Functional electrical stimulation

1. Introduction

Version followed: NICE interventional procedures guidance IPG278, Functional electrical stimulation for drop foot of central neurological origin (published 28 January 2009, minor maintenance update 9 January 2012), read alongside the 2023 UK stroke guidance (NICE NG236 and the National Clinical Guideline for Stroke 2023) as quoted in NHS service material, UK clinic patient information, and US device labelling. Regulatory and commissioning status as of October 2026 per the sources listed.

What it is. Functional electrical stimulation (FES) delivers small electrical pulses to a nerve, usually through adhesive skin-surface electrodes (less often through implanted electrodes), so that a weak or paralysed muscle contracts at the moment it is needed for a functional movement. NICE describes the aim as producing contractions that "mimic normal voluntary gait movement" [source: NICE IPG278]. It is used for people with upper motor neurone damage: stroke, multiple sclerosis (MS), cerebral palsy, incomplete spinal cord injury (SCI) and acquired brain injury [source: NICE IPG278; UCLH FES clinic]. It does not work where the lower motor neurone (the peripheral nerve) is damaged, because the nerve itself must be intact to carry the stimulus [source: NICE IPG278; SCIRE FES cycling toolkit lists lower motor neurone involvement as a precaution].

This is not a psychotherapy. FES is assessed, set up and reviewed by registered rehabilitation professionals, chiefly physiotherapists (and in some UK services clinical scientists in medical physics or rehabilitation engineering), within consultant-led or multidisciplinary neurorehabilitation services [source: UCLH FES clinic; HCPC professions list]. This guide is written for the psychotherapist working alongside that team. It gives a descriptive account of the treatment, with no stimulation settings, electrode positions or protocol numbers, and then the psychotherapist's own work: adjustment to disability, motivation and ambivalence, body image, informed consent, and collaboration with the team.

How change happens (as the sources frame it). Three mechanisms appear in the sources: (1) an orthotic effect: while the device is switched on it substitutes for lost muscle activity (for example lifting the front of the foot during walking so the person trips less); (2) a training or therapeutic effect: repeated, intensive, task-linked practice is thought to support motor learning and neuroplasticity, especially in upper-limb rehabilitation after stroke; (3) exercise and health effects in SCI, where FES cycling exercises paralysed muscles, with reported benefits for circulation, muscle bulk and bone [source: NICE IPG278; Pennine Lancashire upper-limb FES presentation; SCIRE toolkit; MSKTC FES and SCI]. Psychological change (confidence, independence, social participation, a more "normal" looking walk) is reported by users as a major part of the benefit [source: Bulley et al. 2011 [first author's name uncertain]; Burns, Calder & Devan 2023].

2. Framework

FES has no psychotherapeutic phases. The pathway below is the treatment pathway as clinics and commissioners describe it, with the psychotherapist's parallel tasks. Session counts for FES are set by the treating team and are not given here.

Main uses (descriptive)

Foot drop (lower limb, walking): the commonest use. A stimulator worn on the lower leg, triggered during walking (for example by a heel or foot sensor), lifts the foot in the swing phase. Users may also keep an ankle-foot orthosis (AFO) as a backup or alternative [source: NICE IPG278; Bulley et al. 2011]. Some US-cleared devices also assist knee movement [source: FDA K173682].
Upper limb after stroke: used as an adjunct to arm therapy (wrist and finger extension, reaching, shoulder subluxation), mainly to increase repetition and intensity of practice [source: Pennine Lancashire presentation].
FES cycling (and rowing) after SCI: exercise of paralysed legs (or upper body) on a stimulator-linked cycle, in hospital or community settings, under trained staff [source: SCIRE toolkit; MSKTC FES and SCI].
Other uses named in sources: shoulder pain after stroke, standing and balance in SCI, hand and grasp function; implanted FES after SCI is described by MSKTC as mainly a research setting [source: Pennine Lancashire presentation; MSKTC]. [uncertain] Uses in breathing or bladder control are not covered here.

Typical treatment pathway (UK clinic model) [source: UCLH FES clinic; Derbyshire ICB policy; NICE IPG278]

Referral by a doctor or therapist to a specialist FES or gait service. In England, NHS funding for foot-drop FES is decided locally and often requires prior approval or an individual funding request.
Specialist assessment (a full physiotherapy assessment): whether FES is likely to help, contraindications, skin, cognition and communication, the ability to put the device on alone or with a carer, motivation, and the wider management plan. UCLH states plainly that FES "is not suitable for everyone".
Set-up and teaching over further appointments; the device is often loaned.
Early review within weeks, then reviews at increasing intervals (months, then six-monthly or yearly), part virtual and part face to face.
Continuation, change or stopping: if FES does not help or the person declines it, other treatments or specialist referral are offered.

Criteria for moving on (as commissioners state them). Derbyshire ICB (version 3.0, August 2023, review July 2026) funds surface FES for neurological foot drop only if all criteria are met, including: upper motor neurone cause; assessment by a foot-drop specialist with all options considered; trips, falls or gait problems causing significant clinical problems; independent walking with or without aids; ability to manage the device physically with no more than minimal help; cognition sufficient to manage it independently; no accepted contraindication. Implanted and wireless FES are not commissioned there [source: Derbyshire ICB policy]. Bristol, North Somerset and South Gloucestershire (policy adopted 2016, rebranded 2018) did not fund FES routinely and used individual funding requests [source: BNSSG policy]. Funding therefore varies by area.

Regulatory and guideline status (as of October 2026)

England and Wales, NICE IPG278 (2009, updated 2012): evidence on safety and efficacy in terms of improving gait is adequate to support use, provided normal arrangements are in place for clinical governance, consent and audit. Patient selection for implantable FES should involve a multidisciplinary team specialising in rehabilitation. NICE asked for more research on patient-reported outcomes (quality of life, daily activities) across ethnic and socioeconomic groups. Interventional procedures guidance covers safety and efficacy only; it does not decide NHS funding [source: NICE IPG278]. [uncertain] The BNSSG policy reads IPG278 as covering surface devices only; the NICE document itself describes both surface and implanted FES.
Stroke, NICE NG236 (Stroke rehabilitation in adults, 2023; replaces CG162 of 2013): as quoted in NHS service material, NICE says to "consider a trial of electrical stimulation therapy as part of a comprehensive rehabilitation programme" for strength, to continue it if strength and task practice improve, to consider neuromuscular electrostimulation for shoulder pain, and to consider a trial of NMES, FES or TENS for focal spasticity [source: NICE NG236 overview; Pennine Lancashire presentation] [uncertain: exact recommendation numbers not verified].
Stroke, National Clinical Guideline for Stroke (2023, UK and Ireland): FES to the wrist and finger extensors should be considered as an adjunct to conventional therapy where weakness limits function; electrical stimulation for subluxation within six months; electrical stimulation should not be used to reduce spasticity; AFO and/or FES may be considered for limited dorsiflexion affecting balance, with training for the person, carers and clinicians; exercise and repetitive task practice remain the main approaches [source: Pennine Lancashire presentation; Derbyshire ICB policy] [uncertain: guideline text itself not verified].
United States: foot-drop stimulators are regulated as Class II devices under 21 CFR 882.5810 (external functional neuromuscular stimulator) via 510(k) clearance. For example, the Bioness L300 Go System (K173682, cleared 9 March 2018) is indicated to provide ankle dorsiflexion in adult and paediatric individuals with foot drop and to assist knee flexion or extension in adults with weakness from upper motor neuron disease or injury [source: FDA K173682]. Other cleared foot-drop devices appear in FDA records [uncertain: individual clearances not verified].
EU (CE marking) and other jurisdictions: [uncertain: not verified].

Who delivers it. In the UK, physiotherapists (protected titles "physiotherapist" and "physical therapist") and clinical scientists are registered with the Health and Care Professions Council (HCPC), which also regulates occupational therapists and practitioner psychologists [source: HCPC professions]. In the US, FES should be used under the guidance of a trained health professional [source: MSKTC]; [uncertain] state licensure of physical therapists is not covered here.

The psychotherapist's parallel tasks by phase [synthesis]

Before referral or assessment: explore hopes, fears and readiness; support informed consent; prepare the client for the possibility that FES is "not suitable".
Set-up and early use: normalise frustration with the learning curve; work on body image and visibility of the device; problem-solve routines with the client and carers; pass practical or medical concerns back to the team.
Ongoing use: motivation, fatigue and mood; fear of falling; trust in the device; social participation.
Change or ending: grief and meaning if FES is withdrawn, not funded or no longer helps; adjustment to alternatives.

3. Guiding principles

Stay in role. The rehabilitation team owns assessment, device set-up and settings; the therapist owns psychological care. Practical meaning: never advise on wearing, adjusting or stopping the device; route every such question to the FES clinician [synthesis].
Collaborate actively. NICE wants multidisciplinary selection for implants, and services list motivation, adherence, cognition and communication as part of suitability [source: NICE IPG278; Pennine Lancashire presentation]. Practical meaning: with consent, share relevant psychological observations (low mood, cognitive change, carer strain) with the team.
Function and identity matter as much as gait speed. Users value independence, confidence, social participation and looking more "normal" [source: Burns et al. 2023; Bulley et al. 2011]. Practical meaning: ask what walking or using the arm means to this person, not only how far they can go.
Respect choice and trade-offs. Users weigh benefits against aesthetics, usability, reliability in complex environments and cost; some prefer an AFO for certain situations [source: Burns et al. 2023; Bulley et al. 2011]. Practical meaning: support decisions without pushing towards or away from FES.
Informed consent includes uncertainty. NICE ties support for FES to normal consent arrangements and notes that evidence is mainly from stroke [source: NICE IPG278]. Practical meaning: help clients prepare questions for the team about likely benefit for their condition.
Know the safety signals, do not manage them. Skin reactions, increased spasms or spasticity, seizures in people with epilepsy, autonomic dysreflexia in SCI, and implant infection are documented [source: NICE IPG278; SCIRE toolkit]. Practical meaning: recognise them, ask the client to contact the team, and act urgently on emergencies.
Carers are part of the system. Some users cannot put the device on alone and rely on a partner; carers may feel freer when the person is more independent [source: Bulley et al. 2011]. Practical meaning: include carers where the client wants this and watch for strain and changing roles.
Mood and cognition affect use. The SCIRE toolkit lists psychological or cognitive disorders, severe depression or anxiety, and recent alcohol misuse as precautions for FES cycling [source: SCIRE toolkit]. Practical meaning: treat depression and anxiety in parallel and tell the team when they change.
No home experimentation. FES should be used under a trained professional and correct electrode placement matters [source: MSKTC]. Practical meaning: discourage self-sourced devices or self-adjustment and point to the clinic [synthesis].

4. Intervention inventory

Part A describes how the treatment is delivered, at a descriptive level only, so the therapist can talk about it accurately. Part B covers the psychotherapist's own interventions. All example language is illustrative.

A1. How FES is delivered (descriptive, for the therapist's understanding)

Purpose: to know what the client is going through, so conversations are accurate and questions go to the right person.
Steps (as sources describe them): (1) referral to a specialist FES or gait service; (2) physiotherapy assessment of suitability, skin, cognition, ability to manage the device, and the wider plan; (3) if the client agrees, set-up and teaching appointments, often with a loaned device; (4) skin-surface electrodes linked to a small stimulator, for walking usually triggered by a foot sensor; implanted systems are placed under general anaesthesia; (5) reviews at widening intervals, and any change of settings needs a face-to-face appointment; (6) the equipment remains the hospital's property and missed appointments without notice can lead to discharge [source: UCLH FES clinic; NICE IPG278]. Practical advice from the clinic includes avoiding moisturiser or shaving the legs on the day of appointments because these can affect the pads [source: UCLH FES clinic].
Example language (illustrative): "From what you've said, the physio will set the stimulator up and teach you to use it. That part belongs to them. What we can look at here is how it fits into your life and how you feel about it."
Watch for: clients asking the therapist technical questions (placement, strength of stimulation, how long to wear it). Redirect every one of these to the FES clinician.

A2. Safety, contraindications and side effects (as official sources state them)

Purpose: to recognise problems and pass them on, not to assess or manage them.
What the sources list:
- NICE IPG278: skin redness with percutaneous electrodes, wound infection and device malfunction with implants; anecdotal reports of increased seizures in people with epilepsy, autonomic dysreflexia in SCI, problems with CT or MRI imaging, increased spasticity or spasms, infection and skin intolerance; theoretical concerns in pregnancy and with pacemakers [source: NICE IPG278].
- NHS upper-limb service material: contraindications include cardiac pacemakers, implanted defibrillators or other active implants, cancerous tumours, orthopaedic metalwork in the stimulation area, open wounds or inflamed areas, pregnancy, and poorly controlled epilepsy; precautions include poor skin, epilepsy, autonomic dysreflexia (stop if it occurs), diabetes and spasticity [source: Pennine Lancashire presentation].
- FES cycling after SCI: listed risks include fatigue, a brief drop in blood pressure, more spasticity, light-headedness, skin redness, incontinence, leg swelling, autonomic dysreflexia, muscle haematoma and bone fracture; contraindications include recent or fragility fractures, serious pressure injuries and pregnancy; pacemakers and defibrillators need a team discussion; precautions include osteoporosis, uncontrolled cardiovascular disease, clotting problems or recent thrombosis, active infection, epilepsy, malignancy, and psychological or cognitive disorders, severe depression or anxiety and recent alcohol misuse [source: SCIRE toolkit]. MSKTC adds that people with certain heart conditions, recent blood clots, fractures, autonomic dysreflexia or pregnancy should not use it [source: MSKTC].
- Patient-facing view: UCLH states there are no serious side effects or risks, that the sensation may be slightly uncomfortable at first but should not be painful, and that skin irritation can occur [source: UCLH FES clinic].
Steps [synthesis]: (1) Before FES starts, ask the client (with consent) for the team's written safety information and know who to contact about skin, device or medical problems. (2) At each contact, ask briefly about skin, pain, spasms, falls and device trouble. (3) Pass anything new to the FES team or GP the same day, in plain words, without interpreting it. (4) For urgent signs (below), follow the client's emergency plan at once.
Example language (illustrative): "That rash under the pads sounds worth showing the FES team this week. Shall we agree that you'll ring them, and we'll check next time how it went?"
Watch for (urgent): in a client with SCI, signs consistent with autonomic dysreflexia (pounding headache, flushing or sweating above the injury level, blocked nose, slow pulse, feeling of dread) need immediate medical help following the client's own emergency plan; a seizure, chest pain or breathlessness means emergency services [synthesis, based on the risks listed in NICE IPG278 and the SCIRE toolkit]. Note: sources differ in tone (UCLH reassuring, cycling toolkits detailed); both are accurate for their setting.

B1. Recognising when to suggest referral or review

Purpose: to make sure clients who might benefit know FES exists, and that problems with existing FES reach the team.
When to use: a client with stroke, MS, cerebral palsy, incomplete SCI or brain injury describes tripping, falls, a dragging foot, fear of walking out, or arm weakness limiting daily tasks, and has not had a specialist gait or arm assessment; or a current FES user reports skin problems, device failure, worsening spasms, new falls, or that it no longer helps.
Steps: (1) ask what treatment the client has had for the walking or arm problem; (2) if no specialist review, suggest they raise it with their GP, neurologist or physiotherapist; (3) explain that FES is not suitable for everyone and funding varies by area, so the answer may be no; (4) for current users, encourage contact with the FES clinic rather than adjusting things themselves; (5) with consent, write or call the team [source: UCLH; Derbyshire ICB policy; synthesis].
Example language (illustrative): "You mentioned you've stopped going to the shops because your foot catches. Has anyone looked at that specifically? There are specialist services that assess things like braces and electrical stimulation. It might be worth asking your GP or physio whether a referral makes sense."
Watch for: over-promising. Do not suggest FES will work or is available; present it as something to ask about. Working: the client raises it with a clinician and gets an answer.

B2. Psychoeducation about FES

Purpose: to give an accurate, balanced picture that reduces fear ("electric shocks") and unrealistic hope ("it will cure my leg").
Steps: (1) ask what the client already knows and fears; (2) explain in plain words that FES uses small pulses to make the client's own muscles work at the right moment, through pads or, less often, implants; (3) distinguish the effect while it is switched on from possible training effects; (4) say that most evidence is from stroke and that NICE judged it adequate for improving walking; (5) point to the team's patient information; (6) check understanding [source: NICE IPG278; synthesis].
Example language (illustrative): "It's more like a prompt to your own muscle than a shock. While it's on, it can help lift your foot. Whether it changes things when it's off varies, and that's a good question for the physio."
Watch for: confusion between FES and other stimulation (TENS for pain, or brain stimulation). Working: the client can describe the treatment in their own words and names one question to ask the team.

B3. Supporting informed consent and shared decision-making

Purpose: to help the client weigh FES against alternatives (AFO, physiotherapy, no device) according to their own values.
When to use: before or after the assessment, or when deciding whether to continue.
Steps: (1) list the options the team has offered; (2) for each, explore what the client hopes it would make possible and what worries them; (3) name the trade-offs users report: walking ability, independence, confidence and social participation on one side; looks, usability, reliability in complex settings and cost on the other [source: Burns et al. 2023]; (4) ask about practicalities users mention: battery failure, wet conditions, travel and security screening, skin reactions, needing help to put it on [source: Bulley et al. 2011]; (5) help the client write down questions for the team; (6) respect the decision, including declining or using FES only in some settings.
Example language (illustrative): "Some people use the stimulator day to day and keep the brace for holidays or the swimming pool. There's no right answer. What matters most to you when you picture a normal week?"
Watch for: pressure from family or from the client's own wish to please the team. Working: the client can state a reason for their choice that is their own.

B4. Expectations and preparing for the assessment outcome

Purpose: to cushion disappointment if the client is found unsuitable, not funded, or gains less than hoped.
Steps: (1) ask what the client imagines the best outcome would be; (2) gently introduce the range of possible outcomes, including "not suitable" or an individual funding request being refused [source: UCLH; BNSSG and Derbyshire ICB policies]; (3) plan what support the client will want either way; (4) schedule a session soon after the assessment.
Example language (illustrative): "Let's hope it goes well. It's also worth thinking now about how you'd want to handle it if they say it isn't right for you, so it doesn't knock you sideways."
Watch for: the client pinning all recovery hopes on the device. Working: the client holds hope and a plan B at the same time.

B5. Adjustment to disability and loss

Purpose: to work with grief, identity change and meaning after stroke, MS, SCI or brain injury, which may surface when a device makes the disability more visible or more manageable.
Steps: (1) invite the story of the injury or diagnosis and what has been lost; (2) notice mixed feelings about the device (relief and sadness at needing it); (3) explore values and roles that can continue; (4) use the client's preferred evidence-based approach for adjustment (for example acceptance-based or cognitive work) [synthesis]; (5) link small functional gains to valued activity.
Example language (illustrative): "It sounds like putting the stimulator on each morning is a reminder of the stroke, and also the thing that gets you to the bus stop. Both of those can be true."
Watch for: depression, hopelessness, or the device becoming a symbol of failure. Working: the client talks about the device in terms of what it allows, not only what it signals.

B6. Body image and visibility of the device

Purpose: to address self-consciousness about wearing equipment, and the reported sense of looking more "normal" when walking with FES.
Steps: (1) ask how the client feels about how they look walking with and without the device; (2) explore situations where visibility matters (work, dating, holidays); (3) note that users report FES can make gait look more natural and that some forget they are wearing it, while others find device aesthetics a barrier [source: Bulley et al. 2011; Burns et al. 2023]; (4) use graded, client-led exposure to avoided social settings where appropriate, with consent [synthesis]; (5) pass practical concerns about wearability (clothing, cables) to the team.
Example language (illustrative): "When you say people stare at the box on your leg, what do you imagine they're thinking? And what do you notice about your walking when it's on?"
Watch for: avoidance that limits participation more than the disability does. Working: the client re-enters valued social settings.

B7. Motivation, adherence and ambivalence

Purpose: services call motivation and adherence essential [source: Pennine Lancashire presentation]. The therapist explores ambivalence about using the device or practising, without telling the client what to do.
Steps: (1) ask openly how use is going; (2) reflect both sides of ambivalence (benefits and hassles); (3) elicit the client's own reasons; (4) problem-solve barriers the client names (routine, help to put it on, skin, fatigue); (5) route any question about how much or how often to use it to the FES team; (6) never advise starting, stopping or changing use.
Example language (illustrative): "Part of you finds it makes walking easier, and part of you is fed up with the fuss of fitting it every day. What would need to change for the fuss to feel worth it, or for you to talk to the team about other options?"
Watch for: hidden reasons for non-use (pain, skin rash, unreliable device, shame, low mood) that the team needs to know. Working: the client either uses the device as agreed with the team or raises their doubts with the team directly.

B8. Fear of falling and trust in the device

Purpose: users report reduced tripping and greater confidence, but also limited confidence because the device can break down; commissioners cite falls and fear of falling as reasons for FES [source: Bulley et al. 2011; Derbyshire ICB policy].
Steps: (1) assess fear of falling and its effect on activity; (2) distinguish realistic caution from avoidance; (3) help the client plan for failure (backup AFO if the team has provided one, charging routines, who to call) together with the team; (4) graded return to feared activities within the limits the physiotherapist has set [synthesis].
Example language (illustrative): "What goes through your mind when you think about walking to the park on your own? What would make it feel safe enough to try a short part of it?"
Watch for: physical risk is the team's call; check with them before encouraging more walking. Working: activity increases within agreed limits, with less anticipatory anxiety.

B9. Upper-limb FES: frustration, effort and slow gains

Purpose: upper-limb FES is an adjunct meant to increase repetition and intensity of practice [source: Pennine Lancashire presentation]; gains can be slow and practice effortful.
Steps: (1) ask what the arm practice is like and how the client feels during and after it; (2) link practice to a concrete valued task the client and therapy team have chosen; (3) help the client notice small changes (self-monitoring in the client's own words); (4) address self-critical thinking about "not trying hard enough"; (5) feed back fatigue or discouragement to the team.
Example language (illustrative): "You said the exercises feel pointless because your hand still won't open properly. What did you notice this week that's different from a month ago, even slightly?"
Watch for: stroke-related cognitive or communication difficulties, which services list as suitability factors [source: Pennine Lancashire presentation]; adapt language, use written summaries. Working: the client keeps practising as agreed with the team and describes progress with less self-blame.

B10. FES cycling after spinal cord injury: exercise, identity and participation

Purpose: FES cycling exercises paralysed muscles in hospital or community settings; patient quotes in the SCIRE toolkit describe strong motivation and a wish to start early, while apprehension and pain can limit tolerance [source: SCIRE toolkit].
Steps: (1) explore what exercise meant before the injury and now; (2) work on hope that is realistic (health and fitness benefits, not a promise of walking) [source: MSKTC; SCIRE toolkit]; (3) address apprehension about the sensation or about seeing paralysed legs move; (4) support access to community gyms or programmes the team suggests; (5) attend to depression, anxiety and alcohol use, which the toolkit lists as precautions.
Example language (illustrative): "Watching your legs move on the bike, what was that like for you? Some people find it hopeful, some find it strange or upsetting, and many find it both."
Watch for: autonomic dysreflexia and low blood pressure are managed by the team (see A2). Emotional over-investment ("if I cycle enough I'll walk"). Working: the client values the exercise for what it gives now.

B11. Fatigue, pacing and mood (especially MS)

Purpose: fatigue, mood and cognition interact with whether a device is usable day to day [synthesis]; services ask whether the person can apply FES daily, alone or with help [source: Pennine Lancashire presentation].
Steps: (1) map the client's daily energy pattern; (2) identify where fitting and using the device fits; (3) work on pacing and prioritising valued activities [synthesis]; (4) screen for depression and anxiety and treat or refer; (5) tell the team (with consent) if fatigue or mood is affecting use.
Example language (illustrative): "On the days you don't put it on, what's usually going on? Tired, low, short of time, something else?"
Watch for: a relapse or new symptoms in MS; route to the MS team. Working: the client's routine is sustainable and decisions about use are made with the team.

B12. Working with carers and role change

Purpose: some users need a partner to put the device on; carers have described feeling able to leave the person alone once FES was in use [source: Bulley et al. 2011].
Steps: (1) with the client's consent, invite the carer to a joint session; (2) explore how the device has changed roles, dependence and independence; (3) address carer strain and frustration on both sides; (4) agree who contacts the team about problems.
Example language (illustrative): "It sounds like you both feel the stimulator has given some freedom back, and also that needing help to put it on each morning is a bit of a sore point. Can we talk about that?"
Watch for: resentment, over-protection, or safeguarding concerns. Working: both describe the arrangement as fair and workable.

B13. Monitoring and passing on side effects and warning signs

Purpose: the therapist sees the client often and may hear about problems first.
Steps: (1) at review points, ask briefly about skin, comfort, falls, spasms and device reliability; (2) for non-urgent problems, encourage the client to contact the FES clinic and, with consent, inform the team; (3) for emergencies (suspected autonomic dysreflexia, seizure, chest pain) follow emergency procedures; (4) record what was passed on and to whom [source: NICE IPG278; SCIRE toolkit; synthesis].
Example language (illustrative): "Before we finish, any problems with the stimulator this week, skin, spasms, falls? If so, the clinic would want to know."
Watch for: clients downplaying problems for fear of losing the device. Working: the team hears about problems promptly.

B14. Collaboration and information sharing

Purpose: to integrate psychological care with the rehabilitation plan.
Steps: (1) get written consent to talk with the FES or rehab team; (2) agree shared goals (for example, getting to a valued activity); (3) share psychological factors relevant to suitability and use (mood, cognition, motivation, carer strain) without sharing unnecessary detail; (4) ask the team what they need from you; (5) for implanted FES, where NICE wants selection by a multidisciplinary rehabilitation team, offer psychological input if the team requests it [source: NICE IPG278; synthesis].
Example language (illustrative, to the team): "With [client]'s consent: their mood has dipped since the funding decision and they've stopped walking outside. I'm working on that with them. Is there anything you'd like me to know or reinforce?"
Watch for: role drift (the therapist giving device advice; the team expecting the therapist to "make" the client comply). Working: clear roles and coordinated goals.

B15. When FES is not offered, not funded, withdrawn or stops helping

Purpose: loss of a device can feel like loss of independence; implanted and wireless FES are not commissioned in some areas, and surface FES is often available only on criteria [source: Derbyshire ICB policy; BNSSG policy].
Steps: (1) allow anger and grief about the decision; (2) separate the client's worth and effort from the decision; (3) if the client wants to challenge a decision, point to the referring clinician and the local individual funding request route rather than advising on it; (4) support adjustment to alternatives (AFO, physiotherapy); (5) watch for mood decline.
Example language (illustrative): "Being told no after hoping for so long is a real loss. It isn't a verdict on you. When you're ready, we can think about what still matters most and how to get there."
Watch for: pressure to buy unsupervised devices privately; encourage any private route to go through a qualified clinician [synthesis; source: MSKTC]. Working: the client re-engages with rehab goals.

B16. Crisis and safety planning

Purpose: neurological illness and injury carry risks of depression and suicidal thinking; device setbacks can be a trigger [synthesis].
Steps: follow standard risk assessment; build a safety plan with warning signs, coping steps, contacts and crisis numbers; involve the GP or neurological team as appropriate; include practical access issues (mobility, communication) in the plan [synthesis].
Example language (illustrative): "When things feel this heavy, some people have thoughts of not wanting to be here. Has anything like that been on your mind?"
Watch for: hopelessness after a funding refusal, a fall, or device withdrawal. Working: the client can name and use the plan.

5. Handling problems

The client asks the therapist how to use or adjust the device. Decline warmly and redirect: "That's one for the FES team; shall we write the question down so you don't forget?" [synthesis].
Non-use or low use. Explore reasons without judgement (B7); common reported barriers are looks, usability, unreliability in complex settings, cost and skin reactions [source: Burns et al. 2023; Bulley et al. 2011]. Pass practical barriers to the team; work on psychological ones.
Unrealistic hope ("it'll fix my leg"). Validate hope, then explore the difference between help while it is on and longer-term change; suggest the client asks the team what is realistic for them [synthesis].
Fear or aversion to electrical stimulation. Normalise; use psychoeducation (B2); suggest the client ask the team to explain or demonstrate the sensation; do not encourage or discourage the treatment [synthesis]. UCLH describes the sensation as possibly slightly uncomfortable at first but not painful [source: UCLH].
Overwhelm at set-up (cables, pads, sensors, routines). Break tasks down, plan a written routine with the client, involve a carer if wanted, and ask the team for written instructions [synthesis].
Device failure in public or a fall. Process the event; plan backups with the team (B8); watch for new avoidance [source: Bulley et al. 2011; synthesis].
Cognitive or communication difficulties after stroke or brain injury. Use short sentences, written summaries and carers where appropriate; share observations with the team, since cognition and communication affect suitability [source: Pennine Lancashire presentation; Derbyshire ICB policy].
Mood disorders, anxiety or alcohol misuse. Treat or refer in parallel; with consent, tell the team, since these are listed precautions for FES cycling [source: SCIRE toolkit].
Rupture with the rehab team (feeling judged as "non-compliant", angry about a funding decision). Validate, help the client voice concerns directly, and offer to support a joint conversation; do not side against the team [synthesis].
Rupture with the therapist ("you don't understand, you're not disabled"). Acknowledge the limits of your understanding, invite correction, and keep the focus on the client's experience [synthesis].
Carer conflict over the device. Use joint sessions (B12); watch for safeguarding concerns [synthesis].
Client wants to buy a device online or use it without supervision. Explain that sources say FES should be used under a trained professional and correct placement matters, and encourage discussion with the GP or physiotherapist; do not help source or set up equipment [source: MSKTC; synthesis].
Emergency signs (suspected autonomic dysreflexia in SCI, seizure, chest pain): follow emergency procedures and the client's own medical plan; inform the team afterwards [source: NICE IPG278; SCIRE toolkit; synthesis].
Uncertain or changing guidance. Funding, device clearances and guidance change; ask the treating team for the current local position rather than relying on this guide [synthesis].

Guidance in this section marked [synthesis] is the author's own clinical synthesis and is not drawn from FES sources.

Sources

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