The Equipment

What You Will Learn

In this chapter, we explain the equipment that makes up an FES cycling system. We cover the two core components (the stimulator and the bike), the two main approaches to combining them (integrated systems and universal stimulator systems), the electrodes and consumables you will use, how the technology is controlled, and how people typically fund a purchase. We also touch on what to look for when comparing systems and what ongoing costs to expect. By the end, you should understand what you are buying and why, regardless of which brand or configuration you choose.

The Two Components

Every FES cycling system consists of two essential components working together.

The Stimulator

The stimulator is the device that generates the electrical pulses delivered to your muscles through surface electrodes. It is, in effect, doing the job your brain and spinal cord would normally do: sending signals to your muscles telling them when to contract and when to relax.

A stimulator designed for FES cycling must be able to deliver pulses to multiple muscle groups (typically four to eight channels, each driving a pair of electrodes on a different muscle). It must also be able to synchronise those pulses with the movement of the bike pedals, so that the right muscles fire at the right moment in the pedalling cycle. The stimulation parameters (frequency, pulse width, and current) are adjustable, allowing the system to be tailored to your individual needs and progress over time as your muscles adapt.

All the stimulators used in FES cycling are regulated medical devices. This matters because it means they have been through rigorous design, safety testing, and regulatory approval. The cost of this process is one reason why medical-grade stimulators are substantially more expensive than consumer electrical stimulation units you might see online. The difference is not cosmetic: medical devices typically use current-controlled stimulation for precision and consistency, meet international safety standards (IEC 60601), and include protections such as electrical isolation and fault detection that consumer products do not.

The Bike

The bike is a passive/active cycle ergometer: an exercise bike designed for rehabilitation that includes a built-in motor that moves your legs through a pedalling motion even when you cannot pedal voluntarily. The motor can also provide adjustable resistance while you are actively pedalling with FES.

Key features to look for in a bike include:

• Passive and active modes. The motor should be able to move your legs passively over a wide range of speeds (useful for warm-up and cool-down) and provide resistance when your muscles actively drive the pedals.

• Spasticity protection. It's important that the bike has some form of spasticity response. If a user's legs are 'fighting' the pedal movement, you won't want the bike to continue forcing that forward motion. Most bikes will have a way to manage this. Typically by sensing the resistance to pedalling and then reversing the direction of movement for a few seconds.

• Adjustable resistance. You need to be able to increase resistance over time as your muscles get stronger. A bike with a wide resistance range and adjustable motor power gives you more room to progress.

• Secure foot fixation. Your feet must be safely secured to the pedals, typically with straps or adapted footplates, to prevent them from slipping during the cycling motion. Clients with complete spinal cord injuries will also need supports for the lower leg. The type of foot and leg fixings can vary and might allow some individuals to use them independently. If support during operation is needed, this is less significant.

• Stability. The bike must be stable enough to stay in place when your muscles contract forcefully, especially if you experience spasms. Some bikes have accessories that stabilise a wheelchair and prevent tipping.

• Legs only or Arm and leg exercise. Although we have primarily discussed leg cycling systems, many clients appreciate the opportunity to actively exercise their arms and shoulders with FES, as well as their legs. This is typically requested for clients with high-level spinal cord injuries where the upper limbs as well as the legs are affected. Of course, a leg-only bike will be less expensive than one which supports both arm and leg exercise.

• Appropriate size for your environment. Bikes vary in footprint. Some are compact enough for a living room; others are larger. As we discussed in Chapter 7, fitting the equipment into your home matters.

Well-known passive/active bike ranges include the TheraTrainer (such as the Tigo models) and the MOTOmed (such as the Muvi and Loop models). Both are widely used in hospitals and homes and are designed to accommodate people with varying levels of mobility. Other manufacturers produce suitable bikes, and your choice may depend on availability, features, personal preference and of course, price.

Two Approaches: Integrated and Universal

There are two fundamentally different ways to combine a stimulator with a bike, and understanding this distinction will help you evaluate your options.

Integrated Systems

In an integrated system, the stimulator and bike are designed to work together as a matched pair. They are connected by a communication cable that allows the stimulator to read the pedal position directly from the bike's sensors. This tight integration means the system can precisely synchronise stimulation with pedal rotation and, in some designs, automatically adjust stimulation intensity based on your pedalling performance.

The RehaMove system (which we offered for many years, combining a Hasomed RehaStim stimulator with MOTOmed bikes) exemplifies this approach. The Restorative Therapies RT300 system from the USA follows a similar philosophy.

Advantages: Seamless synchronisation between the stimulator and the bike. The system "knows" exactly where the pedals are at every moment.

Limitations: You are restricted to the specific bike models that the stimulator is designed to work with. If you already own a passive/active bike of a different brand, you cannot use it as an FES cycling system. The integrated approach also tends to result in higher overall system costs because you must purchase both components as a package.

Universal Stimulator Systems

A universal stimulator system separates the stimulator from the bike. Instead of reading pedal position from the bike via a cable, the stimulator uses its own sensors (typically inertial or motion sensors) to detect your limb movement and synchronise stimulation accordingly.

The Stim2go from Pajunk is the product we now work with, and it exemplifies this approach. The Stim2go unit is strapped to your thigh and tracks your leg's position through the complete pedal stroke using built-in motion sensors. It maps this movement as a percentage of the cycle (0 to 100%) and triggers stimulation to the appropriate muscles at the correct moment, just as an integrated system would, but without any physical connection to the bike. The same stimulator can be attached to an arm and used for arm exercises on an appropriate bike.

Advantages: You can use any passive/active bike. If you already own a TheraTrainer, a MOTOmed, or any other suitable bike, you can add FES capability without replacing it. This flexibility can significantly reduce the overall cost of a system. The stimulator is also portable and can be used for many applications beyond cycling (including upper limb exercise, transcutaneous spinal cord stimulation, pain management, and neuromuscular strengthening), making it a more versatile investment.

Limitations: Because the stimulator senses your movement rather than reading the bike's sensors directly, the synchronisation is based on limb movement patterns rather than the exact pedal position. In practice, this works well, but it is a different technical approach from the integrated model.

Which Approach Is Right for You?

For most new users, we think the universal stimulator approach offers the best combination of flexibility, cost, and future-proofing. If you already have a passive/active bike, adding a universal stimulator is a straightforward way to create an FES cycling system without a large additional outlay on a new bike. If you are purchasing everything from scratch, your approach may depend on the specific products available to you and your provider's recommendations.

There is no evidence that one approach produces better clinical outcomes than the other. Both deliver synchronised FES cycling, and the health benefits described in Chapter 4 are achievable with either.

Electrodes and Consumables

Electrodes are the interface between the stimulator and your body. In FES cycling, self-adhesive surface electrode pads are placed on the skin over each muscle group to be stimulated. A typical leg-cycling setup uses electrode pairs on the quadriceps, hamstrings, gluteal muscles, and (in many programmes) the calf muscles and the tibialis anterior.

What You Need to Know About Electrodes

• Size matters. Larger electrodes distribute the electrical energy over a wider area, which is generally more comfortable and produces a broader muscle contraction. However, on smaller limbs, electrodes that are too large may inadvertently stimulate adjacent muscles. Your provider will advise you on the appropriate size.

  

• Placement consistency. Getting the electrodes in roughly the right position is not difficult, and most people learn this quickly. What matters more is consistency: placing the electrodes in the same position from session to session to ensure a predictable stimulation effect. Some people find it helpful to mark the electrode positions with a skin-safe marker until the placement becomes second nature. The Stim2Go unit we work with has a virtual reality feature that deals with this issue.

• Electrodes are consumable. The adhesive pads lose their stickiness over time and need to be replaced. How often depends on usage, skin condition, and storage between sessions. You should expect to replace electrodes regularly, and the cost of replacement pads is an ongoing expense to factor into your budget. Electrodes can be expected to last between 15 and 20 sessions if cared for according to the manufacturer's instructions.

• Skin care. The skin beneath the electrodes should be clean and dry before each session. After the session, check the skin for any redness or irritation. Mild redness that fades within an hour is normal; persistent redness, spots, or broken skin should be reported to your provider. They are available in different grades, and in rare cases when sensitivity develops, special electrodes are available to reduce skin irritation if this becomes an issue. We would advise individuals never to use skin cream on their legs before a training session, as it can interfere with the effectiveness of muscle stimulation. We also would not advise most individuals to shave their skin. If hair is very long, then this can be trimmed, but shaving is generally not necessary

Other Consumables

Beyond electrodes, the other consumable items are electrode cables (which can wear out over time and occasionally need replacing).

Controlling the System

Modern FES cycling systems are controlled through software, either on a dedicated screen built into the stimulator, on a connected tablet or computer, or (increasingly) through a smartphone app.

The Stim2go, for example, is controlled via an iOS or Android app. This allows your stimulation programmes to be set up, customised, and updated easily. Approximately 30 programme templates are available covering different applications, and each can be tailored to your individual needs by you or your clinician. Programme updates can be delivered through the app, so your system stays current without needing hardware changes.

Regardless of the system you use, the software will typically allow you to:

• Select which muscles are stimulated and in what sequence
• Adjust stimulation parameters (frequency, pulse width, current) for each muscle group
• Set or adjust the timing of stimulation relative to the pedal cycle
• Control warm-up and cool-down phases
• View session data such as cycling speed, power output, and session duration

In the early stages, your provider or clinician will configure these settings for you. Over time, many users learn to make adjustments themselves, though the level of independence varies. Some prefer to manage everything; others prefer periodic reviews with their provider. Either approach is fine, and what matters is that you feel confident in how the system operates.

What Does It All Cost?

Cost is a significant consideration.

System Costs

A complete FES cycling system (stimulator, bike, assessment, setup, training, and initial follow-up support) has historically cost upwards of £14,000. Integrated systems based on the RehaMove platform, for example, were typically priced between £12,400 and £15,900 depending on the bike model and configuration.

The universal stimulator approach can reduce costs, particularly if you already own a suitable passive/active bike. In that case, your investment is primarily in the stimulator, assessment, setup, and training. If you need a new bike as well, the combined cost will depend on the bike model you choose.

Most users with a medical condition will not need to pay VAT, as these products are zero-rated for VAT purposes when supplied for a qualifying disability.

Quoted prices from a reputable provider should always include hardware, software, delivery, initial assessment, system setup, personalised configuration, training (for you and your carer or family if applicable), and initial follow-up support. If a provider quotes a price that does not include these elements, ask what is and is not covered before committing.

Ongoing Costs

Beyond the initial purchase, expect the following ongoing costs:

• Replacement electrodes. These are regular consumable expenses. The frequency of replacement depends on usage and skin condition.

• Electrode cables. These are durable but not indestructible. Occasional replacement may be needed, and they can be quite expensive.

• Periodic clinical reviews. Your provider might offer periodic reviews to check your progress and adjust your programme. Whether these are included in the initial price or charged separately varies by provider, so it is worth clarifying at the outset.

• Equipment servicing. Bikes may require occasional maintenance (particularly if they have a motor and moving parts). Stimulators are generally low-maintenance but may need software updates or battery replacement over their lifespan.

Funding Pathways

In the UK, the most common routes to funding an FES cycling system include:

• Medico-legal settlements. Following a catastrophic injury (most commonly spinal cord injury), compensation settlements frequently include provision for rehabilitation equipment. This is the most common funding route for our clients and is supported by the strong evidence base for FES cycling.

• Insurance claims. Where personal injury insurance is in place, FES cycling may be included as part of the rehabilitation provision.

• Charitable grants. A number of charities support people with spinal cord injuries and other neurological conditions. Some have funded FES cycling systems for individuals who would otherwise be unable to afford them.

• Personal funds. Some individuals choose to invest in FES cycling from their own resources.

• Employer or trade union support. In some cases, employers or trade unions have contributed to the cost of equipment for injured employees or members.

• NHS provision. A small but growing number of NHS services have adopted FES cycling for neurorehabilitation. Access varies by region and is often limited by staffing and resource pressures. Community-based or clinic-based access on a "pay as you go" basis is becoming more available through therapy partner networks.

We discussed the cost barrier in Chapter 6. It remains a significant issue, particularly for people with stroke, MS, or other conditions who do not have access to medico-legal funding. We hope that as products become more affordable and accessible, this barrier will reduce over time.

Medical Devices vs Consumer Products

You will find electrical stimulation products at a wide range of prices, from under £30 to many thousands of pounds. It's reasonable to ask why medical devices should be so much more expensive than consumer devices. It is worth understanding what you are comparing.

Products marketed as medical devices have been through a regulatory approval process that verifies their safety, performance, and manufacturing quality. They use current-controlled stimulation (which ensures consistent and precise muscle contractions regardless of changes in skin moisture or electrode condition), meet international safety standards, and are supported by clinical evidence.

Consumer-grade products (often marketed for sports, fitness, or general wellness) are not subject to the same regulatory requirements. They may use simpler voltage-controlled circuits, offer less precise stimulation, and lack the safety protections that medical devices provide. They are not designed for people with neurological conditions and may not deliver the therapeutic parameters needed for effective use. Of course, for FES cycling, it's necessary to have a stimulator that can deliver appropriate stimulation to multiple muscle groups in sync with movement. Only specialised devices can do this.

For FES cycling, we strongly recommend using equipment that is classified as a medical device. The safety and effectiveness of the stimulation depend on it, and the consequences of using an inappropriate device with paralysed limbs (where you may not be able to feel if something is wrong) are not worth the saving.

Beyond Cycling: Versatility of Modern Stimulators

One advantage of modern universal stimulators is that they are not limited to cycling. The Stim2go, for example, supports:

• FES cycling (leg and, where appropriate, arm exercise)

• Neuromuscular electrical stimulation (NMES) for targeted muscle strengthening

• Transcutaneous spinal cord stimulation (tSCS) for spasticity management and emerging functional applications

• TENS for pain management

• Motion-triggered functional exercises for upper and lower limbs

This means your investment in a stimulator can support a broader range of therapeutic activities beyond cycling. If your rehabilitation goals include upper-limb function, pain management, or spasticity control, a versatile stimulator may offer better value than a device designed solely for cycling.

Chapter Summary

• An FES cycling system consists of two components: a stimulator and a passive/active bike.
• Integrated systems connect the stimulator directly to a specific bike model, offering tight synchronisation but possibly limiting your bike options.
• Universal stimulator systems (such as the Stim2go) use motion sensors to synchronise with any bike, offering greater flexibility and potentially lower cost.
• Both approaches deliver effective FES cycling. There is no evidence that one produces better clinical outcomes than the other.
• Electrodes are consumable and need regular replacement. Consistent placement matters more than perfect positioning.
• Modern systems are controlled through software or smartphone apps, allowing personalised programming and easy updates.
• Complete system costs have historically started at around £14,000 for integrated systems. Universal stimulator systems can reduce costs, especially if you already own a suitable bike.
• Funding pathways include medico-legal settlements, insurance, charitable grants, personal funds, and (increasingly) NHS or community-based provision.
• Use medical-grade devices, not consumer products. Safety, precision, and clinical evidence matter.
• Modern stimulators offer versatility beyond cycling, potentially supporting multiple therapy applications from a single device.

In Chapter 9, we turn to what happens during your sessions: how a typical session is structured, how to manage common challenges such as spasticity and autonomic dysreflexia, and how to get the most from each workout.