(physician\055prescription\055form)
Physician Prescription Form
ALL SECTIONS MUST BE FILLED OUT COMPLETELY
Computer Fillable PDF
| PATIENT INFORMATION | |||||
|---|---|---|---|---|---|
| First Name | Last Name | Phone Number | |||
| Street Address | City | State Zip | |||
| Date of Birth(MM/DD/YYYY) | Email Address* |
Indications for Use:
The Cionic Neural Sleeve 2 (NS-200) is intended to provide ankle dorsiflexion and/or plantarflexion and/or eversion in adult individuals with foot drop and/or to assist knee flexion or extension in adult individuals with muscle weakness related to upper motor neuron disease/injury (e.g. stroke, damage to pathways to the spinal cord). The Cionic Neural Sleeve NS-200 electrically stimulates muscles in the affected leg to provide ankle dorsiflexion and/or plantarflexion and/or eversion of the foot and/or knee flexion or extension; thus, it also may improve the individual's gait.
- Facilitate muscle re-education
- Increase local blood flow
- As a powered muscle stimulator the Cionic Neural Sleeve NS-200 is indicated for the following conditions: Relaxation of muscle spasm
- As a biofeedback device the Cionic Neural Sleeve NS-200 is indicated for the following conditions: Biofeedback, relaxation and muscle re-education purposes
Contraindications:
Individuals with implanted demand-type cardiac pacemakers or defibrillators should not use the Cionic Neural Sleeve; it should not be used over malignant tumors; it should not be placed over any areas where existing thrombosis is present; and it should not be used on a leg where a regional disorder, such as fracture or dislocation, could be adversely affected by motion from stimulation.
| PHYSICIAN INFORMATION | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Name | License # | NPI # | ||||||||||||
| Street Address | City | State | Zip | |||||||||||
| Phone Number | Office Contact | |||||||||||||
| I certify that the above-prescribed device is medically indicated and in my opinion is reasonable and necessary for this patient's treatment. | ||||||||||||||
| Physician Signature | Date |
772-00792 Rev B Last Revision 3/19/2026
For individuals with 20+ upper motor neuron conditions, including multiple sclerosis, stroke cerebral palsy, and spinal cord injury.
Cionic Neural Sleeve 2
Powered by an entirely new stimulation paradigm, the Neural Sleeve 2 combines the diagnostic power of a gait lab with the therapeutic power of Functional Electrical Stimulation (FES) for movement and sensory stimulation for muscle spasm relaxation.
The first mobility device to:
- Target the four major muscle groups of the leg
- Combine sensing, analysis, and AI-powered augmentation
- Activate functional muscle spasms at the cycling movement and relax time
- Feature an award-winning "bionic clothing" design for easy, lightweight, discreet wear
The Cionic Neural Sleeve 2 may also:
- Facilitate muscle re-education
- Prevent disuse atrophy
- Increase local blood flow
Thoughtfully Designed, from Software to Soft Goods
| Software-steerable stimulation | Closed-loop system integrates electromyography(EMG) and kinematic data. Adaptive algorithms analyze and recalibrate every step to provide real-time adjustments to stimulation |
|---|---|
| Multiple Treatment Modalities | Many programs designed to target different needs and mobility levels. |
| ·FES Gait: range of protocols for various gait patterns | |
| ·Afferent: relaxation of muscle spasms | |
| ·FES Cycle: stationary bike protocol | |
| ·NMES: exercise library for muscle strengthening | |
| CIONIC App | The intuitive iOS and Android application acts as both a telehealth platform between the user/provider and Cionic, as well as the command center for the Neural Sleeve 2 experience |
| Progress Tracking and Metrics | Daily, weekly, and monthly progress tracking, including gait speed, stride length, steps, and activity levels |
| Comprehensive Treatment | 24 total electrodes for standard sizes - 6 per muscle group, with option for individual electrode configuration as needed |
Patient Considerations
- For home use, patient needs to be able to ambulate independently, with or without an assistive device
- Does not exclude patients who would use the device for seated exercises in-home and are working toward independent ambulation in physical therapy
Contraindications
- Implanted demand-type cardiac pacemakers or defibrillators
- Use over malignant tumors
- Use over an existing thrombosis
- Use over a fracture or dislocation, or where movement is contraindicated
Other Considerations & Precautions
- Limited hand dexterity for donning/doffing
- Recent or uncontrolled seizures
- Edema or swelling that could impact effectiveness of stimulation
- Areas of skin on the leg(s) that are frequently open or infected
Taking Accurate Measurements
Use a measuring tape to help your patients take accurate measurements while standing.
Measure the circumference of the thigh, 11" from the center of your kneecap (should be close to the widest part of the thigh)
| Thigh | Calf | Inseam | |
|---|---|---|---|
| Extra Small | 15"-21" | 9.5"-14.5" | ≥24" |
| Small | 17"-23" | 11"-15.5" | ≥25" |
| Medium | 19"-25" | 12"-17" | ≥25.5" |
| Large | 22"-28.5" | 14"-19" | ≥26" |
| Hybrid LS | 22"-28.5" | 11"-15.5" | ≥25.5" |