Delivering a high-dose walking booster program after stroke: a multimethod study of therapists’ beliefs and experiences nested within a randomized trial

BACKGROUND: High-dose motor training is rarely implemented later after stroke. This study explored intervention therapists' beliefs and experiences delivering a high-dose walking booster program (HiWalk) within a Phase II trial. OBJECTIVE: The objectives of this study were to (i) describe the beliefs intervention therapists held about a high-dose walking booster program prior to delivery, (ii) report facilitators and barriers to delivery, and (iii) to describe the strategies intervention therapists used to maintain training intensity during the program. METHODS: A multimethod design examined intervention therapists' perspectives of delivering a high-dose walking booster program to stroke survivors who were more than 6-months post-stroke. Pre-program surveys assessed beliefs about high-dose motor training. Observational audits evaluated program delivery. Semi-structured interviews, informed by the Theoretical Domains Framework (TDF), identified facilitators and barriers to program delivery. Survey and observational audit data were descriptively analyzed, and qualitative data were analyzed thematically. The HiWalk Trial was registered on January 10, 2023 (registration number ACTRN12623000316606). RESULTS: = 6) participated. Before delivery, intervention therapists believed high-dose training was important (98.5/100, SD 2.5) but were less confident that stroke survivors could complete 3 hours of training per day (74.8/100, SD 25.8). Audit observations indicated that, on average, observed intervention sessions met protocol expectations. Key facilitators included training (TDF Skills), team support (TDF Social Influences), and resources (TDF Environmental Context and Resources). Barriers were beliefs about stroke survivor capability (TDF Beliefs about Capabilities) and resource limitations (TDF Environmental Context and Resources). CONCLUSIONS: Intervention therapists can deliver a high-dose walking booster program within a clinical trial when supported by training, resources, and team collaboration. Findings inform future trial design and clinical practice translation.