Neuro-MEP.NET User Manual Ver 3 Oct 2016

2.7.2.10. Formulas for Additional Traces Calculation ...108 2.7.2.11. Use of EMG Triggers ...109 2.7.2.12. Traces View ...112 2.7.2.13. Marker Names on Traces...114 2.7.2.14. Test Protocols (Macros) ...115 2.7.2.15. Comments/Windows/Reference Values...116 2.7.2.16. Linked Tests...118 2.7.2.17. Setup Completion ...119 2.7.3. Exam Templates...120 3.

4

Electroneuromyography and Electromyography...121 3.1. EMG Electrodes Marking ...121 3.2. Motor Conduction Velocity ...122 3.2.1. M-Wave Acquisition...122 3.2.2. Analysis Windows...130 3.3. Sensory Conduction Velocity ...141 3.3.1. Nerve Action Potential Acquisition...141 3.3.2. Analysis Windows...148 3.4. F-Wave...153 3.4.1. F-Wave Acquisition...153 3.4.2. Analysis Windows...159 3.4.3. Express F-wave Analysis ...165 3.5. H-Reflex ...167 3.5.1. H-Reflex Acquisition ...167 3.5.2. Analysis Windows...173 3.6. H-Reflex (Paired Stimulation)...177 3.6.1. H-Reflex Acquisition ...177 3.6.2. Analysis Windows...181 3.7. Motor Inching ...182 3.7.1. M-Wave Acquisition...182 3.7.2. Analysis Windows...186 3.8. Sensory Inching ...188 3.8.1. Nerve Action Potential Acquisition...188 3.8.2. Analysis Windows...193 3.9. Motor Conduction Collision ...195 3.9.1. M-wave Acquisition...195 3.9.2. Analysis Windows...199 3.10. Sensory Conduction Collision ...200 3.10.1. Nerve Action Potential Acquisition...200 3.10.2. Analysis Windows...204 3.11. Quantitative EMG (QEMG) ...205 3.12. Spontaneous Activity...206 3.12.1. Spontaneous Activity Acquisition...206 3.12.1.1. “Free Recording” Mode ...208 3.12.1.2. “Free Run with Long Trace” Mode ...209 3.12.2. Analysis Windows...216 3.13. Interference EMG...218 3.13.1. Interference EMG Acquisition...218 3.13.2. Spontaneous Activity Recording in Interference EMG Test ...223 3.13.3. Analysis Windows...224 3.14. Motor Unit Potentials (MUP) ...229 3.14.1. Long Epoch Acquisition with Online MUP Selection ...230 3.14.2. Long Epoch Acquisition ...232 3.14.3. Short Epoch Acquisition (Single MUP) ...232 3.14.4. MUP Selection for Analysis ...235 3.14.5. Automatic MUP Selection...235 3.14.6. Manual MUP Selection ...236 3.14.7. MUP Analysis ...236

3.14.8. Analysis Windows...243 3.15. Macro EMG ...248 3.15.1. Macro EMG Acquisition ...249 3.15.2. Analysis Windows...252 3.16. Repetitive Stimulation (Decrement Test) ...254 3.16.1. Repetitive Stimulation Acquisition ...254 3.16.2. Analysis Windows...259 3.17. Incremental MUNE...262 3.17.1. M-wave Acquisition...263 3.17.2. Analysis Windows...267 3.18. MUNE (MUP Decomposition) ...268 3.18.1. Interference Curve Acquisition ...268 3.18.2. Analysis Windows...271 3.19. Single Fibre (Jitter)...272 3.19.1. Jitter Acquisition ...272 3.19.2. Long Epoch Acquisition with Online SFAP Selection ...274 3.19.3. Short Epoch Acquisition ...276 3.19.4. Analysis Windows...279 3.20. Blink Reflex ...281 3.20.1. Blink Reflex Acquisition ...281 3.20.2. Analysis Windows...286 3.21. Galvanic Skin Response (GSR)...288 3.21.1. GSR Acquisition ...288 3.21.2. Analysis Windows...290 3.22. T-Reflex...291 3.22.1. T-Reflex Acquisition...291 3.22.2. Analysis Windows...296 3.23. Tremor...299 3.23.1. Tremor Acquisition...299 3.23.2. Analysis Windows...300 3.24. Nociceptive Reflex (RIII) ...301 3.24.1. Reflex Acquisition ...301 3.24.2. Analysis Windows...303 3.25. Heart Rate Variability (HRV) ...304 3.25.1. ECG Acquisition (ECG) ...304 3.25.2. Analysis Windows...306 4.

Transcranial Magnetic Stimulation...311 4.1. Transcranial Magnetic Stimulation ...311 4.1.1. Acquisition of Muscle Motor Evoked Potential...311 4.1.2. Analysis Windows...316 4.2. Paired Stimulation ...321 4.2.1. Acquisition of Muscle Motor Evoked Potential...321 4.2.2. Analysis Windows...323 4.3. Silent Period...324 4.3.1. Acquisition of Muscle Motor Evoked Potential...324 4.3.2. Analysis Windows...325 4.4. Triple Stimulation Test ...326 4.4.1. Responses Acquisition at Triple Stimulation ...326 4.4.2. Analysis Windows...330 4.5. Recruitment...331 4.5.1. Acquisition of Muscle Motor Evoked Potential...331 4.5.2. Analysis Windows...333 4.6. Repetitive Stimulation ...334 4.6.1. Acquisition of Muscle Motor Evoked Potential...334 4.6.2. Analysis Windows...336 4.7. Paired Associative Stimulation...337 4.7.1. Response Acquisition ...337 5

4.7.2. Analysis Windows...340

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5.

Evoked Potentials ...342 5.1. Recommendations for EP Acquisition...342 5.2. EP Acquisition ...343 5.3. Analysis Windows ...354 5.4. Visual EP Features ...359 5.5. Auditory EP Features ...361 5.6. Somatosensory EP Features ...364 5.7. Cognitive EP P300 Features...365 5.8. Cognitive EP MMN Features...368 5.9. Cognitive EP CNV Features...369 5.10. Cognitive EP MRCP Features (Movement Related Cortical Potential, Bereitschaftspotential) ...371

6.

Electroretinography ...371

7.

Appendix...373 7.1. Footswitches ...373 7.2. Operation with Third-party Firm Stimulators ...374 7.3. XML-format of Data Export ...375

Attention!

Attention! If you have bought the computer separately, install the software before you connect the device to the computer for the first time (see technical manual of the device)! After the first start of the program execute the Setup|Change menu command, enter the hospital name on the “General” page and set the correct parameters of your equipment on the “Equipment” page (see more information in section 2.7 “Hardware and Software Configuration Setting”). In case LCD monitor (i.e. reversal pattern) is available in your delivery set, set the turn-on delay time in the program settings for the pattern correct operation. Otherwise, visual evoked potential latencies will be incorrect. In case you purchased LCD monitor together with the device, it already has a special Neurosoft marking with the monitor turn-on delay time. Keep in mind that the delay values specified in the monitors’ acquisition certificates disagree with actual values as a rule and the special equipment for their measurement is needed. For reversal patterns based on CRT monitors the delay time always equals to 0 (zero). If activation (i.e. the file with license key) is needed while working with the device, it is necessary to contact your dealer or Neurosoft Ltd. and provide them with the device serial number to get the license key. To install the file with license key, double-click with the left mouse button on the corresponding file or select it and choose “Install” item from the local menu opened by right mouse button click. This file can be recorded either in work directory of the program or in root directory of any computer disc. The license key is required only for data recording from the device. In case data analysis without recording is carried out on any computer, the license key is not needed. You can install the program and license key on any number of computers without restrictions. If the device has been changed, a new activation (i.e. a new file with license key) will be necessary. In case several Neurosoft devices are used on one computer, you will need several files with license key as well (one file for one device).

7

Neuro-MEP.NET (Version 3) (User Manual)

Introduction Neurosoft Ltd. constantly improves its devices and software. Therefore, the program may be slightly different from the one described in this manual. The current version of the manual is on the electronic storage media supplied with the device. This manual is supplied with Neuro-MEP.NET software and one of the following Neurosoft devices: 1.

Neuro-MEP-4 (Neuro-MEP-8/16) multifunctional PC-based system for electroneuromyography, electroretinography, transcranial magnetic stimulation, studies of auditory, visual, somatosensory and cognitive evoked potentials and otoacoustic emission (the set of supported techniques depends on delivery set).

2.

Neuro-EMG – the device for electroneuromyography produced on the basis of Neuro-MEP complex.

3.

Neuro-ERG – the device for electroretinography, electro-oculography and visual evoked potentials studies produced on the basis of Neuro-MEP complex.

4.

Neuro-MEP-Micro (version 2009) – the miniature device for electroneuromyographic studies and studies of auditory, visual, somatosensory and cognitive evoked potentials. There are Neuro-MEP-Micro delivery alternatives without auditory and visual stimulators.

5.

Skybox (Neuro-MEP-5) – the miniature 5-channel device for electroneuromyography, studies of auditory, visual, somatosensory and cognitive evoked potentials

6.

Neuro-Audio (version 2010) – the portable hearing screening device for objective audiometry.

7.

Neuron-Spectrum-4/EP and Neuron-Spectrum-4/EPM digital systems for electroneuromyographic studies and studies of auditory, visual, somatosensory and cognitive evoked potentials registered by additional device channels.

8.

Neuro-EMG-Micro – the miniature device for electroneuromyographic studies and studies of somatosensory and cognitive evoked potentials.

9.

Neuron-Spectrum-5 and Neuron-Spectrum-5/S digital systems for electroneuromyographic studies and study of auditory, visual, somatosensory and cognitive evoked potentials registered by additional device channels.

10. Neuro-IOM system for intraoperative neurophysiological monitoring and EMG/EP studies. Neuro-MS magnetic stimulator produced by Neurosoft Ltd. should be bought separately in order to carry out magnetic stimulation.

8

Introduction

Neuro-MEP-Micro, Neuron-Spectrum-4/EP, Neuron-Spectrum-5 and Neuro-EMG-Micro have limited capacity in comparison with Neuro-MEP digital system. While using these devices, some software facilities are inaccessible (for example, it is impossible to set noise masking into unstimulated ear while recording auditory EP). Besides, when using different complete sets of Neuro-MEP, Neuro-MEP-Micro, Neuro-Audio and also Neuron-Spectrum devices, some techniques become impossible. Yet, there are no special notes about it in the description of separate techniques in this manual. Application of high technologies, imported components, development of software with modern requirements and advanced tools in production of Neurosoft devices guarantees high reliability and easy operation of the devices; its small weight and size ensure convenience for conducting exams and high flexibility of applied techniques. We hope that our device will increase diagnostic capabilities and prestige of your clinic and you will enjoy working with it. You can send your responses and recommendations to the following address: Post Office Box 10, Ivanovo, 153000, Russia or by e-mail: [email protected] You can find additional information on Neurosoft products on our website: www.neurosoft.ru or ask questions by phone: +7 (4932) 24-04-37; +7 (4932) 59-21-12 (Service Department) +7 (4932) 24-04-34; +7 (4932) 95-99-99 You can also contact SAS Neuromed Company, Authorized European Representative of Neurosoft Ltd. (to Mr. Pierre Scholl) by the following address: Chemin du tomple 84330 Le Barroux, France Phone: +33 490-650-470, +622-748-384 Fax: +33 490-650-470 E-mail: [email protected]

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Neuro-MEP.NET (Version 3) (User Manual)

1.

Quick Start 1.1. General Requirements In this section the short instructions are given describing the sequence of user actions to execute some widely distributed techniques. They are helpful:  in case when there is no possibility to study the user manual in details;  as a prompt for those who starts working with the program. To execute one of the techniques first refer to the part “The very beginning: new exam” and then to the part concerned with the necessary technique. In the text the square brackets ([ ]) mean the hotkeys which can be used instead of the described menu commands to speed up the work. In this section the minimum possibilities of the program for acquisition and study of the bioelectric signals are described. Study the complete manual to master all the functions. Most of high frequency actions in the program can be carried out in several ways. For instance, to start single stimulation you can:  use Acquisition|Acquisition/Stimulus menu item; to select the menu item use either the left mouse button or the keyboard ([Alt] key is the menu activation; then you can use arrow keys and [Enter] for selection);

 use button located on the toolbar in the upper part of the screen – place the mouse cursor on the button and click its left button;  if a footswitch is available, press the left foot pedal;  if you use the device with built-in keyboard (Neuro-MEP-Micro, Skybox), press “·” button located on the unit’s panel;

 if you use dedicated Bluetooth keyboard, press

button;

 if you use a stimulation electrode with steel stimulation points, press “Start” button on the stimulator’s case.

10

Quick Start

The first variant (menu command) is more understandable and can be easily found when you start working with the program. The last variants are fast and easy-to-use if you already have some experience. In this section all the possible variants of user actions are not specified but only the main ones are described to present the information clearly. During EMG studies keep in mind that the active electrode is black or white and the reference one is red. On the stimulating bar electrode next to the negative terminal (cathode) the mark is placed (and vice versa at the negative stimulus polarity). During EP studies take into consideration that on the amplifier casing the active electrode must be connected to the negative terminal (“-”) which is usually black and the reference electrode must be connected to the positive terminal (“+”) which is usually red. During EMG and EP studies do not forget to place the ground (general) electrode on the patient (its terminal on the amplifier casing is usually of green color). If the ground electrode is not available, the interference (noise) level can be too high and you fail to get good quality signal. Before the first exam you must execute Setup|Change menu command and on the “Equipment” page check whether the power frequency corresponds to that of your region accepted by default (for Russian Federation – 50 Hz); then check CRT size of the reversal pattern (if available) if LCD monitor is used as a reversal pattern, set the delay time in the program settings, otherwise, visual evoked potential latencies will be incorrect.; then check the type of headphones used for auditory evoked potentials (if they are available). Enter the hospital name on the “General” page to ensure its correct displaying in the exam report.

1.2. If You Have No Dedicated Keyboard Neuro-MEP.NET software is developed in such a way that bioelectric signals can be recorded easier with the use of dedicated keyboard. During signal recording the doctor’s right hand is usually busy (it is holding stimulating electrode, needle etc.) and working with the mouse or complex hotkey combinations is notably uncomfortable. As for the dedicated keyboard, which can be placed closely to the patient, it helps to carry out the necessary actions quickly and accurately. If you have bought Neuro-MEP-Micro or Skybox, you should know that this device has a built-in keyboard. If you use another device (Neuro-MEP, Neuron-Spectrum, Neuro-EMG etc.) it is strongly recommended that you use these devices together with the wireless Bluetooth keyboard manufactured by Neurosoft Ltd.. If you have no dedicated keyboard due to some reasons, it is recommended to select the old style of Neuro-MEP functional keys to lighten the work. For that purpose execute the Setup|Change menu command, select the “Program” page and put a mark against “Use Neuro-MEP old style”. The functional keys ([F1] – [F12]) of the computer keyboard will change their functions and during signal recording you will be able to use them in the following way: 11

Neuro-MEP.NET (Version 3) (User Manual)

 [F2], [F3] – changing of stimulus intensity;  [F4], [F5] – changing of stimulus duration;  [F6] – starting/ending of signal monitoring;  [F7] – beginning of signal recording or stimulus supply;  [F9] – beginning of repetitive stimulation;  [F8] – ending of signal recording and saving results for analysis. If you use the old style of Neuro-MEP functional keys, the context-sensitive commands must be executed by pressing the functional keys together with the [Alt] key.

1.3. The Very Beginning: New Exam

To start Neuro-MEP.NET software, find the shortcut on the desktop and double-click on it with the left muse button or select it and press [Enter] key. To start a new examination of a new patient, select Exam|New ([F2]) menu item. In the appeared “New exam” dialog box enter patient’s basic data (optional). If you are short of time, press “OK” ([Enter]) in the dialog box without input of any information. It is more convenient to enter the main information in the “Exam” dialog box in the following order:  input patient’s name;  press [Tab] key; if patient is a man, press [Space] key and [Tab] key; if patient is a woman, press [Tab] key and [Space] key.  press [Tab] key;  enter the date of birth by pressing numeric keys and keys with delimiter character (it is “.” or “/” symbol depending on language specified in Windows). For example, if a patient was born on the 21st of May, 1956, it is enough to enter “21.05.56”). The date format specified in your Windows system is used that is why in some countries other sequence than “day-month-year” can be applied;  to enter a patient’s height (the height is used while calculating some indexes), press [Tab] key and enter the height in centimeters;  to enter the department (the number of ward, hospital etc.), press [Tab] key and enter the necessary name;  to enter a provisional diagnosis, press [Tab] key and enter the diagnosis;

12

Quick Start

 if you need to enter data on the “Additional” page, press [Ctrl+Tab] key combination and continue entering;  press [Enter] to close the “New exam” window. To select a test type use Test|New menu item or quick-access “New test” toolbar buttons.

1.4. Motor Conduction Velocity Execute the actions described in the section 1.3 “The Very Beginning: New Exam”.

To perform a motor conduction velocity test press button on the “New test” toolbar and select the name of a test template and recording site side from the dropdown list. If test template name is missing you need use the Test|New menu item and select a default test template. Make the stimulating electrode ready and connect it to the control unit. Start the process of impedance measuring (the Acquisition|Impedance menu command, [Ctrl+Z] or the button on the dedicated keyboard) then place the electrodes on a patient and connect them to the amplifier input. The numbers of used amplifier channels and the names of sites are displayed in the top left corner of the window under the “Montage” heading. Press [F1] key to receive reference information on electrode placement and stimulation sites. Close the impedance measurement window ([Esc] key) when acceptable impedance level is reached. If you are experienced enough, you can perform the test without impedance measurement. Set the required initial value of electrical stimulus by means of the Acquisition|Stimulus|Increase and Acquisition|Stimulus|Decrease menu items or dedicated keyboard. Place the stimulating electrode in the projection of nerve under examination. Start the single stimulation by means of the Acquisition|Acquisition/Stimulus menu item (or by the corresponding button on the dedicated keyboard). If you fail to get the required M-wave, repeat the stimulation start-up and simultaneously change the stimulus intensity or move the stimulating electrode till you get the acceptable result. Instead of single stimulation the repetitive stimulation can be started by the Acquisition|Repetitive stimulation menu item (or by the corresponding button on the dedicated keyboard). At supramaximal stimulus intensity and qualitative M-wave finish the acquisition and save the M-wave for further analysis by means of the Acquisition|Stop menu item (or by the corresponding button on the dedicated keyboard). If you do not want to save the results press [Esc].

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Neuro-MEP.NET (Version 3) (User Manual)

If M-wave is not found on the trace automatically (very low amplitude) you can start the manual search by means of the mouse cursor – press [Alt] and holding it click the left mouse button on the proposed wave location. If the markers are placed inaccurately, you can correct them with the mouse. After you save M-wave, enter the value of stimulation site distance from the computer or dedicated keyboard (Test| Enter conduction distance menu command ([F2])). If the wireless Bluetooth keyboard is available, you can enter the distance in this way: by turning the “Select trace” knob

you can change the distance value by 1 mm,

- by 10 mm. If you have Neuro-MEP-Micro deby turning the “Shift trace” knob vice, then you can change the distance value by 1 mm by turning the Sweep knob and by 10 mm by turning the “Sensitivity” knob. If you use Neuro-MEP-Micro (version

2009) device, rotate change by 10 mm.

knob to change the distance by 1 mm and

knob to

Move the stimulating electrode to a new stimulation site and repeat the procedure. After recording all the necessary M-waves you can study the other side of the same muscle (Test|New test, opposite side, [Ctrl+F4]), other muscle ([F12]) or you can start another technique using either the Test|Linked tests menu command ([F3]) or Test|New menu command (or the corresponding button on the “New test” toolbar). To print the results and exit the program, see the section 1.12 “How to Print the Results and Exit the Program”.

1.5. Sensory Conduction Velocity Execute the actions described in the section 1.3 “The Very Beginning: New Exam”.

To perform a sensory conduction velocity test press the button on the “New test” toolbar and select the name of a test template and the recording site side from the drop-down list. If test template name is missing you need use the Test|New menu item and select a default test template. Make the stimulating electrode ready and connect it to the control unit. Start the process of impedance measurement (the Acquisition|Impedance menu command, [Ctrl+Z] or the button on the dedicated keyboard) then place the electrodes on a patient and connect them to the amplifier input. The numbers of used amplifier channels and the names of sites are displayed in the top left corner of the window under the “Montage” heading. Press [F1] key to receive reference information on electrode placement and stimulation sites. Close the impedance measurement win-

14

Quick Start

dow ([Esc] key) when acceptable impedance level is reached. If you are experienced enough, you can perform the test without impedance measurement. Set the required initial value of electrical stimulus by means of the Acquisition|Stimulus|Increase and Acquisition|Stimulus|Decrease menu items or dedicated keyboard. Start the single stimulation by means of the Acquisition|Acquisition/Stimulus menu item or repetitive stimulation by means of the Acquisition|Repetitive stimulation menu item. The signal averaging is switched on/off by the Acquisition|Averaging/Accumulation menu command ([Ins]). If you fail to get the required nerve action potential, you can stop acquisition by the Acquisition |Cancel menu command ([Esc]) and then restart it. When you get qualitative nerve action potential, finish the acquisition and save the results for further analysis by means of the Acquisition|Stop menu item (or the corresponding button on the dedicated keyboard). If you do not want to save the results, press [Esc]. If nerve action potential is not found on the trace automatically (very low amplitude) you can start the manual search by means of the mouse cursor – press [Alt] and holding it click the left mouse button on the proposed wave location. If the markers are placed inaccurately, you can correct them with the mouse. After you save wave enter the value of stimulation site distance from the computer or dedicated keyboard (Test| Enter conduction distance menu command ([F2])). If the wireless Bluetooth keyboard is available, you can enter the distance in this way: by turning the “Select trace” knob

you can change the distance value by 1 mm, by

turning the “Shift trace” knob - by 10 mm. If you have Neuro-MEP-Micro device, then you can change the distance value by 1 mm by turning the “Sweep” knob and by 10 mm by turning the “Sensitivity” knob. If you use

Neuro-MEP-Micro (version 2009) device, rotate

by 1 mm and

knob to change the distance

knob to change by 10 mm.

Move the stimulating electrode to a new stimulation site and repeat the procedure. After recording all the necessary results you can study the other side of the same nerve (Test|New test, opposite side, [Ctrl+F4]), other nerve ([F12]) or you can start another technique (Test|New or the corresponding button on the “New test” toolbar). To print the results and exit the program, see the section 1.12 “How to Print the Results and Exit the Program”. 15

Neuro-MEP.NET (Version 3) (User Manual)

1.6. F-Wave Execute the actions described in the section 1.3 “The Very Beginning: New Exam”. Before F-wave studying it is recommended to perform a motor conduction velocity test first and then begin F-wave study by means of the Test|Linked tests|F-wave menu item. Make the stimulating electrode ready and connect it to the control unit. Set the required initial value of electrical stimulus by means of Acquisition|Stimulus|Increase and Acquisition|Stimulus|Decrease menu items or dedicated keyboard control. Place the stimulating electrode in the projection of nerve under examination. If you want to get the required M-wave first and then proceed to F-waves accumulation, start traces accumulation by the Acquisition|Averaging/Accumulation menu command (hotkey [Ins] or the corresponding button on the dedicated keyboard). Start the single stimulation by means of the Acquisition|Acquisition/Stimulus menu item (or by the corresponding button on the dedicated keyboard). If you fail to get the required M-wave or F-wave repeat the stimulation start-up and simultaneously change the stimulus intensity or move the stimulating electrode till you get the acceptable result. At supramaximal stimulus intensity and qualitative M-wave switch the accumulation of traces by the Acquisition|Averaging/Accumulation menu command (hotkey [Ins] or the corresponding button on the dedicated keyboard). You can use either single pulse (Acquisition|Acquisition/Stimulus or the corresponding button on the keyboard) or repeated (Acquisition|Repetitive stimulation or the corresponding button on the keyboard) stimulation. After accumulation of the required number of traces the acquisition is finished automatically, but you can finish the stimulation earlier by means of the Acquisition|Exit menu item (or the corresponding button on the keyboard). If you don’t want to save the results press [Esc]. If M-wave is qualitative and you wish to start F-waves accumulation procedure from the first stimulus, switch to the accumulation mode first (the Acquisition|Averaging/Accumulation menu command, hotkey [Ins] or the corresponding button on the dedicated keyboard) and then start stimulation. If the markers are placed inaccurately, you can correct them with the mouse. After recording all the necessary responses you can study the other side of the same muscle Test|New test, opposite side, [Ctrl+F4]), other nerve ([F12]) or you can start another technique (Test|New or the corresponding button on the “New test” toolbar). To print the results and exit the program, see the section 1.12 “How to Print the Results and Exit the Program”.

16

Quick Start

1.7. H-Reflex Execute the actions described in the section 1.3 “The Very Beginning: New Exam”. Make the stimulating electrode ready and connect it to the control unit.

To perform H-reflex test press the button on the “New test” toolbar and select the name of a test template and recording site side from the drop-down list. If test template name is missing, you need use the menu item Test|New and select a default test template. Start the process of impedance measurement (the Acquisition|Impedance menu command, [Ctrl+Z] or the button on the dedicated keyboard) then place the necessary electrodes on a patient and connect them to the amplifier input. The numbers of used amplifier channels and the names of sites are displayed in the top left corner of the window under the “Montage” heading. Press [F1] key to receive reference information on electrode placement and stimulation sites. Close the impedance measurement window [Esc] when acceptable impedance level is reached. If you are experienced enough, you can perform the test without impedance measurement. Set the required value of electrical stimulus at which the significant М-wave and Hreflex are expected by means of the Acquisition|Stimulus|Increase and Acquisition|Stimulus|Decrease menu items or dedicated keyboard control. Place the stimulating electrode in the projection of nerve under examination. Start the single stimulation by means of the Acquisition|Acquisition/Stimulus menu item (or by the corresponding button on the dedicated keyboard). If you fail to get the required M-wave and H-reflex, repeat the stimulation start-up and move the stimulating electrode till you get the acceptable result. Pay attention that for H-reflex test the automatic increase of the stimulus for one stage after each stimulation is set by default. If you get qualitative responses, close the acquisition window (the Acquisition|Cancel menu command, key [Esc] or the corresponding button on the dedicated keyboard). Set the minimum initial value of the stimulus and execute the Acquisition|Repetitive stimulation menu command (or press the corresponding button on the keyboard). Pay attention that in this test the stimulation frequency is set rather low by default (as a rule, one stimulus for 10-20 sec.) to restore H-reflex completely. If it is necessary you can use the manual start-up of the stimulus by the Acquisition|Acquisition/Stimulus menu command (or by the corresponding button on the keyboard). At supramaximal stimulus intensity finish the acquisition by means of the Acquisition|Stop menu item (or the corresponding button on the keyboard). If you do not want to save the results press [Esc]. If you don’t like the automatic H-reflex or M-wave marking you can start the search of waves in the desired area. First, select the desired area with the mouse: place the 17

Neuro-MEP.NET (Version 3) (User Manual)

cursor at the beginning of the search area, press the left button and move it till the end of the search area then release the left mouse button. After that, use the Test|M-wave search by selection or Test|H-reflex search by selection menu command. If the markers are placed inaccurately, you can correct them with the mouse. To switch М-wave and Н-reflex state block (skip) use the Test|М-wave skip/realization and Test|H-reflex skip/realization menu commands. After recording all the necessary responses, you can study the other side of the same muscle Test|New test, opposite side) or you can start another technique (Test|New or the corresponding button on the “New test” toolbar). To print the results and exit the program, see the section 1.12 “How to Print the Results and Exit the Program”.

1.8. Repetitive Stimulation (Decrement Test) Execute the actions described in the section 1.3 “The Very Beginning: New Exam”. Before you start repetitive stimulation, it is recommended to perform a motor conduction velocity test first and then begin repetitive stimulation by means of the Test|Linked tests|Repetitive stimulation menu item. Set the required value of electrical stimulus by means of the Acquisition|Stimulus|Increase and Acquisition|Stimulus|Decrease menu items or dedicated keyboard control. Place the stimulating electrode in the projection of nerve under examination. On the “Protocol” panel select a stimulation protocol (algorithm) you need ([F2] key). For example, the protocol “3 Hz, 5 stim., every 10 sec.” corresponds to series of 5 stimuli given every 10 seconds. The protocol “Test with tetanization” corresponds to a repetitive stimulation with titanic series. Place the stimulator and start a protocol by the Acquisition|Repetitive stimulation menu item (or press the corresponding button on the dedicated keyboard). During the protocol performing you can skip some commands or repeat the executed ones. To do it, left-click the command in the list to select it. It will be executed next one. To finish the protocol, use the Acquisition|Stop menu item (or press the corresponding button on the dedicated keyboard or [Esc] key). After recording all the necessary responses you can study the other side of the same muscle Test|New test, opposite side), other muscle ([F12]) or you can start another test (Test|New or the corresponding button on the “New test” toolbar). To print the results and exit the program, see the section 1.12 “How to Print the Results and Exit the Program”.

18

Quick Start

1.9. Blink Reflex Execute the actions described in the section 1.3 “The Very Beginning: New Exam”.

To perform a blink reflex test press the button on the “New test” toolbar and select the name of a test template from the drop-down list. If test template name is missing you need use the Test|New menu item and select a default test template. Make the stimulating electrode ready and connect it to the control unit. Start the process of impedance measuring (the Acquisition|Impedance menu command, [Ctrl+Z] or the button on the dedicated keyboard) then place the necessary electrodes on a patient and connect them to the amplifier input. The numbers of used amplifier channels and the names of sites are displayed in the top left corner of the window under the “Montage” heading. Press [F1] key to receive reference information on electrode placement and stimulation sites. Close the impedance measurement window [Esc] when acceptable impedance level is reached. If you are experienced enough, you can perform the test without impedance measurement. Set the required initial value of electrical stimulus by means of the Acquisition|Stimulus|Increase and Acquisition|Stimulus|Decrease menu items or dedicated keyboard control. Place the stimulating electrode in the projection of nerve under examination. Start the single stimulation by means of the Acquisition|Acquisition/Stimulus menu item (or by the corresponding button on the dedicated keyboard). If you fail to get the required response repeat the stimulation start-up and simultaneously change the stimulus intensity or move the stimulating electrode till you get the acceptable result. Instead of single stimulation the repetitive stimulation can be started by the Acquisition|Repetitive stimulation menu item (or by the corresponding button on the dedicated keyboard). When you get a qualitative response, finish the acquisition and save the traces for further analysis by means of the Acquisition|Exit menu item. If you do not want to save the traces, press [Esc]. Move the stimulating electrode to a new stimulation site and repeat the technique. If the markers are placed inaccurately, you can correct them with the mouse. To switch the block (realization/skip) of R1 and R2 waves on the selected trace use the Test|R1 skip/realization menu commands (hotkey [F2]) or Test|R2 skip/realization (hotkey [F3]). After recording all the necessary traces you can start another technique (Test|New or the corresponding button on the “New test” toolbar). To print the results and exit the program, see the section 1.12 “How to Print the Results and Exit the Program”. 19

Neuro-MEP.NET (Version 3) (User Manual)

1.10. Quantitive EMG (QEMG) This test is performed using needle electrode, and is used for recording and analysis of muscle spontaneous activity, motor unit potentials (MUP) and interference pattern at tonic contraction. It is not necessary to perform signal recording in all abovementioned modes for further analysis. Perform steps described in chapter 1.3 “The Very Beginning: New Exam”.

To perform QEMG test, click on the button located on the “New test” toolbar, and choose exam template and recording site side from the drop down list. If the required name is missing, use the Test|New menu command and choose the default template. QEMG test contains four signal review/acquisition modes:  spontaneous activity (muscle spontaneous activity acquisition and analysis);  motor unit potentials (MUP acquisition and analysis);  interference pattern (EMG acquisition and analysis at muscle tonic contraction);  QEMG (includes analysis result review of all mentioned modes). To switch between modes use [F2] – [F5] keys; you can switch at any time, even during signal acquisition. Prepare needle electrode, apply ground electrode to a patient, and connect electrodes to amplifier input. If it is necessary you can use surface electrodes instead of concentric needle ones. To display help information concerning needle insertion point, press [F1] key or use the View|Help window menu command. To switch to spontaneous activity recording mode, press [F2] key or use the Test|Work mode|Spontaneous activity menu command. Insert the needle into a muscle and start signal acquisition with the Acquisition|Acquisition/Stimulus menu command. To pause acquisition, use the Acquisition|Pause menu command or [Space] key or corresponding button on the dedicated keyboard. If it is required to record each next fragment as a new trace, use the Acquisition|Averaging/Continuous menu command, [Ins] key or corresponding button on the dedicated keyboard. To add the recorded traces to analysis, use the Acquisition|Stop menu command or corresponding button on the dedicated keyboard. To refuse, use the Acquisition|Cancel menu command, [Esc] key or corresponding button on the dedicated keyboard.

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Quick Start

If it is necessary repeat these steps for another needle insertion. In case the spontaneous activity presents, you can mark the observed phenomenon in the “Phenomena” window, or differentiate and measure these phenomenon more accurately. To do it, position the mouse cursor over the phenomenon, press [Alt] key and press left mouse button holding [Alt] key down. Then release [Alt] key and in the drop down list that appears choose the type of selected phenomenon. You can also use the option of automatic spontaneous activity phenomena classification activated by the Test|Spontaneous activity classification menu command. To switch to the MUP acquisition mode press [F3] key or use the Test|Work mode|MUP menu command. Start the signal acquisition with the Acquisition|Acquisition/Stimulus menu command and adjust the muscle contraction in order to obtain not overlaying MUPs. Observe the obtained MUPs in the Preview window. Move the needle slightly till all the buttons located near potentials that appears becomes green. Green color of these buttons indicates a good quality of obtained MUPs. Then start MUP accumulation using the Acquisition|Averaging/Continuous menu command ([Ins] key). To add the recorded traces to analysis, use the Acquisition|Stop menu command or corresponding button on the dedicated keyboard. To refuse, use the Acquisition|Cancel menu command, [Esc] key or corresponding button on the dedicated keyboard. If it is necessary repeat these steps for another needle insertion. To switch to interference curve acquisition mode press [F4] key or use the Test|Work mode|Interference pattern menu command. Start the signal acquisition with the Acquisition|Acquisition/Stimulus menu command. To pause acquisition, use the Acquisition|Pause menu command or [Space] key or corresponding button on the dedicated keyboard. If it is required to record each next fragment as a new trace, use the Acquisition|Averaging/Continuous menu command, [Ins] key or corresponding button on the dedicated keyboard. To add the recorded traces to analysis, use the Acquisition| Stop menu command or corresponding button on the dedicated keyboard. To refuse, use the Acquisition|Cancel menu command, [Esc] key or corresponding button on the dedicated keyboard. If it is necessary repeat these steps for another needle insertion. If a spontaneous activity trace were obtained in interference curve mode, you can move it to the spontaneous activity window using the Spontaneous activity trace local menu command. The same algorithm is used in case the interference trace were obtained in spontaneous activity mode.

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Neuro-MEP.NET (Version 3) (User Manual)

To switch to QEMG mode press [F5] key or use the Test|Work mode|Quantitative EMG menu command. When all required responses are obtained you can move to the same musle on the other side of the body (Test|New test, opposite side menu command), other muscle [F12] or a new technique (Test|New menu command or corresponding “New test” toolbar button). To print the results and finish working with the software move to chapter 1.12 “How to Print the Results and Exit the Program”.

1.11. Evoked Potentials (EP) Execute the actions described in the section 1.3 “The Very Beginning: New Exam”. To study the evoked potentials click on the necessary button on the “"” toolbar and select the name of a test template from the drop-down list. For instance, for shortlatency auditory EP acquisition, use the button. If test template name is missing you need use the Test|New menu item and select a default test template. Start the process of impedance measuring (the Acquisition|Impedance menu command, [Ctrl+Z] or the button on the dedicated keyboard) then place the electrodes on a patient and connect them to the amplifier input. The numbers of used amplifier channels and the names of sites are displayed in the top left corner of the window under the “Montage” heading. Press [F1] key to receive reference information on electrode placement and stimulation sites. Close the impedance measurement window [Esc] when acceptable impedance level is reached. If you are experienced enough, you can perform the test without impedance measurement. Set the required initial value of stimulus using the Acquisition|Stimulus|Increase and Acquisition|Stimulus|Decrease menu commands or dedicated keyboard controls. Make the necessary stimulator ready and connect it to the device. Start the repetitive stimulation by means of the Acquisition|Repetitive stimulation menu item (or by the corresponding button on the dedicated keyboard) and follow the process of signal averaging. If you fail to get the required evoked potentials, you can stop averaging by the Acquisition|Cancel ([Esc]) menu command and then restart it. When you get qualitative evoked potentials, finish the acquisition and save the results for further analysis by means of the Acquisition|Stop menu item. If you do not want to save the results, press [Esc]. To mark the EP components manually, click the left mouse button on the corresponding component name on the toolbar and shift the appeared crosshair cursor to the point of the assumed component and press the left mouse button once more.

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