ollowing a stroke, individuals are
often left with sensorimotor impair
ments, such as paresis and abnormal
muscle tone, which significantly limit
their ability to mobilize and participate in
activities of daily living. Physical rehabil
itation aims to resolve these impair
ments, enabling recovery of movement
and function. One intervention that is
recommended for stroke rehabilitation
by numerous best practice guidelines is
functional electrical stimulation (FES).1-3
Functional electrical stimulation can pro
duce appropriately sequenced and timed
muscle contractions for functional tasks.
This stimulation is accomplished by
delivering a low-level, electrical current
through electrodes on the skin to acti
vate motoneurons, causing muscle con
traction. Functional electrical stimula
tion has been used in individuals with
stroke to improve strength,4 upper
extremity function,5 and gait6 and to pre
vent hemiplegic shoulder subluxation.7
Moreover, FES therapy is associated with
neuroplasticity poststroke8-10 and thus
can contribute to neural recovery.
The most recent guidelines from the
American Stroke Association recom
mend FES for gait and upper extremity
training, including shoulder subluxation,
in clients with impaired muscle contrac
tion.2 Two Canadian best practice guide
lines also recommend FES for stroke
care.1-3 These recommendations are
based on the strength of the scientific
literature for FES in stroke. For example,
the Stroke Rehabilitation Evidence-Based
Review states there is level 1A evidence
(ie, findings supported by a meta-analysis
or at least 2 randomized controlled trials)
that FES improves upper extremity func
tion, prevents the development of shoul
der subluxation, and decreases spasticity
and, when combined with gait retrain
ing, can improve gait performance.3
Although the evidence for the therapeu
tic benefits of FES is strong, this evidence
does not imply that FES is superior to
other treatment approaches that physical
therapists may use.1112
Even though FES has been recom
mended for stroke rehabilitation, physi
cal therapists may not use it regularly in
practice. Functional electrical stimula
tion devices are not available in every
clinical environment, and not all physical
therapy programs include FES in their
curriculum. Thus, FES may be underuti
lized by physical therapists. To deter
mine the usage of FES to address com
mon therapeutic goals in stroke
rehabilitation, we undertook an FES sur
vey involving physical therapists across
Canada. The aims of our study were: (1)
to determine how frequently physical
therapists use FES to address common
therapeutic goals for their clients with
stroke (eg, improve walking), (2) to
assess how knowledgeable physical ther
apists are of the scientific evidence sup
porting the use of FES poststroke, and (3)
to identify the barriers and facilitators
influencing the use of FES. We hypothe
sized that the majority of physical thera
pists do not use FES as a means to
achieve therapeutic goals for clients with
stroke. We also hypothesized that a lack
of education and access to FES equip
ment would be identified as barriers to
the use of FES in clinical practice,
whereas the substantial scientific evi
dence and access to continuing educa
tion courses in FES would be facilitators.
Method
Study Design
This cross-sectional study involved 2
phases. First, a valid and reliable online
survey was developed. Second, the sur
vey was distributed to physical therapists
across Canada.
Survey Development
The survey was developed by a focus
group consisting of 3 physical therapists
and the study authors. Of the 3 physical
therapists, 2 used FES routinely in their
practice, and 1 did not use FES but
worked with the stroke population. The
focus group developed an ordinal-level
survey (ie, mostly closed-ended ques
tions) (Appendix). The survey consisted
of 4 parts: (1) demographic information
(eg, practice setting, number of years
practicing), (2) frequency of FES use for
various therapeutic goals relevant to
stroke, (3) facilitators of and barriers to
FES use, and (4) knowledge of the FES
literature for stroke rehabilitation.
Response options consisted of Likert
scales with both numeric and descriptive
anchors. To explore barriers and facilita
tors, closed-ended questions were modi
fied from a previous study.13 Two open-
ended questions also were included in
this section (Appendix). After several
iterations of refining the questions, the
survey was translated into Frenc