BASIC OPERATING INSTRUCTIONS

FOR THE SIERRA II

Setup and Start up

Always check the PCMCIA Ethernet Card to make sure it is well seated and the cable
connection is made with the base unit. Always turn the base unit on first, then the
Laptop. From the Windows ‘desktop’ screen double-click the SierraXP icon. The
program will take about 15 seconds to load and will take you directly to the Add Patient
Information screen (if this screen does not appear, press the New Patient (F1) function
key). You will need to put in a last name and a first name before proceeding. The ID# is
generated automatically using a combination of the lastname, firstname and date. If
desired, you can change the ID# before exiting this screen. This is how the Sierra
software keeps track of and saves patient information. To continue on and select a test
press the Enter key on laptop keyboard or click the Start Test button. The system will
now display a menu of tests.

Selecting a Test

You can select a test from the Test Protocol menu, using Knob 1, (highlight the test by
turning the knob then press the knob to select), or by using the Test Keys 1, 2, and 3 on
the base unit. On the base unit, under the bold word TEST, typically (1) will load EMG,
(2) will load NCV/F/H, (3) will load SEP, and (ALL) will display the full Test Protocols
menu. You can go back and forth between tests at will without losing any data. The test
select buttons can be reprogrammed to select any test from your test protocols list. You
can also use the mouse for any of these functions.

Controls on the Base Unit

In any given test protocol you will see four small boxes on the lower left side of the
screen. These refer to the F1-F4 keys on the base unit. You will also see four small
circles on the lower right side of the screen, these refer to the four Knobs on the base
unit. Turn the knobs to select/highlight a parameter and press to modify. The words
written to the (left of) the knobs define what the knobs do. An example of this is if you
are in ‘NCV/F/H’ or ‘EMG’, Knob 4 is defined as Gain and Sweep on the screen. To
change the Gain – simply turn Knob 4. The adjusted Gain will display in the Gain box
on the upper left corner of the screen. To change the Sweep – simply press Knob 4 (the
word Sweep is now highlighted) now turn the knob to adjust the sweep speed. Each of
the knobs uses similar logic.

EMG Function keys.

EMG Knobs.

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Nerve Conduction Studies
When you select the NCV/F/H protocol you will get a list of nerves. You can select the
specific nerve and call it up on the screen by using Knob 1 or the mouse. You can select
the appropriate “Side” prior to selecting the nerve by using the F1-Ch. Side key.

Nerve List.

Adjust the stimulus intensity by turning the black roller on the hand held stimulator or by
using the Intensity knob (knob #3)on the base unit. To stimulate, pull back the black
roller on the stimulator or press the Single key on the base unit.

On the NCV/F/H screen the top grid (box) is for active traces. Once you get the desired
response, press the store key on the bottom right side of the base unit. You can also
press the footswitch to perform the store function. In order for the numbers (values) to
be stored, you must store the traces. Storing moves the active trace down into the
stored grid (box). You are now ready to stimulate the next site.

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 NCV test protocol screen.

You can re-stimulate and/or replace any trace by using F2-Next Site. Press Next Site
until the black triangular pointer is next to the site name in the site table (upper right side
of screen) that you want to re-stim. Now, stimulate the nerve and acquire an active trace.
If you store this trace, it will replace the trace for the selected site in the stored grid. If
you decide not to replace the original stored trace, simply press the Clear key.

Adjusting Cursors Manually

You can adjust the ‘onset’ and ‘peak’ latency cursors (that the auto cursors did
not pick accurately) while the trace is still in the active grid – simply use Knob 2-
Onset/Peak and turn to adjust. If the trace has been stored and is in the lower
grid – press the button labeled ‘Cursor’ on the base unit. By using Knob 1-
Cursor Sel/Move you can select and move all the cursors on the trace. Just turn
and press. You can also use the mouse in the stored grid to easily move cursors
around. Point and left-click the mouse on the cursor +, by holding down on the
mouse you may drag the cursor to whatever point you want and then release the
mouse.

Note: If you use the Cursor key method, press the OK key when you are finished
moving the cursors. This will reset the knob and function key labels to their
normal acquisition labels.

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 How to Use ‘Distance’ for Velocities

Press F1-Distance and enter the distance (in centimeters) from the laptop
keyboard - followed by Enter. The velocity will appear in the velocity box of the
segment table (lower right). If you want to change the distance – simply press
F1-Distance again until you return to the appropriate line. Always make sure you
are measuring the right segment by reviewing the segment sites in the lower right
corner of screen. For example, Wrist to Elbow and the appropriate distance
should be applied.

Other Options in Nerve Conduction

Using Knob 1 (or the mouse) you can change the Gain, Hi-cut filter, Lo-cut
filter, Sweep, etc. for the Live Grid.

Parameters toolbar.

Further to the right you can Sort Traces (according to ascending latencies),
Swap Sides (if you forgot to select the proper side first), adjust Pulse

Duration, or turn ‘Averager’ on/off . By highlighting the icon with the

mouse, a small box will appear and tell you the function of the toolbar button.
While the mouse is positioned over an icon you can also look at the Status Bar
(area of screen just below the Function key prompts) for a description of what the
highlighted button will do.

Status Bar.

To go on to the next nerve, press F3-Next Nerve and you are back at the nerve list.

To change test protocols, press one of the test keys 1, 2, or 3 or the All key. You can also
use the mouse to click on the Test Protocols menu at the top of the screen.

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How to Change the Nerve List Order, Default Parameters, and Normals
Start the Sierra program. Select System Setup from the Edit menu. Click on the Test
Setup tab, then, click on NCV/F/H to highlight this test. Now, click on the Test Setup
button. Three tabs are available. When you close this window all your changes are
automatically saved.

NCV/F/H Test Setup screen.

Changing the Nerve List Order:

Select Nerve List (see next page). Position the mouse at the leftmost box on the
row (nerve) and left-click to highlight the row, left-click again and while holding
down the mouse button drag the row to the desired location. A red line indicates
where the row will be positioned when the button is released. The row is position
above the red line.

Deleting a Nerve from the list:

Select Nerve List and use the mouse to right-click on the leftmost box on the
row (nerve) you wish to delete. A popup menu is displayed with the options
Insert row or Delete row. Click Delete row.

Inserting a New Nerve in the list:

Select Nerve List and use the mouse to right-click on the leftmost box on the row
(nerve) where you want the new nerve to go (the new nerve will be inserted above
the row you click on). A popup menu is displayed with the options Insert row or
Delete row. Click Insert row. Next, fill in the Nerve name, select the type
(motor, sensory) and fill in the ref site (recording site). Now proceed to the
bottom of the window and fill in the Site names and then define the Segments.
Note: if you do not fill in the type and ref site fields the Sierra will use the name
you entered as a section header (i.e., Upper Motor).

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 Reprogramming Nerve Sites, Segments and Normals:
To reprogram nerve sites on a given nerve select the nerve with the mouse. Then
retype the site names in the lower left corner of screen. Segments can also be
reprogrammed from this screen by using the mouse (left button) and clicking on
the segment to be changed (a small menu of available sites will pop up and again
by selecting with the mouse you can select the desired site and build your
segment). Distances can be pre-entered simply by typing the distance (cm) in the
distance field.

Setting up the nerve list.

Programming Default Parameters:

Change default parameters on any of the nerves from the ‘Nerve\Group
Settings’ tab. This can be done for individual nerves or for all of the Motors,
Sensory, F-Waves, etc by changing the parameters for the default nerves at the
bottom of the drop-down list.

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Using the TabData View
At any time during testing, press the F4-TabData function key to view a summary of all
the tests that have been performed on the patient.

The left side of this view shows a “tree” of the tests performed. You can turn Knob 1 to
highlight the individual entries in this tree. The right half of this view will then update to
show the data for the highlighted entry in the tree. For example, if you highlight the Left
Median Motor nerve in the tree, the right half of the screen will show the traces and
tabulated measurements for this nerve. If you highlight a section heading, like All Motor,
then you will see a table of all motor nerves.

TabData View with All Motor nerve table selected.

Opening a Test:
You cannot adjust any of the cursors in the TabData view. In order to do this you
must first re-open the test, simply press Knob 1 or click the Open Test button to
re-display the acquisition screen. Now you can make adjustments to the cursors
either by using the mouse or Cursor key.

Sorting the NCV entries:

You can sort the NCV/F/H tables in 3 ways. Click on Nerve/Side to sort the
tables first by nerve name then by side. Click on Side/Nerve to sort the tables
first by side then by nerve name. Or, select None to sort the tables in the order
the nerves were acquired.

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 Sorting the EMG Scoring Table:
Double click the mouse at the top of any column in the muscle score table to sort
the table based on the contents of that column. For example, if you double click
on the Nerve column the table will be alphabetically sorted by nerve name.

Column Setup for Motor & Sensory tables:

When any part of the NCV/F/H tree (left side) of the TabData View is highlighted
a button labeled “Column Setup” will be displayed. Clicking on this button will
display a setup screen that will allow you to select the columns for the motor and
sensory tables. These settings take effect when viewing the All Motor, the All
Sensory, and the Motor & Sensory tables. The selected columns are also those
that will be used for the tables in printed reports.

Cancel:
To exit the TabData view without opening a test click on the Cancel button. You
can also press the F4 function key on the base to cancel.

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Recording and Scoring EMG
After selecting EMG from the test protocols menu you will have the active EMG trace
on the screen. There are four primary grids or areas of the EMG protocol screen. First is
the Live EMG Data grid, to the right of this is a Muscle List, below the muscle list is
the Stored EMG Data grid, across the very botton of the window is the Scored Muscle
Table which is initially blank. The View key on the base unit will toggle through various
combinations of these initial screen areas.

EMG test protocol screen.

Volume can be adjusted using the Volume knob at the lower left side of the base unit.
Knob 4 can be used to adjust the Gain or Sweep. The toolbar across the top of the
display shows the current amplifier settings, side and notch filter status. Make sure to use
the Side select box at top of screen to select the appropriate side.

You can ‘capture’ traces using F1-Live/Capture and you can go back and forth from
insertional activity to recruitment by pressing F2-Fibs/Recrt. You can always look back
at your ‘Tabular Data’ by pressing F4-TabData.

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 Storing EMG Traces:
To Store a trace with a muscle label for your report, freeze the EMG by using the
footswitch or by pressing the Run/Stop button on the base unit. Use the Review
knob (Knob 1) to review through the last 16 sweeps of data until the activity of
interest is displayed. Now, turn the Muscle Sel/Score knob (Knob 2) until the
appropriate muscle is highlighted in the Muscle List and then press the Store
button on the base unit, answer Yes to the confirmation message. The trace is
placed into the Stored EMG Data grid and can be included in reports.

Scoring Muscles:
To Score a muscle, use the Muscle Sel/Score knob (Knob 2) to highlight the
muscle in the muscle list and then press this same knob to Score. All scoring
columns default as normal. By using the Score Tbl/Modify knob (Knob 3) you
can make appropriate changes. Turn Knob 3 (the cursor moves across the score
table) until you reach the appropriate box. Press Knob 3, a list of choices is
displayed, turn again to select one and press to select it. (The mouse can also be
used to score muscles and make scoring choices) Scoring can also be done easily
using the F3-Score key. Pressing this key takes you to a view with the Muscle
List on top and the Scored Muscle Table on the bottom. Now, by using Knobs 2
and 3 you may score the muscles as explained before. To return to the Live EMG
screen, press the F1-Main View key.

Score View in EMG Protocol

Scoring Multiple Muscles Simultaneously:

Using the Muscle Sel/Score knob (knob #2) you can click on the section name
(i.e., Hand) and all the muscles in that section will be highlighted. If you press
the knob a second time all the highlighted muscles will be scored with the normal

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 defaults. If you click on the wrong section by mistake, just turn Knob 2 and the
muscles will be un-highlighted.

Deleting a Scored Muscle from the Scored Muscle Table:

Use the Score Tbl/Modify knob (Knob 3) to highlight the row in the scored
muscle table that you want to delete. Next, press the DEL or Delete key on the
computer keyboard.

Changing the SIDE of a scored muscle:

Use the Score Tbl/Modify knob (Knob 3) to highlight the row in the scored
muscle table that you want to change. Next, use the mouse to click on the Swap
Sides button on the main toolbar at the top of the screen.

Editing the EMG Muscle List and Scoring Choices

Editing the EMG Muscle List
Start the Sierra program. Select System Setup from the Edit menu. Click on the Test
Setup tab, then, click on EMG to highlight this test. Now, click on the Test Setup
button. Two tabs are available, EMG and Muscle List. When you close this window
all your changes are automatically saved.

Changing the Muscle List Order

Select the Muscle List tab. Position the mouse at the leftmost box on the row
(muscle) and left-click to highlight the row, left-click again and while holding
down the mouse button drag the row to the desired location. A red line indicates
where the row will be positioned when the button is released. The row is
positioned above the red line when the mouse button is released.

Inserting New Muscles into the List

Select the Muscle List tab and use the mouse to right-click on the leftmost box on
the row (muscle) where you want the new muscle to go (the new muscle will be
inserted above the row you click on). A popup menu is displayed with the options
Insert row or Delete row. Click Insert row. Next, fill in the Muscle name, the
nerve and the root level. Note: if you do not fill in the nerve and root fields the
Sierra will use the name you entered as a section header, i.e., Hand.

Deleting Muscles from the List

Select the Muscle List tab and use the mouse to right-click on the leftmost box
on the row (muscle) you wish to delete. A popup menu is displayed with the
options Insert row or Delete row. Click Delete row.

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 EMG Test Setup – Muscle List.

Changing the Muscle Scoring Choices

The bottom of the EMG tab has the muscle scoring definition table. The first four
rows, Side, Muscle, Nerve and Root cannot be modified. The remaining rows can
be modified or deleted and new rows can be inserted. It is important to understand
that each row in this table actually appears as a column in the Muscle Score Table.

EMG Test Setup – Scored Muscle Table Definition.

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 Changing Existing Scoring Choices:
Type the new choices and separate them with a space. For example, the first
word to appear in the ‘list values’ is the default word. In this case it is Nml (for
normal), after this word leave a space and type in the next choice, i.e. Incr (for
increase), etc.

Inserting a New Scoring Column:

Use the mouse to right-click on the leftmost box on the row where you want the
new column to go (the new column will be inserted above the row you click on).
A popup menu is displayed with the options Insert row or Delete row. Click
Insert row. Next, fill in the Column name, i.e., Fibs. Now, click in the Options
field, choose between Read Only, Text, List and ListEdit. ReadOnly is for non-
editable data like the muscle name. Text is for comment fields and allows free
text entry. List and ListEdit are used for fields that contain preset choices. List
only allows you to pick from the pre-defined choices. ListEdit allows you to select
from the pre-defined choices or type something else. It you choose List or
ListEdit then you must fill in your choices in the List Values field. Be sure to
separate your choices with spaces.

Deleting a Scoring Column:

Use the mouse to right-click on the leftmost box on the row you wish to delete.
A popup menu is displayed with the options Insert row or Delete row. Click
Delete row.

Printing Your Results

Use the Report 1 and Report 2 buttons on the base unit to generate reports. Typically
the Report 2 button will take you right into a ‘Quick Print’ routine. This can be modified
to fit your specific needs at the time of inservice. The Report 1 button will typically take
you to a list of other types of reports and you can choose which one you would like to
generate. All of these may also be modified. Answer the appropriate questions as the
report is generated. You will eventually arrive at a preview screen of the report. This is
similar to a word processing screen. From this screen you can make any changes to your
report by using the mouse, i.e. bold, italic, change font, size, insert page break, etc. After
the report is finalized, select the ‘Printer’ icon at the top of the screen to print.

After the report is printed, close the report generator program by clicking on the “X” in
the upper right hand corner or, select File-Exit. The program will ask you if you want to
save the report, click on the button labeled “Save Report in Database”. The report will be
saved and can be recalled and re-printed at any time.

For more detailed information on the Report Generator and Template Editor see the
document titled “Report Generation and Template Editor Description”.

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Next Patient
Note: If you are currently viewing the TabData screen for a previous patient, click on
Cancel or press the F4 button on the base unit to close this view before starting a new
patient.

To start your next patient, use the mouse to go to the File Menu at the top left corner of
the screen, and select New Patient. (ALT & F keys, then Enter key on computer
keyboard will also accomplish this) This will take you to the Add Patient information
page and you can begin a new patient. NOTE: THE SYSTEM AUTOMATICALLY
SAVES YOUR PREVIOUS TABDATA WHENEVER YOU CLOSE DOWN THE
PROGRAM OR SELECT A NEW PATIENT.

Reviewing Previously Acquired Patient Data and Stored Reports

Reviewing Patient Data:
To recall a patient record you must either select Review from the File Menu or
you can press the F3-Review key if you are in the initial startup screen. After
selecting Review a menu will pop up displaying a list of patient files. By using
Knob 1 or the mouse you may select the patient to be recalled. Press the knob or
click the left mouse button twice to select the appropriate patient. The patient’s
Tabular Data and Traces are re-displayed. If a particular patient name is not
visible in the Review menu, use the search tools on the left side of the review
screen or scroll down through the list of records using the scroll bar controls.

Reviewing Stored Reports:

From the Review screen change the file type of “Sierra”, on the left side of the
Review screen, to “Report”. A list of stored reports will be displayed. Use
Knob 1 or the mouse to select the report of interest. The stored report will be
displayed. **If the report is not visible within a few seconds place the mouse
anywhere on the screen and click once and the report should appear. You may
now edit or re-print the report.

The Custom Report Header File

The report header is an RTF (rich text format) file that is created in the Sierra’s System
Setup menu. The Sierra saves this information in a file called “[Link]”. Each user
of the Sierra can have their own unique report header.

Creating the Report Header:

Start the Sierra program, and if necessary, select the appropriate login name.

1) From the Edit menu, select System Setup. The System Setup menu is
displayed.

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 2) Click on the Report Header button.

3) Depending on the software installed on your computer, the report header file
will be opened with either the WordPad or Word97 program.

WordPad program showing report header information

4) Change the information in the report header as needed. You can use bold text
and different character sizes. All the lines should be “left justified” in this
file.

5) To close the file, click on the “X” in the top right of the window. Select
“Yes” to save your changes.

6) The System Setup menu is re-displayed on the screen. Click “OK” to exit this
menu.

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