There is a thread on an American nurses' forum with a four-word title: "To mepilex or not?" The nurse who started it described an arrangement many wards will recognise. Once a patient's risk score crossed a threshold, foam dressings went onto the sacrum and both heels more or less automatically, and nobody had ever explained when a dressing earns its place and when turning would do. One reply answered in four words of its own: "No dressing prevents pressure."

The thread is American, but the question is not. I've spent more than thirty years supplying devices that float the heel, so you might expect me to side with that reply. I don't, entirely. A dressing and a floating heel do different jobs, and the formal evidence for each is thinner than either camp tends to admit.

Put plainly we can say that a dressing changes the surface. Offloading changes the load.

We first started to work with FES cycling around 17 or 18 years ago now. We were told that many people with MS would be our clients. Actually that hasn't been the case, largely because the cost of most FES cycling systems were unaffordable. We couldn't help them. As we've started to work with the Stim2Go, we've found many more of our clients now have MS. They've been able to use the Stim2go for FES cycling and much more.

Most people with MS who own a motorised passive-active bike did not start out with one. They started with an ordinary exercise bike, and at some point it stopped being usable. They could no longer get on the upright one. The standard bike became unusable because they could not generate enough momentum. Their feet would not stay on the pedals, or a heel kept catching the frame, or tone made the whole thing impossible. A MOTOmed or a THERA-Trainer, with a motor that moves the legs when they will not move on their own, was the answer to that problem, and for many people, it has been a good one.

The question this article answers is whether the electrical stimulation you may have seen on a bike in a rehabilitation gym can be added to the bike you already have at home, and whether it is worth it. The Stim2Go, a very flexible yet powerful stimulator, is not tied to any bike. Let's look at what the evidence supports.

Many people have a motorised passive-active bike at home. They use it for a year or two, usually a MOTOmed or a THERA-Trainer, and they use it most days. Their legs go round. The question is whether their legs are getting anything from it beyond going round, and whether the electrical stimulation they saw on the bike in the spinal unit gym could ever come home.

Passive cycling does beneficial things, and adding synchronised electrical stimulation provides a measurable step on top. And the part that has changed recently is that the stimulator no longer has to arrive bolted to a new bike. For many years, we worked with the RehaMove system, which integrated an 8-channel stimulator with a version of the MOTOmed bike. We were always aware that the total cost of the system meant that many people could not adopt it. And as the stimulator needed to communicate directly by cable with the bike, we were restricted to one or two models of MOTOmed. Why should they give up the bike that they were already using and replace it with one that happened to support FES cycling?

Things have changed now with the arrival of Stim2Go. The bike you already own, whatever the make, is the awkward part of an FES cycling system, and you already have it. Let's see whether adding Stim2Go would be worth it.

Stim2Go from Pajunk is proving a very popular system for electrical stimulation due to its flexibility. In addition to supporting FES Cycling, it boasts many novel applications and the ability to create custom applications. Amongst its programs, there have been a number of transcutaneous spinal cord stimulation (tSCS) applications. Up until now, these were typically utilised to target severe spasms or pain.

We're getting to grips with some new cervical tSCS programs and two combined cervical-lumbar tSCS programs. These place one electrode on the neck and another on the lower back, and run both in the same 20-minute session. It is in beta testing, available under European and UK medical device rules only, and not cleared in the United States. I want to walk through the idea behind this configuration and what the human evidence shows.

Over roughly 250 years, therapeutic electrical stimulation has jumped to a new level perhaps seven times, and each jump was made possible by a new technological development. It might have been a way of handling current, storing it, generating it, shaping it, measuring it, timing it, or using it to tune the nervous system rather than drive it, and finally today triggering it from the person's own movement or intention. These are the stages I allude to in the title.

The first stimulator I worked with, as a PhD student in the late 1970s, filled a good part of a laboratory bench and needed someone who understood it standing beside it. The Stim2Go electrical stimulation device I carry to homes or clinics now is the size of my hand. It can be strapped to a client's thigh, senses when they start to move, and is set up from an app on my phone. Both deliver a pulse of current to a nerve. Almost everything else about them has changed.

You might expect the guidance on pressure ulcer prevention to have plenty to say about protecting the heels of larger patients, but that is not the case. In this article I want to show where the guidance goes quiet, what the research evidence really says about body size and heel ulcer risk (it is not what most people assume), and how I suggest thinking about the problem instead: as a question of equipment fit rather than a question of risk scores.

A note on language before we start. Following the Obesity UK "Language Matters" guidance, I use person-first phrasing for people, and I keep the word "bariatric" for equipment, pathways and products, where it remains the standard term. In manual handling circles, "plus-size" is the preferred word for the person, and I follow that convention here.