FES Cycling for Stroke Rehabilitation
A Supplement to Conventional Practice
Developed by Rob Sykes, SPT
Overview
I previously had a clinical rotation at the UNC Health Care Rehabilitation Center where many of my patients were rehabilitating from stroke. Stroke is a common diagnosis in inpatient rehabilitation facilities (IRFs) with one recent report showing that stroke represents the most common diagnosis among Medicare beneficiaries, accounting for 19.5% of all IRF cases.1 Following stroke, patients often demonstrate impairments, such as decreased strength, that can have a significant impact on their functional capacity.2 Physical therapy can diminish these impairments, help patients regain their independence and prepare them for the demands of their daily lives. As such, physical therapists are continually seeking ways to improve patient outcomes.
One intervention that is available to physical therapists is functional electrical stimulation (FES). FES can be implemented in a variety ways, one of which is FES cycling. I knew during my time at UNC’s Rehab Center that the facility owned an FES cycle, but it was something that was infrequently utilized. A curiosity about the potential benefits of this therapeutic modality led to the development of my capstone project. I wanted to learn more about the clinical benefit of FES cycling as it relates to individuals post stroke and present this information in such a way that would be useful to therapists in the rehab setting.
Products
I first developed a critically appraised topic that specifically addresses the benefits of FES cycling within the acute/subacute phase of stroke rehabilitation. I then performed an additional literature review that examines the benefits of FES, in general, among individuals rehabilitating from stroke. This information was organized into an evidence table. I presented my findings to a group of 10 rehab therapists (PTs, PTAs, OTs, and OTAs) at the UNC Health Care Rehabilitation Center. The PowerPoint presentation can be accessed here, as well as the demonstration videos associated with slides 9, 12, 13, and 17. The aim of the presentation was to dismantle some of the barriers that prevent therapists from utilizing FES, suggest different ways for utilizing the FES cycle, and discuss the types of patients that would benefit most from this intervention. Lastly, I created a user guide to help therapists use the FES cycle.
Evaluation
In order to evaluate the quality and utility of my presentation, I created a feedback survey for presentation attendees. Overall, I received very positive feedback indicating that the presentation was “very informative,” “relevant,” and “beneficial.” As I modify the material for future presentations, I aim to broaden the scope and give consideration to audience members from other professions, such as occupational therapy.
Acknowledgements
I would like to thank my faculty advisor, Vicki Mercer, for helping me brainstorm ideas during the nascent stages of project development. I would also like to extend my sincere gratitude to my project committee members, Karen McCulloch, Audrey Osinski, and Calvin Wang. This project would not have been possible without their continual assistance and feedback along the way. I also want to thank my former clinical instructor Carty Husted for her support during my time as her student but also for helping me get this project off the ground. Last, but certainly not least, I want thank the UNC Health Care Rehabilitation Center for allowing me to return and share this project with its rehab therapy team.
References
- Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy [pdf]. MedPAC website. http://www.medpac.gov/-documents-/reports. Published March 15, 2016. Accessed March 26, 2016.
- Olney SJ, Richards C. Hemiparetic gait following stroke. Part I: Characteristics. Gait & Posture. 1996;4:136-148.
5 Responses to “FES Cycling for Stroke Rehabilitation: A Supplement to Conventional Practice”
KMac
Hi Rob – Nice work here, Rob – I’m glad that you took something you observed in clinic and turned it into a project! I think there is often excitement about new equipment and/or treatment ideas, but the ability to really integrate them into the clinical context that is the current practice environment isn’t easy. I like that you addressed potential barriers one by one in the presentation and “knocked those down” so that maybe this equipment will be better utilized in practice!
kmac
Rob Sykes
Thanks, Chris! I’m glad you enjoyed it. Is FES worth doing instead of something else? Unfortunately, there are a lack of controlled studies that have examined a fair comparison between FES cycling and other interventions. In most studies, the experimental group that receives FES is receiving FES in addition to the standard therapy that the control group is receiving. Thus, it’s difficult to say whether or not the benefits conferred by FES would have been as large if the control group had received an equal amount of total treatment.
In light of this gap in the evidence, here are my thoughts: In the inpatient rehab setting our goal is to get patients home as quickly and safely as possible. So as you can imagine, the most important things to work on are the functional activities that patients have to perform when they return home (e.g., transfers, ambulation, stair climbing, etc.). These activities can absolutely not be overlooked. However, what about patients who can only ambulate 5 to 10 feet at a time and require significant rest breaks due to deconditioning? Then the therapist must ask himself the question, “What’s better: a small volume of task-specific training or a considerably larger volume of FES cycling?” For these patients and others that I mention in my presentation, it is appropriate to consider FES cycling as a worthwhile intervention. But to be clear, I would not suggest that FES become your principal intervention, just a supplement.
Hope that helps,
-Rob 🙂
Christopher Hope
Hey Rob. Excellent job on this project. This is something that has direct clinical application and meaningfulness, especially to the providers and patients at the IRF where you were on clinical rotation. I’m not surprised that you received such positive feedback regarding your presentation.
Your PowerPoint slides are great; they’re even entertaining to read through. Great job of almost making it conversational while maintaining an appropriate level of professionalism. I learned a great deal about FES cycling, and I especially appreciated that you tied in ways to make the results more functional. The slides were crisp, clean, and neat – easy to read through. And the content flowed well thanks to good organization, spacing, and pace of information. Now I want to see the presentation!
I also liked that you went the extra step by making a user’s guide for the FES cycle. If I were a practicing clinician, this is exactly the type of thing that would make it easy for me to jump back into using it. It shows that you were in tune with your audience and really were interested in drawing therapist interest back to that therapeutic tool.
The evidence table is a nice tool to quickly reference the literature and synthesize the evidence. Nice job putting that together.
Finally, I couldn’t help but wonder how the FES compares to other therapeutic interventions in the IRF setting. Sure it improves function and outcome measure scores, but is it worth doing instead of something else? You noted that the systematic review by Kafri & Laufer was unable to draw conclusions of the effectiveness of FES versus conventional therapy, but did you come across other comparisons in your research? Thanks for clarifying.
Again, excellent job. You did a great job putting together this presentation, and I appreciate you sharing what you learned.
– Chris
Rob Sykes
Thanks for the feedback, Katie!
Regarding set up time, that’s going to depend on the therapist’s experience, the number of channels being used, and whether or not the patient has used the cycle before. There is a registration process for new patients but this is a one-time occurrence. Even with the registration, it shouldn’t take more than 10 minutes to get the patient registered and set up on the cycle. For returning users, it’s really just a matter of placing the electrodes on the targeted muscles and pressing “Go.” The parameters can be saved, so adjusting parameters doesn’t take much time at all. However, if you’re going to use the FES cycle, I would also encourage you to think of ways to incorporate therapy into the set up time.
I could not find any studies that compared FES during ambulation to FES during cycling, and you raise a really good point about task-specificity. The study by Bogataj et al (1995), which was also cited in the meta-analysis by Robbins et al (2006), utilized multi-channel FES during ambulation and demonstrated a large effect for FES training. One of the limitations of this study, however, is that the protocol did not seem feasible for most clinical settings secondary to time constraints and personnel requirements. In short, if a patient is ambulatory, then I suspect you are always better off opting for task-specific training. However, for patients who perhaps demonstrate profound muscle weakness or deconditioning and cannot tolerate a high volume of weight-bearing activity, then the FES cycle should be considered.
Great questions!
-Rob 🙂
Katie Sly
Hi Rob!
I enjoyed reviewing your capstone project! I did not have a lot of prior knowledge regarding FES, so your presentation was very informative and thoroughly reviewed current evidence for use of FES in clinical practice. As you mentioned in your materials, FES cycling can be used as a useful adjunctive therapy to traditional rehabilitation.
Overall, I thought your CAT and evidence table were well organized and clearly described the current literature related to FES. It is clinically relevant to be aware of the benefits of FES, including improvements in strength, gait speed and walking independence.
I thought your PowerPoint was easy to follow, and the videos were a nice touch! I did have a few questions when reviewing your materials:
-What is the typically set up time for the FES cycle? I know you mentioned time might be a barrier to use in the clinic.
-Is there any literature that directly compares FES during ambulation to FES during cycling? I noticed that Kafri et al reviewed FES during gait and cycling but did not compare their effectiveness. Is it safe to assume that clinicians should use the most specific training as possible if attempting to improve gait (ie if a patient can ambulate, should FES be utilized with ambulation instead of cycling)?
I greatly appreciate the information that you presented in your capstone project! I know that a lot of time and effort was put into your products!
Thanks,
Katie Sly