Stroke is a common cause of mortality and morbidity in the United States, affecting nearly 800,000 persons yearly [1]. Even though early rehabilitation of patients with stroke is pivotal for adequate recovery [2], rehabilitation is frequently delayed and underused [3]. Insufficient and untimely rehabilitation has been partly attributed to distance and transport challenges to rehabilitation facilities, especially for rural dwellers, inducing geographic disparity [4]. Nevertheless, both urban and rural residents experience various limitations to accessing facility-based rehabilitation: increasing rehabilitation costs, medical staff shortages, inadequate transportation systems and, after March 2020, pandemic-related contact restrictions [5,6]. In addition, more restriction to care is inflicted by the attitudinal, architectural, economic, and sensory barriers representing the omnipresent societal discrimination against people with disability [7].

Telerehabilitation is at least as effective as facility-based rehabilitation [8-10] and is typically less costly [11]. For that, home-based telerehabilitation is a promising solution that provides an opportunity for timely, effective, and accessible services to a large base of patients [12], especially in low-resource rural areas [13].

Multiple forms of technology provide a medium for telerehabilitation: telephone, messaging, email, videoconferencing, web-based platforms, robots, and virtual reality [14]. Currently, telerehabilitation via phone and videoconferencing is considered a basic technology [15,16]. Advanced technology includes virtual reality as it creates a physical experience with multiple sensory inputs: tactile, visual, auditory, and olfactory [12,17,18]. Robotics use in telerehabilitation is another advanced and evolving technology with great potential to enhance motor functions and measure patient progress [19].

Most studies addressing telerehabilitation are feasibility and efficacy studies, leaving a gap in understanding the effective implementation of telerehabilitation [13,20]. Implementation science is “the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, hence aiming to improve the quality and effectiveness of health services” [21]. Many barriers hinder implementation: lack of knowledge and misbeliefs about the effectiveness of the intervention, inadequate planning for implementation, insufficient engagement of different stakeholders, and lack of resources, among others [22]. To overcome those barriers, implementation science pivots to designing and studying implementation strategies [23]. Implementation strategies are “methods or techniques to enhance a clinical program or practice’s adoption, implementation, and sustainability” [24]. Training, audit and feedback, coaching, and piloting are examples of implementation strategies.

While using the same strategies to enable implementation across various contexts is appealing, it brings limited success [25]. This is attributed to the multicomponent nature of implementation strategies and the complexity of the process of implementation that represents the interactions between the implementation strategy, the context of the setting in which implementation occurs, and the change process required for implementation [26,27].

Understanding the mechanisms of implementation strategies is vital to determine how and which strategies work and in what context for telerehabilitation [24,28,29]. Mechanisms are dynamic processes that drive and generate outcomes, often involving the understanding and reasoning of actors involved in implementation [30]. Establishing a telerehabilitation Community of Practice is an implementation strategy that might enhance telerehabilitation adoption; however, it does not directly result in adoption [31]. Through an underlying mechanism (eg, cognitive participation of the Community of Practice members), stakeholders may decide to adopt the change. Mechanisms are not observable by themselves, but observable data suggest their existence [31]. For example, increased adoption could be measured, but cognitive participation might be inferred to but not directly observed.

Context, Mechanisms, and Outcomes (CMO) configurations are at the heart of realist synthesis. CMO configurations are hypothetical until they are tested and found explanatory to the relationship between the strategies and the outcomes of interest [32]. CMO configurations explain what worked, how it worked, and what the involved mechanisms are [33]. Ultimately, researchers can respond to “will it work in a different context?” [33]. Realist researchers understand that implementation strategies work selectively, and outcomes vary in different settings [34,35]. Thus, recognizing implementation strategies patterns, as well as outcomes patterns, provide insight into the success or failure continuum [34].

This realist review aims to develop generalizable theories by examining each study to uncover the mechanism through which an implementation strategy works and the effects of various contexts on making it work [35]. The reviewers will untangle the complexity of implementation strategies through a frequent enhancement of the theoretical explanations of the empirical findings [36,37]. The output of this realist synthesis is a refinement of how the strategy “works, for whom, in what circumstances, in what respects and why?” [38].

The purpose of this realist review is to synthesize a theoretical explanation of the adoption and implementation of telerehabilitation of patients with stroke. For practitioners, this review will offer empirically rooted strategies for facilitating the implementation of telerehabilitation.

This study will follow the guidelines proposed by Rycroft-Malone et al [39] and Pawson [34]. To explain how the implementation of telerehabilitation of patients with stroke operates, we will develop a middle-range theory (MRT), subject to refinement and validation as it can be used in the future implementation of telerehabilitation.

The review steps are (1) clarifying the scope and initial program theory (IPT) development, (2) searching for evidence appraising primary studies, (3) extracting data and synthesizing evidence, and (4) narrative development of conclusions. Figure 1 summarizes the main steps involved in this realist review.

The review team will formulate a descriptive and explanatory theoretical framework from the reviewed evidence. The focus of this review is on the implementation strategies of telerehabilitation. Implementation strategies are based on an initial practical understanding of the most effective way to deliver and implement an intervention, focusing on better implementation outcomes and addressing context-specific barriers to implementation.

Constructing a presynthesis conceptual framework marks the initial step in conducting a realist review [38]. This initial framework is referred to as IPT [40], which will provide an initial theoretical understanding of the implementation of telerehabilitation, necessary to explore implementation mechanisms. We will develop the IPT using concepts from multiple theoretical frameworks that researchers use for studying telemedicine adoption and implementation [41], namely: the Technology Acceptance Model, the Diffusion of Innovation Theory, the Theory of Interpersonal Behavior, the Perceived Usefulness, the Perceived Ease of Use, the Unified Theory of Acceptance and Use of Technology, and the Theory of Reasoned Action [42]. In addition, the review team will contribute their implementation science, telerehabilitation, and quality improvement knowledge and experience to refine the IPT [41]. The IPT will be refined and expanded as evidence arises throughout the iterative synthesis process [43]. The continuous iteration of the theory is essential to follow logic trails discovered in the literature to develop the understanding of telerehabilitation and its implementation.

The literature search is iterative and directed to answer the questions that arise as the review progress [34,44]. To gain familiarity with the size and type of the available literature, one reviewer (MMH) will use PubVenn [45], which provides a graphical display of the extent of the literature, and PubReMiner [46], which analyzes the literature indexed in the PubMed MEDLINE database for frequent terms, journals, and authors.

The review team will use the 4 theoretical domains of the Realist Synthesis of Implementation Strategies (RES-IS) model to guide literature search and data extraction [39]. RES-IS is developed to research implementation strategies using the realist synthesis approach. It represents implementation strategies in 4 theoretical domains: properties of change agents, system change, technologies, and education interventions [39]. The change agent refers to the individuals’ attributes and the strategies they use to implement telerehabilitation successfully. Many terms are synonyms for change agents like facilitators, opinion leaders, knowledge brokers, champions, and experts. Systems changes refer to the organizational characteristics that facilitate the implementation and sustainment of telerehabilitation. Other terms related to systems change include social networks, culture, leadership, learning organizations, teamwork, and collaboration. Properties of technologies refer to the telerehabilitation technology itself and other technologies involved in facilitating its implementation. Education and training include academic detailing, reflection, action learning, and adult learning [39].

The context of implementation is at the center of the RES-IS model for its ubiquitous influence on the use and effect of strategies. In addition, an implementation strategy can target different levels: audits can induce changes in policies at the organizational level or alter local practices at the unit or individual level [47]. The term dose refers to the needed frequency and intensity of an implementation strategy (eg, training) to activate mechanisms that bring about outcomes [24,39].

The review team will use PubMed via MEDLINE, the PEDro database, a physical therapy evidence database, and CINAHL to conduct the topical search. A health information specialist (MB) leads the literature search. After reviewing the outcome of this topical search, we will rerun the search strategy, applying a search filter to limit the results to systematic reviews, logic models, and opinion pieces rich in concept-based discussions [48].

After identifying index papers, the review team will use the CLUSTER approach to search for Citations, Lead Authors, Unpublished Material, Scholar Searches, Theories, Early Examples, and Related Projects [48]. The CLUSTER search will be iterative and repeated to enhance the finding of relevant theories. The reviewers will also explore telerehabilitation-specialized journals (eg, International Journal of Telerehabilitation, Smart Homecare Technology and Health, and Annual Review of Cybertherapy and Telemedicine). As part of the CLUSTER approach, the reviewers will use the identified index documents to conduct a citation search of the index documents on Google Scholar using Publish or Perish software (Anne-Wil Harzing). To reach more resources, the reviewers will consult the American Telemedicine Association, the American Physical Therapy Association, and The American Occupational Therapy Association.

Documenting the literature search—The literature search is iterative and sometimes opportunistic [48]. The reviewers will use the EndNote software (Clarivate) [49] to manage the literature search process. To keep track of the literature search output, a new folder on EndNote will be added. Each literature search (a folder on EndNote) will document the sampling strategy, type of studies included, approaches, range of years, limits, inclusions and exclusions, terms used, and electronic sources [48,50].

The review team will use Rayyan (Oatar Computing Research Institute), a review management platform [51], to facilitate papers’ review and data extraction. To exclude irrelevant papers, 2 reviewers (MMH and AT) will screen the titles and abstracts. Based on the inclusion and exclusion criteria (Textbox 1), 3 reviewers (MMH, AT, and ST) will independently review the included full papers. The reviewers will meet regularly to discuss their decision on papers’ inclusion. Disagreement will be resolved by examining the paper’s language, focus, and inclusion criteria with another reviewer (MRR). Copies of papers or book chapters will be attached to the citation on Rayyan. Once saturation of the themes is achieved, the analysis of the included literature will conclude. Based on this analysis, the team may identify new inclusion criteria.

The quality appraisal of the included papers will pass through 2 stages: the first stage will focus on relevance of the included papers to the objective of the review and the second one will evaluate their rigor. The review team developed criteria of relevance for this study (Textbox 2). The criteria for the relevance are to guide the team to include studies that can inform the MRT development [34].

Assessment of rigor will be conducted through a combination of 2 different frameworks: TAPUPAS (Transparency, Accuracy, Purposivity, Utility, Propriety, Accessibility, and Specificity) framework, devised by Pawson et al [52], and Weight of Evidence (WoE) framework, devised by Gough [53,54].

TAPUPAS stands for Transparency, Accuracy, Purposivity, Utility, Propriety, Accessibility, and Specificity [52]. Transparency addresses whether the process of knowledge generation is open to external review and scrutiny [52]. Transparency extends beyond reporting research methods to how the researchers develop the research question, aims, and objectives [55]. Accuracy examines whether the researchers made accurate claims based on the results of their study [52,55,56]. Purposivity assesses the fit of the used methods for the purpose of the study [55]. Purposivity ensures the process of inquiry is methodologically sound and contextually appropriate. Utility considers the needs of the stakeholders and the fit of the study to satisfy those needs [56]. Propriety focuses on the ethical aspects of conducting the research [55]. Accessibility necessitates the dissemination and implementation of the research findings [55]. Both academic and nonacademic routes are appropriate for dissemination depending on who the end users are [55]. Specificity evaluates the methodological quality of the study and its conformance with the available standards [56].

WoE framework allows the opportunity to provide a grade for each of its 3 focus areas to be added up to an average grade for each paper [53]. WoE focus area A addresses the trustworthiness and coherence of the study, focus area B addresses appropriateness of the methods to the research question, focus area C assesses the relevance of evidence to the research question, and focus area D is the total grade based on the focus areas A, B, and C [53].

The focus area A of the WoE comprises 4 factors of the TAPUPAS framework: transparency, accuracy, accessibility, and specificity. The focus area B comprises purposivity. The focus area C comprises utility and propriety. Each focus area will be assigned a grade range from 1 (low quality), 2 (medium quality), or 3 (high quality) based on the TAPUPAS criteria within each of the WoE focus areas. For example, if a study is considered transparent and accurate, but it is not accessible or specific, it will receive a grade of 1.5 for WoE A [54]. The same logic will follow in the other focus areas. The score of WoE D will then reflect an overall average score, adding the scores of WoE A + B + C and dividing the total score by 3. Papers with WoE D score of 2 or more will be included. However, some papers with lower score, which provides important insight into the theory development will be included. In this case, the evidence generated out of inclusion of lower-quality studies will be marked as low-quality evidence.

A narrative synthesis will summarize the nature of the implementation strategy, context, mechanism, and outcome configurations, and the supportive evidence from the primary studies. One reviewer (MMH) will take the lead in coordinating the presentation of the narrative synthesis using text, summary tables, and a logic model. After developing the theoretical framework, one reviewer (MMH) will write the review for publication. The origins of the inferences, the hypothesis, the developed MRT, and the source of the primary evidence on which they are based will be documented and defended. The reasoning process used to create the chains of inference, the hypotheses, and the final MRT will be documented and reported to enhance transparency [59].

Ethics approval is not required for this study as it is secondary research, synthesizing evidence from primary studies. The review team will disseminate the findings through peer-reviewed publications and conference presentations.