Development and evaluation of content of the mobile app Cinesia for patients with unilateral motor deficits after stroke

Abstract Introduction The incidence of stroke in adults has increased in recent years, and individuals who survive often have one or more motor and cognitive deficits. In Brazil, the Unified Health System (SUS) faces difficulties in reabsorbing the entire population that needs physiotherapy after hospital discharge. In addition, the distance to rehabilitation units in Rio de Janeiro can be far, making it impossible for some patients to receive the treatment they need. Objective To create a complementary mobile application for adults with unilateral motor deficits and to evaluate its content through expert judges. Methods Applied research for the construction of a mobile app with the prototyping method by Pressman. Steps: 1) literature review; 2) development of the technological framework; 3) construction of the content; and 4) construction of a prototype. The app content was evaluated using the e-Delphi Method for peer review using a Likert-type questionnaire on the Google Forms platform. Results The application was developed and designed to run on the Android operating system. Three rounds were carried out to evaluate the app's content. The final average of the content validity index (CVI) of all content items was 0.85, reaching the minimum agreement of 0.80, suggested by authors. Conclusion The content of a mobile app for adults with unilateral post-stroke motor deficits was developed and approved, and its content was evaluated by expert judges. We believe that this app can contribute to the promotion of physical rehabilitation in people with unilateral motor deficits after hospital discharge.


Introduction
Stroke or cerebrovascular accident is one of the main causes of disability in adults, and its incidence has increased in recent years. 1 Each year, around 13.7 million cases of stroke occur worldwide.However, half of the patients are unable to restore sufficient functionality to carry out their activities of daily living, and one-third of stroke survivors may develop permanent disability.It is not surprising, therefore, that there are many studies that highlight the role of prevention, risk factors and the costs related to the disease. 1,2e increase in population aging and the prevalence of stroke risk factors is likely to further increase the number of people living with stroke-related disabilities.In addition, World Health Organization (WHO) projections indicate a great global demand for stroke rehabilitation services, which is of concern mainly in low-and middleincome countries, where there is a high incidence of stroke and few available rehabilitation services. 3roke survivors often have one or more deficits, whether motor or cognitive, and they require regular physical rehabilitation care and need programs aimed at minimizing their deficits. 4Motor function deficits after stroke usually include partial or total loss of function of the upper or lower limbs on a given side, with associated muscle weakness, low endurance, lack of muscle control and even paralysis. 4These deficits, also called unilateral motor deficits, impact the patient's independent lifestyle and decrease their performance in activities of daily living. 5,6nitoring the functional status of post-stroke patients after transitioning home is significant for rehabilitation, and mobile health (mHealth) technologies may provide an opportunity to reach and follow up patients after discharge.However, the feasibility and validity of functional assessments administered by mHealth technologies are still unknown. 6Various information technology resources have been created and used to provide rehabilitation to stroke patients, making strategies available for short-term effectiveness, but they still do not reach most of the people who need them, because of various reasons regarding costs and technological skills for their operation. 6,7ming at a better recovery after stroke and preventing its recurrence, survivors need continuous home rehabilitation, as studies 8,9 indicate that this can stimulate neuroplasticity and result in much better clinical outcomes.The main barriers to providing highquality home rehabilitation services are high cost and being labor intensive. 2,8,9solution 58.33 of the World Health Assembly on May 16-25, 2005 states that everyone should have access to health services without the need for financial sacrifices. 10,11 Although Brazil has a universal public health system, private health spending is higher than public spending.13   According to the Fiscal Aspects of Health in Brazil report, published in 2018 by the National Treasury, total health spending in Brazil is about 8.3% of the gross domestic product (GDP), with 4.5% of GDP coming from private spending and 3.8% from public spending.13,14   There are many factors, including health care, social support and rehabilitation, that contribute to effective recovery after periods of illness or injury.If a person does not recover well, it is more likely that an unplanned hospital readmission will be required within 30 days of discharge home.14 Readmissions may represent deficiencies in meeting the needs corresponding to a given disease.The shorter the interval between hospital discharge and readmission, the greater the chance that the return was potentially avoidable.Readmissions can be avoided with better management of the patient's clinical condition, hospital discharge planning and provision of resources at home to meet the patient's needs.14 The experience of caring for someone affected by a neurological deficit has become more and more frequent in daily life at home.15  In many families, domestic workers who are closer to the elderly, or who develop some affinity for them, often take on the role of caregivers.
without being qualified for these functions.On March 18, 2020, the new coronavirus pandemic was declared, and with that, some concepts in the world regarding the use of telemedicine were modified.
Evidence points to a significant advance in health care in the future.27   We took in consideration the conflict between hospital discharge only after the clinical condition improves, without taking into account the possibility of physical therapy rehabilitation of the patient, and due to the rise of telemedicine -especially at the time of the new coronavirus pandemic -, combined with the high percentage of users with internet access via cellphone.
So, the aim of the project was to create a technological product, a mobile app for adults with post-stroke unilateral motor deficits that provides a complement to institutional extramural rehabilitation and well-being and to evaluate the content of the mobile app by expert judges.

Methods
This was a qualitative study of the construction of a mobile app aimed at patients with unilateral motor deficits after hospital discharge, with operationalization and prototyping method according to Pressman.28 The prototyping paradigm described by Pressman in 2011had the following steps: 1) communication; 2) fast design; 3) modeling (fast design); 4) construction of a prototype; and 5) use, delivery and feedback.In this study, the first four steps were performed.
In the first step, an integrative literature review on mobile apps aimed at motor rehabilitation was carried out.In the second, the technological framework for the design and layout of the mobile app was developed.
The development of the mobile app took place in partnership with a hired graphic designer, who developed the design and the technology interface, taking into account the specificity of knowledge of technologies required for the realization of the intended product.The mobile app was developed using the Unity platform and C# programming language (C Sharp).The layout was developed using the CorelDRAW program.
The application was designed to run on smartphones and tablets with Android operating system.
In the third step, the content of the app was built through a search for articles related to motor rehabilitation in the main international databases.For the evaluation of the application's content by the expert judges, the modified e-Delphi method was used for peer evaluation through a Likert-type questionnaire available on the Google Forms platform, so that judges could evaluate the app's content and then decide whether or not to allow its useo.29 There are three ways to administer the questionnaires in the steps of the Delphi method.The first is through letters.The second requires judges to be in the same environment responding to the tool.The third method chosen for this study uses virtual resources and platforms and is called the e-Delphi method.29 The first questionnaire consisted of 24 questions related to the mobile app, including the graphic materials to be evaluated, and a space for suggestions, in addition to five questions about the professional profile of the evaluators, totaling 29 questions.
The first round of the Delphi method has two approaches.In the traditional approach, the first-round questionnaire consists of open-ended questions to guide ideas, present opinions, and gain consensus.
The modified approach used in this study requires the investigator to identify issues relevant to the purpose of the study and requires, in advance, the development of an initial assessment instrument, so that the first-round judges the instrument's items.29 The Likert-type scale is one of the most used psychometric tools in studies that apply the e-Delphi method, due to the measurement system using points,

Results
The study derived from a master's thesis.31  The content of the mobile application was developed after reviewing the literature related to the topic, taking into account the fact that the exercises were performed without supervision by professionals.Accordingly, we decided to include functional exercises, which are already part of common daily life activities.
Initially, 22 graphic elements were included in the application, 18 videos and four pictures, containing nine functional exercises for upper limbs in video format, five functional exercises for lower limbs in video format, four changes in decubitus or transfer in video format and four positions in bed or chair in image format (Figure 1).
After the responses to the second round of the questionnaire, nine new videos were developed for patients with hemiplegia and hemiparesis grades 1 and 2 of muscle strength, six exercises for upper limbs and three for lower limbs (Figure 1).The character in the application has half of the body colored and the other half in gray tone, with the gray side representing the weaker side of the patient.The name of the application CINESIA originates from the Greek word kinesis and is a feminine noun that means ability to move, mobility, movement.32 In the first round of app validation, 10 questionnaires were received and properly answered by expert judges.
Of the 23 items evaluated in the first round of the questionnaire, three had a CVI of less than 0.78, being considered as having failed.
The item sitting and standing up received the following comments from the evaluators: "Safe once there has been training for it before discharge by the physiotherapist"; "Place the chair next to a wall with the affected side facing the wall to reduce the risk of falling.";"Risk of falls"; and "Attention to the risk of falling". .The item climbing a 'step' with hand support obtained the following comments from the evaluators: "Safe if patient has been trained and guided by the physiotherapist before discharge.";"Depending on the degree of weakness, risk of falls"; "Be careful with compensations in hip abduction.Perhaps guide the patient to position themselves with the most affected side very close to a wall.;"and "If you don't have enough strength in your upper limbs to hold it, maybe it's not safe".
The item walking obtained the following comments from the evaluators: "Once again, the video shows axillary support on the affected side, this may favor shoulder injuries.."; "Orient the companion to hold the waist so that the center of gravity is at S2 and have greater stability for walking and, in case of instability, do not generate any overload on the paretic shoulder"; "There needs to be guidance and training with a physiotherapist beforehand"; "Inspires greater care and attention"; and "Perhaps it is necessary to correct some gait maladjustment that only the physiotherapist can recognize." The three items were changed according to the experts' suggestions and underwent a new analysis through the second round of the questionnaire on Google Forms.In addition to these items, three other items that were approved in the first round, but with some considerations by the specialists, were changed for the second round, namely: Opening and closing a bottle: "If the priority is movement distally, it may be advisable to support the elbow, as in the previous video, to avoid shoulder

Discussion
During the pandemic, mHealth has become an essential resource not only to contain the spread of the virus but also to ensure continuity of care for patients with chronic diseases.show a greater tendency for patients to be the end user of mobile apps, such as the mobile CINESIA.38   A limiting factor of the Delphi method, as well as most survey studies, is the low response rate.Studies estimate abstention ranging from 30 to 50% of respondents in the first round and from 20 to 30% in the second.In addition, a meta-analysis has shown that the proportion of respondents in surveys conducted virtually is, on average, 11% lower than other modes of study.The literature is consistent with the study's finding, given that the number of respondents reached in the three rounds of the questionnaire only reached the minimum value suggested by the authors.22  The high level of agreement with the exercises selected for the app's content can be explained by their selection criteria, including, for the most part, functional exercises with a low level of difficulty.
The study has some limitations.In addition to the sample size of the expert judges being small, information regarding the dose of the exercises was not included in the evaluation of the content of the mobile app.A new round including evaluation of the intensity, frequency and duration of the exercises seems to be interesting to be carried out later.

Figure 1 -
Figure 1 -Flowchart of steps of validation process.

Figure 2 -
Figure 2 -Initial screen of the mobile app CINESIA (only available in Portuguese).

Table 1 -
Result of the content validity index (CVI) in the first and second round of questionnaires Note: CVI¹ = CVI result in the first Delphi round; CVI² = CVI result in the second Delphi round; *CVI reference value ≥ 0.80.

Table 2 -
Result of the content validity index (CVI) in the third round of questionnairesThe target audience chosen for the end user of the CINESIA mobile app content is justified by the fact that stroke is the second cause of death in the world and, among survivors, temporary or permanent neurological and/or motor deficits are acquired, requiring special care to perform activities of daily living, evolving with a certain degree of dependence.Studies aimed at the use of mobile apps for motor rehabilitation show a greater tendency towards neurological rehabilitation apps focused on patients affected by stroke.35-37According to integrative reviews carried out,25,38few mobile apps in health were intended for their final audience target, the patients.It is possible to observe, however, a change in the focus profile of app developers, since recent studies25,38 Note: CVI³ = CVI result in the third Delphi round; *CVI reference value ≥ 0.80.FISIOTERAPIA EM MOVIMENTO Physical Therapy in Movement Vital IPDA, Machado WCA.Fisioter Mov.2023;36:e36119 9