Table 3 Supporting quotes for thematic analysis

Getting in the game

Acceptability

Age

“age of our participants was young in comparison with the population’s studies of stroke; this may have improved acceptability of the study intervention, evidenced by the low number of participants discontinuing the intervention” [28]

“In fact, the two oldest participants were also those who had never used a computer, and also the ones who were least accepting of the technology” [39]

Previous experience

“Despite some initial apprehension and preconceived ideas, following exposure and an opportunity to try the tablet, eight participants were more open to the use of this technology, and much less anxious” [39]

“I had some initial problems with understanding the technology but once I got into routine use (of the device), it became easy to use.” [59]

“But I think the fact that being something different and being interactive is the main motivator with it actually, than just exercising” [65]

Support

“The therapists’ attitude towards the intervention may have influenced the participants’ attitude” [28]

“Previous experience of rehabilitation (i.e. therapist led rehabilitation to patient led rehabilitation) could influence expectations of service delivery. One participant did not believe it was his responsibility to lead his rehabilitation, “It’s not up to me to sit here and do it all myself is it…You’re the experts you should be doing it”” [54]

Fit

“Direct observations of the home environment revealed other related barriers to use based on the physical nature of the devices themselves. Many of the homes were crowded spaces with limited room, few available electrical outlets or without a table or chair at proper height. As a result, setting up and using the device was sometimes difficult.” [52]

“One of these two participants had reassessed his home situation (in view of some relatives living in his house for holiday) and felt there was inadequate space in his house to accommodate the device for the period of the study” [59]

Usability

Device characteristics

“Participants were also asked what they would change about the device, and most responses involved adding more games with greater levels of difficulty, refining the system for sending data to the secure server after use, and making the computer component of the controller device smaller and easier to handle.” [36]

“One of the complaints about the devices was their size and weight, and the resulting difficulty of moving them around the home as a result. One participant said, ‘‘It’s so bulky and when you move it you throw it out of whack, so you have to stay in the same place and work around it’’. Most participants reported that they did not move the device from where it was originally set up.” [52]

Personal characteristics

“For Participant 3, accessing the game on the computer (e.g., finding the icon to click, following the steps to log-in) presented a barrier to play. Participant 3 was able to play the game with verbal cues when the OT was present in the home; however at other times, she did not use assistance from caregivers to load or play the game. Due to her cognitive deficits, she had difficulty processing and following directions, both written and pictorial.” [56]

“Patients with severe impairments of arm function used the system less than those with moderate or mild impairments” [66]

Technical issues

“Comments of dissatisfaction generally focused on technical aspects of the device, such as recurrent freezing of the computer games and taking too long/failure of the device to send data to the secure server.” [36]

“Each participant encountered at least one instance of technological malfunction that required troubleshooting.” [10]

“Technical issues that arose due to the glove being a prototype could restrict use. P4 reported on a few occasions that these made her want to throw the computer out of the window.” [61]

Support

“Very important aspects of our study were the educational sessions before discharge home, the caregivers’ support and the availability of the physiotherapist to manage phone call contacts, home visits and videoconference sessions, where possible.” [31]

“JT’s dependence on his wife for set-up and manual progressions meant opportunities for practice were missed.” [42]

Sticking with it

Staying engaged

Social interaction

“Family support was crucial: “My granddaughter used to play the Balloonpop and encouraged me. I mean, obviously she got fantastic scores that I wouldn’t be able to achieve, but I was so there, wanting to get as much as I could.... It’s good to have other people to play with you because you said, you know, that we could set her up, and we did.” (P23)” [61]

“The phone call seemed to play a bigger role in the intervention period for those who were house-bound or spent a significant proportion of the time on their own. It provided a form of company and a link with the ‘outside world’.” [65]

Accountability

“On Day 10, when the therapist noticed that daily time of use was lower than requested of the participant, she called the participant to encourage greater compliance. Thereafter, there was a noticeable increase in daily use” [49]

“It is easier for him to tell other people that ‘I did catch the ball and I got 3100′ or… ‘I’m better this week I got 3600′ and even though it might not make much sense to other people, they can tell it is going up and it always seems to appeal to him and he wants to do better on it each time” [54]

Meaningful outcomes

“Marie wanted to use motion games to accomplish her own goals” [29]

“Participants reported that being both engaged and successful motivated them to continue with NGT and this appeared to reduce, although not completely eliminate, frustration” [10]

“Functional changes observed by the participant along with the modifications made to the games motivated her to continue playing them throughout the intervention.” [47]

“stroke survivors and their caregivers took ownership of their rehabilitation, especially where the Wii™ was perceived as improving arm function” [65]

Customisation and Variety

“Participants were also asked what they would change about the device, and most responses involved adding more games with greater levels of difficulty” [36]

“Participants' feedback also highlighted the importance of choosing from a variety of games to engage participants.” [10]

“Comments of dissatisfaction generally focused on limited game selection.” [43]

“In order to improve the users’ ability to relate to the avatar, it was suggested that the graphical interface needs to be individualised to the user. The user may wish to alter the avatar image to look like them (i.e. male/ female) and therefore, make it both recognisable and easier to relate to. One user found it difficult to relate to the avatar as she thought it did not represent her, “It’s not me on the screen, that’s a man and I’m a woman!”” [54]

“Participants indicated they liked the customized aspect of the Mystic Isle. They claimed they were inspired to play and enjoyed the games because they were tailored to help them achieve their particular goals.” [56]

Challenge

“In many cases, subjects performed within a challenging session more repetitions than in a challenging – then supporting one – i.e. they performed better for a longer time. This confirms the effect of challenge on subjects’ motivation, i.e. by challenging the subject it is possible to extend the training intensity without affecting his/her performance. The role of challenge in motivation is also confirmed by the lower number of repetitions in under-challenging sessions compared to the under-supporting ones.” [30]

“A few, suggested that the game was not cognitively challenging and did not motivate them” [10]

“Three participants liked the concept of the levels becoming progressively harder as that kept them interested in using the device” [59]

“Participants wanted to exceed a previous score or ‘beat the machine’, as some participants described it, and this spurred them on. A minority of participants felt they had become obsessed in this way and played longer than the allotted 45 min per day.” [65]

Feedback

“One of Marie’s most persistent requests was for additional feedback from the games. She wanted the games to “make me feel good” by pointing out when she had increased her range of motion or completed a task more quickly.” [29]

“Participants enjoyed watching themselves complete exercises, and used the visual and auditory feedback to identify where they needed to work harder or in a different way.” [39]

“JT was motivated by the 4-wk time period that the SMART Arm was available, on-screen feedback and automatic progressions in response to his success, and in-home coaching sessions during which his progress was reviewed and guidance was gained to progress further.” [42]

“In addition, one participant explained that the feedback would be more meaningful if his results were something he could relate to in everyday life like being able to play his guitar or using his hand to hold a plectrum, “The feedback would be better if I could relate it to playing my guitar or holding the plectrum because these are things I want to be able to do… goals”” [54]

“Because the onscreen display was sometimes inaccurate, the participants (and in some instances the carers as well) became frustrated, lost patience, and trust in the feedback provided. This resulted in the participants being less willing to use the equipment and/or dismissing the feedback as an inaccurate evaluation of their performance.” [54]

Integrating practice into everyday life

Competing priorities

“many people recovering from stroke experience periods of disabling fatigue that require periods of rest throughout the day: “In my first 4 months, I was really a bit tired every day.... I don’t think I'd have had the chance to do that (use the glove).”” [61]

“Analysis of the interviews also suggested the possibility that the patients recruited were those who were more likely to be trying to return to their prestroke life, and attempts to return to work or other activities away from the home precluded the recommended level of use of the intervention.” [62]

“Family and life role responsibilities such as taking care of children or going to work occasionally interfered with compliance.” [67]

Fitting it in

“Six out of ten participants reported including the game into their daily routine. Hannah had it setup at the office and reports, “So it was easy to form a routine about when I would do it because I have a lot of cheerleaders there.””1 [10]

“2 h of robotic therapy per day may be perceived as excessively burdensome, especially when coupled with 1 h of HEP activities” [47]

“Due to the convenience of being able to use the device in their homes, participants gained a sense of control over the scheduling of their therapy.” [52]

“tailoring game sessions and exercises so that they can be completed with minimal effort and in short amounts of time is likely to facilitate adoption on an ongoing basis by stroke survivors” [56]

“All the participants and their caregivers were unanimous in their preference for carrying out this type of rehabilitation in their homes. This was perceived to have provided a more flexible and less stressful environment, and enabled the participants to fit their rehabilitation in with their day-to-day lives and they were able to accommodate their responsibilities, social activities and other medical appointments.” [65]

Continuing

“One suggestion made by two participants was that the length of time that participants used the system should be increased. Gerald stated that he wanted “more time, uh, just, 30 days is not time enough.” Mary concurred, reporting, “Four weeks might not be enough to see results.”” [10]

“The two participants who owned tablets reported that they were now using them more often. Four others advised that they planned on making new purchases or borrowing family member’s tablets.” [39]

“Two participants were interested in buying the device if it were available commercially.” [59]

“Overall system usage and the reported desire to continue training after completion of the study protocol suggest that the therapy could even be applied over longer periods.” [66]

“And the cost and everything else. Like if you’re in business or at [son’s] age, you can use them all the time. At our age, we’ve been good for 80 years without them, I can live a bit longer without them.” [39]

“Furthermore, although costs are minimal for direct therapy care, the cost of robotic devices has not traditionally been covered by third-party payers.” [48]

“Patients also responded positively to the way in which rehabilitation was delivered by the home-based robotic device itself, such as having control over the timing and duration of the rehabilitation therapy sessions, and avoiding the cost and time involved with travel to do physical therapy in a clinical setting.” [52]

“During the follow-up period, many more participants continued to self-train using the video-games compared with traditional self training. This fact is of great importance since self-training programs need to be long term and sustainable. Most participants who continued to play the video-games also demonstrated clinical meaningful UE functional improvement during the period after the study.” [57]

Moving on

“A few also reported that they were incorporating their affected upper extremity in daily activities in new ways. Michael who had more severe impairment reported that, “When one's in a grocery store, pushing a shopping cart, most people do it with both arms or both hands, and so I'm trying now to make sure I rest my affected arm on the shopping cart handle … just at least it would start to emulate or simulate a more normal approach to ADL.” [10]

“engaging in a home program like NGT could help a person after stroke attempt to use their affected upper extremity, yet individuals likely still need assistance in identifying which activities are most appropriate for continued practice” [10]

“I can envision discovering more things to do.” [55]

“All five participants who noticed improved power in their arms reported that they were using the affected arm more in daily activities and there was an improvement in functional ability in everyday tasks.” [59]

“Inevitably, as participants recovered, they wanted to return to their prestroke life, especially if they were mobile. This barrier to use included returning to work, going on holiday, driving, or hobbies: “I’ve got my allotments to do; there’s obviously going out shopping and... trying to fit round the rest of your day.”” [61]

“The set period of time (six weeks) appeared to motivate participants to play the Wii™ regularly. Most participants viewed the Wii™ intervention as a specific stage in the rehabilitation process, and once the six weeks had finished felt it was time to move onto other activities. “Cos you (caregiver) said, ‘I’ll go & buy you one (a Wii™)’, and I said, ‘No, no, no’…It was awful in one way it was going but, in another way, because I was getting better, um, it didn’t make me go and sit in a chair …I kept trying do little bits round the house, didn’t I?”” [65]