1Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Korea
2Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Korea
3Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
4Institute of Medical and Biological Engineering, Seoul National University, Seoul, Korea
5National Traffic Injury Rehabilitation Research Institute, National Traffic Injury Rehabilitation Hospital, Yangpyeong, Korea
6Department of Biomedical Engineering, Ulsan National Institute of Science and Technology, Ulsan, Korea
7Institute on Aging, Seoul National University College of Medicine, Seoul, Korea
Correspondence: Byung-Mo Oh Department of Rehabilitation Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea. Tel: +82-2-2072-2619 Fax: +82-2-743-2838 E-mail: moya1@snu.ac.kr
• Received: January 30, 2026 • Revised: April 9, 2026 • Accepted: April 30, 2026
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
To explore the perspectives of individuals with high cervical spinal cord injury (C-SCI) regarding expectations, concerns, and desired applications of brain–computer interface (BCI).
Methods
A structured focus group interview was conducted with four individuals with chronic high cervical spinal cord injury, all with neurological levels of C4 or above. Pre- and post-interview questionnaires were administered to assess expectations, concerns, and acceptance of BCI before and after discussion. The interview was facilitated by experts in rehabilitation medicine and biomedical engineering, and qualitative data were analyzed inductively to identify key themes.
Results
Five major themes emerged: digital accessibility, offline physical activity, social interactions and psychological health, usability, and acceptance. Participants expressed strong interest in using BCI to improve digital independence, particularly for messaging, online banking, internet use, and smart home control. They also viewed BCI as a potential tool to enhance autonomy in daily activities and reduce reliance on caregivers. Most participants were open to training and, in some cases, invasive procedures; however, concerns regarding surgical safety, device maintenance, reliability, and practical usability were frequently raised. Views on the emotional and social impact of BCI varied across individuals. Questionnaire responses showed increased willingness to undergo invasive procedures after the focus group interview, while expected functional outcomes became more realistic, suggesting that structured group discussion may have shaped participants’ understanding of BCI.
Conclusion
BCI was perceived as a promising pathway to greater independence, participation, and autonomy among individuals with high C-SCI. These findings emphasize user-centered design and demonstrate how lived experience can guide assistive neurotechnology development in rehabilitation research.
With rapidly advancing brain–computer interface (BCI) technologies pioneered by companies such as Neuralink, Synchrom, and Paradromics, restoring lost motor function in severe paralysis is becoming increasingly realistic [1]. Neurological injuries including spinal cord injury [2], stroke [3], and amyotrophic lateral sclerosis [4] substantially impair motor function and limit activities of daily living (ADL). Among these, cervical spinal cord injury (C-SCI) is one of the most severe conditions, resulting in tetraplegia due to impaired voluntary movement of all four limbs [5]. Higher neurological injury levels are associated with greater motor and sensory loss, leading to marked reductions in independence and quality of life [6,7].
Assistive technologies such as powered wheelchairs [8], smart home systems [9], and robotic exoskeletons [10] aim to enhance mobility, communication, and ADL performance in individuals with C-SCI. However, those with high-level C-SCI often face fundamental difficulties in controlling these technologies because of severe motor impairment [6,7]. BCI has therefore emerged as a promising approach to enable direct neural control of assistive devices and restore functional autonomy in individuals with tetraplegia [5,6].
BCI establishes a direct communication pathway between the brain and external devices, allowing control via neural signals [9]. These signals are translated into commands for devices such as robotic arms, wheelchairs, and digital interfaces including smartphones and computers [1]. BCIs are classified as invasive or non-invasive. Invasive BCIs use surgically implanted electrodes with high signal fidelity but involve surgical risks and long-term biocompatibility concerns [3,5]. Non-invasive BCIs, most commonly based on electroencephalography, offer greater safety but reduced precision due to signal attenuation [9].
Despite technological progress, BCIs remain largely unavailable for routine clinical or consumer use because of limitations in reliability, training requirements, and cost [1,9,11]. As BCI development remains largely experimental, incorporating user perspectives is critical to ensure alignment with real-world functional needs, particularly for individuals with C-SCI.
Accordingly, this study explores perceptions of BCI among individuals in the chronic phase of C-SCI using a structured focus group interview (FGI) approach. It addresses two key questions: how users envision integrating BCI into daily life, and which requirements and concerns are essential for effective implementation. By engaging individuals with limited prior BCI exposure, this study aims to inform user-centered development of accessible and functionally meaningful BCI systems for tetraplegia.
METHODS
Participants
Study participants were recruited from between the period of November 8, 2024 and November 14, 2024. The number of C-SCI patients who participated in this study was four, consistent with the recommended group size of four to eight participants for FGI in clinical and health research [12,13]. Clinical characteristics of the participants are described in Table 1. All participants had high C-SCI with ASIA Neurological Level of Injury C4 or above. All participants were individually informed about this study and gave written consent. This study was approved by the Seoul National University Hospital Institutional Review Board (IRB No. 2409-067-1570) and the National Traffic Injury Rehabilitation Hospital Institutional Review Board (IRB No. 2024-08-001).
FGI
The FGI method was employed to explore potential applications of BCI and to understand perceptions of prospective users. FGI facilitates direct discussion of participants’ experiences and viewpoints, allowing collection of diverse qualitative insights within a relatively short period and offering greater efficiency than one-on-one interviews [12,13]. A semi-structured format was adopted to promote interactive communication and allow clarifying questions during discussion [14].
The interview development team consisted of five experts with multidisciplinary backgrounds in rehabilitation medicine, occupational therapy, and biomedical engineering, each with 7–26 years of experience. FGI items are presented in Supplementary Table S1. In addition, a 10-item pre-interview questionnaire and a 14-item post-interview questionnaire were developed to assess participants’ understanding of and expectations regarding BCI. The pre-interview questionnaire was administered five days before the FGI, and the post-interview questionnaire one week after, both by a research professor with 10 years of experience in occupational therapy (GS). All interviews and questionnaires were conducted in Korean and translated into English for this article (Supplementary Table S2).
Five days prior to the FGI, participants were informed about the study and completed the pre-interview questionnaire. The FGI was moderated by two trained facilitators, one with 8 years of experience in rehabilitation medicine (YM) and the other with 7 years of experience in biomedical engineering. After a brief introduction and a short educational video on BCI, participants engaged in two 45-minute FGIs focusing on clinical and engineering perspectives, separated by a 15-minute break. Sessions were recorded using two video cameras and five audio recorders, with individual microphones to ensure clear communication without caregiver assistance. Audio recordings were transcribed using ClovaNote (Corps.), and transcripts were cross-checked by all authors.
Data analysis
A general inductive approach was applied to analyze the qualitative FGI data, enabling systematic condensation of raw interview transcripts into meaningful themes [15,16]. The analysis proceeded through the following steps.
First, audio recordings from both FGI sessions were transcribed verbatim using ClovaNote and subsequently cross-checked against the original recordings by all authors to ensure transcription accuracy. All transcripts were produced in Korean and translated into English by bilingual members of the research team prior to analysis.
Second, two researchers (YM and BMO) independently read the finalized transcripts in their entirety to achieve familiarity with the data. Each researcher then conducted open coding, generating initial codes by identifying segments of text that were relevant to the study objectives—specifically, participants’ expectations, concerns, and desired applications of BCI.
Third, the independently generated codes were compared and discussed between the two researchers. Discrepancies in coding were resolved through consensus, with reference to the original transcript text. Where disagreement persisted, a third researcher was consulted to reach a final determination.
Fourth, codes were grouped into broader categories based on shared conceptual content. These categories were then reviewed in relation to the study objectives and progressively refined into overarching themes. Five major themes emerged from this process: (1) digital accessibility, (2) offline physical activity, (3) social interactions and psychological health, (4) usability, and (5) acceptance and concerns.
Fifth, the identified themes and their constituent codes were reviewed by the full research team to confirm that they accurately represented the range of participant perspectives and were grounded in the transcript data. Representative quotations were selected for each theme to illustrate the findings in the Results section, with additional supporting quotations provided in Supplementary Table S3.
Pre- and post-interview questionnaire responses were analyzed descriptively, with individual-level pre-post comparisons conducted to examine changes in participants’ perspectives on BCI acceptance, expected functionality, and tolerable risk following the FGI. These results are presented in Table 2 and Fig. 1.
Digital accessibility
Digital accessibility refers to the use of BCI to operate electronic devices such as computers, smartphones, and smart home systems [17]. This theme focuses on BCI as a control interface for digital communication, internet use, and home automation, highlighting its potential to expand independence in work, education, and daily activities. Usability considerations, including adaptability, learning burden, and intuitive interface design, were also addressed, underscoring the importance of technology-enabled independence for individuals with severe physical impairments.
Offline physical activity
This theme examines the role of BCI in supporting daily living activities and promoting independence in essential functions [18,19]. The term “offline physical activity” was adopted to distinguish real-world, in-person functional tasks—encompassing ADL, instrumental ADL, health management, and leisure participation—from the digitally mediated activities described in the preceding theme of digital accessibility. Participants’ responses were categorized using two frameworks. First, activities were classified according to the Occupational Therapy Practice Framework: Domain and Process, Fourth Edition (OTPF-4) [20]. Second, the Generic Indicator Criteria (GIC) framework was applied to link activities with broader usability indicators [21]. This classification was performed by two board-certified physiatrists (YM and BMO) to systematically contextualize BCI-assisted activities within established functional domains.
Social interactions and psychological health
This theme addresses the potential impact of BCI on social participation, body image, and psychological well-being. Participants discussed how BCI could facilitate communication, environmental interaction, and engagement in social activities, potentially reducing barriers to social inclusion. The importance of seamless integration between BCI and communication technologies was emphasized to support meaningful interpersonal interactions.
Psychological considerations included changes in self-perception and body image following integration of neuroprosthetic devices. While some individuals anticipated improved confidence and independence, others expressed concerns about identity, emotional adjustment, and societal perceptions [22,23]. These findings highlight the need to address psychological adaptation alongside functional outcomes to support long-term BCI acceptance.
Usability
The usability theme focuses on factors influencing practical BCI adoption, including accuracy, response speed, setup complexity, and training demands [24,25]. Key parameters discussed included acceptable accuracy thresholds, response time expectations, training duration, device portability, maintenance requirements, and the level of caregiver assistance needed for daily use.
Acceptance and concerns
This theme explores participants’ willingness to adopt BCI technology and concerns related to safety, invasiveness, and data privacy. Attitudes toward invasive versus non-invasive BCIs, perceived surgical risks, and ethical considerations associated with brain-controlled interfaces were examined [26,27]. Privacy and security issues regarding brain signal data collection and potential misuse were also discussed, providing insight into factors that may influence long-term adoption and societal integration of BCI technology.
RESULTS
Data analysis yielded five major themes reflecting participants’ perspectives on BCI: (1) digital accessibility, (2) offline physical activity, (3) social interactions and psychological health, (4) usability, and (5) acceptance and concerns. For each theme, the most representative direct quotations are presented in the main text to illustrate key findings. Additional quotations supporting each theme are provided in Supplementary Table S3. Pre- and post-interview questionnaire responses are summarized in Table 2 and Fig. 1, which document changes in participants’ perspectives on BCI acceptance, expected functionality, and tolerable risk following the FGI.
Digital accessibility
As communication and administrative or financial tasks increasingly rely on digital platforms, participants expressed a strong need for digital accessibility via BCI. Regardless of age, they emphasized the importance of accessing smartphone messaging applications such as KakaoTalk (Kakao Corp.), the primary messaging platform in Korea. In addition, the ability to write emails, make phone calls, and independently manage online banking was consistently identified as a priority.
“It would be nice if BCI could let me send KakaoTalk messages, or make phone calls for me.” (D)
“I can’t even enter my bank account password because I can’t move my fingers. It would be better if BCI could help me do that.” (A)
Offline physical activity
Participants remarked on the activities they want and need to perform the most from FGI questions 1–3. The responses categorized according to OTPF activity domains and GIC are shown in Table 3. Some of the responses made by the participants are as follows:
“If I were discharged today, I wouldn’t be able to manage essential daily activities like using the restroom or eating without full assistance. However, if BCI enables me to handle these tasks independently, it could significantly improve my ability to live without relying on a caregiver.” (C)
Social interactions and psychological health
Participants were strongly involved in discussing how BCI would affect their social interactions and psychological health. In general, participants responded favorably toward BCI on their social interactions and psychological health. Participants also expressed that not only will it be them who become independent via BCI, it will also be their caregivers (significant others and/or family) who will be freed from having to take care of them continuously. Participants described their needs and how BCI would benefit their lives.
“First of all, if the caregiver doesn’t have to be constantly by my side and I can manage my daily life independently, it would create a more natural and harmonious environment for both of us. It would help maintain a comfortable relationship without feeling awkward. As for friendships, I can continue meeting my existing friends as usual, but making new friends might still be somewhat challenging.” (A)
“I feel the same way. If I can manage daily activities at home independently without needing constant assistance from a caregiver, it would allow them to have more personal time and ease their burden. At the same time, I would feel more at ease within my home environment. This could improve the relationship between the patient and the caregiver, ultimately making both of us happier.” (D)
Participants responded that if BCI could make them more independent, their self-image and emotional health would improve significantly.
“I think once I achieve a certain level of independence, my relationships and social connections would improve significantly. My self-esteem in daily life would also increase. Why? Because after the accident, my self-esteem took a hit. But if BCI allows me to regain some functional abilities, then regardless of how people look at me, the most important thing is that I can move and act on my own.” (A)
One participant responded that, since he feels the same way about himself now compared to how he felt before, BCI would not impact his body image and emotional health.
“I don’t think there would be a big difference. Ultimately, I’m just trying to live my life, and if someone were to use that against me or criticize me for it, that wouldn’t be right. I don’t see a need to tie this to self-esteem. My self-esteem hasn’t changed much as it is, and whether I use BCI or not, I am still the same person. So, I don’t think it would have much of an impact on my self-esteem.” (B)
Usability
In the domain of usability assessment, we defined the key characteristics as follows: (1) motion speed, (2) accuracy, (3) setup, (4) training period for use, (5) usage time per single charge, and (6) cost. Table 4 shows the summary of usability perspectives from the participants.
Regarding motion speed, participants expressed that they are willing to endure some degree of latency and delay for improved accuracy. For accuracy, expectation was higher than motion speed.
“A delay of around 10 seconds when drinking water seems acceptable. I think it would be good if the accuracy were around 8 out of 10 times.” (D)
“Of course, both accuracy and speed would be ideal, but accuracy should take priority over speed.” (B)
When setting up the BCI, the participants expected to be helped by a caregiver, with minimum expected setup time of 10 minutes, to maximum 30 minutes.
“If the setup time is around 10 to 20 minutes, it seems manageable, but if it takes more than 30 minutes, relying on a caregiver would become a burden.” (C)
Furthermore, the participants’ expected usage time per single battery charge ranged between 3 to 8 hours.
“Ideally, it should last up to 3 hours on a single charge.” (A)
“Five to six hours would be ideal.” (D)
The expected training period to master the usage of BCI ranged widely, from 3 months to 2 years. However, the participants were in general willing to go through a rigorous training period for BCI use.
“If training takes three months, I’d accept it. Even if it’s long, I could commit to about six months.” (A)
“At a minimum, I think six months would be necessary.” (B)
“One to two years would be fine for me.” (D)
Lastly, three participants (A, B, and D) responded that they are willing to spend 10 million KRW (7,500 USD) or less on BCI, while one participant (C) was willing to spend 50 million KRW (37,500 USD) or less.
Acceptance and concerns
Even though most participants have never heard of BCI before and are rather aged, they were in general quite willing to use the technology, provided that BCI is safe and effective. Furthermore, they showed slightly favorable acceptance toward invasive BCI compared to noninvasive options primarily because they perceived it as offering greater reliability, higher accuracy, and a more seamless integration with their intended functions, reducing the need for external attachments or frequent recalibrations.
“If I’m going to do it, I might as well go for the best option. Since it’s a significant decision, it should be done properly, even if it involves risks.” (B)
“Even if there are risks, if the technology can significantly enhance functionality, then it’s something worth considering.” (C)
There were multifaceted concerns regarding the safety of the procedure.
“The biggest concern is death—undergoing surgery and not making it through. Also, I really don’t want to end up in the ICU.” (B)
Furthermore, safety during usage and maintenance issue were of large concern among the participants.
“If using an invasive BCI means that I would need another surgery if it malfunctions, then I wouldn’t want to use it.” (D)
“If I have to undergo another surgery due to side effects from the implant, I wouldn’t be able to trust the device.” (B)
DISCUSSION
Despite recent advancements in BCI technology [1], it has not yet achieved widespread clinical or consumer adoption [9,11,27], largely due to persistent challenges related to reliability, usability, and accessibility [26,27]. As BCI development accelerates, incorporating user perspectives is increasingly important to ensure alignment with real-world functional needs rather than purely technological possibilities. In this study, we explored perceptions of BCI among individuals with high C-SCI using a structured, multidisciplinary focus group approach. Five key themes emerged—digital accessibility, offline physical activity, social interactions and psychological health, usability, and acceptance and concerns—revealing that while participants were generally receptive to BCI, they emphasized functional utility, safety, and reliability, alongside concerns regarding surgical risk, device longevity, and training burden.
The sample size of four participants warrants methodological consideration. FGI is a qualitative approach that does not follow power-based sample size calculations; rather, group sizes of four to eight participants are recommended in clinical and health research to balance diversity of perspectives with productive group dynamics [12,13]. In this study, recruitment was further constrained by the highly specific eligibility criteria—chronic-phase C-SCI with neurological level C4 or above—which represents a clinically rare population. Despite the small sample, considerable thematic convergence was observed across participants and across both FGI sessions, lending support to the adequacy of the sample for the exploratory aims of this study. Additionally, the wide age range of participants (34 to 71 years) may have introduced generational heterogeneity in baseline familiarity with digital technologies, potentially influencing perspectives on BCI-enabled digital accessibility. Notably, participant D, the youngest participant, was the only individual with prior awareness of BCI. Nonetheless, the core priorities identified across all participants—functional independence, safety, and caregiver burden reduction—were remarkably consistent, suggesting that the lived experience of high C-SCI may be a more dominant driver of BCI-related perspectives than generational background alone.
A central finding was participants’ strong demand for improved digital accessibility through BCI. As communication, financial transactions, and administrative tasks increasingly rely on digital platforms, participants reported substantial limitations in independently using smartphones, messaging applications such as KakaoTalk, online banking, and internet services. BCI-enabled digital access was perceived as a critical means to enhance independence and participation across social, professional, and financial domains. Beyond personal convenience, digital accessibility was viewed as a way to reduce caregiver dependence and alleviate emotional and logistical burdens on families. Participants anticipated that greater independence in digital interactions would support more balanced caregiver relationships and help mitigate social isolation and stigma associated with severe physical disability.
The prominence of digital accessibility as a primary theme in this study warrants consideration in its sociocultural context. Korea’s exceptionally high rates of smartphone penetration and digital platform dependency—with mobile banking, government services, and social communication mediated almost exclusively through applications such as KakaoTalk—mean that the inability to independently operate a smartphone represents a particularly acute form of social exclusion for individuals with high C-SCI in this setting. This may explain why digital accessibility emerged as a more salient priority in the present study than has been reported in comparable qualitative studies conducted in other populations [26,27], where physical mobility and communication restoration have tended to dominate user-defined BCI priorities. Future cross-cultural research should examine whether the relative weighting of digital versus physical BCI applications varies systematically across healthcare and technological contexts, as such differences would have direct implications for the design of culturally responsive BCI systems.
Participants also expressed interest in applying BCI to offline physical activities essential for daily living and mobility. While acknowledging the difficulty of fully restoring lost motor function, they envisioned BCI as a potential assistive tool for tasks such as eating, dressing, personal hygiene, home management, and wheelchair control. It should be noted, however, that current BCI technology remains largely experimental for such complex motor tasks, and the perspectives reported here reflect participant expectations and aspirational goals rather than established clinical capabilities. Nonetheless, these user-defined priorities offer valuable targets to guide future BCI development toward functionally meaningful applications. The identified activity domains align with prior studies documenting the potential of BCI to support functional independence in individuals with severe motor impairments [22,26], and integrating BCI across both digital and physical domains may ultimately reduce caregiver reliance and enhance personal autonomy.
Psychological and social implications of BCI use were also highlighted. Some participants anticipated improvements in self-esteem and emotional well-being through regained independence, whereas others expressed concerns related to body image, identity, and societal perceptions of neuroprosthetic use. One participant reported no expected change in self-image, underscoring variability in psychological responses to assistive technologies and the importance of addressing psychosocial adaptation alongside functional outcomes.
Variability in psychological responses to BCI across participants highlights the heterogeneity of lived experience even within a clinically homogeneous population. While most participants anticipated meaningful improvements in self-esteem and social participation through BCI-enabled independence, participant B reported no expected change in self-image, framing his identity as stable and independent of functional capacity. This divergence may reflect differences in psychological adaptation to disability, coping style, or duration and mechanism of injury rather than age or technology familiarity per se. Prior qualitative work has identified self-concept stability and pre-injury identity as important moderators of assistive technology acceptance [26], and the present findings are consistent with this literature. Clinically, these individual differences underscore the importance of psychosocial assessment as a component of BCI candidacy evaluation, and suggest that standardized measures of disability adjustment and technology self-efficacy should be incorporated into future user-centered BCI research to enable more nuanced prediction of adoption outcomes.
Safety emerged as a dominant concern, particularly regarding invasive BCI procedures and unintended movements. Participants emphasized risks related to device malfunction, involuntary actions, and physical harm, underscoring the need for robust control accuracy and fail-safe mechanisms. Usability factors—including response speed, accuracy, portability, battery life, and setup complexity—were also emphasized, with most participants prioritizing accuracy over speed.
Training burden was another key factor influencing adoption. Although acceptable training duration varied, participants were generally willing to undergo prolonged training if meaningful functional benefits could be achieved, suggesting that adaptable training protocols and intuitive interfaces will be essential for broader BCI uptake.
The pre- and post-interview questionnaire data provide insight into how structured group discussion shaped participants’ perspectives on BCI. Willingness to undergo brain surgery increased in three of four participants following the FGI, suggesting that expert-facilitated discussion and peer exchange may reduce ambivalence toward invasive procedures—an effect that has been observed in other contexts where deliberative group processes promote informed risk acceptance [26,27]. Notably, however, increased surgical willingness was accompanied by a downward recalibration of expected functional outcomes in two participants, with anticipated functional levels decreasing from “enhanced” to “moderate” or “slight improvement” after the FGI. This pattern suggests that the educational component of the FGI helped participants form more realistic expectations, tempering initial optimism with a clearer understanding of current technological limitations. Participant B showed the most pronounced shift, moving from willingness to accept even life-threatening surgical risk (score 5) to tolerance of only mild side effects (score 2) post-interview—a reversal that may reflect deeper engagement with the risk-benefit calculus prompted by group discussion. Taken together, these findings suggest that the FGI functioned not merely as a passive data collection instrument but as an active educational intervention that meaningfully restructured participants’ understanding of BCI, underscoring the value of deliberative, multidisciplinary engagement in early-stage neurotechnology research.
The perspectives gathered in this study carry several implications for the future development and clinical translation of BCI technology. Participants consistently prioritized accuracy over speed, expressed tolerance for prolonged training periods, and demonstrated cautious but genuine openness to invasive procedures—provided that safety and long-term reliability could be assured. These user-defined benchmarks offer concrete targets for engineering development: an accuracy threshold of approximately 70%–80% per task was identified as the minimum for perceived usability, setup time should ideally remain within 30 minutes with caregiver assistance, and battery life should sustain at least four to eight hours of daily use. That participants were willing to undergo training periods of up to two years further suggests that the adoption barrier for BCI may be lower than previously assumed among motivated individuals with severe motor impairment, and that longitudinal training paradigms should be explored as a viable clinical pathway.
Beyond hardware and algorithmic improvements, the present findings highlight the need for systemic and policy-level interventions to support BCI adoption. All four participants in this study were hospitalized and reliant on professional caregivers, reflecting the broader reality that individuals with high C-SCI in Korea—and in many healthcare systems globally—remain institutionalized long after the acute phase of injury due to insufficient community support infrastructure. BCI technology, however sophisticated, will fail to deliver meaningful independence gains if the social and structural conditions for home-based use are not in place. Policymakers should therefore consider BCI-enabling frameworks that include reimbursement pathways for device acquisition and maintenance, caregiver training programs, and home modification support, as parallel investments alongside device development. Furthermore, the participants’ concerns regarding brain signal data privacy and the conditions under which continuous neural recording would be acceptable underscore the urgency of regulatory frameworks governing neurotechnology data, an area that remains largely unaddressed in existing biomedical device legislation in Korea and internationally. Future research should engage patients, caregivers, clinicians, engineers, ethicists, and policymakers in co-design processes to ensure that BCI systems are developed not only to be technically effective but also to be socially acceptable, economically accessible, and institutionally supported across the full continuum of rehabilitation care.
This study has several limitations. The small sample size and inclusion of only Korean male participants limit generalizability. Future research should include more diverse populations and individuals with other motor impairments, such as stroke, amyotrophic lateral sclerosis, and traumatic brain injury. As this study relied on qualitative FGI data, additional quantitative research is needed to establish standardized functional and usability benchmarks. Additionally, data on the level of social participation and daily activity prior to the interview were not systematically collected as part of the study protocol, which limits the extent to which individual contextual factors can be linked to the perspectives reported herein. Future studies should incorporate structured assessments of social participation and functional independence to enable more nuanced interpretation of user perspectives on BCI adoption. Finally, although this study focused on patient perspectives, successful clinical implementation of BCI will also require input from healthcare professionals. Integrating perspectives of physicians, therapists, and rehabilitation specialists will be essential to support shared decision-making and long-term clinical feasibility.
Conclusions
This study provides user-centered insights into perceptions of BCI among individuals with C-SCI, highlighting its potential to enhance independence, digital accessibility, and social participation, alongside challenges in safety, usability, and acceptance. Participants demonstrated cautious optimism toward BCI, emphasizing functional benefit, reliability, and user burden as key determinants of adoption. Future BCI development should prioritize user needs, safety, and accessibility to enable clinically meaningful and acceptable applications of neurotechnology in rehabilitation and assistive care.
CONFLICTS OF INTEREST
Byung-Mo Oh is the Editor-in-Chief of Annals of Rehabilitation Medicine. The author did not engage in any part of the review and decision-making process for this manuscript. Otherwise, no potential conflict of interest relevant to this article was reported.
FUNDING INFORMATION
This research was supported by the Challengeable Future Defense Technology Research and Development Program through the Agency for Defense Development (ADD) funded by the Defense Acquisition Program Administration (DAPA) in 2022 (No. 915069201).
AUTHOR CONTRIBUTION
Conceptualization: Kim E, Shin G, Oh BM. Methodology: Myong Y, Kim E, Shin G; Data curation: Myong Y, Kim E, Shin G, Oh E. Funding acquisition: Oh BM. Supervision: Oh BM. Visualization: Myong Y. Writing – original draft: Myong Y, Oh BM. Writing – review & editing: all authors. Approval of final manuscript: all authors.
ACKNOWLEDGMENTS
The authors would like to thank all the participants for their time and valuable insights. The authors would also like to thank Professor Min-Yong Lee for contributing to the study design and data collection.
DATA AVAILABILITY STATEMENT
The raw data (interview script) of this study can be retrieved upon reasonable request to the corresponding author.
Summary of pre- and post-interview questionnaire responses by participant. Radar plots illustrate changes in brain–computer interface (BCI)-related expectations and acceptance before and after the focus group interview. Panels (A-D) represent individual responses from participants A, B, C, and D, respectively, while panel (E) summarizes the average scores across all four participants. Blue lines indicate pre-interview responses, and orange lines indicate post-interview responses. Each axis represents a questionnaire domain related to BCI expectations or usability, including touch, speed, accuracy, setup, training, portability, design, safety, and cost. Higher scores indicate greater perceived importance, acceptance, or expectation for the corresponding domain.
Table 1.
Focus group interview participants
ID
Age (yr)
Sex
AIS classification
Etiology
Time since injury (mo)
Living situation
Primary caregiver
Prior BCI exposure
A
48
Male
SCI C5/C4 NLI C4 AIS A
Non-traumatic
6
Hospitalized
Professional caregiver
No
B
71
Male
SCI C4/T9 NLI C4 AIS C
Traumatic
7
Hospitalized
Professional caregiver
No
C
59
Male
SCI C3/C3 NLI C3 AIS C
Traumatic
12
Hospitalized
Professional caregiver
No
D
34
Male
SCI C6/C4 NLI C4 AIS C
Traumatic
17
Hospitalized
Professional caregiver
Aware of BCI concept
AIS, American Spinal Injury Association Impairment Scale; BCI, brain–computer interface; SCI, spinal cord injury; NLI, neurological level of injury.
Table 2.
Summary of pre- and post-interview questionnaire responses by participant
Min. speed improvement to accept sensory BCI (post only)
1=10 s · 2=20 s · 3=30 s · 4=40 s faster · 5=Would not accept
1
3
3
4
BCI, brain–computer interface; Min, minimum.
Table 3.
Activity classification according to OTPF-4 and GIC
Activity
Response
Generic indicator
ADL
Feeding
Having a meal, drinking water or juice
Self-care
Personal hygiene
Using restroom, Showering, brushing teeth, washing hair, dressing/undressing
Self-care
Home establishment and management
Turning on/off lights, locking/unlocking doors, using remote controllers for television
Home management activities
Safety and emergency maintenance
Fastening safety belts on public transportation
Mobility
Instrumental
Functional mobility
Getting in/out of bed, getting on/off wheelchair
Mobility
Driving and community mobility
Getting on/off public transportation, braking and controlling powered wheelchair, getting on/off curbside, driving a car
Mobility
Health
Physical activity
Assisting physical therapy and rehabilitation exercises, working out
Leisure activities
Leisure
Leisure participation
Hiking and jogging (ambulation assists)
Leisure activities
OTPF-4, Occupational Therapy Practice Framework: Domain and Process, Fourth Edition; GIC, Generic Indicator Criteria; ADL, activities of daily living.
Table 4.
Potential user perspectives on the usability of BCI system
Usability feature
Summarized description
Motion speed
Between 10 seconds to a minute per motion
Accuracy
Around 70% to 80% accuracy per task
Setup
Between 10 to 30 minutes
Training period for operation
Ranging from 3 months up to two years
Usage time per single charge
Between 3 and 8 hours
Cost
Ranging from USD 7,500 to USD 37,500
BCI, brain–computer interface.
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Reconnecting Minds to the World: Patient Perspectives on Brain–Computer Interface After High Cervical Spinal Cord Injury
Fig. 1. Summary of pre- and post-interview questionnaire responses by participant. Radar plots illustrate changes in brain–computer interface (BCI)-related expectations and acceptance before and after the focus group interview. Panels (A-D) represent individual responses from participants A, B, C, and D, respectively, while panel (E) summarizes the average scores across all four participants. Blue lines indicate pre-interview responses, and orange lines indicate post-interview responses. Each axis represents a questionnaire domain related to BCI expectations or usability, including touch, speed, accuracy, setup, training, portability, design, safety, and cost. Higher scores indicate greater perceived importance, acceptance, or expectation for the corresponding domain.
Graphical abstract
Fig. 1.
Graphical abstract
Reconnecting Minds to the World: Patient Perspectives on Brain–Computer Interface After High Cervical Spinal Cord Injury
, Eunkyung Kim, PhD1,3
