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Viasys Teca Synergy EMG-EP Systems User Manual

1. E 1 SYNERGY USER MANUAL Cable management for PIU Deluxe stim probe and power supply E 2 APPENDICES Management of monitor cables 3 39 SYNERGY USER MANUAL SSO Mouse and key board connections 4 N eS 4 i in OO NO 9 amp 10 39 9 E 4 APPENDICES Connecting the Printer to the Tower 5 Ss patt E 5 APPENDICES E 7 SYNERGY USER MANUAL Key to Numbers used on the System Connection Drawings and on Examples A to E ODANANDNBRWNK E 8 Patient Interface Unit PIU Synergy power supply Notebook PC Notebook PC power supply Junction box Wall of room Separate fixed mains socket outlets Mains inlet DC power to PIU USB cable To PC USB port DC power to Notebook PC Other non medical equipment Class I protectively ear
2. User Set up Users can change their User Set up with the exception of changing their logon name full name and access rights These are set by the Administrator Aspects of User Set up that users can change include their password clinic name default temperature display scale default height format and paths where results and reports are stored Muscle Lists Users can define their own muscle lists from a Master Muscle List Report Set up Users define the components and layout of their online reports Tests Users can configure test and protocol settings See also gt Customising the report layout chapter 3 gt Configuring protocols chapter 5 Changing your User Set up 1 Select Set up User from the System menu The User Set up dialog is displayed The User Name and Full Name dialog boxes are for display only You cannot change these fields 2 You can edit the Clinic Name field 3 Select whether you want the default temperature display in Celsius or Fahrenheit 4 Select whether you want height entered and displayed in metric metres and centimetres or imperial feet and inches units 5 To change your password or the paths for storing results and reports click one of the following options and follow the 55 SYNERGY USER MANUAL 56 6 instructions Changing a password Changing paths Click OK to return to the main Synergy screen Changing a password 1 Click the Change Password button
3. The test Toolbar may include a temperature display Press the icon alongside the display to attach the temperature to the result table Results in the result table may be corrected for temperature If you have configured Reference Values these may also be corrected for temperature Trolley A standard accessory with mounting or storage provided for the system and its components and accessories Arm A standard accessory that provides flexible and height adjustable mounting for the PIU and electrical stimulator Optionally a mounting can be fitted at the PIU end for a Deluxe Stimulator Probe The arm can be mounted on either side of a trolley Desk Mount An optional accessory that provides flexible mounting for the PIU and electrical stimulator Optionally a mounting can be fitted at the PIU end for a Deluxe Stimulator Probe Printer Synergy supports a recommended range of printers Ask Oxford Instruments for information Network card and cables When supplied the network card for the Synergy Tower is a PCI or ISA card with a UTP connector The cable is a foil shielded crossover network cable CATS SYNERGY USER MANUAL Components of the Synergy Suite The Synergy Suite combines the components of the Notebook and Tower systems A Suite system typically comprises a Tower PC and one or more Notebooks all of which include network cards as standard to enable them to be networked together and to allow direct transf
4. To disconnect the interface connectors Release the securing mechanism spring clips or screws before pulling apart the connections Details of pin connections are found in Appendix B Synergy should only be used with printers recommended by Oxford Instruments For more information about installing your printer see the manual which is provided with the printer Signal Cable A high quality screened cable must be used when connecting a printer to Synergy Notebook to ensure compliance with EMC regulations Braid screened or double screened braid plus foil cables are the preferred types The cable screen should make a 360 connection to the screening shells of the connectors on each end of the cable Cables described as IEEE 1284 compliant are likely to be suitable A 23 SYNERGY USER MANUAL Maintenance After sales service support The manufacturer of the Synergy and the distributors provide a comprehensive after sales service support For details please contact the manufacturer or your local distributor Service contracts are available A workshop manual is available for purchase containing all the information necessary to enable appropriately qualified technical personnel to carry out repair and calibration of those parts of the equipment that are repairable Maintenance of the instrument The instrument is inherently reliable it contains many solid state electronic components which need no maintenance a
5. cccssccssssscssscssseccesee L Sipha Cablen n e cetvedh cons a de pegstle Sashes E Eo Sn RE du yevers 1 Connectors on Notebook PC and PC Tower ssessssesessseesseeesressrerereserssreeee 1 Connectors On PIU seiso eiee a ae e a EEEO Gea EREA 1 Appendix C Technical Specifications ssccccscsssesssseseee L Amplifiersand Filters oiniessisiie rrini enn e R R aE 1 Data Acquisition and Display cceesceseceeseeceseeeenseceeeeeeneeceeeeeneeceseeeenaeess 1 Electrical Stimulator ieena e e a E R 1 Dimensions Patient Interface UNit cccccccessecessececsesteceeseeeecessneeeensaeees 2 Power Requirements eneon a ae aaee a aE Eaa S E Eoia 2 INTRODUCTION ISO800 Mains Isolating Transformer ee eee cee ceeecreeeeeeeeeeeeeeeseeeaees 2 Safety StandafdSe ioner e elie ieot ghee eb tog atte E A a s 3 EMC Standards 5 cisniesirh ie eels sheets bn eek 3 Quality Standards 2 cccc chee ies tested algeiseuleyien e EE eE REY 3 Appendix D Assembling the Notebook Stand s0ss008 L Assembly iNStrUuctiONS cccsscccsssecssscsessccesnccessaeessaccscnaccesaseesssceenaccesanes 1 Appendix E Cable management for the Tower 1 vii SYNERGY USER MANUAL Using this Manual viii This user manual is intended to be read by anyone who is to use Synergy Notebook Synergy Tower or Synergy Suite Immediately after this section are notes on safety considerations and a list of the symbols us
6. The purpose of the Sensory NCS test is 1 To investigate the conduction in sensory nerves demyelination 2 To assess loss of sensory axons Running the Sensory NCS test Select the test From the entry screen select the test you want from the appropriate folder Select a protocol From the Select protocol dialog box select the protocol that you want to use for this test Connect the electrodes stimulator Median Nerve Recording electrode Wraparound ground electrode 83 SYNERGY USER MANUAL 84 Usage 1 Prepare the area over the nerve to be stimulated by cleaning the skin with dry gauze Surface disk or ring electrodes are placed over the skin where the tested nerve is superficially located The following electrodes are recommended Large bipolar stimulating electrode 16893T Digital ring electrodes 16639T Apply the stimulating electrodes using a conductive electrode gel The nerve is stimulated at sites where it is superficially located The cathode of the stimulator is oriented towards the active recording electrode Acquire the data Turn on the amplifier and observe the monitor trace at the lower right of the screen to ensure that it is noise free If it is not check electrode connections and cables 1 Position the stimulator at the appropriate site and begin stimulation for recurrent stimulation press the Acquire On button for a single stimulus press the Acquire Si
7. 0 cece eect cee ereeeee 63 Adding comment cece cece eeeeeee 39 After sales service support App A 24 After sales SUpPOTt eee eee eeeeeee 16 Artefact Reject setup eee 65 AUCIO SOUP sic ssccss ssyedssesictsysesscesssescesess 65 Automatic marker placement 143 Blink Reflex test eects 108 Cable management for the Tower App E E E A albert beeen oratee 1 Cables App A uv cece cee cseereeeeeeeeees 7 Cancelling a search eee eee eeeeeee 34 Change trace duration 0 60 145 Change trace sensitivity 0 0 60 145 Changing a password eee 54 Changing paths esssesseeeseeeereereeeeeseeee 54 Changing your User setup 00 53 Channel settings cece eeeeeeeees 63 Cleaning App A eee eee eeeereeees 24 Clinical overview Blink reflex test eee 108 Fibre Density Analysis test 135 F2Wave test 3ccsheccaehsae 87 H Reflex test 92 Interference Pattern Analysis test 113 Macro EMG test eee 138 Motor NCS test soseer 74 Multi MUP Analysis test 0 118 Needle EMG test ee eeeeeeeee 95 Repetitive Nerve Stim test 102 Sensory NCS test eee eee 81 Single Fibre Jitter test 2 000 124 COMMENDS szinen a 42 Comments utility eee eee 38 INDEX Comments adding eee ee eee 39 COMPALe snsseelesessccscesipedoessoeesstpsatereesy 145 Comparing results eee eee eee See COMPONENUS sernpr
8. Connect the electrodes Signals are recorded from 2 channels The default set up is Channel 1 Records Left side Channel 2 Records Right side The recording electrodes are placed over the appropriate area Usually electrical stimulation is used to excite the nerve near the frontal notch Recommended electrodes are Large bipolar stimulating electrode 16893T Deluxe Stimulator Probe 031K025 110 6 THE TESTS Acquire the data Turn on the amplifier and observe the monitor trace at the lower right of the screen to ensure that it is noise free If it is not check electrode connections and cables Ask the patient to wink one eye at a time and check that the EMG activity is on the expected channel channel 1 for the left eye channel 2 for the right eye 1 Stimulate in the supraorbital notch for recurrent stimulation press the Acquire On button for a single stimulus press the Acquire Single button Perform four trials since the waveform changes on successive stimuli If traces are not acceptable press the Erase button on the PIU to clear the trace area If using recurrent stimulation press the Acquire On button to stop stimulation When you stop acquisition both of the most recently acquired traces are selected Measure the latencies on the first channel set Press the up arrow key to ensure that only a trace from the first channel set is selected highlighted in yellow then if necessary press the
9. Push the switch to the ON position The instrument is now ON and the screen displays a message indicating that Windows 98 is starting Once loaded the Test Menu will appear Switching off Warning Before switching OFF disconnect all patient electrodes Before switching OFF the instrument it is essential that the Synergy application and Windows 98 are closed down Failure to do this may result in loss of data and operating problems the next time the instrument is switched on Close down Synergy by selecting Exit Windows from the FILE menu Wait until the system has closed down before switching off the power plug If the instrument is to be switched OFF and ON again wait approximately 5 seconds before switching OFF and ON SYNERGY USER MANUAL Special instructions for use Switch ON the instrument before connecting patient electrodes Disconnect all patient electrodes before switching OFF Do NOT use electrical stimulators for the direct stimulation of exposed nerves unless the stimulator output has been set to the Low range A patient with an implanted electronic device for example a cardiac pacemaker should not be subjected to electrical stimulation unless specialist medical opinion has first been obtained Accidental contact between electrodes connected to the amplifier and stimulator connectors but not applied to the patient and other conductive parts including protectively earthed parts should be avoided APPEN
10. Running the Motor NCS test Select the test From the entry screen select the test you want from the appropriate folder 76 6 THE TESTS Select a protocol From the Select protocol dialog box select the protocol that you want to use for this test Connect the electrodes The following stimulating electrodes are recommended Large bipolar stimulating electrode 16893T Deluxe Stimulator Probe 031K025 Ulnar Nerve y Wraparound ground electrode Recording electrode Large bipolar stimulator Usage The active recording electrode is placed over the end plate zone of a muscle innervated by the tested nerve The reference electrode is placed nearby in an electrically quiet area The ground electrode is usually placed between the stimulating and recording electrodes Using electrolytic gel between the skin and recording electrode improves the electrical contact and reduces noise When recording from a deep muscle one may use a concentric or monopolar needle for recording 77 SYNERGY USER MANUAL 78 Note The recording electrode is placed on a muscle even though we are interested in the conduction along the nerve The nerve is stimulated using surface electrodes at two or more sites where the nerve is located superficially The stimulator is oriented so that the cathode of the stimulator faces the active recording electrode Acquire the data Turn on the amplifie
11. handling data both in the office and on patient visits Access to the database is restricted to authorised users thereby safeguarding security See also gt Handling Patient Information chapter 2 SYNERGY USER MANUAL The Tests You can configure new tests from a set of default Test Types These provide shortcuts to defining complex sets of results and graphs Utilities are also provided for setting protocols and optimising results Online test configuration enables you to select settings for results tables and graphs See also gt Configuring protocols chapter 5 gt The tests chapter 6 20 1 OVERVIEW OF THE SYSTEM Generating Reports Synergy provides a comprehensive reporting facility which enables you to compile a report as you carry out a patient examination With Synergy you can Optionally include tables graphs and traces in your reports Define the structure of your report tables specifically for use in your reports Optionally indicate results that are outside reference ranges Enter comments in the report as you carry out the examination Configure custom headers and signature files for your reports Generate a Microsoft Word compatible report If you decide to modify the test results after you have finished the examination for example you may want to move an incorrectly placed marker or review and analyse traces and results you can recall the results and recompile a repo
12. macro MUP amplitude gives better correlation with the MU size Since the single fibre electrode has a very small uptake area even a slight movement of the needle can significantly reduce the AP amplitude This makes it difficult to maintain a stable trigger To stabilise the needle insert the needle deep into the muscle and then retract it partially the muscle tends to grab the needle and hold it better in place during retraction When you can recognise individual APs rotate the needle to further optimise the signal amplitude Orienting the active electrode The needle has a special holder and cable a dent on the hub of the holder indicates the location of the side port on the needle This makes it easier to orient the needle or to rotate it while optimising the signal recordings 141 SYNERGY USER MANUAL 142 Acquire data Ask the patient to perform a minimal contraction of the tested muscle Adjust the needle position and the trigger level so that only one muscle unit MU triggers the sweeps Begin acquisition The upper window of the trace area displays the monitor traces from the two channels with the trace from the single fibre channel at the top and the trace from the macro channel below it Note that the sweep duration sensitivity and filter settings for the two channels are quite different The lower window of the trace area displays the average of the signals from the second channel While averaging assess
13. the same key to return to the acquisition screen 2 Click on the site label in the result table to review the traces from an earlier acquisition The current site label is shown in blue 3 Press the Print key to obtain a hard copy of the results 118 6 THE TESTS Exit Press the Test Menu function key to exit the test You may also press the New Muscle key to perform IP analysis in another muscle Upon exiting the analysis in the current muscle the data are automatically transferred to the report generator 119 SYNERGY USER MANUAL Multi MUP Analysis Test Clinical Overview Rationale A motor unit potential MUP is a sum of the extracellular action potentials APs of all muscle Fibres belonging to one motor unit MU The shape of the MUP depends upon the MU architecture i e number and size of muscle fibres terminal innervation etc In pathology changes of the MU architecture due to disease processes will be seen as changes in the MUP waveforms This forms the basis for MUP analysis In quantitative analysis 20 or more MUPs are recorded at minimal force of contraction For each MUP its peak peak amplitude duration and number of phases are measured A MUP is called polyphasic if it has more than 4 phases The mean amplitude mean duration and percentage of polyphasic MUPs are computed and compared against appropriate reference values The latter are affected by the type of needle force of contraction and
14. 129 SYNERGY USER MANUAL 130 Colour Condition White Sweeps used for calculations of jitter Red Sweeps with blocks Blue Sweeps with IPI outside the limits defined by cursors The sequential IPI plot is shown under the result table with the vertical scale of this plot set so that the MIPI value is approximately at the centre A yellow band is displayed on this plot which represents 3 standard deviations from the MIPI IPI values within these limits are used to compute jitter The sequential plot of IPIs is extremely useful to detect traces that were acquired due to technical problems in recording e g triggering from two MUs It is much easier to exclude them by adjusting the IPI limits rather than by excluding them individually during trace review The 3 standard deviation limit will automatically exclude some of the potentials To exclude others use the mouse to reduce the height of the yellow band To manually include or exclude sweeps from analysis 1 Press the Review key This displays the first 5 sweeps in the lower half of the trace area 2 To change the status of an individual sweep from included to excluded or vice versa click on it with the mouse 3 To include or exclude all of the displayed traces right click on the trace area from the popup that is displayed choose Include displayed or Exclude displayed 4 To include or exclude all traces right click on the trace area from the popup that is displ
15. 27 SAVING s cscssctyiesseescesrssersseaboes irii r 23 Searching for oo eee eeeeeeeeeeee 34 Patient Interface Unit eee 9 Patient LiStis scessiseetsssesssssusesssessesscneees 27 Patient Table eee ee eeeeeeeeeeeeeees 42 Power supply connections App A 2 Printer Connecting App A uu eee 23 Printing a PePOTt eee eee eee eeeee 46 Protocol Creating situs eee E in 62 Eins oie cinsetin canoe tink 62 Protocol Configuration Wizard 61 Protocol Table setup 68 69 Protocols On line configuration 59 Selecting ninn 73 Protocols configuration eee 59 QEMG tests 113 118 Recalling a patient 27 31 Recalling a report eeeeeeseeceeeeeenees 41 Recalling results eee eee eeeeeee 33 Recompiling a report 0 0 eee 39 Reference Values ccccscceceeeees 68 150 Repetitive Nerve Stimulation test 102 Report Editing and saving 41 OPeMIN Sesis ci ses torii eaeoe 41 Recalling s cc ccc cseedwecececesnte da ceecee cote 41 Recompiling eee eeeeeeeeeees 39 ViewName a 38 39 Report data EXPONE niine nne estes 35 Report layout customising 0 42 Report sequence defining 0 45 Report Setup nantin 39 42 Reportin ameniona a 21 Reports snn a 21 37 PRNUNG apren i ernie ena 46 Result Mode siiin 149 Result Tables 42 Results iordanian oeteeeoeee 38 Configuring eee eeeeeeeteeeeee 149 Deleting se c sce ccesseetsistes heasseteiegcss 3
16. For example you may want to Save to File a patient s data from an acquisition system so that you can perform analysis on a Synergy Reader system If you do not Save the patient s reports then if you import the data back onto this system after analysing the data on 36 2 HANDLING PATIENT INFORMATION the Synergy Reader system the reports on this system will be overwritten See also gt Synergy Reader Software in chapter 1 Loading patient and report data from File If you Load data from File for a patient who is currently on the system the imported data overwrites the data on the system 1 2 3 Display the Patient List From the File menu choose Load Patients from File Select the file containing the data to import by default the system displays files with the extension mps A list of the patient details in the file is displayed Select the patient file to be loaded and click on the Load button Note that you can import more than one patient at once by using multiple select The patient details are imported onto the system If a patient already exists on the system Synergy asks if you want to replace the data on the system with the imported data 37 3 GENERATING REPORTS 3 Generating reports Overview Synergy provides a comprehensive reporting facility which enables you to compile a report as you carry out a patient examination With Synergy you can Optionally include tables graphs and
17. N 8634992 Save Patient s for Transfer 6294730 Save Patient s for Copy ha 3948576 wROXBURGH Earl 0 8271634 Notes To highlight a block of several patients from the list hold down the Shift key and click on the top and bottom names in the list To highlight selected patients from the list hold down the Ctrl key and click on the names required The selected patients will be erased from the patient list and saved in an export file The export file is located in C Program Files Medelec S ynergy Transfer Data Using Copy to transfer patient data between systems 1 Click the Patient List button or press Alt T in the main Synergy screen to list all the patients in the Patient Database or use the Search utility to find a patient 2 Highlight the patient or patients whose details you want to transfer 3 Select Save Patient for Copy in the File menu or right click and select Save Patient for Copy from the drop down menu 29 SYNERGY USER MANUAL Note To highlight a block of several patients from the list hold down the Shift key and click on the top and bottom names in the list To highlight selected patients from the list hold down the Ctrl key and click on the names required The selected patients are saved in an export file ready for transfer to the other system The export file is located in C Program Files Medelec S ynergy Transfer Data Completing the Transfer T
18. Next button on the PIU A blank trace is displayed on the screen repeat the procedure as for the first site Calculate the velocity Distances may be entered after each site has been acquired or all distances may be entered after all sites have been acquired Enter distances in cm to decimal place e g 23 5 cm The distance entered will be displayed in the active distance field Press Enter to accept the distance and to calculate the conduction velocity Note 1 If you enter distances after each site the active distance field will refer to the active store unless you change it by clicking the mouse or using the tab Enter or up and down arrow keys If you enter distances after you have acquired all sites the active distance field will remain at the second site allowing you to enter all distances in sequence 85 SYNERGY USER MANUAL 86 Note 2 Itis possible to enter Default Distances using the protocol table Conduction Velocities will then be automatically calculated Trace analysis and display Traces may be selected for marking or trace analysis Synergy offers comprehensive and powerful ways of configuring the trace area See the following sections later in this chapter gt Selecting traces Moving traces Superimposing traces Automatic marker placement gt Manual marking of traces gt Changing trace sensitivity gt Changing trace duration gt Compare results
19. PIU A blank trace is displayed where you can repeat the above procedure Note Subsequent responses may diminish in amplitude or disappear altogether because of habituation 114 6 THE TESTS Interference Pattern Analysis Test Clinical Overview At minimal force of contraction the EMG signal contains discharges of only a few motor units Mus One may recognise individual motor unit potentials MUPs by visual assessment When the force of contraction is increased more MUs are recruited and they also discharge at higher rates The EMG signal becomes complex in which individual MUPs may not be recognised This signal called the Interference Pattern or the recruitment pattern contains information about the number and size of MUPs at higher force levels The IP Interference Pattern signal can be quantified using a variety of features In the Turns amp Amplitude TA technique a turn occurs at a peak of the EMG signal If a turn occurs on a positive going peak the preceding and following turns occur on a negative going peak and vice versa Finally to exclude peaks generated by noise the signal amplitude must change by at least 100 uV between successive turns The number of turns sec NT and the mean amplitude change between successive turns MA are measured EMG signals are recorded at different force levels ranging from minimal to maximum at each of the 6 10 tested sites A plot of MA versus NT is constr
20. Repetitive Nerve Stim test Select the test From the entry screen select the test you want from the appropriate folder Select a protocol From the Select protocol dialog box select the protocol that you want to use for this test 104 6 THE TESTS Connect the electrodes Ulnar Nerve Wraparound ground electrode Recording electrode Large bipolar stimulator Usage 1 First the electrodes are placed on the tested muscle preferably over the end plate area 2 The stimulator is placed on the appropriate nerve using one of the following Large bipolar stimulating electrode 16893T Deluxe Stimulator Probe 031K025 Acquire the data The Repetitive Nerve Stim test has three Acquisition Stim modes The mode is selected via the Acquisition menu Stim Set up Mode allows you to stimulate and obtain a supramaximal response without acquiring data Rep Stim Mode is used to deliver a stimulation train and acquire the data up to 20 stims Stim Set up Mode 1 When the test is first entered it will be in Stim Set up Mode 2 This mode is used to establish supramaximal stimulation 105 SYNERGY USER MANUAL 106 3 Press Acquire ON to lock acquisition ON 4 Adjust the stimulus intensity until a supramaximal response is obtained Each cascade will update in turn 5 Exit Stim Set up Mode either by pressing Next or selecting RepStim Mode Notes No data is kept when Stim Set up is exite
21. any of the fields displayed to find out more about a particular field and also how to change the entry if you want to It is also possible to print out a table of the current settings on all your channels 68 5 CONFIGURING PROTOCOLS Electrical Stimulator Set up This allows you to modify stimulus settings for the test Click on Electrical Stim Set up from the Stimulus menu to access the Electrical Stimulator dialog box in order to set up parameters for the Electrical Stimulator Electrical Stimulator Setup Kil f Dims E EE TESS OTN Ee Settings Stimulator Stim A is the PIU internal electrical stimulator Stim B is the optional external Deluxe Stimulator Probe Output Current Selects constant current output Voltage Selects constant voltage output Range Low Selects low range appropriate to somato sensory responses High Selects high range appropriate for standard Nerve Conduction studies 69 SYNERGY USER MANUAL Limit You are not obliged to accept the maximum values specified for low or high range in either case you can set a limit below the default limit offered Stim Options button Click the Stim Options button to display the Stimulus Options dialog This dialog box allows you to specify whether you want the stimulus to continue to be delivered after Acquisition has stopped Protocol Table set up 70 This dialog box allows you to set up parameters for the Protocol
22. duration Low Filter setting Can range from DC to a maximum of 2kHz High Filter Setting Can range from OFF to a maximum of 20kHz Monitor Sensitivity Can range from 10 nanovolts up to 100 millivolts Stores Sensitivity Can range from 10 nanovolts up to 100 millivolts Cascades Sensitivity Can range 10 nanovolts up to 100 millivolts LongTrace Sensitivity Can range from 10 nanovolts up to 100 millivolts Buttons Average Options button Clicking on the Average Options button in the Acquisition Set up dialog box brings you to the Average Options dialog box where you can set up parameters relating to the Average Type Selects from the list the type of average you want to use Mean or Exponential Display Mode Selects the display mode you want to use Sweep Limit Enter the number of sweeps you want to make up your store to be used in the averaging process 5 CONFIGURING PROTOCOLS Artefact Reject Set up button Click the Artefact Reject Set up button to display the Artefact Reject dialogbox Artefact Reject Channel Detect on Channel Reject Level uv Reject Start Time ms 7 2 M Reject ALL a This dialog box allows you to set up the parameters for Reject Level and Reject Start Time on the various Channels It also allows you to specify which channel is providing the input to operate the facility on this channel Detect on Channel Indicates if the Artefact Reject facility is off or wh
23. existing patient seeeessseesesrsererrsreerserrrsserrrsresrsserrenersreeresee 31 Opening the Test Catalo Zi risisisserrisincsrosi eer ivers essersi eonennek 31 Recalling results using the Test Catalog sssesssseesseeeessereeresrsrrerrsreersrreresee 33 Viewing results in the Test Catalog eee ee ceecesecesecesecsseceeeeeeeseeeneeneeena 33 Deleting eSults scapes eene eneeier a ea neoe eier E ieS EIRENE ESKS 33 Searching for patient information ccsscesscessssssscesceencesecsenseeessees 35 Searching on patient details eee cseeereeeeeeeeeeeeeeeeeeeeeeeeeeeeeseenseenaes 35 Clearing the Search Criteria dialog DOX oe eee eee ceecneeceeeeeeeeeeeeeeeeees 35 Cancelling a searche nine n AA A eee tisk E 35 Saving and loading patient and report data to file o on 36 Saving patient and report data to file ee eee eeeceeeceseceseeeseeseenseenaes 36 Loading patient and report data from File eee eee cese cee ceeecneeeseeeee 37 3 Generating reports sccrsscccssscssssscssssssscsescccssssscssssssoses OD Overview essi raeas a oenina tases daseaiaaa ins ieee teaaasee Nas 39 Obtaining a report online csscccsescessccesnsecesssssssscssnncceessasessscssnaceeses 40 Selecting an online report esesseesseeeeseetseiesrsrtsrrsteersseereeseresresreneseeersseeees 41 VIEWING a repofar orin onei a EEE EEEE EEVEE EEE iR 41 Adding comments anessen E E EEEE EE A E EET 41 ReCompiling 4 TEPOre e eea iaee EE Ea EE EEEE es 41 RECALLIN
24. following technique helps to reduce problems 1 Insert the needle at an angle of between 20 and 30 to the surface of the skin instead of nearly perpendicular as performed in concentric or monopolar needle EMG studies When the needle moves the angular insertion produces far less displacement in a radial direction giving more stable AP amplitudes 2 Insert the needle all the way to the hub and then retract it partially The muscle tends to grab the needle and holds it better in one place during retraction Rotate the needle to investigate fibres in all directions Orienting the active electrode The SFEMG needle has a special holder and cable a dent on the hub of the holder is on the same side as the recording surface This makes it easier to orient the needle or to rotate it while optimising the signal recordings Connecting the stimulator Use an intramuscular monopolar needle as the cathode Place a surface electrode nearby to use as the anode Since the stimulation is near nerve set the stimulus intensity to the low range This is set via the Stim Setup dialog from the Stimulus menu choose Stim Setup 6 THE TESTS Press the STIM key on the front panel to begin stimulation Adjust the stimulus intensity and the intramuscular cathode position so that a faint twitch of the tested muscle can be seen You may wish to fix the stimulator with tape Acquire data Press the STIM button to begin stimulation
25. gt Trace arithmetic and also gt Trace area set up in chapter 5 6 THE TESTS You can use the full screen to examine and process your trace if you wish Select Full Trace Area ON from the Display menu Sorting results If responses have not been acquired in order distal to proximal select Sort from the Analysis Menu to automatically sort responses in order of ascending latency Note This facility will only be available if you have just one channel active All responses acquired for the current nerve study will be rearranged with the distal response placed first and the most proximal response last If segment distances have been entered and are no longer valid they will be erased and you will need to re enter them Reference Values may be deleted following a sort Results for the Sensory NCS test Results can be seen on screen immediately as you acquire data If columns on the table are not on view you can either scroll the table or click on results screen from the Display menu to see the Table and Graphs full screen Available results Sensory NCS You can display any 15 of the following results Peak Latency Total Area Take off Latency Distance Delta Peak Latency Temperature Delta take off Latency Recording Site Label Peak Amplitude Stimulus Intensity Peak to Peak Amplitude Stimulus Duration Peak Duration Take off Velocity Total Duration Peak Velocity ve peak Area Path Velocity ve peak Ar
26. in the User Set up dialog box The Change Password dialog box is displayed Complete the following fields Old Password Enter your current password New Password Enter a new password using a maximum of 14 characters The password is not displayed on screen Confirm New Retype your new password The Password password is not displayed on screen Click OK to save your changes and return to the User Set up dialog box Changing paths 1 Click the Paths button in the User Set up dialog box The Paths dialog box is displayed Click the Browse button next to the field showing the path you want to change A file dialog box is displayed from which you can select the path you want Alternatively you can edit the field directly using up to 255 characters Note You are strongly recommended to specify a local path for result data If you use a remote path and the network becomes unavailable for some reason your result data will be lost The default paths are Acquisition Results c synergy patients Acquisition Reports Path c synergy reports Archive Results m synergy archive patients Archive Reports Path m synergy archive reports Click OK to save your changes and return to the User Set up dialog box 4 CONFIGURING THE SYSTEM Defining a muscle list 1 Select Muscle Configuration from the System menu The User Muscle Selection dialog box is displayed 2 You can create your own User Muscle List Click one of the f
27. later in this chapter gt Results Table gt Result Mode gt Reference values gt Configuring the results table gt Sorting results Temperature probe 113 SYNERGY USER MANUAL Sympathetic Skin Response Test Running the Sympathetic Skin Response Test Select the test From the entry screen select the test you want from the appropriate folder Select a protocol From the Select protocol dialog box select the protocol that you want to use for this test Connect the electrodes The following stimulating electrodes are recommended Large bipolar stimulating electrodes 16893T Digital ring electrodes 16639T Acquire the data Turn on the amplifier and observe the monitor trace at the lower right of the screen to ensure that it is noise free If it is not check electrode connections and cables 1 Set the stimulus intensity and duration so that the subject can feel the stimulus this is usually guessed from the intensity levels used in earlier nerve conduction studies 2 Wait until the subject is relaxed and there is a stable baseline then stimulate and acquire the response by pressing the Acquire Single button on the PIU 3 Position the vertical cursor at the onset of the response by rotating the Fn button Note the latency which is displayed in the Vertical Cursors table To record the latency press the F7 function key 4 To record the response from another site press the Next button on the
28. open it See also gt Recompiling a report Opening a report in Microsoft Word 1 Run the Microsoft Word program 2 Open the report from the File menu Opening a report in MedPad 1 Click the Patient List button in the main Synergy screen to display a list of all the patients 2 Highlight the patient whose report you want to view 3 Click the Catalog button to display the patient s Test Catalog 4 Double click the Report Information folder for the appropriate visit date to open the patient s report in the MedPad application Editing and saving a report using MedPad A report is edited and saved using the standard functionality of Medpad which is a WordPad derivative To edit a table in MedPad double click on the table To add text click and type anywhere in the report To save your work select Save from the File menu or press CTRL S Note It is not possible to edit graphs and traces However these can be moved or deleted 43 SYNERGY USER MANUAL Customising the report layout A Report can be made up of some or all of the following components Header file This file typically contains a letterhead perhaps including a graphic For example the file may contain the name address and logo of a hospital Signature file This file typically contains the name and qualifications of the examining physician Patient Table This contains patient demographics and visit information retrieved
29. performed on the current patient Using Electronic Mail Select E Mail from the System menu to start the electronic mail program Getting support The manufacturers of the Synergy and the distributors provide a comprehensive after sales service support For details please contact the manufacturers or your local distributor 16 1 OVERVIEW OF THE SYSTEM Synergy Reader Software The optional Synergy Reader software allows you to analyse and review data and recompile reports away from the acquisition system This means that you can prepare reports in your own office using data acquired on a Synergy machine The Synergy Reader looks identical to the Synergy program used on an acquisition system However since the Synergy Reader does not have the dedicated electronics that are available on an acquisition system you cannot use it to stimulate or acquire data You may use the EMG LivePlay feature which means that your notebook is perfect as a demonstration tool in lectures conferences and classroom situations The Synergy Reader is usually connected to an acquisition system via a network This allows you to access data on other machines as if it were on the Synergy Reader system Note however that it is not possible to access data remotely on an acquisition system until that data has been saved so you cannot access information about the current patient until the visit is complete A special version of Synergy Reader softw
30. power plug 3 pin for the UK hospital grade for the USA and Canada Instruments supplied to other countries have a mains lead and connector but may not have a mains power plug APPENDICES The wires of the mains lead are colour coded as follows COLOUR CONNECTION l When a mains plug needs to be fitted ensure that the correct connections are made The protective earth wire green yellow must be connected to the protective earth conductor For instruments supplied to the UK and the to USA and Canada the protective earth connection is automatic when the appropriate and correctly wired socket is used When the mains plug is designed to hold a fuse fit the following Synergy Notebook 3A rated fuse Synergy Tower 7A rated fuse The mains lead and connector which is supplied with the instrument or a lead and connector of equivalent standard should be used with the instrument Do not use adaptor plugs or extension leads Synergy Notebook System Power Requirements For the Synergy power supply 035C005 Rated input voltage range Rated supply frequency 100 240 V 50 60 Hz No adjustment is required to connect to mains voltages within the rated range Max peak power consumption Approximately 70V A For power requirements of the Synergy Notebook refer to the PC user manual A 3 SYNERGY USER MANUAL SynergyTower PC System Power Requirements All parts of the Synergy Tower system must be powered from th
31. secesio co lasevcas needles ta desces 16 Getting SUpport access aachshish ei edi eai eo wise dens o E SEE RESE 16 Synergy Reader Software scccsssccssscssssccesssesssscssnsccecnncessacsessccsennceesees 17 Configuring the System ssssssssssssssesssesssessoesssosssosssoessoessoessoesssesssessse 18 The Patient Dat b se sssrini iesse 19 IAAI TI EEA E A E E E 20 Generating ReportsS esssssssesssesssosssoessosssoessoessosssoessoessoessoessoesssesssesese 21 2 Handling Patient Information ccsccccsssssssssscsssseeses 23 Entering and saving patient infOrmMation ccecsesssesssessssseeseseees 23 Entering and saving a new patient eeeeceeceeseeceeeceeeeceeeeeeneeceeeeeneeeeees 24 Entering and saving Visit details eee cseeeeeeeeeeeeeeeeeeeeeeceseenseenaes 25 Retrieving existing patient information sssssesessssessessessseseeesesseeeses 27 INTRODUCTION Recalling a patiente onirin e coaster esc R E A RE E 27 Deleting a patient sicvsics cil ei E i a lin eee eves 27 Transferring patient information between Synergy systems 28 Transferring patient data between host and satellite eee eee 28 Using Transfer to transfer patient data between systems cece 28 Using Copy to transfer patient data between systems 0 0 0 lees eeeeeeee 29 Completing the Transfer iiieoo ereis eoii enea erse eer S 30 Reviewing results and reports for an existing patient 100cec000 31 Recalling an
32. select the item that you want 4 Click on the OK button To remove an item from the Results Table 1 Click on Table Options from the Results menu 2 On the Table Configuration dialog box click on the right arrow beside the item you want to remove 3 From the Test List pop up click on Off at the top of the pop up list 6 THE TESTS 4 Click on the OK button To create a custom result for display on the Results Table 1 Click on Table Options from the Results menu 2 On the Table Configuration dialog box click on a right arrow beside a blank Description panel 3 From the Test List pop up click on the Custom button at the foot of the pop up list This will take you to the Custom result configuration dialog box 4 From the list select the Result type and the Unit you wish to use if a choice is offered 5 Select the From Marker and if applicable to the test you select the To Marker and Channel details 6 Click on the OK button 7 Your customised test appears on the Test Configuration dialog box Note that the label panel will be blank enter an appropriate label 8 Click on the OK button to add this custom result to the Results Table To change the result label You can change the result label for any result appearing on your Results Table 1 Click on Table Options from the Results menu 2 On the Table Configuration dialog box overwrite the existing label for any item with the text you want
33. square to the left of the traces Use the up and down arrow keys to select the other side for review Right half The right half of the display shows all four trials for the selected side in the left half of the display Trace analysis and display The default protocol assumes stimulation on the left side first then on the right side If you stimulated the right side first you need to change the labels manually as follows 1 Press the F5 function key to display the Results menu 2 Press S to select Change Site Label then click the mouse pointer on the labels and change them as necessary 3 Press Enter to return to the acquisition screen See also the following sections later in this chapter gt Selecting traces Moving traces Superimposing traces Manual marking of traces gt Changing trace sensitivity Changing trace duration gt Compare results gt Trace arithmetic and also Trace area set up in chapter 5 6 THE TESTS You can use the full screen to examine and process your trace if you wish Select Full Trace Area ON from the Display menu Results for Blink Reflex tests Results can be seen on screen immediately as you acquire data If columns on the table are not on view you can either scroll the table or click on results screen from the Display menu to see the Table and Graphs full screen Use the custom results set up to create the Blink Reflex results See also the following sections
34. them together for averaging To add traces l 2 3 Acquire the traces From the Analysis menu choose Add In the dialog box that is displayed specify the numbers of the traces to add together with signs between them Clicking on the arrow shows the available trace numbers and the sign The result of the trace addition is put into the next empty store 6 THE TESTS To subtract traces 1 Acquire the traces 2 From the Analysis menu choose Subtract 3 In the dialog box that is displayed specify the numbers of the traces to add together with signs between them Clicking on the arrow shows the available trace numbers and the sign 4 The result of the trace subtraction is put into the next empty store Split sensitivity Note this is applicable to F Wave and H Reflex only Split Sensitivity allows the Left and right hand sides of the trace area to be displayed at different sensitivities This allows both the M and the F responses to be seen Click on Split Sensitivity Set up on the Display menu to access the dialog box and select the appropriate set up parameter On OFF Split sensitivity Split position Using the full trace area To change to full screen layout select Full Trace Area ON from the Display menu To revert to normal screen layout select Full Trace Area OFF from the Display menu Trace area setup Use this dialog box to set up trace area parameters that you want to be glob
35. traces in your reports Define the structure of your report tables specifically for use in your reports Optionally indicate results that are outside reference ranges Enter comments in the report as you carry out the examination Configure custom headers and signature files for your reports Generate a Microsoft Word compatible report If you decide to modify the test results after you have finished the examination for example you may want to move an incorrectly placed marker or review and analyse traces and results you can recall the test data and recompile the report See also gt Obtaining a report online gt Recompiling a report Recalling a report Customising the report layout gt Printing a report 39 SYNERGY USER MANUAL Obtaining a report online Synergy enables you to compile a Word compatible report online whilst you carry out a patient examination The report is updated automatically when you select a new nerve new muscle or a new test The results are appended to the report in the following way Results from the same test are appended to the same results table in the report Results from a new test are appended to a new results table in the report You can also enter comments in the report during the examination You can enter comments either directly in the report or you can configure them using the Comments utility so that they appear in a report after the relevant res
36. 0 GET TECA 438 8322 WEB http www oxfordinstruments com Optional Features Oxford Instruments Medical Ltd reserves the right to change product specification without notice in line with our policy of constant product improvement EMG LivePlay and LongTrace are trademarks of Oxford Instruments Medical Ltd Microsoft Office and Windows are registered trademarks of Microsoft Corporation Intel Pentium is a registered trademark of INTEL Corporation C 3 APPENDICES Appendix D Assembling the Notebook Stand Assembly instructions Attach the PC tray assembly to the pole using 3 black countersunk screws supplied The PC tray can be attached so that the arm when mounted is positioned on either the left or right Arm to left Arm to right D 1 SYNERGY USER MANUAL Attach the metal plate and cable clips Turn the pole upside down and attach the plate for the power supplies and cable clips D 2 APPENDICES Attach the base to the pole using the large black bolt supplied Attach the pole to the base weights and optionally the printer tray If you are attaching the printer tray position it so that its rubber feet rest on the tops of two of the legs of the base The printer tray can be mounted at the front side or back of the stand When you have finished attaching these items turn the stand assembly upright again D 3 SYNERGY USER MANUAL D 4 Attach the arm to the pole Note Befo
37. 3 Displaying 2 csccssceieescescsvssssessveseees 149 Recalling cocc sce ccsccsees beehsetitasoe ess 33 SOLD gici sei 79 85 VICWING niesie s 33 Results available 79 85 90 94 100 106 Results information 0 cece 31 Results Table c ccccceeseseeeees 149 151 Retrieving patient information 27 Reviewing results for a patient 31 Safety cies Resists tesa Ee RE E ion ix Saving patient information 23 Search cancelling eee eres 34 Searching for patient information 34 Selecting a notch filter setting 49 Selecting a protocol 0 eee 73 Selecting a trace 0 ee eeeeeeeeeeees 142 Selecting an online report 39 Selecting the test eee eeeeeeeeeee 73 Sensitivity settings setup 63 Sensitivity SWitCh oe eee eeeeneee 10 Sensory NCS test eeeeeeeeeee 81 Setting UP a NEW USEL ee eee 50 SPI testis seine tii Sele ais 124 SPI tests sas vais 124 135 138 Signature file 0 eee eee eee eee 42 Selecting and defining 44 Single Fibre Jitter test ee 124 DOLKEY So sscccenad ha es ete 15 Sorting results eee eee eres 79 85 Sources of artefact eee reer xii Specifications App C ee eeeeeeeee 1 Stim Duration sWitch ee 10 Stim Intensity switch ee 10 Stim SWitCH oe cee cecteeceeeeeeeeeees 10 Stimulators App A eseese 22 SUPPOrtiescperiene atisentovtesveemmnseemeveroeneds 16 Sweep Duration switch ee 10 Switching o
38. 601 1 and CAN CSA22 2 No 601 1 is maintained when patient connected equipment or accessories not supplied by Oxford Instruments Medical Ltd are used with Oxford Instruments Medical Ltd equipment If any mains powered equipment for example printers video monitors or other medical equipment is to be connected to Synergy to form a medical electrical system then the requirements of standard EN60601 1 1 Medical Electrical Equipment Part 1 General requirements for safety Section 1 1 Collateral standard Safety requirements for medical electrical systems must be complied with to ensure patient and operator safety is maintained There are no user serviceable parts inside the instrument Only appropriately trained and qualified personnel should adjust maintain or repair the instrument when it is connected to the electricity supply The instrument must be disconnected from the electricity supply first before any cover is removed Responsibility of the manufacturer Oxford Instruments Medical Ltd and our distributors consider themselves responsible for the effects on safety reliability and performance of the equipment only if assembly operations extensions readjustments modifications or repairs are carried out by persons authorised by them the electrical installation of the relevant room complies with the appropriate requirements the equipment is used in accordance with the instructions for use Full compliance of this product c
39. AND WARNINGS ON THE USE OF STIMULATORS BEFORE CONNECTING ENSURE THAT MAINS VOLTAGES AND FUSE RATINGS ARE CORRECT THE PATIENT INTERFACE UNIT MUST ONLY BE POWERED FROM THE SYNERGY POWER SUPPLY 035C005 1 OVERVIEW OF THE SYSTEM 1 Overview of the system The System and its parts Synergy Notebook and Synergy Tower are 2 channel electromyographs which provide facilities for EMG testing for a range of clinical applications Synergy Suite is a 2 channel electromyograph which provides facilities for EMG testing for a range of clinical applications This system comprises a single Patient Interface Unit with both a Tower PC and a Notebook PC The PIU may be used with either PC for acquiring raw patient data Network cards are fitted to both the Tower PC and the Notebook PC and a cable supplied to allow direct transfer of patient data between them Synergy is designed to enable reliable recording display and documentation of electrophysiological information from the human nervous and muscular system in a clinical environment The Synergy Notebook comprises the following main items Multimedia Notebook PC Patient Interface Unit with integral 2 channel amplifier and electrical stimulator Power supply module medical grade Footswitch Desk mount for PIU Optional items for Notebook include Deluxe Stimulator Probe Temperature probe Arm and Stand Arm and Clamp Printer External loudspeakers Netwo
40. DICES Electrical stimulating electrodes Electrical stimulators must be used only by appropriately medically trained and qualified personnel Electrodes must never be positioned so that electrical current flows across the heart trans thoracic stimulation i e never apply a positive electrode to one limb and a negative electrode to any other limb Keep the positive and negative stimulating electrode sites in close proximity When stimulating for long periods there may be a risk of damage to tissue under the stimulating electrodes due to the dc component in the stimulator output Surface electrodes must make good electrical contact with the skin surface WARNING Connection of a patient to high frequency electrosurgical equipment and to Synergy simultaneously may result in burns at the sites of stimulating and recording electrodes Damage may also occur to the electrical stimulator and amplifiers however Synergy includes protection components to reduce the risk of this happening WARNING Operation of Synergy in close proximity for example metre to shortwave or microwave therapy equipment may produce instability in the electrical stimulator output NOTE Current densities for any electrodes exceeding 2mA r m s cm may require the special attention of the operator Note Electrical stimulating electrodes supplied by the manufacturer can operate at the maximum output of the Synergy A 21 SYNERGY USER MANUAL Electrical
41. Fn button to position the cursor at the onset of the largest amplitude H response Note the latency value which is displayed in the Vertical Cursors table Record the minimum H latency in the result table by pressing the Fn button Autocompare If you have already performed this test on the opposite side press the F9 function key to display results from both sides so that you can compare them When you have finished press F9 again to return to the normal display Trace analysis and display Traces may be selected for marking or trace analysis Synergy offers comprehensive and powerful ways of configuring the trace area See the following sections later in this chapter gt Selecting traces Moving traces Superimposing traces Automatic marker placement Manual marking of traces gt Split sensitivity gt Changing trace sensitivity gt Changing trace duration Compare results gt Trace arithmetic and also 95 SYNERGY USER MANUAL 96 gt Trace area set up in chapter 5 You can use the full screen to examine and process your trace if you wish Select Full Trace Area ON from the Display menu Results for H Reflex tests Results can be seen on screen immediately as you acquire data If columns on the table are not on view you can either scroll the table or click on results screen from the Display menu to see the Table and Graphs full screen Available results H Reflex You can display an
42. Fn button to select the R1 cursor displayed in red Rotate the Fn button to position the cursor at the onset of R1 if R1 is not expected position the R1 cursor at the extreme left of the display the latencies are displayed in the Vertical Cursors table Press the F7 function key to record the latencies in the results table Press the Fn button to select the R2 cursor position the cursor at the onset of R2 and record the latencies in the results table as for R1 Press the down arrow key until a trace from the second channel set is selected highlighted in yellow then position the R1 and R2 cursors and record the latencies as for the first channel set Set up Synergy to record from the other side by pressing the Next button on the PIU This clears the trace area Repeat the stimulation process as described above Review If you want to review the trials from both sides press the F10 function key to select the complex 1 display mode 111 SYNERGY USER MANUAL 112 In complex 1 display mode the display is split in half To move from one half to the other press the F11 function key To return to the default display press the F9 function key Left half The left half of the display shows four traces The top two represent the last trial for the first side used in stimulation The bottom two represent the last trial for the second side used in stimulation The selected side is highlighted by a yellow
43. G a tepoitiopceneinnen a S 43 Opening a report in Microsoft Word essseessesseseseseeeseseeersreersserrresesrrsresre 43 Opening a report in MedPad seseeseseeeseseeesesesereseseesresresrrseeereserrrssesrenresee 43 Editing and saving a report using MedPad use ee ee eeseeseceecnseeneeeeeeene 43 Customising the report layout ccsessesscesscesceeeccesecesaceseseeeseeeceees 44 Selecting and defining a header file 0 ee eeeeeeeceseceseeesecsseenaeenee 45 Selecting and defining a signature file 20 0 ee eee eeeceeecneeesecnseenseeaee 46 Defining the report sequence and inserting page breaks ceeeeeeeeeeeee 47 Defining Test Report setih S netsen nea n a N 47 Printing a report cccssesccssscarsscectstesssessesasascusasese ca chevaseestacee sack esebsecaacesda att 48 4 Configuring the System ccsscccsssscsssscssscscssscssssssssees 49 System configuration ssccccssecessceessncesnccesaceessscsenaccscanceesssesssscseaceees 49 Defining the host and satellite ccccscccsssccssscssssccecssccssscssscsensccesaees 50 Defining asystent as a NOSt sernpre eneee e eian is 50 SYNERGY USER MANUAL Defining a system as a Satellite 0 eee eee cee eneeeeeeeeeeeeeeeeeeeeeeeeereeseensees 50 Configuring an E mail program 0 ec eeeeeceseceeeceeeeeeeeeeeeeeeeeeseeeeennees 51 Selecting a Notch Filter Setting seeessseeesseeesesseesssreessserrrsrerrssrrrrnserersresreee 51 Configuring Patient Demographics
44. If necessary adjust the following until you see APs from a single or more muscle fibres The position of the stimulator cathode Stimulus intensity SFEMG needle position When the signals are suitable for analysis press the Acquire ON key or the footswitch to begin acquisition To suspend and resume signal acquisition press the Acquire ON key To delete all traces acquired during the current recording press the Erase key To return to a state where you can acquire a new set of data press the Next key or the middle footswitch To analyse the data later for example after the patient has left press the Next key or the middle footswitch to save the traces to the hard disk You can then acquire another set of traces Note At the threshold of a muscle s stimulation there may appear to be high jitter even in normal muscle fibres Therefore if you see jitter you should increase the stimulus intensity to ensure that the abnormalities of jitter are not artefact caused by inadequate stimulation Analyse data When the system reaches the Cascade sweep limit it automatically stops acquisition and automatically analyses the data If you stop acquisition manually before the sweep limit is reached press the Analyse key to make Synergy analyse the data The top portion of the trace area shows all acquired sweeps superimposed on each other A window called SFJ Window2 is displayed as a horizontal bar over th
45. MedelecSynergy Multimedia EMG Notebook Tower and Suite User Manual 035W001B Vs8 0 OXFORD IH STRUMENTS Oxford Instruments Medical Ltd Manor Way Old Woking Surrey GU22 9J U UK Tel 44 0 1483 770331 Fax 44 0 1483 727193 E Mail sales msd oxinst co uk ww w oxford instruments com Copyright All rights reserved This manual contains proprietary information which is protected by copyright and may not be copied in whole or in part except with the prior written permission of Oxford Instruments Medical Ltd The copyright and the foregoing restrictions on the copyright use extend to all media in which this information may be preserved This copy of the User Manual shall be used only in accordance with the conditions of sale of Oxford Instruments M edical Ltd or its distributors Oxford Instruments Medical Ltd makes no representations or warranties of any kind whatsoever with respect to this document Oxford Instruments Medical Ltd disclaims all liabilities for loss or damage arising out of the possession sale or use of this document Medelec and TECA are registered trademarks of Oxford Instruments Medical Ltd in the UK and other countries This product complies with the provisions of the Medical Device Directive 93 42 EEC FRANCE Oxford Instruments SARL Domaine Technologique de Saclay Batiment Ariane 4 rue Ren Razel 91892 SACLAY Cedex Tel 33 1 69 85 25 00 Fax 33 1 69 85 25 09 E Mail oxfor
46. ON scceesceceeeeeenceceteceeneeceeeeeneeceteeeeneeens xi SOUTCES OF artefacto srei rriei e rRe Eo ie E EEEE Tr A xii Symbols and their definition sscccsssccssscssrssccesssccsscssssccscnsccesnees xiii Tnformato neen e oee ar eA E ie EEE E SE E E EE EEAS xiii Connections ee n n e EA i A NEE EEEE EEEE E Sai XV SWITCHES a etken oee eneore r suctupdevuveveensea Una uvesocnectunteadnsecasnessdestadtes xvii Warming SYMBOLS ys esere eneee eee deus endo rena pae EEEE SEENE EEE SHE RERE REIS xvii 1 Overview of the system e sscesscoessocssecesoosscosssoesssccesocesoosssee L The System And its Parts c sccssccssssssssessesssesssscesscesscesscesseesecsseeesneesees 1 Components of the Synergy Notebook ssseessseesseeeesssessesrrsreerrsrrrrserrsererrssen 4 Components of the Synergy TOWer sseesseeeeseerseissesrreresreersserrrssrsreerrsrenrssen 6 Components of the Synergy Suite eee cee cee cseeceeeesecnsecseecseeeseeeneeees 8 The Patientnterface Unit onee eieiei REER i iKa eE EOSS 9 FOOLS Wite De eneee e n e a EE AANE 11 Deluxe Stimulator Probe preine aia i iia 12 ORITA A A PE ETOS ETER AES A AA 14 Logging onto the system ceeeesseceeeeeeseeceeeeeesceceeeeesaeceeneecaeceeeeeeaeeeenes 14 Components of the GUI esesssesseeessseressssesresresteerrsrerrsserrrsestrnresrenreseeerssee 15 Opening and closing folders eee ee ceeceseceecesecesecseecaeeeaseeeeeneenseenaes 16 Using Electronic Mail isseire censonis
47. Oxford Instruments approved printer Oxford Instruments approved monitor Mouse Microphone signal Audio output Keyboard SVGA signal to monitor Oxford Instruments approved Tower PC Isolated mains outlets ISO 800 Isolation Transformer Internal stimulator output connectors Amplifier input connectors IEC socket to local mains connector 3 core 16AWG Suitable cable to connect isolation transformer to other non medical equipment Suitable cable to connect isolation transformer to Notebook PC power supply Suitable cable connecting local mains connector to input of isolation transformer IEC plug to IEC socket connects isolated mains Network direct connection CATS shielded STP patch cable crossover type with RJ45 connectors Alternative printer connection Network card PCMCIA Ethernet Media coupler for network APPENDICES Switching on Warning Switch ON before connecting patient electrodes Caution All peripheral equipment including the preamplifier and any external printer or keyboard must be connected to the Synergy before the Synergy is switched ON Identify the plug on the mains lead which fits the connector on the instrument and push it firmly into its socket on the rear panel Then connect the mains power plug to the mains electricity supply and switch ON at the mains power plug The mains power ON OFF switch for the instrument is a rocker switch sited to the lower left hand side of the front of the unit
48. S other devices such as the trigger and averager etc By analysing multiple MUPs one is less likely to record from the same motor unit twice The time required to acquire and analyze 20 different MUPs is also reduced to just a few minutes The MMA algorithm is ideally suited to perform quantitative analysis in a fast and efficient manner In the routine EMG examination it can be used to quickly capture examples of abnormal MUPs i e the outliers A printout from this test will supplement the subjective assessment and make it more objective Technique EMG signals are recorded at minimal force of contraction using a monopolar or a concentric needle electrode By default a ten second epoch containing discharges of 3 4 motor units MU is analysed The MU activity is identified based on a rapid change of voltage i e short rise time and or high amplitude The discharges of individual MUs are identified and used to extract the motor unit potential MUP Each MUP is quantified by measuring features such as amplitude duration phases turns area amplitude ratio and firing rate The stability of the MUPs can also be indicated as YES or NO The duration phase and turns measurements can be changed manually The area and area amplitude ratio are automatically recomputed when the duration markers are changed The mean values of the MUP features and the percentage of polyphasic MUPs are tabulated The mean values are also computed for the s
49. SER MANUAL 124 Analyse the data Analysis of a 10 second epoch requires a few seconds Up to 6 MUPs may be extracted For each MUP the system displays the averaged signal superimposed on the individual MUP discharges This makes it easy to assess the validity of the automated decomposition Above the MUP the amplitude duration phases and turns are listed The beginning and end of the MUP are indicated by the markers The discharge pattern is shown in the bottom right corner The horizontal bar represents the duration of epoch Each vertical tick mark represents one discharge of the MUP The result table shows the measurements from individual MUPs and also the summary statistics You may review these results as described in the Review of current analysis section or press the Next button function key for the next acquisition All results can be reviewed and corrected post acquisition Review of current analysis 1 Use the sensitivity and sweep duration controls to change these settings Change the marker positions if necessary The phases turns and stability settings can be changed by clicking in to these fields in the result table 2 The Edit Screen To edit and review click on the MUP Press the Edit MUP function key The averaged MUP and the individual discharges are shown Review the discharges using the scroll bar and or Page up down keys Use the Superimpose function key to assess the validity of the decomposition and to
50. Tables and also to set the Reference Values Reference Values For each relevant result in each test reference values may be entered For each result the reference values will be defined using the following equations Upper Limit Constant Age Factor Patient Age Reference Age Height Factor Patient Height Reference Height Distance Factor Distance Reference Distance Temperature Factor Temperature Reference Temperature n s d Lower Limit Constant Age Factor Patient Age Reference Age Height Factor Patient Height Reference Height Distance Factor Distance Reference Distance Temperature Factor Temperature Reference Temperature n s d 5 CONFIGURING PROTOCOLS You can use a Constant value by setting all other values to zero Alternatively it is possible to correct reference values for age height distance and temperature by entering the appropriate correction factor Channel Mapping and Trace Depth set up Simple area You can set the number of traces displayed on screen when any of the simple trace types is displayed Complex areas For each area you can define the number of traces displayed Also if you are acquiring from more than one channel you can define which sub area displays traces from each channel 71 6 THE TESTS 6 The tests Using the tests You can run the following tests using Synergy Notebook Synergy Tower or Synergy Suite Motor NCS S
51. Test ssessseeesseeeeseerssreeseseees 114 Interference Pattern Analysis TeSt cccssccssssssssscesssccesscsessscssnscceses 115 Clinical OVErViEW vrenr irn cat sidered lan towe a E 115 Running the Interference Pattern Analysis test scesceeeseeceeeeseceenees 117 Multi MUP Analysis TeSt sscccssccssssecssscssssscssnccesccessscsssaccscnsceeses 120 Clinical Oyeryje Wpro e AE EE EEE E REE E 120 Running the Multi MUP Analysis Test sseeeeeeeseeesesreerrsrerreserrreresrees 122 Single Fibre Jitter Test cccssccssscsssssccsssscsssscssssccsssccesssesssscssncceseees 126 Clinical OVervie w e a aar fave cvastagasotes akan L E svasts Ea 126 Running the SFJ Test Volitional eee eeceeeeeeeseeceeeceeneeceeeeeeneeceeeeeeeens 126 Running the SFJ Test Stimulated 2 0 eee eeeeesseceseeeeneeceeeeeeneeceeeeeenaeees 131 Fibre Density Analysis TeSt csscccsssccesssssssscssssccecsscessscssssscscnsceees 137 Clinical Overview moetie neeaae cape ocak take eee E uh a a ses ob aae eae 137 Running the Fibre Density Analysis Test essseesseeeessereeeesrsresrrreerrsreees 137 Macro EMG Testaeieeneiiiieiarerene eaii 140 Clinical OVErVie Weneh EE E EE E S 140 Running the Macro EMG Test seeeeseeesseeeessererresrsrreresreerrererresreseerrsseeees 140 Trace analysis and display ccscccsscesscesscessssssssecssnscessceescseesseeseees 144 SELECTING traces onne ee eeaeee ea i SEIE EAEI R E ES SS 144 Moving traces
52. a test icon to display the protocol s available with that test Ifa folder icon is selected buttons available allow you to create a new folder Ifa test icon is selected buttons available allow you to create a new protocol for the selected test Ifa protocol icon is selected buttons available allow you to create a new protocol or to edit an existing protocol 63 SYNERGY USER MANUAL 64 Editing an existing protocol 1 From the Test Configuration dialog box select the icon for the protocol you want to modify Click on the Edit Protocol button and then click on the Next button in the Protocol Configuration Wizard welcome dialog box The Wizard takes you to the Acquisition Set up dialog box where you can modify the settings See Acquisition set up below Then click on the Next button The Wizard takes you to the Electrical Stimulator Set up dialog box where you can modify these settings See Electrical Stimulator set up below Then click on the Next button The Wizard takes to the Protocol Table dialog box where you can modify these settings and also enter the Reference Values that you want to be used with this protocol See Protocol Table set up below The Wizard takes you to the Channel Mapping and Trace Depth dialog box where you can define how traces are displayed in simple and complex areas See Channel Mapping and Trace Depth set up below Click on the Next button to exit from t
53. al for the test 1 2 Select the required Default Trace Type from the list Check the Trace Area Grid On checkbox to display a grid on your trace areas Select either the Full or Edge radio button to modify the appearance of your grid 149 SYNERGY USER MANUAL 4 Check the Indicate Amplifier Off checkbox to display a label to remind you when the amplifier is switched off See also Trace area set up in chapter 5 150 6 THE TESTS Configuring and displaying results Synergy offers you considerable flexibility in configuring and displaying the results of your test Results can be seen on screen immediately as you acquire data If columns on the table are not on view you can either scroll the table or click on Results screen from the Display menu to see the Table and Graphs screen in full Results Table The Results Table displays results on screen for the current nerve muscle You may set up the Results Table to display only those parameters you wish to include Note Displaying Extra Results If you have selected to include more results than can fit on the screen these can be displayed using the scroll bars or by clicking on Results Screen from the Display menu to display the full Results Screen Result Mode The results in a table may be displayed in a number of formats determined by the Result Mode The Result Mode may be altered by the user from the Results menu item or by using the Results Ta
54. alResults 3 Select a data source then click on the Configure button This shows the currently configured path by default this points to the local system 4 Inthe Database section click on the Select button and in the dialog set the path to the shared database Setting up configuration information 1 From the System menu choose System Configuration 2 In the Local Configuration Path enter the name of the shared drive or global UNC of the drive that holds configuration information Note Since the configuration path is system wide a warning is displayed changing the configuration path on this machine changes it for all networked machines Thus a UNC is better than the name of a shared drive since it means the same on all machines Changing the local configuration path changes all database entries from this point on It does not change any data that has already been saved if such data exists you need to set up machines to be able to see it Setting up users to share data Reports and patients are saved on a per user basis Therefore you need to ensure that all users on the system are set up correctly to share data 1 Login as a user with administrator access rights 2 From the System menu choose Setup User 59 SYNERGY USER MANUAL 3 Select a user from the list and click on the Edit User button 4 From the screen that is displayed click on the Paths button 5 On the screen that is displayed modif
55. an one muscle is selected it is not possible to acquire data You can select a muscle by double clicking on its name in the muscle selection window Connect the electrodes Use an SFEMG needle as the active recording electrode The active recording surface is located in a side port on the opposite side to the bevel 126 6 THE TESTS The cannula acts as a reference electrode and is automatically connected to the pre amplifier by the cable Place the ground electrode close to the tested muscle Inserting the needle The SFEMG electrode has a very small uptake area so locating a pair of action potentials APs from the same motor unit MU can be difficult Furthermore a slight movement of the needle can significantly reduce the AP amplitude This makes it difficult to maintain a stable trigger The following technique helps to reduce problems 1 Insert the needle at an angle of between 20 and 30 to the surface of the skin instead of nearly perpendicular as performed in concentric or monopolar needle EMG studies When the needle moves the angular insertion produces far less displacement in a radial direction giving more stable AP amplitudes 2 Insert the needle all the way to the hub and then retract it partially The muscle tends to grab the needle and holds it better in one place during retraction Rotate the needle to investigate fibres in all directions Orienting the active electrode The SFEMG
56. and press the ADD key 2 Select the side and then press the Acquire button Any data you store and any findings you report in the EMG summary table will be associated with this muscle Notes If you do not wish to annotate which muscle you are recording from you can turn off this selection window by selecting Don t Display Muscle List from Test Options in the Display menu If you select more than one muscle you can report findings for more than one muscle at the same time This saves time especially if all the findings are normal However if more than one muscle is selected it is not possible to acquire data You can select a muscle by double clicking on its name in the muscle selection window 131 SYNERGY USER MANUAL 132 Connect the electrodes and stimulator Connecting the stimulator Use an SFEMG needle as the active recording electrode The active recording surface is located in a side port on the opposite side to the bevel The cannula acts as a reference electrode and is automatically connected to the pre amplifier by the cable Place the ground electrode close to the tested muscle Inserting the needle The SFEMG electrode has a very small uptake area so locating a pair of action potentials APs from the same motor unit MU can be difficult Furthermore a slight movement of the needle can significantly reduce the AP amplitude This makes it difficult to maintain a stable trigger The
57. annot be ensured unless all components leads etc are provided by Oxford Instruments Medical Limited INTRODUCTION Disposal of equipment When the equipment comes to the end of its operating life it should be disposed of in accordance with local waste disposal regulations Advice on this can usually be obtained from the local waste regulation authority which is typically to be found within the local government office Electrical interference suppression These notes are intended as a guide to the location and suppression of electrical interference This may affect apparatus involving the detection and analysis of signals of a few microvolts in the frequency range DC to 20kHz such as for Electroencephalographs EEG or Electromyographs EMG and Evoked Potential EP Recording Systems 1 50Hz 60Hz magnetic field from power transformers induction motors etc The only practical protection from this type of interference is the avoidance of loops in the pick up circuits of the EEG or EMG EP since the magnitude of the interfering voltages is directly proportional to the area enclosed by any such loop 2 Magnetic field from staff location systems using inductive loops This type of interference is of an intermittent character and may be serious where the inductive loop runs alongside the wall of the examination room and where the transmitted frequencies fall within the pass band of the EEG or EMG EP Most modern staff location sy
58. are starts up automatically if when you start up your Notebook or Tower the PIU is not connected This may be only used to review the tests that are licensed on the system If a fully licensed version of Reader software has been purchased this may be opened from the Notebook desktop screen This will give you the full facilities of Reader software If you do not have a network connection it is still possible to use the Save and Load from File options to exchange data via floppy disk or other transportable medium You Save to File data from the acquisition system and then Load from File onto the Synergy Reader system See Also gt Exporting and importing patient and report data in chapter 2 gt Transferring patient information between Synergy systems in chapter 2 gt Configuring Synergy on a Network in chapter 4 17 SYNERGY USER MANUAL Configuring the System A key feature of Synergy is its high degree of configurability This enables you to configure many settings to suit your own requirements Settings can be configured at a system level or at user level System settings apply to a whole system or to a number of systems across a network User level settings can be either global settings that affect a user s set up or settings that apply to a particular test User level settings are invoked when a user logs onto Synergy All configuration options are accessed from the System menu depending on your level of acce
59. ay any 15 of the following results Peak Latency Total Area Take off Latency Distance Delta Peak Latency Temperature Delta take off Latency Recording Site Label Peak Amplitude Stimulus Intensity Peak to Peak Amplitude Stimulus Duration Peak Duration Take off Velocity Total Duration Peak Velocity ve peak Area Path Velocity ve peak Area Click on Result Options from the Results menu to select the results that you want Units Used 81 SYNERGY USER MANUAL 82 The units used to display absolute results are fixed as follows Result All Latency results All Amplitude results Duration All Area types Velocity Distance Temperature Graphs Up to two graphs can be displayed on the test screen Up to six graphs can be displayed in the full screen RESULTS view You can display any six of the following Graphs bar type or Y vs X plots Peak Latency Take off Latency Peak Amplitude Peak to Peak Amplitude Peak Velocity Take off Velocity Peak Latency v Distance Take off Latency v Distance Peak Amplitude v Distance Peak to Peak Amplitude v Distance Peak Velocity v Distance Take off Velocity v Distance Click on Graph Options from the Results menu to select the results that you want See also the following sections later in this chapter gt Results Table gt Result Mode gt Reference values gt Configuring the results table Temperature probe 6 THE TESTS Sensory NCS Test Clinical Overview
60. ayed 4 Complete the following fields User Name This field is mandatory Enter a logon name for the user using a maximum of 52 4 CONFIGURING THE SYSTEM 14 characters Full Name Enter the user s full name using a maximum of 40 characters This is the name that will be used for display and report purposes Clinic Name Enter the name of the user s clinic using a maximum of 40 characters Password Enter a password for the user using a maximum of 14 characters Note The password is not displayed on screen Confirm Re type the user s password Password Note The password is not displayed on screen Access Level Select an access level for the user from the drop down list box 5 Select the Temperature Scale either Celsius or Fahrenheit 6 Select the Height Format either Metric or Imperial 7 To change the user s default paths for storing results and paths or to define the user s muscle list click one of the following options and follow the instructions Changing Paths Defining a Muscle List 8 When you have completed all the fields click OK to save your changes and close the dialog box gt Changing paths gt Defining a muscle list Editing a user s set up 1 Logon as Administrator 2 Select Set up User from the System menu in the main Synergy screen The User Manager screen is displayed showing all the known users 3 Highlight the user whose set up you want to change and click the Edit Use
61. ayed choose Include all or Exclude all To accept the calculations and move on to the next recording press the Next key or the middle footswitch If you move a window or change between rising and falling edge the system automatically recalculates these values Blockings generated by mis triggers are automatically discarded Results are shown numerically in the result table at the right hand side of the display Overriding automatic results By default the jitter value is set to the lower of the MCD or MSD values To use the other value press the F5 key If the algorithm finds blocking the number of blocks is indicated If you believe these are technical artefacts you can 6 THE TESTS exclude them by pressing the Block F4 key The number of blocks is replaced by the symbol and the number of discharges analysed changes To restore the number of blocks press the Block F4 key again To reject the current pair press the Delete F9 key The entries in the result table are indicated by Press the F9 key again to re accept the results To delete all pairs acquired during the current recording press the Erase key Running the SFJ Test Stimulated Select the test From the Test Manager on the right of the entry screen select the test you want from the appropriate folder Select a muscle On entering the test a muscle selection window is displayed 1 Select the muscle you are about to record from
62. be impaired the instrument should be made inoperable and secured against unintended use Remove the equipment from the packing case s and check with the parts list that all ordered items have been received Assembly instructions for accessories may be found in their packing cases It is suggested that these instructions are filed with this manual Check for signs of damage due to unfavourable conditions during transit or storage If any damage is found do not use the instrument contact your distributor Environment The instrument is designed to operate within the following ranges Temperature 10 C to 35 C Relative humidity 20 to 80 non condensing A 1 SYNERGY USER MANUAL Atmospheric pressure 700mB to 1060mB When in store or during transport the following ranges are tolerated Temperature 20 C to 50 C Relative humidity 10 to 80 Atmospheric pressure 500mB to 1060mB Do not obstruct the cooling slots Position the instrument so that air flows freely from the cooling slots Power supply connections A 2 Warning There are no user serviceable parts inside the instrument Only appropriately trained and qualified personnel should adjust maintain or repair the instrument The instrument must be disconnected from the electricity supply first before any cover is removed Power connections Instruments supplied to the United Kingdom and to the USA and Canada have a mains lead connector and mains
63. ble Pop Up Menu The following Result Modes are provided Absolute The absolute values of each result are displayed in the table Z score The Results are converted to z scores and displayed The display of Z scores will require the relevant reference values to have been entered Results are expressed as a number of Standard deviations from the reference mean value Difference This Mode can only be selectable when more than one Site has been recorded in Site based tests or when more than one Run has been recorded Using a second level menu from the Result Mode pop up you will be able to select one Site or Run as the base the Site or Run to which all others are referred Site 1 or Run 1 will be the 151 SYNERGY USER MANUAL default The sub menu contains a list of the available Sites or Runs The base Site or Run is displayed as Standard absolute values all other Results are expressed as the difference from this base Selection of the base is performed via the Results Table pop up selecting Difference or Percent Difference causes a child menu containing a list of Sites or Runs 1 is selected by default to be displayed Percent Difference Identical to Difference other than that the results are expressed as a percentage of the base Reference Values 152 For each relevant result in each test reference values may be entered For each result the reference values will be defined using
64. box select the protocol that you want to use for this test 89 SYNERGY USER MANUAL Connect the electrodes Ulnar Nerve Recording electrode Large bipolar stimulator Wraparound ground electrode Usage 1 The active recording electrode is placed over the end plate zone of a muscle innervated by the tested nerve 2 The reference electrode is placed nearby in an electrically quiet area 3 The ground electrode is usually placed between the stimulating and recording electrodes 4 Using electrolytic gel between the skin and recording electrode improves the electrical contact and reduces noise 5 When recording from a deep muscle one may use a concentric or monopolar needle for recording Note The stimulation sites are the same as in Motor NCS Usually the F Wave recordings are by stimulation at the distal site only using one of the following Large bipolar stimulating electrode 16893T Deluxe Stimulator Probe 031K025 One may reverse the polarity of the stimulator pins i e the anode of stimulator is closer to the active recording electrode to prevent anodal block 90 6 THE TESTS Acquire the data Turn on the amplifier and observe the monitor trace at the lower right of the screen to ensure it is noise free If it is not check electrode connections and cables The monitor trace also allows you to assess whether the patient is relaxed 1 Position the Stimulator at the appropriate si
65. caecesecaeecaeseseseeeeeeeeesseeesees 62 Protocol Configuration WiZdrd cccsscccsssssssscssssccssnsccescssssaccesnceess 63 Entering the Protocol Configuration Wizard eee eeeeeeeceseceseenseenees 63 Editing an existing protocol ressesie egs pei ee a 64 Creating a new protocol sccoscsissecusessceessestes saonastsesin ce ve sp oire oe EE EEES 64 ACQUISILION Set UP iriiri eser srr reee EE EEE E eepo EE EEE nET ET aE 65 Electrical Stimulator Set up sseesseeeeseeeserseeesssesrteserreestesresrerrnserrsreersse 69 Protocol Table set up sie sc sssecssasses sagessab resteren e esei ospe Erea ee eT iTr asi 70 Channel Mapping and Trace Depth set uUp eeeesseeeesserresssrsererrsrrerrsrrerseene 71 The test 73 6 The tests cass cccsccesincteccescceccusedccesvesasaccasbescsececseneseSeaccasvocncesesseas Using th LOSES sass dccSececdsetees vate sconacesatesesdeedeeaes sueasudecs savsegcusbtaveeedeeacdsoss 73 The typical test procedure ee eeececeeeceeseeceseeeenceceeeseneeceeeeeeneecereeeneeennees 74 SClOCH NG NE TSE a ae sa okies che be easa bgt aa iieiea 75 Selecting d protocols cisccenccncdivaeccvsseed cosceateatecacesceosdondendecneasebacensesuncuse 75 Moto NES Test e eeaeee s iat eaaa E eeaeee Eae eR Ees IS 76 Clinical OVerViEW Iior na ERETTA A ROEA 76 Running the Motor NCS tESt srasni inn aae 76 Sensory NOS TOSt wcsscececcsstessnnssvedccsvsressnovsvssercvutesdenvevececevstecsnnvevesonss sets 83 Clinical OVErViEW sccsiv
66. cording from you can turn off this selection window by selecting Don t Display Muscle List from Test Options in the Display menu Ifyou select more than one muscle you can report findings for more than one muscle at the same time This saves time especially if all the findings are normal However if more than one muscle is selected it is not possible to acquire data You can select a muscle by double clicking on its name in the muscle selection window Connect the electrodes Use an SFEMG needle as the active recording electrode The active recording surface is located in a side port on the opposite side to the bevel 137 SYNERGY USER MANUAL 138 The cannula acts as a reference electrode and is automatically connected to the pre amplifier by the cable Place the ground electrode close to the tested muscle Inserting the needle The SFEMG electrode has a very small uptake area so locating a pair of action potentials APs from the same motor unit MU can be difficult Furthermore a slight movement of the needle can significantly reduce the AP amplitude This makes it difficult to maintain a stable trigger The following technique helps to reduce problems 1 Insert the needle at an angle of between 20 and 30 to the surface of the skin instead of nearly perpendicular as performed in concentric or monopolar needle EMG studies When the needle moves the angular insertion produces far less displacemen
67. cted using the same interface Acquire the data 1 Adjust the needle position to record sharp and crisp signals 2 Instruct the subject to exert the desired force of contraction and maintain it 117 SYNERGY USER MANUAL 3 Press the Acquire key The system will acquire 5 sweeps i e 500 msec epoch 4 Acquisition will stop automatically and analysis initiated Analyse the data The analysis time depends upon the measurements and graphs used for display If only the TA Equip analysis is selected the results are available instantaneously Computation of the FFT takes slightly longer Plotting a 3D plot of spectrum is more time consuming and may require several seconds The numerical data is shown in the result table Itis also shown graphically on the plots FFT Rel Power v Freq kHz do 01 1 5 Editing the data Ifthe results are unsatisfactory delete the current results by pressing the Erase key on the front panel or by pressing the Delete Site function key You may press the Next key to advance to the next site However this is not necessary When acquisition starts the system automatically does this task for you For more data go back to the Acquire the Data step above Reviewing the results 1 Press the Results function key to see the summary table This will display all measurements configured for the test some of which may not displayed in acquisition screen Press
68. ctrical shock Type BF For degree of protection against harmful ingress of liquid Ordinary no protection For the mode of operation Continuous For the degree of safety of application in the presence of a flammable anaesthetic mixture with air or with oxygen or nitrous oxide Not suitable Synergy also complies with UL2601 1 the American standard for safety for medical electrical equipment CAN CSA22 2 No 601 1 the Canadian standard for safety for medical electrical equipment EN60601 1 1 the European standard for safety for medical electrical systems EN 60601 1 2 the European standard for electromagnetic compatibility requirements for medical electrical equipment EN60601 2 40 the European standard specifying particular safety requirements for electromyographs and evoked response equipment Synergy bears the CE Mark to show compliance with the European Medical Device Directive 93 42 EEC Synergy is designed and manufactured under approved Quality Management Systems EN 29001 ISO 9001 1994 Quality System Standard SYNERGY USER MANUAL EN 46001 1994 Quality System Standard application to manufacture medical devices Caution and warnings 1 U S Federal law restricts this device to sale by or on the order of a physician or other licensed practitioner It should be noted that it is the responsibility of the user to ensure that conformance to the Type BF patient isolation requirements of EN60601 1 UL2
69. d A specific Stim Set up Rep Rate may be set up The Stim Set up Rep Rate is set up in the Electrical Stim Set up dialog Select Stim Options from this dialog to change these settings Rep Stim Mode Having established the appropriate stimulation level select the REPSTIM mode of operation This erases all traces and results on the screen The system is now ready to acquire a train of up to 20 responses The Train Length number of responses acquired can be set to between 2 and 20 in the Electrical Stim Set up dialog box accessed via the Stimulus menu The Rep Rate used is set up in the Electrical Stim Set up dialog box accessed via the Stimulus menu Pressing Acquire begins stimulation and Acquisition Traces are automatically marked during acquisition When the Train Length limit has been reached Acquire is turned off automatically Results are updated based on the sweeps used for Decrement Response The first sweep is shown in a specific colour colourl The Decrement sweeps used for result calculations are also seen in a different colour Other sweep colours are standard Pressing Next allows you to acquire another train It is possible to set an automatic sequence for this test This is setup in the Rep Stim Table dialog found in Change Train Label under the Results menu Enter the Pause period which should follow each run 6 THE TESTS ast sin ae To set acquisition into an auto
70. d instruments wanadoo fr GERM ANY Oxford Instruments Medical GmbH Otto von Guericke Ring 10 65205 Wiesbaden Postfach 4509 D 65035 Wiesbaden Tel 49 0 6122 937 0 Fax 49 0 6122 937 100 E Mail msd sales oxford de NETHERLANDS Oxford Instruments Medical NV Avelingen West 1 4202 MS Gorinchem Tel 31 0 183 692111 Fax 31 0 183 6 92119 E Mail sales nl oxinst be ITALY Oxford Instruments Medical Spa Via Leone Tolstoi 86 20098 San Giuliano Milanese Milano Tel 39 0 2 982 531 Fax 39 0 2 982 41407 E Mail sloxinst tin it SPAIN Oxford Instruments Medical SA Avda Mata Pin nera 2 28700 San Sebastian de los Reyes Madrid Tel 34 91 653 8198 8387 8398 Fax 34 91 654 6794 E Mail oxfordsales arrakis es BELGIUM Oxford Instruments Medical NV Molenberglei 21 B 2627 Schelle Tel 32 0 3 880 82 80 Fax 32 0 3 844 78 42 E Mail sales be oxinst be TECASynergy Multimedia EMG Notebook Tower and Suite User Manual 035W001B Vs8 0 OXFORD IH STRUMMER TS Oxford Instruments Medical Inc 12 Skyline Drive Hawthorne New York 10532 2133 USA Tel 1 914 593 7100 1 800 438 8322 Fax 1914 593 7290 E Mail sale_msd idsi net www oxford instruments com Copyright Oxford Instruments Medical Ltd Manor Way Old Woking Surrey GU22 9JU UK Tel 44 0 1483 770331 Fax 44 0 1483 727193 E Mail sales msd oxinst co uk All rights reserved This manual contains proprietary informa
71. dge Equipotential earth terminal Isolating transformer Next store Acquire Double arrow head continuous Acquire Single arrow head momentary Acquire Erase stores Direct current dc Alternating current ac Risk of explosion do not use in the presence of inflammable anaesthetics Stimulus duration increase decrease Rotate clockwise to increase Connections 2 nn E EF INTRODUCTION The Type BF symbol is placed adjacent to connectors used for Type BF floating patient applied parts Input Output External printer interface Footswitch External keyboard Mouse Patient ground Stimulus Probe Universal Serial Bus Communications Port XV SYNERGY USER MANUAL Temperature Probe External Monitor oO xvi Switches O INTRODUCTION OFF Mains supply ON Mains supply Amplifier OFF Amplifier ON Warning Symbols The symbol Z with a letter adjacent to it is used to refer to one of the specific warnings listed below These symbols will not appear on your unit if the warning is written in full in your own language EEE E CAUTION TO REDUCE THE RISK OF ELECTRIC SHOCK DO NOT REMOVE COVER REFER SERVICING TO QUALIFIED SERVICE PERSONNEL BEFORE CONNECTING REFER TO SYNERGY USER MANUAL CAUTION DO NOT OBSTRUCT COOLING VENTS NO USER SERVICEABLE PARTS INSIDE xvii SYNERGY USER MANUAL xviii EEE REFER TO CAUTIONS
72. displayed Click the Configure button The Suite Configuration dialog box is displayed 50 4 CONFIGURING THE SYSTEM Suite Configuration 21x Suite Function C Host Satellite Add UNC Paths for Satellite Synergy Applications WTower_p1 c Program Files Medelec Synerqy Delete Cancel 3 Select Satellite and then click the Add button to add the network path name for the host system that it is to be connected to 4 Click OK and then tick the Use as part of a Suite check box Configuring an E mail program 1 Logon as Administrator 2 Select System Configuration from the System menu The System Configuration dialog box is displayed 3 To change the default E mail program c windows winpopup exe either type the new path and program directly in the E mail Program field or click the Browse button to display the Select E mail program to launch screen Select the program you want and double click on it to load it 4 Click OK to save your changes and close the System Configuration dialog box Selecting a Notch Filter Setting 1 Logon as Administrator 2 Select System Configuration from the System menu The System Configuration dialog box is displayed 3 To select a Notch Filter Setting click on either the 50Hz or 60Hz button 51 SYNERGY USER MANUAL 4 Click OK to save your changes and close the System Configuration dialog box Configuring Patient Demographics 1 Logon as Admi
73. displays the histograms of fibre density and macro amplitude and a plot of area vs amplitude You can enter a comment to summarise your findings The numerical data and graphs are automatically transferred to the report along with any comments Notes Ifthe MUP is very small in amplitude the automatic marking algorithm may fail Use the marker tool bar to place the markers manually marker 1 should be used to mark the beginning of the MUP and marker 2 used to mark the end Itis possible to record the same macro MUP by using two different triggering potentials If you suspect that a macro MUP is repeated you can delete it by selecting it and pressing the Erase key This allows you to initiate a new acquisition using the same store Switching the display mode to stores displays the macro MUPSs in groups of ten 143 SYNERGY USER MANUAL Trace analysis and display Traces may be selected for marking or trace analysis You can do the following Select a trace Move a trace Superimpose traces Use automatic marker placement Mark traces manually Change the trace sensitivity and duration Compare test results on screen manually or automatically except for Needle EMG or F Wave tests Use trace arithmetic to add up to 10 traces together or to subtract them except for Needle EMG or F Wave tests You can use the full screen to examine and process your trace if you wish select Full Trace Area ON from
74. e file name to save it under By default the file includes patient demographics visits and test results You also have the option to include reports or LivePlay data since they take up a lot of disk space they may be too large to fit on a floppy disk However you should include them if you intend to import the patient s data back on to this machine at a later date see the Tips below If you have the WinZip utility installed and configured on your system then you have the option of compressing the file before it is saved so that the file takes up less disk space The WinZip path must be setup in Machine Configuration under the system menu If you have WinZip installed the Compress output file option is available if WinZip is not installed the option is greyed out If you choose to compress a file you should save it with the file extension zip Note You cannot Save to File the patient you are currently working on until all the data has been saved Choose New Patient before trying to Save to File the current patient s data Saving patient information always includes the patient demographics visits and test results It is not possible to Save partial information such as a single visit If you intend to import a patient s data back on to this machine at a later date you must include all data that you want to retain This is because importing data onto a system overwrites the data on the system with the data that is imported
75. e outlets of the ISO800 Mains Isolating Transformer Before switching on the system check the following The ISO800 is marked with the correct input voltage for your local mains supply The ISO800 is factory set to either 230V input 230V output or 115Vinput 115V output The input voltages of the PC Tower the monitor and the optional printer are all set to match the output voltage of the ISO800 Isolating Transformer Refer to the rating labels and user manuals of this equipment to check if adjustment is necessary and for information on how to carry out any required adjustments Rated input voltages 115V 230V Rated supply frequency 50 60Hz Maximum peak power consumption 840VA The ISO800 Isolating Transformer has fuses in both Line and Neutral connections These two fuses F3 and F4 are situated in the mains inlet module These must have the values shown below Supply Voltage F3 and F4 115V TIOA L 250V 230V T6 3A L 250V A 4 APPENDICES Synergy Notebook System Connections For key to item numbers used below please refer to page 18 SR A J VU Multiple portable socket outlets must not be used Refer to notebook PC user manual to determine the position of the input output connectors The Patient Interface Unit PIU must only be powered from the Synergy Power Supply 035C005 The PIU must not be connected to any other power supply Note that on
76. e position of SFJ Window so that it is over the new APs The system recalculates the results using the new window positions and displays them as a new line in the results table Up to 8 computations can be performed from a single recording 6 THE TESTS Sorting traces by firing rate To display the traces sorted by firing rate right click on the screen and from the popup choose Sort traces The traces are displayed in increasing order of firing rate and the sequential IPI plot is replaced by a plot of IPI versus IDI Results The system automatically computes the mean inter potential interval MIPI mean consecutive difference MCD mean sorted difference MSD and the number of blocked potentials and displays the values in the results table The jitter is set equal to the lower of the MCD or MSD values Viewing results The sweeps used in computing the results are shown superimposed in the lower half of the trace display window The IPI data and traces are colour coded to represent the following conditions Colour Condition White Sweeps used for calculations of jitter Red Sweeps with blocks Blue Sweeps with IPI outside the limits defined by cursors The sequential IPI plot is shown under the result table with the vertical scale of this plot set so that the MIPI value is approximately at the centre A yellow band is displayed on this plot which represents 3 standard deviations from the MIPI IPI values within the
77. e soii iise 1 Components of the GUI ee 15 Components of the Synergy Suite 8 Components of the Synergy Tower 6 Configuring and displaying results 149 Configuring protocols eee 59 Configuring tests 0 00 eee 20 Configuring the network s s s 56 Configuring the protocols 61 Configuring the Results Table 151 Configuring the system uo 47 Configuring the System 18 Connecting the electrodes Blink reflex test 0 eee 108 Fibre Density Analysis test 135 F Wave test cece eeeeeeeeeeeeenees 88 H Reflex test n se 92 Macro EMG test n se 139 Motor NCS test 75 Needle EMG test eee 96 Repetitive Nerve Stim test 103 SPU testetan n ap 124 130 Connecting the equipment App A 7 Creating a new protocol s s s 62 Custom result eee eeeeeeeeeee 152 Custom Tables eee eceeeeeeeeeees 46 Customising the report layout 42 Database siseses eceso 19 Defining a muscle list ee 55 Defining host and satellite 48 Defining the report sequence 45 Deleting a patient ee ceeeeeseeeeeeees 27 Deleting a USET 52 Deleting results eee eee eeeeeees 33 Disposal of equipment ceeeeeeeeeee xi Editing a protocol eeeseeeseeereeesees 62 Editing a user s Setup eee 51 Editing and saving a report 41 Electrical interference suppression xi Index 1 SYNERGY USER MANUAL Electrical stimulating elec
78. e sweeps in this area When 133 SYNERGY USER MANUAL 134 the EMG signal crosses the window an AP is detected and is used for computing the inter potential interval IPI The IPI is measured with respect to the onset of the sweep The occurrence of AP can be detected from its rising edge or the falling edge By default the rising edge is used to change to the falling edge from the menu bar select Analysis then SFJ Window Setup Jfa signal crosses the window at more than one point its first crossing is used to compute the IPI Traces are colour coded to represent the following conditions Colour Condition White Sweeps used for calculations of jitter Red Sweeps with blocks Blue Sweeps with IPI outside the limits defined by cursors Moving and resizing SFJ Window2 You can move the window using either the mouse or the arrow keys on the keyboard Using the mouse click in the horizontal part of the bar and drag the window to its new position On the keyboard use the Up Down Left and Right arrow keys to move the window to its new position You can resize the window using the mouse Click on one of the vertical ends and drag to resize Multiple pairs from the same recording When recording the data for a stimulated SFJ test it is possible to record two or more time locked APs In this case you can analyse the additional combinations of APs 1 Press the New Pair F2 key 2 Adjust th
79. e will be associated with this muscle Note If you do not wish to annotate which muscle you are recording from you can turn off this selection window by selecting Don t Display Muscle List from Test Options in the Display menu 97 SYNERGY USER MANUAL 98 If you select more than one muscle you can report findings for more than one muscle at the same time This saves time especially if all the findings are normal However if more than one muscle is selected it is not possible to acquire data Connect the electrodes Gastrocnemius Usage The needle is inserted in the tested muscle preferably away from the end plate zone For a monopolar needle the reference electrode is placed in an electrically quiet area The ground electrode is also placed in the vicinity of the tested muscle Acquire the data Turn on the amplifier and observe the monitor trace at the lower right of the screen to ensure that it is noise free If it is not check electrode connections and cables 1 Change the sensitivity and sweep duration as necessary 2 Press the Fn button on the PIU to turn on the amplitude trigger Rotate the Fn button to adjust the amplitude level 3 Select a display format by pressing the relevant function key Monitor gives a free running full screen EMG display Complex 1 shows the monitor signal on the left of the screen and the rastered signal on the right This display format is useful for assessing moto
80. ea Click on Result Options from the Results menu to select the results that you want 87 SYNERGY USER MANUAL 88 Units Used The units used to display absolute results are fixed as follows Result All Latency results All Amplitude results Duration All Area types Velocity Distance Graphs Up to two graphs can be displayed on the test screen Up to six graphs can be displayed in the full screen RESULTS view You can display any five of the following Graphs Peak Latency Take off Latency Peak Amplitude Peak to Peak Amplitude Peak Velocity Take off Velocity Peak Latency v Distance Take off Latency v Distance Peak Amplitude v Distance Peak to Peak Amplitude v Distance Peak Velocity v Distance Take off Velocity v Distance Click on Graph Options from the Results menu to select the results that you want See also the following sections later in this chapter gt Results Table gt Result Mode gt Reference values Configuring the results table 6 THE TESTS F Wave Test Clinical Overview The purpose of the F Wave Test is 1 To investigate the conduction in proximal nerve segments that are not assessed by the nerve conduction study 2 To assess excitability of motor neurons 3 To assess loss of motor axons Running the F Wave test Select the test From the entry screen select the test you want from the appropriate folder Select a protocol From the Select protocol dialog
81. ecssceeeeecsseeeeneees 144 Marker toolbar 00 eee eeeeeeeeeeees 144 MedPad cniinn aina 39 46 Menu Bat 00 eee eee cee irienn 15 Motor NCS Test 74 MOVING a trace oe eeeeeeeeeeees 143 Multi MUP Analysis test 118 Muscle configuration 0 0 eee ee 55 Muscle list definition cccceeeee 55 Index 2 Needle EMG testo eee eeeeeeeneee 95 Network configuration 0 0 cee 56 NeXt SWitCh oo eee cece eeteceseenseeneee 10 Notch filter setting eee 49 Obtaining a report online 38 On line configuration 0 0 0 59 Online report oe eee eeeeeeteeeees 39 Online reporting ee eee eee 38 Opening a repOrt eee eee eeteeeeee 41 Opening and closing folders 16 Opening the Test Catalog 31 Overview of the system eee 1 Page breaks 0 0 eee eeeeeeeeeeeseeeeeeees 45 Parts of the SysteM eeeeesceeneeeseeeeeee 1 Password Changing esanaren e 54 Paths Chanting ieser nnen 54 Patient Deleting details ceeeeeseceeeeees 27 Entering and saving details 24 Recalling risene eena 27 31 Reviewing results and reports 31 transferring data between systems 28 Patient data CXPOLUN Dinna R 35 Patient Database eee eee eteeeeee 19 Patient demographics Configuring seosest isre 50 Patient details sise spiiiiisains 23 Searching ON s sssscsicisiessissis 34 Patient information eee eee eee 23 Eterm gessits irsin 23 Retri vihe eregine
82. ed For key to item numbers used below please refer to page 18 13 If the other Class I non medical equipment has an earth leakage current of greater than 500uA greater than 300UA in the United States at 110 of the highest rated supply voltage it must be powered from a suitable mains isolation transformer with a floating secondary winding to reduce the earth leakage current below 500uA 300uA in the United States Multiple portable socket outlets must not be used Refer to PC Tower user manual to determine the position of the input output connectors a The Patient Interface Unit PIU must only be powered from the Synergy Power Supply 035C005 The PIU must not be connected to any other power supply e Separate fixed mains socket outlets must be used SYNERGY USER MANUAL Key to Numbers used on the System Connection Drawings and on Examples A to E ODANANDNBRWNK Patient Interface Unit PIU Synergy power supply Notebook PC Notebook PC power supply Junction box Wall of room Separate fixed mains socket outlets Mains inlet DC power to PIU USB cable To PC USB port DC power to Notebook PC Other non medical equipment Class I protectively earthed Signal cable To appropriate PC connector Isolation transformer Isolated mains Other non medical equipment Class II double insulated Y junction mains cable Deluxe Stimulator Probe optional Footswitch optional Signal to printer
83. ed in Synergy Then the manual is structured in chapters as follows Chapter 1 Overview of the system illustrates and describes the Synergy and its parts explains briefly how basically to use the system outlines the basic features of the system Chapter 2 Handling patient information describes how to enter save and retrieve patient details review patient results and reports and search for patient information and how to transfer patient information between the Synergy systems Chapter 3 Generating reports describes how to obtain reports on line recall reports and print them and customising the report layout Chapter 4 Configuring the system describes how to configure such elements as database paths user set up and muscle lists Some information in this chapter is for administrators only Chapter 5 Configuring protocols describes how to configure on line and how to use the Protocol Configuration Wizard Chapter 6 The tests describes all the tests in detail and how to run them selecting and marking traces configuring and displaying results The Appendices cover installation and maintenance of the system interface connections and full technical specification of the system INTRODUCTION Safety and symbols Safety considerations Synergy complies with EN 60601 1 the European standard for safety for medical electrical equipment For type of protection against electrical shock Class 1 For degree of protection against ele
84. eescesstedeneivvecteds E a A E E Y 83 Running the Sensory NCS test eesseseseeeseeeseseeerrsrerrrsrrrresesrrsrrsrenresreerrse 83 INTRODUCTION F Wave Test 0 03 issi8ice sade setsve soni sa ievnsuaacesevh ca cached sotessedssnssescotaedseeunedetes 89 Clinical OVERVIEW isarog eer er aE E EEEE EEEE ENES 89 Running the F Wave test cece ceecseseseeeeeeeeeesecesecesecsecssecsaecnaecnaesneeees 89 THAR e flex Test ooiaseccisccsceuck teases Sackedacidivacse Soskssavsh a tabaevenssesediawnicsereeeees 94 ChittiGal Overview aiicsiccecnc ives ceccoters eean e e EEE EEEE 94 Running the H Reflex test cece ceeeeeeeeeeeeeeeeeesecnsecaecaecseseaeeeeeees 94 Needle EMG TOS civeieiuctatecedcictiscessanbics scale vlaleasenstipiicasa rena aaneueieiens 97 Clinical OVErvieW reiese a E E sazeceotevsdepensua ue sevenivpseactooneenys 97 Running the Needle EMG test eeeecesecesecesecssecsecseecneeeseseneeeeeeed 97 Repetitive Nerve Stimulation Test c csscccssscssssccesssccssscssssscssnncceess 104 Clinical OVervie W noen e E bovekestanton E 104 Running the Repetitive Nerve Stim test esssesseessereesseesererrsreeresreresreees 104 Blink Reflex Testrit nasia eseist re iosi saiae not 110 ChinicaltOverview Aa e ede E a E E e SA 110 Running the Blink Reflex test ssesesseessseeesseesesesesesrsresrrsrerresesreeeresenees 110 Sympathetic Skin Response Test cssscesscssscsssssssssssssssssssssesceeeses 114 Running the Sympathetic Skin Response
85. en eee e nEn e a E ea OSa eet 145 Superimposing traces 2 505555 see5 seca esd esses p ee EEE soes ea TOE ES ioe ea I Eise 145 Automatic marker placement sssesseeeseseseseeesesreerssrerrssertrsrerresesresresreness 145 Manual marking of traces ccc ssccesisissssosessseesgeessescesscetecgetenasesessenssenssodsess 146 Change trace Sensitivity soisccccesseckesistsvesos taseesgeessesaet Sea Eses p te S EEES 147 Change trace Curation ss scis c cscs soene ditsvs cose diteescetvsesoes seckacdstesasceedseess EEES 147 COMP are is E EEEE 147 SYNERGY USER MANUAL vi Tracearithmetic sieni nn ha ets RS te as Rs 148 Split Sensitivity sects he Sheth A ea adhe Se isl ie ae 149 Using the full trace area eee ee iess ee re eeter eor eppes Sk 149 Trace area SCtUp niies nn lhe Se ee hs Rei aS eo heed ees 149 Configuring and displaying results cssccssscesscesscesscessssessceeesees 151 Results Be To AEA S E Ea E E E eae 151 Result Mode meoir a aE E E R A E R ies 151 Reference Valte Sneinen re arses rE Tee Ee E rE E SE EEE E Torn TES E 152 Configuring the Results Table ee eeceseceeecreeceeeeeeeeeeeeeeeeeeeeeees 153 Setting UP CUSTOM FeSUIts oo eee eee irer itr esre ri TE E EE 155 Temperature Proberen eioan soasscevssuates Ee rE PEES ar EE Esra TE EE ESS 156 Displaying the full Results Screen seessesesesseesereresreerrseeesssrrrrsrerrrsrerreee 156 Appendix A Installation amp Maintenance scccccssseseee L Ins
86. ensory NCS F Wave H Reflex Needle EMG Repetitive Nerve Stimulation Blink Reflex Sympathetic Skin Response Optionally the following tests are available under special licence EMG analysis software Interference Pattern Multi MUP and FFT Single Fibre Jitter tests Single Fibre Jitter Fibre Density Analysis and Macro EMG See the individual test descriptions below for details that are specific to that test Each description gives Clinical overview of the test Outline of how to run the test Description of placing the electrodes Description of acquiring the data Notes on trace analysis and display Details of results that can be obtained 73 SYNERGY USER MANUAL General information that is common to all the tests is given first in the following sections The typical test procedure The typical procedure for using the tests is as follows Some procedures are common to all tests but note that others are either different or not used at all in some tests 1 Select the test see Selecting the test From the entry screen select the test you want from the appropriate folder 2 Select a protocol see Selecting a protocol From the Select protocol dialog box select the protocol that you want to use for this test Not used for EMG tests 3 Connect the electrodes see Connecting the electrodes Attach the electrodes as described for the individual tests 4 Acquire the data Data is acqui
87. er of data between systems 1 OVERVIEW OF THE SYSTEM The Patient Interface Unit The Patient Interface Unit PIU provides single control operation for setting essential parameters during a patient examination There may be one or two PIUs depending on the Synergy system combination being used Socket for Deluxe Socket for Stimulator Probe B Footswitch Sensitivity g Volume ww gt Fn Sweep Duration Next A Erase Stim fe Stim Duration TECAs Acquire ON WMergy Acquire Single Stim Intensity On Off switch List of controls Acquire ON switch Press this switch to set acquire ON Press it again to set Acquire OFF Acquire Single switch Press once to deliver a stimulus and acquire a response If you hold down this switch for more than 1 second Acquisition is locked on Press again to stop Acquisition Erase switch Press this switch to erase the selected trace or traces This enables you to collect a fresh set of data in the same SYNERGY USER MANUAL 10 Fn Next switch Sensitivity switch Stim switch Stim Duration switch Stim Intensity switch Sweep Duration switch Volume switch switch Trigger Rising Falling Edge store Programmable via the Display menu to control Marker Trigger or Cursor Press this switch to move to the next site in NCS and EMG tests Rotate this switch to adjust the display sensitivity of the selected trace or traces If n
88. er use an existing signature file that has been created using WordPad and saved with a rtf extension or you can define a simple signature file Click one of the following options and follow the steps Use an existing signature file Define a signature file Note You can only make changes using Report Set up when there is no report currently active Use an existing signature file 1 2 3 Click the Browse button Using the drive and directory folders navigate to the file you want to use and click on Open Note The file must have been created using WordPad and must have a rtf extension If you have graphics in your file check that they are inserted using Insert Picture not Insert Object otherwise they will not be visible in MedPad Click OK Define a signature file wR wo Click the Define button Enter the text for the signature using a maximum of 5 lines Position the text using the Right Left or Centre buttons Click Save In File name type the name of the signature file Save it as type RTF and either use the default path C Synergy Reports Signats or choose a folder in which to save it Click Save Click OK 3 GENERATING REPORTS Defining the report sequence and inserting page breaks 1 2 Select Report Set up from the System menu Click the Sequence tab in the Report Set up dialog box A list of icons each of which represents a report component appears Use the scroll bar to
89. erimposed on each other Two windows called SFJ Window and SFJ Window2 are displayed as horizontal bars over the sweeps in this area When the EMG signal crosses a window an AP is detected and is used for computing the inter potential interval IPI The occurrence of AP can be detected from its rising edge or the falling edge By default the rising edge is used to change to the falling edge from the menu bar select Analysis then SFJ Window Setup Ifa signal crosses a window at more than one point its first crossing is used to compute the IPI Traces are colour coded to represent the following conditions Colour Condition White Sweeps used for calculations of jitter Red Sweeps with blocks Blue Sweeps with IPI outside the limits defined by cursors By default SFJ Window is centred at the trigger point of the trace and has a duration of 500 us SFJ Window begins 500 us later and has a duration of 4 ms It is set at 50 amplitude level of the trigger point These settings may need adjustment depending on the configuration of the signal Moving and resizing SFJ Windowl and SFJ Window2 You can move either window using either the mouse or the arrow keys on the keyboard 6 THE TESTS To move a window using the mouse click in the horizontal part of the bar and drag the window to its new position To move the active window using the keyboard use the Up Down Left and Right arrow keys to move the window to i
90. et outlets must not be used Refer to Notebook PC user manual to determine the position of the input output connectors x The Patient Interface Unit PIU must only be powered from the Synergy Power Supply 035C005 The PIU must not be connected to any other power supply e Separate fixed mains socket outlets must be used APPENDICES Example D Synergy Tower System Connections To Other Non Medical Equipment of Class I Protectively Earthed With Earth Leakage Current Of Less Than 500UA For key to item numbers used below please refer to page 18 To permit the direct connection of Class I non medical equipment to the Synergy Tower system the Class I non medical equipment must have an earth leakage current of less than 500uA 300uA in the United States at 110 of the highest rated supply voltage Refer to Example E for connection of Class I non medical equipment which exceeds the above earth leakage current figures Multiple portable socket outlets must not be used SYNERGY USER MANUAL Refer to PC Tower user manual to determine the position of the input output connectors The Patient Interface Unit PIU must only be powered from the Synergy Power Supply 035C005 The PIU must not be connected to any other power supply Separate fixed mains socket outlets must be used APPENDICES Example E Synergy Tower System Connections To Other Non Medical Equipment of Class I Protectively Earth
91. f the current application The Menu Bar The Menu Bar is displayed across the top of the screen directly below the Title Bar It provides access to all of Synergy s functionality depending on the screen that is displayed Each Menu Bar title provides access to a drop down list of menu items These items are accessed using either the mouse or keyboard in the standard Windows way Keyboard shortcuts for menu items are displayed alongside the menu items where available The Function Key Bar The Function Key Bar appears at the bottom of the Test screen It contains ten softkeys F1 to F10 for tasks or parameters that you need to access or adjust quickly These can be activated using the mouse or keyboard function keys F1 to F10 The Toolbar The Toolbar appears under the Menu Bar and contains icons for frequently used commands The name of each Toolbar icon is displayed by pointing to an icon with the mouse To open an icon click on it with the mouse SYNERGY USER MANUAL Opening and closing folders The Test Navigator and Test History screens contain folders that you can use to recall a test or test result In Test Navigator clicking on a folder takes you to the test The Test Navigator on screen window displays and allows you to select all the tests in the currently selected folder In Test History clicking on a folder displays the result of the test The Test History on screen window displays all the tests that have been
92. ff the system App A 19 Switching on the system App A 19 SYMBOLS irera ix XiV Sympathetic Skin Response test 112 SYMELBY enai S ERE E ESA 1 Synergy Reader software 17 SYMELELY SUE ann eens 8 Synergy TOWE nnie 6 Synergy SiNg reisini 14 System configuration eee 47 System OVELVIEW ee eeeeeeesecesecseeeneeeeee 1 Technical specifications App C 1 Temperature probe ee 5 6 154 Test Navigator Test History screens 16 Test Catalogs 31 40 Test Menu screen 23 Test Report settings 0 0 eee 45 Test Report Settings 0 eee 42 TESTS c 1ccr setae cia ess eRe eee 20 71 Blink reflex siiis sscescetseseseee ce 108 Fibre Density Analysis 0 00 135 FW ave aan a es oinneiis 87 H Retlex ecin nianna 92 Interference Pattern Analysis 113 Macro EMG eee cece eseeeeeees 138 Motor NCS 000 eee eeeeeeeeeeeeeeneees 74 Multi MUP Analysis 118 Needle EMG w eee cee eeeeeee 95 Repetitive Nerve Stimulation 102 Selecting ns ied ieehences 73 Sensory NCS oo eeeeeeeeseenees 81 SEJ aes a E E 124 Index 3 SYNERGY USER MANUAL Single Fibre Jitter ee 124 Sympathetic skin response 112 Typical procedure ceeeeeeeeeseeeee 72 USNS shar cee eee 71 The tests arcsin e 71 Title Bats esnie o ninni 15 Toolbars vescusg innen e 15 Trace analysis and display 142 Trace arithmetic eee cere 146 Trace du
93. from the Patient Database Result Tables Graphs Waveforms Comments Text entered into a report either directly or via the Comment utility This enables you to configure your comments and have them placed automatically after the relevant results table in a report The first two components are defined using the Report Set up utility This enables you to retrieve existing header and signature files for use in your reports or define new ones You can also define the sequence of the components within your report including the results sequence Results from the same test are appended to the same result table Tables of results from different tests of the same Test Type are grouped together The order in which these are placed is defined in Report Set up You can also specify where you want page breaks Nerve protocols are reported in the order they are defined in the protocol list for each Test This may be modified using the Test Configuration dialog from the System menu Finally you can select to generate reports online Once you have defined a report layout it can be used for all your reports The remaining components are test specific and settings for these are accessed via Test Report Settings in the Results menu See also gt Configuring patient demographics chapter 4 Adding comments gt Selecting an online report 44 3 GENERATING REPORTS Selecting and defining a header file l 2 3 Select Report Se
94. g a maximum of 3 characters Address 1 to Enter the patient s address using a Address 4 maximum of 25 characters in each line Phone Enter the patient s telephone number using a maximum of 50 characters Sex Select either Male or Female from the drop down list box Height Enter the patient s height in the format shown in the field using a maximum of 20 characters You should enter a patient s height if you intend using height 2 HANDLING PATIENT INFORMATION correction for your Reference Values Note Height format is defined under the option User Set up in the System menu Weight Enter the patient s weight in kilograms Kg in the field using a maximum of 20 characters Date of Birth Enter the patient s date of birth in the format shown in the field You should enter a patient s date of birth if you intend using age correction for any of your Reference Values User 1 to These fields may be defined to meet local User 4 requirements using the System Configuration option in the System menu Notes Enter any additional notes about the patient 4 Now either click the Save button or select Save Patient in the File menu to save the patient or proceed to the Test Navigator Note It is not mandatory to enter any patient information to perform a test However you must enter a Family Name and Patient ID if you intend saving patient information You can proceed to the Test Menu without saving patient informati
95. g of traces gt Split sensitivity gt Changing trace sensitivity Changing trace duration and also Trace area set up in chapter 5 You can use the full screen to examine and process your trace if you wish Select Full Trace Area ON from the Display menu Results for F Wave tests Results can be seen on screen immediately as you acquire data If columns on the table are not on view you can either scroll the table or click on results screen from the Display menu to see the Table and Graphs full screen Available results F Wave You can display any of the following results F Latency F Velocity F M Latency F Ratio F Amplitude A Latency F M Amplitude Distance M Latency Temperature M Amplitude Patient Height F Click on Result Options from the Results menu to select the results that you want Units Used The units used to display results are fixed as follows Result All Latency results All Amplitude results F Temperature F Velocity F Ratio Distance Patient Height 6 THE TESTS See also the following sections later in this chapter gt Results Table gt Reference values Configuring the results table gt Temperature probe 93 SYNERGY USER MANUAL H Reflex Test Clinical Overview The purpose of the H Reflex Test is to investigate conduction in the proximal segments of the tibial nerve Running the H Reflex test Select the test From the entry screen select the te
96. gTrace The duration is a multiplication factor of the sweep duration For example with a sweep duration of 100 ms and a LongTrace factor of 100 10 seconds of data are displayed on the screen 99 SYNERGY USER MANUAL 100 Using LongTrace With LongTrace set acquire data as normal When you stop acquiring data two traces are displayed with a review bar between them The top trace is the long compressed trace The bottom trace is an uncompressed portion of the long trace as defined by the review bar The review bar defines a section of the LongTrace to display in the bottom trace You can move the review bar under any part of the LongTrace display and can vary its length so that the bottom trace displays the portion of the trace you are interested in To move the review bar click in its centre and drag it to the new position To change the length of the review bar click on either end and drag LivePlay mode LivePlay is included as standard LivePlay allows you to replay up to 20 s of EMG data with Audio Re played data can be re analysed e g re triggered etc If LivePlay is set to ON in the Acquisition Set up dialog box under Options the last 20 seconds of acquired data is held in a buffer allowing it to be replayed with Audio re analysed or saved to disk When LivePlay is selected the system goes into LivePlay mode The system starts playing the signal in the 20 s buffer starting at 0
97. gle Result entry to delete a single result or a Visit Date and Time entry to delete all results for that visit in the Test Catalog 2 Click Delete Result in the File menu You are prompted to confirm the deletion 34 2 HANDLING PATIENT INFORMATION Searching for patient information You can use the Search utility to search for a single existing patient using criteria such as Family Name or Patient ID Searching on patient details 1 Click the Search button in the Synergy screen to display the Search Criteria dialog box 2 Edit the fields in the dialog box to specify your search criteria Use the vertical scroll bar to scroll down the fields 3 Click the Search button below the dialog box to activate the search 4 The Patient List is updated with the patient s that match the search criteria The number is shown in the Patients Found field Clearing the Search Criteria dialog box Click the Clear button below the Search Criteria dialog box to clear the search fields Cancelling a search Click the Cancel button below the Search Criteria dialog box to cancel a search 35 SYNERGY USER MANUAL Saving and loading patient and report data to file Saving patient and report data to file 1 From the Patient List select one or more patients whose data you want to Save to File 2 From the File menu choose Save Patient to File 3 Specify where you want to save the data the type of data you want to save and th
98. h the associated full name can be However a user with Administrator access can change the password See also gt Defining the host and satellite gt Configuring an E mail program gt Selecting a Notch Filter setting gt Configuring Patient Demographics gt Setting up a new user gt Editing a user s set up gt Deleting a user 49 SYNERGY USER MANUAL Defining the host and satellite In the Synergy Suite the system used to hold the main patient database is defined as the host system and the other one or more up to ten systems to which it may be connected are defined as satellites The host is typically a Synergy Tower and the satellites are typically Synergy Notebooks but any combination of systems may be used Defining a system as a host 1 Logon as Administrator 2 Select Machine Configuration from the System menu The Machine Configuration dialog box is displayed 3 Click the Configure button The Suite Configuration dialog box is displayed 4 Select Host and then click the Add button to add the network path name for each satellite system that is to be connected to it Machine Configuration BE m Suite Settings V Use as part of Suite Configure 5 Click OK and then tick the Use as part of a Suite check box Defining a system as a satellite 1 Logon as Administrator 2 Select Machine Configuration from the System menu The Machine Configuration dialog box is
99. he correct position then press the Fn button again to position the marker Continue placing the other markers in the same way 6 THE TESTS If you accidentally move beyond the marker you want to move or place you must use the mouse pointer to select it You can then position it using the Fn button 5 To record from another site press the Next button on the PIU A blank trace is displayed on the screen repeat the procedure as for the first site Calculate the velocity Distances may be entered after each site has been acquired or all distances may be entered after all sites have been acquired Enter distances in cm to decimal place e g 23 5 cm The distance entered will be displayed in the active distance field Press Enter to accept the distance and to calculate the conduction velocity Note 1 If you enter distances after each site the active distance field will refer to the active store unless you change it by clicking the mouse or using the tab Enter or up and down arrow keys If you enter distances after you have acquired all sites the active distance field will remain at the second site allowing you to enter all distances in sequence 79 SYNERGY USER MANUAL Note 2 Itis possible to enter Default Distances using the protocol table Conduction Velocities will then be automatically calculated Trace analysis and display Traces may be selected for marking or trace analysis Synerg
100. he Configuration Wizard Creating a new protocol 1 From the Test Configuration dialog box select either a test icon or a protocol icon Click on the New Protocol button From the Base Anatomy dialog box select the appropriate Nerve Name Enter the name that you wish to give to the new protocol and click on the Next button The Wizard takes you to the Acquisition Set up dialog box where you can modify the settings See Acquisition set up below Then click on the Next button The Wizard takes you to the Electrical Stimulator Set up dialog box where you can modify these settings See Electrical Stimulator set up below Then click on the Next button 5 CONFIGURING PROTOCOLS 7 The Wizard takes to the Protocol Table dialog box where you can modify these settings and also enter the Reference Values that you want to be used with this protocol See Protocol Table set up below Click on the Next button to exit from the Configuration Wizard Acquisition set up Acquisition Set up allows you to set up global parameters for the acquisition process and also to set up Filter settings Sensitivity settings etc for each Channel Click on Set up from the Acquisition menu to access the Acquisition Set up dialog box Acquisition Setup 77x Chi cn2 T Average ChannelOn Algorithm Jor BY Amplifier Range fioomv Ney eae 100ms Delay Div ja arene Bild p Average Options Filters Sensitivities Am
101. he Deluxe Stimulator Probe enables you to control the following Stim ON OFF Next switch Stimulus Polarity Stim Intensity Acquire Stim Duration Up Down Press this switch to deliver a stimulus without acquiring data This switch turns the stimulus ON and OFF If all stimuli are OFF when you press the switch stimulus is set ON If Acquire is ON pressing this switch has no effect Press to move to the next site and start a new acquisition Press this switch to change the polarity of the stimulus the positive probe tip changes to negative and the negative probe tip changes to positive Note that the positive probe tip has its LED lit Rotate this switch to adjust the amplitude of the stimulus Stim Intensity is displayed in the Toolbar Push this switch to deliver the stimulus and acquire the data Press the up or down button to increase or decrease the duration pulse width of the stimulus The head of the Deluxe Stimulator Probe may be removed allowing access to 2 x 1 5mm Touchproof connectors You can also modify the head of the Deluxe Stimulator Probe for paediatric use 1 Unscrew the probe tip T next to the locking button 2 Check that there is no grub screw in position P 3 Ifa grub screw is present remove it using an allen key 1 OVERVIEW OF THE SYSTEM 4 Screw the probe tip into position P O Ss Position P e Locking button Mw Tip T Note Do not force the probe ti
102. ich channel is providing the input to operate the facility for this channel Reject Level Level in mV for rejecting artefacts Reject Start Time Time in mS at which artefact rejection starts Artefact reject occurs if the reading is above the reject level and within the reject time settings which have been set for this channel Audio Set up button Click the Audio Set up button to display the Audio Set up dialog box This dialog box allows you to switch the Audio facility On or Off and also to specify whether you want to receive Single you can then indicate the Channel you want to use or Multi in which case you can indicate which Channels you want to use Audio On Off Sets the Audio facility on Single button Sets the system to receive audio input from the channel selected below Only one channel can be selected 67 SYNERGY USER MANUAL Multi button Sets the system to receive audio input from the channels selected The signal received is the average of the signals from the selected channels Channel buttons Selects the channel for audio input View All button Click the View All button to display the View All dialog box This dialog box gives you an opportunity to review all the settings that are currently in force for your Acquisition Set up You will not be able to make any changes on this screen but you can use the context sensitive help facility click on the question mark and then click on
103. ight the patient you want in the Patient List 3 Click the Catalog button below the Patient List or press Alt C The Test Catalog appears in the right hand side of the screen Opening the Test Catalog from the File menu Select Catalog in the File menu Opening the Test Catalog from the menu bar Select the menu item Catalog from the menu bar The Test Catalog for the current patient is displayed in the middle of the main Synergy screen Note This selection is only available when you are performing a test See also gt Deleting results Recalling results using the Test Catalog Double click a Result folder in the Test Catalog The test results are displayed in the Test Screen Double click a Visit Information folder to display visit details The Visit Details are displayed Double click a Report folder to display the report generated for the patient s test s Viewing results in the Test Catalog Results can be grouped by test name or by anatomy You can view the results in either view The default is by test name Click the Order by Anatomy button to view the results by anatomy Click the Order by Test Name button to view the results by test name Deleting results 33 SYNERGY USER MANUAL Test results and associated data are deleted from the Patient Database via the Test Catalog Note that you must have Administrator rights to delete any data from the Test Catalog 1 Highlight either a sin
104. imple MUPs only The summary results can be presented in a tabulated fashion or by plotting the MUP waveforms The signals can be re viewed post acquisition After practice 20 30 MUPs can be acquired within 5 10 minutes References Nandedkar et al Muscle amp Nerve 18 1155 1166 1995 Barkhaus et al Muscle Nerve 1990 13 247 253 Bischoff et al Muscle Nerve 1994 17 842 851 Buchthal and Kamieniecka Muscle Nerve 1982 5 265 290 McGill and Dorfman Computer Aided Electromyography and Expert Systems New York Elsevier 1989 pp 91 101 Nandedkar and Sanders Med Biol Comput 1989 27 556 571 Stalberg et al J Clin Neurophysiol 1986 3 3 13 348 121 SYNERGY USER MANUAL Stalberg et al Muscle Nerve 1994 17 392 399 Stewart et al Muscle Nerve 1989 12 141 148 Running the Multi MUP Analysis Test Select the test From the Test Manager on the right of the entry screen select the test you want from the appropriate folder Select a muscle On entering the test a muscle selection window is displayed 1 Select the muscle you are about to record from and press the ADD key 2 Select the side and then click on the Acquire button 3 Any data you store and any findings you report in the EMG summary table will be associated with this muscle Notes Ifyou do not wish to annotate which muscle you are recording from it is possible to turn this selection window off by selecting Don t Display Muscle List from Test O
105. ing protocols Introduction Some protocols can be configured on line while you are using them gt Online configuration In some tests the Protocol Configuration Wizard allows you to set defaults for the protocols gt Protocol configuration wizard On line configuration Some protocols can be configured on line while you are using them Several set up screens are available through the menus depending on which test you are doing The settings you alter revert to the default settings for the next test you perform unless you use the option Save Settings from the System menu before you leave the test Display menu gt Change Trace Sensitivity below Change Trace Duration below Acquisition menu Acquisition Set up in the Protocol Configuration Wizard section below gt Audio Set up in the Protocol Configuration Wizard section below 61 SYNERGY USER MANUAL Stimulus menu gt Electrical Stimulator set up in the Protocol Configuration Wizard section below Results menu Results options may be set up from within individual tests Table and graph options are available gt The tests chapter 6 Change trace sensitivity Rotate the Sensitivity Switch on the PIU to adjust the display sensitivity of the selected trace or traces If no trace is selected to deselect a trace click away from it the sensitivity of all the traces in the current test is changed Alternatively you can access a dialog box by se
106. ing sections later in this chapter gt Selecting traces Moving traces Superimposing traces Automatic marker placement Manual marking of traces gt Changing trace sensitivity 101 SYNERGY USER MANUAL 102 gt Changing trace duration and also Trace area set up in chapter 5 You can use the full screen to examine and process your trace if you wish Select Full Trace Area ON from the Display menu Creating an EMG report There are two ways of creating an EMG Summary Report using the Summary Toolbar or using the New Muscle function Using the Summary Toolbar 1 Select the Summary Toolbar if necessary by pressing the F10 function key When the toolbar is selected its top line appears in blue 2 Press Enter to display settings for the selected EMG characteristic 3 Use the left and right arrow keys to select the desired EMG characteristic such as Fib or PSW 4 Use the up and down arrow keys to select the correct setting for the characteristic 5 When you have finished entering the characteristics press Enter Using the New Muscle function Report on one or more muscles by selecting a muscle and side and pressing ADD Then select the Report button For each Heading select the appropriate findings and press OK Select EMG Summary to display the current Summary Table Results for Needle EMG tests Results can be seen on screen immediately as you acquire data If columns on
107. lay Overriding automatic results By default the jitter value is set to the lower of the MCD or MSD values To use the other value press the F5 key If the algorithm finds blocking the number of blocks is indicated If you believe these are technical artefacts you can exclude them by pressing the Block F4 key The number of blocks is replaced by the symbol and the number of discharges analysed changes To restore the number of blocks press the Block F4 key again To reject the current pair press the Delete F9 key The entries in the result table are indicated by Press the F9 key again to re accept the results To delete all pairs acquired during the current recording press the Erase key 6 THE TESTS Fibre Density Analysis Test Clinical Overview The purpose of this test is to assess the grouping of muscle fibres belonging to the same motor unit MU Running the Fibre Density Analysis Test Select the test From the Test Manager on the right of the entry screen select the test you want from the appropriate folder Select a muscle On entering the test a muscle selection window is displayed 1 Select the muscle you are about to record from and press the ADD key 2 Select the side and then press the Acquire button Any data you store and any findings you report in the EMG summary table will be associated with this muscle Note If you do not wish to annotate which muscle you are re
108. le High quality screened cables must be used when connecting to the interface connectors of Synergy to ensure compliance with EMC regulations Braid screened or double screened braid plus foil cables are the preferred types The cable screen should make a 360 connection to the screening shells of the connectors on each end of the cable Connectors on Notebook PC and PC Tower Refer to the user manuals for the Notebook PC and PC Tower Connectors on PIU AJLO Stim A Internal 2 x Touchproof Sockets Red Stim B 1 SYNERGY USER MANUAL Stim B Ext Deluxe Stimulator Probe 9 way D type socket OV EMG negative trigger Stim OK Footswitch 9 way D type socket 1 N C N C B 2 APPENDICES Appendix C Technical Specifications Amplifiers and Filters Input Impedance CMRR Noise Low Frequency High Frequency Notch Filter 1000MQ lt 30pF gt 110dB lt 0 7uV r m s 0 1 10kHz bandwidth inputs short circuited 6dB octave 0 1 1 3 10 20 100 500Hz 12dB Octave 100 200 500Hz 1 2 3 5 1OKHz 50Hz or 60Hz or OFF Data Acquisition and Display A D Conversion Sweep Duration LongTrace facility Averager mode Artefact Rejection Display Sensitivity 16 Bit ADC 10ms to 10s per channel independent control per channel Continuous acquisition of up to 100 x sweep duration 1000s Mean Configurable per channel 0 01LV to 100mV div Electrical S
109. lecting Change Trace Sensitivity from the Display menu 1 Select the trace 2 Click on Trace Area Sensitivity from the Display menu 3 Use the drop down list to select a new sensitivity value Change trace duration 62 Rotate the Sweep Duration switch on the PIU to adjust the acquisition sweep duration for the selected trace s Once data has been acquired you can also increase or decrease the sweep duration for selected traces If you deselect a trace all traces are affected Alternatively you can access a dialog box by selecting Change Trace Duration from the Display menu 1 Select the trace 2 Click on Change Trace Duration from the Display menu 3 Use the drop down list to select a new duration value 5 CONFIGURING PROTOCOLS Protocol Configuration Wizard In some tests the Protocol Configuration Wizard allows you to set up the protocols Essentially protocols concern the settings for Acquisition Electrical Stimulus Site Labels and Reference Values This Wizard leads you step by step through the process of configuring a new protocol or of editing an existing protocol Entering the Protocol Configuration Wizard Select Test Configuration from the System menu to display the Test Configuration screen Test Configuration Rep Slim Your options at this point will depend on which of the icons on display you select Click on a folder icon to open it to display the test s it contains and click on
110. ly PCMCIA cards approved by Oxford Instruments Medical Limited may be fitted into the Synergy Notebook A 5 SYNERGY USER MANUAL Synergy Tower System Connections For key to item numbers used below please refer to page 18 The maximum permitted load for the ISO800 Mains Isolating Transformer is 840VA The ISO800 Mains Isolating Transformer must not be placed on the floor It should only be mounted in the cradle provided on the lower shelf of the system trolley The non medical equipment supplied as part of the Synergy Tower system the Tower PC the monitor and the optional printer must only be powered from the outlets of the ISO800 mains isolating transformer If non medical equipment supplied as part of the system were to be connected directly to a wall socket outlet then there may be a risk of allowable leakage currents being exceeded Note that only PC cards and drives approved by Oxford Instruments Medical Limited may be fitted into the Tower PC A 6 APPENDICES Synergy Patient Interface Unit PIU Connections Deluxe Stimulator Probe DC Power and Data Cable captive Foot Switch Internal Stimulator Channel 1 DIN 1 Temperature probe Channel 1 DIN 2 NADNDNPWNrE Connecting the equipment Cables Important Connect the Patient Interface Unit and Stimulator Probe if used and any other peripheral equipment before switching on Position the equipment so that cables are not s
111. matic sequence Select Continuous Sequences from the Acquisition menu Then press the Acquisition button on the control panel The Pause period set is the time before the next acquisition commences Acquisition will continue until it is turned off Trace analysis and display Traces may be selected for marking or trace analysis Synergy offers comprehensive and powerful ways of configuring the trace area See the following sections later in this chapter gt Selecting traces Moving traces Superimposing traces Automatic marker placement Manual marking of traces gt Changing trace sensitivity gt Changing trace duration Compare results 107 SYNERGY USER MANUAL 108 gt Trace arithmetic and also Trace area set up in chapter 5 You can use the full screen to examine and process your trace if you wish Select Full Trace Area ON from the Display menu Results for Repetitive Nerve Stim tests Results can be seen on screen immediately as you acquire data If columns on the table are not on view you can either scroll the table or click on results screen from the Display menu to see the Table and Graphs full screen Available results Repetitive Nerve Stim You can display any of the following results Facilitation Area Facilitation Amplitude Delta Amplitude 1 Rate Delta Amplitude 2 Delta Response 1 Delta Area 1 Delta Response 2 Delta Area 1 Temperature Click on Table Options from
112. ment must have an earth leakage current of less than 400UA 200A in the United States at 110 of the highest rated supply voltage A 9 SYNERGY USER MANUAL Refer to Example B for connection of Class I non medical equipment which exceeds the above earth leakage current figures Multiple portable socket outlets must not be used Refer to Notebook PC user manual to determine the position of the input output connectors The Patient Interface Unit PIU must only be powered from the Synergy Power Supply 035C005 The PIU must not be connected to any other power supply Separate fixed mains socket outlets must be used APPENDICES Example B Synergy Notebook System Connections To Other Non Medical Equipment of Class I Protectively Earthed For key to item numbers used below please refer to page 18 If the other Class I non medical equipment has an earth leakage current of greater than 400uA greater than 200uA in the United States at 110 of the highest rated supply voltage it must be powered from a suitable mains isolation transformer with a floating secondary winding to reduce the earth leakage current below 400UA 200A in the United States A 11 SYNERGY USER MANUAL Multiple portable socket outlets must not be used Refer to Notebook PC user manual to determine the position of the input output connectors The Patient Interface Unit PIU must only be powe
113. more information see Configuring Patient Demographics in chapter 4 23 SYNERGY USER MANUAL 24 None of these fields are mandatory However you must enter a Family Name and Patient ID fields in the Current Patient dialog box if you intend saving patient information See also gt Entering and saving a new patient gt Entering and saving visit details gt Configuring Patient Demographics chapter 4 Entering and saving a new patient 1 Start up Synergy The main Synergy application window appears on the screen Click the New Patient button or select New Patient in the File menu If a patient already exists this clears the Current Patient dialog box ready for you to enter information for a new patient Also if Patient Results have not been saved you are prompted to save them before you can proceed Enter patient demographics in the fields in the Current Patient dialog box Press Enter or Tab to move between the fields Use the scroll bar on the right hand side of the dialog box to scroll down You must enter a Patient ID and Family Name The other fields are optional Note The field names may be different in your system Patient ID Enter a unique identifier for the patient using a maximum of 25 characters Family Enter the patient s family name using a Name maximum of 25 characters First Name Enter the patient s first name using a maximum of 25 characters Initial Enter the patient s initials usin
114. n Synergy screen to list all the patients in the Patient Database or use the Search utility to find a patient 2 Use the vertical scroll bar or up down arrow keys to scroll down the fields to the patient you want To load the patient highlight the patient name and click the Load Patient button or press Enter Note Loading a patient replaces the current patient and you may be prompted to save the current patient before you can proceed See also gt Searching for patient information Deleting a patient 1 Highlight the patient you want to delete in the Patient List 2 Select Delete Patient in the File menu You are prompted to confirm the deletion The patient is deleted from the Patient Database 27 SYNERGY USER MANUAL Transferring patient information between Synergy systems One of the principal features of the Synergy Suite system is the ability to transfer patient data between systems giving you the flexibility to handle the data both in the office and out on patient visits The system used to hold the main patient database is defined as the host system The host may be connected via a direct network connection to up to ten other systems that are defined as satellites The host is typically a Synergy Tower and the satellites are typically Synergy Notebooks but any combination of systems loaded with Synergy Application or Reader software may be used You define the host and satellite set up as part of machine c
115. n be finished within 3 5 minutes References Nandedkar et al Muscle amp Nerve 9 431 439 9 491 500 1986 Stalberg et al EEG amp Clinical Neurophysiology 56 672 68 1 1983 6 THE TESTS Running the Interference Pattern Analysis test Select the test Enter the IP test and select the tested muscle and side Select a muscle On entering the test a muscle selection window is displayed 1 Select the muscle you are about to record from and press the ADD key 2 Select the side and then click on the Acquire button 3 Any data you store and any findings you report in the EMG summary table will be associated with this muscle Notes Ifyou do not wish to annotate which muscle you are recording from it is possible to turn this selection window off by selecting Don t Display Muscle List from Test Options in the Display menu Ifyou select more than one muscle it is possible to report findings for more than one muscle at the same time This saves time especially if all the findings are normal However if more than one muscle is selected it will not be possible to acquire data Select a Normal cloud If normal clouds for the tested muscle are known these can be programmed into the system Choose IP Clouds from the System Configuration menu Press the Normal Cloud function key From the pop up list select the desired cloud The display of cloud can be turned ON OFF or a different cloud may be sele
116. nd no parts need regular replacement Cleaning Warning Switch OFF and unplug the instrument before cleaning with liquid The casing panels and screen may be cleaned using a cloth moistened with water and detergent Do not allow any liquid to enter the case of the instrument The instrument may also be cleaned using a low pressure air line or a vacuum cleaner with an appropriate attachment Do not use propanone acetone on any part of the instrument The instrument must not be autoclaved or sterilised by any means APPENDICES Electrodes An integral electrical stimulator and or a remote electrical stimulator is provided with the instrument Oxford Instruments offer a comprehensive range of neurodiagnostic accessories Instructions for use Please request our Neurodiagnostic Accessories Catalogue for full details Electrode kit supplied by the Synergy manufacturer Stimulating electrodes The stimulating electrodes in the EMG Electrode Kit are designed to deliver the maximum stimulus current available from the Synergy Usage and cleaning Electrodes supplied by Oxford Instruments are accompanied by instructions for use and these include recommendations for cleaning and sterilisation A 25 APPENDICES Appendix B Interface Connections This information may be useful to some users of the instrument Full technical specifications are provided in the workshop manual which is available for purchase Signal Cab
117. needle has a special holder and cable a dent on the hub of the holder is on the same side as the recording surface This makes it easier to orient the needle or to rotate it while optimising the signal recordings Acquire data Ask the patient to perform a minimal contraction of the tested muscle Adjust the needle position and the trigger level so that only one muscle unit MU triggers the sweeps The recording should contain at least two time locked APs that are separated by ideally 400 4000 uS When the signals are suitable for analysis press the Acquire ON key or footswitch to stimulate and acquire responses To suspend and resume signal acquisition press the Acquire ON key To delete all traces acquired during the current recording press the Erase key To return to a state where you can 127 SYNERGY USER MANUAL 128 acquire a new set of data press the Next key or the middle footswitch To analyse the data later for example after the patient has left press the Next key or the middle footswitch to save the traces to the hard disk You can then acquire another set of traces Analyse the data When the system reaches the Cascade sweep limit it automatically stops acquisition and automatically analyses the data If you stop acquisition manually before the sweep limit is reached press the Analyse key to make Synergy analyse the data The top portion of the trace area shows all acquired sweeps sup
118. ngle button Stimulator settings are indicated on the toolbar Increase the stimulus intensity and duration as necessary to record the sensory nerve action potential SNAP During acquisition the response is marked automatically 1 Onset 2 negative peak 3 positive peak 4 End When an acceptable response is observed using recurrent stimulation switch off the stimulus by pressing the Acquire On button Assess the validity of the automatic markings changing the sensitivity if necessary If one or more marked positions is not correct Select the marker to change by pressing the Fn button the selected marker is displayed red and double height note that marker 1 is automatically selected after acquisition Rotate the Fn button to move the position of the selected marker When you are happy with its position press the Fn button to move to the next marker 6 THE TESTS If Synergy has not placed automatic markers but you are happy with the trace you can place the markers yourself Press the Fn button to place marker at its default position rotate the Fn button to move the marker to the correct position then press the Fn button again to position the marker Continue placing the other markers in the same way If you accidentally move beyond the marker you want to move or place you must use the mouse pointer to select it You can then position it using the Fn button 5 To record from another site press the
119. nistrator 2 Select System Configuration from the System menu The System Configuration dialog box is displayed 3 Click the Patient Demographics button to display the Patient Demographics Configuration dialog box This shows the current and default settings for each patient demographic field The dialog box allows you to modify the fields and select fields on and off for entering patient demographics and displaying patient demographics in reports Press Enter or Tab to scroll down the fields 4 You can enter a maximum of 16 characters in each field or leave a field blank Note You can edit any of the fields but you must not change the meaning of the following fields since they each have a specific role in Synergy Patient ID Family Name First Name Initial Sex Date of Birth Age Height Weight 5 If you de select a Show check box the corresponding current and default fields and the Report check box are disabled and the field will not be displayed in the Patient Demographics dialog box 6 De select the Report check box if you do not want a field to appear as a column in the Patient Table in a report 7 Click OK when you have finished configuring Patient Demographics Setting up a new user 1 Logon as Administrator 2 Select Set up User from the System menu in the main Synergy screen The User Manager screen is displayed showing all the known users 3 Click the New User button The User Set up dialog box is displ
120. ntral server but this makes the acquisition system dependent on the stability of the network if there are problems with the network during data acquisition Synergy will be unable to acquire data To configure Synergy on a network you need to do the following Set up access to the shared database The Synergy data sources for each machine must refer to the shared database By default these refer to the local system Ensure that the pointers written to the database are correct When Synergy saves data it creates a path name in the database that includes the name of the drive containing the data Therefore all machines must map the drive name to the same drive in order to be able to access the data For this reason UNC names are preferable if you map shared drives all machines that access shared data must map the shared drive to the same letter for example all machines could map the shared drive to K You need to set up global configuration information and also information on a per user basis If you network an existing Synergy system with data stored locally you must set up the other machines to be able to access the existing data 58 4 CONFIGURING THE SYSTEM Setting up a shared network database 1 Set up the Synergy database on a shared drive 2 From Windows Control Panel choose 32bit ODBC This displays the three data sources that are used by Synergy MedLocalConfig MedLocalPatients MedLoc
121. o complete the transfer the host and satellite systems must be connected using the network connection and both systems must be running Using the destination system transfer the data as follows 1 Open the Patient List 2 Select Complete Transfer in the File menu A dialog box is displayed with a message that there is data available for transfer 3 Click Yes to display a dialog box listing the patients that are available for transfer in the export file Patient Transfer Completion 21 x Select from Transfer Patients Available Selected Patient Descriptions Anthony N THOMPSON 74638 it 10 05 2000 Laptope c 10 05 00 17 13 05 29 Anthon Name Tanyal SHARP PID 83409 Last Visit 10 05 2000 zi Transfer i Cancel 4 Select those patients whose files you want to import If the patient data is already on the database you are prompted to replace the file or add new visit details to it The options are Append New Visits is the default and adds any new visits details to the existing patient data without changing the existing details 30 2 HANDLING PATIENT INFORMATION Replace overwrites the existing file with the new one Apply to all replaces all existing files with new ones Confirm Patient Transfer 29x Tanya SHARP 83409 Already Exists in this Database Append New Visits Replace i T Apply this selection to all subsequent duplicate patient transfers 5 The
122. o trace is selected to deselect a trace click away from it the sensitivity of all the traces in the current test is changed This switch toggles Stimulus ON and OFF If Acquire is ON pressing this switch has no effect Rotate this switch to adjust the duration pulse width of the stimulus Use this switch to adjust the amplitude of the stimulus Stim Intensity is displayed in the Toolbar Rotate this switch to adjust the acquisition sweep duration for the active trace s Once data has been acquired you can also increase or decrease the sweep duration for selected traces Rotate this switch to change the level of the audio output of the input signal Set it to zero for no audio output The switch is associated with the Trigger switch It toggles the trigger edge polarity between positive and negative The setting takes effect when you select trigger signal mode 1 OVERVIEW OF THE SYSTEM Patient Interface Unit End Panels Ground DIN 1 DIN 2 Ventilation grille Deluxe Footswitch Cable n Footswitch Press once to deliver a stimulus and acquire a response If you hold down this switch for more than one second Acquisition is locked on Press again to stop acquisition 11 SYNERGY USER MANUAL 12 Deluxe Stimulator Probe Your system will have one or two stimulators One stimulator is internal with an output on the PIU The optional second stimulator is the Deluxe Stimulator Probe T
123. ollowing options and follow the instructions Add muscles to your Muscle List Remove muscles from your Muscle List Reorder your Muscle List 3 Click OK to save your changes and return to the main Synergy screen Add muscles to the User Muscle List Highlight one or more muscles in the Master Muscle List and click the Add gt gt button to add them to the User Muscle List Remove muscles from the User Muscle List Highlight one or more muscles in the User Muscle List and click the lt lt Remove button to remove them to the Master Muscle List Reorder the User Muscle List Highlight one muscle only in the User Muscle List and click either the Move Up or Move Down button to move the selected muscle either up or down one position in the list 57 SYNERGY USER MANUAL Network Configuration If you have a network you can configure Synergy to share data across the network This is particularly useful if you have more than one Synergy acquisition system or if you have the optional Synergy Reader software When Synergy is set up to share data all users of Synergy and the Synergy Reader can access patient data and reports as if they were held locally It is strongly advised that the acquisition system stores its information on its local hard disk which is shared and accessible to other users over the network This allows a Synergy acquisition system to operate independently of the network The alternative is to save all data to a ce
124. on The patient details are saved automatically when any Test data is saved either manually or using Automatic Save Alternatively you are prompted to save patient details either when you click the New Patient button again or you close Synergy Entering and saving visit details 1 Start up Synergy The main Synergy application window appears on the screen Click on the Visit Details button to display the Visit Details dialog box Enter information in the following fields Examining Enter the name of the physician Physician carrying out the test s using a maximum of 50 characters 25 SYNERGY USER MANUAL Referring Physician Referral Diagnostic Code Diagnostic Code Referral Letter Current Height Note 1 Note 2 Note Enter the name of the physician who referred the patient for testing using a maximum of 50 characters Enter the appropriate referral diagnostic code using a maximum of 50 characters Enter the appropriate diagnostic code using a maximum of 50 characters Enter the full pathname for the letter of referral or click the Browse button and select the pathname The View Letter button is enabled Click the View Letter button to view the letter in MS Word Enter the current height of the patient in the format shown in the field using a maximum of 20 characters This must be entered if reference values include a height factor Note Height format is defined under the option User Se
125. on OK Recompiling a report Display the Patient Catalogue Select Report One Select Re compile Report from the File menu There is a short pause and you are returned to the main Synergy screen Notes You cannot recompile Report One during a patient examination since it is automatically compiled by Synergy during the examination You can click on Report One with the right mouse button to display a menu where you can choose to re compile the 41 SYNERGY USER MANUAL 42 report You may find this quicker than selecting Re compile Report from the File menu 1 Display the Test Catalog 2 Highlight either a Report entry or a Visit Information entry 3 Select either the Recall Report or Re compile Report If you have highlighted a Visit Information entry you can select either Recall Visit or Recompile Report If you recall a report it is displayed on screen If you recompile a report there is a short pause and you are returned to the main Synergy screen Note You cannot make these selections during a patient examination 3 GENERATING REPORTS Recalling a report You can open a report on screen after a patient s visit to edit it and add any comments or conclusions using either Microsoft Word or Medpad If you have modified the result data since the patient s visit the results will not be updated automatically in the report In this case use the Re compile Report option to update the report before you
126. onfiguration See also gt Defining the host and satellite in chapter 4 Transferring patient data between host and satellite There are two methods of transferring data between host and satellite Transfer removes all data results and reports from one database and transfers the information to the other database The data on the original database is erased Copy makes a copy of all the data results and reports from one database and transfers the copy to the other database The data in the original database is not erased and so all information is retained These methods can be used for transferring data in either direction host to satellite or satellite to host In either case if you use Transfer the data in the database you transfer from whether host or satellite will be erased Patient files can be transferred singly or several at a time Using Transfer to transfer patient data between systems 28 2 HANDLING PATIENT INFORMATION 1 Click the Patient List button or press Alt T in the main Synergy screen to list all the patients in the Patient Database or use the Search utility to find a patient 2 Highlight the patient or patients whose details you want to transfer 3 Select Save Patient for Transfer in the File menu or right click and select Save Patient for Transfer from the drop down menu Family Name Name Initial Patient ID PERKINS Polly 0 Richard Albert Kristian 7162589
127. ons manually click on the marker concerned and drag it to the new position An algorithm controls the placement of the markers 145 SYNERGY USER MANUAL Manual marking of traces By default in some tests Synergy places markers on the trace automatically It is possible to turn this facility off select Automarking OFF from the Acquisition set up dialog box All markers whether placed manually or automatically can be moved by clicking and dragging To place markers manually on a selected trace select Marker Toolbar from the Analysis menu This brings up the marker toolbar Ma ma mis omer oe fe fo aa we mka mke Mee Mkio ostMe cea E To place markers Click on a Marker button and then click on the appropriate place on the trace The selected marker is placed there Alternatively click on Fast Mark on the toolbar then clicking at various places on the trace places the markers in order along the trace Note that you can specify the First in the Marker set up dialog box see below Clicking on the trace to the right of a marker already in position places the next consecutive marker clicking to the left places the immediately preceding marker The Clear button on the Marker toolbar clears the currently selected marker The Clear All button on the Marker toolbar clears all the markers from the currently selected trace Marker set up Access the Marker set up dialog box by clicking on Marker
128. option Define Custom Tables 2 Click OK Define Custom Tables 1 Click Custom Tables to use table contents for the report that are different to those defined for the test 2 Click the Define custom tables button The Result Options dialog box appears 3 Click the buttons to select the result options you want in your report You can set up to fifteen columns on Smaller fonts are used in the report if you use a large number of columns 4 Click OK Printing a report You can print a report from within MedPad a WordPad derivative using the Print function 4 CONFIGURING THE SYSTEM 4 Configuring the system System configuration System configuration covers the following activities Defining the set up of the system with host and satellite s Defining a path for the electronic mail program Defining the Notch Filter Setting Configuring Patient Demographics Adding modifying and deleting users Synergy has three levels of access User Administrator and Service Engineer These confer different rights to access parts of the system to users Access levels are defined by a user with Administrator rights New systems are pre configured with a default Administrator user Only users with Administrator level of access can carry out system configuration activities Note A system delivered from the factory is pre configured with a default Administrator user This user name cannot be renamed or deleted thoug
129. patient age among other factors In patients with myopathy the polyphasic MUPs should be excluded from the calculation of mean duration to increase the diagnostic yield The MUPs can be identified manually by reviewing free running EMG traces Use of a triggered delay line and averager facilitates MUP extraction However this approach is biased towards the large amplitude MUPs Regardless acquisition and analysis of 20 MUPs is quite time consuming The multi MUP analysis MMA is a computer aided technique of extracting and analysing the MUP It decomposes the signal into discharges of the constituent MUPs The emphasis of the technique is to extract good quality MUPs that can be used for measuring amplitude duration and phases Hence the algorithm does not bother to resolve each and every MUP discharge when different MUPs superimpose It is developed to analyse recordings made at minimal force of contraction and not the interference pattern generated at moderate force levels Thus the results of analysis supplement the visual MUP assessment The technique is developed to run almost On Line i e the results are available within a few seconds Finally it can identify up to 6 different MUPs from a single EMG recording The system works best when the signal contains discharge of 3 4 MUPs The signals are acquired in a free running mode just as in the routine needle EMG examination It does not require manipulation of 120 6 THE TEST
130. plifier Inputs Audio Setup Low fh a Monitor fico E Active Reference View All oa ell ooo m LongTrace fioopy z Global settings Run Select Stim Triggered to lock the signal to a stimulus or trigger Select Free Running for continuous data acquisition Average checkbox Check to average data Notch Filter checkbox Check to filter out mains frequency noise from the signal Channel specific settings By clicking on the appropriate Channel tab you can set parameters for specific channels Channel On checkbox Indicates whether this channel is on or off Rectify On Off checkbox Indicates whether this channel is rectified or not Algorithm On Off Indicates whether the algorithm appropriate to the test being conducted is on or off for this channel 65 SYNERGY USER MANUAL 66 Amplifier Gain Select the appropriate range from the list For example 2 5 mV for sensory nerve conduction and cortical evoked potentials 100 mV for Motor NCS F Wave and EMG This is the input range for the amplifier and tells Synergy the amplitude range of the patient signal It does not alter the amplitude of the trace on the screen Sweep Duration Can range from 5 milliseconds up to 10 seconds Delay Div Sets the starting point of the sweep in relation to the stim Can be set to begin before or after the stim point by entering minus or plus values in milliseconds LongTrace Defines the length of the LongTrace as a multiple of the sweep
131. ps when you move them Always slide down on the locking button before you attempt to release them SYNERGY USER MANUAL Using Synergy Synergy has a fast intuitive and flexible graphical user interface GUD that conforms to Windows 98 The GUI provides A means of adjusting or activating all the Synergy settings and controls Multiple ways in which you can carry out a task For example you can select an item from a menu using the mouse or the keyboard or open an item by double clicking on an icon Single stroke keyboard function keys for key tasks carried out during a patient examination Alternative methods of control for novice and experienced users In addition to using the GUI key tasks can be carried out via control switches on the Patient Interface Unit Deluxe Stimulator Probe and Footswitch See also gt Logging onto the system gt The System and its parts Components of the GUI gt Opening and closing folders gt Using Electronic Mail Getting support Logging onto the system The Synergy program starts automatically when you switch on the notebook If your system is not a single user system you will be prompted for a login name and password If you exit from Synergy at any time you can restart it by double clicking on the Synergy icon 14 1 OVERVIEW OF THE SYSTEM Components of the GUI The Title Bar The Title Bar is displayed at the top of the screen and contains the name o
132. ptions in the Display menu Ifyou select more than one muscle it is possible to report findings for more than one muscle at the same time This saves time especially if all the findings are normal However if more than one muscle is selected it will not be possible to acquire data You can select a muscle by double clicking on its name in the muscle selection window Acquire the data Manipulate the needle position to record crisp EMG signals The force of contraction should be minimal Ideally the EMG should contain discharges of 3 4 MUPs Begin acquisition You may change the display mode to Complex to view cascades or Complex 2 to view the long trace 122 6 THE TESTS Cascade display Long trace display HAM du M f ji When the 10 second epoch is acquired the acquisition will stop automatically and initiate the analysis You can stop acquisition manually and begin analysis by pressing the Analysis function key To suspend and resume signal acquisition press the Acquire ON key To delete all traces acquired during the current recording press the Erase key To return to a state where you can acquire a new set of data press the Next key or the middle footswitch To analyse the data later for example after the patient has left press the Next key or the middle footswitch to save the traces to the hard disk You can then acquire another set of traces 123 SYNERGY U
133. r and observe the monitor trace at the lower right of the screen to ensure that it is noise free If it is not check electrode connections and cables 1 Position the stimulator at the appropriate site and begin stimulation for recurrent stimulation press the Acquire On button for a single stimulus press the Acquire Single button Stimulator settings are indicated on the toolbar Increase the stimulus intensity and duration as necessary to record the compound muscle action potential CMAP During acquisition the response is marked automatically 1 Onset 2 negative peak 3 baseline crossing 4 positive peak 5 End When an acceptable response is observed using recurrent stimulation switch off the stimulus by pressing the Acquire On button Assess the validity of the automatic markings changing the sensitivity if necessary If one or more marked positions is not correct Select the marker to change by pressing the Fn button the selected marker is displayed red and double height note that marker 1 is automatically selected after acquisition Rotate the Fn button to move the position of the selected marker When you are happy with its position press the Fn button to move to the next marker If Synergy has not placed automatic markers but you are happy with the trace you can place the markers yourself Press the Fn button to place marker 1 at its default position rotate the Fn button to move the marker to t
134. r button The User Set up dialog box is displayed showing the information for the user Note that the user s password is not displayed 53 SYNERGY USER MANUAL 4 You can edit the following fields User Name Full Name Clinic Name Password Access Level You can also change the user s paths and muscle list Click one of the following options and follow the instructions Changing Paths Defining a Muscle List When you have finished editing the user s set up click OK to save your changes and close the dialog box Notes If the User Name is Administrator this field will be greyed out and you cannot edit it If you change the user s password you must retype it in the Confirm Password field gt Changing paths gt Defining a muscle list Deleting a user 54 Logon as Administrator Select Set up User from the System menu in the main Synergy screen The User Manager screen is displayed showing all the known users Highlight the user that you want to delete and click the Delete User button Note You cannot delete the built in Administrator user A warning is given that all configuration information for that user will be deleted Click Yes to confirm that you wish to delete the user Click the Exit button to leave the User Manager screen 4 CONFIGURING THE SYSTEM User Configuration Users with the default user level of access can configure the following aspects of Synergy
135. r unit potential waveform and the firing rate Complex 2 shows the signal at normal speed 10 ms div on the left of the screen and at slow speed 50 ms div on the right This display format is useful for assessing spontaneous activity and the interference pattern at maximal effort Note When using the Complex 1 or Complex 2 display format signals must be acquired before they are displayed on the right half of the screen 6 THE TESTS 4 Acquire signals by pressing the Acquire On button on the PIU 5 Select the next muscle Ensure that EMG acquisition is turned off and press the F1 function key to select a new muscle Repeat the procedure given above Automatic MUAP Analysis It is possible to Average and automark triggered MUAPs The Marking Algorithm is turned ON OFF in the Acquisition Setup dialog box select Setup from the Acquisition menu Turn the Averager ON again from the Acquisition menu At Acquire OFF the MUAP will be automarked and the MUAP result table updated LongTrace LongTrace is a special display format for traces in EMG tests that allows you to display a long run of data on the screen The data is displayed in a compressed format but there is no loss of resolution since the uncompressed version of the trace is also displayed Setting up LongTrace 1 Choose Setup from the Acquisition menu 2 In the dialog box that is displayed set the LongTrace duration in the box labelled Lon
136. ration c cccccccessssseeeees 60 145 Trace Sensitivity 0 eee 60 145 Traces Manual marking 0 ceeeeeeeeeeeeeees 144 MOVIN 8 sipirc ninani 143 Transferring patient information 28 Units used 80 86 90 94 101 106 Index 4 User Configuration eee eee eee 53 User interface oe ee eeceeeeseeeeenees 15 User Setup cece eeeeeeeeeeeeeeeeeeeees 50 53 Changing 0 eee eeeeeseceneeeneeenee 53 User setup editing eee eee 51 User deletion ere eee 52 Using Synergy eeseeeeeeeereerrereerrrrerrreees 14 Using the patient database 19 Using the tests 0 eee eeeeeeeeeees 71 View All button eee 66 Viewing A LEPOLt wee ee eeeete eee eeeee 39 Visit details ccccesessecceseesseteeee 23 25 Entering and saving 25 Volume Switch eee eeeeeeeeseeeees 10 Wizards sinice cetreria 61
137. re moving the stand between rooms ensure that the arm is locked into position using the locking nuts Attach the Deluxe Stimulator Probe holder to the arm optional using 2 countersunk screws provided Attach the power supplies to the stand The power supplies incorporate a Velcro type pad for easy attachment and removal They can be fitted to the metal plate on the pole Clean the plate using alcohol remove the self adhesive backing from the pad and press the pad firmly into position Cables may then be routed up through the cable clips If you have the optional printer tray attached there may be room to mount the power supply at the back of it instead if you prefer Attach the PIU to the plate at the end of the arm using the three thumbscrews Position Synergy Notebook on the top of the stand APPENDICES Put the Synergy Notebook on top of the PC tray clean the corners of the tray using alcohol and attach the L shaped self adhesive rubber feet at the corners to secure it in place Connect cabling to the cable clips See separate cabling diagram in Appendix A for system connections Excess cabling can be tucked onto the shelf under the PC D 5 APPENDICES Appendix E Cable management for the Towe r Refer to page E 7 for a pull out Key to the numbers a Securing the isolated power supply a 24 30
138. red by the instrument stored in memory and displayed on the screen when Acquire is ON 5 Calculate the velocity The distances between electrode sites must be entered before the conduction velocity results can be calculated and displayed on the screen Not used for Blink Reflex H Reflex Repetitive Nerve Stim or EMG tests 6 Selecting traces for analysis and display Traces may be selected for marking or trace analysis Synergy offers comprehensive and powerful ways of configuring the Trace Area 7 Configuring and displaying results Synergy offers you considerable flexibility in configuring and displaying the results of your test Detailed procedures are given in the description of each test For general information about trace analysis and results see gt Trace analysis and display gt Configuring and displaying results You also need to understand about Configuring protocol settings This allows you to set up global parameters for the acquisition process and to set up Filter settings Sensitivity settings etc for each Channel and to modify stimulus settings for the test Configuring protocols chapter 5 74 6 THE TESTS Selecting the test Tests are automatically allocated to function keys by Synergy If the folder containing the test you want is already open and the test is displayed on the Function Key Bar simply press the appropriate function key on the keyboard Ifthe folder containing the test yo
139. red from the Synergy Power Supply 035C005 The PIU must not be connected to any other power supply Separate fixed mains socket outlets must be used APPENDICES Example C Synergy Notebook System Connections To Other Non Medical Equipment of Class II Double Insulated For key to item numbers used below please refer to page 18 In this situation when other non medical equipment of Class II is to be connected to Synergy Notebook the system that is Synergy notebook and the other Class IT non medical equipment together must not exceed the enclosure leakage current limit of 100A SYNERGY USER MANUAL To meet this requirement a suitable mains isolating transformer with a floating secondary winding will be required to power the non medical equipment including the Notebook PC This transformer must have an enclosure leakage current of less than 75uA that is the current measured between the floating secondary winding of the isolation transformer and earth must not exceed 75uA The reduction from 100UA to 75uA makes allowance for the enclosure leakage current of the Synergy Notebook itself If two or more non medical equipments of Class II are to be connected simultaneously to Synergy Notebook then all the items of non medical equipment must be powered from a single mains isolating transformer to ensure that the enclosure leakage currents do not add and exceed the limit Multiple portable sock
140. reduces the effect of digitizing the EMG signals A plot of the power in each sinusoid computed as a square of the amplitude against the frequency is called the power spectrum The median frequency divides the spectrum divided in two halves The mean frequency is computed by summating the product of frequency and power and dividing the sum by the power The power is also related to the root mean square value of the signal amplitude The power spectrum quantifies the sound of the EMG In myopathy the IP has a high pitch sound that corresponds to increased mean or median frequency Changes in amplitude are reflected in the RMS value The FFT analysis is also useful to assess changes in muscle due to fatigue Technique Insert the needle into the tested muscle Adjust the electrode position to record signals with crisp sound This ensures that we are close to the MUs of the tested muscle Instruct the patient to give minimal contraction and maintain it Press the Acquire button or the foot switch By default a 500 msec epoch will be acquired analysed The result table and graphs will be updated For the basic TA Equip analysis the results are available almost instantaneously Perform similar analysis at moderate and maximum force level Repeat the process at 6 10 different sites using 2 4 different needle insertions If available superimpose the normal cloud on the data to assess the abnormality With practice this quantitative study ca
141. rk card SYNERGY USER MANUAL Network cable Mouse The Synergy Tower comprises the following main items Multimedia Tower PC Keyboard and mouse CRT monitor or LCD monitor Patient Interface Unit with integral 2 channel amplifier and electrical stimulator Deluxe Stimulator Probe Power supply module medical grade Footswitch Mains isolating transformer module Trolley and Arm Desk mount for PIU Optional items for Tower include Temperature probe Printer Network card Network cable The Synergy Suite comprises the following main items Multimedia Notebook PC including network card Multimedia Tower PC including network card Keyboard and mouse CRT monitor or LCD monitor Patient Interface Unit with integral 2 channel amplifier and electrical stimulator Deluxe Stimulator Probe Power supply module medical grade Footswitch Mains isolating transformer module Network cable to link Tower PC and Notebook PC Trolley and Arm Desk mount for PIU 1 OVERVIEW OF THE SYSTEM Optional items for Suite include Temperature probe Printer Arm and Stand Notebook MS Office is supplied as standard As an option to the Synergy application software and the standard range of tests EMG analysis software and SFJ tests can also be supplied under special licence Oxford Instruments Medical Ltd has a policy of continual product improvement hence the specifications of instruments in the range are subject to change wi
142. rt See also Generating reports chapter 3 21 2 HANDLING PATIENT INFORMATION 2 Handling Patient Information Entering and saving patient information For each patient you can enter the following information Patient demographics the personal details about a patient such as their Family Name First Name Patient ID Date of Birth and Address Visit details the details relating to each patient s visit such as the Name of the Referring Physician the Name of the Examining Physician the Date of the Visit and any clinical notes about the patient Patient details are entered in the Current Patient dialog box and visit details are entered in the Visit Details dialog box Visit details are specific to each visit made by a patient Both dialog boxes are accessed from the main Synergy screen The Test Menu screen displays all the folders of tests for the current user You can open folders and select tests by either double clicking a folder or test with the mouse or using function keys You can use the function keys F1 to F8 to access the first eight tests in a folder F to F8 open the first eight tests in a folder F9 displays any additional tests in the folder F10 selects the next folder Notes Since Synergy offers a high degree of flexibility and can be configured to meet local requirements some of the field names in the Current Patient dialog box in your system may be re configured or switched off For
143. s can be selected from the list To select a result for display 1 Click on the arrow head to the right of an empty text box 2 Select the required result from the list screen displayed To remove a result from the Test screen display 1 Click on the arrow head to the right of the result 153 SYNERGY USER MANUAL 154 2 Select the Off option in the top left from the list screen displayed To change a result heading on the test screen Edit or over type the displayed heading as shown in the text boxes to the right of the arrow heads on the Result Options dialog box To configure a custom result 1 Click on the right arrow head to the right of an empty text box 2 From the list screen displayed click on the Custom button to display the Custom result configuration dialog box Display Reference Values checkbox Select this checkbox if you want the reference values displayed on the test screen Check Reference Values checkbox Select this checkbox if you want readings that are outside the range specified by the reference values to be shown enhanced Click on the Display Reference Values checkbox if you want the reference values to be displayed on the Results Table in addition to the test values To add an item to the Results Table 1 Click on Table Options from the Results menu 2 On the Table Configuration dialog box click on a right arrow beside a blank Description panel 3 From the Test List pop up
144. s sesssseesssseesrsreesssrrrrsrerresrrsreeresrerrsse 52 Setting UP amp MEW USEL osiedlono uec oeren eosi eo oaio sran eeens roerien 52 Editing a uSet s SCt Up ee oeri censis eesin soe ireo e eos e eE 53 Deleting a User oricine e eE EEE eE a a EEE EEEa 54 User COnfiQuration ccccssccccsrcccssssssscssssccessncsssscssnsccscscccssscssssscesnaceeses 55 Changing your User Set Up sssi i ieies en E ss 55 Changing a pass Word cisien skeessaeesstes sasuasesesaseus EEEE E ETES ES 56 Changing paths cter eap e Ee TET S EE E EEE EET ES ES 56 Defining a Muscle UString er or rE EE Ts E E reS 57 Network Configuration c ccssccsssccssscccsssccsssccsssccscnaccsssacsssscsenscceseeeess 58 Setting up a shared network database eseeseeeseeeseseeesrsessrsrrerssreereserereee 59 Setting up configuration information essseeeseeeseeseseserererrsrreresreerrseeerese 59 Setting up users to Share data eseseeserereresssreresererssreesrerereeseenensrerersesersre 59 Sharing existing data on a local drive sesssesssseesseeeesesresersrsserrrererreeresee 60 5 Configuring protocolS ssseescoessocssscsssocesocesoossoossssessseeesoe OL Inirod cton sevsicsshensusospstaiesswossodinansuevaasyessiactond eaters roisses p Ssss irasi a Sn 61 On line CONFIGUTATION cssccessccsrsccesnsccesncecssacssnsaccesaseessccsenccssaaceesaes 61 Change trace Sensitivity 0 eee ee R e e e eiri E 62 Change trace Curation eee eceeccesscesecesecese
145. screen Manually or automatically compare results obtained during the current test for example compare left and right side results Manually compare the results of the current test with the results of a previous test held in the Patient Database With manual comparison you can decide how the results are displayed for example next to each other or on top of each other With automatic comparison results are always displayed next to each other 147 SYNERGY USER MANUAL 148 Manual Comparison From the Display menu choose Compare Setup In the dialog box that is displayed determine how the data will be displayed Acquire the data then choose a test to compare it with In the Patient Catalogue select the test then click on the compare button Inthe Test History window right click on the test and choose Compare Auto compare If auto compare is set Synergy lets you compare the left and right side results while you perform the test by displaying the results next to each other 1 2 3 From the Display menu choose Auto compare Acquire data for the first side When you choose to acquire the other side the side you have just acquired remains displayed beside the new data Trace arithmetic Note not used for Needle EMG or F Wave tests Trace arithmetic allows you to add up to 10 traces together or to subtract them For example this lets you acquire sweeps singly into store then add
146. scroll up and down Use the mouse to re order the sequence of the components Click on a component and drag it to a new location in the list box Click in the tick box to the left of a component to insert a page break in the report AFTER the component Click OK Defining Test Report settings 1 7 Select Test Report Options from the Results menu from within a test The Report Settings dialog box appears Choose the type of tables to use in the report Click one of the following options and follow the steps Use Tables As Test Screen Define Custom Tables Click the Graph check box to display results in a graphical form in the report Click the Display reference check box to include Reference Values in the report These are values that are in the normal range for a test You can choose to have results that are outside the range of reference values flagged in your reports Click the Check reference values check box to highlight results that are outside the normal range Optionally select trace format s Stores and or Cascades to include in the report Click OK Tables as Test Screen 1 Click As Test Screen to use the same table contents for the report as defined for the test All the result columns that have been selected to appear in the test screen will appear in the 47 SYNERGY USER MANUAL 48 report If you want a different set of results to appear in the report use the
147. se limits are used to compute jitter The sequential plot of IPIs is extremely useful to detect traces that were acquired due to technical problems in recording e g triggering from two MUs It is much easier to exclude them by adjusting the IPI limits rather than by excluding them individually during trace review The 3 standard deviation limit will automatically exclude some of the potentials To exclude others use the mouse to reduce the height of the yellow band To manually include or exclude sweeps from analysis 1 Press the Review key This displays the first 5 sweeps in the lower half of the trace area 135 SYNERGY USER MANUAL 136 2 To change the status of an individual sweep from included to excluded or vice versa click on it with the mouse 3 To include or exclude all of the displayed traces right click on the trace area from the popup that is displayed choose Include displayed or Exclude displayed 4 To include or exclude all traces right click on the trace area from the popup that is displayed choose Include all or Exclude all To accept the calculations and move on to the next recording press the Next key or the middle footswitch If you move a window or change between rising and falling edge the system automatically recalculates these values Blockings generated by mis triggers are automatically discarded Results are shown numerically in the result table at the right hand side of the disp
148. sec A dialog box is displayed indicating the current position of the signal being replayed you can change this by dragging the bar with a mouse LivePlay 6 THE TESTS Four buttons are displayed Play Stop Load Save Save As Close Starts and stops replay from the LivePlay buffer Allows you to recall previously saved LivePlay files A selection of samples files are available in C My documents Resources LivePlay Examples These can be used for training Note Files MUST have been named with the extension MRL Allows you to save the current contents of the LivePlay buffer under the Patient name in the Catalog If no patient name has been entered in the Patient Demographics then this option is not available Note LivePlay files contain raw data including audio and are large A file containing 20 sec of data will be about 2 Mbytes Files MUST be named with the extension MRL Allows you to save the current contents of the LivePlay buffer if no patient name has been entered in the Patient Demographics Note LivePlay files contain raw data including audio and are large A file containing 20 sec of data will be about 2 Mbytes Files MUST be named with the extension MRL Takes you out of LivePlay and back to normal data Acquisition Trace analysis and display Traces may be selected for marking or trace analysis Synergy offers comprehensive and powerful ways of configuring the trace area See the follow
149. selected data is imported into the database Reviewing results and reports for an existing patient You can recall and review the test results and reports for an existing patient via the Test Catalog Recalling an existing patient An existing patient is a patient that has been entered in the Patient Database The Patient List is a list of all the patients in the Patient Database To recall a patient from the Patient List see Recalling a patient Opening the Test Catalog The Test Catalog contains the results reports and visit information for each visit for a patient including the current visit The most recent visit is listed at the top of the Catalog A result entry in the Test Catalog is composed of a Test Name and Anatomy and depends on the type of test as follows For NCS tests the test result entry is composed of Test Name Nerve Side For EMG tests the test result entry is composed of Test Name Muscle 31 SYNERGY USER MANUAL 32 Results are grouped either by Test Name or by Anatomy You can switch between these two views See Viewing results in the Test Catalog Notes The Test Catalog also allows you to view the tests performed on the current patient during the current visit You can open the Test Catalog from a number of locations and in a number of ways By clicking the Catalog button on the left hand side of the screen when patient demographics are displayed in the Current Patient dialog bo
150. set up on the Analysis menu This dialog box allows you to Define up to a 4 character label for each marker label to replace the defaults M1 M2 etc Turn the auto marking facility OFF or ON Specify which marker you wish to be considered as the First marker when using Fast Mark 146 6 THE TESTS Change trace sensitivity Rotate the Sensitivity Switch on the PIU to adjust the display sensitivity of the selected trace or traces If no trace is selected to deselect a trace click away from it the sensitivity of all the traces in the current test is changed Alternatively you can access a dialog box by selecting Change Trace Sensitivity from the Display menu 1 Select the trace 2 Click on Trace Area Sensitivity from the Display menu 3 Use the drop down list to select a new sensitivity value Change trace duration Rotate the Sweep Duration switch on the PIU to adjust the acquisition sweep duration for the selected trace s Once data has been acquired you can also increase or decrease the sweep duration for selected traces If you deselect a trace all traces are affected Alternatively you can access a dialog box by selecting Change Trace Duration from the Display menu 1 Select the trace 2 Click on Change Trace Duration from the Display menu 3 Use the drop down list to select a new duration value Compare Note not used for Needle EMG or F Wave tests Synergy allows you to compare test results on
151. specific MUP select it by clicking with the mouse Press the Edit MUP function key The details of the review are described under Review of current analysis above 3 To review results from an earlier acquired site click on the site label in the result table The label for the current site is indicated in blue 4 Press the Print function key at any time to obtain a hard copy of the results 125 SYNERGY USER MANUAL Single Fibre Jitter Test Clinical Overview The purpose of the Single Fibre EMG Jitter SFJ test is to assess the efficacy of neuromuscular transmission Running the SFJ Test Volitional Select the test From the Test Manager on the right of the entry screen select the test you want from the appropriate folder Select a muscle On entering the test a muscle selection window is displayed 1 Select the muscle you are about to record from and press the ADD key 2 Select the side and then press the Acquire button Any data you store and any findings you report in the EMG summary table will be associated with this muscle Notes If you do not wish to annotate which muscle you are recording from you can turn off this selection window by selecting Don t Display Muscle List from Test Options in the Display menu If you select more than one muscle you can report findings for more than one muscle at the same time This saves time especially if all the findings are normal However if more th
152. splay menu Ifyou select more than one muscle you can report findings for more than one muscle at the same time This saves time especially if all the findings are normal However if more than one muscle is selected it is not possible to acquire data You can select a muscle by double clicking on its name in the muscle selection window 140 6 THE TESTS Connect the electrodes The electrode used in the Macro EMG test is a modified SFEMG needle insulated except for the distal 15mm Using this needle it is possible to record a single fibre channel and a macro channel simultaneously The active recording surface for the single fibre channel channel 1 is located in a side port at the centre of the exposed cannula on the opposite side to the bevel The cannula acts as a reference electrode for channel 1 and is automatically connected to the pre amplifier by the cable Usea surface electrode or monopolar needle as the reference electrode on the macro channel channel 2 Place the ground electrode close to the tested muscle Setting up the PIU 1 Connect the macro EMG cable to channel 1 2 Connect a jumper lead between the red plug of channel 1 and the black plug of channel 2 This connects the reference electrode of channel 1 to the active input of channel 2 Inserting the needle Unlike single fibre tests the needle for the Macro EMG test should be inserted perpendicular to the skin surface so that the
153. ss Users with the default User level access can configure Muscle lists Report Set up User Set up Protocol Settings Note Test Protocol Specific Settings can also be changed and saved from within a test by using the Save Settings option in the System menu Users with Administrator access can Configure Patient Demographics Create modify and delete users Configure their own muscle lists Edit database paths See also gt System Configuration in chapter 4 gt User Configuration in chapter 4 18 1 OVERVIEW OF THE SYSTEM The Patient Database The Patient Database is central to the entire Synergy system It contains Patient Demographics and links to Test Catalogs that contain a patient s results reports and visit information Each patient in the database is uniquely identified by a Patient ID Using the Patient Database you can Enter and save new patients Retrieve results and reports for existing patients Search for a patient or a group of patients This functionality applies to both standalone and networked systems A large degree of flexibility is built into the database For example you can Configure the fields in Patient Demographics to meet your local requirements Access the Test Catalogs in different ways and obtain different views of them You can also transfer patient details in both directions between the Tower and Notebook systems giving you flexibility in
154. st you want from the appropriate folder Select a protocol From the Select protocol dialog box select the protocol that you want to use for this test Connect the electrodes 1 The active surface recording electrode is placed on the Gastrocnemius or Soleus muscle 2 The reference electrode is placed on the back of the leg just above the foot 3 The ground electrode is placed between the active recording electrode and the stimulating electrode 4 The following stimulating electrodes are recommended Large bipolar stimulating electrode 16893T Deluxe Stimulator Probe 031K025 The tibial nerve is stimulated in popliteal fossa with anode facing the active recording surface Acquire the data Turn on the amplifier and observe the monitor trace at the lower right of the screen to ensure it is noise free If it is not check electrode connections and cables The monitor trace also allows you to assess whether the patient is relaxed 1 Position the stimulator at the appropriate site 94 6 THE TESTS 2 Press the Stim key to switch on the stimulus without acquiring data 3 Press the Acquire Single Key to stimulate and Acquire a single response Press the Acquire ON Key to perform continuous Acquisition The data acquired will automatically fill each cascade 4 Gradually increase the stimulus intensity 5 To stop acquisition press either Acquire Key again Measure and record the minimum H latency Rotate the
155. standard for example EN60950 UL1950 CAN CSA 22 2 No 950 If other electrical equipment powered from a mains wall socket outlet is to be connected to Synergy then standard EN60601 1 1 1993 should be consulted to determine the appropriate actions necessary to ensure safety for a particular installation Several examples of medical electrical systems meeting EN60601 1 1 requirements are shown on the following pages However it must be emphasised that these are only examples and every installation must be individually checked for compliance with EN60601 1 1 and the appropriate actions taken to ensure patient and user safety is maintained For the examples shown on the following pages all parts of the systems may be within the patient environment Note that for Synergy Tower and Synergy Suite the outlets of the ISO800 Mains Isolating Transformer must only be used to power equipment approved by Oxford Instruments Medical Ltd No other equipment may be powered from these outlets as there may be a risk of exceeding the power rating of the ISO800 Mains Isolating Transformer A 8 APPENDICES Example A Synergy Notebook System Connections To Other Non Medical Equipment of Class I Protectively Earthed For key to item numbers used below please refer to page 18 To permit the direct connection of Class I non medical equipment to the Synergy Notebook the Class I non medical equip
156. stems now use frequencies above 20kHz and should therefore cause minimum interference unless the loop is very close to the EEG or EMG EP 3 50Hz 60Hz electrostatic field from unshielded conductors lamps etc This type of interference is possibly the simplest to locate and correct Any conductor of supply frequency not covered by an earthed metal screen is a potential source of interference Obvious sources are flexible cables to desk lamps and X ray viewing boxes unshielded fluorescent tubes and filament lamps It is important that all encasing metalwork of electrical equipment be securely bonded electrically to the local circuit earth xi SYNERGY USER MANUAL Sources o xii 4 HF interference from short wave diathermy radio ambulances television and sound broadcasting This class of interference is the most difficult to track down to its source and by far the most difficult to eliminate Short wave diathermy is easily the most frequent source of HF interference particularly in or near a physical medicine department or operating theatre The interference may reach the EEG or EMG EP via a number of paths falling into two main categories 1 Conducted and 2 Radiated Conducted HF interference is found on the mains supply This kind of interference on modern equipment is eliminated by efficient mains filtering Radiated interference is transmitted through the air and emitted either from poorly screened electrical eq
157. stimulus output of Synergy Max intensity 300V constant voltage pulsed or 100mA constant current pulsed High range 0 300V or 0 100mA Low range 0 75V or 0 25mA Max duration Ims per pulse Max repetition rate 10 pulses second at lt lms Stimulators The Stimulator can be either the internal one in the PIU or an external Deluxe Stimulator Probe The internal stimulator has 1 5mm touchproof plugs at the side of the PIU The Deluxe Stimulator probe also has 1 5mm touchproof plugs or can be fitted with the special probe head with built in electrodes The probe plugs into the back of the Patient Interface Unit via a 2 4m 8ft lead To connect Deluxe Stimulator Probe to Synergy Notebook Correctly align the plug with the socket on the PIU Firmly push home the plug and tighten the screws on either side of the plug To disconnect the Deluxe Stimulator Probe Unscrew the screws either side of the plug and pull firmly to separate the connection APPENDICES Footswitch Printer The foot control is attached via a socket on the PIU To connect to the Synergy Correctly align the plug with the socket on the PIU Firmly push home the plug and tighten the screws on either side of the plug To disconnect Unscrew the screws either side of the plug and pull firmly to separate the connection To connect the interface connectors Firmly push home the connectors of the parallel port and then secure them in place
158. t in a radial direction giving more stable AP amplitudes 2 Insert the needle all the way to the hub and then retract it partially The muscle tends to grab the needle and holds it better in one place during retraction Rotate the needle to investigate fibres in all directions Orienting the active electrode The SFEMG needle has a special holder and cable a dent on the hub of the holder is on the same side as the recording surface This makes it easier to orient the needle or to rotate it while optimising the signal recordings View sweeps Ask the patient to perform a minimal contraction of the tested muscle Adjust the needle position and the trigger level so that only one MU triggers the sweeps Maximise the amplitude of the triggering AP by rotating or moving the needle If you want to store the sweeps press the Acquire ON key 6 THE TESTS Enter data Observe and count APs and enter them into the table 1 Type the number of APs into the yellow highlighted box and press the Enter key A list of options for signal stability is displayed with Normal selected as the default Use the Up and Down arrow keys to highlight the correct signal stability and press the Enter key Note that the last option a blank line allows you to enter your own text to describe the signal stability Press the Next key or the middle footswitch to advance to the next site The yellow highlight moves to the next line in the
159. t up from the System menu Click the Header tab in the Report Set up dialog box You can either use an existing header file that has been created using WordPad or Word and saved with a rtf extension or you can define a simple header file Click one of the following options and follow the steps Use an existing header file Define a header file Note You can only make changes using Report Set up when there is no report currently active Use an existing header file 1 2 3 Click the Browse button Using the drive and directory folders navigate to the file you want to use and click Open Note The file must have been created using WordPad and must have a rtf extension If you have graphics in your file check that they are inserted using Insert Picture not Insert Object otherwise they will not be visible in MedPad Click OK Define a header file nan A N Click the Define button Enter the text for the header using a maximum of 5 lines Position the text using the Right Left or Centre buttons Click Save In File name type the name of the header file Save it as type RTF and either use the default path C Synergy Reports Headers or choose a folder in which to save it Click Save Click OK 45 SYNERGY USER MANUAL 46 Selecting and defining a signature file 1 Select Report Set up from the System menu 2 Click the Signature tab in the Report Set up dialog box 3 You can eith
160. t up in the System menu Enter any additional information about the patient for example the patient s clinical history or notes arising from a physical examination Enter any additional information about the patient for example the patient s clinical history or notes arising from a physical examination If you entered the patient s date of birth in the Current Patient dialog box the age of the patient in years is displayed automatically in the Patient Age On Visit Date field 4 Click Done to save the visit details for this patient You are returned to the main Synergy window Note Visit information is specific to each visit made by the patient 26 2 HANDLING PATIENT INFORMATION Retrieving existing patient information You can recall an existing patient from the Patient Database to change their details and review test results and reports You can also delete a patient from the Patient Database The Patient List is a list of all the patients in the Patient Database There are columns for the Family Name First Name Initial Patient ID and Date of Birth for each patient Use the vertical and horizontal scroll bars or the Tab key to view all the columns See also gt Reviewing results and reports for an existing patient gt Searching for patient information gt Transferring patient information between Synergy systems Recalling a patient 1 Click the Patient List button or press Alt T in the mai
161. table A maximum of 20 sites is allowed in the table Based on the values you enter Synergy calculates the mean value and standard deviation and displays them at the bottom of the table Notes You can change data for any site in the table by clicking on the appropriate row Count APs with peak to peak amplitude greater than 200 uV and rise time less than 300 us If the APs superimpose on each other you can modify the criteria to an amplitude greater than 100 uV or a formation of a notch in the rising falling edge of the first AP 139 SYNERGY USER MANUAL Macro EMG Test Clinical Overview The main purpose of this test is to assess the size of motor units MUs In addition it can also be used to measure fibre density and to make subjective assessment of jitter Running the Macro EMG Test Select the test From the Test Manager on the right of the entry screen select the test you want from the appropriate folder Select a muscle On entering the test a muscle selection window is displayed 1 Select the muscle you are about to record from and press the ADD key 2 Select the side and then press the Acquire button Any data you store and any findings you report in the EMG summary table will be associated with this muscle Notes Ifyou do not wish to annotate which muscle you are recording from you can turn off this selection window by selecting Don t Display Muscle List from Test Options in the Di
162. tallati n ananena ann a S 1 WARNING hernie e E R T E E E 1 CHECKS seis soetsseessacctee sous cauaten oid dane sans vaneea ous sapetaa Qeaue sous rheuse stata aaTeeoetia 1 ENVITONMEMN ereire arr ie E E eE E E EEE AE 1 Power supply connections eeseesssesssessseerssessrtsstessreerereesseersrrssressressreseenees 2 Connecting the equipment sseesseseseeesesteessstrresresteerrseretsserrrsrsreereseeerssene 7 Cables E E edie aea aed E A EERE R ARE S aug 7 Connecting other electrical equipment ssseeseseeesseeesersrreresreerrserrrssesrssene 8 Switching Onie ener ee E a rA AE I oe ase aes eens 19 Switching offs nra iee teed AN ee a sei ede 19 Special instructions fOr USC eee eeceeeceeecesecesecaecaeecaeeeseeeeeeeeseaeeeeeees 20 Electrical stimulating electrodes esceeeececeesceceeeceeneeceseeeeneeceeeeeneeesaes 21 SUMUIALONS na el aceae ce EE tease cages E AE EER ERE ER E a aek 22 F otsWwite hernen aa E E EA ee E 23 Printer innen n n E E ae VEA AE AT Ee 23 Maintenance sseni sessesiiessiseirier isien estesse seseo ea ie EEE 24 After sales ServViceSUpPOrt sierra iere e i a R A ii 24 Maintenance of the instrument sessessesssseeseesseesseresseeereseerersseessrrssressree 24 CVG amt Bia sc chests EE A AE 24 PVCCE OD OS sda sistasscavsasiensedssveetauastasvsiaaicwsnddessteossdsuniek sibesssbieedabevaasoesssess 25 Electrode kit supplied by the Synergy manufacturer eee eens 25 Appendix B Interface Connections
163. te 2 Begin stimulation for recurrent stimulation press the Acquire On button for a single stimulus press the Acquire Single button and adjust the stim intensity if necessary to acquire a supramaximal compound muscle action potential CMAP If using recurrent stimulation acquisition stops automatically after acquiring 10 traces 3 Traces are displayed on the screen using split sensitivity with the CMAP displayed to the left of the Fmin cursor and the F Wave displayed to the right If any of the traces were acquired at submaximal intensity press the Erase button twice to delete all traces Press the Acquire On or Acquire Single button to acquire new traces Measure and record the minimum F latency Rotate the Fn button to position the cursor at the onset of the earliest F wave Note the latency value which is displayed in the Vertical Cursors table Record the minimum F latency in the result table by pressing the Fn button Calculate the velocity Velocity is calculated using the formula 2 x segment distance Velocity SSLN Min F M latency 1 ms Trace analysis and display Traces may be selected for marking or trace analysis Synergy offers comprehensive and powerful ways of configuring the trace area See the following sections later in this chapter gt Selecting traces Moving traces 91 SYNERGY USER MANUAL 92 Superimposing traces Automatic marker placement gt Manual markin
164. the following equations Upper Limit Constant Age Factor Patient Age Reference Age Height Factor Patient Height Reference Height Distance Factor Distance Reference Distance Temperature Factor Temperature Reference Temperature n s d Lower Limit Constant Age Factor Patient Age Reference Age Height Factor Patient Height Reference Height Distance Factor Distance Reference Distance Temperature Factor Temperature Reference Temperature n s d It is possible to use a Constant value by setting all other values to zero Alternatively it is possible to correct reference values for age height distance and temperature by entering the appropriate correction factor To display Reference Values select Table options from the Results menu and then click on the Reference Values checkbox to see the reference values displayed below the measured values in the Result Table 6 THE TESTS Configuring the Results Table Click on Table Options from the Results menu to access the Table Configuration dialog box This lists the results that are currently being displayed on your Results Table and will allow you to add or remove items from the list or to create customised results for display A maximum of 16 results can be displayed on the Results Table Use this dialog box to specify which results you want to appear in the Result section of the Test screen A maximum of 15 result
165. the Display menu Revert to a normal screen layout by selecting Full Trace Area OFF from the same menu Synergy offers comprehensive and powerful ways of configuring the Trace Area Use the Trace area setup dialog box to set up trace area parameters that you want to be global for the test Selecting traces To set Synergy Notebook so that you can select traces individually for example for changing sensitivity or sweep duration from the Display menu choose Test Options You can then Select a single trace by pointing and clicking Select non contiguous traces by holding down the Ctrl key while you click on the traces concerned 144 6 THE TESTS Moving traces Click on the trace and drag it up or down to the new position You might need to do this to counter a DC offset Superimposing traces To superimpose traces choose Superimpose ON from the Analysis menu To specify how channels are superimposed choose Superimpose setup from the Analysis menu By channel traces will be superimposed in groups according to channel All all the captured traces will be superimposed Use Superimpose OFF from the Analysis menu to have all the traces revert to their original positions on the screen Automatic marker placement If automarking is used When you switch Acquire ON markers are automatically placed on the traces and the result table updated as you acquire data It is possible to change marker positi
166. the Results menu to select the results that you want Units Used The units used to display results are fixed as follows Result All Area results All Amplitude results All Delta Amplitude and Area results Temperature degrees C Rate pps Decrement Response You can define up to two sweeps that are used to calculate a Decrement value The responses selected are used for Amplitude and Area ratios with respect to the first response See also the following sections later in this chapter gt Results Table 6 THE TESTS gt Result mode gt Reference values gt Configuring the results table Temperature probe 109 SYNERGY USER MANUAL Blink Reflex Test Clinical Overview Blink reflex is a special motor nerve conduction procedure to assess the facial nerves function e g in Bell s Palsy It is performed on only the left and right supra orbital nerve while recording responses bilaterally The stimulation can be in the form of electrical pulses or mechanical excitation using a reflex hammer The response contains two waves R1 and R2 The R1 is seen only on the ipsilateral side i e same side of stimulation The ipsi and contralateral sides have an R2 response Running the Blink Reflex test Select the test From the entry screen select the test you want from the appropriate folder Select a protocol From the Select protocol dialog box select the protocol that you want to use for this test
167. the number of APs time locked to the triggering potential the fibre density and enter it in the yellow highlighted box using the keyboard If there are two or more time locked APs visually assess the jitter When assessing jitter you may want to select the Complex 2 display to see a cascaded display of single fibre signals Next to the number of APs is a list of options for signal stability with Normal selected as the default Use the Up and Down arrow keys to highlight the correct signal stability and press the Enter key Note that the last option a blank line allows you to enter your own text to describe the signal stability When the averaged MUP is acceptable stop acquisition Press the Next key or the middle footswitch to advance to the next site The yellow highlight moves to the next line in the table A maximum of 20 sites is allowed in the table Note Count APs with peak to peak amplitude greater than 200 uV and rise time less than 300 us If the APs superimpose on each other you can modify the criteria to an amplitude greater than 100 uV or a formation of a notch in the rising falling edge of the first AP Analyse data Results The averaged MUP is marked automatically You can move the markers manually if you do the results are automatically updated The results table shows the mean fibre density and the median macro MUP amplitude Displaying the results full screen also 6 THE TESTS
168. the table are not on view you can either scroll the table or click on results screen from the Display menu to see the Table and Graphs full screen Available results Needle EMG You can display any of the following results 6 THE TESTS Phases Duration Turns Area Sweep Count Amplitude Click on Result Options from the Results menu to select the results that you want Units Used The units used to display results are fixed as follows Result Unit Phases Turns Sweep No unit Count and Firing Rate Duration Area Amplitude See also the following sections later in this chapter gt Results Table gt Reference values gt Configuring the results table Temperature probe 103 SYNERGY USER MANUAL Repetitive Nerve Stimulation Test Clinical Overview The purpose of the Repetitive Nerve Stim Test is 1 To diagnose diseases of the neuromuscular junction NMJ i e Myasthenia Gravis Eaton Lambert Syndrome Botulinum intoxication etc 2 The results of this test may also be abnormal in other diseases due to the secondary involvement of the NMJ 3 Although it can be performed in any muscle that is used for nerve conduction studies it is often performed in proximal muscles e g Nasalis Trapizius Deltoid Anconius etc that tend to be more sensitive in diagnosing Myasthenia Gravis 4 In many laboratories the ADM muscle used for Ulnar nerve conduction study is also tested Running the
169. thed Signal cable To appropriate PC connector Isolation transformer Isolated mains Other non medical equipment Class II double insulated Y junction mains cable Deluxe Stimulator Probe optional Footswitch optional Signal to printer Oxford Instruments approved printer Oxford Instruments approved monitor Mouse Microphone signal Audio output Keyboard SVGA signal to monitor Oxford Instruments approved Tower PC Isolated mains outlets ISO 800 Isolation Transformer Internal stimulator output connectors Amplifier input connectors IEC socket to local mains connector 3 core 16AWG Suitable cable to connect isolation transformer to other non medical equipment Suitable cable to connect isolation transformer to Notebook PC power supply Suitable cable connecting local mains connector to input of isolation transformer IEC plug to IEC socket connects isolated mains Network direct connection CATS shielded STP patch cable crossover type with RJ45 connectors Alternative printer connection Network card PCMCIA Ethernet Media coupler for network Index switch Trigger Rising Falling O86 evee eentenari abies 10 ACCESS IO VEIS tie ccscivecsiesscecdpesscssdgsuptereeee 18 Acquire ON switch eee eee eee eres 9 Acquire Single switch eee 9 Acquiring the data Blink reflex test eee 109 Motor NCS test ceeeeseeeeees 76 82 Repetitive Nerve Stim test 103 Acquisition setup
170. thout notice Note A full range of electrodes and accessories is available Contact the manufacturer or your local distributor for details SYNERGY USER MANUAL Components of the Synergy Notebook Arm Deluxe Stimulator Probe Patient Interface Unit Stand Footswitch Printer Multimedia Notebook PC The Synergy Notebook has an internal flat panel multi sync colour SVGA monitor Synergy supports an additional standard multi synch colour SVGA or higher monitor and can drive two displays simultaneously Patient Interface Unit see page 9 Power supplies Footswitch see page 11 Desk mount for PIU The desk mount provides flexible mounting for the PIU and electrical stimulator Optionally a mounting can be fitted at the PIU end for a Deluxe Stimulator probe 1 OVERVIEW OF THE SYSTEM Deluxe Stimulator Probe see page 12 Temperature Probe When supplied the thermistor probe for monitoring temperature is plugged into the PIU Notes The test Toolbar may include a temperature display Press the icon alongside the display to attach the temperature to the result table If you have configured Reference Values they may be corrected for temperature Stand An optional accessory with mounting or storage provided for the system and its components and accessories Arm An optional accessory that provides flexible and height adjustable mounting for the PIU and electrical stimulator Optionally a mo
171. timulator Switchable constant voltage or constant current with a low or high range Repetition Rates Stimulus Duration Output Type Range 0 5 to 10 pps Fine and random control 0 05 0 1 0 2 0 5 1 0ms Constant Current or Constant Voltage High 0 100mA or 0 300V C 1 SYNERGY USER MANUAL Low range 0 25mA 0 75V Delay 0 to 9 screen divisions Dimensions Patient Interface Unit Size 156 x 55 x 241mm 6 2 x 2 2 x 9 5 Weight 1 kg 2 2lbs Power Requirements Synergy power supply 035C005 Input 100 240 V 50 60Hz Approx 70VA max 1SO800 Mains Isolating Transformer Input 115V 230V 50 60Hz 840VA max APPENDICES Safety Standards EN 60601 1 1990 inc A1 A11 A12 1993 A2 1995 amp A13 1996 UL2601 1 2 edition 1997 CAN CSA22 2 No 601 1M90 inc S1 94 EN 60601 1 1 1993 inc A1 1996 EN60601 2 40 1998 EMC Standard EN60601 1 2 1993 Quality Standards CE marked product in compliance with the Medical Devices Directive 93 42 EEC Manufactured under approved Quality Management Systems ISO 9001 1994 EN 46001 1993 and BS EN 46001 1994 TickIT approved procedures for software development Oxford Instruments Medical Ltd Manor Way Old Woking Surrey GU22 9JU U K Tel 44 01483 770331 Fax 44 01483 727193 WEB http www oxfordinstruments com Oxford Instruments Medical Inc 12 Skyline Drive Hawthorne New York10532 2133 USA Tel 1 914 593 7100 Fax 1 914 593 7290 1 80
172. tion which is protected by copyright and may not be copied in whole or in part except with the prior written permission of Oxford Instruments Medical Ltd The copyright and the foregoing restrictions on the copyright use extend to all media in which this information may be preserved This copy of the User Manual shall be used only in accordance with the conditions of sale of Oxford Instruments M edical Ltd or its distributors Oxford Instruments Medical Ltd makes no representations or warranties of any kind whatsoever with respect to this document Oxford Instruments Medical Ltd disclaims all liabilities for loss or damage arising out of the possession sale or use of this document Medelec and TECA are registered trademarks of Oxford Instruments Medical Ltd in the USA Caution Federal law restricts this device to sale by or on the order of a physician SYNERGY USER MANUAL Contents Using this Manual ccssccsssscssssscsssssccssssccsssscssssccsssssscsseeee Vil Safety and SYMONS sicsscicccsocsccsncdossuscsvecnvoevsecseecdouveseoveesueeseoenseecde X Safety considerations s sssssssssesssesssosssossoosssossseesssossoossoossoosssoesseossoosso ix Caution and Warnings s 55 ccsssesctscosesstesiedees ii riese perp ii Eaa asip ser sei X Responsibility of the manufacturer e ce eecceeeeesseceeeeeeneeceeeeeeeeceereeenaeeeee xX Disposal Of egq pmMent a ee porer eA aE E T EEE EEE TR xi Electrical interference SUPPLESSI
173. to use 3 Click on the OK button Setting up custom results Custom results allow you to define your own amplitude and latency results for each of up to 10 markers To set up a custom result 1 Click on the right arrow head to the right of an empty text box 155 SYNERGY USER MANUAL 2 From the list screen displayed click on Custom to display the Custom result configuration dialog box The customised result is inserted in the Result Options dialog box and appears in the Results area on the test screen Temperature probe When supplied a thermistor probe for monitoring temperature is plugged into the PIU You can configure the test toolbar to include a temperature display Press the icon alongside the display to attach the temperature to the result table If you have configured Reference Values they may be corrected for temperature Displaying the full Results Screen 1 To display the Results Screen in full select Full Results Screen from the Results menu 2 To return to the test screen select Full Results Screen from the Results menu again 156 APPENDICES Appendix A Installation amp Maintenance Installation WARNING Checks Ensure that this section is read and understood before the instrument is switched on The function or safety of the instrument could be impaired if it has been subjected to unfavourable conditions in storage or in transit If at any time the function or safety is thought to
174. tretched and cannot be pulled or cause a trip hazard Cable management facilities are provided on the Notebook stand and the Tower trolley Always disconnect cables by holding the connector do not pull on the cables Wires within a cable may be damaged if the cable is stretched or improperly disconnected this damage may cause a failure in the supply of power or acquisition of data It is recommended that cables and connectors are visually inspected each day for signs of wear for example cracks and breaks If necessary do not use the cable but have it removed for service A 7 SYNERGY USER MANUAL Full compliance of this product cannot be ensured unless all components leads etc are provided by Oxford Instruments Medical Limited Connecting other electrical equipment For example printers monitors etc Precautions must be taken to ensure the safety of medical electrical equipment such as Synergy is not adversely affected by the connection of other electrical equipment to it Standard EN60601 1 1 1993 Collateral Standard Safety requirements for medical electrical systems stipulates the necessary action s to be taken to ensure that medical electrical equipment continues to comply with EN60601 1 1990 General requirements for safety when other electrical equipment is connected to medical electrical equipment Any non medical equipment connected to a medical electrical system must comply with an appropriate safety
175. trodes App A Le eae as La AR eee dS 21 Electrical Stimulator setup 0 0 67 Electrodes App A sesers 21 25 Electronic Mail eects eects 16 Email e enerne daa esain teen 16 E mail program Configuring ee eee eeeeeeeeeeeees 49 Entering patient information 23 Erase SWith csser erros 9 Exporting patient and report data 35 Fibre Density Analysis test 135 Filter settings Setup eee eeeeeeee 63 FOOtS with a erasua 11 23 Connecting App A 23 Function Key Baf 15 FUnCtiOn Keys r eoneseniinin ase 15 F Waye test iirinn 87 Generating reports 37 Generating Reports 0 eee eee 21 Getting SUpport 0 eee eee eee eeee 16 Graphs eiiiccsiiersceretentidetecsstes 42 80 86 GU Dronen a A 15 Handling patient information 23 Header Alenen eigens 42 Selecting and defining 43 Host and satellite COMFIQUTING 0 eee resies etss 48 H Reflex testisi tisores 92 Importing patient and report data 36 Inserting page breaks eee 45 Installation and maintenance App A 1 Interface connections App B 1 Interference Pattern Analysis test 113 List of controls 00 ee cece eeeeceeeeeeeeeee 9 LOSING Oemar a 14 Macro EMG test sseeeeeeeeseeeesee 138 Maintenance App A eeeeeereeeseeeee 24 Manual marking of traces 0 144 Marker placement 0 eee ee eeeeeeeee 143 Marker Setup eeec
176. ts new position You can resize either window using the mouse To resize a window click on one of the vertical ends and drag to resize Multiple pairs from the same recording When recording the data for a volitional SFJ test it is possible to record three or more time locked APs In this case you can analyse the additional combinations of APs 1 Press the New Pair F2 key 2 Adjust the positions of SFJ Window and SFJ Window2 so they are over the new pair of APs The system recalculates the results using the new window positions and displays them as a new line in the results table Up to 8 separate pairs can be analysed from a single recording Sorting traces by firing rate To display the traces sorted by firing rate right click on the screen and from the popup choose Sort traces The traces are displayed in increasing order of firing rate and the sequential IPI plot is replaced by a plot of IPI versus IDI Results The system automatically computes the mean inter potential interval MIPI mean consecutive difference MCD mean sorted difference MSD and the number of blocked potentials and displays the values in the results table The jitter is set equal to the lower of the MCD or MSD values Viewing results The sweeps used in computing the results are shown superimposed in the lower half of the trace display window The IPI data and traces are colour coded to represent the following conditions
177. u want is already open but the test is not displayed on the Function Key Bar press the F9 function key This allocates other tests in the folder to the Function Key Bar so the test you want should now be displayed on the Function Key Bar press the appropriate function key to select the test If the folder containing the test you want is not already open press the F10 function key to open other folders When the correct folder is open select the test as described above Selecting a protocol Not used for Needle EMG Test 1 Select the nerve muscle using the up arrow or down arrow keys 2 To select the left side press the left arrow key to select the right side press the right arrow key to select both side use the pointer to click on the Both button 3 Press Enter The protocol defines The default Acquisition and Stimulus settings Site labels Reference values if entered Note To use the same protocol for ALL nerves from the Display menu choose Test Options and select Don t Display Nerve Muscle List The first protocol in the list is then used for all nerves 75 SYNERGY USER MANUAL Motor NCS Test Motor NCS Test Screen Clinical Overview The purpose of the test is 1 To investigate the conduction velocity along the nerve 2 To assess functional continuity along the nerve conduction block 3 To assess degeneration and wasting in innervated muscles due to the compromise of the nerve
178. ucted Superimposed on the plot is an area called the normal cloud which contains more than 95 of data points in normal muscles In neuropathy the data points are outside and on the upper side of the normal cloud In myopathy the data points are below the normal cloud In Expert s Quantitative IP Equip analysis the signals are quantified using three features The activity measures the fullness of the pattern It has a value between 1 and 1000 msec which corresponds to the number of milliseconds from a one second IP signal that contained the spiky components of the MUPs The amplitude is measured from the signal envelope The number of small segments NSS quantify the short duration spikes that correspond to the high frequency component heard on the audio monitor The data are acquired and analysed as in TA technique from two plots Envelope versus activity NSS versus activity In neuropathy the activity values are reduced along with increased envelope amplitude and reduced NSS In myopathy the activity values at maximum force are 115 SYNERGY USER MANUAL 116 normal The envelope amplitude is reduced and the NSS is increased An EMG signal can be expressed as a sum of harmonically related sinusoids of different amplitudes This calculation is usually performed using the so called Fast Fourier Transform algorithm Special window functions may be applied to the signal before computing the FFT This
179. uipment or other sources such as radio and TV transmitters and hospital paging systems In severe cases of this kind a screened enclosure is essential f artefact The following list shows some of the more usual causes of corruption of the signal that Synergy has to process Audio feedback Broken electrode lead wire including ground electrode wire Diathermy Dirty electrodes Electrode lead wire movement Electronic dimmers Excessive low or high power line voltage Fluorescent lights Ignition noise Incorrect electrode connection to apparatus Intermittent power line load Microphony Multiple grounds in the screened room Pick up from monitor screens Poor apparatus ground Poor ground electrode location Poorly shielded printers Power cables near patient not unplugged at wall socket Radio and TV Ungrounded observers Ungrounded wheelchair or table INTRODUCTION Symbols and their definition Note Some symbols are used only on Synergy Tower or only on Synergy Notebook Some symbols will not appear on your unit if they are replaced by text in your own language Information Fn Refer to the appropriate pages of this manual for information Warning that the unit contains high voltage parts inside Preamplifier Stimulus Stimulus duration Stimulus repetition rate Audio signal Display Sensitivity Sweep Duration Function xiii SYNERGY USER MANUAL xiv Trigger rising edge Trigger falling e
180. ults table You can quickly view the report during an examination with a single keystroke using the Report function key or via the results menu Result data is transferred automatically depending on the report configuration until you select a New Patient If you later modify the traces and results you can recompile the report to ensure that it is up to date before you review the results or print the report See also gt Selecting an online report gt Viewing a report Adding comments Recompiling a report gt Editing and saving a report using MedPad gt Recalling a report Customising the report layout gt Printing a report 40 3 GENERATING REPORTS Selecting an online report l 2 3 Select Report Set up from the System menu Click the General tab in the Report Set up dialog box Click the Generate Report On line checkbox Note This selection will generate reports online for all patients If you do not want to use the online report facility set Generate Report On line to off Viewing a report 1 Click the function key to view the report online in the MedPad application The report will contain the latest test results Click the icon in the MedPad toolbar or select Main Application from the MedPad View menu to return to the Test Screen Adding comments 1 Select Comments from the Results menu A blank Comments text box is displayed Enter your comments Click
181. unting can be fitted at the PIU end for a Deluxe Stimulator Probe The arm can be mounted on either side of a stand Clamp An optional accessory that provides flexible mounting for the PIU and electrical stimulator Optionally a mounting can be fitted at the PIU end for a Deluxe Stimulator Probe Printer Synergy supports a recommended range of printers Ask Oxford Instruments for information External loudspeakers If used these must be powered by battery and must not be used with an external mains adapter When not in use switch off these speakers to maximise the life of their batteries Network card and cables This is a compatible PCMCIA network card with a foil shielded crossover network cable CATS SYNERGY USER MANUAL Components of the Synergy Tower Patient interface Unit Multimedia Tower PC The Tower PC has CDROM and floppy disk drives and is supplied with a CRT or LCD monitor keyboard and mouse Patient Interface Unit see page 9 Isolated power supply Footswitch see page 11 Trolley and arm with clamp see page 7 Desk mount for PIU see page 7 The desk mount provides flexible mounting for the PIU and electrical stimulator Optionally a mounting can be fitted at the PIU end for a Deluxe Stimulator probe Deluxe Stimulator Probe see page 12 Temperature Probe When supplied the thermistor probe for monitoring temperature is plugged into the PIU 1 OVERVIEW OF THE SYSTEM Notes
182. view the stability of the MUP Use the function keys to delete or accept a MUP for analysis A deleted MUP is indicated in grey colour Press the Edit MUP key to exit this mode 3 To combine two MUPs that represent discharges of the same MU press the Combine function key In the dialog box select the MUPs to be combined These will be shown in the superimposed mode Click the OK button to proceed with this task Press the Cancel button to abort this function 4 Press the Review EMG function key to see the raw EMG traces One can assess the validity of automated decomposition by identifying the MUPs in the EMG signals This is usually not necessary but can be a powerful teaching tool Press the Analysis key to return to the analysis mode 5 Press the Reject Site function key to delete or re accept all MUPs acquired at that site 6 THE TESTS Review of all results 1 Press the Results function key to view the full result table This will allow one to assess other MUP parameters that may not seen in the acquisition screen 2 Press the All MUPs function key to view MUP traces Up to 25 MUPs can be shown on the display area If more MUPs were analysed they can be viewed using the scroll bar A calibration bar is provided to assess the amplitude and duration of the MUPs Use the sensitivity and sweep duration knobs to change the MUP display if necessary In this mode one can also change the duration markers of the MUP To review a
183. x for the currently loaded patient This allows you to review the results from a previous visit and to redisplay and review the results during the current Visit See Opening the Test Catalog from the Current Patient dialog box From the Patient List for a patient that you have highlighted in the Patient List This allows you to review the Catalog for any patient in the Patient List without recalling the patient If you recall any results to display review or analyse the patient is loaded and overwrites any existing patient You will be prompted to save any changes for an existing patient before you can proceed See Opening the Test Catalog from the Patient List From the File menu This is useful if you are in the Test Menu screen See Opening the Test Catalog from the File menu From the Catalog menu item This allows you to quickly re display the results for the current patient during an examination See Opening the Test Catalog from the menu bar Opening the Test Catalog from the Current Patient dialog box Click the Catalog button below the Current Patient dialog box in the main Synergy screen or press Alt C The Test Catalog for the currently loaded patient appears in the right hand side of the screen Opening the Test Catalog from the Patient List 1 Click the Patient List button in the main Synergy screen The Patient List appears in the right hand side of the screen 2 HANDLING PATIENT INFORMATION 2 Highl
184. y offers comprehensive and powerful ways of configuring the trace area See the following sections later in this chapter gt Selecting traces Moving traces Superimposing traces Automatic marker placement gt Manual marking of traces gt Changing trace sensitivity gt Changing trace duration gt Compare results gt Trace arithmetic and also gt Trace area set up in chapter 5 80 6 THE TESTS You can use the full screen to examine and process your trace if you wish Select Full Trace Area ON from the Display menu Sorting results If responses have not been acquired in order distal to proximal select Sort from the Analysis Menu to automatically sort responses in order of ascending latency Note This facility will only be available if you have just one channel active All responses acquired for the current nerve study will be rearranged with the distal response placed first and the most proximal response last If segment distances have been entered and are no longer valid they will be erased and you will need to re enter them Reference Values may be deleted following a sort Results for Motor NCS tests Results can be seen on screen immediately as you acquire data If columns on the table are not on view you can either scroll the table or click on results screen from the Display menu to see the Table and Graphs full screen Available results Motor NCS You can displ
185. y of the following results M Latency H M Latency M Amplitude peak Max M Ampl Max H Ampl M Amplitude peak peak Temperature H Latency F Latency H Amplitude peak Facilitation H Amplitude peak peak Response Number Click on Result Options from the Results menu to select the results that you want Units Used The units used to display results are fixed as follows Result All Latency results All Amplitude results Max M Ampl Max H Ampl Temperature degrees C or F See also the following sections later in this chapter gt Results Table gt Reference values gt Configuring the results table Temperature probe 6 THE TESTS Needle EMG Test Clinical Overview The purpose of the Needle EMG Test is 1 To assess the excitability of the muscle Fibres Insertional activity Spontaneous activity 2 To assess the morphological changes in the motor unit Motor Unit potential analysis 3 To assess the number of motor units and their recruitment pattern Inference Recruitment Pattern Analysis Running the Needle EMG test Select the test From the entry screen select the test you want from the appropriate folder Select a muscle On entering the test a muscle selection window is displayed 1 Select the muscle you are about to record from and press the ADD key 2 Select the side and then press the Acquire button Any data you store and any findings you report in the EMG summary tabl
186. y the following paths Acquisition Results Path to point to patient data created by this user Acquisition Reports Path to point to report data created by this user If you want to use a local drive to store this user s data it is best to set it up as a UNC drive and use the UNC name here Sharing existing data on a local drive If you have an existing Synergy acquisition system that until now has been used standalone you need to set up the other machines on the network so that they can access the existing data on the acquisition system Set up the Synergy acquisition system Set up the drive containing the data as a shared drive Set up the other machines on the network On each machine that needs access to the existing data on the Synergy acquisition system 1 Map the Synergy acquisition system s shared drive 2 From the System menu choose System Configuration 3 Tick the alternate drive box and select the mapped drive that corresponds to the acquisition system s shared drive For example data may have been held on the acquisition system s machine s C drive Map it on this machine say to drive F and choose drive F as the alternate drive box When this machine attempts to access old data on the acquisition system where the database refers to files on drive C before reporting failure it attempts to access the data on the alternate drive in this case drive F 60 5 CONFIGURING PROTOCOLS 5 Configur

Viasys Teca Synergy EMG-EP Systems User Manual

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