. Results: We analyzed the images of 111 patients (66\% male; median age=69 years; median National Institutes of Health Stroke Scale score on admission=4). Interdevice agreement regarding DWI-ASPECTS between the smartphone and the desktop PC monitor was favorable (vascular neurologist 1: $\kappa$=0.777, P<.001, vascular neurologist 2: $\kappa$=0.787, P<.001). Interrater agreement was also satisfactory for the smartphone ($\kappa$=0.710, P<.001) and the desktop PC monitor ($\kappa$=0.663, P<.001). Median elapsed interpretation time was similar between the smartphone and the desktop PC monitor (vascular neurologist 1: 1.7 min vs 1.6 min; P=.64); vascular neurologist 2: 2.4 min vs 2.0 min; P=.14). Conclusions: The use of a smartphone app enables vascular neurologists to estimate DWI-ASPECTS accurately and rapidly. The Join medical smartphone app shows great promise in the management of acute stroke. ", doi="10.2196/15893", url="https://www.jmir.org/2020/6/e15893", url="http://www.ncbi.nlm.nih.gov/pubmed/32515744" } @Article{info:doi/10.2196/18358, author="Koka, Avinash and Suppan, Laurent and Cottet, Philippe and Carrera, Emmanuel and Stuby, Loric and Suppan, M{\'e}lanie", title="Teaching the National Institutes of Health Stroke Scale to Paramedics (E-Learning vs Video): Randomized Controlled Trial", journal="J Med Internet Res", year="2020", month="Jun", day="9", volume="22", number="6", pages="e18358", keywords="active learning", keywords="electronic learning", keywords="video", keywords="stroke", keywords="online learning", keywords="e-learning", abstract="Background: Prompt and accurate identification of stroke victims is essential to reduce time from symptom onset to adequate treatment and to improve neurological outcomes. Most neurologists evaluate the extent of neurological deficit according to the National Institutes of Health Stroke Scale (NIHSS), but the use of this scale by paramedics, the first healthcare providers to usually take care of stroke victims, has proven unreliable. This might be, at least in part, due to the teaching method. The video used to teach NIHSS lacks interactivity, while more engaging electronic learning (e-learning) methods might improve knowledge acquisition. Objective: This study was designed to evaluate whether a highly interactive e-learning module could enhance NIHSS knowledge acquisition in paramedics. Methods: A randomized controlled trial comparing a specially designed e-learning module with the original NIHSS video was performed with paramedics working in Geneva, Switzerland. A registration number was not required as our study does not come into the scope of the Swiss federal law on human research. The protocol was nevertheless submitted to the local ethics committee (Project ID 2017-00847), which issued a ``Declaration of no objection.'' Paramedics were excluded if they had prior knowledge of or previous training in the NIHSS, or if they had worked in a neurology or neurosurgery ward. The primary outcome was overall performance in the study quiz, which contained 50 questions. Secondary outcomes were performance by NIHSS item, time to course and quiz completion, user satisfaction regarding the learning method, user perception of the course duration, and probability the user would recommend the course to a colleague. Results: The study was completed by 39 paramedics. There was a better overall median score (36/50 vs 33/50, P=.04) and a higher degree of satisfaction regarding the learning method in the e-learning group (90\% vs 37\%, P=.002). Users who had followed the e-learning module were more likely to recommend the course to a colleague (95\% vs 63\%, P=.02). Paramedics in the e-learning group took more time to complete the course (93 vs 59 minutes, P<.001), but considered the duration to be more adequate (75\% vs 32\%, P=.01). Time to quiz completion was similar between groups (25 vs 38 minutes, P=.12). Conclusions: Use of an e-learning module shows promising results in teaching the NIHSS to paramedics. ", doi="10.2196/18358", url="http://www.jmir.org/2020/6/e18358/", url="http://www.ncbi.nlm.nih.gov/pubmed/32299792" } @Article{info:doi/10.2196/17804, author="Held, Oskar Jeremia Philipp and Yu, Kevin and Pyles, Connor and Veerbeek, Marieke Janne and Bork, Felix and Heining, Sandro-Michael and Navab, Nassir and Luft, R{\"u}diger Andreas", title="Augmented Reality--Based Rehabilitation of Gait Impairments: Case Report", journal="JMIR Mhealth Uhealth", year="2020", month="May", day="26", volume="8", number="5", pages="e17804", keywords="HoloLens 2", keywords="gait", keywords="rehabilitation", keywords="stroke", keywords="augmented reality", keywords="sensors", abstract="Background: Gait and balance impairments are common in neurological diseases, including stroke, and negatively affect patients' quality of life. Improving balance and gait are among the main goals of rehabilitation. Rehabilitation is mainly performed in clinics, which lack context specificity; therefore, training in the patient's home environment is preferable. In the last decade, developed rehabilitation technologies such as virtual reality and augmented reality (AR) have enabled gait and balance training outside clinics. Here, we propose a new method for gait rehabilitation in persons who have had a stroke in which mobile AR technology and a sensor-based motion capture system are combined to provide fine-grained feedback on gait performance in real time. Objective: The aims of this study were (1) to investigate manipulation of the gait pattern of persons who have had a stroke based on virtual augmentation during overground walking compared to walking without AR performance feedback and (2) to investigate the usability of the AR system. Methods: We developed the ARISE (Augmented Reality for gait Impairments after StrokE) system, in which we combined a development version of HoloLens 2 smart glasses (Microsoft Corporation) with a sensor-based motion capture system. One patient with chronic minor gait impairment poststroke completed clinical gait assessments and an AR parkour course with patient-centered performance gait feedback. The movement kinematics during gait as well as the usability and safety of the system were evaluated. Results: The patient changed his gait pattern during AR parkour compared to the pattern observed during the clinical gait assessments. He recognized the virtual objects and ranked the usability of the ARISE system as excellent. In addition, the patient stated that the system would complement his standard gait therapy. Except for the symptom of exhilaration, no adverse events occurred. Conclusions: This project provided the first evidence of gait adaptation during overground walking based on real-time feedback through visual and auditory augmentation. The system has potential to provide gait and balance rehabilitation outside the clinic. This initial investigation of AR rehabilitation may aid the development and investigation of new gait and balance therapies. ", doi="10.2196/17804", url="http://mhealth.jmir.org/2020/5/e17804/", url="http://www.ncbi.nlm.nih.gov/pubmed/32452815" } @Article{info:doi/10.2196/17219, author="Li, Li and Huang, Jia and Wu, Jingsong and Jiang, Cai and Chen, Shanjia and Xie, Guanli and Ren, Jinxin and Tao, Jing and Chan, H. Chetwyn C. and Chen, Lidian and Wong, K. Alex W.", title="A Mobile Health App for the Collection of Functional Outcomes After Inpatient Stroke Rehabilitation: Pilot Randomized Controlled Trial", journal="JMIR Mhealth Uhealth", year="2020", month="May", day="13", volume="8", number="5", pages="e17219", keywords="telemedicine", keywords="cell phone", keywords="stroke", keywords="rehabilitation", keywords="activities of daily living", keywords="outcome and process assessment", keywords="health care", abstract="Background: Monitoring the functional status of poststroke patients after they transition home is significant for rehabilitation. Mobile health (mHealth) technologies may provide an opportunity to reach and follow patients post discharge. However, the feasibility and validity of functional assessments administered by mHealth technologies are unknown. Objective: This study aimed to evaluate the feasibility, validity, and reliability of functional assessments administered through the videoconference function of a mobile phone--based app compared with administration through the telephone function in poststroke patients after rehabilitation hospitalization. Methods: A randomized controlled trial was conducted in a rehabilitation hospital in Southeast China. Participants were randomly assigned to either a videoconference follow-up (n=60) or a telephone follow-up (n=60) group. We measured the functional status of participants in each group at 2-week and 3-month follow-up periods. Half the participants in each group were followed by face-to-face home visit assessments as the gold standard. Validity was assessed by comparing any score differences between videoconference follow-up and home visit assessments, as well as telephone follow-up and home visit assessments. Reliability was assessed by computing agreements between videoconference follow-up and home visit assessments, as well as telephone follow-up and home visit assessments. Feasibility was evaluated by the levels of completion, satisfaction, comfort, and confidence in the 2 groups. Results: Scores obtained from the videoconference follow-up were similar to those of the home visit assessment. However, most scores collected from telephone administration were higher than those of the home visit assessment. The agreement between videoconference follow-up and home visit assessments was higher than that between telephone follow-up and home visit assessments at all follow-up periods. In the telephone follow-up group, completion rates were 95\% and 82\% at 2-week and 3-month follow-up points, respectively. In the videoconference follow-up group, completion rates were 95\% and 80\% at 2-week and 3-month follow-up points, respectively. There were no differences in the completion rates between the 2 groups at all follow-up periods (X21=1.6, P=.21 for 2-week follow-up; X21=1.9, P=.17 for 3-month follow-up). Patients in the videoconference follow-up group perceived higher confidence than those in the telephone follow-up group at both 2-week and 3-month follow-up periods (X23=6.7, P=.04 for 2-week follow-up; X23=8.0, P=.04 for 3-month follow-up). The videoconference follow-up group demonstrated higher satisfaction than the telephone follow-up group at 3-month follow-up (X23=13.9; P=.03). Conclusions: The videoconference follow-up assessment of functional status demonstrates higher validity and reliability, as well as higher confidence and satisfaction perceived by patients, than the telephone assessment. The videoconference assessment provides an efficient means of assessing functional outcomes of patients after hospital discharge. This method provides a novel solution for clinical trials requiring longitudinal assessments. Trial Registration: chictr.org.cn: ChiCTR1900027626; http://www.chictr.org.cn/edit.aspx?pid=44831\&htm=4. ", doi="10.2196/17219", url="https://mhealth.jmir.org/2020/5/e17219", url="http://www.ncbi.nlm.nih.gov/pubmed/32401221" } @Article{info:doi/10.2196/17816, author="Ifejika, L. Nneka and Bhadane, Minal and Cai, C. Chunyan and Noser, A. Elizabeth and Grotta, C. James and Savitz, I. Sean", title="Use of a Smartphone-Based Mobile App for Weight Management in Obese Minority Stroke Survivors: Pilot Randomized Controlled Trial With Open Blinded End Point", journal="JMIR Mhealth Uhealth", year="2020", month="Apr", day="22", volume="8", number="4", pages="e17816", keywords="smartphone", keywords="stroke", keywords="obesity", keywords="telemedicine", keywords="minority groups", keywords="cognitive dysfunction", keywords="outcome assessment, health care", abstract="Background: Minorities have an increased incidence of early-onset, obesity-related cerebrovascular disease. Unfortunately, effective weight management in this vulnerable population has significant barriers. Objective: Our objective was to determine the feasibility and preliminary treatment effects of a smartphone-based weight loss intervention versus food journals to monitor dietary patterns in minority stroke patients. Methods: Swipe out Stroke was a pilot prospective randomized controlled trial with open blinded end point. Minority stroke patients and their caregivers were screened for participation using cluster enrollment. We used adaptive randomization for assignment to a behavior intervention with (1) smartphone-based self-monitoring or (2) food journal self-monitoring. The smartphone group used Lose it! to record meals and communicate with us. Reminder messages (first 30 days), weekly summaries plus reminder messages on missed days (days 31-90), and weekly summaries only (days 91-180) were sent via push notifications. The food journal group used paper diaries. Both groups received 4 in-person visits (baseline and 30, 90, and 180 days), culturally competent counseling, and educational materials. The primary outcome was reduced total body weight. Results: We enrolled 36 stroke patients (n=23, 64\% African American; n=13, 36\% Hispanic), 17 in the smartphone group, and 19 in the food journal group. Mean age was 54 (SD 9) years; mean body mass index was 35.7 (SD 5.7) kg/m2; education, employment status, and family history of stroke or obesity did not differ between the groups. Baseline rates of depression (Patient Health Questionnaire-9 [PHQ-9] score median 5.5, IQR 3.0-9.5), cognitive impairment (Montreal Cognitive Assessment score median 23.5, IQR 21-26), and inability to ambulate (5/36, 14\% with modified Rankin Scale score 3) were similar. In total, 25 (69\%) stroke survivors completed Swipe out Stroke (13/17 in the smartphone group, 12/19 in the food journal group); 1 participant in the smartphone group died. Median weight change at 180 days was 5.7 lb (IQR --2.4 to 8.0) in the smartphone group versus 6.4 lb (IQR --2.2 to 12.5; P=.77) in the food journal group. Depression was significantly lower at 30 days in the smartphone group than in the food journal group (PHQ-9 score 2 vs 8; P=.03). Clinically relevant depression rates remained in the zero to minimal range for the smartphone group compared with mild to moderate range in the food journal group at day 90 (PHQ-9 score 3.5 vs 4.5; P=.39) and day 180 (PHQ-9 score 3 vs 6; P=.12). Conclusions: In a population of obese minority stroke survivors, the use of a smartphone did not lead to a significant difference in weight change compared with keeping a food journal. The presence of baseline depression (19/36, 53\%) was a confounding variable, which improved with app engagement. Future studies that include treatment of poststroke depression may positively influence intervention efficacy. Trial Registration: ClinicalTrials.gov NCT02531074; https://www.clinicaltrials.gov/ct2/show/NCT02531074 ", doi="10.2196/17816", url="http://mhealth.jmir.org/2020/4/e17816/", url="http://www.ncbi.nlm.nih.gov/pubmed/32319963" } @Article{info:doi/10.2196/16496, author="Zhang, Yuanjin and Fan, Dongsheng and Ji, Hong and Qiao, Shudong and Li, Xia", title="Treatment Adherence and Secondary Prevention of Ischemic Stroke Among Discharged Patients Using Mobile Phone- and WeChat-Based Improvement Services: Cohort Study", journal="JMIR Mhealth Uhealth", year="2020", month="Apr", day="15", volume="8", number="4", pages="e16496", keywords="stroke", keywords="secondary prevention", keywords="WeChat", keywords="self-monitoring", abstract="Background: Real-world studies have indicated that adherence is important for guaranteeing medication effectiveness. Few studies have tested the feasibility and efficacy of WeChat-based improvement services, via mobile phone, in secondary prevention-specific follow-up among discharged stroke patients. Objective: We evaluated a quadruple-domain, WeChat-based service for ischemic stroke secondary prevention designed to improve treatment adherence of discharged patients. This service focuses on sending reminders for drug use, blood pressure recording, and glucose recording; it also records medication use. We compared the endpoint event rate between WeChat self-monitoring and traditional monitoring. Methods: A cohort study was used to determine the feasibility of a physician-assisted, WeChat-based improvement service and follow-up self-monitoring platform for the secondary prevention of ischemic stroke. The platform was developed by the Peking University Third Hospital based on the information-motivation-behavioral skills model. The overall adherence rate was calculated as the proportion of medication doses verified via uploading. The ischemic endpoint event rate and medication noncompliance rate were compared between traditional prevention monitoring and WeChat self-monitoring. Factors influencing adherence were summarized. Results: The 1-year follow-up event rate of the WeChat self-monitoring group was 11.9\% (12/101), which was less than that of the traditional group (21/157, 13.4\%). Compared with the traditional group, the risk ratio of the WeChat group was 0.983 (95\% CI 0.895-1.080); this difference was not noted to be significant. The 1-year medication noncompliance ratio tended to be lower in the WeChat monitoring group (3/101, 3.0\%) than in the traditional group (11/157, 7.0\%; $\chi$2=1.9, df=1, P=.16). Of the platform registry participants, 89.7\% (210/234: 167 hospital-based and 43 community-based participants) adhered to inputting information into WeChat for 8-96 weeks. The average adherence time was 16.54 (SD 0.80, range 2-24) months. The average decrease in adherence was 4 participants (1.1\%) per month. Being a member of a community-based population was an influencing factor for good adherence at the 2-year follow-up (OR 2.373, 95\% CI 1.019-5.527, P=.045), whereas transient ischemic attack was an influencing factor for poor adherence at the 2-year follow-up (OR 0.122, 95\% CI 0.016-0.940, P=.04). Conclusions: Use of WeChat self-monitoring showed a trend of increasing medication compliance and decreasing ischemic endpoint event rate compared with traditional monitoring. However, there were ceiling effects in the outcomes, and a relatively small sample size was used. Male participants displayed better adherence to WeChat self-monitoring. The community-based population displayed good adherence when using WeChat self-monitoring. Trial Registration: ClinicalTrials.gov NCT02618265; https://clinicaltrials.gov/ct2/show/NCT02618265 ", doi="10.2196/16496", url="https://mhealth.jmir.org/2020/4/e16496", url="http://www.ncbi.nlm.nih.gov/pubmed/32293574" } @Article{info:doi/10.2196/15377, author="Kim, Yeon Do and Kwon, Hee and Nam, Ki-Woong and Lee, Yongseok and Kwon, Hyung-Min and Chung, Seob Young", title="Remote Management of Poststroke Patients With a Smartphone-Based Management System Integrated in Clinical Care: Prospective, Nonrandomized, Interventional Study", journal="J Med Internet Res", year="2020", month="Feb", day="27", volume="22", number="2", pages="e15377", keywords="mHealth", keywords="mobile apps", keywords="stroke care", keywords="health care", keywords="patient education", keywords="self-monitoring of blood pressure", abstract="Background: Advances in mobile health (mHealth) have enabled systematic and continuous management of patients with chronic diseases. Objective: We developed a smartphone-based mHealth system and aimed to evaluate its effects on health behavior management and risk factor control in stroke patients. Methods: With a multifaceted stroke aftercare management system that included exercise, medication, and educational materials, we performed a 12-week single-arm intervention among eligible poststroke patients in the stroke clinic from September to December 2016. The intervention consisted of (1) regular blood pressure (BP), blood glucose, and physical activity measurements; (2) stroke education; (3) an exercise program; (4) a medication program; and (5) feedback on reviewing of records by clinicians. Clinical assessments consisted of the stroke awareness score, Beck Depression Inventory-II (BDI), EuroQol-5 Dimensions (EQ-5D), and BP at visit 1 (baseline), visit 2 (4 weeks), and visit 3 (12 weeks). Temporal differences in the parameters over 12 weeks were investigated with repeated-measures analysis of variance. Changes in medication adherence at visit 1-2 (from visit 1 to visit 2) and visit 2-3 (from visit 2 to visit 3) were compared. System satisfaction was evaluated with a self-questionnaire using a 5-point Likert scale at visit 3. Results: The study was approved by the Institutional Review Board in September 2016, and participants were enrolled from September to December 2016. Among the 110 patients enrolled for the study, 99 were included in our analyses. The mean stroke awareness score (baseline: 59.6 [SD 18.1]; 4 weeks: 67.6 [SD 16.0], P<.001; 12 weeks: 74.7 [SD 14.0], P<.001) and BDI score (baseline: 12.7 [SD 10.1]; 4 weeks: 11.2 [SD 10.2], P=.01; 12 weeks: 10.7 [SD 10.2], P<.001) showed gradual improvement; however, no significant differences were found in the mean EQ-5D score (baseline: 0.66 [SD 0.33]; 4 weeks: 0.69 [SD 0.34], P=.01; 12 weeks: 0.69 [SD 0.34], P<.001). Twenty-six patients who had uncontrolled BP at baseline had ?13.92 mmHg (P=.001) and ?6.19 mmHg (P<.001) reductions on average in systolic and diastolic BP, respectively, without any antihypertensive medication change. Medication compliance was better at visit 2-3 (60.9\% [SD 37.2\%]) than at visit 1-2 (47.8\% [SD 38.7\%], P<.001). Conclusions: Awareness of stroke, depression, and BP was enhanced when using the smartphone-based mHealth system. Emerging mHealth techniques have potential as new nonpharmacological secondary prevention methods because of their ubiquitous access, near real-time responsiveness, and comparatively lower cost. ", doi="10.2196/15377", url="http://www.jmir.org/2020/2/e15377/", url="http://www.ncbi.nlm.nih.gov/pubmed/32130140" } @Article{info:doi/10.2196/12113, author="Kamal, Ayeesha and Khoja, Adeel and Usmani, Bushra and Magsi, Shahvaiz and Malani, Aresha and Peera, Zahra and Sattar, Saadia and Ahmed Akram, Masood and Shahnawaz, Sumaira and Zulfiqar, Maryam and Muqeet, Abdul and Zaidi, Fabiha and Sayani, Saleem and Artani, Azmina and Azam, Iqbal and Saleem, Sarah", title="Effect of 5-Minute Movies Shown via a Mobile Phone App on Risk Factors and Mortality After Stroke in a Low- to Middle-Income Country: Randomized Controlled Trial for the Stroke Caregiver Dyad Education Intervention (Movies4Stroke)", journal="JMIR Mhealth Uhealth", year="2020", month="Jan", day="28", volume="8", number="1", pages="e12113", keywords="stroke", keywords="mobile health", keywords="noncommunicable diseases", keywords="adherence", abstract="Background: Pakistan is the sixth most populous nation in the world and has an estimated 4 million stroke survivors. Most survivors are taken care of by community-based caregivers, and there are no inpatient rehabilitation facilities. Objective: The objective of this study was to evaluate the effectiveness and safety of locally designed 5-min movies rolled out in order of relevance that are thematically delivered in a 3-month program to deliver poststroke education to stroke survivor and caregiver dyads returning to the community. Methods: This study was a randomized controlled, outcome assessor--blinded, parallel group, single-center superiority trial in which participants (stroke survivor-caregiver dyads) with first-ever stroke (both ischemic and hemorrhagic) incidence were randomized within 48 hours of their stroke into either the video-based education intervention group or the control group. The video-based education intervention group had health education delivered through short videos that were shown to the participants and their caregivers at the time of admission, before discharge, and the first and third months of follow-up after discharge. The control group had standardized care including predischarge education and counseling according to defined protocols. All participants enrolled in the video education intervention and control groups were followed for 12 months after discharge for outcome assessment in the outpatient stroke clinics. The primary outcome measures were the proportion of participants achieving control of blood pressure, blood sugar, and blood cholesterol in the video intervention versus the control group. Several predefined secondary outcomes were included in this study, of which we report the mortality and functional disability in this paper. Analysis was by performed using the intention-to-treat principle. Results: A total of 310 stroke survivors and their caregiver dyads (participant dyads) were recruited over a duration of 6 months. In total, 155 participant dyads were randomized into the intervention and control groups, each. The primary outcome of control of three major risk factors revealed that at 12 months, there was a greater percentage of participants with a systolic BP<125 mm Hg (18/54, 33\% vs 11/52, 21\%; P=.16), diastolic BP<85 mm Hg (44/54, 81\% vs 37/52, 71\%; P=.21), HbA1c level<7\% (36/55, 65\% vs 30/40, 75\%; P=.32), and low-density lipoprotein level<100 mg/dL (36/51, 70\% vs 30/45, 67\%; P=.68) in the intervention group than in the control group. The secondary outcome reported is the mortality among the stroke survivors because the number of stroke-related complications was higher in the control group than in the intervention group (13/155, 8.4\% vs 2/155, 1.3\%), and this difference was statistically significant (P<.001). Conclusions: The Movies4Stroke trial failed to achieve its primary specified outcome. However, secondary outcomes that directly related to survival skills of stroke survivors demonstrated the effectiveness of the video-based intervention on improving stroke-related mortality and survival without disability. Trial Registration: ClinicalTrials.gov NCT02202330; https://www.clinicaltrials.gov/ct2/show/NCT02202330 ", doi="10.2196/12113", url="http://mhealth.jmir.org/2020/1/e12113/", url="http://www.ncbi.nlm.nih.gov/pubmed/32012080" } @Article{info:doi/10.2196/15981, author="Parker, Jack and Powell, Lauren and Mawson, Susan", title="Effectiveness of Upper Limb Wearable Technology for Improving Activity and Participation in Adult Stroke Survivors: Systematic Review", journal="J Med Internet Res", year="2020", month="Jan", day="8", volume="22", number="1", pages="e15981", keywords="wearable electronic devices", keywords="stroke", keywords="rehabilitation", keywords="upper extremity", abstract="Background: With advances in technology, the adoption of wearable devices has become a viable adjunct in poststroke rehabilitation. Upper limb (UL) impairment affects up to 77\% of stroke survivors impacting on their ability to carry out everyday activities. However, despite an increase in research exploring these devices for UL rehabilitation, little is known of their effectiveness. Objective: This review aimed to assess the effectiveness of UL wearable technology for improving activity and participation in adult stroke survivors. Methods: Randomized controlled trials (RCTs) and randomized comparable trials of UL wearable technology for poststroke rehabilitation were included. Primary outcome measures were validated measures of activity and participation as defined by the International Classification of Functioning, Disability, and Health. Databases searched were MEDLINE, Web of Science (Core collection), CINAHL, and the Cochrane Library. The Cochrane Risk of Bias Tool was used to assess the methodological quality of the RCTs and the Downs and Black Instrument for the quality of non RCTs. Results: In the review, we included 11 studies with collectively 354 participants at baseline and 323 participants at final follow-up including control groups and participants poststroke. Participants' stroke type and severity varied. Only 1 study found significant between-group differences for systems functioning and activity (P?.02). The 11 included studies in this review had small sample sizes ranging from 5 to 99 participants at an average (mean) age of 57 years. Conclusions: This review has highlighted a number of reasons for insignificant findings in this area including low sample sizes and the appropriateness of the methodology for complex interventions. However, technology has the potential to measure outcomes, provide feedback, and engage users outside of clinical sessions. This could provide a platform for motivating stroke survivors to carry out more rehabilitation in the absence of a therapist, which could maximize recovery. Trial Registration: PROSPERO CRD42017057715; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=57715 ", doi="10.2196/15981", url="https://www.jmir.org/2020/1/e15981", url="http://www.ncbi.nlm.nih.gov/pubmed/31913131" } @Article{info:doi/10.2196/15758, author="Gong, Enying and Gu, Wanbing and Luo, Erdan and Tan, Liwei and Donovan, Julian and Sun, Cheng and Yang, Ying and Zang, Longkai and Bao, Peng and Yan, L. Lijing", title="Development and Local Contextualization of Mobile Health Messages for Enhancing Disease Management Among Community-Dwelling Stroke Patients in Rural China: Multimethod Study", journal="JMIR Mhealth Uhealth", year="2019", month="Dec", day="17", volume="7", number="12", pages="e15758", keywords="phone messages", keywords="stroke", keywords="secondary prevention", keywords="rural population", keywords="China", abstract="Background: Rural China has experienced an increasing health burden because of stroke. Stroke patients in rural communities have relatively poor awareness of and adherence to evidence-based secondary prevention and self-management of stroke. Mobile technology represents an innovative way to influence patient behaviors and improve their self-management. Objective: This study is part of the System-Integrated Technology-Enabled Model of Care (the SINEMA trial) to improve the health of stroke patients in resource-poor settings in China. This study aimed to develop and pilot-test a mobile phone message--based package, as a component of the SINEMA intervention. Methods: The SINEMA trial was conducted in Nanhe County, Hebei Province, China. A total of 4 villages were selected for pretrial contextual research and pilot study. The 5 stages for developing the mobile phone messages were as follows: (1) conducting literature review on existing message banks and analyzing the characteristics of these banks; (2) interviewing stroke patients and caregivers to identify their needs; (3) drafting message contents and designing dispatching algorithms for a 3-month pilot testing; (4) collecting feedback from pilot participants through questionnaire survey and in-depth interviews on facilitators and barriers related to their acceptance and understanding of messages; and (5) finalizing the message-based intervention based on participants' feedback for the SINEMA trial. Results: On the basis of 5 existing message banks screened out of 120 papers and patients' needs identified from 32 in-depth interviews among stroke patients and caregivers, we developed a message bank containing 224 messages for a pilot study among 54 community-dwelling stroke patients from 4 villages. Of 54 participants, 51 (response rate: 94.4\%) completed the feedback survey after receiving daily messages for 3 months. Participants' mean age was 68 years (SD 9.2), and about half had never been to school. We observed a higher proportion of participants who were in favor of voice messages (23/42, 54\%) than text messages (14/40, 35\%). Among participants who received voice messages (n=43) and text messages (n=40), 41 and 30, respectively, self-reported a full or partial understanding of the contents, and 39 (39/43, 91\%) and 32 (32/40, 80\%), respectively, rated the messages as helpful. Analyses of the 32 interviews further revealed that voice messages containing simple and single-theme content, in plain language, with a repeated structure, a slow playback speed, and recorded in local dialect, were preferred by rural stroke patients. In addition, the dispatching algorithm and tools may also influence the acceptance of message-based interventions. Conclusions: By applying multiple methodologies and conducting a pilot study, we designed and fine-tuned a voice message--based intervention package for promoting secondary prevention among community-dwelling stroke patients in rural China. Design of the content and dispatching algorithm should engage both experts and end users and adequately consider the needs and preferences of recipients. ", doi="10.2196/15758", url="https://mhealth.jmir.org/2019/12/e15758", url="http://www.ncbi.nlm.nih.gov/pubmed/31845901" } @Article{info:doi/10.2196/14222, author="Johnson, Louise and Burridge, Jane and Demain, Sara and Ewings, Sean", title="Comparing the Impact of an Implicit Learning Approach With Standard Care on Recovery of Mobility Following Stroke: Protocol for a Pilot Cluster Randomized Controlled Trial", journal="JMIR Res Protoc", year="2019", month="Nov", day="5", volume="8", number="11", pages="e14222", keywords="stroke", keywords="rehabilitation", keywords="learning", keywords="attention", abstract="Background: Although implicit and explicit learning approaches have been well investigated in healthy populations, there is less evidence regarding the relative benefits of each approach in clinical practice. Studies in stroke typically investigate single elements of an implicit learning approach (ILA; eg, reduced quantity feedback or an external focus of attention) within controlled environments. These studies predominantly evaluate performance, with few measuring this over time (ie, learning). The relevance and transferability of current research evidence into stroke rehabilitation is therefore limited. Objective: The objective of this study was to compare the ILA with standard care in the acute phase following stroke, to generate data and insights to inform the design of a definitive trial, and to understand patient and therapist perceptions of the ILA. Methods: This is a multicenter, assessor-blind, cluster randomized controlled pilot trial with nested qualitative evaluation. Stroke units (clusters) will be randomized to either ILA (intervention) or standard care (control) arms. Therapy teams at the intervention sites will be trained in the ILA and provided with an intervention manual. Those at the control sites will have minimal input from the research team, other than for data collection. Consent will be provided at the individual participant level. Once enrolled, participants will receive rehabilitation that focuses on lower limb recovery, using the designated approach. Measures will be taken at baseline, every 2 weeks until the point of discharge from hospital, and at 3 months post stroke onset. Measures include the Fugl Meyer Assessment (motor leg subsection), modified Rivermead Mobility Index, Swedish Postural Adjustment in Stroke Scale, and achievement of mobility milestones. Fidelity of the treatment approach will be monitored using observational video analysis. Focus groups and interviews will be used to gain insight into the perceptions of trial participants and clinical teams. Results: The first site opened to recruitment in February 2019. The opening of a further 5 sites will be staggered throughout 2019. Results are expected in early 2021. Conclusions: The findings from this mixed methods pilot study will be used to inform the design of a definitive study, comparing the ILA with standard care in acute stroke rehabilitation. Trial Registration: ClinicalTrials.gov NCT03792126; https://clinicaltrials.gov/ct2/show/NCT03792126 International Registered Report Identifier (IRRID): DERR1-10.2196/14222 ", doi="10.2196/14222", url="https://www.researchprotocols.org/2019/11/e14222", url="http://www.ncbi.nlm.nih.gov/pubmed/31687935" } @Article{info:doi/10.2196/14926, author="Wang, Guangyu and Zhou, Silu and Rezaei, Shahbaz and Liu, Xin and Huang, Anpeng", title="An Ambulatory Blood Pressure Monitor Mobile Health System for Early Warning for Stroke Risk: Longitudinal Observational Study", journal="JMIR Mhealth Uhealth", year="2019", month="Oct", day="30", volume="7", number="10", pages="e14926", keywords="ambulatory blood pressure monitor", keywords="mHealth", keywords="stroke-risk early warning", keywords="abnormal blood pressure data analyzing", keywords="longitudinal observational study", abstract="Background: Stroke, as a leading cause of death around the globe, has become a heavy burden on our society. Studies show that stroke can be predicted and prevented if a person's blood pressure (BP) status is appropriately monitored via an ambulatory blood pressure monitor (ABPM) system. However, currently there exists no efficient and user-friendly ABPM system to provide early warning for stroke risk in real-time. Moreover, most existing ABPM devices measure BP during the deflation of the cuff, which fails to reflect blood pressure accurately. Objective: In this study, we sought to develop a new ABPM mobile health (mHealth) system that was capable of monitoring blood pressure during inflation and could detect early stroke-risk signals in real-time. Methods: We designed an ABPM mHealth system that is based on mobile network infrastructure and mobile apps. The proposed system contains two major parts: a new ABPM device in which an inflation-type BP measurement algorithm is embedded, and an abnormal blood pressure data analysis algorithm for stroke-risk prediction services at our health data service center. For evaluation, the ABPM device was first tested using simulated signals and compared with the gold standard of a mercury sphygmomanometer. Then, the performance of our proposed mHealth system was evaluated in an observational study. Results: The results are presented in two main parts: the device test and the longitudinal observational studies of the presented system. The average measurement error of the new ABPM device with the inflation-type algorithm was less than 0.55 mmHg compared to a reference device using simulated signals. Moreover, the results of correlation coefficients and agreement analyses show that there is a strong linear correlation between our device and the standard mercury sphygmomanometer. In the case of the system observational study, we collected a data set with 88 features, including real-time data, user information, and user records. Our abnormal blood pressure data analysis algorithm achieved the best performance, with an area under the curve of 0.904 for the low risk level, 0.756 for the caution risk level, and 0.912 for the high-risk level. Our system enables a patient to be aware of their risk in real-time, which improves medication adherence with risk self-management. Conclusions: To our knowledge, this device is the first ABPM device that measures blood pressure during the inflation process and has obtained a government medical license. Device tests and longitudinal observational studies were conducted in Peking University hospitals, and they showed the device's high accuracy for BP measurements, its efficiency in detecting early signs of stroke, and its efficiency at providing an early warning for stroke risk. ", doi="10.2196/14926", url="http://mhealth.jmir.org/2019/10/e14926/", url="http://www.ncbi.nlm.nih.gov/pubmed/31670694" } @Article{info:doi/10.2196/14338, author="Driver, Simon and Swank, Chad and Froehlich-Grobe, Katherine and McShan, Evan and Calhoun, Stephanie and Bennett, Monica", title="Weight Loss After Stroke Through an Intensive Lifestyle Intervention (Group Lifestyle Balance-Cerebrovascular Accident): Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2019", month="Oct", day="18", volume="8", number="10", pages="e14338", keywords="cerebrovascular accident", keywords="physical activity", keywords="eating", keywords="weight loss", keywords="rehabilitation", abstract="Background: Weight gain can be a consequence of stroke, or cerebrovascular accident (CVA), because of impaired mobility, behavioral and emotional disorders, and sensory losses. Weight gain increases the patient's risk of recurrent stroke and chronic diseases, such as diabetes, metabolic syndrome, and pulmonary and heart disease. Approaches to weight loss in this population are lacking, although necessary because of the unique physiological and cognitive needs of persons after a stroke. Evidence shows that intensive behavioral therapy interventions that address both physical activity and diet offer the greatest potential for weight loss. The Group Lifestyle Balance (GLB) intervention is a 12-month, evidence-based weight loss program that has been used extensively with the general population; this program was modified to meet the needs of people who have had a stroke (GLB-CVA). Objective: This randomized controlled trial (RCT) aims to examine the efficacy of the GLB-CVA on weight and secondary outcomes, compared with that of a waitlist control group. Methods: This RCT will enroll and randomize 64 patients over an 18-month period. Results: Currently, 51 people are waitlisted, with 23 out of 51 screened and 16 out of 23 eligible. Conclusions: It is anticipated that the findings from this RCT will contribute to the evidence base regarding weight loss strategies for people living with stroke. Clinical Trial: ClinicalTrials.gov NCT03873467; https://clinicaltrials.gov/ct2/show/NCT03873467 ", doi="10.2196/14338", url="https://www.researchprotocols.org/2019/10/e14338", url="http://www.ncbi.nlm.nih.gov/pubmed/31628790" } @Article{info:doi/10.2196/14001, author="Tsurushima, Hideo and Mizukami, Masafumi and Yoshikawa, Kenichi and Ueno, Tomoyuki and Hada, Yasushi and Gosho, Masahiko and Kohno, Yutaka and Hashimoto, Koichi and Iizumi, Yuichi and Kikuchi, Toshihiro and Matsumura, Akira and ", title="Effectiveness of a Walking Program Involving the Hybrid Assistive Limb Robotic Exoskeleton Suit for Improving Walking Ability in Stroke Patients: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2019", month="Oct", day="11", volume="8", number="10", pages="e14001", keywords="Hybrid Assistive Limb (HAL)", keywords="gait training", keywords="stroke", keywords="hemiparesis", abstract="Background: Gait disturbance often occurs in stroke survivors. Recovery of walking function is challenging, as some gait disturbance due to hemiparesis often remains even after rehabilitation therapy, presenting a major obstacle towards regaining activities-of-daily-living performance and achieving social reintegration. Objective: This study aims to clarify the effectiveness of a walking program involving the wearable Hybrid Assistive Limb (HAL-TS01) robotic exoskeleton for improving walking ability in stroke patients with hemiparesis and stagnant recovery despite ongoing rehabilitation. Methods: This is a multicenter, randomized, parallel-group, controlled study (HAL group, n=27; control group, n=27). The study period includes preintervention observation (until stagnant recovery), intervention (HAL-based walking therapy or conventional rehabilitation; 5 weeks), and postintervention observation (2 weeks). Following provision of informed consent and primary registration, the patients undergo conventional rehabilitation for preintervention observation, during which the recovery of walking ability is monitored to identify patients with stagnant recovery (based on weekly assessments using the 10-meter maximum walking speed [MWS] test). Patients with an MWS of 30-60 m/minute and insufficient weekly improvement in MWS undergo secondary registration and are randomly assigned to undergo HAL-based walking therapy (HAL group) or conventional rehabilitation (control group). The primary outcome is the change in MWS from baseline to the end of the 5-week intervention. Results: This study began in November 2016 and is being conducted at 15 participating facilities in Japan. Conclusions: Assessments of walking ability vary greatly and it is difficult to define the threshold for significant differences. To reduce such variability, our study involves conducting conventional rehabilitation to the point of saturation before starting the intervention. Stagnation in the recovery of walking ability despite conventional rehabilitation highlights the limits of current medical care. The present study may bring evidence that HAL-based therapy can overcome such limitations and induce added recovery of walking ability, which would promote the use of HAL technology in the clinical setting. Trial Registration: UMIN Clinical Trials Registry UMIN000024805; https://upload.umin.ac.jp/cgi-open-bin/ctr\_e/ctr\_view.cgi?recptno=R000028545 ", doi="10.2196/14001", url="https://www.researchprotocols.org/2019/10/e14001", url="http://www.ncbi.nlm.nih.gov/pubmed/31605515" } @Article{info:doi/10.2196/13734, author="Appireddy, Ramana and Khan, Sana and Leaver, Chad and Martin, Cally and Jin, Albert and Durafourt, A. Bryce and Archer, L. Stephen", title="Home Virtual Visits for Outpatient Follow-Up Stroke Care: Cross-Sectional Study", journal="J Med Internet Res", year="2019", month="Oct", day="7", volume="21", number="10", pages="e13734", keywords="telemedicine", keywords="eHealth", keywords="eVisit", keywords="mobile health", keywords="health services accessibility", abstract="Background: Timely, in-person access to health care is a challenge for people living with conditions such as stroke that result in frailty, loss of independence, restrictions in driving and mobility, and physical and cognitive decline. In Southeastern Ontario, access is further complicated by rurality and the long travel distances to visit physician clinics. There is a need to make health care more accessible and convenient. Home virtual visits (electronic visits, eVisits) can conveniently connect physicians to patients. Physicians use a secure personal videoconferencing tool to connect to patients in their homes. Patients use their device of choice (smartphone, tablet, laptop, or desktop) for the visit. Objective: This study aimed to assess the feasibility and logistics of implementing eVisits in a stroke prevention clinic for seniors. Methods: A 6-month eVisit pilot study was initiated in the Kingston Health Sciences Centre stroke prevention clinic in August 2018. eVisits were used only for follow-up patient encounters. An integrated evaluation was used to test the impact of the program on clinic workflow and patient satisfaction. Patient satisfaction was evaluated by telephone interviews, using a brief questionnaire. Access and patient satisfaction metrics were compared with concurrent standard of care (patients' prior personal experience with in-person visits). Values are presented as median (interquartile range). Results: There were 75 subjects in the pilot. The patients were aged 65 (56-73.5) years, and 39\% (29/75) resided in rural areas. There was a shorter wait for an appointment by eVisit versus in-person (mean 59.98 [SD 48.36] days vs mean 78.36 [SD 50.54] days; P<.001). The eVisit was also shorter, taking on an average of only 10 min to deliver follow-up care with a high degree of patient satisfaction versus 90 (60-112) min for in-person care. The total time saved by patients per eVisit was 80 (50-102) min, 44 (21-69) min of which was travel time. Travel distance avoided by the patients was 30.1 km (11.2-82.2). The estimated total out-of-pocket cost savings for patients per eVisit was Can \$52.83 (31.26-94.53). The estimated savings (opportunity cost for in-person outpatient care) for our eVisit pilot project was Can \$23,832-\$28,584. The patient satisfaction with eVisits was very good compared with their prior personal experience with in-person outpatient care. Conclusions: The eVisit program was well received by patients, deemed to be safe by physicians, and avoided unnecessary patient travel and expense. It also has the potential to reduce health care costs. We plan to scale the project within the department and the institution. ", doi="10.2196/13734", url="https://www.jmir.org/2019/10/e13734", url="http://www.ncbi.nlm.nih.gov/pubmed/31593536" } @Article{info:doi/10.2196/12010, author="Mubin, Omar and Alnajjar, Fady and Jishtu, Nalini and Alsinglawi, Belal and Al Mahmud, Abdullah", title="Exoskeletons With Virtual Reality, Augmented Reality, and Gamification for Stroke Patients' Rehabilitation: Systematic Review", journal="JMIR Rehabil Assist Technol", year="2019", month="Sep", day="8", volume="6", number="2", pages="e12010", keywords="stroke", keywords="robot", keywords="exoskeleton", keywords="virtual reality", keywords="augmented reality", keywords="gamification", keywords="rehabilitation", abstract="Background: Robot-assisted therapy has become a promising technology in the field of rehabilitation for poststroke patients with motor disorders. Motivation during the rehabilitation process is a top priority for most stroke survivors. With current advancements in technology there has been the introduction of virtual reality (VR), augmented reality (AR), customizable games, or a combination thereof, that aid robotic therapy in retaining, or increasing the interests of, patients so they keep performing their exercises. However, there are gaps in the evidence regarding the transition from clinical rehabilitation to home-based therapy which calls for an updated synthesis of the literature that showcases this trend. The present review proposes a categorization of these studies according to technologies used, and details research in both upper limb and lower limb applications. Objective: The goal of this work was to review the practices and technologies implemented in the rehabilitation of poststroke patients. It aims to assess the effectiveness of exoskeleton robotics in conjunction with any of the three technologies (VR, AR, or gamification) in improving activity and participation in poststroke survivors. Methods: A systematic search of the literature on exoskeleton robotics applied with any of the three technologies of interest (VR, AR, or gamification) was performed in the following databases: MEDLINE, EMBASE, Science Direct \& The Cochrane Library. Exoskeleton-based studies that did not include any VR, AR or gamification elements were excluded, but publications from the years 2010 to 2017 were included. Results in the form of improvements in the patients' condition were also recorded and taken into consideration in determining the effectiveness of any of the therapies on the patients. Results: Thirty studies were identified based on the inclusion criteria, and this included randomized controlled trials as well as exploratory research pieces. There were a total of about 385 participants across the various studies. The use of technologies such as VR-, AR-, or gamification-based exoskeletons could fill the transition from the clinic to a home-based setting. Our analysis showed that there were general improvements in the motor function of patients using the novel interfacing techniques with exoskeletons. This categorization of studies helps with understanding the scope of rehabilitation therapies that can be successfully arranged for home-based rehabilitation. Conclusions: Future studies are necessary to explore various types of customizable games required to retain or increase the motivation of patients going through the individual therapies. ", doi="10.2196/12010", url="https://rehab.jmir.org/2019/2/e12010", url="http://www.ncbi.nlm.nih.gov/pubmed/31586360" } @Article{info:doi/10.2196/14077, author="Garcia-Rudolph, Alejandro and Laxe, Sara and Saur{\'i}, Joan and Bernabeu Guitart, Montserrat", title="Stroke Survivors on Twitter: Sentiment and Topic Analysis From a Gender Perspective", journal="J Med Internet Res", year="2019", month="Aug", day="26", volume="21", number="8", pages="e14077", keywords="stroke", keywords="emotions", keywords="Twitter", keywords="infodemiology", keywords="infoveillance", keywords="sentiment analysis", keywords="topic models", keywords="gender", abstract="Background: Stroke is the worldwide leading cause of long-term disabilities. Women experience more activity limitations, worse health-related quality of life, and more poststroke depression than men. Twitter is increasingly used by individuals to broadcast their day-to-day happenings, providing unobtrusive access to samples of spontaneously expressed opinions on all types of topics and emotions. Objective: This study aimed to consider the raw frequencies of words in the collection of tweets posted by a sample of stroke survivors and to compare the posts by gender of the survivor for 8 basic emotions (anger, fear, anticipation, surprise, joy, sadness, trust and disgust); determine the proportion of each emotion in the collection of tweets and statistically compare each of them by gender of the survivor; extract the main topics (represented as sets of words) that occur in the collection of tweets, relative to each gender; and assign happiness scores to tweets and topics (using a well-established tool) and compare them by gender of the survivor. Methods: We performed sentiment analysis based on a state-of-the-art lexicon (National Research Council) with syuzhet R package. The emotion scores for men and women were first subjected to an F-test and then to a Wilcoxon rank sum test. We extended the emotional analysis, assigning happiness scores with the hedonometer (a tool specifically designed considering Twitter inputs). We calculated daily happiness average scores for all tweets. We created a term map for an exploratory clustering analysis using VosViewer software. We performed structural topic modelling with stm R package, allowing us to identify main topics by gender. We assigned happiness scores to all the words defining the main identified topics and compared them by gender. Results: We analyzed 800,424 tweets posted from August 1, 2007 to December 1, 2018, by 479 stroke survivors: Women (n=244) posted 396,898 tweets, and men (n=235) posted 403,526 tweets. The stroke survivor condition and gender as well as membership in at least 3 stroke-specific Twitter lists of active users were manually verified for all 479 participants. Their total number of tweets since 2007 was 5,257,433; therefore, we analyzed the most recent 15.2\% of all their tweets. Positive emotions (anticipation, trust, and joy) were significantly higher (P<.001) in women, while negative emotions (disgust, fear, and sadness) were significantly higher (P<.001) in men in the analysis of raw frequencies and proportion of emotions. Happiness mean scores throughout the considered period show higher levels of happiness in women. We calculated the top 20 topics (with percentages and CIs) more likely addressed by gender and found that women's topics show higher levels of happiness scores. Conclusions: We applied two different approaches---the Plutchik model and hedonometer tool---to a sample of stroke survivors' tweets. We conclude that women express positive emotions and happiness much more than men. ", doi="10.2196/14077", url="http://www.jmir.org/2019/8/e14077/", url="http://www.ncbi.nlm.nih.gov/pubmed/31452514" } @Article{info:doi/10.2196/14399, author="Appalasamy, Rani Jamuna and Subramanian, Pathmavathi and Tan, Mun Kit and Seeta Ramaiah, Siva and Joseph, Pauline Joyce and Chua, Siang Siew", title="The Needs and Barriers of Medication-Taking Self-Efficacy Among Poststroke Patients: Qualitative Study", journal="JMIR Nursing", year="2019", month="Jul", day="22", volume="2", number="1", pages="e14399", keywords="poststroke", keywords="medication taking self-efficacy", keywords="medication adherence", abstract="Background: Stroke is one of the top 10 leading diseases worldwide, with high mortality and morbidity rates. There is an incomplete understanding of the various types of self-efficacy involved in the prevention of recurrent stroke, and one of them is medication-taking self-efficacy. Objective: This study aimed to explore the fundamental needs and barriers of medication-taking self-efficacy in poststroke patients in Malaysia. Methods: We performed in-depth individual interviews with poststroke patients (N=10) from the Outpatient Neurology Clinic, Hospital Kuala Lumpur. All interviews were transcribed verbatim, and an inductive thematic analysis was performed on the data collected from the interviews. Results: Two key themes were identified: (1) self-efficacy in taking the effort to understand stroke and its preventative treatment for recurrent stroke and (2) self-efficacy in taking prescribed medication to prevent stroke. Patients needed to be proactive in seeking reliable information about stroke and the perceived benefits of preventative treatment for stroke. The discussion was focused on eliciting the needs and barriers related to medication-taking self-efficacy. Patients needed to develop independence and self-reliance to overcome barriers such as dependency and low motivation. External factors such as limited information resources, low perceived severity, poor social environment, and poor communication add to the challenges of poststroke patients to improve their self-efficacy of managing their medications. Conclusions: The study identified potential key findings related to the needs of patients in a localized setting, which are also related to several health behavioral concepts and constructs, indicating the importance of overcoming barriers to improve the quality of life in poststroke patients. We anticipate that the results will be taken into consideration for future personalized patient education interventions. ", doi="10.2196/14399", url="https://nursing.jmir.org/2019/1/e14399/", url="http://www.ncbi.nlm.nih.gov/pubmed/34345772" } @Article{info:doi/10.2196/13503, author="Wu, Na and Gong, Enying and Wang, Bo and Gu, Wanbing and Ding, Nan and Zhang, Zhuoran and Chen, Mengyao and Yan, L. Lijing and Oldenburg, Brian and Xu, Li-Qun", title="A Smart and Multifaceted Mobile Health System for Delivering Evidence-Based Secondary Prevention of Stroke in Rural China: Design, Development, and Feasibility Study", journal="JMIR Mhealth Uhealth", year="2019", month="Jul", day="19", volume="7", number="7", pages="e13503", keywords="stroke", keywords="secondary prevention", keywords="rural health services", keywords="mobile application", keywords="software design", keywords="China", abstract="Background: Mobile health (mHealth) technologies hold great promise in improving the delivery of high-quality health care services. Yet, there has been little research so far applying mHealth technologies in the context of delivering stroke care in resource-limited rural regions. Objective: This study aimed to introduce the design and development of an mHealth system targeting primary health care providers and to ascertain its feasibility in supporting the delivery of a System-Integrated techNology-Enabled Model of cAre (SINEMA) service for strengthening secondary prevention of stroke in rural China. Methods: The SINEMA mHealth system was designed by a multidisciplinary team comprising public health researchers, neurologists, and information and communication technology experts. The iterative co-design and development of the mHealth system involved the following 5 steps: (1) assessing the needs of relevant end users through in-depth interviews of stakeholders, (2) designing the functional modules and evidence-based care content, (3) designing and building the system and user interface, (4) improving and enhancing the system through a 3-month pilot test in 4 villages, and (5) finalizing the system and deploying it in field trial, and finally, evaluating its feasibility through a survey of the dominant user group. Results: From the in-depth interviews of 49 relevant stakeholders, we found that village doctors had limited capacity in caring for village-dwelling stroke patients in rural areas. Primary health care workers demonstrated real needs in receiving appropriate training and support from the mHealth system as well as great interests in using the mHealth technologies and tools. Using these findings, we designed a multifaceted mHealth system with 7 functional modules by following the iterative user-centered design and software development approach. The mHealth system, aimed at 3 different types of users (village doctors, town physicians, and county managers), was developed and utilized in a cluster-randomized controlled trial by 25 village doctors in a resource-limited county in rural China to manage 637 stroke patients between July 2017 and July 2018. In the end, a survey on the usability and functions of the mHealth system among village doctors (the dominant group of users, response rate=96\%, 24/25) revealed that most of them were satisfied with the essential functions provided (71\%) and were keen to continue using it (92\%) after the study. Conclusions: The mHealth system was feasible for assisting primary health care providers in rural China in delivering the SINEMA service on the secondary prevention of stroke. Further research and initiatives in scaling up the SINEMA approach and this mHealth system to other resource-limited regions in China and beyond will likely enhance the quality and accessibility of essential secondary prevention among stroke patients. ClinicalTrial: ClinicalTrials.gov NCT03185858; https://clinicaltrials.gov/ct2/show/NCT03185858 International Registered Report Identifier (IRRID): RR2-10.1016/j.ahj.2018.08.015 ", doi="10.2196/13503", url="http://mhealth.jmir.org/2019/7/e13503/", url="http://www.ncbi.nlm.nih.gov/pubmed/31325288" } @Article{info:doi/10.2196/13166, author="Jiang, Xinchan and Ming, Wai-Kit and You, HS Joyce", title="The Cost-Effectiveness of Digital Health Interventions on the Management of Cardiovascular Diseases: Systematic Review", journal="J Med Internet Res", year="2019", month="Jun", day="17", volume="21", number="6", pages="e13166", keywords="telemedicine", keywords="cardiovascular diseases", keywords="stroke", keywords="heart failure", keywords="myocardial infarction", keywords="heart attack", keywords="cost-effectiveness", keywords="medical economics", keywords="decision modeling", keywords="systematic review", abstract="Background: With the advancement in information technology and mobile internet, digital health interventions (DHIs) are improving the care of cardiovascular diseases (CVDs). The impact of DHIs on cost-effective management of CVDs has been examined using the decision analytic model--based health technology assessment approach. Objective: The aim of this study was to perform a systematic review of the decision analytic model--based studies evaluating the cost-effectiveness of DHIs on the management of CVDs. Methods: A literature review was conducted in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature Complete, PsycINFO, Scopus, Web of Science, Center for Review and Dissemination, and Institute for IEEE Xplore between 2001 and 2018. Studies were included if the following criteria were met: (1) English articles, (2) DHIs that promoted or delivered clinical interventions and had an impact on patients' cardiovascular conditions, (3) studies that were modeling works with health economic outcomes of DHIs for CVDs, (4) studies that had a comparative group for assessment, and (5) full economic evaluations including a cost-effectiveness analysis, cost-utility analysis, cost-benefit analysis, and cost-consequence analysis. The primary outcome collected was the cost-effectiveness of the DHIs, presented by incremental cost per additional quality-adjusted life year (QALY). The quality of each included study was evaluated using the Consolidated Health Economic Evaluation Reporting Standards. Results: A total of 14 studies met the defined criteria and were included in the review. Among the included studies, heart failure (7/14, 50\%) and stroke (4/14, 29\%) were two of the most frequent CVDs that were managed by DHIs. A total of 9 (64\%) studies were published between 2015 and 2018 and 5 (36\%) published between 2011 and 2014. The time horizon was ?1 year in 3 studies (21\%), >1 year in 10 studies (71\%), and 1 study (7\%) did not declare the time frame. The types of devices or technologies used to deliver the health interventions were short message service (1/14, 7\%), telephone support (1/14, 7\%), mobile app (1/14, 7\%), video conferencing system (5/14, 36\%), digital transmission of physiologic data (telemonitoring; 5/14, 36\%), and wearable medical device (1/14, 7\%). The DHIs gained higher QALYs with cost saving in 43\% (6/14) of studies and gained QALYs at a higher cost at acceptable incremental cost-effectiveness ratio (ICER) in 57\% (8/14) of studies. The studies were classified as excellent (0/14, 0\%), good (9/14, 64\%), moderate (4/14, 29\%), and low (1/14, 7\%) quality. Conclusions: This study is the first systematic review of decision analytic model--based cost-effectiveness analyses of DHIs in the management of CVDs. Most of the identified studies were published recently, and the majority of the studies were good quality cost-effectiveness analyses with an adequate duration of time frame. All the included studies found the DHIs to be cost-effective. ", doi="10.2196/13166", url="http://www.jmir.org/2019/6/e13166/", url="http://www.ncbi.nlm.nih.gov/pubmed/31210136" } @Article{info:doi/10.2196/12437, author="Zhang, Yonglai and Zhou, Yaojian and Zhang, Dongsong and Song, Wenai", title="A Stroke Risk Detection: Improving Hybrid Feature Selection Method", journal="J Med Internet Res", year="2019", month="Apr", day="02", volume="21", number="4", pages="e12437", keywords="machine learning", keywords="stroke", keywords="risk", keywords="feature selection", keywords="WRHFS", abstract="Background: Stroke is one of the most common diseases that cause mortality. Detecting the risk of stroke for individuals is critical yet challenging because of a large number of risk factors for stroke. Objective: This study aimed to address the limitation of ineffective feature selection in existing research on stroke risk detection. We have proposed a new feature selection method called weighting- and ranking-based hybrid feature selection (WRHFS) to select important risk factors for detecting ischemic stroke. Methods: WRHFS integrates the strengths of various filter algorithms by following the principle of a wrapper approach. We employed a variety of filter-based feature selection models as the candidate set, including standard deviation, Pearson correlation coefficient, Fisher score, information gain, Relief algorithm, and chi-square test and used sensitivity, specificity, accuracy, and Youden index as performance metrics to evaluate the proposed method. Results: This study chose 792 samples from the electronic records of 13,421 patients in a community hospital. Each sample included 28 features (24 blood test features and 4 demographic features). The results of evaluation showed that the proposed method selected 9 important features out of the original 28 features and significantly outperformed baseline methods. Their cumulative contribution was 0.51. The WRHFS method achieved a sensitivity of 82.7\% (329/398), specificity of 80.4\% (317/394), classification accuracy of 81.5\% (645/792), and Youden index of 0.63 using only the top 9 features. We have also presented a chart for visualizing the risk of having ischemic strokes. Conclusions: This study has proposed, developed, and evaluated a new feature selection method for identifying the most important features for building effective and parsimonious models for stroke risk detection. The findings of this research provide several novel research contributions and practical implications. ", doi="10.2196/12437", url="https://www.jmir.org/2019/4/e12437/", url="http://www.ncbi.nlm.nih.gov/pubmed/30938684" } @Article{info:doi/10.2196/11539, author="Appalasamy, Rani Jamuna and Joseph, Pauline Joyce and Seeta Ramaiah, Siva and Quek, Fatt Kia and Md Zain, Zaini Anuar and Tha, Kyi Kyi", title="An Intervention to Promote Medication Understanding and Use Self-Efficacy: Design of Video Narratives for Aging Patients at Risk of Recurrent Stroke", journal="JMIR Aging", year="2019", month="Mar", day="21", volume="2", number="1", pages="e11539", keywords="Delphi technique", keywords="self-efficacy", keywords="stroke", keywords="personal narratives", keywords="video-audio media", keywords="beliefs", abstract="Background: The debilitating effects of recurrent stroke among aging patients have urged researchers to explore medication adherence among these patients. Video narratives built upon Health Belief Model (HBM) constructs have displayed potential impact on medication adherence, adding an advantage to patient education efforts. However, its effect on medication understanding and use self-efficacy have not been tested. Objective: The researchers believed that culturally sensitive video narratives, which catered to a specific niche, would reveal a personalized impact on medication adherence. Therefore, this study aimed to develop and validate video narratives for this purpose. Methods: This study adapted the Delphi method to develop a consensus on the video scripts' contents based on learning outcomes and HBM constructs. The panel of experts comprised 8 members representing professional stroke disease experts and experienced poststroke patients in Malaysia. The Delphi method involved 3 rounds of discussions. Once the consensus among members was achieved, the researchers drafted the initial scripts in English, which were then back translated to the Malay language. A total of 10 bilingual patients, within the study's inclusion criteria, screened the scripts for comprehension. Subsequently, a neurologist and poststroke patient narrated the scripts in both languages as they were filmed, to add to the realism of the narratives. Then, the video narratives underwent a few cycles of editing after some feedback on video engagement by the bilingual patients. Few statistical analyses were applied to confirm the validity and reliability of the video narratives. Results: Initially, the researchers proposed 8 learning outcomes and 9 questions based on HBM constructs for the video scripts' content. However, following Delphi rounds 1 to 3, a few statements were omitted and rephrased. The Kendall coefficient of concordance, W, was about 0.7 (P<.001) for both learning outcomes and questions which indicated good agreement between members. Each statement's Cronbach alpha was above .8 with SD values within a range below 1.5 that confirmed satisfactory content and construct validity. Approximately 75\% (6/8) of members agreed that all chosen statements were relevant and suitable for video script content development. Similarly, more than 80\% (8/10) of patients scored video engagement above average, intraclass correlation coefficient was above 0.7, whereas its Kendall W was about 0.7 with significance (P<.001), which indicated average agreement that the video narratives perceived realism. Conclusions: The Delphi method was proven to be helpful in conducting discussions systematically and providing precise content for the development of video narratives, whereas the Video Engagement Scale was an appropriate measurement of video realism and emotions, which the researchers believed could positively impact medication understanding and use self-efficacy among patients with stroke. A feasibility and acceptability study in an actual stroke care center is needed. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12618000174280; https://www.anzctr.org.au /Trial/Registration/TrialReview.aspx?id=373554\&isReview=true ", doi="10.2196/11539", url="http://aging.jmir.org/2019/1/e11539/", url="http://www.ncbi.nlm.nih.gov/pubmed/31518260" } @Article{info:doi/10.2196/10440, author="Lee, A. Mikyoung and Shin, Cha-Nam and An, Kyungeh", title="Trustworthiness, Readability, and Suitability of Web-Based Information for Stroke Prevention and Self-Management for Korean Americans: Critical Evaluation", journal="Interact J Med Res", year="2018", month="Jul", day="20", volume="7", number="2", pages="e10440", keywords="stroke", keywords="website evaluation", keywords="trustworthiness", keywords="readability", keywords="suitability", abstract="Background: Websites are common sources of health information to stroke survivors and caregivers for continual management of stroke and its long-term sequelae. The presence of risk factors and mortality rates related to stroke are high in Korean Americans. A vast majority of this group are active Web users and rely on the Web-based information due to lack of insurance and, thus, limited access to long-term stroke care. Thus, it is critical to evaluate existing stroke websites for their trustworthiness, readability, and suitability. Objective: The objective of our study was to provide a systematic evaluation of stroke-related websites regarding (1) trustworthiness, (2) readability, and (3) suitability for stroke prevention and self-management for Korean Americans. Methods: We selected a total of 156 websites using search terms ``stroke,'' ``CVA,'' ``?? (jungpung),'' and ``??? (noejoljung)'' on Google and Yahoo. After eliminating duplicates and irrelevant websites (n=116), we evaluated a total of 42 websites (15 in English and 27 in Korean) using the National Library of Medicine's health website's evaluation tool for trustworthiness; Simple Measure of Gobbledygook for readability; and Suitability Assessment of Materials for suitability. All three instruments used the 3-point Likert scale: superior (=2), adequate (=1), or not suitable (=0). Results: Of the 42 websites evaluated, we rated 62\% (26/42) websites as ``adequate'' or above for trustworthiness. The information on 48\% (20/42) websites had not been updated for more than a year, which indicates poor currency; 33\% (14/42) websites failed to provide the publisher and contact information, which yields poor authority; 50\% (21/42) websites did not cite sources of health information, which indicates lack of accuracy. Only 2 websites met the recommended readability (5th grade or lower reading level). The suitability was also suboptimal; only 1 website was rated as ``superior''; 60\% (25/42) websites were ``adequate,'' and 38\% (16/42) were ``not suitable.'' Most websites were limited in graphical directions, interactive motivations for desired healthy behaviors, and multiple language translations. Conclusions: The existing stroke-related websites in either English or Korean are trustworthy and suitable, yet precise citation of evidence-based information will improve trustworthiness. The contents requiring high reading level may set a barrier to the utilization of Web-based health information for Korean Americans with a lower level of education. In addition, supplementing graphical examples, interaction features, and culturally relevant information in multiple languages are the areas for improvement in suitability. The improved features can reduce the reading burden of stroke patients or caregivers and build their confidence when applying the information for stroke management in daily living. These strategies are especially crucial to Korean Americans, who inevitably seek Web-based information to fill the gap between their demand and access to health care for a long-term self-management after a stroke. ", doi="10.2196/10440", url="http://www.i-jmr.org/2018/2/e10440/", url="http://www.ncbi.nlm.nih.gov/pubmed/30030210" } @Article{info:doi/10.2196/cardio.8199, author="Rozanski, M. Gabriela and Aqui, Anthony and Sivakumaran, Shajicaa and Mansfield, Avril", title="Consumer Wearable Devices for Activity Monitoring Among Individuals After a Stroke: A Prospective Comparison", journal="JMIR Cardio", year="2018", month="Jan", day="04", volume="2", number="1", pages="e1", keywords="physical activity", keywords="heart rate", keywords="accelerometry", keywords="stroke rehabilitation", keywords="walking", abstract="Background: Activity monitoring is necessary to investigate sedentary behavior after a stroke. Consumer wearable devices are an attractive alternative to research-grade technology, but measurement properties have not been established. Objective: The purpose of this study was to determine the accuracy of 2 wrist-worn fitness trackers: Fitbit Charge HR (FBT) and Garmin Vivosmart (GAR). Methods: Adults attending in- or outpatient therapy for stroke (n=37) wore FBT and GAR each on 2 separate days, in addition to an X6 accelerometer and Actigraph chest strap monitor. Step counts and heart rate data were extracted, and the agreement between devices was determined using Pearson or Spearman correlation and paired t or Wilcoxon signed rank tests (one- and two-sided). Subgroup analyses were conducted. Results: Step counts from FBT and GAR positively correlated with the X6 accelerometer ($\rho$=.78 and $\rho$=.65, P<.001, respectively) but were significantly lower (P<.01). For individuals using a rollator, there was no significant correlation between step counts from the X6 accelerometer and either FBT ($\rho$=.42, P=.12) or GAR ($\rho$=.30, P=.27). Heart rate from Actigraph, FBT, and GAR demonstrated responsiveness to changes in activity. Both FBT and GAR positively correlated with Actigraph for average heart rate (r=.53 and .75, P<.01, respectively) and time in target zone ($\rho$=.49 and .74, P<.01, respectively); these measures were not significantly different, but nonequivalence was found. Conclusions: FBT and GAR had moderate to strong correlation with best available reference measures of walking activity in individuals with subacute stroke. Accuracy appears to be lower among rollator users and varies according to heart rhythm. Consumer wearables may be a viable option for large-scale studies of physical activity. ", doi="10.2196/cardio.8199", url="http://cardio.jmir.org/2018/1/e1/", url="http://www.ncbi.nlm.nih.gov/pubmed/31758760" }