Designing accessible, scalable digital rehabilitation to reduce fall risk after stroke

Background: People recovering after stroke are at increased risk of falls due to impairments in balance, strength and functional mobility. Exercise-based rehabilitation is critical to fall risk reduction; however, access remains limited. Digitally delivered rehabilitation has potential to extend care beyond traditional service models, but successful uptake depends on real-world implementation. Using an integrated knowledge translation approach, this mixed-methods study aimed to inform and evaluate the codesign, delivery and implementation of a tailored digital exercise program after stroke. 

Methods: Fifty-three participants were included, spanning stroke survivors, hospital and community-based clinicians, and public health bodies. Stakeholder engagement informed program design and implementation priorities. A 2-month feasibility study was conducted in 30 outpatients. Qualitative data on usability, acceptability and feasibility were thematically analysed. Quantitative outcomes included adherence to prescribed exercise (minutes completed).  

Results: Three implementation-relevant themes were identified. First, gaps in post-discharge rehabilitation limited continuity of care; a digitally delivered program was viewed as a potential solution if integrated within existing referral pathways. Second, accessibility and inclusivity were essential, particularly for people with aphasia. Third, accurate reporting of adherence and progress was considered critical to support clinical decision-making.  
 
In the feasibility study, adherence varied to a prescribed dose (680-780 minutes over 9 weeks). Thirteen percent were overachievers (n=4, median=838 minutes; IQR=797-894), 17% were consistent adherers (n=5, median=348 minutes; IQR=333-373). Ten percent were intermittent adherers (n=3, median=198 minutes; IQR=191-208), 33% showed early attrition (n=10, median=30 minutes; IQR=13-46) and 27% were non-adherers (n=8; median=0 minutes; IQR 0-2).

Qualitative findings indicated perceived improvements in balance and confidence while competing time demands were a common barrier for sustained adherence. 

Conclusions: Digitally delivered rehabilitation can be designed and implemented to support fall prevention after stroke. Tailored digital exercise programs offer a scalable pathway to improve access, continuity and sustainability of post-stroke fall prevention within usual care.