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Mollii Suit
The content of this document is OFFICIAL.
Please note:
This document is intended to assist Technical Advice and Practice Improvement Branch
(TAPIB) staff with provision of technical advice or practice improvement activities.
Branch Manager clearance is required before research documents are shared outside
the branch.
The TAPIB Research and Capability team take care to ensure the research presented is
accurate at the time of writing. Due to the nature of our work, we are not able to ensure
that all relevant research has been considered in the development of this document or
that information remains accurate after publishing.
Research questions:
Does available evidence suggest the Molli suit is a time-limited, goal-oriented, therapy tool?
Is there any evidence regarding recommended dosage?
Does available evidence suggest the Molli suit is a tool to increase function and build capacity? For example, is there evidence to suggest the participant puts on the suit to increase functional performance in activities whilst wearing the suit as part of the dosage? Conversely, does the evidence suggest that it increases function for the periods of time after when the suit is taken off?
Is there any evidence regarding home-based use and what oversight is required by an allied health professional?
Is there evidence regarding whether the Mollii suit is more effective than conventional physio and occupational therapy and caregiver education/training, with regards to short and long term outcomes?
Is there any evidence regarding risks/contra-indications of the Mollii suit?
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- Contents
Mollii Suit 1
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Contents ……………………………………………………………………………………………………….. 2
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Summary ………………………………………………………………………………………………………. 2
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The Mollii suit …………………………………………………………………………………………………. 3
3.1 What is it? 3
3.2 How does it work? 4
3.3 Where can you buy it in Australia? 5
3.4 When not to use it 6
- Summary of research on Mollii suit ……………………………………………………………………. 7
4.1 Published peer reviewed studies using Mollii suit 8
4.2 Unpublished studies and grey literature on the Mollii suit 11
4.3 Future studies on the Mollii suit 12
4.4 Research on electrical stimulation 12
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Cost-effectiveness ………………………………………………………………………………………… 13
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Time-limited, goal-oriented therapy ………………………………………………………………….. 15
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Literature Summary Table ……………………………………………………………………………… 16
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References ………………………………………………………………………………………………….. 35
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Summary
This paper discusses the Exopulse Mollii suit. Research was first compiled in 2019 and reviewed in 2021, 2022 and 2025.
Exopulse Mollii suit is an assistive device aimed to improve mobility, balance, blood circulation and reduce spasticity and pain. It is a kind of electrical stimulation device. The suit requires programming by a trained Mollii therapist and follow-ups with the therapist are required. The manufacturer intends the suit to be used for 60- to 90-minute sessions every other day. However, exact recommendations differ among clinicians, providers and researchers. The suit can be used unsupervised at home after an initial assessment. There are some warnings and counter-indications. For example, the manufacturer recommends that the suit is not used outdoors. The suit may be worn at rest or during activity though evidence does not speak to whether activity during use contributes to functional performance.
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Some evidence suggests that use of the Mollii suit can positively affect spasticity, pain, limb functionality, gross motor function, trunk control and acceleration among other things. It can also increase patients’ ability to participate in daily/usual activities. However, due to conflicting results in studies as well as the type, quantity and quality of evidence, we cannot say with any certainty that treatment with the Mollii suit causes these effects. There is some evidence that certain types of exercise may be equally or more beneficial than use of the Mollii suit for individuals with fibromyalgia. However, more research is needed comparing the Mollii suit with other interventions.
There is no conclusive evidence of optimal dosage. Some evidence indicates that positive effects are related to the duration of the intervention. Other evidence indicates that the possible benefits do not remain after the intervention is discontinued. The Mollii suit may be intended for short term rehabilitation after injury or for long-term maintenance of capacity.
Due to the state of the evidence and lack of information comparing Mollii suit with other conventional therapies, we cannot determine whether there are any circumstances in which the Mollii suit is likely to be a cost-effective treatment or therapy option.
- The Mollii suit
3.1 What is it?
Mollii suit is a two-piece suit with shirt, pants and a control unit operating 58 electrodes positioned around the garment. It can be used by adults or children starting from 2 years old. The manufacturer suggests treatment sessions should last 60 to 90 minutes and be administered every other day (Exopulse Mollii Australia, Clients). Some providers recommend treatment every day depending on symptoms (see Orthotics Plus, 2025). Treatment can be in a health care setting or at home after an initial assessment. Patients can move around freely while wearing the suit, with some exceptions (refer to 3.4 When not to use it).
Since the first version of this paper in 2019, the Mollii suit has been renamed the Exopulse Mollii suit. The Mollii suit was invented in Sweden by the chiropractor Fredrik Lundqvist. The disability technology company Ottobock bought the company making the Mollii suit in January 2021 (Exopulse Mollii Suit, n.d). Mollii Australia is owned by Metier Medical Limited and based in Maitland, NSW (Exopulse Mollii Australia, About Mollii). They are the Australian retailer of the Mollii Suit. Metier Medical Limited registered the Mollii suit as a medical device with the Therapeutic Goods Administration in 2017 (Therapeutic Goods Administration, 2022).
Mollii suit is intended for therapy and treatment of people with chronic pain, stroke, cerebral palsy, spasticity, and other motor disabilities. Mollii Australia says the suit is intended to improve mobility, balance, blood circulation and pain (Exopulse Mollii Australia, Home) and elsewhere that it “designed to relax spastic, tense and aching muscles safely and simply thus helping those with spasticity and motor impairment” (Exopulse Mollii Australia, About Mollii).
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Mollii Australia notes that “[o]n-going exercise or therapy is vital however to develop lasting improvements” (Exopulse Mollii Australia, About Mollii).
3.2 How does it work?
Ottobock says that the Mollii suit:
makes use of a physiological reflex mechanism called reciprocal inhibition: By sending an electrical signal to an antagonistic muscle, the spastic muscle subsequently relaxes. The combined effect of relaxing tense muscles and enabling the activation of weak muscles allows its users to enjoy a more active and less painful daily life. It is a personal assistive medical device which is used for low-energy whole-body transcutaneous electrical stimulation, reducing the typical symptoms associated with neurological conditions such as cerebral palsy, multiple sclerosis, stroke or spinal cord injuries (Exopulse Mollii Suit, n.d).
Mollii Australia describes the theorised mechanism for spasticity, dystonia and pain:
For Spasticity: The Mollii method uses low frequencies and low intensities that evokes sensory input but does not directly elicit muscle contractions. The principle mechanism in the Mollii approach is the activation of the disynaptic reciprocal Ia inhibitory pathway. Relaxation of the agonist muscle is achieved by the electrical stimulation of the antagonist (opposite) muscle, thus enhancing contraction of the agonist and voluntary movements.
For Dystonia: Treatment with Mollii may be relevant for focal, segmental and general dystonia although controlled clinical trials are needed. Clinical experiences suggest that Mollii may reduce dystonic symptoms and maintain body posture. The sensory input provided by both electrical stimulation and the physical sensation of the tightly fitted suit may also have an impact on proprioceptive awareness, which is essential not only for motor control in dynamic activity but also for maintaining position and balance control.
For Pain: Mollii may reduce pain through both central and peripheral mechanisms. In the central nervous system, the activation of opioid, GABA, serotonin, and muscarinic receptors, induced by Mollii, may reduce pain related dorsal horn neuron activity. In
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peripheral nerves, opioid and a-2 noradrenergic receptors are involved in electrical stimulation-induced analgesia at the site of stimulation.
Low-frequency ES electrical stimulation activates -opioid receptors in the spinal cord and the brainstem leading to a decreased sensation of pain. Spinal serotonin concentrations are also increased during and immediately after treatment (Exopulse Mollii Australia, Professionals).
3.3 Where can you buy it in Australia?
The Mollii suit itself may retail for $17,000 - $19,000 not including assessments, training or
additional items.
Mollii suit has been available in Australia since 2017. Metier Medical Limited own Mollii Australia and are the Australian retailer of the Mollii Suit. They are a registered NDIS provider, stating on their website “[We are] working closely with the NDIS in funding the Mollii Suit” (Exopulse Mollii Australia, Professionals). Other Mollii agents or retailers operate in New South Wales, Queensland, Tasmania and Victoria.
Organisation
Mollii Australia
Contact
Maitland NSW 0491 616 452
Services
Assessment, Trial, Rental Purchase
Cerebral Palsy Education Centre
Glen Waverly, VIC
Agent of Mollii Australia (Mollii Australia, n.d.)
Therapies)
*Note: phone listed on website appears to be disconnected
03 9560 0700
info@cpec.org.au Supportivity (formerly 121 Birtinya, QLD “Supportivity is the only Care — Suncoast Integrated 07 5443 9777* licensed provider for Mollii
suits in South East Queensland” (Supportivity, n.d.). Not listed as agent by Mollii Australia (Mollii Australia, n.d.).
Optimum Health Solutions
Multiple locations in NSW and TAS
02 8599 6284 optimumenquiries@opt.net.au
Agent of Mollii Australia (Mollii Australia, n.d.)
Mollii Suit
GEIS ts
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Organisation Contact Services
Enhanced Living Sunshine Coast, QLD Agent of Mollii Australia (Mollii 07 5437 8777 Australia, n.d.)
reception@enhanced- living.org.au
Orthotics Plus Melbourne, VIC Prescription, trial and 03 9077 6414 purchase
3.4 When notto use it
Ottobock offers the following warnings and counter-indications:
Never use the Exopulse Mollii Suit if:
e If the user has implanted electronic medical devices or equipment which can be disrupted by magnets, for example, shunts
e Together with electronic life-support equipment or high-frequency operation equipment
e Together with ECG-equipment
e Near a magnetic resonance imager
e Over swollen, infected, or inflamed areas or skin eruptions e.g., phlebitis, thrombophlebitis, varicose veins, etc.
e Over the neck or mouth, as severe spasm of the laryngeal and pharyngeal muscles may occur and the contractions may be strong enough to close the airway or cause difficulty in breathing
e Transthorically, as the introduction of electrical current into the heart may cause cardiac arrhythmias
e §=6Transreecancaiy’
e While driving, operating machinery, or during any activity in which involuntary muscle contractions may put the user at undue risk of injury
e While being serviced
e Without authorization of the manufacturer
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• Outdoors, in wet rooms, in direct sunlight, or in connection with flammable
materials/liquids. Keep away from dusty, damp and bright environments to avoid
damage or harm to Exopulse Mollii Suit
• Without a person who has read and understood the entire user manual.
Do not use Exopulse Mollii Suit without consulting a doctor in connection with:
• Cardiovascular diseases or other types of related conditions
• Malignancy (cancer)
• Infectious diseases
• Fever
• Epilepsy
• Skin disease, rashes or other skin problems
• Usage together with another medical device (Exopulse Mollii Suit, n.d).
- Summary of research on Mollii suit
TAPIB Tactical Research Team has collected research on the Mollii suit in September 2019, February 2021, July 2022 and June 2025. There are an increasing number of published peer- reviewed studies and several studies reported in unpublished papers and grey literature. In general, the evidence is unreliable due to study design, low sample sizes, high risk of bias, failure to report relevant facts or other quality issues.
Some noteworthy issues include:
• Several studies note barriers due to the company not sharing proprietary information
about the equipment.
• The grey literature often reports large effect sizes, while the published peer-
reviewed literature reports small or no effects.
• There is often a contrast between participant reports and objective measures.
• Few studies compare Mollii suit treatment with conventional treatment.
• No studies found compare Mollii suit treatment with other forms of electrical
stimulation.
• Some studies mention the possible effect of wearing the suit itself (apart from any
electrical stimulation) but no studies found aim to measure this effect.
• There is minimal evidence suggesting an optimal dosage or length of treatment.
This section contains a general assessment of the evidence and quality of sources. Assessment of individual sources is contained in 7. Literature Summary Table.
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4.1 Published peer reviewed studies using Mollii suit
In the earlier 2022 research review, 9 published peer-reviewed studies were found. In the most recent 2025 review, the research literature on the Mollii Suit has grown, including a 2023 systematic review (Perpetuini et al, 2023). There are more peer-reviewed studies though in general the quality of the evidence is still low. A selection of more recent papers have been added to 7. Literature summary table.
4.1.1 2025 literature review
Recent studies indicate that the Mollii suit may have a positive effect on a variety of symptoms.
Patients with fibromyalgia may experience a reduction in pain levels and an improvement in several other areas including muscle oxygenation, parasympathetic modulation, cortical arousal, heart rate variability (HRV), fatigue, anxiety, and disease impact (see Mattar et al., 2025; Riachi et al., 2023; Rubio-Zarapuz et al., 2024a; Rubio-Zarapuz et al., 2024b).
A systematic review by Perpetuini et al. (2023b) found conflicting results for the effects of the Mollii suit in children with cerebral palsy. Several reviewed studies show no significant differences in pain, passive range of motion (PROM), spasticity, mobility and arm-hand ability with use of the Mollii suit. Other reviewed studies did show significant improvements in pain, PROM, spasticity and the Canadian Occupational Performance Measure (COPM). Results indicate that positive effects in relation to motor functions and spasticity are related to the duration of the administration period, the dosage of the treatment, which, in turn, depend on the individual’s condition and treatment goals (Perpetuini et al., 2023b, p. 1). The authors suggest that a minimum of 6 weeks of treatment administration is necessary to obtain statistically significant results (Perpetuini et al., 2023b, p. 12).
Perpetuini et al. (2023a) conducted a study on the effectiveness of the Mollii suit in treating children with cerebral palsy. They measured the feasibility of the intervention in 26 children via a one-hour training session. 12 of the children then either purchased or rented the suit and continued to receive the therapy for one month at a dosage of three sessions per week. Results of the one-hour therapy session showed statistically significant trunk control as measured by the Level of Sitting Scale (LSS), but no significant changes in spasticity as measured by the Modified Ashworth Scale (MAS). Children in the subset who continued to receive treatment for one month did not undergo retesting for LSS or MAS at the end of their treatment. However, they did report improved functional capability, independence and performance via the Psychosocial Impact of Assistive Devices Scale (PIADS) questionnaire.
Significant improvements in the gross motor function measure (GMFM) Domain C crawling and kneeling were found in a study on 20 children with spastic cerebral palsy who wore the Mollii suit daily for 60 minutes over a period of 4 weeks (see Weller et al., 2025). Usual activity as measured via the EQ-5D-Y (an instrument used for measuring mobility, looking after myself, doing usual activities, having pain or discomfort and feeling worried, sad or unhappy via self-reporting in children) also improved significantly after the intervention but significance was lost after 1 month (Weller et al., 2025, p. 6). Gait Profile Score (GPS) of participants also
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increased significantly but did not reach the level of minimally important clinical difference (MCID) (Weller et al., 2025, p. 5).
Improvement in the temporal structure of trunk acceleration in the anterior-posterior direction was found in patients with unilateral cerebral palsy while other patients with multiple sclerosis experienced a beneficial effect on spasticity, limb functionality and daily living activities such as walking, use of keyboard and dressing (see Raffalt et al., 2022 and Vanderhauwaert, 2023 respectively).
Although a study by Yen et al. (2024) included only a small cohort of 3 subjects, preliminary positive results were found for measures of spasticity, balance and gait in children with spinal cord injuries who used the Mollii suit for 60 minutes. 2 out of the 3 subjects showed improvements meeting MCID in walking speed and Five Times Sit to Stand Test (5xSTS) as well. Similar positive results were found for an individual with severe cerebellar ataxia who showed improvements in the sit-to-stand test, 10m walking test, visual focus and the ability to speak and swallow after 15 sessions of using the Mollii suit (see Wagner et al., 2023).
However, the effects of the Mollii suit are often reported to be temporary. It is also not clear whether the Mollii suit is value for money when compared with other interventions. A randomised, longitudinal crossover study including patients with fibromyalgia showed exercise had a similar effect to the Mollii suit in reducing pain and improving muscle oxygenation (see Rubio-Zarapuz et al., 2024c). The exercise program also yielded more pronounced long term basal adaptations in muscle oxygenation. Moreover, one study which included the Molli suit and robotic and biomechatronic technologies, showed an increase in pain levels in an individual with dystonic spastic tetraparesis despite having positive effects on upper limb motor function, coordination, range of motion, trunk function and stability, an increase in score on the Barthel Index for functional independence in daily activities and an MCID increase in scores on the Fugl-Meyer (quality of life) scale and (see Leogrande et al., 2025).
Most recent studies on the Mollii suit have small participant cohorts of <100, and in some instances only one participant. Often treatment sessions are limited to 1 x 1-hour session, or, when longer dosage timeframes are implemented, they differ across studies. Studies are often not blinded, or only certain phases of studies are blinded (see Mattar et al., 2025), making it impossible to tease apart real from sham effects. The use of different scales for measuring pain (e.g. numeric rating scale (NRS) verse visual analogue scale (VAS) creates issues in comparing results (see Rubio-Zarapuz et al., 2023, Rubio-Zarapuz et al., 2024a and Riachi et al., 2023 respectively). It is also worth noting that as of 2023 there are still no shared protocols on the dosage and timing of the electrosuit in neurological patients (Boanna & Calabrò, 2023, p. 4).
4.1.2 2022 literature review
Three of the reviewed studies are randomised controlled double-masked trials (Bakaniene et al, 2018; Pennati et al, 2021; Ertzgaard et al, 2018). Pennati et al (2021) found no consistent reduction in spasticity across their group of 20 patients in the chronic phase after stroke. This
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study was significantly limited as only half of those participants were properly evaluated according to the study protocol and the duration of the treatment was only one 60-minute session. Individual results were also highly variable, with participants showing higher initial spasticity more likely to show reduced spasticity after treatment. Bakaniene et al (2018) did find similar though mild effects on gross motor function from treatment with Mollii suit and treatment with conventional physiotherapy. However they found no improvement in spasticity or passive range of motion. As with other studies the sample was too small to draw significant conclusions. The limitations of the study from Ertzgaard et al (2018) also prevent conclusions. The sample was higher than the other controlled trials, however compliance was low with only half the 30 participants meeting treatment compliance standards. The study found no significant difference between active and non-active treatment periods. Jonasson et al (2022) relate positive responses to the treatment in their semi-structured interview based qualitative follow up to Ertzgaard et al’s study. However, there are several issues with method and quality of the study.
Three case series included a total of 42 participants (Flodstrom et al, 2021; Palmcrantz et al, 2020; Hedin et al, 2020). One study presented 7 experimental single-case studies with ABAB design and found no discernible effect on spasticity in children with CP (Arkkukangas et al, 2022). This study should be taken in the context of the high variability of results between participants reported in previous studies (Bakaniene et al, 2018; Pennati et al, 2021).
Flodstrom et al (2021) included 6 children with CP in their case-series. All children perceived improvements in goal attainment following treatment. Half the children studied experienced pain at baseline which was reduced to 0 or 1 at 3 month follow up. 5 out of 6 children showed minor improvement (2-7%) in gross motor function for standing, walking, running and jumping. Muscle tone, passive range of motion and spasticity were mostly unchanged however the authors note that the participants did not experience an increase in spasticity despite abstaining from botulism treatment.
These results are similar to Flodstrom’s 2015 unpublished Master’s thesis which also found a perceived reduction in pain with little change to muscle tone or passive range of motion (Flodstrom, 2015). There is reason to think the 2021 publication is a report from the Master’s study. For example, ethics approval for the 2021 publication was granted in 2014. For this reason, currency of information may be an issue. Nordstrom and Prellwitz (2021) followed up Flodstrom et al’s study with semi-structured interviews and qualitative analysis of the same participants and their carers. They found some children had generally positive experiences while others found the suit uncomfortable and worried about stigma associated with assistive technology. Some parents and children reported reduced spasticity, which contrasts with the findings of the case series.
From their case series of 20 participants who had experienced stroke, Palmcrantz et al (2020) found some positive results though this was reflected inconsistently across different measures. Modified Ashworth scale (MAS) and Action reach arm test (ARAT) showed no significant difference between baseline and treatment. Fugl-Meyer Assessment showed some
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improvement in sensorimotor function and Neuroflexor measurement showed some improvement in spasticity. 12 of the 20 participants reported perceived positive effects including decrease in muscle tone, improvements in gait, pattern functions or control of voluntary movement in the upper extremity. Palmcrantz et al suggest the Mollii suit is feasible as an option to reduce spasticity and improve sensorimotor function. However, it should be noted the study was exploratory with a small sample size and requires.
Hedin et al (2020) report more positive results in a case series of 16 children with CP. They found improvement in spasticity from MAS and Modified Tardieu scale as well as improvements in passive range of motion. The authors contend that their study shows at the least that Mollii suit does have an effect on spasticity. However, it is worth noting that over half the participants dropped out of the study before completing the 6-month trial and so quality of results at the 6-month mark are further affected by a much smaller sample.
No systematic reviews related to the Mollii suit were found.
4.2 Unpublished studies and grey literature on the Mollii suit
No further investigation into unpublished studies or grey literature was conducted during the 2025 research review due to the increased number of published, peer-reviewed studies.
National Institute for Health Care Excellence (NICE) produced guidance on the Mollii suit in 2017. The guidance suggests that the technology has the potential to be a cost-effective treatment for muscle spasticity but due to minimal and low-quality evidence, it is not possible to determine effectiveness. This guidance considered only two unpublished studies originating with the company that created the equipment (Westerlund et al, n.d; Torabi et al, n.d) and does not consider any of the currently published, peer-reviewed literature.
The Cerebral Palsy Education Centre (CPEC) released two reports in 2019 based on a feasibility study conducted through Monash University in September and October 2018 (Brooke-Taylor, 2019; Shi & Carter, 2019). Brooke-Taylor’s report describes findings collected via semi-structured interview from 10 parents and one teenager. Reported benefits include improved attention, energy levels, concentration, standing posture, joint positioning, motor skills and reduced pain. Shi and Carter’s report is an economic analysis of Mollii suit treatment. They conclude that the economic analysis is not possible from available data due to lack of follow-up data collection for the primary outcomes.
Both reports have similar drawbacks. The primary study had a small sample size due to lack of resources, which limited the statistical power of results. Significantly, it’s also not clear if this primary study has been published or reported anywhere besides tangentially in the two secondary reports. This means results mentioned in the two reports are not verifiable with the primary study. Also of note, CPEC is a service provider that hires out the Mollii suit to clients. This creates some risk of conflict of interest.
Metier Medical Limited, the Australian retailer of the Mollii suit, has released a 181-page evidence package which they say “contains details of current and ongoing research and
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personal experiences surrounding benefits of the Mollii Suit and similar technologies.” (Metier Medical Ltd, n.d, p.1). This evidence package is undated, though it contains material from as late as 2021 (Blackburn, 2021). This document contains some of the studies listed in 4.1 Published peer reviewed studies above. It also contains testimonials, unpublished case- studies and other grey literature.
10 items presented in the Mollii suit evidence package were not found elsewhere. This includes:
• 6 case studies including participants with Multiple Sclerosis, traumatic brain injury,
severe ataxia, anxiety and depression and chronic fatigue (Green, n.d; Marsden,
n.d; Reed, n.d; Sandell, n.d a; Sandell, n.d b; Blackburn, 2021)
• a cost-effectiveness analysis (Shi et al, n.d)
• two case series studies (Westerlund et al, n.d; Torabi et al, n.d)
• a description of the theoretical framework of the Mollii suit (Penatti, n.d).
These sources suggest Molli suit treatment is cost-effective (Shi et al, n.d), can reduce muscle spasticity, pain, anxiety, depression and tiredness and can improve balance, trunk, stability, range of motion, mobility, speech, digestion, mood, and sleep quality (Metier Medical Ltd, n.d). The level of evidence of these studies is very low due to study design. There is high risk of bias and conflict of interest as they appear to originate with the company that produces the Mollii suit and there is no evidence of peer review. There are significant quality issues with the reports including under-reporting of methods, results, dates of study, and limitations of study. These sources should not be used as evidence of efficacy.
4.3 Future studies on the Mollii suit
As of 8th July 2025, there are 12 studies utilising the Mollii suit that are listed on ClinicalTrials.gov as currently recruiting. These studies investigate the use of the Mollii suit for conditions such as cerebral palsy, multiple sclerosis, fibromyalgia, stroke and lower back pain.
4.4 Research on electrical stimulation
In contrast to the research focussing on the Mollii suit, the research literature dealing with other associated methods of electrical stimulation is considerably more robust with evidence weighed in many systematic reviews and reviews of reviews. For example, a PubMed search for “transcutaneous electrical stimulation” revealed 208 systematic reviews from 2018-2022. However, considering the variety of methods and protocols for applying electrical stimulation, the research cannot be considered as a whole. For further consideration of varieties of electrical stimulation, refer to TAPIB research papers:
• RES 344 Therapy for chronic cervical SCI
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• RES 314 Transcranial magnetic stimulation for the treatment of psychosocial
conditions
• RES 293 Lower limb functional electrical stimulation after spinal cord injury
• RES 277 Posterior tibial nerve stimulation for painful bladder syndrome
• RES 275 Dorsal root ganglion stimulation for complex regional pain syndrome.
Mollii suit promotional material compares the product to transcutaneous electrical stimulation. There is evidence that this can produce positive outcomes for people with pain and spasticity. Fernandez-Tenorio et al (2019) reviewed 10 clinical trials of low intensity transcutaneous electrical stimulation for spasticity including a total of 330 participants. They found that TENS is likely a valid treatment option for spasticity. However, due to variability in the form of stimulation, the parameters and the variables analysed, they could not make recommendations around dosage, frequency or intensity. Lin et al (2018) reviewed 7 RCTs and found TENS could reduce spasticity, increase static balance and walking speed in patients with stroke compared with a placebo. Mahmood et al (2019) also found TENS could improve spasticity in people with stroke when combined with physical therapy compared with just physical therapy.
Johnson et al (2022) reviewed 381 RCTs including 24,532 participants and found moderate- certainty evidence that pain intensity is lower during or immediately after TENS compared with a placebo. Of note, they found no statistically significant difference between low and high frequency TENS but could not draw conclusions regarding comparative intensity of stimulation.
In addition, neuromuscular electrical stimulation (NMES) has also been shown to reduce spasticity, improve mobility and muscle strength in patients with Cerebral Palsy (Ou et al, 2022; Chen et al, 2022). Kristensen et al (2022) have shown NMES can improve activities of daily living in people with stroke.
There is evidence that some form of electrical stimulation can lead to benefits in spasticity, mobility, pain and daily functioning. However, the optimal mode of delivery, protocols, intensity and frequency of stimulation, frequency and duration of therapy sessions is less clear.
- Cost-effectiveness
No further cost-effectiveness studies were found in the 2025 research review.
There are two available studies looking at cost-effectiveness of the Mollii suit. One was unable to determine whether the Mollii suit was a cost-effective solution (Shi & Carter, 2019), due to insufficient follow-up around outcomes of the participants. The other found Mollii suit to be more cost-effective than other treatments considered in the context of the Swedish healthcare system (Shi et al, n.d). There are significant quality issues with both studies including high risk of bias due to commercial interest of the parties involved with the studies.
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The state of the research on Mollii suit poses a significant problem in determining cost- effectiveness. Due to the type, quality and quantity of research on the Mollii suit, there is insufficient evidence to determine whether it is an effective therapeutic intervention for treating any condition or removing functional barriers associated with any condition. Most research is of low or very low quality. In addition, the results of the research are mixed. For example, in relation to spasticity, some published studies show treatment with Mollii suit positively affects spasticity (Flodstrom et al, 2021; Hedin et al, 2020; Palmcrantz et al 2020), whiles other show no improvement (Bakaniene et al, 2018; Pennati et al, 2021; Ertzgaard et al, 2018). There is insufficient evidence to determine the long-term outcomes of using the Mollii suit. There is insufficient evidence to determine how many sessions are required to achieve a desired benefit or how long the sessions should be to achieve the benefit.
Insofar as the Mollii suit is making use of transcutaneous electrical stimulation, it is possible to appeal to the evidence of benefit of low frequency electrical stimulation for spasticity, mobility, pain and daily functioning. However, there is no research comparing use of the Mollii suit with other electrical stimulation modalities. There is a suggestion in the literature that wearing the suit itself might have an effect but there is no research which attempts to separate this effect from the electrical stimulation.
There is insufficient evidence that Mollii suit is more effective than other treatments. Neither cost-effectiveness study compares cost-effectiveness of Mollii with other electrical stimulation devices (Shi & Carter, 2019; Shi et al, n.d). The evidence demonstrating that other electrical stimulation devices can achieve functional outcomes is more robust than the evidence related to the Mollii suit. Other electrical stimulation devices can be low cost as well. Considering this, it is not clear whether Mollii would ever be value for money in relation to these other devices.
There is also insufficient evidence that Mollii suit will be cost-effective against conventional physiotherapy. One RCT found no statistically significant difference between a group receiving Mollii suit therapy and a group receiving conventional physiotherapy (Bakaniene et al, 2018). There is no evidence that Mollii in conjunction with conventional therapy improves function more than conventional therapy alone. Also of note, Mollii Australia recommends continuing ongoing therapy and exercise (Exopulse Mollii Australia, About Mollii) notes that the Mollii suit is a “complementary tool to existing therapies” (Exopulse Mollii Australia, Professionals) and reiterates that the suit should be used “preferably together with physiotherapy, training, activity or movement” (Exopulse Mollii Australia, Clients). Considering this, it is not likely that use of the Mollii suit will result in any significant reduction in need for other therapies and it is not known whether use of Mollii suit alone or in conjunction with conventional therapy will result in substantial increase to functional capacity.
There are many individual case studies and testimonials claiming use of the Mollii suit has improved spasticity, pain, mobility, continence and general wellbeing. In several published studies, participants report perceived positive outcomes. In addition, it is possible that the Mollii suit might be beneficial for some people and not others. For example, it is possible that Mollii suit might have a larger impact on spasticity of people experiencing more severe
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symptoms versus those with only mild spasticity. However, the current research is not sufficient to justify this claim.
- Time-limited, goal-oriented therapy
Mollii Australia makes claims for the Mollii suit regarding both functional and health related outcomes. For example, they say the suit can improve mobility and balance but also that it can improve pain and blood circulation (Exopulse Mollii Australia, Home). Ottobock note that the suit is intended for people with Multiple Sclerosis, Cerebral Palsy, Stroke, and Spinal Cord Injuries (Exopulse Mollii Suit, n.d), while Mollii Australia also include motor neurone disease, Parkinson’s disease, back and shoulder pain and fibromyalgia (Exopulse Mollii Australia, Home). They also state the Mollii suit can be used for acute or chronic pain.
Mollii Australia says that the suit “should be used for one hour every second day, unless otherwise specified by your healthcare provider, and preferably together with physiotherapy, training, activity or movement. The effects are individual and can last for up to 48 hours and possibly longer” (Exopulse Mollii Australia, Clients).
The Mollii suit may be used as a time-limited, goal oriented therapy if it is intended to help manage an acute episode of pain or to assist with rehabilitation after an injury. However, it may also be intended as a long-term adjunct to ongoing maintenance therapies for people with chronic health conditions or disabilities.
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- Literature Summary Table
Author
Title
Source
Aim / Objective
For Internal Use Only
Methods
Results
Evaluation of evidence
REFIG UM.
Leogrande E, | Enhancing Biomimetics, | To explore the 1 x 31-year-old adult Improvements in motor | VERY LOW level of Piccoli, S Motor 2025. 10. innovative integration of | male with dystonic function of the right and | evidence due to small Dell’Olio F, Function and robotic and spastic tetraparesis due | left upper limbs, slight sample size, no control Smania, N Quality of Life biomechatronic to neonatal trauma. improvements in group. Authors cite an Mazzoleni,S | Combining technologies, including Undertook an intensive sensory and passive additional limitation is Gandolfi, M Advanced the Motore and Ultra+ physiotherapy program, | joint motion scores. the observational nature Robotics and devices and neuro-suits, | supplemented by a Functional of the study and its Biomechatron in a 10-session Exopulse Mollii Suit fora | independence and limited generalisability. ics in an Adult rehabilitation program one-hour session, three | physical functioning with for a young adult with times a week. After one | increased, as did Dystonic dystonic spastic month of using the suit, | emotional well-being and Spastic tetraparesis. treatment was general health. Data Tetraparesis: supplemented with ten from the robotic and A Case tailored sessions of biomechatronic devices Report robotic rehabilitation (the | showed increased joint Motore device and mobility and the ability to Ultra+ biomechatronic manage progressively device) designed for the | challenging tasks. patient’s specific needs. | Trunk function and stability improved. Pain increased as did role limitations due to emotional problems. PerpetuiniD, | Assessing the | Brain To evaluate the 26 children with cerebral | Following a single 1- VERY LOW level of Russo EF, Impact of Sciences, effectiveness of palsy, aged 2 to 18 hour session of electrical | evidence due to small Cardone D, Electrosuit 2023. 13 electrosuit therapy in the | years of age. Used the stimulation with the suit, | sample size, no control Palmieri R, Therapy on clinical treatment of Mollii suit for 1 hour. A patients exhibited a group, short timeframe De Giacomo | Cerebral children with cerebral subset of 12 children statistically significant of study and lack of A, Palsy: palsy, focusing on the continued to use the suit | enhancement in trunk intervention testing for Intiso O, A Study on effect of the therapy on | three times a week for 1 | control. No significant spasticity and trunk the Users’ spasticity and trunk month. Gross Motor control for those Mollii Suit Page 16 of 39
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Methods
Results
Evaluation of evidence
REFS Ms
Pellegrino R, | Satisfaction Function Classification changes in spasticity participants who Merla A, and Potential System (GMFCS) were recorded. completed the 1-month Calabro RS, Efficacy carried out initially to For those who continued | intervention. Filoni S. evaluate gross motor this study, the QUEST
functions. The Modified | and PIADS
Ashworth Scale (MAS) Questionnaires
and Level of Sitting demonstrated a good
Scale (LSS) were used acceptability and
to assess the outcomes | satisfaction of the suit by
of the single 1-hour the patients and
session. The the caregivers and
Psychosocial Impact of | showed improved
Assistive Devices Scale | functional capacity,
(PIADS) questionnaire independence and
and the Quebec User performance.
Evaluation of
Satisfaction with
Assistive Technology
(QUEST) questionnaire
was used to assess the
12 children who received
therapy for 1 month. PerpetuiniD, | Use and Bioengineerin | To investigate the Systematic review of Positive effects of the LOW review quality due Russo EF, Effectiveness | g. 2023. 10 effectiveness of the literature. 12 papers garment on improving to the lack of inclusion Cardone D, of Electrosuit Exopulse Mollii Suit for included focusing on motor functions and and exclusion criteria, Palmieri R, in rehabilitation and its cohorts with cerebral reducing spasticity have | the absence of De Giacomo | Neurological acceptability by patients. | palsy, stroke and other been shown to discussion of the quality A, Disorders: pathologies such as be related to the and Risk of Bias of Pellegrino R, | A Systematic fibromyalgia and duration of the included articles and the Merla A, Review with Parkinson. The literature | administration period absence of information Calabro RS, Clinical was collected through and to the dosage of the | about how data Filoni S. Implications several databases treatment, which, extraction was
following the performed.
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Methods
Preferred Reporting
Results
in turn, depend on the
Evaluation of evidence
Items for Systematic individual’s condition Reviews and Meta- and the treatment goals. analyses (PRISMA) statement. Vanderhauwa | Patient Multiple To share initial 3 persons with multiple Participants reported a VERY LOW level of ert, F. experience of | Sclerosis experiences with the sclerosis wore the beneficial effect on evidence due to small transcutaneo | Journal, Exopulse Mollii Suit in 3. | Exopulse Mollii Suit for 1 | spasticity and sample size, no control us electrical 2023. 29(IS) | persons with multiple hour per day for atleast | functionality of the group, short timeframe stimulation sclerosis. To show the 1 week. upper and lower limbs, of study and patient- with Exopulse author’s next steps to and experienced a reported results. Mollii Suit get more experience positive change in Methodology and results with the Exopulse Mollii different activities of unclear from abstract. Suit. daily living, such as walking, use of keyboard, dressing etc. Raffalt PC, Electro-suit Clinical To investigate the effect | Twelve patients (mean There is evidence that VERY LOW level of Benckle J, treatment of Biomechanics | of systematic treatment | age: 12 years, range 7— | 24 weeks of Exopulse evidence due to small Mortensen K, | children with | , 2022. with the Exopulse Mollii | 17 years) with unilateral | Mollii Suit treatment sample size. No follow- Torabi TP, unilateral Suit on the nonlinear cerebral palsy received | alters the nonlinear up is reported after the Wong C, cerebral palsy dynamics and variability | 24 weeks Exopulse dynamics but not the post-treatment tests Speedtsberg | alters of trunk accelerations Mollii Suit treatment with | variability of the trunk which occurred within 25 MB. nonlinear during walking in patient-specific muscle accelerations during hours of the last dynamics of children with unilateral stimulation. Before and walking in children with treatment session. walking cerebral palsy. after the treatment, the unilateral cerebral palsy.
patients completed 4 min treadmill walking while trunk accelerometry was obtained. The non-linear dynamics, complexity index from the multiscale entropy and movement
The temporal structure of the trunk acceleration in the anterior-posterior direction was altered towards that of healthy individuals.
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variability were quantified.
Results
Evaluation of
evidence
Flodstr6mC, | Apilotstudy | Assistive To evaluate the possible | Six children, five to ten All children perceived VERY LOW level of wiklund of the impact | Technology. effect of Mollii on body years of age, used the improvements in evidence due to small Axelsson S-A, | of the electro | 2021. function, activity and electro-suit for one hour, | performing self-selected | sample size, no control Nordstr6m B. | suit Mollii on participation in self- every other day for three | activities, according to group, short timeframe body selected activities for months. Assessment at | both performance and of study. In addition, functions, children with Cerebral four weeks and three satisfaction. 5 children participants began activity and Palsy. months by measuring improved standing by treatment with low participation passive range of motion | 5% according to COPM. | degree of spasticity so in children (ROM), muscle tone, 5 children improved possible effects were with Cerebral pain, gross motor walking, running, small. Palsy. function and jumping by 2-7% participation. according to COPM. Hedin H, The effects of | European To evaluate the effect of | 16 children with GMFCS | Passive range of motion | VERY LOW level of Wong C, using an Journal of electrostimulation using | I-IV. Joint motion, tonus | (pROM) improved during | evidence due to low Sjédén A. electrodress Physiotherap | an electro-dress to and a dynamic treatment with a sample size, high (Mollii) to y. 2020 reduce spasticity and component were significant number of participant drop-out rate, reduce enhance mobility in evaluated at baseline, improved muscles after | control unit/suit size was spasticity and children with CP. one month, three one, three and six not individualised for enhance months, six months and_ | months. The spasticity each participant. functioning in one year. Caregiver level measured using children with logged pain, sleep, the modified Ashworth cerebral bowel function and scale (MAS) significantly palsy: a pilot temperature / decreased at one and study. discolouration of hands __| six months and was and feet for one-week almost significant after prior to evaluations. three months. The GMFCS was taken at modified Tardieu baseline and 6 months. _| significantly decreased
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after one month, but not after three or six months. Palmcranitz S, | Feasibility Journal of To explore usability, Case Series. 20 60% of participants LOW due to case series Pennati GV, and potential | NeuroEngine | changes in spasticity or | participants used Mollii reported perceptions of | with low sample size. Bergling H, effects of ering and level of functioning after | suit in the home for 60 either decreased muscle | Authors note that the Borg J. using the Rehabilitation | using Mollii suit in the minutes every 2 days for | tone, improved gait study is explorative and electro-dress | 2020. 17(1). home for 6 weeks. 6 weeks. Weekly pattern function and may guide future Mollii on telephone interviews voluntary movement in studies. spasticity and assessed usability and the upper extremity. A functioning in perceived effects. Other | significant decrease in chronic measures were taken neural component of the stroke. before and after wrist flexors was intervention. Spasticity detected with the measured using NeuroFlexor. MAS did Neuroflexor and not show a significant Modified Ashworth scale | change. Other measures (MAS). Sensorimotor were mixed. function, upper extremity function, grip strength, walking speed, balance and perceived function / disability were also tested. Bakaniene |, | Effects of the | Neurologia i To investigate the effect | 8 children with CP used | Though both groups LOW level of evidence Urbonavicien | Inerventions | Neurochirurgi | of the Inerventions Mollii suit for 1 hour 3 experienced due to small sample size eG, method on a Polska. method on gross motor | times per week for 3 improvements in gross despite presence of Janaviciute K, | gross motor 2018. 52(5). function in children with | weeks. Control group motor function and control group. Prasauskiene | function in spastic cerebral palsy. consisted of 8 children mobility, the difference in A. children with doing functional exercise | effect was not spastic program at same statistically significant. dosage. Outcomes
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REESC Ms
cerebral measured using Gross palsy. Motor Function Measure, passive range of motion (PROM), the Modified Tardieu Scale, and the Timed Up and Go test.
Flodstrom C. | Electrodress | Unpublished | To evaluate Mollii’s Six children studied over | Little change to passive | VERY LOW level of Mollii, impact | Master’s effects on participation in | 3 months. Measures range of movement and _ | evidence. Abstract of on degree thesis | a self-selected activity, include Gross Motor muscle tone. Positive unpublished Master’s participation, | sourced from | the effects on body Function Measure effect on pain. degree thesis. Low spasticity and | http://www.div | functions, range of (GMFM), Goal sample size and method Joint mobility | a-portal.org/. | motion and muscle tone. | Attainment Scale (GAS), unclear from abstract. in children 2015 Canadian Occupational with cerebral Performance Measure palsy (COPM), Modified
Ashworth Scale (MAS). Other methodological elements unclear from abstract.
Nordstrom B, | Apilot study | Assistive To describe experiences | Individual interviews Some parents and VERY LOW level of
Prellwitz M. of children Technology. from children with were conducted with six | children felt the positive | evidence due to and parents 2021. 33(5) cerebral palsy and their | children 5 to 10 years of | impact on the child’s qualitative interview experiences parents regarding the age and their parents. spasticity. The children based study with low of the use of use of the suit. The interviews were and their parents had sample size. anew transcribed and both positive and assistive analysed using a negative experiences of device, the qualitative content the use of the suit. electro suit analysis.
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REPS Ms
Shi J, Sjoberg | Cost- Presented in | To assess the cost- Mixed methods cost- Preliminary results VERY LOW due to non- E, Lundqvist | effectiveness | Mollii suit effectiveness of effectiveness study. showed that peer reviewed Fr. analysis of evidence Inerventions method Standardized Inerventions method publication, research the pack. Date compared to measurements and was more effective than | date unknown, cost- Inerventions unknown. conventional treatments | patient all alternative treatments | effectiveness only in the in the context of the interviews/surveys used _ | in this study, and less context of the Swedish Swedish healthcare to assess the treatment | costly than baclofen and | healthcare system. Risk system. effectiveness in surgery and similar costs | of bias and conflict of randomly selected as botulinum toxin. interest as research is patients’ medical only available on conditions. Costs were manufacturer’s website obtained by estimations and co-author is the from suppliers, hospitals inventor of the product. and healthcare agencies. Sensitivity analysis was performed to compensate for data uncertainty. Torabi TP, The Mollii- Presented in | To investigate whether a | 31 children wore Mollii A statistically significant | VERY LOW levels of Mortensen K, | suit®- A novel | Mollii suit novel method using suit for 1 hour ever two decreased change in evidence due to non- Michelsen J, | method using | evidence reciprocal inhibition days for six months. spasticity was measured | peer reviewed Wong C. reciprocal pack. Date affects range of motion Measurements at 4, 12 in m. biceps femoris, m. | publication, research inhibition on unknown. and spasticity on and 24 weeks using semitendinosus andm. | date unknown and small children with children with cerebral goniometer (for PROM), | quadriceps femoris. A sample with no control cerebral palsy. MAS, modified Tardieu significant increased group and very minimal palsy, scale, and Goal modified Tardieu scale information reported on GFMCS IV-V. Attainment scale. was measured in m. methods and results. A6 month biceps femoris and m. There is a risk of bias as prospective semitendinosus. The origin of research is study PROM showed a unclear. Study appears suggestive trend to be conducted at a towards statistically hospital in Copenhagen, significance different in though publication is m. biceps femoris, m. unclear. Information is Mollii Suit Page 22 of 39
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REFS Ms
semitendinosus and m. presented on the quadriceps. Goals manufacturer’s website. related to function and mobility improved significantly throughout the intervention period at 24 weeks, except for 4. Green J. A Case Study | Poster To explore the potential | Case study of women 1 hour Mollii treatments | VERY LOW level of to Assess the | presented in | effects of 1 hour Mollii with secondary consistently led to evidence due to case Effects of an | Mollii suit treatments on mobility, progressive MS. immediate study design, non-peer Electrical evidence upper limb function and | Participant wore suit for | improvements in the reviewed publication Stimulation pack. Date effort. To identify if any 1 hour on two occasions | efficiency and with unclear date and Suit on the unknown. benefits that occurmay | and then repeated for1 | effectiveness of mobility | publication status. Functional be cumulative following | week on alternate days. | and upper limb function. | Poster presented on Mobility of an alternate day Measures taken before | Diary records indicate manufacturer website Individual with intervention over a week | and after treatment. that these benefits and appears to have Secondary carried over into the been removed from Progressive following day, during the | original source MS week when alternate day | (www.hobbsrehabilitatio interventions were n.co.uk). Author notes performed. 3 out of 4 variability in MS baseline scores were symptoms mean results improved and the may not reflect effect of treatment effect was treatment. greater in 3 out of four OM’s after a week of alternate day use, which may indicate a training effect. Westerlund The Mollii Suit | Presented in | Aim / objective not 117 subjects using Mollii | General condition VERY LOW quality with MO, Sjéberg | Method - Mollii suit stated. suit for 6-24 months improved in 90% of the aim/objective, methods E, Sandell J, | followup and | evidence were assessed using patients, locomotion and results not Sandstr6ém C, | long term use | pack. Date patient reports. Unclear | improved in 61%, transparently reported. of anew unknown if other methods were general spasticity was Risk of bias and conflict Mollii Suit Page 23 of 39
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Lauritsen HK, | possible used to measure reduced in 60%, ability of interest is high as Lundqvist F. therapy for outcomes. to straighten the non-peer reviewed patients with hand/fingers improved in | publication was authored spasticity 46% and 34% of the by manufacturer. (previously patients respectively. called the Patients also reported Inervations improved balance, trunk Method) stability, range of motion, mobility, speech, digestion, better mood, reduced pain, improved sleep quality, and an overall improved quality of life. 32% of the patients had planned spasticity treatments at baseline, and 90% of these patients could cancel these treatments due to improvement. Westerlund Electrical Ortopediskt To study the effects of Patients were Reported reduction in VERY LOW levels of MO, Sjéberg | stimulation Magasin using the Mollii suit for recommended to use spasticity which was evidence due to E, Sandell J, | asa 3/2014 children and young Mollii suit for 60-90 reported in 61% of the publication in apparent Sandstrém C, | treatment for adults with CP. minutes 3 or 4 times per | patients. 48% reported industry magazine Lauritsen HK, | spasticity in week and presented with | an improvement of associated with the Lundavist F. children a questionnaire. general range of motion | Swedish Orthopaedic Treatment period was and just over 30% Association. Methods not reported. experienced that it was and results were not easier to place the heel | transparently reported. on the floor, lift the arms | Risk of bias and conflict above the head and/or of interest is high as straighten fingers and non-peer reviewed hands. Several patients | publication was authored also reported reduced by manufacturer. Mollii Suit Page 24 of 39
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muscle stiffness, increased range of motion and improved core stability and
Evaluation of
evidence
posture.
Pennati, GV, | Effects of 60 | Frontiers in To evaluate the Twenty patients in the At group level, analyses | MODERATE level of Bergling H, Min Neurology. effectiveness of one chronic phase after showed no significant evidence from double- Carment L, Electrostimula | October session of stimulation stroke were enrolled ina | effect of stimulation at masked randomly Borg J, tion With the | 2021. with the EXOPULSE cross-over, double-blind | any frequency on controlled cross-over Lindberg PG, | EXOPULSE Mollii suit at different controlled study. NeuroFlexor neural trial with reduction in and Mollii Suit on stimulation frequencies Electrical stimulation component (NC) and level of evidence due to Palmcraniz S. | Objective on objective signs of delivered through EMG amplitude in the low sample tested using
Signs of spasticity and clinical EXOPULSE Mollii was upper or lower Neuroflexor.
Spasticity measures, and the applied for 60 min at two | extremities (p > 0.35).
subjective perceptions of | active frequencies (20 Nevertheless, the effect
the intervention.
and 30 Hz) and in OFF- settings (placebo) in a randomized order, every second day. Spasticity was assessed with controlled-velocity passive muscle stretches using the NeuroFlexor hand and foot modules. Surface electromyography (EMG) for characterizing flexor carpi radialis, medial gastrocnemius, and soleus muscles activation, Modified Ashworth Scale and range of motion were used as complementary
was highly variable at the individual level, with eight patients exhibiting reduced NC (>1 N) in the upper extremity after stimulation at 30 Hz, 5 at 20 Hz and 3 in OFF settings. All these patients presented severe spasticity at baseline, i.e., NC > 8 N. Modified Ashworth ratings of spasticity and range of motion did not change significantly after stimulation at any frequency. Finally, 75% of participants reported an overall feeling of well-
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Methods
tests. Finally, a questionnaire was used to assess the participants’ perceptions of using the EXOPULSE Mollii suit.
Results
being during stimulation, with 25% patients describing a muscle- relaxing effect on the affected hand and/or foot at both 20 and 30 Hz.
Evaluation of evidence
Jonasson LL, Sorbo A, Ertzgaard P, Sandsjo L.
Patients’ experiences of self- administered electrotherap y for spasticity in stroke and cerebral palsy: a qualitative study
Journal of Rehabilitation Medicine. 2022. 54
To explore patients’ experiences of a self- administered electrotherapy treatment, the Exopulse Mollii Suit, for muscle spasticity in cerebral palsy and stroke
Information letters were sent to all potential participants (n=27) from a previous study. Semi- structured interviews (21-57 min) were carried out with all subjects who volunteered (n=15), administered by an experienced interviewer who was not involved in the previous study. Transcribed interviews were subject to content analysis
Increased mobility, reduced spasticity, and a reduction in the use of medication for spasticity- related symptoms were positive outcomes described by participants, although this was not experienced by everyone. Interest in continuing using the treatment for home- based training after the study was based on each individual’s experience of whether the treatment was effective, the (initial) motivation, and determination to try the new concept, the support from relatives or home service personnel
VERY LOW level of evidence due to qualitative self-report study with low sample size and issues with methodology and quality. Follow up interviews 6-12 months after treatment, participant responses are not quantified (for example, authors report that “the respondents said…” or “some respondents said…”), unclear if respondents were also treatment compliant. Of particular note, all the participants were offered the Mollii suit to keep but some chose not to. It is significant how many of
to use the treatment and | the 27 participants overcome difficulties that | declined a piece of free might appear, and the therapy equipment. overall usability of the
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REFS Ms
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Methods
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electrotherapy suit. The participants’ interest in using the training concept thus depended on the outcome from using the suit, motivation to use the suit, the usability of the suit, and available support when using the suit.
Evaluation of evidence
NHS and social care commissioners and staff who are considering using new medical devices and other medical or diagnostic technologies.
the production of MedTech Innovation
Briefings.
Pennati G. Theoretical Presented in | To describe the n/a n/a Should not be read as framework for | Mollii suit theoretical basis for the evidence of the clinical evidence Mollii suit method. effectiveness as this applications pack. Date paper simply describes of Mollii. unknown the theoretical basis and mechanism by which it is assumed the Mollii suit works. National Mollii suit for | https://www.ni | MedTech innovation Includes description of The current evidence LOW quality evidence Institute for spasticity: ce.org.uk/ briefing on Mollii Suit: technology and its use base for this technology | due to age. Most Healthcare MedTech 2017 MedTech innovation and review of clinical is low in quality and available research on evidence innovation briefings (MIBs) are evidence in line with quantity. There are no Mollii suit has been briefing. NICE advice. They are Interim process and published randomised published after 2017. designed to support methods statement for controlled studies or
high quality comparative observational studies available to assess the effectiveness of the Mollii suit
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REESE Ms
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Author Title Source Aim / Objective Methods Results Evaluation of evidence
Ertzgaard P, | Evaluation of | European To assess the Participants used the Fifteen of the 27 LOW despite controlled Alwin J, a self- Journal of effectiveness of Mollii, a | suit with and without participants fulfilled the trial due to lack of Lindgren M, administered | physicaland | garment with integrated | electrical stimulation treatment protocol in compliance and small Sandsjo L. transcutaneo | rehabilitation | electrodes for multifocal | (active/non-active terms of recommended sample size. us electrical Medicine transcutaneous electrical | period) for six weeks use. Deviations were stimulation 2018 stimulation intended for | each, followed by six frequent. No statistically concept for august;54(4) | self-treatment of weeks without treatment. | significant differences in the treatment spasticity, in study Goal attainment scaling | outcome were found of spasticity: participants with (Gas), change in between the active and a randomized spasticity due to stroke mobility, arm-hand the non-active treatment placebo- or cp. ability, spasticity and periods. During the controlled trial pain were measured at active period, an baseline and after 6,12 | improvement was seen and 18 weeks. in the 10-meter comfortable gait test, time and steps. an improvement was seen in both the active and
non-active periods for the Gas. Compliance was low, partly due to deviations related to the garment, complicating the interpretation of the results. further research should focus on identifying the target population and concomitant rehabilitation strategies.
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Author Title Source Aim / Objective Methods Results Evaluation of
evidence
Bourke-Taylor | Report for the | Cerebral To evaluate the Interviews with parents The suit was acceptable | VERY LOW levels of H. board of the Palsy feasibility, practicalities and one teenager before | to most children and evidence due to self- cerebral palsy | Education and experiences of ten and after treatment with | families, perceived to be | reported responses of education Centre. May | children who wore the Molli suit for 6 weeks. ‘relaxing’ and easy to 10 people measuring centre: 2019. MOLLII suit for 6 weeks include in the weekly perceived effects. qualitative per a specific protocol schedule by most Quantitative data was study of a families. It is important to | collected but not transcutaneo note the variability and reported in this report us electrical individualised responses | and unclear if that data stimulation to the Mollii suit — each is published elsewhere. garment family had a different This study is a report for (Mollii suit) to response, with some CPEC and does not reduce pain, common themes and appear in a peer- improve individual differences. reviewed publication. capabilities The changes perceived and quality of by parents included life in children improvements in with cerebral attention, energy levels, palsy concentration, improved standing posture, joint positioning, motor skills and reduced pain. Shih S, Carter | Economic Cerebral To answer the question | A cost-outcome Due to lack of follow-up | VERY LOW levels of R. assessment Palsy What are the direct and | description. Use of the data collection for the evidence due to self- of an Education associated costs of the term ‘description’ primary outcomes, reported responses of electrical Centre. 2019. | Molli Suit, including the clarifies the point that particularly in the quality- | 10 children and their stimulation impact on healthcare this is not a full of-life measures, the carers measuring garment resource use? economic evaluation. economic research perceived effects. This (Mollii suit) to Preference-based question proposed in the | study is a report for reduce quality of life protocol could not be CPEC and does not spasticity and measurement tools — the | answered. appear in a peer- improve Child Health Utility 9D reviewed publication. motor and the Assessment of Quality of Life 8D were
Mollii Suit
REFS Us
Page 29 of 39
Author
function in
Source
DISCLOSURE LOG DOCUMENT
Research Paper
OFFICIAL
Aim / Objective
For Internal Use Only
Methods
used to measure the
Results
Evaluation of
evidence
children change in quality of life
with Cerebral in 10 children and their
Palsy carers, respectively. A diary was used to gather cost information.
Riachi N, Pain Journal of the | Investigate the Mollii Suit | An open-label Wearing the Mollii suit VERY LOW level of
Khazen G, Reducing Neurological | effect on pain in adults uncontrolled study for 1 hour demonstrated | evidence due to format,
Ahdab R, Properties of | Sciences with different pain included 200 adults (75 | significant subjective lack of control and no
Lundavist F, the Mollii Suit | 405S (2019) | diagnoses. males and 115 females) | improvements in VAS follow up. Good sample
Jorgen S. on Adults with who used Mollii suit scores. size however treatment Chronic pain therapy for one-hour. 72 was for 1 hour one time syndromes were diagnosed with only. Abstract presented
Fibromyalgia, 29 with in a peer reviewed Parkinson, while other journal however appears diagnosis had a to be a transcription of a frequency b 20. Patients poster presented at a were asked to fill a conference.
Visual Analogue Scale
(VAS) just before the
intervention (VAS-0),
immediately afterwards
(VAS-1) and twenty-four
hours (VAS-24) later.
Marsden S. Single Case Presented in | To explore the benefit of | Participant assessed Combining Mollii suit VERY LOW levels of Study: Low Mollii suit the Low Threshold using Modified Fatigue regimen with active evidence due to case threshold evidence Electrical Stimulation Impact Scale, Motricity therapy input helped to study methodology and electrical pack. Date using the Mollii suit to Index and Trunk Control | subdue the symptoms of | presentation in Mollii suit stimulation unknown. subdue symptoms of Test, Scale for the ataxia, which had evidence pack from an (LTES) using |} Originally a ataxia and improve Assessment and Rating | significant carry over unknown conference. the Mollii suit | presentation | function in acommunity | of Ataxia, Arm Activity effect in the participant’s as treatment | at unknown setting Measure and Video functional performance. modality for conference analysis including time severe ataxia taken for Arm
Mollii Suit Page 30 of 39
REF Ue
Author
Title
in an adult with Multiple Sclerosis
Source
DISCLOSURE LOG DOCUMENT
Research Paper
OFFICIAL
Aim / Objective
For Internal Use Only
Methods
movements, drinking from water hydrant tube, slide transfer and walking. Mollii suit worn 1 hour daily for 3 days prior to admission; and then daily for first 2 weeks of admission. This regimen was reduced to alternate days for the remaining period of the study 4 weeks inpatient rehabilitation, input ranging from 8 to 10 sessions per week. Measures repeated post intervention. Follow up measures were repeated 4 weeks later to assess carry over effect. Participant continued home programme during this period.
Results
Evaluation of evidence
Reed S
A Case Study to Assess the Effects of an Electrical Stimulation Suit on the Functional Mobility of an Individual with
Presented in Mollii suit evidence pack. Date unknown.
To explore whether a single hour use of the Mollii Suit would improve objective gait measures due to a reduction in spasticity, ataxia and dystonic movements
Following individual subject assessment, the small control unit is programmed by the clinical specialist and the suit is worn for one 60 minute session to observe the initial effects. Measures of
Step and stride length,
Significant observable changes in the patients gait parameters including the decrease in difference of step length from 18.2cm to 7.3cm, a decrease in percentage of time spent in double support of 9.8% (L) and 3.1% (R), an equal
VERY LOW level of evidence due to case study design, non-peer reviewed publication with unclear date and publication status. Methods not clearly reported.
Mollii Suit
REFIG Ms
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Author
Title
a Traumatic
Source
DISCLOSURE LOG DOCUMENT
Research Paper
OFFICIAL
Aim / Objective
For Internal Use Only
Methods
Swing and double
Results
increase in stride time
Evaluation of evidence
Brain Injury support Phase, Stride from 1.18secs to and step time, Step 1.30secs, step length asymmetry, Centre of asymmetry decreased load mapping, cadence | by 16.3%, cadence and Step width are decreased by 9.4 retaken after treatment. | (despite the speed remaining constant) and a narrower base of support of 3.4cm. Sandell J. A Case Study | Presentedin | To explore whether Following individual A single hour of wearing | VERY LOW level of to Assess the | Mollii suit using Mollii suit for one subject assessment, the | the Mollii suit for thirty evidence due to case Effects ofan | evidence hour each day over thirty | small control unit Is straight days, after being | study design, non-peer Electrical pack. Date straight days would programmed by the programmed by a reviewed publication Stimulation unknown. improve measures for clinical specialist and the | trained therapist, clearly | with unclear date and Suit on Pain Pain, Sleep and Energy | suit is worn for 60 demonstrated subjective | publication status. Origin and Sleep levels. minute sessions to improvements in the Self | of case study is unclear. pattern of an observe possible effects. | Assessment Evaluation Individual forms as well as diagnosed objective changes in the with Chronic Sleep Monitoring and Fatigue Total Daily Active Hours. Syndrome/M E Blackburn M. | A Case Study | Presentedin | To examine whether The control unit is The use of the Mollii VERY LOW level of to Assess the | Mollii suit using Mollii (Exopulse) programmed by a (Exopulse) Suit for one evidence due to case Effects of the | evidence for one hour per day for | trained therapist based hour a day significantly study design, non-peer Mollii pack. Date 30 days will reduce on an assessment of the | improved the reviewed publication (Exopulse) unknown. symptoms of anxiety and | individual and is then participant’s mental with unclear date and Suit on depression in a 20 year | worn for 60 minutes health. Prior to Mollii, the | publication status. Anxiety and old female. each day for 30 days. participant’s DASS Conflict of interest and Depression Measures were taken for | evaluation indicated to risk of bias are possible one week pre-Mollii, “moderate” depression, | as study written by during 30 days of “severe” anxiety and Mollii Suit Page 32 of 39
REFS Ms
Author
Title
Source
DISCLOSURE LOG DOCUMENT
Research Paper
OFFICIAL
Aim / Objective
For Internal Use Only
Methods
wearing Mollii and for two weeks post-Mollii. Measure include Depression Anxiety Stress Scale and Revised Child Anxiety
Results
“moderate” stress. During the 30 days wearing the suit, the participant’s DASS evaluation indicated to being in the normal
Evaluation of evidence
employee of Mollii suit retailer.
REFS UM.
and Depression Scale range for depression, anxiety and stress. Sandell J Case Study to |} Presentedin | To explore whether a Following individual After a single hour of VERY LOW level of Assess the Mollii suit single hour of wearing a | subject assessment, the | wearing the Mollii suit evidence due to case Effects of the | evidence Mollii suit could improve | small control unit is the test subject went study design, non-peer Mollii Suiton | pack. Date resistance weight programmed by the from 100 kg to 120 kgin | reviewed publication Maximum unknown. performance in a male clinical specialist and the | 5 repetition Bench press. | with unclear date and Output resistance training suit is worn for a 60 From 190 kg to 250 in5 | publication status. Athletic athlete minute session to repetition Sitting leg Sections of methods Performance observe possible effects. | press. And from 17 to 25 | section may be copy and in Max repetitions in pasted from other case Chin-ups. Other, studies. Conflict of subjective effects that interest and risk of bias were noted by the test are possible as study subject were: - quicker written by employee of recovery — less soreness | Mollii suit retailer. the day after the trial — improved night sleep. Arkkukangas_ | Evaluation of | COGENT To evaluate the effect of | 7 experimental single- The results suggest that | LOW levels of evidence M, Graff JH, the electro- ENGINEERIN | electrical stimulation case studies with ABAB | the multiple electrical due to case study Denison E. dress Mollii to | G 2022, VOL. | treatment with the full- design. Electrode stimulation treatment design, though this study affect 9, NO. 1 body suit (electro-dress) | placing was done by the | had little or no impact on | presents multiple single spasticity and Mollii, on spasticity, company while health the primary outcome— case studies and does motor mobility, sitting, upper professionals from study | spasticity—in any of the | not contend results are function in limb activity, sleep, pain, | facilities were present. studies. generalisable across a children with and adherence The treatment regimen group. cerebral (frequency of use) to the | was 1 hour every other palsy: Seven treatment using day (3-4 times per Mollii Suit Page 33 of 39
DISCLOSURE LOG DOCUMENT
Research Paper
OFFICIAL For Internal Use Only
Author Title Source Aim / Objective Methods Results Evaluation of evidence
experimental experimental single-case | week) in daily activities.
single-case studies with an ABAB All participants were studies with design among children evaluated on 12 an ABAB with CP (4-18 years of occasions during a 4- design age) week period, three times each week. Mollii Suit Page 34 of 39
REFS Ms
DISCLOSURE LOG DOCUMENT ResearchFOI 25/26-0388Paper
OFFICIAL For Internal Use Only
- References
Ayache, S. S., Mattar, J. G., Créange, A., Abdellaoui, M., Zedet, M., Lefaucheur, J. P., Megherbi, H., Khaled, H., Abi Lahoud, G. N., & Chalah, M. A. (2025). The effect of the EXOPULSE Mollii suit on motor functions in patients with multiple sclerosis - a randomized sham-controlled crossover trial. Multiple sclerosis journal - experimental, translational and clinical, 11(2), 20552173251348304. https://doi.org/10.1177/20552173251348304
Bakaniene, I., Urbonaviciene, G., Janaviciute, K., & Prasauskiene, A. (2018). Effects of the Inerventions method on gross motor function in children with spastic cerebral palsy. Neurologia i Neurochirurgia Polska, 52(5), 581–586. https://doi.org/10.1016/j.pjnns.2018.07.003
Blackburn, M. (2021). A Case Study to Assess the Effects of the Mollii (Exopulse) Suit on Anxiety and Depression. In Metier Medical Limited (Ed.), Mollii (EXOPULSE) suit: evidence package.
Bonanno, M., & Calabrò, R. S. (2023). Bridging the Gap between Basic Research and Clinical Practice: The Growing Role of Translational Neurorehabilitation. Medicines (Basel, Switzerland), 10(8), 45. https://doi.org/10.3390/medicines10080045
Chen, Y.-H., Wang, H.-Y., Liao, C.-D., Liou, T.-H., Escorpizo, R., & Chen, H.-C. (2022). Effectiveness of neuromuscular electrical stimulation in improving mobility in children with cerebral palsy: A systematic review and meta-analysis of randomized controlled trials. Clinical Rehabilitation, 2692155221109661. https://doi.org/10.1177/02692155221109661
Ertzgaard, P., Alwin, J., Sörbo, A., Lindgren, M., & Sandsjö, L. (2018). Evaluation of a self- administered transcutaneous electrical stimulation concept for the treatment of spasticity: a randomized placebo-controlled trial. European Journal of Physical and Rehabilitation Medicine, 54(4), 507–517. https://doi.org/10.23736/S1973- 9087.17.04791-8
Exopulse Mollii Suit. (n.d). Ottobock. https://exopulse.com/en/home/
Exopulse Mollii Australia. (n.d). Metier Medical Limited. https://molliiaustralia.com.au/
Fernández-Tenorio, E., Serrano-Muñoz, D., Avendaño-Coy, J., & Gómez-Soriano, J. (2019). Transcutaneous electrical nerve stimulation for spasticity: A systematic review. Neurología (English Edition), 34(7), 451–460. https://doi.org/10.1016/j.nrleng.2018.08.001
Flodström, C. (2015). Electrodress Mollii, impact on participation, spasticity and joint mobility in children with cerebral palsy (Elektrodress Mollii, påverkan på delaktighet, spasticitet och ledrörlighet hos barn med cerebral pares) (Masters thesis, Sweden).
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Flodström C, Wiklund Axelsson S-A, Nordström B. (2021). A pilot study of the impact of the electro suit Mollii on body functions, activity and participation in children with Cerebral Palsy. Assistive Technology. https://doi.org/10.1080/10400435.2020.1837288
Green, J. (n.d). A Case Study to Assess the Effects of an Electrical Stimulation Suit on the Functional Mobility of an Individual with Secondary Progressive MS. In Metier Medical Limited (Ed.), Mollii (EXOPULSE) suit: evidence package.
Hedin H, Wong C, Sjödén A. (2020). The effects of using an electrodress (Mollii) to reduce spasticity and enhance functioning in children with cerebral palsy: a pilot study. European Journal of Physiotherapy, 24(3), 134-143. https://doi.org/10.1080/21679169.2020.1807602
Johnson, M. I., Paley, C. A., Jones, G., Mulvey, M. R., & Wittkopf, P. G. (2022). Efficacy and safety of transcutaneous electrical nerve stimulation (TENS) for acute and chronic pain in adults: a systematic review and meta-analysis of 381 studies (the meta-TENS study). BMJ Open, 12(2), e051073. https://doi.org/10.1136/bmjopen-2021-051073
Jonasson, L.-L., Sörbo, A., Ertzgaard, P., & Sandsjö, L. (2022). Patients’ experiences of self- administered electrotherapy for spasticity in stroke and cerebral palsy: A qualitative study. Journal of Rehabilitation Medicine: Official Journal of the UEMS European Board of Physical and Rehabilitation Medicine, 54, jrm00263. https://doi.org/10.2340/jrm.v53.1131
Kristensen, M. G. H., Busk, H., & Wienecke, T. (2022). Neuromuscular electrical stimulation improves activities of daily living post stroke: A systematic review and meta-analysis. Archives of Rehabilitation Research and Clinical Translation, 4(1), 100167. https://doi.org/10.1016/j.arrct.2021.100167
Leogrande, E., Piccoli, S., Dell’Olio, F., Smania, N., Mazzoleni, S., & Gandolfi, M. (2025). Enhancing Motor Function and Quality of Life Combining Advanced Robotics and Biomechatronics in an Adult with Dystonic Spastic Tetraparesis: A Case Report. Biomimetics (Basel, Switzerland), 10(2), 113. https://doi.org/10.3390/biomimetics10020113
Mahmood, A., Veluswamy, S. K., Hombali, A., Mullick, A., N, M., & Solomon, J. M. (2019). Effect of transcutaneous electrical nerve stimulation on spasticity in adults with stroke: A systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation, 100(4), 751–768. https://doi.org/10.1016/j.apmr.2018.10.016
Marsden, S. (n.d). Single Case Study: Low threshold electrical stimulation (LTES) using the Mollii suit as treatment modality for severe ataxia in an adult with Multiple Sclerosis. In Metier Medical Limited (Ed.), Mollii (EXOPULSE) suit: evidence package.
Mattar, J. G., Chalah, M. A., Ouerchefani, N., Sorel, M., Le Guilloux, J., Lefaucheur, J., Abi Lahoud, G. N., & Ayache, S. S. (2025). The effect of the EXOPULSE Mollii Suit on pain
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and fibromyalgia‐related symptoms—A randomized sham‐controlled crossover trial. European Journal of Pain, 29(2), e4729-n/a. https://doi.org/10.1002/ejp.4729
Metier Medical Limited. (n.d). Mollii (EXOPULSE) suit: evidence package.
Mollii Australia (n.d.). Contact our Team. http://www.mollii.com.au/
National Institute for Healthcare Excellence. (2017). Mollii suit for spasticity: MedTech innovation briefing [MIB100]. NICE. https://www.nice.org.uk/advice/mib100
Nordstrom, B., & Prellwitz, M. (2021). A pilot study of children and parents experiences of the use of a new assistive device, the electro suit Mollii. Assistive Technology, 33(5), 238– 245. https://doi.org/10.1080/10400435.2019.1579267
Orthotics Plus. (2025). Mollii Suit. https://orthoticsplus.com.au/orthotics/mollii-suit/
Ou, C.-H., Shiue, C.-C., Kuan, Y.-C., Liou, T.-H., Chen, H.-C., & Kuo, T.-J. (2022). Neuromuscular electrical stimulation of upper extremities in patients with cerebral palsy: A systematic review and meta-analysis of randomized controlled trials. American Journal of Physical Medicine & Rehabilitation. https://doi.org/10.1097/PHM.0000000000002058
Palmcrantz, S., Pennati, G. V., Bergling, H., & Borg, J. (2020). Feasibility and potential effects of using the electro-dress Mollii on spasticity and functioning in chronic stroke. Journal of Neuroengineering and Rehabilitation, 17(1), 109. https://doi.org/10.1186/s12984-020- 00740-z
Pennati, G. V., Bergling, H., Carment, L., Borg, J., Lindberg, P. G., & Palmcrantz, S. (2021). Effects of 60 min electrostimulation with the EXOPULSE Mollii suit on objective signs of spasticity. Frontiers in Neurology, 12, 706610. https://doi.org/10.3389/fneur.2021.706610
Pennati, G. (n.d). Theoretical framework for the clinical applications of Mollii. In Metier Medical Limited (Ed.), Mollii (EXOPULSE) suit: evidence package.
Perpetuini, D., Russo, E. F., Cardone, D., Palmieri, R., De Giacomo, A., Intiso, D., Pellicano, F., Pellegrino, R., Merla, A., Calabrò, R. S., & Filoni, S. (2023a). Assessing the Impact of Electrosuit Therapy on Cerebral Palsy: A Study on the Users’ Satisfaction and Potential Efficacy. Brain Sciences, 13(10), 1491-. https://doi.org/10.3390/brainsci13101491
Perpetuini, D., Russo, E. F., Cardone, D., Palmieri, R., De Giacomo, A., Pellegrino, R., Merla, A., Calabrò, R. S., & Filoni, S. (2023b). Use and Effectiveness of Electrosuit in Neurological Disorders: A Systematic Review with Clinical Implications. Bioengineering (Basel), 10(6), 680-. https://doi.org/10.3390/bioengineering10060680
Raffalt, P. C., Bencke, J., Mortensen, K., Torabi, T. P., Wong, C., & Speedtsberg, M. B. (2022). Electro-suit treatment of children with unilateral cerebral palsy alters nonlinear
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dynamics of walking. Clinical Biomechanics (Bristol), 98(NA), 105714–105714. https://doi.org/10.1016/j.clinbiomech.2022.105714
Reed, S. (n.d.). A Case Study to Assess the Effects of an Electrical Stimulation Suit on the Functional Mobility of an Individual with a Traumatic Brain Injury. In Metier Medical Limited (Ed.), Mollii (EXOPULSE) suit: evidence package.
Riachi, N., Chalah, M. A., Ahdab, R., Arshad, F., & Ayache, S. S. (2023). Effects of the TENS device, Exopulse Mollii Suit, on pain related to fibromyalgia: An open-label study. Neurophysiologie Clinique, 53(4), 102863–102863. https://doi.org/10.1016/j.neucli.2023.102863
Rubio-Zarapuz, A., Apolo-Arenas, M. D., Tomas-Carus, P., Tornero-Aguilera, J. F., Clemente- Suárez, V. J., & Parraca, J. A. (2024a). Comparative Analysis of Psychophysiological Responses in Fibromyalgia Patients: Evaluating Neuromodulation Alone, Neuromodulation Combined with Virtual Reality, and Exercise Interventions. Medicina (Kaunas, Lithuania), 60(3), 404. https://doi.org/10.3390/medicina60030404
Rubio-Zarapuz, A., Apolo-Arenas, M. D., Fernandes, O., Tornero-Aguilera, J. F., Clemente- Suárez, V. J., & Parraca, J. A. (2024b). Comparative Efficacy of Neuromodulation and Structured Exercise Program on Autonomic Modulation in Fibromyalgia Patients: Pilot Study. Journal of Clinical Medicine, 13(15), 4288. https://doi.org/10.3390/jcm13154288
Rubio-Zarapuz, A., Apolo-Arenas, M. D., Tornero-Aguilera, J. F., Parraca, J. A., & Clemente- Suárez, V. J. (2024c). Comparative Efficacy of Neuromodulation and Structured Exercise Program on Pain and Muscle Oxygenation in Fibromyalgia Patients: A Randomized Crossover Study. Frontiers in Physiology, 15, 1414100. https://doi.org/10.3389/fphys.2024.1414100
Rubio-Zarapuz, A., Apolo-Arenas, M., Clemente-Suárez, V., Costa, A., Pardo-Caballero, D., & Parraca, J. (2023). Acute Effects of a Session with The EXOPULSE Mollii Suit in a Fibromyalgia Patient: A Case Report. International Journal of Environmental Research and Public Health, 20(3), 2209. https://doi.org/10.3390/ijerph20032209
Sandell, J. (n.d a). A Case Study to Assess the Effects of an Electrical Stimulation Suit on Pain and Sleep pattern of an Individual diagnosed with Chronic Fatigue Syndrome/ME. In Metier Medical Limited (Ed.), Mollii (EXOPULSE) suit: evidence package.
Sandell, J. (n.d b). A case Study to Assess the Effects of the Mollii Suit on Maximum Output Athletic Performance. In Metier Medical Limited (Ed.), Mollii (EXOPULSE) suit: evidence package.
Shi J, Sjoberg E, & Lundqvist F. (n.d). Cost-effectiveness analysis of the Inerventions (Mollii) method. In Metier Medical Limited (Ed.), Mollii (EXOPULSE) suit: evidence package.
Supportivity. (n.d.). Allied Health. https://supportivity.com.au/allied-health/
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Therapeutic Goods Administration. (2022). Public Summary of 285154 Metier Medical Ltd - Stimulator, electrical, neuromuscular. Department of Health. https://www.ebs.tga.gov.au/servlet/xmlmillr6?dbid=ebs/PublicHTML/pdfStore.nsf&docid =AF5CBF8A024404E6CA2588550042D907&agid=(PrintDetailsPublic)&actionid=1
Torabi TP, Mortensen K, Michelsen J, Wong C. (n.d). The Mollii-suit - A novel method using reciprocal inhibition on children with cerebral palsy, GFMCS IV-V. A 6 month prospective study. In Metier Medical Limited (Ed.), Mollii (EXOPULSE) suit: evidence package.
Vanderhauwaert, F. (2023, May 4-6). Patient experience of transcutaneous electrical stimulation with Exopulse Mollii Suit. [Conference presentation]. RIMS Annual Conference 2023, Genoa, Italy. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahU KEwjRwOfs1OqNAxUPS2cHHTY6CncQFnoECBgQAQ&url=https%3A%2F%2Freposito rio.ipl.pt%2Fbitstreams%2F89db626a-35e3-4c4b-96d0- a65dfcb367e0%2Fdownload&usg=AOvVaw3r4IcRVuk45I2bP-BAP4Ah&opi=89978449
Wagner, V., Knudsen, M. S., Curtis, D. J., & Riberholt, C. G. (2023). Use of the EXOPULSE Mollii for severe ataxia in an adult male 4 months after cardiac arrest. BMJ Case Reports, 16(3), e249574-. https://doi.org/10.1136/bcr-2022-249574
Weller, L. J. R., Sherwood, S. M., Ng, S. H., Vellaichamy, M., Noordin, A. A., Tan, L. Y., Mahadev, A., Yeo, T. H., & Ng, Z. M. (2025). Can External Neuromodulation Garments Improve Gait and Function in Children With Cerebral Palsy? A Prospective Single‐Arm Study. Health Science Reports, 8(3), e70566-n/a. https://doi.org/10.1002/hsr2.70566
Westerlund MO, Sjöberg E, Sandell J, Sandström C, Lauritsen HK, Lundqvist F. (n.d). The Mollii Suit Method - follow up and long term use of a new possible therapy for patients with spasticity. In Metier Medical Limited (Ed.), Mollii (EXOPULSE) suit: evidence package.
Yen, J. M., Kamsani, N. S., Tang, N., Sen Lai, H., Low, J. S., & Chew, E. (2024). Effects of the Exopulse Mollii suit on spasticity and gait in spinal cord injury. Gait & Posture, 113, 259–260. https://doi.org/10.1016/j.gaitpost.2024.07.278
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Research – Adverse effects of bidet use
Does habitual bidet toilet use lead to an increase in adverse health concerns (e.g. urological infections, haemorrhoids, bacterial vaginitis, and aggravation of vaginal microflora)? Does this differ between biological sexes? Brief Is there a significant increase in adverse health concerns from bidet use when compared to the general population (e.g. increased likelihood of infection caused by bidet use, or infections are typically present in general population regardless of bidet use)?
Date 16/04/2021
s22(1)(a)(ii) - irre Requester(s) Claire - Senior Technical Advisor (TAB)
s22(1)(a)(ii) - irrelev Researcher Jane - Research Team Leader (TAB)
Cleared N/A
Please note:
The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision-making.
Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters they are to call the TAPS line for advice.
The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters.
1 Contents
2 Summary ………………………………………………………………………………………………………….. 1
3 Evidence of infections ………………………………………………………………………………………… 2
4 Hygiene status of bidet toilets …………………………………………………………………………….. 3
5 Association with pre-term birth …………………………………………………………………………… 3
6 Implementing bidet in aged care or disability settings ……………………………………………. 3
7 References ……………………………………………………………………………………………………… 18
2 Summary
• Literature investigating the adverse effects of bidet use is sparse
Research – Adverse effects of bidet use Page 1 of 19
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• There is some evidence to suggest that habitual bidet use can cause haemorrhoids, irritated perianal skin, urological infection, vulvar pruritus and bacterial vaginitis o Apart from irritated perianal skin, there are no differences between sexes in infection rate • There is conflicting evidence around the use of bidet use and pre term birth • The implementation of bidets in nursing homes has shown that only 50% of residents and nurses are supportive of bidet use, and that in the majority of cases residents remain unclean and still require toileting assistance (duplication of supports) o One study found that more 28% of bidet users were still required to wipe using toilet paper multiple times • A single study has found that bidet use can assist in reducing toileting time for people with spinal cord injury. However, further studies are required to confirm its effectiveness
3 Evidence of infections
There is some evidence of a positive relationship between haemorrhoids, irritated perianal skin, urological infection, vulvar pruritus and bacterial vaginitis in those considered habitual bidet users [1, 2]. These findings were obtained from moderate quality retrospective surveys that included up to 18,000 participants. It was also found that 28 % of the bidet users wiped off excess water with toilet paper many times [3].
When comparing incidence of non-genital related conditions, Asakura, Nakano [1] found that men more commonly reported subjective symptoms of irritated skin around the anus, which were newly experienced during follow-up than non-habitual users (adjusted risk ratio 1.36 (95% confidence interval 1.06–1.75)). Furthermore, Tsunoda, Takahashi [3] found that men were more commonly affected by an “itch on the anus” because they had faecal leakage more frequently (OR = 3.82) and used a bidet more actively. Other than men being more likely to use a bidet, there were no other gender differences found.
A cross sectional study investigating the possible relevancy of bidet usage to changes in vaginal microflora in 268 women found that normal microflora (Lactobacillus species) was not present in 42.86% of bidet toilet users, compared to 8.77% of non-users. Faecal bacteria were detected in 50 of the 268 cases (18.66%), 46 cases in users (92%) and only 4 cases in non-users (8%). Contamination by other pathogens was 4 to 6 times higher in users than in non-users.
Various case studies have reported that bidet use can cause:
• Anal fissure in the anterior midline
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• Rectal mucosal prolapse syndrome • Scald burn in the perianal region
4 Hygiene status of bidet toilets
A handful of studies have investigated the hygiene status of bidet toilets in public restrooms such as hospitals and Universities. They have found that:
• Pseudomonas aeruginosa is present on about 2% of the toilet seats. P. aeruginosa was found to remain for long durations in biofilms that formed inside warm-water tanks [4] • 86.9% of bidet toilets were found to be contaminated by one or more of the following organisms [5]: o S. aureus, Streptococcus spp o Enterococcus spp o Enterobacteriaceae o non-glucose-fermenting rods (NFR) o other Gram-negative bacteria • The nozzle surface of 87% and 94% of the spray water were found to be contaminated by one or more of the following organisms [6]: o Enterobacteriaceae o Enterococcus spp., o Staphylococcus spp., o non-glucose-fermenting rods, o other Gram-negative bacteria, o other Gram-positive bacteria o Candida spp.
5 Association with pre-term birth
Two studies investigated the bidet use and the association with pre term birth. Both came to differing conclusions. Asakura, Nakano [7] found that normal use of bidet toilets by pregnant women does not pose any clinical health risk with regard to preterm birth. In contrast, Kim, Kim [8] found that chronic bidet toilet use, before and during pregnancy, is associated with abnormal vaginal colonization by gram-negative bacteria (mostly by E coli) and preterm birth.
6 Implementing bidet in aged care or disability settings
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Two studies have investigated the use of bidet toilets in an aged care facility [9] and a spinal cord injury rehabilitation setting [10]. Both of these studies were of low quality with small sample sizes. In the nursing home setting, it was found that only 50% of nurses and residents responded positively to the use of the bidet. Logbook entries revealed that residents were rated as clean only 49% of the time, as slightly dirty 34% of the time, and in the range from somewhat to very dirty for the remaining 17% of the times that they used the wash-and-dry toilets. Therefore, residents still required cleaning following the use of a bidet in most instances.
In those with spinal cord injury time needed for bowel management with the modified bidet device was shorter than that with patients’ usual manner of bowel care (P 0.01). However, residual stools were found in 8 of the 15 patients.
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Table 1. Literature Review
Author Aim/Objective Evidence of infections Asakura, Nakano [1] Tere tne
relationship between bidet toilet use and haemorrhoids or urogenital infections.
Research — Adverse effects of bidet use
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Methods
Retrospective cross sectional survey
A total of 18,562 people were randomly selected using a computer programme, to whom a web survey questionnaire was randomly delivered until the number of respondents exceed 10 000. A total of 10 305 individuals were involved in the baseline survey.
1-year and 3-year follow up studies were also conducted.
See methods given in Kiuchi, Asakura [2] below for full details of questionnaire.
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Results
Final number of subjects analysed was 7759, giving a follow-up rate of 75.3%.
50.1% of respondents were habitual bidet
users. They were more likely to be older, married and wealthier.
In men, more habitual users reported subjective symptoms of irritated skin around the anus, which were newly experienced during follow-up than non- habitual users (adjusted risk ratio 1.36 (95% confidence interval 1.06—1.75)).
Risk ratio based on prevalence of haemorrhoids diagnosed by a physician, subjective symptoms of haemorrhoids and subjective symptoms of irritated perianal skin were significantly higher in habitual users.
Regarding women, no cumulative incidence of outcomes was significantly
associated with bidet toilet use.
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Level & Quality of evidence
MODERATE
Large sample, followed over many years. Still low prevalence rates of some conditions to determine an effect.
Large number of respondents eliminated due to inconsistent outcomes.
Table 1. Literature Review
Author Aim/Objective Garg [11] Preliminary report of various cases of anterior fissure-in-ano. 5 T h Kiuchi, Asakura [2] © assess the
relationship between habitual bidet toilet use and the incidence of haemorrhoids or urogenital infection.
Research — Adverse effects of bidet use
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Methods
Multiple Case Reports
Prospective web based survey 18,562 people were randomly
selected from an online database
to receive the questionnaire. A
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Results
10 patients of anal fissure in anterior
Midline. Two patients presented with acute and eight patients had chronic fissures.
9 men and 1 female patient
Age ranged from 22 to 46 years (median 36 years).
Duration of symptoms ranged from 4 to 7 days in acute cases and 3-8 months (median 5 months) in patients with chronic fissure.
All the patients reported using a bidet-toilet and exposing the perianal region to water stream for a few minutes (range: 1—
5 min).
They were recommended to stop the usage of such a water stream and were advised to use water poured from a container. Conservative treatment was also continued. All except one patient responded well to the treatment and became asymptomatic within 2—3 weeks.
The patient who did not respond to the treatment required an operation.
A total of 7637 subjects were analysed
using single or multiple logistic regression models.
The prevalence odds ratios (ORs)
_ between bidet toilet users and non-users
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Level & Quality of evidence
_ VERY LOW
Very brief report. Only descriptions provided.
Considering the rarity of
anterior fissure in men and the ‘cause and effect’ relationship seen in these cases, the water stream of the bidet-toilet being the causative factor of anterior fissure in these cases looks probable.
_ MODERATE
There is a positive relationship between habitual bidet toilet use and haemorrhoids and
| urogenital symptoms, except
Table 1. Literature Review
Author
Research — Adverse effects of bidet use
Aim/Objective
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Methods
total of 10,305 individuals were involved in the baseline survey.
A follow-up web survey was conducted in February 2014. 8255 of the baseline subjects participated again (follow up rate 80.1%).
Survey questions e Frequency of bidet use:
“never used”, “use less than once a week”, “use every day or more than once a week
e Physician diagnosis and subjective symptoms of haemorrhoids, irritated perianal skin, cystitis, pyelonephritis, candida vaginitis, bacterial vaginitis, and vulvar pruritus.
Baseline included questions about
smoking, drinking, fitness, sleeping, showering/bathing, bowel movements, direction of wiping the anus after defecation, menstrual status, sexual activity, academic background, and past/current histories of diseases.
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Results
_ for haemorrhoids, urological infections, and vulvar pruritus were significantly >1.0
but their incidence ORs were not
significant. The adjusted incidence OR for
bacterial vaginitis symptoms was significant (2.662, 95% confidence interval [Cl] [1.315—5.520]).
No gender differences in relation to prevalence of disease/symptoms. Males more likely to be habitual bidet users.
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Level & Quality of evidence
bacterial vaginitis, were due to reverse causation. The incidence of bacterial vaginitis might be caused by bidet toilet use, but the incidence rates were too small to make a definite conclusion, and further studies are needed.
Table 1. Literature Review
Author Aim/Objective Miura, Kimura [12] Presentation a case of adverse effect after
excessive bidet use.
The present study was designed to clarify the possible relevancy of bidet usage to changes in vaginal microflora
Ogino, lino [13]
Research — Adverse effects of bidet use
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Methods Results Level & Quality of evidence
Case Study An irregular, elevated, inflamed lesion in ¥ERr LO
the rectal canal was found. At 10 cm from the anus, a raised, haemorrhagic lesion involving the posterior and right rectal wall was also found.
14-year-old boy presented to Hospital because of passage of blood and bloody stools for several months.
Single case study.
The patient’s height was 165 cm,
his weight was 45 kg. Rectal mucosal prolapse syndrome diagnosed and caused by overuse of
No physical abnormal findings of _ bidet.
anus/rectum on examination.
Laboratory data were all within reference ranges. Stool culture was negative.
The patient had used a bidet since he was 2 years old. Recently he had been remaining in the bathroom for nearly an hour, using a stream of water at the
highest flow setting. Cross Sectional Study 268 women participated MODERATE Participants were recruited ina 57.6% were habitual bidet users. Cross sectional, uncontrolled
study. Relatively small sample to be able to generalise to the greater population.
hospital setting, after attending for complaints relating to vaginal discharge.
Normal microflora (Lactobacillus species) was not present in 42.86% of bidet toilet users, compared to 8.77% of non-users. Inclusion criteria
Page 8 of 19
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Table 1. Literature Review
Author Aim/Objective
Presentation a case of scald burn in the perianal region caused by using a bidet
Shulman, Wolf [14]
Research — Adverse effects of bidet use
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Methods
Women of reproductive age (from 19 to 40 years).
All patients were questioned whether or not they were habitual bidet toilet users. Habitual users were defined as those who use bidet toilets every time at toileting.
An aliquot of cervicovaginal secretion was obtained by a sterilized cotton swab and transferred into culture tubes
Single Case Study
69-year-old female was admitted to the emergency room with a complaint of a pain in the right side of her perineum as a result of hot water from a bidet.
Medical history
Multiple sclerosis diagnosed 2 years prior to her admission and treated with immunoglobulins.
In the last 6 weeks she had received high dose hydrocortisone due to exacerbation of the disease. As
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Results Level & Quality of evidence
_ Faecal bacteria were detected in 50 of the
268 cases (18.66%), 46 cases in users (92%) and only 4 cases in non-users (8%).
Contamination by other pathogens was 4 to 6 times higher in users than in non- users.
Physical examination on arrival revealed a VERY LOW deep third degree burn in the right perianal region measuring less than 1% of | Single case design. Lowest level
total body surface area. on evidence hierarchy.
The burn wound was debrided, its
margins, close to the anal orifice were In the case described, a lack of
sutured. motor coordination in conjunction with sensory
A course of oral antimicrobial treatment problems, caused a deep third was initiated. Conservative treatment was__ degree burn to the right maintained and recovery of the burn perianal region.
occurred within 9 weeks.
No infection or other complications were observed.
Page 9 of 19
Table 1. Literature Review
Author Aim/Objective
To investigate the use of bidet toilets among community dwelling Japanese people and explored the correlates for an itch on the anus.
Tsunoda, Takahashi [3]
Research — Adverse effects of bidet use
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Methods
part of her disease she suffered from diminished sensation in the lower part of her body.
Cross sectional survey
Convenience sample
Subjects were hospital outpatients and employees or students and employees at two technical colleges
Inclusion criteria Aged >14 years old
Data collection occurred over 2 weeks.
Questionnaire
e Basic demographic information (age and sex)
e General questions on bidet toilet use
e Questions targeting those who use bidet toilets before defecation
e Questions targeting those who use bidet toilets after defecation
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Results
4,963 respondents included in the final
analysis (3,190 (64 %) women and 1,773 men)
The mean + standard deviation (SD) (range) age of the respondents was 49.6 + 20.2 years
55 % (2,724/4,952) of respondents washed the anus either before or after defecation
83 % (2,253/2,724) of the respondents reported that they had a bidet toilet at home
Men, and older people (aged >50 years) used bidets more actively.
Washing the anus before defecation was associated with constipation (p = 0.005).
28 % (698/2,500) of the respondents wiped off excess water with toilet paper many times.
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Level & Quality of evidence
_ MODERATE
Convenience sample, subjective responses
Table 1. Literature Review
Author
| Hygiene status of bidet toilets
lyo, Asakura [4]
To evaluated the disinfection status and microbial hygiene of the
spray water.
Kanayama Katsuse, Takahashi [5]
Research — Adverse effects of bidet use
Aim/Objective
To survey the state of residual chlorine and microbial indicators in the spray water of warm-water tanks of bidet toilet seats.
To investigate the distribution of antimicrobial-resistant
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Methods
e Questions targeting women who use bidet toilets to wash their genitals
Prospective survey (of bacterial presence)
Residual chlorine and microorganism indicators in the spray water from the warm-water bidet toilet seats were surveyed twice.
Spray water
Spray water was collected directly as it came out of the nozzle, and tap water was used as a control.
Tap water
Approximately 50 mL of tap water was collected for residual chlorine testing in sterilized bottles.
Cross sectional survey
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Results
| Men might be affected by an itch on the
anus, because they had faecal leakage more frequently (OR = 3.82) and used a bidet more actively.
A total of 127 seats were analysed. There were
43 toilet seats for men’s use, 71 for women’s use, and 13 for barrier-free use.
Spray water from the toilet seats had less residual chlorine than their tap water sources. However, the total viable microbial count was below the water- quality standard for tap water.
Heat of the toilet seats’ warm-water tanks caused bacteria in the source tap water to proliferate inside the nozzle pipes and the warm water tanks.
Pseudomonas aeruginosa was detected on about 2% of the toilet seats. P. aeruginosa was found to remain for long durations in biofilms that formed inside
| warm-water tanks.
254 (86.9%) were found to be contaminated by one or more of the
Page 11 of 19
Level & Quality of evidence
LOW
The existence of P. aeruginosa in spray water, even at low levels is concerning. This has the potential to cause opportunistic infections, especially in immunocompromised individuals.
| MODERATE
Table 1. Literature Review
Author Aim/Objective bacteria recovered from bidet toilets at a university-affiliated hospital in Japan.
Tsunoda, Otsuka [6] To evaluate the hygiene
status of bidet toilets
Research — Adverse effects of bidet use
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Methods
All 292 electronic bidet toilets at a_ single hospital in Japan were sampled for bacterial contamination.
Swabs were used to sample the warm spray jet from nozzles and toilet seats.
Chromosomal DNA analysis by pulsed-field gel electrophoresis of S. aureus, E. coli and P. aeruginosa isolates were performed.
Prospective survey (of bacterial presence)
A total of 192 tank type bidet toilets were surveyed, of those 103 were in an inpatient ward (48 individual, 55 shared), 34 were in an outpatient clinic, and 55 were in a research building for employees.
Sampling protocol
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Results
following organisms: S. aureus, Streptococcus spp., Enterococcus
spp., Enterobacteriaceae, non-glucose- fermenting rods (NFR) and other Gram- negative bacteria.
Enterobacteriaceae were isolated from 84 (28.8%) bidet toilets: E. coli, Enterobacter spp., Klebsiella spp., Citrobacter spp. and other Enterobacteriaceae were found in warm-water nozzles of 38 (13.0%), 22 (7.5%), 13 (4.5%), five (1.7%) and six (2.1%) bidet toilets, respectively.
_ Of the 192 toilets sampled, the nozzle
surface of 167 (87%) and the spray water of 181 (94%) were found to be contaminated by one or more of the following organisms: Enterobacteriaceae Enterococcus spp., Staphylococcus spp., non-glucose-fermenting rods, other Gram-negative bacteria, other Gram-positive bacteria Candida spp.
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Level & Quality of evidence
Single cross sectional study. Unable to confirm ongoing contamination.
Authors conclude that warm- water nozzles of bidet toilets are contaminated with a wide range of bacteria, making them a potential vehicle for infection. In the hospital setting, shared use of bidet toilets must consider the clinical background of patients. Based on these findings, bidet toilets must be part of the risk management programme, and steps should be included for monitoring and
_ disinfection.
LOW
Because the interval of scrubbing the toilets did not have an influence on the contamination of the spray water, self-cleaning mechanisms of spray water should be developed to prevent patients’ possible infections.
Table 1. Literature Review
Author Aim/Objective
Association with pre-term birth/pregnancy
To estimate the association between bidet toilet use and preterm birth, as well as the effect of bidet toilet use on bacterial vaginosis, in pregnant women.
Asakura, Nakano [7]
Research — Adverse effects of bidet use
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Methods
e Nozzle surface was sampled using swabs before spray water
e Spray water was collected directly as it came out of the nozzle
e Tap water for control specimens was collected from faucets in the restrooms which were surveyed
Retrospective cross sectional survey
All women who gave birth between 2006 and 2010, at Keio University Hospital in Tokyo were invited to participate.
A structured, 6-page questionnaire containing 27 questions about bidet toilet use and other lifestyle factors was sent via mail.
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Results
An extended spectrum of B- lactamase producing Escherichia coli was found in one nozzle surface and one spray water. The frequency of colonization from the nozzle surface was significantly greater in the toilets scrubbed every week than that in the units scrubbed every day.
The nozzle surface and the spray water in the bidet toilets were contaminated with a wide range of bacteria.
The final response rate was 64.1%
Of 1,293 women, 63.3% were users of bidet toilets. The incidence of preterm birth was 15.8% among bidet users and 16.0% among nonusers.
Incidence was 9.8% for late preterm birth and 6.0% for early preterm birth.
No association between bidet toilet use and the incidence of preterm birth (adjusted OR 1.04, 95% confidence interval [Cl] 0.72 — 1.48).
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Level & Quality of evidence
MODERATE
Big sample, however, retrospective surveys lack reliabilities due to recall bias. Not generalizable to greater female population.
Normal use of bidet toilets by pregnant women does not pose any clinical health risk with regard to preterm birth.
Table 1. Literature Review
Author Aim/Objective
To evaluate the association of bidet toilet use with abnormal vaginal microbial colonization and preterm birth (PTB) in high-risk pregnancies.
Kim, Kim [8]
Research — Adverse effects of bidet use
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Methods
Analysis focused on those who had a microbiological screening test conducted at approximately 35 weeks.
Bidet toilet use before and during pregnancy, was collected by a self-report questionnaire.
Primary outcome of this study was the incidence of preterm birth. Preterm birth, delivery before 33 weeks of gestation was defined as early preterm birth. Secondary outcome was bacterial vaginosis estimated by the balance of lactobacilli and non- lactobacillus microbes.
Prospective Cohort Study
Pregnant women, who were hospitalized in high-risk units from April 2015 to July 2017, in two tertiary hospitals in Seoul, South Korea were recruited.
Cases with delivery due to maternal foetal indications (N = 4) were excluded.
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Results
No association was observed between bidet toilet use and bacterial vaginosis (adjusted OR 0.96, 95% Cl 0.70—1.33).
No association between bidet toilet use and intestinal bacteria (adjusted OR 0.97, 95% Cl 0.68—1.38) or between bidet toilet use and bacterial vaginosis— related bacteria (adjusted OR 1.00, 95% Cl 0.73- 1.36).
Detection rate of fungi was significantly higher among bidet toilet users (adjusted OR 1.68, 95% Cl 1.14—2.48)
_ 32.8% of the patients responded as users
of a bidet toilet.
There were no significant differences in the maternal baseline characteristics, such as the age, the rate of primiparity, and pre pregnancy BMI.
Abnormal vaginal microbial colonization was significantly higher in the bidet user group, compared to the nonuser group
| (60.7% vs 44.2%, P = 0.036).
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Level & Quality of evidence
_ MODERATE
Prospective, more precise questions asked and swabs used to determine infection rather than recall.
Authors conclude that chronic bidet toilet use, before and during pregnancy, is associated with abnormal vaginal
_ colonization by gram-negative
Table 1. Literature Review
Author Aim/Objective
Implementing bidet in aged care or disability settings
To investigate the feasibility of using a “wash-and-dry” toilet in the nursing home.
Cohen-Mansfield and Biddison [9]
Research — Adverse effects of bidet use
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Methods
Patients completed a questionnaire which included questions, such as bidet use, purpose of use, duration, mode (feminine mode: cleansing genital lesion, general mode: cleansing anus, or both mode), frequency, time, and strength of the bidet toilet.
Vaginal cultures were taken at the time of admission.
Pseudo randomised trial
Luscence Luxury Lavage toilet used.
Recruitment focused on female residents who had been identified by nursing staff as having difficulty with cleanliness or toileting care.
Participants randomised to experimental or control group.
15 women received new toilets and were included in the experimental group and 13
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Results
This higher rate of abnormal vaginal colonization was attributed to the increased colonization of gram negative bacteria (16.4% vs 6.7%, P = 0.039), especially E. coli (13.1% vs 3.3%, P = 0.023).
Preterm delivery rate of bidet users was significantly higher than that of non-users (87.3% vs 73.0%, P = 0.040).
14 experimental and 8 comparison participants.
27 nursing assistants, of whom 82% were female were interviewed.
8 (57%) of participants in the experimental group had some difficulty in communicating or could not always answer all the questions.
Feasibility
64% (n = 9) of residents were not able to operate the remote control and therefore required staff assistance.
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Level & Quality of evidence
_ bacteria (mostly by E coli) and preterm birth.
LOW
Not completely randomised, small sample, significant drop out rate, self-reported questionnaires used, however, high percentage of participants were unable to provide responses. This severely effects the reliability of the study.
The toilet offered some help with cleaning and drying residents, it was not sufficiently
Table 1. Literature Review
Author
Research — Adverse effects of bidet use
Aim/Objective
DISCLOSURE LOG DOCUMENT FOI 25/26-0388
Methods Results
women were included in the
comparison group Nursing assistants often not willing to use the bidet as easier to change an adult diaper. 50% (n = 7) of residents were Interviews conducted each week __ reported to be physically or mentally
Procedure
with the nursing assistant and disabled and consequently difficult to residents participating. Following _ either verbally persuade or physically lift toilet instillation all baseline onto the toilet. assessments were repeated each week, an additional toilet Reaction questionnaire reaction scale was administered Approximately half of staff and residents to the experimental group. Final responded positively to the use of the assessments administered after 2 _ bidet. months. Logbook entries revealed that residents Outcome measures were rated as clean 49% of the time, as e Resident questionnaires: slightly dirty 34% of the time, and in the toileting experience and range from somewhat to very dirty for reaction the remaining 17% of the times that they
e Nursing staff questionnaires: | used the wash-and-dry toilets. toileting experience Urine test 86% of participants in the comparison Demographic data group versus only 36% in the experimental group had significant bacterial growth in their urine.
Toilet installation was more complex than anticipated.
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Level & Quality of evidence
thorough in this regard, and it requires further development.
Table 1. Literature Review
Author Aim/Objective
To study the effectiveness of a modified washing toilet seat equipped with a CCD camera monitor and an electronic bidet to facilitate precise hitting of the anal area with water streams to stimulate bowel movement in patients with spinal cord injury.
Uchikawa, Takahashi [10]
Research — Adverse effects of bidet use
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Methods
Multiple Case Study Design
Washing toilet seat equipped with an electronic bidet, a CCD camera and a light.
All participants had traumatic SCI.
All patients were at least 5 months post-acute injury and could independently transfer to the toilet seat and change their position on it while watching the CCD monitor.
The maximum duration of stimulation was set at 30 mins, and the maximum power of the water stream was used.
After 30 mins, the amount of residual stool in the rectum was examined using digital evacuation.
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Results
years (SD 17.9, range 18-73).
The level of injury was cervical in 11
patients, thoracic in 7 patients, and lumber in 2 patients.
Fourteen of the 20 patients (70%) could not direct the water stream precisely to the anorectal area without the use of the
monitor.
Bowel movement was successfully
induced with the modified device within 30 mins [average time 17mins (range 3—
28)] in 75% of patients.
Time needed for bowel management with the modified device was shorter than that with patients’ usual manner of bowel care
(P.0.01).
Time required for successful bowel
movement was shortened in 11 of 13 patients (85%) who had spent more than 30 mins with their usual manner of bowel management. However, residual stools
were found in 8 of the 15 patients.
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Level & Quality of evidence
20 patients, all males, mean age was 46.3 melee
Small sample, no control group.
No complications were observed, however, further research is needed to confirm positive results.
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7 References
-
Asakura K, Nakano M, Omae K. Relationship between bidet toilet use and haemorrhoids and
urogenital infections: a 3-year follow-up web survey. Epidemiology and infection [Internet]. 2018; 146(6):[763-70 pp.]. Available from: doi:10.1017/S0950268818000584. 2. Kiuchi T, Asakura K, Nakano M, Omae K. Bidet toilet use and incidence of hemorrhoids or urogenital infections: A one-year follow-up web survey. Preventive medicine reports [Internet]. 2017; 6:[121-5 pp.]. Available from: https://dx.doi.org/10.1016/j.pmedr.2017.02.008. 3. Tsunoda A, Takahashi T, Arika K, Kubo S, Tokita T, Kameda S. Survey of electric bidet toilet use among community dwelling Japanese people and correlates for an itch on the anus. Environmental health and preventive medicine [Internet]. 2016; 21(6):[547-53 pp.]. Available from: https://doi.org/10.1007/s12199-016-0578-3. 4. Iyo T, Asakura K, Nakano M, Yamada M, Omae K. Bidet toilet seats with warm-water tanks: residual chlorine, microbial community, and structural analyses. Journal of water and health [Internet]. 2016; 14(1):[68-80 pp.]. Available from: https://dx.doi.org/10.2166/wh.2015.057. 5. Kanayama Katsuse A, Takahashi H, Yoshizawa S, Tateda K, Nakanishi Y, Kaneko A, et al. Public health and healthcare-associated risk of electric, warm-water bidet toilets. The Journal of hospital infection [Internet]. 2017; 97(3):[296-300 pp.]. Available from: https://dx.doi.org/10.1016/j.jhin.2017.07.021. 6. Tsunoda A, Otsuka Y, Toguchi A, Watanabe K, Nishino R, Takahashi T. Survey on bacterial contamination of bidet toilets and relation to the interval of scrubbing these units. Journal of water and health [Internet]. 2019; 17(6):[863-9 pp.]. Available from: https://dx.doi.org/10.2166/wh.2019.234. 7. Asakura K, Nakano M, Yamada M, Takahashi K, Sueoka K, Omae K. Effect of bidet toilet use on preterm birth and vaginal flora in pregnant women. Obstetrics and gynecology [Internet]. 2013; 121(6):[1187-94 pp.]. Available from: https://dx.doi.org/10.1097/AOG.0b013e318291bc16. 8. Kim Y-M, Kim JY, Lee M-Y, Choi S-J, Oh S-Y, Shim J-Y, et al. Prospective study of bidet toilet use: Association of abnormal vaginal colonization and preterm birth in high-risk pregnant women. The journal of obstetrics and gynaecology research [Internet]. 2019; 45(6):[1134-42 pp.]. Available from: https://dx.doi.org/10.1111/jog.13953. 9. Cohen-Mansfield J, Biddison JR. The potential of wash-and-dry toilets to improve the toileting experience for nursing home residents. The Gerontologist [Internet]. 2005; 45(5):[694-9 pp.]. Available from: https://doi.org/10.1093/geront/45.5.694. 10. Uchikawa K, Takahashi H, Deguchi G, Liu M. A Washing Toilet Seat with a CCD Camera Monitor to Stimulate Bowel Movement in Patients with Spinal Cord Injury. American Journal of Physical Medicine & Rehabilitation [Internet]. 2007; 86(3). Available from: https://journals.lww.com/ajpmr/Fulltext/2007/03000/A Washing Toilet Seat with a CCD Camera Monitor to.6.aspx. 11. Garg P. Water stream in a bidet-toilet as a cause of anterior fissure-in-ano: a preliminary report. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland [Internet]. 2010; 12(6):[601-2 pp.]. Available from: https://dx.doi.org/10.1111/j.1463- 1318.2009.01867.x. 12. Miura T, Kimura K, Sato Y, Kanai N. Rectal mucosal prolapse syndrome and a bidet. Pediatrics international : official journal of the Japan Pediatric Society [Internet]. 2003; 45(4):[467-8 pp.]. Available from: https://ci.nii.ac.jp/naid/10011918291/. 13. Ogino M, Iino K, Minoura S. Habitual use of warm-water cleaning toilets is related to the aggravation of vaginal microflora. The journal of obstetrics and gynaecology research [Internet]. 2010; 36(5):[1071-4 pp.]. Available from: https://doi.org/10.1111/j.1447-0756.2010.01286.x.
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- Shulman O, Wolf Y, Hauben DJ. Perianal burn caused by using the bidet. Burns : journal of the International Society for Burn Injuries [Internet]. 2001; 27(4):[413-4 pp.]. Available from: https://doi.org/10.1016/S0305-4179(00)00124-8.
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Motorised cycling for wheelchair users
The content of this document is OFFICIAL.
Please note:
The research and literature reviews collated by our TAPIB Research Team are not to be
shared external to the Branch. These are for internal TAPIB use only and are intended to
assist our advisors with their reasonable and necessary decision-making.
Delegates have access to a wide variety of comprehensive guidance material. If Delegates
require further information on access or planning matters, they should contact TAPIB for
advice.
The Research Team are unable to ensure that the information listed below provides an
accurate & up-to-date snapshot of these matters.
Research question: What is an effective dosage of motorised ergometer training for improving physical function and quality of life in people who require a wheelchair for all mobility, compared to standard physiotherapy or home exercise programs?
Date: 28/1/25 Requestor: Helen s22(1)(a)(ii) - irrelevant material
Endorsed by: Researcher: Aaron s22(1)(a)(ii) - irrelevant ma Cleared by: Aaron s22(1)(a)(ii) - irrelevant ma
- Contents
Motorised cycling for wheelchair users ………………………………………………………………………….. 1
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Contents ………………………………………………………………………………………………………….. 1
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Summary …………………………………………………………………………………………………………. 2
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Previous TAPIB Research ………………………………………………………………………………….. 2
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Motorised ergometer as a rehabilitation device ……………………………………………………… 3
4.1 Functional Electrical Stimulation Cycling ………………………………………………………… 3
4.2 Passive leg cycling ……………………………………………………………………………………… 4
4.3 MOTOmed movement therapy ……………………………………………………………………… 4
4.4 Arm crank / cycle ergometry …………………………………………………………………………. 4
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Efficacy for wheelchair users ………………………………………………………………………………. 4
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References ………………………………………………………………………………………………………. 5
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Summary
There is evidence that use of a motorised cycling device may be safe and effective in improving some outcomes for people with significant mobility impairments. However, the variety of types and protocols of motorised cycling training makes general effectiveness difficult to assess. Most research focusses on people with spinal cord injury. For non- ambulatory people with spinal cord injury, there is:
• good quality evidence that functional electrical stimulation (FES) cycling can improve
muscle health
• low to moderate quality evidence that arm cycle ergometer training can improve
muscle strength and fitness
• low to moderate quality evidence that multiple sessions of passive leg cycling can
improve spasticity and range of motion.
For other cohorts there is:
• moderate quality evidence that motorised cycle training can improve some clinical
outcomes including heart rate and respiration for non-ambulatory people with stroke
• preliminary evidence that MOTOmed movement therapy may be safe and tolerated
for non-ambulatory people with cerebral palsy.
Limitations in the research prevent confident recommendations on the comparative efficacy of motorised cycling training in general, physiotherapy or home-based exercise programs. Most research into lower limb motorised cycling protocols either does not include non-ambulatory participants or does not report the mobility status of study participants, including whether they are reliant of a wheelchair for all mobility.
- Previous TAPIB Research
RES 293 Lower limb functional electrical stimulation after spinal cord injury describes evidence for lower limb functional electrical stimulation (FES) for people with spinal cord injury, including evidence related to FES-cycling.
RES 320 Arm cycle ergometer for people with spinal cord injury describes evidence for upper limb outcomes after arm cycle ergometer training in people with spinal cord injury.
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RES 340 Physiotherapy and exercise for progressive neurological conditions provides some general information about the efficacy of physiotherapy and exercise programs for people with motor neurone disease, Parkinson’s disease, multiple sclerosis or muscular dystrophy.
RES 356 Physiotherapy for Multiple Sclerosis is a supplement to RES 340 that describes in more detail the evidence for physiotherapy and exercise programs for people with multiple sclerosis.
- Motorised ergometer as a rehabilitation device
A motorised cycling device or motorised ergometer is a piece of powered exercise equipment. The device can be designed for use by upper or lower limbs. Some specialist devices are designed for both upper and lower limb use. When it is designed for use with the lower limbs it is often referred to as an ergometer or cycle ergometer (though these terms are technically more general), exercise bike or stationary bike. When the device is designed for use with the upper limbs, it is known as an arm cycle ergometer, arm crank ergometer, arm bike, arm cycle or hand cycle (4.4 Arm crank/cycle ergometer).
Motorised cycling devices can be used as part of day-to-day exercise programs or as a core feature of different therapeutic protocols. Most evidence for the efficacy of motorised cycling is clustered around Functional Electrical Stimulation (FES) Cycling, passive leg cycling, arm crank/cycle ergometer training or MOTOmed Movement Therapy.
4.1 Functional Electrical Stimulation Cycling
Functional Electrical Stimulation (FES) cycling uses electrical impulses to stimulate the muscles and nerves involved in cycling. Electrical stimulation is applied to the muscles (e.g., hamstrings, quadriceps, glutes, and calf muscles) to create muscle contractions that mimic the natural movement of cycling. This helps individuals with limited mobility to cycle effectively. FES cycling is particularly beneficial for individuals with spinal cord injuries, stroke, or other conditions that limit their ability to engage in traditional cycling (Physiopedia, n.d.).
Systematic reviews have found:
• low quality evidence of that FES cycling does not improve outcomes for people with
multiple sclerosis (Scally et al, 2020)
• medium to high quality evidence that FES cycling can improve muscle health for
people with spinal cord injury (van der Scheer et al, 2021)
• high quality evidence that FES cycling can improve balance and walking speed for
people after stroke (Shariat et al, 2019)
Refer to RES 293 Lower limb functional electrical stimulation after spinal cord injury for more information.
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4.2 Passive leg cycling
Passive leg cycling involves the use of a motorised cycling device to move the users legs in a way typical of active cycling even if the user has impaired motor control or reduced muscle strength. Passive leg cycling is often prescribed for people with spinal cord injury and is being investigated for use in hospitals for people unable to transition out of bed (Aburub et al, 2024; Soriano et al, 2022; Nardone et al, 2017).
A 2019 systematic review found multiple passive cycling sessions could improve leg blood flow velocity, spasticity, reflex excitability and joint range of motion, and markers of muscle hypertrophy for people with spinal cord injury (Phadke et al, 2019).
4.3 MOTOmed movement therapy
MOTOmed movement therapy involves use of the MOTOmed motorised cycling device for people with limited mobility. It can involve active, partially active and passive uses of the device and planned transition between active and passive uses of the device. The provider notes that MOTOmed movement therapy is intended for exercise-based management of symptoms of stroke, multiple sclerosis, Parkinson’s disease, acquired brain injury, spastic paralysis, type 2 diabetes and dementia (MOTOmed, n.d.).
Systematic reviews have found moderate quality evidence that MOTOmed movement therapy is effective in improving mobility and motor function for Parkinson’s disease and stroke (Pereira-Pedro et al, 2023; Shen et al, 2018).
4.4 Arm crank / cycle ergometry
The arm cycle ergometer or arm crank ergometer is a pedal machine designed for upper limb use. Some models may also include a motor for assisted pedalling. It is used as an alternative aerobic exercise device for people unable to use equipment designed for the lower limbs. It can also be used as a device to measure cardiovascular fitness in clinical or research contexts. The arm cycle ergometer is also often found in mainstream gyms and fitness centres.
Most evidence relating to use of the arm cycle ergometer in rehabilitation relates to people with spinal cord injury. Reviews have found moderate quality evidence that upper limb cycling exercise programs can improve cardiorespiratory fitness for people with spinal cord injury and low certainty evidence that upper limb cycling exercise programs can improve muscle strength, upper limb function and quality of life. Refer to RES 320 Arm cycle ergometer for people with spinal cord injury for more information.
- Efficacy for wheelchair users
Few studies explicitly investigate the use of motorised cycling for wheelchair users (Selph et al, 2021). Most research investigating the efficacy of motorised cycling either does not include non-ambulatory participants or does not report whether study participants are ambulatory or
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wheelchair users. Most studies are focussed on spinal cord injury (Mate et al, 2023; Graf et al, 2023).
A recent feasibility study of 10 non-ambulatory people with cerebral palsy found MOTOmed movement therapy to be safe and acceptable. Most participants in the study reported positive outcomes on fatigue, muscle stiffness and mood (Holmes et al, 2024).
Graf et al (2023) reviewed interventions for non-ambulatory people with severe motor impairments. They included 34 studies, 18 of which investigated some form of motorised cycling protocol (mostly arm cycle ergometry or FES cycling). Most of the cycling interventions showed health benefits including improvements to respiration, power output, muscle strength, heart rate, blood pressure, body mass, and bone mineral density. However, the authors did not analyse outcomes of the studies in detail and did not report on the quality of included studies.
Two systematic reviews investigated passive leg cycling protocols for non-ambulant people with spinal cord injury (assessed mostly as level A to C on the American Spinal Injury Association Impairment Scale). Nardone et al (2019) reviewed preliminary evidence that passive cycling could promote recovery in people with spinal cord injury. A more recent systematic review of intervention studies found:
significant benefits of multiple sessions of passive cycling on cardiovascular (improved leg blood flow velocity), musculoskeletal (improved joint range of motion and markers of muscle hypertrophy), and neurological outcomes (improved spasticity and reflex excitability). [However,] no clear picture emerged with single session studies, with about half the studies showing a statistically significant improvement in acute responses in cardiovascular (blood flow velocity) and neurological outcomes (short interval intracortical inhibition and spasticity), while the rest reported no change (Phadke et al, 2019, p.92).
Neither review reported safety or adverse events and both emphasised the need for further research to understand appropriate protocols before recommending treatment.
Lloyd et al (2018) found motorised cycle training programs are likely safe for non-ambulatory stroke survivors. In addition, the authors found cycle training can improve clinical outcomes including peak heart rate, workload, peak ventilation, peak carbon dioxide production, HDL cholesterol, fasting insulin and fasting glucose. However, these improvements did not appear in measures of activities of daily living or participation.
- References
Aburub, A., Darabseh, M. Z., Badran, R., Shurrab, A. M., Amro, A., & Degens, H. (2024). The Application of Robotics in Cardiac Rehabilitation: A Systematic Review. Medicina (Kaunas, Lithuania), 60(7), 1161. https://doi.org/10.3390/medicina60071161
Graf, E. S., Perret, C., Labruyère, R., Möller, J. C., & Wirz, M. (2023). Health-enhancing physical activity interventions in non-ambulatory people with severe motor impairments
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- a scoping review. Annals of medicine, 55(1), 2219065. https://doi.org/10.1080/07853890.2023.2219065
Holmes, C., Shields, N., Morgan, P., Brock, K., McKenzie, G., & Reddihough, D. (2024). Home-based motorised cycling in Non-ambulant adults with cerebral palsy: a feasibility study. Disability and Rehabilitation, 16, 1–9. https://doi.org/10.1080/09638288.2024.2353234
Lloyd, M., Skelton, D. A., Mead, G. E., Williams, B., & van Wijck, F. (2018). Physical fitness interventions for nonambulatory stroke survivors: A mixed-methods systematic review and meta-analysis. Brain and behavior, 8(7), e01000. https://doi.org/10.1002/brb3.1000
Nardone, R., Orioli, A., Golaszewski, S., Brigo, F., Sebastianelli, L., Höller, Y., Frey, V., & Trinka, E. (2017). Passive cycling in neurorehabilitation after spinal cord injury: A review. The journal of spinal cord medicine, 40(1), 8–16. https://doi.org/10.1080/10790268.2016.1248524
Máté, S., Sinan-Fornusek, C., Dhopte, P., Singh, M. F., Hackett, D., & Fornusek, C. (2023). Effects of Functional Electrical Stimulation Cycling Combined With Arm Cranking Exercise on Cardiorespiratory Fitness in People With Central Nervous System Disorders: A Systematic Review and Meta-analysis. Archives of physical medicine and rehabilitation, S0003-9993(23)00225-3. Advance online publication. https://doi.org/10.1016/j.apmr.2023.03.026
MOTOmed. (n.d.). MOTOmed Movement Therapy. https://www.motomed.com.au/
Pereira-Pedro K. P. , Machado de Oliveira I., Cancela Carral, J.M., & Cardalda, I. M. (2023). Effects of MOTOmed® movement therapy on the motor function and main symptoms of patients with Parkinson’s disease: a systematic review. Retos, 47:249–257. https://doi.org/10.47197/retos.v47.93936
Phadke, C. P., Vierira, L., Mathur, S., Cipriano, G., Jr, Ismail, F., & Boulias, C. (2019). Impact of Passive Leg Cycling in Persons With Spinal Cord Injury: A Systematic Review. Topics in spinal cord injury rehabilitation, 25(1), 83–96. https://doi.org/10.1310/sci18- 00020
Physiopedia. (n.d.). Functional Electrical Stimulation Cycling for Spinal Cord Injury. https://www.physio- pedia.com/Functional Electrical Stimulation Cycling for Spinal Cord Injury
Scally, J. B., Baker, J. S., Rankin, J., Renfrew, L., & Sculthorpe, N. (2020). Evaluating functional electrical stimulation (FES) cycling on cardiovascular, musculoskeletal and functional outcomes in adults with multiple sclerosis and mobility impairment: A systematic review. Multiple sclerosis and related disorders, 37, 101485. https://doi.org/10.1016/j.msard.2019.101485
Selph, S. S., Skelly, A. C., Wasson, N., Dettori, J. R., Brodt, E. D., Ensrud, E., Elliot, D., Dissinger, K. M., Hart, E., Kantner, S., Graham, E., Junge, M., Dana, T., & McDonagh,
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M. (2021). Physical Activity and the Health of Wheelchair Users: A Systematic Review in Multiple Sclerosis, Cerebral Palsy, and Spinal Cord Injury. Agency for Healthcare Research and Quality (US).
Shariat, A., Najafabadi, M. G., Ansari, N. N., Cleland, J. A., Singh, M. A. F., Memari, A. H., Honarpishe, R., Hakakzadeh, A., Ghaffari, M. S., & Naghdi, S. (2019). The effects of cycling with and without functional electrical stimulation on lower limb dysfunction in patients post-stroke: A systematic review with meta-analysis. NeuroRehabilitation, 44(3), 389–412. https://doi.org/10.3233/NRE-182671
Shen C, Liu F, Yao L, Li Z, Qiu L, & Fang S. (2018). Effects of MOTOmed movement therapy on the mobility and activities of daily living of stroke patients with hemiplegia: a systematic review and meta-analysis. Clinical Rehabilitation, 32(12):1569-1580. https://doi.org/10.1177/0269215518790782
van der Scheer, J. W., Goosey-Tolfrey, V. L., Valentino, S. E., Davis, G. M., & Ho, C. H. (2021). Functional electrical stimulation cycling exercise after spinal cord injury: a systematic review of health and fitness-related outcomes. Journal of Neuroengineering and Rehabilitation, 18(1), 99. https://doi.org/10.1186/s12984-021-00882-8
Verschuren, O., Peterson, M. D., Balemans, A. C., & Hurvitz, E. A. (2016). Exercise and physical activity recommendations for people with cerebral palsy. Developmental medicine and child neurology, 58(8), 798–808. https://doi.org/10.1111/dmcn.13053
Vollenweider, R., Manettas, A. I., Häni, N., de Bruin, E. D., & Knols, R. H. (2022). Passive motion of the lower extremities in sedated and ventilated patients in the ICU - a systematic review of early effects and replicability of Interventions. PloS one, 17(5), e0267255. https://doi.org/10.1371/journal.pone.0267255
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Repositioning in Pressure Injury Prevention and Management
The content of this document is OFFICIAL.
Please note:
This document is intended to assist Technical Advice and Practice Improvement Branch
(TAPIB) staff with provision of technical advice or practice improvement activities. Branch
Manager clearance is required before research documents are shared outside the branch.
The TAPIB Research and Capability team take care to ensure the research presented is
accurate at the time of writing. Due to the nature of our work, we cannot ensure that all
relevant research has been considered in the development of this document or that
information remains accurate after publishing.
- Contents
Repositioning in Pressure Injury Prevention and Management ………………………………………….. 1
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Contents ………………………………………………………………………………………………………….. 1
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Summary …………………………………………………………………………………………………………. 1
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Preventing and Treating Pressure Injuries ……………………………………………………………. 2
3.1 Best Practice for Prevention of Pressure Injuries …………………………………………….. 2
3.2 Best Practice for Treatment of Pressure Injuries ……………………………………………… 5
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Pressure Care Mattresses ………………………………………………………………………………….. 5
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Manual Repositioning ………………………………………………………………………………………… 6
5.1 Risks of Manual Handling when Repositioning ……………………………………………….. 7
5.2 Repositioning for Individuals with Disability …………………………………………………….. 8
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References ………………………………………………………………………………………………………. 9
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Summary
The prevention of pressure injuries is multidimensional and includes risk assessment, nutrition screening, repositioning, and full body support surfaces. Best practice clinical guidelines and Australian state government health service policies agree that no support surface can entirely
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replace repositioning and repositioning should occur irrespective of the support surface being used.
There is limited evidence as to the optimal frequency of repositioning. Factors such as an individual’s skin condition, desire for uninterrupted sleep, comfort, physical, cognitive, and psychological needs, and the support surface in use should inform each person’s individualised repositioning regimen. Despite very low certainty of evidence, the most current conditional recommendation is 2- to 3-hourly repositioning for individuals at risk of pressure injury. Other, more dated guidelines suggest 6-hourly repositioning for adults at risk of developing pressure injuries and 4-hourly repositioning for those at high risk. Some sources suggest repositioning intervals can be extended overnight based on the individual’s needs and preferences, though this recommendation appears to be based on clinical judgement rather than evidence of efficacy.
It is generally agreed that pressure relieving mattresses should be used as part of a multidimensional strategy to reduce the risk of pressure injury. Recommendations regarding the type of mattress differ, though the current evidence base does not suggest that one variety of pressure relieving mattress is more effective at reducing the risk of pressure injury.
- Preventing and Treating Pressure Injuries
People who are unable to reposition themselves in bed may be at risk of developing pressure injuries (also known as pressure ulcers or bed sores). The term pressure injury is used in this paper unless the source being referred to uses an alternative term. Pressure injuries can occur in people who are hospitalised in acute/intensive care units or those in the home environment who cannot independently reposition due to age, disability or frailty (HealthDirect, 2024; Yadav & Patil, 2025, p. 814).
The most common ways to prevent pressure injuries include repositioning, pressure relief devices, nutritional assessment, and wound care protocols (HealthDirect, 2024; Pallabi Ghosh et al., 2024, p. 2). This paper focuses on manual repositioning and pressure relief devices.
Repositioning can also occur via rotating beds or continuous lateral rotation therapy (CLRT). CLRT may help to reduce risk of pressure injury and respiratory complications in patients who are critically ill. Such beds are only likely to be beneficial for patients who are unable to be safely repositioned by a carer due to a safety risk to the carer or patient. For more information, refer to TAPIB research paper RES 214 Rotating Beds.
3.1 Best Practice for Prevention of Pressure Injuries
3.1.1 The 2025 Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide Prevention Recommendations
According to the 2025 Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide Prevention Recommendations pressure injury prevention includes nutrition screening, repositioning, and full body support surfaces (National Pressure Injury Advisory Panel
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(NPIAP), European Pressure Ulcer Advisory Panel (EPUAP) & Pan Pacific Pressure Injury Alliance (PPPIA), 2025a).
In terms of repositioning, the guideline states that it is good practice to reposition individuals at risk of pressure injuries regardless of the type of pressure redistribution full body support surface being used. The repositioning interval can be adjusted depending on the pressure redistribution capabilities of the support surface and the individual’s response to it. However, no support surface can entirely replace repositioning (2025a, p. 3).
It is good practice to use specialised equipment designed to reduce friction and shear when repositioning individuals and, if manual handling is necessary, techniques that minimise friction and shear should be applied. It is also good practice to use an individualised regimen for repositioning individuals at risk of pressure injury. These regimens should be based on a clinical assessment and should consider an individual’s level of activity and mobility, ability to independently reposition, skin and tissue tolerance, clinical condition, comfort, sleep patterns, goals of care and the support surface used (2025a, pp. 3-4).
Based on evidence of very low certainty, the 2025 guideline recommends repositioning at 2- hourly or 3-hourly intervals for most individuals at risk of pressure injuries if they are also on an appropriate pressure redistribution full body support surface (2025a, p. 4). It also suggests not routinely extending repositioning intervals to 4-, 5- or 6-hourly intervals for individuals at risk of pressure injuries. Individuals receiving palliative or end of life care should be given the option of repositioning frequency intervals that are best suited to their goals of care and comfort needs (2025a, p. 5).
In terms of full body support surfaces, the guideline contains a strong recommendation based on evidence of low certainty to use a pressure redistribution foam (reactive) full body support surface for individuals at risk of pressure injuries (2025a, p. 7). Other types of active and reactive mattresses and medical grade sheepskin may be used according to conditional recommendations in the guideline (2025a, p. 8).
The following full body support surfaces should not be used:
• non-medical grade sheepskins
• medical grade sheepskins that interfere with the pressure redistribution properties of
the full body support surface
• medical grade sheepskins (if a pressure redistribution foam (reactive) full body
support surface is available)
• a fibre support surface (if a pressure redistribution foam (reactive) full body support
surface is available)
• an air fluidised full body support surface (routinely) (2025a, pp. 8-9).
3.1.2 The 2014 National Institute for Health and Care Excellence (NICE) Guideline
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According to the 2014 National Institute for Health and Care Excellence (NICE) Clinical Guideline for the Prevention and Management of Pressure Ulcers, the steps involved in preventing pressure ulcers in adults and young people (13-17 years old) include:
e risk assessment
e skin assessment
e repositioning
e pressure redistributing devices e barrier creams (pp. 11-14).
The repositioning and pressure redistributing device recommendations for adults and young people are summarised in Table 1 below.
Table 1 NICE Guideline Recommendations for Pressure Ulcer Prevention (Source: NICE Guidelines, 2014, pp. 13-16)
Cohort Repositioning Frequency Mattress Requirement Adults (at risk) At least every 6 hours N/A Adult (high risk) At least every 4 hours High specification foam mattress Young people At least every 4 hours N/A Young person high risk More frequently than every 4 |High specification foam hours mattress
If individuals in these cohorts are unable to reposition themselves, repositioning should occur using appropriate equipment or manual help. At-risk patients may include those with low body mass index (BMI) scores, spinal injuries, reduced mobility, and/or those in neurological or critical care. The Braden Scale, the Waterlow Score or the Norton Risk-Assessment Scale are among the tools that can be used to identify if a patient is at risk of developing a pressure ulcer (NICE, 2014, p. 12).
An individualised care plan should be developed for all individuals who have been assessed as being at high risk of developing a pressure ulcer. These plans should consider the outcome of the abovementioned risk and skin assessments, the individual’s mobility, and ability to reposition themselves, other comorbidities, the need for additional pressure relief at specific at- risk sites and patient preference (NICE, 2014, p. 18).
Intensive Care NSW (2025) recommends repositioning be carried out at a frequency depending on a patient’s risk factors and condition which may be at least every 2 hours even if the patient is on an active or reactive support surface (p. 13).
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Despite noting that recent studies on repositioning frequency have been inconsistent with recommendations, they prescribe the following guideline:
• critically ill adults and children assessed at moderate-to-high risk of pressure injuries
should be repositioned every 2 hours
• patients assessed as low-to-moderate risk of pressure injury should be repositioned
every 3 to 4 hours
• frequency may be reduced to 3-to-4 hourly repositioning depending on a skin
assessment and the skin’s response to increasing intervals between repositioning
(p. 19).
3.2 Best Practice for Treatment of Pressure Injuries
According to the 2014 NICE guideline, if an adult or young person has already developed a pressure ulcer, treatment should include:
• ulcer measurement and categorisation
• nutritional supplements and hydration
• pressure redistributing devices
• debridement (if necessary)
• systemic antibiotics and septics
• dressings (pp. 20-27).
High-specification foam mattresses or, if necessary, dynamic support surfaces should be used. Standard-specification foam mattresses should not be used (pp. 19/25).
According to the PM&R Knowledge article on Pressure Injury Management in Central Nervous System Disorders (Asanza & Patel, 2023), a foam or air overlay may be enough for patients with stage 1 and 2 pressure injuries. For a patient with a stage 3 or 4 sacral pressure injury, a low air loss or dynamic pressure relief mattress is appropriate. Patients should be turned and repositioned every 2 hours.
- Pressure Care Mattresses
There are many kinds of pressure care mattresses used in the prevention and treatment of pressure injuries including active, reactive and hybrid mattresses, foam, gel, air, and water mattresses, and more.
The 2014 NICE guideline for the prevention and treatment of pressure ulcers claims that there is limited evidence of the effectiveness of pressure redistributing devices and that much of the existing evidence has been funded by the industry. They state that there is limited evidence as
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to whether more sophisticated devices (e.g., alternating pressure devices) are more effective compared to more basic devices such as high-specification foam mattresses (pp. 29-30).
In a 2020 study, Andayani et al. found low-quality evidence that both 2-hourly repositioning and pressure mattresses improved the Braden Q scores (a tool used to predict skin breakdown caused by pressure ulcers) in 93 children over a period of 14 days. While both interventions led to improved Braden Q scores, the control group, which received pressure mattresses, showed a larger improvement than the intervention group, whose participants were repositioned every 2 hours, from the beginning to the end of the intervention period.
In a qualitative study, Wan et al. (2025) argue that alternating pressure air mattresses are both frequently overused and used to replace frequent repositioning in acute care settings (p. 2).
There is advice from Australian state government bodies and international clinical guidelines that no single support surface provides complete pressure relief and that repositioning should occur irrespective of the support surface being used (Barakat-Johnson et al., 2023, pp. 7-8; Clinical Excellence Commission, 2021, p. 1; Department of Health, 2023, p. 6; NPIAP, EPUAP & PPPIA, 2025a, p. 3; Queensland Spinal Cord Injuries Service, n.d.).
An umbrella review by Klugar et al. (2025) found that the most cost-effective prevention strategies for pressure injuries were multifaceted interventions including repositioning, pressure redistribution mattresses or overlays and nutritional supplements.
- Manual Repositioning
According to the 2014 NICE guideline, there is limited evidence regarding the most efficient position and frequency of repositioning for all age groups. The guideline considers it necessary to carry out more research on the different repositioning frequencies and positions on a standard support surface (for example, a high-specification foam mattress) (p. 30).
Gillespie et al. (2021) published a Cochrane review assessing the clinical and cost effectiveness of repositioning regimes for the prevention of pressure injuries regardless of risk in any setting. Results were not conclusive as to whether 2-, 3- or 4-hour frequency or a 20-, 30-, 45- or 90-degree tilt were more effective. The certainty of evidence in the systematic review was low due to high risk of bias.
Another systematic review in 2023 by Asiri reviewed 10 studies, 2 of which were reviewed by Gillespie et al. 2021, in order to determine whether 2-, 3-, 4- or 6-hourly repositioning frequency, or 30-degree or 90-degree tilt was optimal. The results were unclear and the author declared that further investigation is necessary.
There is agreement in the sources that a repositioning plan, including repositioning frequency, should be individualised and should consider factors such as the individual’s skin condition, comfort, physical, cognitive and psychological needs, and the support surface in use (Clinical Excellence Commission, 2021, p. 1; Department of Health, 2023, p. 6; Fletcher, 2017, p. 10; EPUAP, NPIAP & PPPIA, 2019).
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We did not find any specific guidelines for repositioning during the night, or for individuals located outside of an acute/intensive care setting. There are recommendations that repositioning can occur at longer intervals during the night to allow for uninterrupted sleep.
The NPIAP, coauthor to the 2025 international guideline described in section 3.1.1, released a list of pressure injury prevention points which was updated in 2016. In the ‘repositioning and mobilization’ section of the list, the NPIAP states “consider lengthening the turning schedule during the night to allow for uninterrupted sleep.”
Jacqui Fletcher, an independent nurse consultant from the United Kingdom, authored a clinical practice article in Wounds International 2017 in which she stated that there is sometimes a need for a different turning frequency at night compared to during the day. However, this recommendation cannot be applied to all patients. Fletcher recommends checking the patient’s skin when they are repositioned to determine whether repositioning frequency can be extended to allow the patient greater comfort and less disturbance. If the skin is red but returns to its normal colour quickly, the turn frequency may be extended. If the redness does not resolve within a short period, the turns are too infrequent (Fletcher, 2017, p. 7).
5.1 Risks of Manual Handling when Repositioning
We found limited information concerning the risks for the patient associated with manual handling when repositioning.
In cases where a patient is too unstable to reposition, a gradual, micro-positioning technique (small incremental shifts in body position) may be used at 2-hour intervals (Intensive Care NSW, 2025, p. 19).
In a standardised care process for pressure injuries in older people in residential aged care settings, the Victorian State Government Department of Health (2023) advises that some residents may damage tissues with excessive movement e.g., residents with agitation or who regularly drag when self-repositioning (p. 6).
Shearing occurs when mechanical force works internally on the skin in a direction parallel to the skin’s surface (Vecin & Gater, 2022, p. 3). Repositioning someone in bed, pulling someone up in bed and pulling someone across sheets are risk factors for shear (MS Society, n.d.; National Multiple Sclerosis Society, n.d.; Vecin & Gater, 2022, p. 3).
A 2019 study by Sharp et al. utilised a cross-section survey of 80 residents’ medical records in Australian residential aged care facilities. They used the records to determine the number of residents at risk of pressure injuries, the use of 2-hourly positioning and the presence of pressure injuries in the last week of life. They found that 90% of residents were at risk of pressure injuries and were repositioned 2-hourly, however, 34% passed away with one or more pressure injuries. The authors argue that the 2-hourly repositioning failed to prevent pressure injuries in a third of the at-risk patients, and that it is harmful and may be responsible for severe sleep deprivation.
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5.2 Repositioning for Individuals with Disability
Recommendations regarding repositioning for individuals with MND, MS and SCI are presented below. We did not find recommendations regarding repositioning for other conditions
MND Australia (2017) promotes the regular repositioning of patients who are unable to reposition themselves. The MND Association of New Zealand’s Best Practice Recommendations (2022) for care of people with MND state that equipment such as bed turning aids does not remove the need for repositioning, although they acknowledge that frequent repositioning at night can have a major impact on sleep.
The United Kingdom’s MS Society (n.d.) and the National Multiple Sclerosis Society (n.d.) recommend individuals with MS reposition at least once every 2 hours (including while in bed) to prevent pressure ulcers/sores. Both societies also discuss special mattresses as a way of relieving pressure.
The Queensland Spinal Cord Injuries Service (n.d.) recommends beginning with turning every 2 hours on a pressure-relieving mattress. The skin should be inspected at each position change and, if tolerated, the time spent in each position should be increased. Groah et al.’s 2015 systematic review into the prevention of pressure injuries in individuals with spinal cord injuries found that there is no optimal positioning or turning frequency in bed. The authors recommended a flexible and individualised pressure injury prevention strategies. A 2022 study by Eren et. al. on the frequency at which individuals with chronic spinal cord injury turn when in bed at home showed that only 25.6% of 86 subjects turned every 2 hours as recommended.15.1% turned every 3 hours,15.1% every 4 hours and 3.5% turned every 6 hours. 40.7% of respondents stated that they do not turn regularly at night. The repositioning requirements of an individual with spinal cord injury will change over time and should be regularly reassessed (NPIAP, EPUAP & PPPIA, 2025b p. 8).
In the Repositioning For Preventing Pressure Injuries chapter in the Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, the NPIAP, EPUAP & PPPIA provide implementation considerations for special populations. For individuals with agitation or dementia, purposeful reminders, person-centred care approaches (e.g., distraction, music therapy etc), communication techniques and movement therapy are recommended to facilitate the acceptance of repositioning, the maintenance of pressure-reliving positions and to reduce high frequency movement that could introduce shear (2025b, p. 3). Individuals and their informal carers should be involved in decisions around repositioning frequency and decisions should be made based on their priorities (e.g., uninterrupted sleep versus more frequent pressure injury preventative care) (2025b, p. 6). The individual’s access to repositioning resources should also be considered. The needs of the individual’s informal carers (e.g., sleep requirements, need for repositioning and manual handling equipment or additional support people) should also be considered (p. 8).
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- References
Andayani, R. P., Nurhaeni, N., & Wanda, D. (2020). Assessing Effectiveness of Regular Repositioning in Preventing Pressure Ulcers in Children. Pediatric Reports, 12(11), 8696. https://doi.org/10.4081/pr.2020.8696
Asanza, L. J., & Patel, H. (2023). Pressure Injury Management in CNS Disorders. PM&R Knowledge. https://now.aapmr.org/pressure-ulcer-management/
Asiri, S. (2023). Turning and Repositioning Frequency to Prevent Hospital-Acquired Pressure Injuries Among Adult Patients: Systematic Review. Inquiry (Chicago), 60, 1-10. https://doi.org/10.1177/00469580231215209
Barakat-Johnson M., Ryan, H., Brooks, M., Carville, K., Coleman, K., Coyer, F., Dunk, A. M., Gibb, M., Leahy, C., Palm, W., Rando, T., & Sage, S. (2023) A ‘Quick Guide’ to Pressure Injury Management. Australian Pressure Injury Treatment Advisory Group (PITA). Wounds International. https://woundsinternational.com/wp- content/uploads/2023/09/Mol23 SUPP PITA WINT-WEBv3.pdf
Clinical Excellence Commission (2021, July). Pressure Injury Prevention – Repositioning and Support Surfaces for People in Bed Released. NSW Government. https://www.cec.health.nsw.gov.au/ data/assets/pdf file/0005/664232/Pressure-injury- prevention-repositioning-and-support-surfaces-for-people-in-bed.PDF
Department of Health. (2023). Pressure injuries - Standardised care process. Victoria State Government. https://www.health.vic.gov.au/sites/default/files/2022-12/standardise-care- pressure-injuries.PDF
Eren, F., DeLuca, R., & Kirshblum, S. (2022). Frequency of turning in bed at home in persons with chronic spinal cord injury. The Journal of Spinal Cord Medicine, 45(3), 390–394. https://doi.org/10.1080/10790268.2020.1800965
European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Injury Advisory Panel (NPIAP) & Pan Pacific Pressure Injury Alliance (PPPIA). (2019). Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). https://static1.squarespace.com/static/6479484083027f25a6246fcb/t/6553d3440e18d57 a550c4e7e/1699992399539/CPG2019edition-digital-Nov2023version.pdf
Fletcher, J. (2017). Reposition patients effectively to prevent pressure ulcers. Wounds International, 8(1), 7-10. https://woundsinternational.com/wp- content/uploads/2023/02/wint 8-1 7-101.pdf
Groah, S. L., Schladen, M., Pineda, C. G., & Hsieh, C.-H. J. (2015). Prevention of Pressure Ulcers Among People With Spinal Cord Injury: A Systematic Review. PM & R, 7(6), 613–636. https://doi.org/10.1016/j.pmrj.2014.11.014
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Gillespie, B. M., Walker, R. M., Latimer, S. L., Thalib, L., Whitty, J. A., McInnes, E., Lockwood, I., & Chaboyer, W. P. (2021). Repositioning for pressure injury prevention in adults: An abridged Cochrane systematic review and meta-analysis. International Journal of Nursing Studies, 120, Article 103976. https://doi.org/10.1016/j.ijnurstu.2021.103976
HealthDirect. (2024). Pressure ulcers (bed sores). https://www.healthdirect.gov.au/pressure- sores-and-ulcers
Intensive Care NSW. (2025, March). Clinical Practice Guide - Preventing pressure injuries in critically ill patients. NSW Government. https://aci.health.nsw.gov.au/__data/assets/pdf_file/0014/240152/ACI-Preventing- pressure-injuries-in-critically-ill-patients-clinical-practice-guide.pdf
Klugar, M., Klugarová, J., Hussain, S., Vrbová, T., Slezáková, S., Búřilová, P., Saibertová, S., Dolanová, D., Krupová, L., Mužík, J., Jarkovský, J., & Pokorna, A. (2025). Economic evaluations of interventions for the prevention and treatment of pressure ulcers: an umbrella review. JBI Evidence Synthesis. https://doi.org/10.11124/JBIES-23-00488
MND Association of New Zealand. (2022). Best Practice Recommendations for the Care of People with Motor Neurone Disease. https://mnd.org.nz/wp- content/uploads/2022/11/NZ-Best-Practice-Recommendations-For-The-Care-Of- People-With-MND-issue-1-November-2022-FINAL.pdf
MND Australia. (2017). Aspects of Care for the primary health care team. https://www.mndaustralia.org.au/getmedia/7d2d9c3c-bd65-455f-894b- 95bbfb973f53/MND-Aspects-of-Care.pdf
MS Society. (n.d.). Pressure ulcers. https://www.mssociety.org.uk/living-with-ms/advanced- ms/pressure-ulcers
National Multiple Sclerosis Society. (n.d.). Pressure Sores. https://www.nationalmssociety.org/managing-ms/treating-ms/advanced-care- needs/pressure-sores
National Institute for Health and Care Excellence. (2014). Pressure ulcers: prevention and management - Clinical guideline. https://www.nice.org.uk/guidance/cg179/resources/pressure-ulcers-prevention-and- management-pdf-35109760631749
National Pressure Injury Advisory Panel (NPIAP). (2016). Pressure injury prevention points. https://npiap.com/page/PreventionPoints
National Pressure Injury Advisory Panel (NPIAP), European Pressure Ulcer Advisory Panel (EPUAP) & Pan Pacific Pressure Injury Alliance (PPPIA). (2025a). Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide. The International Guideline: Fourth Edition. Emily Haesler (Ed.). https://static1.squarespace.com/static/6479484083027f25a6246fcb/t/67bd4fbfd6865e7a 07acc9e8/1740459974549/QRG-abridged-25Feb2025.pdf
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National Pressure Injury Advisory Panel (NPIAP), European Pressure Ulcer Advisory Panel (EPUAP) & Pan Pacific Pressure Injury Alliance (PPPIA). (2025b). REPOSITIONING FOR PREVENTING PRESSURE INJURIES. In E. Haesler (Ed.). Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline: Fourth Edition. Emily Haesler. https://static1.squarespace.com/static/6479484083027f25a6246fcb/t/67beef7346eca23 eddb1a36f/1740566393653/2025-Guideline-Repositioning-25-Feb-2025.pdf
Pallabi Ghosh, B. P., Pritheevi Raj N, B. P., Vachana M N, B. P., Pavish S R, B. P., Prathibha Pereira, M., Tejeswini C J, M., Madhan Ramesh, Ph. D., Jehath Syed, Pharm. D., & Sri Harsha Chalasani, Ph. D. (2024). Advances in technology-driven strategies for preventing and managing bedsores: A comprehensive review. Archives of Gerontology and Geriatrics Plus, 1(3), 100029. https://doi.org/10.1016/j.aggp.2024.100029
Queensland Spinal Cord Injuries Service. (n.d.). Skin considerations in lying. Queensland Government. https://qscis.health.qld.gov.au/resources/skin/key-principles-of-bed-and- mattress/
Sharp, C. A., Schulz Moore, J. S., & McLaws, M.-L. (2019). Two-Hourly Repositioning for Prevention of Pressure Ulcers in the Elderly: Patient Safety or Elder Abuse? Journal of Bioethical Inquiry, 16(1), 17–34. https://doi.org/10.1007/s11673-018-9892-3
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Wan, C. S., Musgrave-Takeda, M., M Gillespie, B., Tobiano, G., & Mcinnes, E. (2025). Barriers and Facilitators to Implementing Pressure Injury Guidelines for Nutrition Assessment and Alternating Pressure Air Mattress Allocation: A Qualitative Study. Journal of Advanced Nursing. https://doi.org/10.1111/jan.16820
Yadav, A., & Patil, P. (2025). Effect of Continuous Lateral Rotation Therapy Vs Manual Lateral Positioning on Bed Sore For Prolonged Bed Ridden Patients. Journal of Neonatal Surgery, 14(22s), 814-820. https://mail.jneonatalsurg.com/index.php/jns/article/view/5619
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