**4. Accessibility review**

The goal of most studies in the area of Web accessibility is to develop inclusive applications. However, this is a great challenge, because most applications do not follow the WCAG 2.1 standards suggested by the World Wide Web Consortium. Web accessibility studies have a high impact and significant benefits in the development of tele-rehabilitation applications. The World Health Organization (WHO) [68] estimates that more than 1 billion people live with some form of disability. This corresponds to approximately 15% of the world's population. Between 110 (2.2) and 190 million (3.8%) people aged 15 years and over have significant operational difficulties.

In addition, disability rates are growing because of the population aging and the chronic diseases associated with the increasing life expectation. Disability is now considered a human rights issue. People are disabled by society, not just by their bodies. Therefore, the universal access to technology must be considered in building an egalitarian society. After applying the search strings defined in **Table 1** and using the PRISMA method, a total of 76 publications were recorded for Web accessibility. In the screening phase, 14 duplicate articles were excluded, 11 articles meeting the inclusion parameters were included, and 51 were rejected as being out of the inclusion criteria. In the eligibility phase, a total of 11 articles were assessed as fully meeting the inclusion criteria (**Table 4**). The phases of the selection process according to the PRISMA literature review method are detailed in **Figure 2**.

**Table 4** presents the references of the 11 articles selected in the literature review.

Calle-Jiménez et al. [69] explain some of the challenges that exist to develop accessible Web platforms in tele-rehabilitation applications for patients after a partial or total hip replacement, known as arthroplasty. The authors propose an iterative method to improve the level of accessibility through automatic evaluation tools. Three online WAVE, AChecker, and TAW tools were applied in the study. The

**41**

5

6

7

8

Open WAX,7

http://tenon.io/

https://wave.webaim.org/

https://siteimprove.com/

*A Systematic Review of Usability and Accessibility in Tele-Rehabilitation Systems*

Analysis and improvement of the web accessibility of a tele-rehabilitation

Personalized technology-enhanced training for people with cognitive

Design and Development of One-Switch Video Games for Children with

Internet Use By People Living With Neurological Conditions: a Scoping

Visual Complexity, Player Experience, Performance and Physical Exertion

Tele-rehabilitation interface strategies for enhancing access to health

services for persons with diverse abilities and preferences

*Summary of the accessibility papers selected in this review.*

**Title Authors Year**

An mHealth App for Users with Dexterity Impairments: Accessibility Study Yu et al. [71] 2019

Educational resources accessible on the tele-rehabilitation platform Acosta-Vargas

Towards Web Accessibility in Tele-rehabilitation Platforms Acosta-Vargas

Computer-based cognitive training in adults with Down's syndrome Bargagna et al.

Calle-Jimenez et al. [69]

et al. [70]

et al. [72]

[76]

[77]

Smeddinck et al.

Buzzi et al. [73] 2018

López et al. [74] 2017

Siegert et al. [75] 2015

Winters [78] 2013

2019

2019

2018

2014

2013

results of the analysis indicate that the studied platform does not comply with all

Accessibility of e-health services for people with disabilities Bąkała et al. [79] 2010

Acosta-Vargas et al. [70] propose to apply the Accessibility Guidelines for educational content, in accordance with the Web Accessibility Initiative, to a tele-rehabilitation platform. The accessibility of the Web resources is assessed by using the Photosensitive Epilepsy Analysis Tool (PEAT). This open access software application applies several WCAG 2.0 standards and is combined with a manual evaluation method. The results of the study show that the multimedia resources

Yu et al. [71] present a mobile health system (m-Health) to assist people with chronic diseases and disabilities in their self-management regimens. The authors studied the accessibility by using the WCAG 1.0 and 2.0 guidelines. The evaluation process was performed manually. The results indicate that on the importance of

Acosta-Vargas et al. [72] present an accessibility study performed on a Web platform to promote a physical rehabilitation of patients with an arthroplasty. Web Content Accessibility Guidelines (WCAG) 2.0 and Website Accessibility Conformance Evaluation Methodology (WCAG-EM) 1.0 were applied. The authors

platform requires improvements to reach an appropriate level of Web accessibility.

were used. The results indicate that the tele-rehabilitation

Siteimprove,6

evaluated do not reach an acceptable level of accessibility, as well.

used tools through plugins installed in the Web browser. WAVE,5

customization of interfaces to improve accessibility.

and Tenon8

https://github.com/goonoo/OpenWAX

*DOI: http://dx.doi.org/10.5772/intechopen.85869*

platform for hip arthroplasty patients

impairment

Study

**Table 4.**

Severe Motor Disabilities

WCAG 2.0 accessibility standards.

in Motion-based Games for Older Adults

*A Systematic Review of Usability and Accessibility in Tele-Rehabilitation Systems DOI: http://dx.doi.org/10.5772/intechopen.85869*


#### **Table 4.**

*Assistive and Rehabilitation Engineering*

decreased to 141 (38.74%).

**4. Accessibility review**

A more recent work conducted on an updated version of ePHoRt synthesizes the results obtained from a study of effectiveness, efficiency, and subjective user satisfaction [38]. Thirty nine participants tested the platform and were asked to evaluate its usability by using the IBM CSUQ. The empirical results based on subjective perception and self-reported feedback show that the application is useful, effective, efficient, easy to use, and its interfaces are acceptable. In addition, the evaluation of the user experience enables us to identify usability aspects that should be implemented, in order to improve the visual interface. The experiment indicates that user guidance is a critical aspect to ensure good usability of the tele-rehabilitation platform. Likewise, the error messages received by users should be as detailed as possible. Finally, in [6] the authors suggest to carry out usability tests with real patients and during the whole completion period of the rehabilitation program, as indicated in [36]. For this purpose, there are usability instruments specifically designed to measure the user experience with e-Health platforms, such as SEQ [52], USEQ [44] and TUQ [47]. Pilco et al. [37] is a very recent usability study that makes use of an agile user centered design process [13, 14] to assess the ePHoRt platform. The evaluation process stated with a heuristic evaluation by using the Nielsen's 10 heuristics principles [67]. In addition, a cognitive workload assessment was performed to complete the usability evaluation. Likewise, users were involved through all the stages of the iterative refinement process. Usability issues were progressively reduced by applying improvements suggested from the iterative assessments. For instance, usability issues originally cataloged as catastrophic were reduced to zero, major usability problems were diminished to 10 (2.75%), and minor usability problems were

The goal of most studies in the area of Web accessibility is to develop inclusive applications. However, this is a great challenge, because most applications do not follow the WCAG 2.1 standards suggested by the World Wide Web Consortium. Web accessibility studies have a high impact and significant benefits in the development of tele-rehabilitation applications. The World Health Organization (WHO) [68] estimates that more than 1 billion people live with some form of disability. This corresponds to approximately 15% of the world's population. Between 110 (2.2) and 190 million (3.8%) people aged 15 years and over have significant operational difficulties.

In addition, disability rates are growing because of the population aging and the chronic diseases associated with the increasing life expectation. Disability is now considered a human rights issue. People are disabled by society, not just by their bodies. Therefore, the universal access to technology must be considered in building

**Table 4** presents the references of the 11 articles selected in the literature review. Calle-Jiménez et al. [69] explain some of the challenges that exist to develop accessible Web platforms in tele-rehabilitation applications for patients after a partial or total hip replacement, known as arthroplasty. The authors propose an iterative method to improve the level of accessibility through automatic evaluation tools. Three online WAVE, AChecker, and TAW tools were applied in the study. The

an egalitarian society. After applying the search strings defined in **Table 1** and using the PRISMA method, a total of 76 publications were recorded for Web accessibility. In the screening phase, 14 duplicate articles were excluded, 11 articles meeting the inclusion parameters were included, and 51 were rejected as being out of the inclusion criteria. In the eligibility phase, a total of 11 articles were assessed as fully meeting the inclusion criteria (**Table 4**). The phases of the selection process

according to the PRISMA literature review method are detailed in **Figure 2**.

**40**

*Summary of the accessibility papers selected in this review.*

results of the analysis indicate that the studied platform does not comply with all WCAG 2.0 accessibility standards.

Acosta-Vargas et al. [70] propose to apply the Accessibility Guidelines for educational content, in accordance with the Web Accessibility Initiative, to a tele-rehabilitation platform. The accessibility of the Web resources is assessed by using the Photosensitive Epilepsy Analysis Tool (PEAT). This open access software application applies several WCAG 2.0 standards and is combined with a manual evaluation method. The results of the study show that the multimedia resources evaluated do not reach an acceptable level of accessibility, as well.

Yu et al. [71] present a mobile health system (m-Health) to assist people with chronic diseases and disabilities in their self-management regimens. The authors studied the accessibility by using the WCAG 1.0 and 2.0 guidelines. The evaluation process was performed manually. The results indicate that on the importance of customization of interfaces to improve accessibility.

Acosta-Vargas et al. [72] present an accessibility study performed on a Web platform to promote a physical rehabilitation of patients with an arthroplasty. Web Content Accessibility Guidelines (WCAG) 2.0 and Website Accessibility Conformance Evaluation Methodology (WCAG-EM) 1.0 were applied. The authors used tools through plugins installed in the Web browser. WAVE,5 Siteimprove,6 Open WAX,7 and Tenon8 were used. The results indicate that the tele-rehabilitation platform requires improvements to reach an appropriate level of Web accessibility.

<sup>5</sup> https://wave.webaim.org/

<sup>6</sup> https://siteimprove.com/

<sup>7</sup> https://github.com/goonoo/OpenWAX

<sup>8</sup> http://tenon.io/

#### **Figure 2.**

*PRISMA 2009 flow diagram chart showing the selection process.*

Buzzi et al. [73] propose a Web platform to offer accessible games to individuals with cognitive disabilities, such as people with Down Syndrome (DS). Some WCAG 2.0 guidelines are applied manually, but no tools are applied in accessibility evaluation. The results of this study highlight the importance of motivation and flexibility to personalize the content according to the limitations of each user. Based on this experience, some basic guidelines for refining protocols for accessibility testing with people with DS have been proposed to maximize engagement, increase usability, and gather feedback to improve the accessibility of game design.

López et al. [74] argue that video games are not played just for fun, but are a useful tool for children's cognitive, emotional and social development. The article contributes to reducing accessibility barriers. The development game, called "Gaming NOMON" or (GNomon) is based on a guide of accessibility for videogames. It application has been evaluated for children with severe motor disabilities, so the study can serve as lessons learned for future research and design of accessible video games.

Richard Siegert et al. [75] indicate that little is known about Internet use among people with disabilities. This study explores how people with neurological conditions, such as multiple sclerosis, traumatic brain injury, or stroke use the new technologies. Some WCAG standards were applied in the research. The authors are not concerned with evaluating the accessibility per se. but the potential benefits of Internet for health and the well-being of people with disabilities.

Also, Bargagna et al. [76] describe a set of computerized exercises designed for cognitive training of adults with Down Syndrome. The objective of the study is to develop a tele-rehabilitation platform by following WCAG 2.0 guidelines for Web application. For future studies, the researchers propose to develop more training games to investigate the long-term effects of software use and assess its relevance in preserving cognitive capacity and individual autonomy in everyday activities.

**43**

*A Systematic Review of Usability and Accessibility in Tele-Rehabilitation Systems*

Smeddinck et al. [77] point out that motion-based video games may have a variety of benefits for players and are increasingly applied in physiotherapy, rehabilitation, and prevention of older adults. The authors suggest that aspects of accessibility and immersion should be considered if the potential benefits of motion-based video games are to be harnessed for target groups with a broad spectrum of visual impairments. The application does not use WCAG-related guidelines, and does not apply specific tools to assess Web accessibility. The results show that visual complexity affects the perception of the games. The findings of this study can help to improve the design of motion-based games for therapy and

Winters [78] proposes a preliminary classification scheme for tele-rehabilitation processes in order to apply it to human factors and to the analysis of the accessibility of electronic systems. The study proposes a novel framework in the development of interfaces that lead to a universal access to tele-rehabilitation for people with disabilities. This study makes use of some guidelines related to WCAG and Section 508. The results suggest that during the development of Web applications, accessibility guidelines should be considered in order to have more inclusive Websites. Finally, Bąkała et al. [79] explain the concept of online health services in Poland, which tends to include people with disabilities. The researchers present a comparative analysis of e-health solutions in Poland and in other European countries. They conclude that there are possibilities to adapt existing services, in order to include people with disabilities. The study analyses the WCAG guidelines, but it does not

The main result of the usability review for tele-rehabilitation systems shows that the user experience predominates over the heuristic studies, and the most used questionnaire to assess user experience is the SUS. Even though it would be relevant to carry out user experiences with real patients and in real conditions, there are still few usability questionnaires proposed in tele-rehabilitation. Likewise, studies do not measure the performance of the patients in terms of completion time of the

Regarding the question of Web accessibility in tele-rehabilitation platforms, the review shows that this topic is still marginally studied. Many applications do not care about developing accessible and inclusive platforms. Some studies refer to Section 508 and WCAG 1.0 and 2.0 guidelines, but they are not applied in their entirety in addition, no work applies the WCAG 2.1, which is the most recent Web accessibility guideline. It is also to mention the fact that the analyzed studies lack the application of combined methods to ensure an adequate level of Web accessibility. Thus, our review suggests that the development of future e-Health applications should apply the guidelines of WCAG 2.1 that will allow access to all types of users regardless of their physical and cognitive abilities. This conclusion is particularly relevant in the case of the development of tele-rehabilitation platforms, which

tasks and percentage of errors during the rehabilitation exercises.

should include both usability and accessibility iterative tests.

*DOI: http://dx.doi.org/10.5772/intechopen.85869*

rehabilitation in older adults.

**5. Conclusions**

apply tools to evaluate tele-rehabilitation platforms.

#### *A Systematic Review of Usability and Accessibility in Tele-Rehabilitation Systems DOI: http://dx.doi.org/10.5772/intechopen.85869*

Smeddinck et al. [77] point out that motion-based video games may have a variety of benefits for players and are increasingly applied in physiotherapy, rehabilitation, and prevention of older adults. The authors suggest that aspects of accessibility and immersion should be considered if the potential benefits of motion-based video games are to be harnessed for target groups with a broad spectrum of visual impairments. The application does not use WCAG-related guidelines, and does not apply specific tools to assess Web accessibility. The results show that visual complexity affects the perception of the games. The findings of this study can help to improve the design of motion-based games for therapy and rehabilitation in older adults.

Winters [78] proposes a preliminary classification scheme for tele-rehabilitation processes in order to apply it to human factors and to the analysis of the accessibility of electronic systems. The study proposes a novel framework in the development of interfaces that lead to a universal access to tele-rehabilitation for people with disabilities. This study makes use of some guidelines related to WCAG and Section 508. The results suggest that during the development of Web applications, accessibility guidelines should be considered in order to have more inclusive Websites.

Finally, Bąkała et al. [79] explain the concept of online health services in Poland, which tends to include people with disabilities. The researchers present a comparative analysis of e-health solutions in Poland and in other European countries. They conclude that there are possibilities to adapt existing services, in order to include people with disabilities. The study analyses the WCAG guidelines, but it does not apply tools to evaluate tele-rehabilitation platforms.
