Table 4:

Themes, Descriptions, and Representative Quotes

Theme	Description	Sub-theme/topic	Representative quotes
Low tech clinical practice	Comprises clinician perspectives on their primary tools for assessment of muscle activity, preferred interventions for muscle strengthening, use and knowledge of technology in practice, and future directions for clinical practice.	Clinical observation; muscle assessment tools; functional assessment	1: “At the impairment level it’s usually like manual muscle testing, range of motion. As OT’s I think we look at functional achievements, you know, like they were able to reach a can on this shelf one day, but the next day they were able to reach the high shelf, things like that” (Laura, OT, Hospital A).
			2: “I use manual muscle test, that’s basically it. I feel like for me, especially when it comes to what is going to most broadly show, um, the greatest amount of improvement, and that insurance companies are going to look at and say, ‘ok, this treatment is justified’, in my mind, it should be something very functional.” (Jack, PT, Hospital D and private company).
			3: “Just manual muscle testing. And even at times, I get to a point where because of our 45- minute sessions run out so quickly, and when I’m doing functional tests or outcomes measures, I don’t really check strength at the end, because all I really care about is that they’re able to do stairs, that they are able to walk, they’re able to do things functionally” (Leah, PT, Hospital C).
		Use of EMG restricted to research environments	4: “I still do clinical practice, and I don’t think I’ve used anything to measure specific muscle activity other than manual muscle testing. Maybe grip strength testing, that’s the only thing I can think of. I just used EMG during our research” (Anna, OT, Hospital D).
		Mixed desire to use more technology in practice	5: “It seems like there are a lot of opportunities for technologies being leveraged, the logistics of how we are going to pay for that is another argument. But then, you know, I guess I’d be interested in knowing to what degree is the outcome different. If you get there faster but it’s still the same outcome, does it justify the cost?” (Jeff, PT, Hospital C).
		Future impact and implementation of rehab technology	6: “You should be using technological means to make some of these measurements to improve the sensitivity of what you’re measuring and document change across time with the therapy…But I don’t think the students, when they go out there to do their clinical internships and beyond, see those things being used very much and therefore they let it all go, rather than trying to change the profession. So, it’s something that I challenge our students to be- the change agents that take some of this technology and actually apply it in their clinical practice” (Julia, PT, Hospital D and academic researcher).
Barriers to EMG uptake	Comprises clinician perspectives on various barriers to implementation of sEMG technology in various clinical settings.	Personal: Lack of time and training	7: “The hardest…not the hardest, but one of the hardest, [is] getting the most out of the 45- minute sessions we have with the patients” (Henley, OT, Hospital A).
			8: “It’s hard to fit [it all] in, so time is really a struggle” (Jasmine, OT, Hospital A).
		Clinical experience and technology ‘savvy’	9: “I think one of the challenges I have as a new therapist is if I want to try a different modality or try a different treatment method, there’s not a lot of room for practice, and I find that if I don’t use it regularly or don’t have the chance to really practice with it until I’ve mastered it, I’m very unlikely to be able to grab- in my one hour treatment session, to run and grab the equipment, set it up, initiate it, explain it to the family, like, it just feels impossible, so I avoid using it” (Jessica, OT, Hospital B).
			10: “Anything technology is hard for me. I’m old, and it’s just, it just, it scares me and I, you know, I’m less likely to do stuff like [EMG] than... unless I had somebody with me. Because I just, we don’t have time to mess around with stuff, and I don’t have my own personal person to help me, you know” (Lauren, OT, Hospital B).
		Availability of appropriate patient supports	11: “Just by virtue of our demographic here, a lot of our patients simply don’t have a lot of resources…they don’t have consistently a lot of great family support, and so, discharge planning and getting equipment for them- you know, there is great technology available but a lot of times they can’t afford it, and then also, um, their [dispo] is often to rural places that they won’t necessarily have follow up, so that’s another challenge that we face with a lot of patients here” (Jasmine, OT, Hospital A).
		Equipment: Current Technology design/function	12: “It was difficult to even just get the electrodes to stay on for a 10-minute test, let alone an hour worth of intervention. It’s like, if I have to scrub the skin really, really hard, and then let it dry, and then wrap it with pre-wrap to keep it from falling off, it was too much” (Rob, PT, Hospital D).
			13: “That system right there looks like a Cold-War era black box…I don’t know how patients might react to that” (Richard, PT, Hospital C).
			14: “[The sensors] are chunky, it’s going to fall off unless you wrap an ace wrap around it or something” (Samantha, Physiatrist, Hospital C).
		Institutional: Logistics; Layout; Willingness to invest in Technology	15: “I have seen a lot of changes…the frustration with the changes are less and less number of visits to achieve desired results. And in the olden days- neuro patients change more slowly, we know that- and so they also tended to be allotted more time for their changes. And there were just more resources- dollar resources- for them so they could be seen for a longer period…[Another frustration] is fitting the diagnosis into the insurance driven market, essentially, and then the other frustration is just knowing that there are pieces of equipment available, and due to funding we just, you know, can’t get it” (Holly, OT, Hospital C).
		Policy: Funding; Healthcare reform	16: “[Technology] is not being something that really likely [is] reimbursed. I think there’s some, there are wonderful innovations but with the money being what it is, you know…Medicare is not of the mind to be spending any more money on anything, and as soon as you bring up new technology, they’ll say, ‘Show me the evidence,’ and then they’ll dispute the evidence. They’ll say it’s not good, it’s not robust enough so we’ll consider it experimental and we won’t pay for it” (Richard, PT, Hospital C).
			17: “And that is sort of the, like, kickoff for, like, consumer-based insurance or private insurances, that they’ll follow Medicare” (Jeff, PT, Hospital C).
		Potential solutions to implementation barriers	18: “We’ve discussed even doing trainings or practice with each other periodically to keep our skills up on the FES bike. And to find time to meet, I mean, we haven’t tried very hard, but I know that to find time for us two to meet and do that would be really challenging with our schedules. Cause that is one of those activities that I don’t just go, ‘Oh, let’s just run them up to the gym and put them on the FES bike’. I feel like, ‘Oh, I need to go there first, I need to remember the settings’, and you know, so…” (Charlotte, OT, Hospital B).
			19: “But I do think that the next generation, the generation we’re training now to become physical therapists, they’re so in tune with technology, and they’ve all got, you know, a fitbit, and apps on their phones and stuff. I think they’re primed to pick this stuff up and use it. The old guys out there, they’re never going to use it, so (laughter) let them go to retirement, you know. But this, I mean, we have an opportunity I think, because [the students] have grown up using this stuff” (Julia, PT, Hospital D).
Potentia Benefits of sEMG	Comprises clinician perspectives of how EMG technology may be a beneficial tool in their professional settings as well as a tool that they might recommend to individuals with neurologic injury as a part of their community reintegration.	Standardization of assessment; specific quantitative evidence	20: “So, if [sEMG] was able to give me information that would drive the therapeutic exercise, or their orthotic [prescription], or the treadmill training, or their- we have body weight suspension capabilities within our clinic- knowing that we need to use that or not use that… so sort of like putting in the context of clinically-meaningful difference” (Jamie, PT, Hospital B).
			21: “I think it would be useful, I was thinking when you have kids, because they’re not reliable, necessarily, and they’re not necessarily motivated, right? So you could do a manual muscle test and I could and Julia could and probably get three different results, depending on the mood of the kid, how hard they were performing, and all our subjectivity. So I think that [sEMG] would actually be useful for a person, kids especially, if you’re just not sure what’s going on and you want to measure at that level. So you know exactly what’s going on with the muscles” (Anna, OT, Hospital D).
		Non-invasive tool to demonstrate early progress	22: “I think [EMG] would be really great for our super weak patients that have like the 1, 2- muscle strength and they’re having trouble distinguishing, maybe they’re working in a flexor synergy and you’re trying to tease out some muscles. I think it would be good feedback for them at that level. It’s hard because they don’t see themselves make these drastic movements, maybe they are only moving an inch, but this is something you could show them, ‘Look! Your muscles are firing!’” (Laura, Hospital A).
			23: “I do agree that right before [a patient’s] arm becomes functional, ‘I swear you’re gaining strength, you just have to trust me, I know you can’t use it yet, but…’ So I think it would be great [for them] to see the actual progress” (Joyce, OT, Hospital A).
		Ability to monitor progress outside of therapy	24: “I think that there’s a lot of benefit to something that we can use in the clinic and show them, so we can track through. For my populations, being able to see how they perform in a home setting would be really valuable- so if it’s something that we can train up with families, or show them some results to watch themselves, there’d be a lot of benefit to that” (Charlotte, OT, Hospital B).
		Benefits vs. privacy concerns	25: “Technology that could be applied in the home would be great. I always like to know what they’re doing when I’m not looking. If they have it on at home, and I can get to that information, or even information that they don’t have it on, I can go, ‘Hey, by the way, could you put it on?’ That kind of stuff. Versus them having it for a week and not knowing whether I’m getting any usable data or not. If I can go on every night and ping in and say, ‘Oh, ok, they wore it for six hours today, this is awesome.’ It’s sort of a big brother thing, which there are some challenges with that, obviously, but that would be very helpful” (Jamie, PT, Hospital B).
		Patient enjoyment; interest in technology	26: “I do think that all the participants, at least in the beginning, thought the technology was cool. ‘This is cool! This is better than that old therapy where you make me do all this stuff, this is cool!’” (Julia, PT, Hospital D).
			27: “I think [they enjoyed it] especially once they got the hang of it. I think in the beginning, especially the adults post-stroke, got frustrated, because they would get stuck and they couldn’t figure it out…and eventually they’d just stumble upon the right thing, and it was, obviously, that’s the point, right? Then it rewards and they just continued to do it” (Anna, OT, Hospital D).
			28: “I think the [bracelet EMG system] just looks cool I mean, I wear a fitbit, it’s kind of the next step up from that, it’s super functional, it looks like you can just pop it on and go” (Jasmine, OT, Hospital A).
		Potential for more specific information in nebulous clinical situations	29: “If I can’t get them to do a certain movement, I’m like, ‘Well, is there any activity in that muscle?’ That would be helpful to get that information in terms of assessing, ‘Oh, yeah, there’s a little bit here’, and then a couple of sessions later, ‘Hey, there’s a lot more activity’. I guess I can see myself tracking it that way, but, just based on the cost and setup time and all of that, I just want to make sure it’s something that’s super functional, worth the 45 minutes I have in the session” (Leah, PT, Hospital C).
			30: “I think [EMG] could add well to practice by giving you something that had a more objective and sensitive measurement system to document change. Small changes, maybe that you don’t see, to improve the sensitivity of what you’re measuring and document change across time with the therapy.” (Julia, PT, Hospital D).
			31. “I would also say, beyond just the sensitivity of the measure, but also improving the reliability of the measure, both inter- and intrarater reliability pieces…since there is so much subjective nature in a lot of what we do with assessments, trying to parse that into more objective measures and ability to improve the reliability of those measures.” (Rob, PT, Hospital D)
Essential features of sEMG systems	Comprises clinician perspectives on desirable or undesirable features of the currently available sEMG systems that were demonstrated during the research visits, as well as hypothetical ‘wish list’ features that clinicians deemed critical if they were	Simplicity	32: “Anything we can do to minimize the prep time, any steps we can do to make it easier to use, people will use it more readily” (Jack, PT, Hospital D and Private Company).
			33: “I would say we’d have to have something that’s less than five minutes. If I can go sticker, sticker, sticker, turn it on and go, then it would happen” (Jamie, PT, Hospital B).
		Minimal skin preparation; multiple sizes, especially for pediatric populations	34: “In a clinical situation if I brought out something that to me, kind of looks like a little rubber toy- a little piece of, uh, flexible rubber, and I wash their skin and I slap it on, that would be tolerated by most school-age kids, and/or kids with developmental disabilities better than if I had to abrade the skin, alcohol, rub… Any of that would be received- that’s not that far from what you do before you get a blood draw, and all of these kids, whether you’re typically developed or not, the minute- they may not- you can keep telling them that there’s no needle coming, there’s no pokes, but I can guarantee you the minute you start abrading a kid’s skin and wiping them down with alcohol, you’ve set them up to not be performing in their normal performance. And I think it would be hard for parents- to get parents to do that” (Jamie, PT, Hospital B).
		Waterproof	35: “They can stay for multiple days even through showers and swimming and bathing and everything else. If I had that technology, it would’ve been much easier and I think it would’ve been very, very much better in a lot of ways for both families and myself” (Rob, PT, Hospital D).
		Low cost, disposable	36: “It seems like the first two [Delsys and Biostamp] you could probably use during therapies but therapies only. I wouldn’t feel comfortable leaving them. Sometimes I’ve built up utensils and I am like, ‘Please don’t lose this’ and it’s gone within two hours. The [Myo] or the [ESS] could be left with the patient. I think it’s less likely the [Myo] would be thrown away, just cause it looks important, you know?” (Laura, OT, Hospital A).
		Evidence-Based	37: “When it comes to PT’s especially, if you’re able to – maybe these devices haven’t been used in specific studies that you can relate it to, but maybe other similar studies have been conducted- I think having those as a way to reference the direction it’s going, the application, and how it’s been beneficial in the past, that way they can kind of understand why they are using this kind of intervention” (Jack, PT, Hospital D and Private Company).
			38: “I think [the tipping point] is evidence-based enough to support the cost. Like, if you said you could buy this one for $200, but, eh, we don’t really know if it’s effective, or you could by the $2000 and research shows that would make a difference” (Joyce, OT, Hospital A).
		Intuitive user interface; compatible with phone or tablet	39: “Because of the things like iPads and iPhones, you can do all kinds of incredible things easily that we never had before the capability of doing that. You’d have to go to your supervisor and ask them for money and buy some big monster video camera and now, you can bring up your cell phone and, you know, take a video and do something with it, cause of the apps and [capabilities]” (Julia, PT, Hospital D).