Participants

We interviewed three PTs and three OTs who had 360 h of combined experience delivering BCI-FEST to individuals with UE paralysis. Interviews ranged from 22 min 41 s to 30 min 43 s in duration. One therapist initially gave consent and did not respond to further contact. Another therapist was an author on this study and therefore unable to participate. All therapists identified as women.

Content analysis

Deductive components of the analysis were based on the COM-B model of behaviour change. As described earlier, these components included (1) Capability (physical, psychological), (2) Opportunity (physical, social), and (3) Motivation (automatic, reflective). Within these components and subcomponents, inductive analysis allowed us to identify a total of eight subthemes (Table 2). These subthemes and sample quotes that exemplify each subtheme are found in the text below and in Table 2. Participant quotes are linked to the text using Quote 1 (Q1), Quote 2 (Q2), etc.

Table 2 Subthemes mapped to the components and sub-components of the COM-B modelCapabilityPhysical capability

All therapists felt that they had the physical capability to conduct BCI-FEST in a clinical setting based on their experience in a research setting. While the BCI operator applied the EEG electrodes and set up the BCI, the therapist placed the stimulation electrodes and set up the FES portion of the system. Each therapist felt that they possessed the skills needed for this task and that no additional skills were necessary (Quote 1- Q1). The subtheme we detected under the physical capability component was:

Transfer of physical ability and electrotherapeutic modality experience

Therapists’ prior experiences included not only their physical abilities but also their use of electrotherapeutic modalities such as FES. These modalities use different forms of energy to stimulate physiological effects and are commonly used in physical therapy practice [28, 29]. Therapists felt that these motor skills transferred directly to their physical ability to use the BCI-FES.

“I don’t think (I needed to increase physical strength and stamina) because the type of therapy we are doing already is quite hands on and it can be physical.” (Participant 2—P2)

Most therapists had built up their physical capabilities (i.e., strength, endurance) through working clinically prior to the research study. Others also mentioned engaging in physical activity outside of work (Q2). One therapist noted that she was used to performing similar movements already as part of her therapy practice and she employed positions that emphasized proper biomechanics when delivering BCI-FEST (Q3).

Psychological capability

All therapists, regardless of experience were comfortable with their mental processes (e.g., clinical reasoning) while delivering BCI-FEST, yet some were more comfortable than others with their depth of knowledge about the system and the supporting research evidence. The following subthemes were identified as part of psychological capability:

Applying varying depths of evidence-based research to BCI-FEST

All therapists wanted to apply evidence-based research to BCI-FEST; however, there was a range among them. Some therapists wanted basic knowledge, while others wanted deep knowledge about the system and the therapy.

“In the beginning, like part of the learning curve, I had to dedicate a little bit more mental space into delivering BCI-FEST.” (P1).

Therapists who had less experience with technology (i.e., FES) prior to engaging in the research study found there was a steeper learning curve compared to their peers. Even experienced therapists thought it was important to know the basics about how BCI-FES works and the potential benefits of BCI-FEST versus FEST, although this information was delivered informally (Q4). The therapists in our study defined sufficient knowledge as basic technical information about the device (including the BCI portion and BCI-FES working together). Clinically, the therapists wanted deeper and specific evidence-based knowledge (i.e., research comparing outcomes of BCI-FEST vs. FES only). They also demonstrated a need to acquire deep evidence-based knowledge to provide answers to patient’s potential questions regarding BCI-FEST(Q5).

Reliance on the supplementary knowledge of the BCI operator

All therapists relied on a BCI operator to set up the BCI, troubleshoot that portion of the BCI-FES system, and answer any BCI-related questions during the preliminary clinical studies.

“There was (a BCI operator) there that was taking care of the technical aspects of (BCI-FEST), so I felt like I didn’t really need to know too much about that. Just a basic idea of how (the BCI-FES) works.” (P2).

There was a feeling that therapists did not require in-depth knowledge about the technical aspects of the system because the BCI operator was there for the set up and session duration. Clinically, therapists felt that having a BCI operator present who understands the technical aspects of the device would help (Q6). Also, having another member of the team there for therapy to assist with difficult cases would be beneficial. Interestingly, one therapist felt that having an extra person in the room (i.e., BCI operator) frustrated the person receiving the therapy (Q7). This therapist preferred to have more knowledge about the BCI so that she could incorporate BCI-FEST by herself clinically to focus on the patient.

OpportunityPhysical opportunity

Both PTs and OTs observed that more physical opportunity was needed to clinically implement BCI-FEST. They felt that a significant amount of support was needed across diverse physical factors to improve the efficiency of clinical sessions in the future. The subthemes we identified under physical opportunity were:

Set-up time relative to therapy time required for BCI-FEST

To set up the system, approximately 20% (i.e., 12 min) of the total therapy session time was used. As therapists became more familiar with the system, set up time decreased. Some therapists perceived that the long set-up time was a barrier to using BCI-FEST (Q8).

“At least for the patient population that we were treating I don’t think they would be able to tolerate more than what we were delivering at the time.” (P3)

Individuals receiving the therapy who had UE paralysis were able to tolerate active BCI-FEST for about a half hour to forty-five minutes before fatiguing as assessed by the treating therapist. This observation that set-up time was a barrier was contradicted when, on reflection, it was perceived that there was more than enough time to facilitate a therapy session despite the set-up time length (Q9). However, the research targeted BCI-FEST only; if other techniques were applied, or there were interruptions, similar to a session in a clinical environment, one hour might not be enough time (Q10).

Extra resources are needed to increase the efficiency and clinical feasibility of BCI-FEST

This subtheme refers to the physical resources related to BCI-FEST delivery such as personnel, facility, and technical components of the device that would facilitate clinical translation of BCI-FEST.

“The system (has) to be more user-friendly, no flaws…It’s just a system, it has technical challenges.” (P5)

To transition BCI-FEST to the clinic, the system would need to be updated so that it is easy to use. Therapists perceived BCI-FEST in general as resource intensive, requiring two individuals (e.g., therapist and BCI operator) to set up the individual devices (i.e., BCI on the head and FES on the UE muscles) (Q11). For clinical implementation of BCI-FEST, therapists want a device that is more user-friendly and a streamlined approach to setup and therapy delivery.

Social opportunity

According to our results, therapists determined that an increase in social opportunity would be necessary to facilitate clinical implementation of BCI-FEST. Therapists provided numerous examples of social support that could enable them to improve therapy delivery. The subtheme we detected as part of social opportunity was:

BCI-FEST therapist community development

Therapists agreed that they would need the support of others, including a community to promote the clinical use of BCI-FEST.

“I think what helps the most is having a mentor or somebody that you can go to on the spot if you are having issues—having like an expert on staff, maybe another therapist that would be the BCI expert.” (P2).

Therapists suggested that having a mentor within their department to help with troubleshooting the BCI-FES system would be beneficial. Many therapists felt that a support network of BCI-FEST therapists where they could share experiences would help with clinical implementation (Q12). In addition to sharing experiences, therapists could reach out to provide support and engage in frequent communication to encourage BCI-FEST use.

MotivationAutomatic motivation

Therapists were comfortable with their automatic motivation for using BCI-FEST in a research setting and expanding that motivation to a larger scale clinical setting. All therapists possessed this type of motivation as evidenced by their participation in the initial BCI-FEST feasibility studies. The subtheme that we identified under automatic motivation was:

Passion for technology promotes the intuitive use of BCI-FEST

Therapists involved in this research were interested in using technology and most were also highly experienced in using technology clinically and/or for research studies.

“I love technology. My PhD was on technology. I think that is the road we have to go. We clinicians have to accept, embrace and utilize (technology), but still, I feel the resistance among us.” (P5).

Therapists who performed BCI-FEST as part of this research study were probably more passionate about technology-enriched therapy than most clinical therapists. Clinically, it will be important to practice BCI-FEST, so it becomes habitual for therapists learning this technology (Q13).

Reflective motivation

All therapists routinely engaged in reflective practice throughout their participation in prior BCI-FEST research and this practice would transfer to the clinical use of BCI-FEST. Reflection is the art of critically and systematically analyzing and evaluating patient abilities and goals in relation to the task demands and performance contexts. This leads to new ways of understanding and thinking in a clinical setting [30, 31]. The subtheme that we recognized under reflective motivation was:

Knowledge from scholarly practice and inquiry innately transfers to BCI-FEST

Reflective processes are part of therapists’ education, both at university and through continuing education. They also engage in reflection as part of their routine rehabilitation practice in all clinical settings.

“I actually did extra work looking at different treatment techniques for stroke and spinal cord just so I had that background information.” (P2)

Using reflective processes, therapists improved their knowledge and use of the BCI-FEST. One therapist did background research on different treatment techniques based on population. Clinically, one therapist would evaluate a patient’s goals and then suggest BCI-FEST, if appropriate (Q14), while another therapist reflected that BCI-FEST could be used as an assessment tool (Q15). Reflecting on research sessions, participants felt that BCI-FEST would not translate clinically as is (i.e., UE only focus), because therapists need to work on other patient goals as well (Q16).