What You Will Learn

This chapter marks the transition from understanding the evidence to putting it into practice. If you have read Part 2 (Chapters 4, 5, and 6), you now know what FES cycling can and cannot do, which conditions it applies to, and where the limitations lie. Here we walk you through what happens when you decide to explore FES cycling for yourself: the initial enquiry, the clinical assessment, suitability screening, goal setting, choosing a provider, preparing your home environment, and what to expect in your first sessions. By the end, you should feel informed and confident about the steps ahead.

Starting the Conversation

Most people first hear about FES cycling through their clinical team, a case manager, a fellow patient, or through their own research. Wherever you encounter the idea, the first step is to contact a provider and start a conversation. This does not commit you to anything.

At Anatomical Concepts, the process typically begins with one of three routes:

A telephone or online enquiry. You, a family member, or a member of your clinical team contacts us to discuss your situation. We ask some initial screening questions to understand your condition, your goals, and whether FES cycling is likely to be suitable for you. In basic terms, both parties need to know that FES cycling would be safe and effective for the individual.
An introductory webinar. From time to time, we run short, low-pressure online sessions that explain the science behind FES cycling, the products available, costs, and what to expect. Family members, carers, and support staff are welcome to attend alongside you. There is no sales pitch, and you will not be added to a mailing list without your permission.
A referral from your therapist or case manager. Quite often, it is a client's physiotherapist or case manager who contacts us first. This is a natural route, and we are happy to discuss your situation with your clinical team before you are directly involved.

The important thing at this stage is that you gather enough information to decide whether a formal assessment is worth pursuing. There is no obligation, and a good provider will never pressure you into a decision.

The Clinical Assessment

If the initial conversation suggests that FES cycling may be suitable for you, the next step is a clinical assessment. This is a detailed, face-to-face evaluation that should demonstrate whether FES cycling is appropriate, safe, and likely to be beneficial for your specific situation. It should always take place before any purchase decision.

What Gets Assessed

A thorough assessment will typically cover the following:

Your medical history and current condition. This includes the nature of your injury or diagnosis, the level and completeness of any spinal cord damage, the time since injury, and any other medical conditions that might affect your suitability.

Whether your lower motor neurons are intact. As we explained in Chapter 5, this is the fundamental requirement for FES cycling. The assessment should include testing your muscles' response to electrical stimulation. If a muscle contracts when stimulated, the lower motor neurons are intact, and FES cycling can work. If there is no response, the muscle may be denervated, and a different approach is needed.

Contraindications. Your assessor will ask you about the contraindications we described in Chapter 6: cardiac pacemakers, active DVT, pregnancy, active fractures, and so on. Some contraindications are absolute (FES cycling cannot be used); others are relative (it may be possible with careful management).

Joint range of motion. You need sufficient movement at the hips and knees to enable pedalling. If contractures (fixed tightness in the joints) limit this range, they may need to be addressed before FES cycling can begin, or the bike setup may need to be adjusted accordingly. The aim is to move through a good range of motion without the legs reaching full extension at any point in the cycle.

Your skin condition. The assessor will check the areas where electrodes will be placed. Electrodes should not be applied over broken skin, open wounds, or areas of active infection.

Autonomic dysreflexia risk. If you have a spinal cord injury above the T6 level, you may be at risk of autonomic dysreflexia during FES cycling. This does not prevent you from using the system, but it does require additional monitoring and precautions, which we cover in Chapter 9.

Your goals and expectations. A good assessment is not just about physical suitability. It is also about understanding what you hope to achieve and ensuring those expectations are realistic. As we discussed in Chapter 6, FES cycling is a long-term health tool, not a pathway to walking recovery for most people. Your assessor should be honest about what is achievable.

When we started working with FES cycling around 2007, one of our biggest concerns was whether clients would continue to use their systems. Thankfully, most do, and checking that a product meets all individual requirements is an important step in making this likely.

Trial Sessions

A trial session is invaluable. This gives you the opportunity to experience FES cycling before committing to a purchase. You can see how your muscles respond to the stimulation, how the equipment feels, and whether the overall experience is comfortable for you. Most providers offer home demonstrations. At Anatomical Concepts, these are arranged with our office following a simple screening for contraindications as described above. One of us will bring a complete system and demonstrate its operation in a session that we expect to last 60 to 90 minutes. We show how to set up the software and customise the stimulation. This can be arranged by the intended user or, if there is one, their clinical adviser.

Setting Realistic Goals

Goal setting is an important part of getting started, and it works best when it is collaborative: a conversation between you, your clinical team, and your provider, rather than something imposed from above.

Goals should be specific, measurable, and grounded in evidence. Some examples of realistic goals include:

Building and maintaining muscle mass in the legs. This can be tracked with a simple tape measure around the thigh at a consistent point.
Improving cardiovascular fitness. This is harder to measure at home but may be reflected in longer session durations, higher power outputs, or (where appropriate and available) heart rate monitoring.
Reducing spasticity. You and your clinical team can track whether your legs feel looser and whether the frequency or severity of spasms decreases over time.
Improving circulation and skin health. Reduced swelling in the feet and lower legs, warmer skin after sessions, and fewer skin issues may all indicate improved circulation.
Maintaining bone density. This can only be confirmed through DEXA scanning, but your clinical team may recommend periodic scans if bone health is a primary concern.
Maintaining or improving general well-being. This is subjective but no less important. Many of our clients describe a sense of purpose and routine that comes from regular FES cycling.

It is worth setting goals at the outset and revisiting them periodically. Your goals may change as your fitness improves or as your priorities shift.

Choosing a Provider

Not all FES cycling providers are the same, and it is worth taking time to choose carefully. This is a significant investment, and the quality of the provider's assessment, setup, training, and ongoing support will directly impact your experience.

Questions to Ask

When evaluating a potential provider, consider asking:

What does the assessment process involve, and is there a charge?
Can I have a demonstration before committing to a purchase?
What training is provided, and does it extend to my carer or family members?
What happens if I have a problem with the equipment after purchase?
How easy is it to reach someone for technical support?
What evidence supports the outcomes you describe?
Can you put me in touch with existing users who are willing to share their experience?

Warning Signs

Be cautious of providers who:

Promise outcomes that sound too good to be true (particularly claims about walking recovery)
Use high-pressure sales tactics or create artificial urgency (an offer that is good for today only!)
Sell equipment without a proper clinical assessment
Are vague about ongoing support and maintenance
Are reluctant to demonstrate the equipment or offer a trial

A good provider will welcome your questions and take the time to ensure that FES cycling is genuinely right for you. If a provider makes you feel rushed or pressured, that is a reason to look elsewhere.

Preparing Your Home Environment

Most of our clients use FES cycling at home, so the practical aspects of fitting the equipment into your living space deserve careful thought.

Space Requirements

An FES cycling setup requires space for the bike itself and room to position yourself comfortably with your feet secured to the pedals. You also need adequate access for carers or family members to assist with electrode placement and setup if needed.

The exact space required depends on the bike model. Some bikes are more compact than others, and some can be folded or partially disassembled when not in use. It is worth discussing this with your provider and, where possible, trying the specific equipment in your home before making a final decision. Equipment that is too large for the room, poorly positioned, or impractical in the home often ends up unused. A home visit or trial can prevent this.

Electrical Requirements

FES cycling equipment uses standard UK mains power. You will need access to a power socket within reach of the bike and stimulator. There are no special electrical requirements.

Storage and Electrode Supplies

You will need a small amount of storage space for electrode pads (which are consumable and need to be replaced periodically), electrode cables, and any cleaning supplies. These items are not large, but having a dedicated space for them helps keep your setup routine efficient.

The Role of Your Support Team

FES cycling at home is rarely a solo endeavour, particularly in the early stages. The people around you play important roles.

Clinical Support

Your provider should carry out the initial setup and configuration of the system, tailored to your individual needs. This includes determining which muscles to stimulate, at what intensity, and how to structure the session. They should then train you (and, where relevant, your carers) to manage sessions independently. After the initial setup, periodic reviews may be advisable to check your progress, adjust stimulation parameters, and progress the programme as your muscles adapt. Follow-up visits may be chargeable. Some providers will have online and self-help resources to support any training and usage needs.

Your own physiotherapist or clinical team should be kept informed. FES cycling works best as part of a broader rehabilitation plan, and your therapist can help integrate it with your other therapy goals.

Carers and Family

Some people can manage electrode placement, system setup, and session management entirely independently. Others need help, particularly with electrode placement on the backs of the legs or on the gluteal muscles, which can be difficult to reach from a wheelchair.

If you rely on a care team, they need training. This training should cover electrode placement, operating the stimulator, recognising problems (such as skin irritation or an unusual muscle response), and knowing what to do if something goes wrong. What matters is that everyone involved feels comfortable and confident with the process. If they do not, more training is needed before you begin using the system independently.

Family members who attend your initial training sessions or introductory webinars will be better placed to support you. Even if they are not directly involved in the setup, understanding what you are doing and why can make a real difference to their ability to encourage and assist you.

Your First Sessions

We described the walkthrough of a typical session in Chapter 1. Here we focus on what to expect in the very first few sessions, when everything is new.

Expect a Learning Curve

Your first session will take longer than subsequent ones. The electrode placement needs to be established for the first time, the stimulation parameters need to be set and tested for each muscle group, and your positioning on the bike needs to be optimised. Your provider or clinician will guide you through all of this. We find that people worry about electrode placement. We teach simple approaches that make placement easy. The Stim2go has a Virtual Reality feature that can "show" users where and how to place electrodes for consistency.

The active cycling portion of your first session may be as short as 10 to 15 minutes. Your muscles have not been working actively, and they will fatigue quickly. This is normal and expected. Do not be discouraged by a short first session; it is a starting point, not a measure of what you will achieve in time.

It's important not to be tempted to maximise stimulation intensity on day one. This is a marathon, not a sprint, so think long-term and gradual adjustments to be kind to your body.

What You Will Notice

If you have no sensation in your legs, you will see your muscles contracting and your legs moving but will not feel the stimulation itself. This can feel unusual at first. If you have some preserved sensation, you will feel a tingling or pulsing sensation beneath the electrodes, which is adjustable.

You may notice that your muscles warm up during the session and that your legs look slightly different (fuller, firmer) immediately afterwards. You may also feel more relaxed in your legs after the session, particularly if spasticity is normally an issue.

In the first few sessions, do not worry about power output, cycling speed, or resistance levels. The priority is to establish that the system is working correctly, that your muscles are responding, and that you and your support team are comfortable with the setup process.

Building the Habit

The research and our experience agree on one point above all others: the people who get the most from FES cycling are those who make it a regular habit. The first few weeks are about establishing a routine, not about chasing performance. If you can get to a point where FES cycling is simply something you do, like brushing your teeth or managing your bladder routine, you have set yourself up for long-term benefit.

We recommend starting with three sessions per week, each lasting 20 to 30 minutes or as long as your muscles will allow. Over the first few weeks, session duration will naturally increase as your muscles adapt. We discuss how to progress your programme in detail in Chapter 10.

Bowel and Bladder Considerations

It is practical advice, but worth mentioning: ensure your bowel and bladder are managed before you begin each session. The muscle contractions during FES cycling can stimulate the bowel, and an unexpected bowel accident during a session is both uncomfortable and disheartening. Most of our experienced clients plan their sessions around their bowel routine to avoid this.

Chapter Summary

Start by contacting a provider. An initial conversation or webinar will help you decide whether a formal assessment is worthwhile. Request a quote for the systems that interst you.
A thorough clinical assessment is essential before you begin. This should assess your basic medical history, lower motor neuron integrity, contraindications, joint range of motion, skin condition, and risk of autonomic dysreflexia.
Set realistic, measurable goals in collaboration with your clinical team and provider. Revisit these periodically.
Choose your provider carefully. Ask questions about assessment, training, support, and evidence. Be wary of anyone who promises too much or pressures you to decide quickly.
Prepare your home environment in practical terms: consider space, access, transfers, and storage.
Your support team (clinician, carer, family) should be trained and confident. FES cycling works best when everyone involved understands the process.
Your first sessions will be short, and that is normal. The priority is to establish the routine and let your muscles adapt.
Manage your bowel and bladder before sessions.
Building the habit matters more than early performance. Consistency is the foundation of long-term benefit.

In Chapter 8, we look at the equipment itself: what is available, how different systems compare, and what to consider when making your choice.

Getting Started: Assessment and Setup