Timing in smartphone-guided home stroke rehabilitation with functional electrical stimulation: feasibility of distributed supervision and retrospective comparison with a front-loaded model

[Purpose] This study reports: (Aim 1) a feasibility study of a distributed supervision model (DSG) within a smartphone-guided home stroke rehabilitation program incorporating functional electrical stimulation (FES); and (Aim 2) a retrospective cohort comparison of DSG outcomes against a previously published front-loaded supervision group (FSG). [Participants and Methods] Thirty-one adults with chronic hemiparetic stroke (onset >6 months) completed a 6-week multicomponent home exercise program (3 sessions/week, 1 hour/session) incorporating gait, strength, and balance training with FES delivered via smartphone app. FSG (n=12) received 2 weeks of supervised onboarding followed by 4 weeks of independent home training. DSG (n=19) received one supervised and two independent sessions weekly. Pre- and post-assessments included the 10-Meter Walk Test, Mini-BESTest, Berg Balance Scale, Timed Up and Go, and 30-Second Sit-to-Stand Test. [Results] No adverse events were reported. Both groups demonstrated high adherence (DSG: 90.3 ± 10.2%; FSG: 87.3 ± 8.7%) and significant within-group improvements across all outcomes, exceeding minimal clinically important differences. Between-group comparisons showed significantly greater improvements in the DSG on the 30STS (Welch's t, p<0.001, d=1.57, achieved power=0.98) and TUG (p=0.020, d=0.74, achieved power=0.48); contrasts for BBS, Mini-BESTest, and 10MWT were non-significant with low achieved power (0.05-0.21) and are reported as inconclusive. All findings should be interpreted as preliminary given the retrospective, non-randomized design. [Conclusion] Both supervision models demonstrated high feasibility, safety, and clinically meaningful functional gains. Supervision timing may influence the magnitude of functional gains and warrants investigation in future randomized trials.