Ten people contacted the research team to engage in the study. Two were unable to participate due to scheduling conflicts, and one did not meet inclusion criteria. Seven people met the inclusion criteria and participated in the study (Table 2).

Table 2 Participant demographics

Three themes were identified (Table 3). Themse 1 and 2 contain subthemes; theme 3 does not.

Table 3 Themes and subthemesTheme 1: Devices must be flexible to meet diverse needs

The diverse needs of users were most apparent when considering that no one device was universally described as positive or negative, suggesting that any device recommended for use must meet a wide range of needs, capabilities, and interests. The quotes from five participants describing the same device, the Neofect Pegboard, in very different ways support this theme.

“The pegboard is extremely repetitive that you’re doing the exact same things. You’re just grasping a peg and putting it in a hole regardless of what the gameplay is” J07

“I like the fact that you can play different games with it and it challenges your memorization skills” J05

“I think the pegboard would just become boring” J03

“… you’re not doing the same thing every day. I think that’s when it kind of gets boring, when you’re doing the exact same thing everyday. So this way you would have an ability to change it up” J01

“it was fun because I knew I was getting something out of it that was gonna benefit me” J06

Within this theme, four sub themes of ability to address multiple treatment targets, just right challenge, gamification and cognitive challenge were found.

Multiple treatment targets

The intention to use the device and enjoyment was linked to the ability use it in different ways. Throughout the interview, respondents identified devices and games as positive when they challenged multiple treatment targets (such as shoulder, cardiovascular endurance, or hand function).

“I would spend a lot of time using this because just with the mouse you can target anything you want to target….I would do that a lot because …those muscles are really weak for me so.” J02

“The Rejoyce was definitely more fun. Just because their graphics and a whole variety of ways that you’re using it, you know, different…. The squeezing, the turning, pinching the key turning thing. There’s just a whole lot more to do with it” J03.

When the device was described as only addressing one treatment area, the intention to use was limited because it was perceived as less engaging.

“The ones that incorporated more than a singular movement got more fun to me…but the ones that did not were pretty boring” J07

Just right challenge

The need for a just-right challenge was described by all participants. When the challenge was just above their current abilities, participants described the device positively.

“It totally kept me engaged because I had to actually challenge myself to move my hand to do the actual movements in the game. And sometimes my hand just didn’t want to work the way I wanted it too.” J05

A lack of fit between the difficulty and their current functional level resulted in a negative experience using the devices.

“It wasn’t really too hard to use. So I just went through it just to get it done; It wasn’t that fun. The games are easy to use” J06

“It’s just hard for me to use…[I’d] probably give up after not working for a while” J06

Gamification

Gamification is the use of game experiences to engage or motivate the user. Participants consistently identified the competitive environment of scoring points or beating levels as motivators to continue training. Or improve performance from previous trials as positive features.

“When you mess up, it’s like ‘Oh, my God. Now let’s do this again. Let’s do this again. I know I can do it, I know I can do it.’ So it keeps you engaged as you want to do better. You don’t want the lower score on the system...you want to be one of the high scores” J05

“The reporting at the end is very interesting. Because then you can kind of see how you’re improving. I’m a competitive person so that makes it a little more interesting than just doing exercise” J01

The ability to play in the game environment was a positive aspect of the technology devices.

“It does challenge you, but it does it in a more playful manner that you don’t realize you’re doing it. Because you’re looking at the game and more so competing with the game and so it’s more like you’re doing it and don’t realize you’re doing it” J05

Cognitive challenge

Participants largely enjoyed the addition of a cognitive challenge, even if they did not identify cognition as a goal. Cognitive challenges were available in puzzle games or as part of sequence and timing of game interaction.

“I like the ones that are cognitive along with it because then I don’t even realize I’m moving my wrist because I’m working on the challenge” J01

Theme 2: Intervention protocols must be individualized to address unique needs and contexts of the users

Participants had unique rehabilitation priorities and varied contexts that included families and the availability of care partners. Users described the influence of contextual factors such as engaging family and caregiver assistance as important reasons why they would choose whether to use a device. Within this theme, sub themes of individualized goal areas, desire to use independently and desire to use device for more than just therapy were seen.

Individualized goal areas

The alignment between the device’s ability to target their treatment priorities was a major factor in willingness to use at home. Participants all spoke of their individual rehabilitation needs and identified when a system would be able to target their treatment needs. The ability to target their needs influenced their intent to use the device. There was a large range in treatment needs that ranged from goals like strengthen or stretching to general fine motor goals to activity-based goals like writing. Some spoke explicitly about needing to tailor any program to their own specific therapy goals.

“I thought it did give me the chance to kind of work on the fine motor skills so I think that was helpful and it would probably be good for, for me when it comes to things like writing legibly and typing” J04

One participant identified that he didn’t have any goal areas he would work on with the device and despite having positive experiences using, clearly identified that he wouldn’t use it.

“[I would use] if I were like fresh out of inpatient and still working on recovery and hadn’t really plateaued at what my ability is. But for me personally, since I’m kind of like at the top of what my ability is capable of, I probably would not” J07

Desire to use independently

Participants identified the ability to set up and use on their own as an essential factor. Devices that users could set up and use independently were devices that users reported they would use at home.

“That’s the aspect I was looking at it for. Being able to move my arms on my own and at my own pace, without having to ask somebody” J05

“I’d use this, this one at home. Yeah. Just because it is smaller. It’s easier to set up. I could do it myself ” J04

In contrast, devices with more complex set up were unlikely to be used, even if they were engaging.

“I’m afraid that someone who is not a professional would not be able to put [the device] on…and when you think about the expense, I don’t know how feasible that kind of technology is even though it’s fun” J04

Four out of seven participants discussed using the device in alternate ways to fulfill other roles like student, worker, parent, or grandparent. Engaging younger family members in the gaming was a frequent comment,

“I can also see me doing this with my granddaughter on my lap. And us doing it together” J05

“I think my son would definitely be interested in trying and maybe we could challenge each other” J03

One device has clear uses beyond therapy gaming. Participants expressed the desire to use the device for more than just a therapy program and include as part of their daily activities.

“I could use [it] for everything. I could use it both functionally and for fun. I could do games and work” J03

Theme 3: Intervention protocols should be developed and updated by a skilled clinician

This category has no subthemes.

Only 1 participant said a device could replace therapy. The remaining participants wanted therapists to develop and update the intervention program they used at home.

“Maybe having a therapist run through it one time with somebody. Just so they’re using all the features. But I think there’s a real value in doing a circle back, you know after a couple weeks, after they’re using it. And I think that would hold true with any of the equipment’ J01

Six out of seven participants were concerned about maintaining fidelity in their treatment program. Participants could clearly describe ways to compensate and ‘cheat’ the rehabilitation program and expressed value in having therapists develop and update a treatment program.

“One thing I did notice since it’s a lot of shoulders, especially in the beginning, I could hear my OT saying to me “Don’t chicken wing” and I felt myself starting to chicken wing” J01

“With the mouse it’s really up to you and your therapists or whatever to make sure you’re targeting exactly what you want to target J02

Developing guiding principles

Using the themes and subthemes, guiding principles for a technology-based upper extremity intervention program for home use were developed. In the person-based approach, guiding principles consist of two parts. The intervention design objectives describe what the intervention will address and key features that describe how those objectives are achieved. The intervention design objectives align with the themes of the qualitative inquiry and subthemes inform the key features. The goal of the qualitative inquiry was to summarize the features of the intervention to optimize the acceptability of the intervention and describe the key ingredients (Table 4).

Table 4 Guiding principles