FES Cycling after a Stroke: A Physical Therapist’s Perspective

By Liz Fuhrhop, Doctor of Physical Therapy and Clinical Support Specialist for MYOLYN

As a physical therapist who worked for years at the top-ranked rehabilitation hospital in the country, a sizable majority of the patients I’ve treated throughout my career have been affected by stroke. And that’s not surprising since every year more than 795,000 people in the US alone have a stroke, according to the CDC.

There are two main types of strokes: ischemic and hemorrhagic. Ischemic strokes are more common and occur when blood flow is blocked to the brain, causing rapid death of brain cells. A hemorrhagic stroke involves bleeding in the brain, also causing damage to brain cells.

After stroke, patients can present with a number of physical challenges, depending on where and how much the brain is impacted. One of the most common presentations after stroke is referred to as hemiparesis or hemiplegia—meaning one side of the body has significant muscle weakness or paralysis. It’s common to also experience issues with coordination, stiffness (spasticity), and changes in sensation. All of these impairments can lead to difficulty carrying out activities of daily living, including standing, balancing, and walking.

FES cycling is an intervention in which functional electrical stimulation is used to facilitate stationary cycling in people with paralysis or weakened muscles. The stimulation causes controlled contractions of muscles that are weakened and/or hard to activate by the patient voluntarily.

Published research on FES cycling after stroke has shown improved strength, reduced spasticity, increased walking distance and improved balance in participants. FES cycling is also an effective, intensive workout, activating key muscles of the trunk, thigh, and lower leg, without the risk of falling. In the research, studies have used the stimulation only on the weaker leg, as well as both legs.

If you or your loved one have had a stroke, you may be familiar with the concept of neuroplasticity, or the nervous system’s ability to rewire and create new connections. One of the tenets of neuroplasticity is intensity; exercise and rehabilitation interventions need to be intense, or demanding in effort, in order to drive neuroplasticity and maximize recovery. Simply put, without intensity, we won’t get optimal results.

Throughout my career, I’ve seen great results in patients after stroke when FES cycling is included in the plan of care. I can recall a patient who had really pronounced weakness on her affected side—so much so that she required the fabrication of a long leg brace, known as a KAFO (knee ankle foot orthosis) because her quad was incredibly weak and her knee would buckle under her weight while standing. She was really fearful of falling and hesitant to try other exercises, so we went full force into FES cycling while we waited for her brace to be fabricated. After about two weeks of intensive FES cycling the brace was delivered, but her quad had recovered so significantly in strength and motor learning that she hardly needed the KAFO, and we were quickly able to transition to a much less cumbersome AFO (ankle foot orthosis).

I also love to use FES cycling as a “neuro-primer” for patients after stroke before other functional interventions; this allows us to drive input into and activate the nervous system to prepare it to rewire and make neuroplastic changes. I’ve seen many instances in which after just a short time cycling (10-20 minutes), we see patients better able to recruit and control their affected lower extremity, allowing the brain to make and strengthen new neural connections required to improve functional mobility.

Finally, for people recovering from stroke in the chronic phase (greater than 6 months after stroke), FES cycling provides a safe and intensive form of ongoing therapeutic exercise to promote long-term health. I found it difficult to prescribe walking home exercise programs for many patients recovering from stroke because they continued to remain at a significant fall risk, especially when we are trying to achieve intensity. FES cycling allows for that intensity without fall risk. It’s also important for people recovering from stroke to maintain range of motion in their affected limbs. Spasticity, or the involuntary contraction of muscles, can lead to contractures, or loss of range of motion, which is very difficult to regain once lost and can lead to other musculoskeletal issues. FES cycling has been shown to reduce spasticity as well as maintain or increase range of motion in the legs, decreasing this risk.

The ability to easily provide an intensive therapeutic workout, both in the clinic and at home, is one of many reasons I love using the MyoCycle for patients after stroke. Additionally:

The user is in control of their level of stimulation at all times. We encourage the use of the highest levels of stimulation tolerable in order to drive the strongest possible muscle contractions. The harder the muscles work, the better the workout!

The MyoCycle detects the user’s output and automatically applies resistance to cycling so that the workout is customized to the specific abilities of the user—if you push hard, the MyoCycle pushes hard back. This ensures a dynamic, load-bearing and challenging workout that automatically adjusts to the unique abilities of the user.

Foot drop is a common presentation seen after stroke. The MyoCycle V2 Plus systems have a “Walking mode” feature where we can coordinate the stimulation to train the motor pattern of the knee straightening/foot lifting as seen during the swing phase of walking. This may help influence the reorganization of the motor programs in the nervous system and improve function in walking.

The “symmetry” reading on the MyoCycle allows the user to determine how much work the left leg is doing compared to the right leg. This metric allows the user to see how much the weak side is lagging and work toward narrowing the gap.

If you or your loved one is recovering from a stroke, I would suggest looking into FES cycling to continue therapeutic exercise at home. You can learn more about FES cycling and the MyoCycle by requesting more information or attending one of our webinar events.