Creating an Assessment Report and Training Plan for the RISE Stimulator
Introduction
In this article we look at how we deal with enquiries about the RISE Stimulator. This product is used to treat muscle denervation using a unique electrical stimulation device. Clients may have experienced a spinal cord injury affecting the lower motor neuorons or they may have a peripheral nerve injury. In all cases, all parties need to know whether the product is likely to be safe and effective to use. Here we look at an ideal situation where complete information is available.
Information Gathering
Using a secure web form, we aim to verify the product’s suitability and ask about any contraindications that might apply. If this form has been completed diligently, we can confidently proceed with a home demonstration and assessment.
Creating a comprehensive assessment report or training plan should cover several key components. It is understood that it will not always be possible to address every point identified below in detail. However, sufficient detail is required to provide the best support for product users and information for other involved health care and other professionals who may be involved in advocating purchase or providing support.
The following notes describe the potential scope of such a comprehensive report:
We often use large wet sponge and rubber electrodes to cover as much affected muscle as possible
Patient Information and Medical Background
Clinical Assessment
Treatment Goals and Objectives
Stimulation Protocol
Progress Monitoring and Evaluation Plan
Safety and Contraindications
Adaptations and Modifications
Interdisciplinary Coordination
Follow-Up and Long-Term Plan
Summary and Recommendations
Patient Consent and Engagement
Appendices and References
A related document is the “RISE Stimulator Home Application Check List”
This can be used to record the treatment plan, provide a prompt for steps to follow and confirm the client’s consent.
Patient Information and Medical Background
Patient Demographics: Age, gender, weight, height. Medical History:
Type of injury (Spinal Cord Injury or Peripheral Nerve Injury).
• If applicable, level and extent of injury (e.g., SCI: Complete or Incomplete; ASIA Impairment Scale score).
Date of onset or injury. It is ideal for stimulation to start as soon as possible following an injury.
Additional medical conditions or co-morbidities (e.g., diabetes, cardiovascular issues).
Current Functional Status: Muscle atrophy grade, range of motion (ROM), muscle strength grading.
Previous Treatments: Physiotherapy, previous electrical stimulation, medications, surgical interventions, or other rehabilitative efforts.
Some of this information will be available from our web form “pre-assessment” but should be verified in the face-to-face assessment.
Clinical Assessment
Muscle Status Assessment:
• Muscle Groups: Identify and list the denervated muscles targeted for stimulation.
• Degree of Denervation: EMG findings (if available), muscle excitability tests.
• Functional Limitations: Details on specific functional impairments due to muscle denervation.
Neurological Assessment:
• Reflexes, sensory function, and motor function assessment (based on standardised neurological examination).
Skin and Tissue Condition:
• Skin integrity, pressure sores or wounds in the stimulation area.
• Tissue quality (atrophy, fibrosis, etc.).
It is unlikely that EMG findings will be available, but testing with NMES can give a good indication of the presence of denervation. Skin issues such as pressure sores in the area to be stimulated would be a contraindication.
Treatment Goals and Objectives
Short-Term Goals:
• Improve muscle mass or prevent further atrophy?
• Enhance blood circulation and reduce oedema?
• Increase range of motion and prevent or reduce joint contractures?
Long-Term Goals:
• Enhance functional abilities if reinnervation is expected (e.g., grasping, standing, transferring)?
• Improve overall quality of life and independence?
• Specific Objectives for Electrical Stimulation?
Discussing meaningful treatment goals with the client and noting these on the report is important. With complete denervation, the primary benefits of use are associated with preventing long-term problems. Many people may find it hard to commit to regular use for a long-term goal that may seem abstract. Training needs to become a habit and, if possible, identify and record meaningful short-term goals.
Stimulation Protocol
Device Specifications:
• Description of Stimulator RISE, including channel configuration, waveform type (biphasic, monophasic), frequency range, intensity levels, and pulse duration Stimulation Parameters:
• Details of the parameters used (frequency, pulse duration, intensity, ramp time, rest time, duration of each session, and number of sessions per week).
• Rationale for selecting specific parameters based on the patient’s condition and response.
Electrode Placement:
• Description of electrode size, type, and specific placement on target muscles.
• Precautions regarding skin conditions or areas to avoid.
The assessment report may be used to support purchase as part of a case-managed situation and shared with individuals unfamiliar with the Stimulator RISE or this method of working with denervated muscle. For this reason, the report should contain a (standard) paragraph explaining the fundamental ideas and research underpinning this approach.
Progress Monitoring and Evaluation Plan
Measurement of Outcomes:
• Muscle strength testing (e.g., dynamometry or manual muscle testing).
• Circumferential measurements of muscle mass or girth.
• ROM and spasticity evaluations.
Frequency of Assessments:
• Define how often the patient’s progress will be monitored (e.g., monthly, bimonthly).
Documentation:
• A clear plan for documenting patient response, changes in muscle condition, and any adverse events.
Outcome measures such as tape measurements of muscle bulk can be used. Other measures may become more meaningful in cases of incomplete injury with functional recovery.
Safety and Contraindications
Safety Precautions:
• Steps to mitigate risks including burns or skin irritation (e.g., proper electrode handling and skin checks before and after treatment).
• Patient and Caregiver Education:
• Instructions on safe use, recognising signs of complications, and emergency procedures.
As part of the information left with the client, there should be details of the contraindications that apply and instructions on what to do if the client’s status changes.
Adaptations and Modifications
Customisation of Treatment Plan:
• Adjustments in stimulation settings based on patient tolerance or response.
• Changes in frequency or duration of sessions depending on progress.
Adaptive Equipment:
• Recommendations for additional equipment or orthotics to support muscle function and rehabilitation goals.
Many times we can use the predefined or “standard” programmes mapped to the PS1, PS2 etc keys. However, these programmes and application protocols may need to be modified to suit particular client needs and this should be noted. In some situations, adaptations may be needed to application methods - for example, clients unable to lie prone may choose to stimulate glutes when in a standing frame.
Interdisciplinary Coordination
Collaboration with Other Healthcare Providers:
• Is there a need for Integration with physical therapy, occupational therapy, and other relevant specialities?
Communication Plan:
• Is there a need for regular updates and discussions with the healthcare team, patient, and caregivers regarding progress, challenges, and adjustments?
Follow-Up and Long-Term Plan
Plan for Ongoing Evaluation:
• Scheduled follow-up appointments to assess long-term effects and the need for continuing or modifying treatment.
Transition Plan:
• Plan for tapering or discontinuing electrical stimulation if appropriate or integrating this into broader rehabilitation goals.
Most clients should use this stimulator for the long term. The frequency of use can be reduced over time to maintain the recovered tissue health, but this reduction in commitment should not occur too soon. If the client commences use, for example, at 18 months post-injury, they are likely to recover suitable tissue health faster than someone who only started five years after injury.
The normal schedule for follow-up appointments is expected to be 6 months.
Summary and Recommendations
Summary of Findings:
• A concise summary of the patient’s initial status, treatment plan, and goals.
Recommendations:
• A clear outline of the recommended course of action, and any specific concerns or suggestions for further interventions.
Patient Consent and Engagement
Consent Documentation:
• Confirmation of patient understanding and agreement with the treatment plan.
Patient Engagement:
• Strategies to ensure patient motivation, treatment plan adherence, and goalsetting involvement.
It is important to ensure that we have covered the necessary and sufficient steps for each client and check their understanding of the processes for safe and effective use.
Appendices and References
Supporting Documentation:
• Include any relevant test results
References:
• Cite any guidelines or scientific literature that support the treatment approach.
The Stimulator RISE contains an impulse testing function (mapped to the IMP key) that allows a strength-duration curve for a tested muscle exhibiting complete denervation. Carrying out this test would allow the denervation status to be tracked over time. Although time-consuming, it is an effective indicator of progress with training.
Conclusion
Research as shown that certain forms of electrical stimulation applied diligently can help preserve the tissue bulk and quality of denervated muscle. If reinnervation is expected then such stimulation can preserve the quality of muscle and nerve whilst reinneration takes place. The RISE Stimulator is optimised for denervated muscle stimulation at home. The article above describes a comprehensive process for assessment and review