Software and Manual Written by
John D. Perry, Ph.D. - Behavioral Medicine Institute
- Strafford, Pennsylvania
Distributed by:
PerryMeter Systems * 3620 Sunrise Drive * Key West, Florida
33040 USA
And Major Biofeedback Instrument Dealers Worldwide
© 1987-1995 by John D. Perry, PhD
WARNING: If you are not familiar with the J&J USE language and interface, do not expect these instructions to make a great deal of immediate sense unless you can imagine that you are looking at the corresponding screens and stepping through the program. These instructions were written to be used with the software itself.
This edition of the PerryMeter Pelvic Muscle Rehabilitation software program includes, in addtion to the complete evaluation and practice modules, these recent additions and improvments:
1) The Improved PerryMeter Evaluation Report [PMREPORT.EXE], which provides an attractive, well-organized narrative report setting forth the most salient results of the pelvic muscle evaluation. The report is formated for use by the patient, referring physicians, and third party payors seeking to understand the results.
2) The Glazer Pain Report [GLAZERPT.EXE] is a specialized version of the standard report (above). It includes the "standard deviation" of the Rest Periods, which according to Glazer et al (J. Repro. Med., 1995) is the best predictor of results in the treatment of Vulvar Vestibulitis. It may be useful in other situations as well. It is also more robust (bomb-proof), and will sometimes read data files that, because they contain an irregular number of trials, cannot be processed by PMREPORT.
3) The Anismus Protocol and Anismus Report [ANREPORT.EXE] includes a unique sequence which adds "Push Out" periods to the traditional "Rest" and "Contract" periods, as necessary for the treatment of Constipation. The report also calculates an "Anismus Index", which is the ratio of Push outs to Rest vs. Contractions to Rest. [Push outs are supposed to be like Rests, and not like Contracts.]
Incontinence on the Internet
Incontinet.com
The Inconti-net is a new World Wide Web "page" that centralizes all the information you need about pelvic muscle rehabilitation, including research reports (published and un), critiques, clinical notes, etc. Incontinet.com is FREE, because it is sponsored by most of the dealers and manufacturers that service and sell PerryMeter and other brands of biofeedback instruments. Look at their ad pages for the latest in product specifications, new product announcements, etc.
ALSO: look for information about the incontinence mailing list, an internet email list to which you can subscribe and contribute to share information, cases, theories, and practical information with your colleagues world-wide!
For more information, just send internet email to "incontinet@incontinet.com"
(page numbers refer to hardcopy edition, and have only relative value here. Use hot links to jump directly to a particular section)
I. Overview of the Program .....4
II. Getting Started
1. Hardware
2. Software
III. Running the PerryMeter Program
1. Select B-Physiological Monitoring .....20
2. Select 1-PerryMeter Application .....20
3. Select B-Establish Patient Muscle Range .....20
4. Select Appropriate Test and Practice Sequence .....22
5. Data Saving and Report Generating .....24
6. Kegel Exercise Practice Session .....26
7. Concluding the Practice Session .....28
8. Alternative Practice Programs .....28
9. The Anismus Evaluation .....30
10. The Glazer Pain Evaluation .....33
IV. Reviewing Patient Data Records
1. The USEDATA Program - Generic Reports and Graphs .....34
2. The PerryMeter Report - Standardized Summary .....35
V. Common Questions and Answers .....38
VI. Appendix
1. Making USE changes-temporary and permanent .....42
2. The Perry Protocol & Patient Classification System .....45
The PerryMeter Pelvic Muscle Software Program is designed to allow rapid evaluation and convenient therapy of medical problems associated with weak, tense, and uncontrollable pelvic muscles. Because it collects data in a standard format (published by Dr. Perry in 1984), this program enables clinicians and researchers to compare their results with the work of others. Because of this standardization, Insurance Reviewers and Referring Physicians will more readily understand and appreciate the patient data collected and presented.
Fig. 1 - Showing DOS-USE-Application Relationships (figures omitted to save bandwidth!)
The PerryMeter program is a high-level "application" written in a general purpose biofeedback language called "USE", which stands for "Universal Sensing Environment" and was developed by J&J Engineering in Washington state. (See Fig. 1) This is similar to, for example, an accounting program that might be written in the "dBase" (which stands for "database") language. The USE language was designed to allow a PC computer to communicate with J&J's I-330 Physiological Interface System (that's a hardware box that attaches to the serial port; it contains a microprocessor-controlled serial interface, an Analog-to-Digital Converter, and various pre-amplifier modules for physiological signals).
Just as an accounting program is made up of many integrated modules (general ledger, accounts payable, etc.) this biofeedback program is composed of many separate volumes. Just as certain accounting procedures involve a sequence of modules (Writing a check, for example, might start in accounts payable, adjust the cash journal, and finally change the general ledger), this program includes sequences (called "Main Menu Items") that call upon several "volumes" in order. For example, the Standard Diagnostic Test for pelvic muscles begins with a short contraction test (a volume), a 10-second contraction test (another volume), an endurance test (another volume) and concludes with a summary (still another volume) that displays, saves to disk, and prints the patient data. Normally, one simply invokes a main menu item (such as "Diagnostic Test"), and everything follows automatically.
A major advantage of the USE system is that the user can make temporary (or permanent) changes to the program at any time, without writing a single line of computer code. You simply start the pre-formed program and run it. When you encounter a part you wish to change, you do so by pressing certain keys (described fully in the J&J USE Manual) Then you "SAVE" your changes, either on top of the originals (in which case your changes are substituted into the original) or in a new location (in which case both the original and your modified version are available to use). You can even keep the entire original program intact, and make a duplicate (in another sub-directory) for experimentation. That enables the user to make changes freely, knowing that it is always possible to revert to the original version in a couple of keystrokes. At the end of this guide we will provide some suggestions about making both temporary and permanent changes.
Figure 2 (next page) shows the general structure of the USE language. A USE "Application" consists of up to 20 set-defined Volumes, each of which has up to 10 pre-defined specifications for four major components. They are (1) Display Screens-all details about what is shown on the computer screen, (2) Program Timing-details about how the program proceeds from one screen to the next, (3) History Options-details about how the collected data as saved, re-displayed, and printed, and (4) [not shown] Audio Control -details about the audio feedback which can accompany visual displays. Note that each "Volume" has its own pre-sets, so that 10 pre-sets, times 4 components, times 10 Timing Periods, times 10 History macros (= 4,000 combinations) make up each of the 20 Volumes; therefore, some 80,000 combinations can be pre-defined in a single application. Actually, there are 29 possible display screens, a hundred possible timing intervals, and 20 possible menu sequences, so the 80,000 pre-defined choices are selected from a field of billions of possibilities. And, if that isn't enough, you can have as many Applications as you wish, and as many USE installations as your computer will hold. In short, the USE language is exceedingly complex. Yet it allows complicated pre-written programs to proceed smoothly with only a few confirming key strokes (such as "Press <INS> to continue") from the operator. The majority of users will find the program quite satisfactory exactly as distributed; the rest can make up to a billion changes before they exhaust the possibilities.
Fig. 2 Simplified View of USE programming structure, showing major components of all "Volumes", which make up "Applications".
A. The Computer System. You will need an IBM-compatible computer, with (1) hard disk drive, (2) color graphics monitor, (3) printer, (4) a Serial Port, and, of course, (5) at least one floppy disk drive to load the program.
* The Computer should be at least an AT-level (286) running at 8 MegaHertz or better with at least 640K of RAM. Smaller, older models will NOT give good results; newer, better models will give quicker response and better results. Now that prices have fallen so drastically, you should consider getting 1 or 2 Megs of "extended memory" on a plug-in card. Extra memory for your operating system means more memory available for collecting data. Without plenty of extra "extended memory, you should not be running any other programs (especially TSR programs) while running this one.
* The Hard Drive should have at least 5 Megs free for use by the PerryMeter/USE system. Newer, faster, bigger drives will work better.
* The Color Monitor should be at least EGA quality, and preferably VGA or XGA. The older "CGA" monitors give crude, chunky graphics and cannot be recommended (or supported). Monochrome VGA displays on laptop computers-if backlit-usually can be adjusted to give acceptable results.
* Any standard dot matrix printer will give reasonable results; a color printer will give prettier results (but take four times longer to print). The new "bubble-jet" and inexpensive "personal" laser printers should definitely be considered as good investments.
* One serial port is required; COM1, COM2, COM3, or COM4 may be used; it should be able to handle 9600 baud (most can). (The PerryMeter System is supplied with a 25-pin Serial Cable, unless 9-pin is specified in original order. [25 to 9 pin adapters are inexpensively available at any Radio Shack store.])
* DOS requirements: The USE system operates with DOS 2.1 or later, which covers all but the oldest PCs. More important, however, are minimum requirements for the "special" IBM file, "CONFIG.SYS". The USE instructions state that you should set "FILES=20" and "BUFFERS=20", but our program is more complex than most USE applications, and we have found that "FILES=30" and "BUFFERS=30" is safer. You should modify (edit) your CONFIG.SYS file to contain these values. (If you don't understand this, you are not qualified to get by with only reading this "Quick Start" chapter!) For further information, see Section 6.1 of the J&J manual. If you do not have DOS 5.0 and Windows 3.0 running on your system, you should definitely consider adding them, along with the extended memory card mentioned above. They add many valuable features, and make your IBM computer almost as easy to use as a Macintosh!
B. EMG Modules and Interface.
The PerryMeter System is normally supplied with the following components: (1) An Interface box containing (2) Two EMG Modules (model M-501), (3) An external Power Transformer, (4) a 25-pin Serial Cable, (5) Two sets of EMG electrodes and accessories, and (6) one "3M-1F" adapter board, used to connect the stereo-mini-plug of Perry™ sensors to the triple-snap leads of one EMG channel. The second EMG channel is for monitoring accessory muscles (optional), using the supplied electrodes, collars, and paste.
CAUTION: Observe customary warnings against Static Electricity around a computer. EMG modules are vulnerable to static zaps, which are NOT covered by warranty. See Section 6.2.3 of the J&J USE Manual for more information about static problems.
1. Install the Interface box on desk or table, at least 24 inches away from the monitor, where it will be convenient to the patient's chair. Obviously the chair must be in a position to easily see the Monitor Screen without straining.
2. Connect the Power Supply to a properly-grounded wall outlet and to the power cord socket next to the 25-pin RS-232 (serial) connector on the back of the Interface box. (Observe the faint key arrow on the plug; it should aim "up".) Because there is no separate On-Off switch, the use of a switchable "power strip" outlet is recommended.
[Hot Tip: The power cable is relatively heavy for the size of its connector; so to avoid undue strain on it, we suggest securing the power cable to the heavier and better-anchored serial cable with electrical tape or a baggie tie, to relieve any strain on the connector.]
3. Connect The Serial Cable between Interface and COM2 port of Computer. We use COM2 by default, since many users already have a mouse or modem connected to COM1. You can use any COM port; just make sure the USE software knows where to find it! Just note which COM port you do use. But if in doubt, you'll find out during hardware testing program, below.
4. Connect one EMG cable to left-most ("A") EMG module; and install 3M-1F adapter board on its snaps. Plug an extra Perry™ sensor into adapter board (or use the supplied surface electrodes and collars for demonstration purposes.) [Recently J&J began shipping special PerryMeter cables into which the Perry sensor plugs directly.]
5. Connect an External Speaker. (Optional, but highly recommended.) Purchase a small (3 to 6 inch) "bookcase" speaker with a short (12") cable terminating in a male 1/8" phone plug; Radio Shack sells many suitable ones; no separate amplifier is needed. Connect it to the 1/8" phone jack located just above Interface's RS-232 Connector.
2. Software.
The PerryMeter System consists of three distinct groups of software, as follows: (1) The USE language itself, (2) One or more "free" application programs from J&J, and (3) The PerryMeter Pelvic Muscle Application (See Figure 1). Each consists of one or more diskettes in a separate 6x9 inch envelope.
Software Installation consists of the following steps, which are accomplished by executing the program in CAPS:
1. USEDISK Installs the USE language in a new directory.
2. USEAPP Installs the PerryMeter Application Program
3. USETEST Tests the Hardware (J&J Interface).
4. USEINST Configures the Program to your computer.
The first command, USEDISK, must be typed from the DOS prompt for the drive on which the installation disks will be placed. All subsequent commands will be selected from the USE Utility menu.
Super Short-Cut
A. USE Language Installation. The USE language consists of several diskettes and an automatic installation program, USEDISK, located on the "UTILITY 1" diskette. Insert it in drive A and type "A:USEDISK". When asked, specify the source (A or B) and destination (usually C) drives, choose "H" for Hard disk System, and "C" to Continue until all diskettes have been copied into a new \USEA directory on your hard drive.) See Section 6.4.1 if you need more information.
After all USE disks have been copied, choose the Q option to quit to the newly created USE system directory. You should see a Grey Menu with Red borders top and bottom.
B. Installing the PerryMeter Application. The PerryMeter application disk(s) are supplied in a 6X9 envelope. From the grey menu, select the "USE UTILITY MENU". On this red menu, select item "F - INSTALL NEW APPLICATION (useapp)". USEAPP will ask for the letter of the drive that your application is on. First insert the application disk, and then type A or B, whichever is correct.
USEAPP then examines your computer's hard disk and selects the first (alphabetical) instance of a USE directory, which should be C:\USEA. Type a C (for continue) if this is correct, or follow on-screen instructions if it is not.
If you have already installed this application (actually, any application with exactly the same name!), USEAPP will ask if you wish to U-upgrade it or A-add another instance of it. If you upgrade, you will completely replace the original with the new copy. [This would be done, for example, if you have inadvertently corrupted the original and want to make a fresh start.] If you choose to add, you will be instructed to change the name to something unique (by at least one letter). [This would be done in order to have both the original and a version to experiment with, or if two different therapists who share the same computer want to each have their own personalized report forms available to them.]
USEAPP then warns you to have all application disks handy; at the bottom of the screen you can see the proposed DOS PATH, which might read "copying from B: to C:\USEA\USEAPP.000" for example. Notice that no files are listed, however, since copying hasn't actually started. Make a note of the three-digit filename extension (000) so you can find these files later.
Write down the sub-directory for future reference-> USEAPP.00__
Then Press C to continue.
The bottom (status) line shows which files are being copied, one at a time. There are over 160 files, so it will take a few minutes. When all files have been copied off the first disk, "CURRENT DISKETTE COPIED --" flashes at the top of the screen. If you have additional disks in this set, insert the next one now; then press C to continue. When you last disk has been copied, press Q to quit the application installation program.
Warning: You must Q - Quit and return to the RED Utilities Menu before attempting to install either another application (such as the "free" J&J applications) or even another copy of this one! From there you can select USEAPP again if you wish. If this is your last (or only) installation, leave the (last) PerryMeter diskette in the a: or b: drive and press <ESC> to return to the grey menu, then <ALT>+X to quit to the DOS prompt.
PerryMeter Configuration files:
The PerryMeter distribution diskette(s) contains certain default configuration files which will not have been copied to the USEAPP.00X sub-directory in the previous step. These should now be copied, using standard DOS commands, directly to (1) your root directory, (2) your USEA directory, and possibly (3) the USEAPP.00X sub-directory to accomplish the following tasks.
1. In the Directory COPY2DOS are two or three files to copy to your root directory (usually C:\)
CONFIG.SYS - sets both files and buffers to 30; this file is essential!
USE.BAT - a simple batch program to (1) change to the USE directory (CD\USEA), (2) install the USE printing utility (USEPRINT), and (3) invoke the USE Shell (i.e., the Grey Menu) program (US). If you install this file in your root directory, you simply type USE at the C> prompt to start the USE program.
AUTOEXEC.BAT - simply sets PATH=C:\USEA. Warning: Most users will only want to add that one line to their existing AUTOEXEC.BAT file, since copying this over will destroy an previous AUTOEXEC file's contents.
An example of the DOS COPY command to be used is:
C:> COPY A:\COPY2DOS\CONFIG.SYS C:
to copy to the root directory.
2. In the Directory COPY2USE are some files you can copy into the USE directory (usually C:\USEA), if you want the standard PerryMeter default configuration choices mentioned above (COM2, EGA, 55XX box, and store patient data on drive B:). Most users will find it easiest to copy all of these files and then make any minor changes desired at the "configure" step, below.USEPATHS.SYS - sets the path for patient data storage to B: drive.
USECONFG.SYS - sets configuration defaults to COM2, EGA-16, and 55XX.
USESHELL.DAT - contains modified versions of the System, Utility, and DOS (Grey, Red, and Blue) Menus, optimized for use with the PerryMeter application. Special items are added, and irrelevant options are eliminated, from the J&J original menu.
PMREPORT.EXE - a separate module that processes and prints diagnostic evaluation reports in the standard format.
GLAZERPT.EXE - a specialized version of the file above that produces a more detailed report, including standard deviations of the data.
ANREPORT.EXE - a module that evaluates anismus evaluation sessions and
prepares a narrative data report.
PERSONAL.TXT - an editable data file which you will modify (lines 2,3 &4) to print your Facility Name, Professional Name, and Address and Telephone information on PerryMeter Reports.
SNAPSHOT.EXE - a module that explains the Snapshot program (for capturing display screens, and information on how to order it.
An example of the DOS command to accomplish this is:
C:> COPY A:\COPY2USE\USESHELL.DAT C:\USEA
to copy to the USE directory.
Alternatively, you can copy all files at once with this line:
C:> COPY A:\COPY2USE\*.* C:\USEA
3. In the Directory COPY4VGA are seven (7) "window" files that you must copy into your PerryMeter Application sub-directory, but only if you plan to use a VGA or Super-VGA Color Monitor [i.e., even higher resolution than EGA]. (The name of that sub-directory was written down in item B-3, two pages back.)
The command to accomplish this would be:
C:> COPY A:\COPY4VGA\*.WIN C:\USEA\USEAPP.000
to copy all 7 VGA files at once.
There is also a "VGA" USECONFG.SYS file here that you can copy to USEA to set the screen for VGA automatically (instead of using "useinst".)
C. Test the Hardware. From the grey System menu, select the item M - USE UTILITY MENU (the red menu). Select B - TEST I-330 INTERFACE (USETEST). Then Select I - Interface Test (Locate and test J&J interface) Use the <SPACEBAR> to step through the test, making sure that the program (1) finds a serial card at the correct COM port, and (2) that it reports "successfully signed-on with I-300" [Fill in the Chart, below.] If the I-330 is not found at COM2, you will have to change the default setting, as described in the next paragraph. If you have connected an (optional) external speaker, you will also hear an audio test. The other (Disk and Video) Tests are optional at this point, but you should be aware that they are here if you later experience difficulties. If you experience difficulties with the interface test, consult Section 6.6 of the J&J manual.
Results of Interface Test
Suggestion: Cross out one answer before and one answer after each COM number so that this chart represents the results of your Interface Test. This information could be very helpful next year when someone new is called upon to figure out how this system was set up!
Card or No Card Not Found or Found & Signed On
Card Found - No Card at COM1- No J&J Interface Found - Successfully Signed On
Card Found - No Card at COM2- No J&J Interface Found - Successfully Signed On
Card Found - No Card at COM3- No J&J Interface Found - Successfully Signed On
Card Found - No Card at COM4- No J&J Interface Found - Successfully Signed On
D. Configure the USE program for your specific computer type and hardware. If you copied the COPY2DOS and COPY2USE files in step 2 above, and you have the standard options (using COM2, EGA, a 55XX box, and you plan to save data on the B: drive), you won't have to complete this step. You might wish to walk through it now, however, so you will understand how the USE system works with the computer - in case you ever change computers in the future.
If you returned to the grey System menu, select M - USE UTILITY MENU again, which brings up the red sub-menu. Select L - SETUP USE SYSTEM (useinst). Read the first screen and press <ESC>. On the second screen, the "J&J model number on Box 1:" will be highlighted. If it does not already say "55XX", you must type 55XX now. (What you are doing is telling the software that your hardware consists of two model "5" modules; i.e., EMG preamplifiers with a model number of "M-501".) Boxes 2,3 & 4 should be designated as "XXXX" ("X" means NO module is installed in this position.) If they are marked with anything else, change them now to "XXXX", using the cursor up and down keys and typing XXXX.
On the other hand, if you have purchased other modules and/or boxes (in order to do other forms of biofeedback as well), enter the appropriate module numbers instead of "X". The most common box is a "5566", which has two EMG (5,5) and two TEMP/EDR (6,6) modules. You must set the software to correspond to the hardware modules that you actually own. See Section 6.7 of the J&J USE manual for additional details.
The second important configuration item is "VIDEO CARD"; use the ENTER key to cycle through the alternatives; most users will choose "EGA 16 color 640 X 350". If you select "VGA", you will get slightly better resolution, but smaller printing, which some people find too small. Also, you will (1) not be able to use SNAPSHOT for capturing screens, and (2) you will have to load (copy) the eight special VGA text screens mentioned in B-3, above.
The third important configuration item is "COM port assignment". If it does not indicate COM2, or if COM2 isn't correct, highlight the 1/2/3/4 numbers by moving with the cursor-down-arrow key. Then press the number (1 thru 4) corresponding to the COM port to which your J&J I-330 is connected. (That was discovered in Section C, USETEST, above.) On-Screen Help is available here by typing ALT+H.
The snow filter defaults to OFF, the 3 sound options to ON, and COM port operation should say "NORMAL operation". Press ESC to save this configuration and move on.
The last configuration page concerns DOS paths. If you intend to use individual floppy disks for patient data storage (and this is highly recommended, unless you have both a very fast computer and a very small patient load), make certain that the [D] path for data storage and retrieval correctly specifies the drive (and therefore, the DOS PATH) that you will be using; either "A:" or "B:". If, on the other hand, you do want to save patient data on your hard disk, you should set the [D] path to "C:\USEA", i.e., the directory where you have just installed the USE system (in Section 1 above).
If you do use individual floppy disks for patient data files, you must have a floppy inserted in the specified drive before you get ready to save data, or you will get a big red "ERROR...!" message box on the screen when the program checks to see if a floppy is available.
E. Personalizing the Program An important feature of this software is the ability to "personalize" the various objective and subjective reports with the name of the professional person, and name and address of the Clinical Facility where the work was done. This improves your professional image, and may be valuable in the future when memories fade and reports are discovered in file folders.
1. Personalizing the PerryMeter Report Header. The PMREPORT (and GLAZER and ANISMUS report modules will print three lines of header information at the top every PerryMeter Evaluation Report. These three lines are read from a text-only file called "PERSONAL.TXT", which was transfered into the USEA directory from the "Copy2Use" sub-directory (see page 12).
You will need to use your text editor to add your personalizing information to the "PERSONAL.TXT" file. You can use the EDLIN program that comes with DOS, or the newer and easier EDIT program that is part of MS DOS 5.0, if you have it. You can also use MS WORD or Word Perfect, providing that you specify the Non-Document (text only) mode; you don't want any paragraph formating information saved with the file.
When you edit the file, you will observe that there is an identifying line first, then three dummy lines, and then a block of instructions. You need to insert your own information in lines 2, 3, and 4. You should observe the quotation marks at the right and left margins (about columns 1 and 79); these need to be preserved for the program to work. You should type your new information, probably in the "typeover" mode. Then use the <INSERT> and <DELETE> keys to add or remove leading and trailing spaces, until you get the quotation marks back to their original positions. It will be easier if you operate on one line at a time.
You should be aware that the PMREPORT.EXE program will read the first four lines of "PERSONAL.TXT" each time it prints a report. It discards the first line, and prints the second, third and fourth lines after the Copyright Notice line on the report. If you get fouled up, you can always re-load the "PERSONAL.TXT" file from the distribution diskette, and start over.
2. Personalizing the (optional) J&J Report Forms. The J&J USE language includes a valuable feature - up to 36 pre-defined fill-in-the-blank forms can be associated with each and every application. These report forms are named "JJFORMRE.TXA" through "JJFORMRE.TX9", and they will be stored in the same USEAPP.00X sub-directory mentioned above. Although there may be 36 report forms, only one can be associated with any individual data collecting session, and that one report form, with whatever information you have added to it, will be saved with your data for this session.
Because these report forms are associated with a particular application (such as the PerryMeter program), you must be running an application in order to use them. At any time an application is open (such as at the very beginning, or at the end, or perhaps even in the middle) you can bring up a window of Report Forms by pressing <ALT>+R. This in turn stops the program and displays a menu of already-defined reports. Two examples are provided, and the first line of each is displayed as a reference. The first is a generic report for any incontinent patient; the second is a sample report for "Leakless Clinic" that you can modify to suit your own name and needs.
The J&J Report Forms are "associated" with the current data session. That means that if you enter a Patient Name in a Report, that name will be automatically supplied when the session data is concluded and the program attempts to save the data to disk. Conversely, if you call up a Report Form after specifying the patient name for a save operation, that same name will automatically be inserted into the Report Form.
Report Forms generally contain blank fields which may be filled-in typewriter style when the report is displayed on the screen. In addition, there are three kinds of special fields that you can include:
1. The ^ (caret symbol, shift+6) acts as a tab stop; it is not printed, but you can "tab" quickly from one part of the form to the next by including the ^ symbol where ever you might want typing to begin.
2. There are four special fields which, when encountered, cause the computer to "fill-in" the information automatically. These are:
^C fills in the Client's name
^D fills in the current Date (from your System Clock)
^T fills in the current Time (from your System Clock)
^A fills in the current Main Menu Title.
3. Non-Printing Areas: Any comments enclosed in brackets [such as this] will not be printed on the form but are displayed on the screen to help the operator fill out the form. For example: [Ask the client how many accidents she had during the past week and type the answer here:] and [How many exercise sets did you recommend for the next week?]. See the sample forms, JJFORMRE.-TXA and -.TXC in the USEAPP.000 sub-directory for additional ideas.
FORMS as HEADERS: It is important to observe that if any Report Form is used during a given session, then the first five lines of that Report Form will be copied automatically to the top of any statistical or graphic report generated by the F4 screen, if the "Include Remarks" option is set to "Yes". See Section 4.2.13 of the J&J manual for more information in this feature.
III. Running The PerryMeter Program
The following two figures (next two pages) depict the "flow" of the PerryMeter Pelvic Muscle Rehabilitation Program. Take a minute to study them so you can understand how the program normally proceeds.
Ideally, you should use yourself as your first test subject, although it is difficult to wear two hats at once, so you might want to start by evaluating a personal friend, spouse, or associate. It is very important that you practice using the PerryMeter System with subjects who are able to be totally honest about their personal experiences. If your evaluation shows weak muscles, but your subject lies about incontinent episodes, you might get confused about the value of perineometry and the interpretation of the EMG values.
PerryMeter™ Sensors. Vaginal-size sensors have three electrodes located at 120 degrees along the axis. One serves as "reference" electrode, while the other two are "active". Because of this 120° spacing, the sensor is slightly more sensitive on the side away from the reference electrode, which is indicated by a small embossed arrow. Single-User Vaginal Sensors should be inserted so that the arrow points towards the rectum; thus it will be most sensitive to muscles on the uretheral side of the vagina.. [Pink (re-useable) vaginal sensors are inserted so that their offset cable leads toward the navel, for the same reason.] The orientation of rectal sensors, on the other hand, is usually not considered critical because of the much greater number of encircling fibers; but the same general orientation should be followed. The Single-User rectal sensor can be rotated to assess damage in each quadrant if that is discovered in manometric tests.
If after working through this section you are still not confident about using the PerryMeter System, you should be aware that The Perry Institute offers training courses leading to Certification in Perineometry several times a year. For more information, contact your equipment supplier, or call (in the USA) 1-800-J-D-PERRY for more information. The Institute also publishes a Master Therapist Directory listing the names and addresses of many experienced users of Perineometry, some of whom may be nearby and available for help.
If you copied USE.BAT to your root directory, type USE<enter> to begin the PerryMeter Program. (If you want the computer to always open to the USE grey menu, put the command lines found in USE.BAT at the end of your AUTOEXEC.BAT file instead.) Otherwise, change to the C:\USEA directory and type "US" (for Use Shell).
Fig. 3. Part One of PerryMeter Program Flowchart. "Weak" and "Strong" sequences follow the same pattern of tests as the "Normal" shown here.
Fig. 4. Part Two of PerryMeter Program Flowchart. Only the Main Pathways are shown. If necessary, the program flow can be interrupted at any point and the therapist can jump to a specific volume to re-do a faulty part, or to take advantage of the specialized displays.
1. Select B Physiological Monitoring. You will see a "J&J Rainbow" screen, and watch as the USE system checks the hardware and software. If you get a flashing red error message relating to the Interface, go back to Step 3, Testing the Hardware, above, and consult your J&J manual. There isn't much point in continuing without live signals from the EMG channel. If you don't correct this, the computer will "simulate live signals" by a built-in signal generator. But the signal options are based on mathematical formulae, and do not bear much resemblance to human muscle signals.
(On the other hand, you can use this feature to promote your practice. Install the same disks on your laptop, and you can demonstrate the program on the road. We don't object to you making as many copies as you wish, so long as (1) they are for the exclusive use of the one person or organization who bought the program, and (2) you can personally guarantee that only one copy can be used at one time to provide clinical services. Multiple copies for a single site or corporation are available at significant discounts.)
2. Select the PerryMeter Application, by one-digit number, from the off-white "Application Menu". An aqua-green Main Menu window appears on the right side of the screen.
3. Select B-Establish Patient Muscle Range - this is always the first step, even with familiar patients. This opens with the Program Title Page; press the <INS> key to move on. (Make sure NUM-LOCK isn't ON, or you'll type zero instead!). Then an explanatory text screen is displayed for 10 seconds, before the line-graph automatically starts. (You can usually jump ahead when a text screen is displayed by pressing the <SPACEBAR> once.)
This Volume (A) serves three important purposes. First, you establish that the patient is reasonably relaxed. Unless tension [pelvic pain] is the presenting symptom, there isn't much point in trying to teach pelvic muscle exercises to someone who is tense. Second, ask the patient to make and hold a pelvic muscle contraction. Have them repeat this several times to see if your estimate is correct. This enables you to estimate the best scale to select for the diagnostic testing and practice sessions which follow. Third, the reasonableness of the observations made in the first and second parts establishes the electrical integrity of the EMG hookup. If the relaxation level isn't reasonable (low) or contractions aren't clearly discernable, there may be a problem with the EMG cable or with the seating of the PerryMeter sensor.
a) 99 times out of a hundred, a very high reading (e.g., over 100 microvolts) is caused by an improperly or incompletely inserted sensor. Removal and repositioning of the sensor usually solves the problem. Sometimes it takes two or three tries.
b) Almost always, a very low reading (e.g., less that 0.3 microvolts) is caused by failing to insert the sensor plug into the adapter board. (The adapter board jack is a closed-circuit type, so what you are seeing is the noise level of the EMG preamp and cable.)
c) Notice the following items. The background is grey, not black. Usually only black-background screens are being recorded (and using up precious computer memory). This is confirmed by the phrase "recOFF" (recording off) in the top white status line; i.e., you can take as long as you need at this step. Notice that "1/99" is repeatedly displayed in the status line. "99" is code for "infinity" in the USE language, so that means that this is the first of an un-ending series of "trials" (screens). Notice that the counter (upper right corner) continually counts down from 10 seconds, and that the horizontal screen sweep time here is 20 seconds. Notice that the lower left indicates that the green tracing is channel (box) A1, which is labeled Perineometer Sensor, and that the current reading in microvolts is displayed at the bottom center (and updated every 1 second).
d) Decide, by studying the screen and by asking the patient to contract, which of the three pre-programed levels of EMG would be best for this patient. If most of the contractions fail to cross the blue line at midscreen, you will want to use the "Weak Muscle" routines. If most of them do cross the blue line, you will select "Medium", i.e., "regular", "normal", or "Average Muscles". Finally, if most of the contractions disappear off the top of this screen, you will need to invoke the "Strong Muscle" series. When you've decided, press the <INS> key to continue. A narrow message window appears on the left side of the screen, re-stating your options. Press <ALT> plus M (or m) to return to the Main Menu. Notice, on the very bottom line, that a "sequence is in progress" and that it must be cancelled by typing an X; do that first so you won't forget, or you will bounce back to the Vol. A sequence when you finish everything else!
You should normally select either E, F, or G on the Main Menu to begin a complete sequence of diagnostic testing, data storage and reporting, followed by Kegel Exercise observation and teaching, with optional data saving and report generation at the end. (This is the sequence recommended in The Perry Protocol.)
Items J-K-L, Diagnostic Testing Only, are intended for (1) research applications, or (2) repeat evaluations at the end of practice (especially if there has been significant learning). But remember: patients should always be evaluated under comparable conditions; i.e., before they are fatigued by a practice session. The normal sequence is test-first-then-practice. These items should only be used at the end of a practice session if you wish to document that the patient made significant gains (learning effect) in today's practice session.
Items O-P-Q, Kegel Practice Only, are intended for optional continued practice (with or without observation and instruction by the therapist) after the short 10-minute basic practice session is over. Note: because Physical Therapists are not reimbursed for diagnostic evaluations, but are readily reimbursed for neuromuscular reeducation even five days a week for several weeks, many PTs will use these items instead of home trainers. An Italian study found that patients who came into the clinic daily for biofeedback practice achieved nearly as good results as other studies have found with daily at-home biofeedback practice.
4. Items E-F-G are the Test and Practice options; they differ only in the scale of the EMG signal; 0-5, 0-10, and 0-20 µV. They all follow the standard diagnostic sequence established in 1984 by Dr. Perry and used world-wide for pelvic muscle evaluation. The Main Menu selection of E, F or G begins an automatic sequence which includes:
Short Contractions (sometimes called "flicks" in the literature)
10-Second Contractions (the best single measure of PC condition)
Endurance Test (not valid if muscles are really weak)
Helpful color-coded on-screen cue words are provided in each section to prompt the therapist, who should notice the cues and then verbally prompt the patient. Since every testing experience is also a learning experience, the prudent therapist will miss no opportunity to stimulate, encourage, educate and motivate the patient.
The Short Contractions section begins with three five-second resting screens to establish a baseline. Then on each of six numbered five-second screens the patient is instructed (verbally, by the therapist) to contract quickly and then quickly let go. It is important to anticipate the screens and give the order at the very onset of the five second interval, or some elderly patients might not get around to it in time. The section ends with three more five-second relaxation screens (to measure what effect the contractions had on the patient's resting level).
The 10-Second Contraction section consists of a 10-second Rest screen, followed by a 10-second Contract screen; this sequence is repeated five times. It is important to cue the patient to start precisely when the display opens, because the program will average the EMG level for each of the ten seconds. While the test is progressing, the examiner will want to watch the patient to see if s/he is (1) holding her breath, (2) making a fist, (3) tightening other muscles, etc. It is our practice to allow the patient to take the first evaluation without criticism, since for the patient's sake, we want to know their present understanding of Kegel Exercises. We prefer to take written notes on the patient's present bad behavior, which usually involves the use of accessory muscles, rather than to interrupt the evaluation.
The most important consequence of this strategy is that for some patients, the "EMG Scores" will actually go down at the second week's evaluation. This would lead the naive observer to think that the patient had gotten worse through practice, but obviously the lower score (after the patient is taught to eliminate accessory muscles) is the "true" measure of their pelvic floor and sphincter condition.
The Endurance Test consists of two 30-second screens, with a "Contract and Hold" cue in the upper left corner. Notice that the signal is somewhat smoother than in the preceding tests; the software filter is set higher to make it easier to observe the overall pattern. This is a traditional physical therapy test of muscle endurance or "tonic" muscle fibers; we measure the time that the patient can maintain a contraction at or above 50% of their maximum. Unfortunately, the test requires that the 50% level be clearly distinguishable from the background resting tension level, and in many elderly incontinent patients this will not be true, at least at the initial evaluations.
Throughout the diagnostic testing one common problem is restlessness or erratic movements during the rest periods. Many patients do not understand how to relax, and they do not comprehend that we are actually trying to measure their resting level. They use the rest period to adjust their posture, as if that would somehow permit a better showing during the "important part", the contraction test. This is especially common among patients with Sensory Urge Incontinence which results from high (noisy) resting levels (as opposed to Motor Urge Incontinence, resulting from lack of bladder inhibition.) Such patients will usually need to be taught relaxation skills in addition to pelvic muscle exercises.
5. Data Saving and Report Generating. At the conclusion of any of the diagnostic testing sequences, control moves to Volume K. Immediately the program tries to automatically save the testing data to disk (first in "normal" format, and then a second time in "High Resolution" format). If a floppy disk drive has been specified as the data path but no disk is yet in the drive, an error message appears. Insert the proper data disk, and press <ESC> to clear the error condition. (Or just press <ESC> but remember to do a manual save in the next step.)
The first saving operation brings up the Client Name Box. If your present client isn't listed, Press "N" for New Client and supply the Lastname, Firstname, and Middle Initial. Be sure to enter an ID number (which normally would be the client's Social Security number for insurance documentation purposes). The Auxiliary field can be used for any purpose you select (and it can later be used to retrieve data based on what is entered here). We usually enter "vaginal" or "rectal" to indicate the type of sensor used.
The program compares the current monitoring channel labels to the labels most recently used for the same patient-name. This is to permit grouping of like data together if multiple session printouts are later programmed. The labels would only be different if you were also treating the same patient for hypertension, for example, and had monitored other parameters in those sessions. Normally, you should "Use Current Labels", and type "Y" for Yes to confirm that.
Be sure to notice the number fly by, in the lower left corner, as the "saving" process follows. That is your assurance that your data is being automatically saved to your disk or diskette. You'll notice also that the second or "hi-res" save takes a little longer. More data is needed for the more detailed PerryMeter report.
The "Evaluation Data Printing and Display" screen provides instructions about what to do next. Pressing the <F3> key displays a summary graph which can be used to discuss the test with the patient. Pressing the <F4> key presents a menu of "history" options, in five categories.
SAVE - data can be saved to disk (from computer memory) in either normal (#1) or high-resolution (#8) format. The difference is that "normal" saves only trial averages, while hi-res saves every single data point (in our case, every one-second average, or about ten times more data). Hi-res is intended for use with external database and statistical programs, whereas Normal is used by the very handy USE companion program, USEDATA. Normally, unless you disable this "history" feature on the F5 Screen of Volume K, the program will automatically execute both #1 and #8 "saves" for you; it isn't necessary to repeat them manually, unless you have reason to think something went wrong the first time (such as the wrong client disk inserted!).
DISPLAY - data and graphs can be presented to the computer screen for "preview" and discussion. While viewing the statistics, the user has the option of pressing a key (listed at the bottom of the Screen) to PRINT or SPOOL the information which is being displayed. [Unfortunately, due to a USE system quirk, that choice goes away if you display all the numerical data and actually get to the end of the data file. Of course, you can repeat the command if you wish.]
During the display of graphs, however, you can P - PRINT each screen (if there is more than one) as it is displayed. You can also re-scale the graph before printing, by pressing S and following on-screen instructions. Graphs, however, cannot be "Spooled" to disk. (But they can be re-created later using the USEDATA program; see below.) (Warning: The program will usually lock up if you select PRINT but don't actually have a printer connected. If that happens, all your un-saved data (if any) is forever lost, and you will have to press <CONTROL> + <ALT> + <DELETE> (all at the same time) to do a "warm boot" of your computer system.) It is, therefore, best to always confirm that your printer is on and on-line before sending printout to it.
PRINT - data and graphics can be sent directly to the printer, to be printed while the therapist and patient are discussing other matters. Color printers can be used (with appropriate optional EGA/VGA utilities, such as PIZAZZ Plus), but color printing takes four times longer than B&W, and besides, the colors don't reproduce well on most copy machines. In the best of all worlds, it is highly recommended that the patient is always given a printout of today's session before leaving.
SPOOL - When a printer is not available (e.g., when working "portable" with a lap-top computer), the data (but not any graphics) can be "spooled" to a "disk file" which will be named "jjspool.txt" At the end of the day, the diskette containing "today's" spool files can be put in the big office computer and printed quickly on the office laser-printer(!). See the J&J Manual if you are interested in using this feature. You can also use the USEDATA and PMREPORTS programs to process data hours and even days later.
ERASE - Only when you have completed all other alternatives, including saving to floppy, should you select option #7, which will erase the current session from the computer's memory. Erasing memory is important, however, to (1) avoid double-saving data and double-printing at the end of the practice session and (2) ensure that there is enough computer memory to complete the up-coming practice session. Rest assured that erasing memory has no effect on data stored on floppy or hard disks, which must be erased by very different commands.
After exercising "F4" Screen options, pressing the <SPACEBAR> will return you to the "F2" Screen of instructions.
6. Kegel Exercise Practice Session. Press the <INS> key to advance to the practice session. [Make sure NUM-LOCK isn't ON, or you'll get an error message!]
This practice session is based on Dr. Perry's copyrighted "Kegel Counter" algorithm. It is unique in using two criteria lines-one, in yellow, for evaluating contraction levels, and one, in blue (cyan), for evaluating relaxation levels. Notice that at the bottom of the screen graph the A1 channel (box) is assigned to both the yellow and the blue(cyan) displays. The line graph is actually drawn twice, first in blue, and then in yellow, the yellow over-prints and obscures the blue line-so long as both tracings have the same range, scale, and filtering. (The reason for pointing this out now will be apparent in a minute.)
Notice that the on-screen instructions call for relaxation on the left half of each screen, and contraction on the right half. Color-coded cues are also displayed. The upper (yellow) and lower (blue) criteria lines provide a horizontal band ("no-person's land") into which the tracing should not stray. That is, when relaxed, the tracing should be below the blue criterion; when contracted, the tracing should be above the yellow criterion. When it is in between, however, a slightly adversive audio tone is heard from the external loudspeaker (if one is attached) or sound system (if connected).
When a patient is doing "very well" (as defined by the criteria lines which you can set), the sound will not be heard for very long. If it is not heard at all, or is heard continuously, then one or both criteria lines need to be adjusted by the therapist. The normal practice in behavioral therapies such as this is to set the criteria so that the patient will be successful about 80% of the time. If it is too hard to be successful, the patient will get discouraged; if too easy, there is no motivation to work at it.
Adjustment of the criteria lines is easy. Notice that there is a "happy-face" character in front of either the yellow legend or the blue legend (on the bottom line). Notice also that pressing the <TAB> key cycles the happy-face from the one to the other. In the USE language, the "signal control keys" (top keyboard row:1 thru 0, -/_ and =/+) modify whichever channel is designated by the happy-face. The plus (+) and minus (-) keys (either on the main keyboard or on the numeric keypad) cause the designated criterion line to move UP(+) or DOWN(-). [On the main keyboard, it is not necessary to press <SHIFT>, even though + is normally an "upper case" choice.] To change the lower line, for example, <TAB> the happy face to the right(blue) legend and press - or +.
In the event that the patient is too weak for even the "weak" screens, the sensitivity ("gain") of the display can be increased temporarily by pressing the 6 key. Note, however, that the top-row keys affect only the channel with the happy-face, and this display is made up of two over-writing tracings. Therefore, you will have to press 6 once (or twice), then <TAB> to move the happy-face to the other channel, and then press 6 once (or twice) again, in order to synchronize the two tracings. (Conversely, if the tracings are separated, you know that they have been differentially altered.)
Kegel Exercises are presented in five groups of five repetitions. Every 100 seconds (5 relax + 5 contract X 10 reps) the program will automatically PAUSE for 15 seconds of rest. Tapping the <SPACEBAR> during the pause will cancel it and return at once to practice screens. These break periods are included both for the patient to rest and for the therapist to make educational interventions ("Now, Mrs. Jones, Let's see if you can do the next set without holding your breath. I noticed that you didn't breath at all during contractions.") Even with four 15-second breaks, the entire Kegel Exercise section takes less than 10 minutes to complete. This should be considered a bare minimum; for many patients, the Kegel Practice section should be repeated one or even two times during an office visit. It is important to convey to the patient that the Exercise Approach to pelvic muscle rehabilitation takes a lot of hard work. If they can't do 20 minutes in the office, how can they honestly do twenty minutes two or three times a day at home?
You can, of course, interrupt the exercise sequence at any point to discuss progress with the patient. To do so, simply tap the <SPACEBAR> once; the word "PauReg" (for "Pause Requested") will appear in the center of the top white status line. At the end of the current 10-second activity (Relax or Contract), that word changes to "PAUSED" and action stops until the <SPACEBAR> is tapped a second time. One should always PAUSE for extended discussions (during which the patient is not following the on-screen cues), since these will otherwise later appear as "poor" contractions in the printout.
7. Concluding The Practice Session. After 25 repetitions, the regular practice session ends and a "DATA" screen is presented, listing alternatives similar to those at the end of the testing sequence. Most therapists do not save practice data, although that is an option. Almost everyone prints the results, either in statistical or graphic format, or both, either immediately, or at the end of the day.
The therapist should consider the many advantages of providing printouts to the patient at the end of every session. First, the patient needs strong weekly encouragement to continue the exercise discipline. Comparing this week's chart with last week, or the first week, may be very rewarding and motivating. Second, patients can use the printout to document the seriousness of their exercise program. ("See how much progress I've made! That's why you need to continue washing the dishes each night, so I can have my scheduled Home Practice time.") Finally, the printout serves as a handy tool to help the shy patient explain the program to family and friends. That makes the patient feel good, and may even generate additional patients for the program. In addition, copies of printout should be sent regularly to referring physicians, and to insurance companies with invoices. Many provide coverage only "by report", so it may even be essential for reimbursement.
Saving data files to disk is inexpensive, and may be essential in a research setting. Provided that good computer disk back-up procedures are followed, your computer files may invaluable in the event that the physical records are lost or damaged.
After saving, displaying, and printing practice session data, you should ERASE all data from the computer memory, either by selecting Option #9 on the F4 menu, or by pressing <ALT>+Q from any screen. "ALT-Q" means "Quit on this patient but restart the program for another". It is absolutely essential to avoid mixing one patient's data with another patient's data.
8. Alternative Practice Programs. There are several specialized practice programs (in other "volumes") that are available for use under appropriate conditions. One use is when the patient isn't responding well to the regular Kegel Practice. Another is for variety, when the patient (or therapist?) is bored. Finally, good clinical judgement might argue for a particular program for a particular patient; each program has certain inherent advantages. You should experiment with each of them (using your friends and colleagues as subjects) to understand their strengths and weaknesses.
To access the alternative programs, first Press <ALT>+Q to return to the Main Menu window, and press X to cancel any sequence still in progress. Then Press <ALT>+V to bring up the purple "Change VOLUME" window. The alternative programs are located in Volumes N, O, S and T.
T - Game Screens for Practice. Volume T contains three video game programs that are both fun and good practice. Press <ALT>+S to see the choices. 1 - Egg-catching Game and 2 - River-Raft Navigation Game are both excellent for building muscular control. Patients must learn to make precise intermediate-strength contractions to control the "basket" that catches eggs, or keep the raft on course and off the rocks. The "number of eggs caught" or "miles traversed down the river" provide an alternative measure of success.
3 Traffic Light requires the patient to keep the EMG level above (or below) a certain level (or "threshold") for the light to "change", allowing the vehicle to move down the highway. (The threshold is accessed by pressing <ALT>+T; press E to enter a value, or +/- to change the threshold by small increments. To reward relaxation instead of contraction, cursor-down to "FREEZE on signal BELOW threshold" about mid-screen, and press <ENTER> twice to get "FREEZE on signal ABOVE threshold". Then press <ESC> to return to the game screen. [See appendix for hints about making such changes permanent.]
Note that EMG data is being recorded during the games, and it may be processed (saved and printed) at the end of 60 X 10 seconds, or 10 minutes, just as in the regular Kegel Practice volume.
There are two groups of patients who have responded well to these games; the young and the old (and, of course, the young at heart).
S - Special Practice Screens. Volume S includes five very different displays that are often useful. Press <ALT>+S to display the list of screens.
1 - Contracting Circle is an isomorphic representation of the vaginal or rectal sphincter space, and has been useful in helping cognitively impaired persons better visualize the required contraction and relaxation.
2 - Pyramid Practice is especially useful for extremely weak muscles, since it provides both a digital bar graph on the left, and an expanded "pyramid" on the right. In making or unmaking the pyramid, each unit on the left scale (initially, 1.0 microvolts) is broken down into 160 discrete "steps" or bricks, thus providing extreme sensitivity (on the right) while preserving a good range on the left.
3 - Spiral Design Practice is an interesting alternative that is similar to the contracting circle, but more "three-dimensional".
4 - Analog Meter Displays are simply computerized displays of traditional (old-fashioned) biofeedback "meters". Press <F10> to cycle through the available meter styles.
5 - Live Graph with History Bars is a very useful alternative. It combines a rapid real-time display (top) with a bar-graph recording the entire practice session (bottom). By alternately instructing the patient to "Contract" and "Relax" on each successive screen, an impressive "short-tall-short-tall" bar-graph of contractions and relaxations can be constructed.
O - Pattern Matching Exercise Sets. Volume O contains some experimental patterns (stair-steps and circles) which are presented automatically (in red). The patient is instructed to "follow" or "match" the red pattern with his/her own tracings, which is presented in yellow. The "patterns" are generated with the Virtual Channels function's Signal Generator; and a "deviation" score calculates precisely how much discrepancy exists between the "pattern" and the patient. The regular Data Saving and Printing functions are available after the five-minute sequence is completed.
N - Accessory Muscle Monitor (A minus B). Volume N presents the traditional Kegel Exercise prompts for use with two EMG channels. The Perineometer sensor is connected to channel (module) A, and a regular surface electrode cable to channel (module) B. On the lower half of the screen, these two channels are displayed as regular line graphs. On the upper half is a "Virtual Channel", defined as "A minus B", plotted in yellow. A threshold line (at zero) shows when the two muscle sites are producing equal output (i.e., A-B=0), and an audio tone sounds when the accessory muscle (B) is more active than the sphincter(A).(i.e., A-B<0).
As the patient develops better isolation through practice, the therapist can adjust the threshold of the yellow graph upwards, so that the net score (A-B) must be progressively greater to get rid of the audio signal. The regular Data Saving and Printing functions are available after the eight and a half minute sequence is completed.
THE ANISMUS EVALUATION
The "Anismus Evaluation Protocol" (Item S) and "Practice Exercises for Anismus" (Item T) should always be selected from the blue-green "<<<Main Menu>>>", (rather than from the purple Volumes list) so that correct coding in applied to the data file when it is stored to disk. Conversely, if you don't select from the Main Menu, you won't be able to use the narrative report generator to analyse the data later.
The Anismus Evaluation should probably only be used after a regular pelvic muscle (rectal sensor) evaluation has been completed. This will enable you to put the results in a better context.
The Anismus Protocol resembles the 10-second test of the PM evaluation, except that the sequence is "REST-SQUEEZE-RENT-PUSHOUT-(repeat once). There is no magic to the 2X2 design; if you want more data, press ALT-Q and run it again.
(Note: Be sure to always clear memory [ALT-Q] between each data collection; otherwise, you'll "lump together" all Squeezes and all Pushouts, with unpredictible results). You will begin on a "set up" screen which allows you to verify connections and signals. Then Press <HOME> to record at least 10 and perhaps 30 seconds of "Baseline" data.
As soon as "Rest#4" is completed you will be presented with a summary graph of the session, which you can review with the patient, or use to verify the data collection. Then Press the F4 key for data display and storage options.
[1] Standard Anismus Evaluation (high resolution save) No Erase - will save your data on the drive designated by you in the USEINSTAL program (default is drive B if you didn't change it.) Be sure to insert a floppy in the correct drive ahead of time, or at least before pressing ESC when you get the error message.
We suggest putting the code "ANISMUS" in the Auxiliary Field. And be sure to put proper patient names and ID numbers (SS numbers prefered) when requested. Remember, your records might end up in a court of law someday. You can watch the progress of the "save" in the lower left corner.
[3] - Display numerical Summary and Graph Results (no erase) - This option displays the summary data on screen, a page at a time. At any time before the last page is displayed you COULD press "P" for printer, but the "standard" way is to select 5 (below) for printing. After scrolling through the numbers, a graph will be drawn; this may or may not be printable, depending on the printer you use. [If it won't print, see our discussion of "Snapshot" (by David Mars, especially for this program), or Pizzaz (a general purpose screen capture program that is more flexible, but a lot more difficult to configure).
Make sure you have your printer connected, ON, on-line, and ready, before sending anything to the printer; otherwise your system will hang up and you'll loose any un-saved data. Your printer may not be able to print the graphs; some combinations don't work. For instance, I can't print the graphics on my own expensive NEC Silentwriter, but they print just fine on an inexpensive Panasonic dot matrix printer. The Simple Bar Graph option provides an easy to explain picture for patient educaton. (Take advantage of the SCALE options before printing).
[5] - Print Numerical Summary and Graph Results (no erase) - This option will send the same data (as in 3 above) directly to the printer. You would select this option if you want to preserve the complete data file for detailed analysis. This is optional; you will always have the option of printing the more interesting summary report from the grey menu.
[E] - Erase - Only after saving the data and optionally printing it, you should select "erase" to clear the most recent examination's data from the computer's active memory. Note that the area in pink, just to the right of the date and day, is blank. After erasing, you will see a flashing message "No data recorded yet!" there. This means there is no (longer any) data in the computer's RAM. Don't panic; if you previously selected "1", your data has been safely recorded on your floppy (or hard) disk for permanent storage! Be sure to erase all (RAM) data before moving on!
[Alt-Q] - If for any reason you wish to repeat the same evaluation immediately, you can skip the "erase" step above and press ALT+Q to automatically (1) erase the data and (2) restart the same application in one step.
The program is set to launch immediately into the practice exercise session when you press <INSERT>; if you want to skip the practice session now, do an ALT-X exit instead, or, more refined, an ALT-M, then X to cancel the sequence in progress.
The Anismus Practice (therapy) Module
The Exercise program is similar to the PerryMeter Kegel exercise program, except that SQUEEZE and PUSHOUT are also cued. And, since control rather than strength is the objective in Anismus treatment, the individual periods are only five seconds each.
The exercises are grouped in five groups of two sets each, with a 15 second rest period in between groups. If you need more time, press the spacebar (J&J's 'pause requested' command). If you need less, just tap the spacebar when the "Let's take a break..." page is displayed and you'll end the break at once.
Notice that the status line at the top of the screen shows the time (based on your computer's clock), the Kegel group number "10" to "50" for 1 to 5, the record status, the trial/period you are currently collecting, and the seconds remaining in the current trial. This is to remind the therapist of where you are in the sequence.
In general, the therapist should try to talk during the breaks, so the patient can focus on internal proprioception during the exercise (that's what biofeedback is all about!) However, there are exceptions to every rule. Also, the therapist usually should not abandon the patient during exercise; as bad habits can develop quickly. The therapist should be observing closely, noting breathing patterns, accessory muscles, posture, vocalizations, etc., and providing massive amounts of "moral encouragement" for this sometimes boring effort.
After the practice session (after 0:00 of 10/10 of Kegel50) you are presented a page of instructions concerning the data saving and printing options available, and the program immedately jumps to an automatic data saving step. Follow the on-screen instructions; select a client name from the list, or press "N" to enter a "new" client name. The data will be saved twice; once in "normal" resolution, once in "high" resolution (for more flexibility in data analysis) [In other words, options 1 and 8 have already been selected for you.]
The Anismus (Narrative) Report Module
(Option H on the red and grey menu)
Because the J&J raw data matrix is not very useful, we have constructed a stand-alone BASIC program which gathers the raw data from your floppy storage diskette and processes it in a meaningful way. It is intended to be useful to you, the patient, the referring physician, and to the third party payor!
Like the PerryMeter PM narrative report, the Anismus narrative report must be selected from the red and gray menu after ALT-Xing out of USE itself. It also works on the same basic principles; in fact, it uses the same "PERSONAL.TXT" file that contains your personalizing information for report headers. If you use the same disk for high-res pelvic muscle data and high res anismus data, you will notice that the Anismus program only lists data files that have "Anism..." in the Main Menu data field, so there may be gaps in the listing of files that you can select to print: e.g., 1,2,3, 7,8,9. (4,5,6 didn't have anismus data).
On the other hand, if you use the PMREPORT program to read a floppy data storage disk containing both or even any anismus data, you WILL be able to select an anismus file, but the program will fail and report and ERROR, that the first period isn't "BaseLin". You can avoid this embarrasment by following our advice above, to always put "ANISMUS" in the auxiliary field of anismus patients' anismus evaluations. Since the AUX field is displayed by the PMREPORT program selection list, you'll know better than select them from the wrong program.
Next year we might change the PMREPORT program so that it doesn't even "see" the anismus files, just as the ANREPORT can't "see" the PM files now.
(Option G on the red & grey menu)
The Glazer Pain Report is a special version of the PM Report program that provides an important extra detail-the standard deviation (variability) of the 10-second contract and relax scores. According to Dr. Glazer's research, reduction in the variation in the resting scores was the best predictor of decreased pain and increased sexual activity in 33 VV patients. Patients must be taught to relax to very low levels (>0.5 microvolts), with very low s.d., and maintain this for several weeks or even months. The results are especially significant because all of his patients had failed to obtain relief from conventional methods.
In addition to the tabular-narrative report, the program also saves about 20 lines of summary data in a file called "jjdfxxxx.wb", which can be read into most spreadsheet programs directly and then used to generate graphic and comparisons over time. The "*.WB" file is normal ASCII text, comma delimited. These files can also be used by SPSS and other popular statistical programs. A "readme" file in the folder "readmes" on the distribution diskette provides a sample.
IV. Reviewing Patient Data Records
1. Using the Built-In USEDATA Report Program.
The USE Language includes a program called "USEDATA", which makes moderately sophisticated statistical analyses and graphic summaries of physiological monitoring data that has been previously stored to disk in the so-called "normal" resolution. (Trial Averages, but not raw data points, are preserved in "normal" resolution.) [During the time that the data is still in the computer's memory, similar operations can be performed using the menus available under the <F4> key.]
USEDATA must be used in conjunction with another J&J USE program, USEPRINT, to print graphics. USEPRINT translates the EGA and VGA screen graphs to a medium-resolution form that can be printed directly. USEPRINT is a "resident" interception program that must be loaded before the Use System is started (which is why it is included in the USE.BAT file.)
An alternative program, commercially available, called PIZAZZ PLUS (about $150) translates VGA graphics screens, including the colors, into a form that any dot-matrix printer (including color) can handle. It provides better resolution and many other options, but it takes extra time, both to learn and to use.
USEDATA is invoked by selecting option D - Review Patient Data (from disk) on the grey System Management Menu. Since each application has it own pre-programmed choices, you must next select the Application (PerryMeter) that first stored the data.
If your data is stored on floppy disks (and this was specified in the USEINST program), USEDATA asks you to insert a data disk (in the previously designated drive) and press any key to continue. (If data is stored on hard disk, there is no pause.)
The Main Menu of History Jobs, a light blue/blue menu, appears to present several choices, somewhat similar to those available under the <F4> key at the end of each physiological monitoring session. The main difference is that the <F4> key works only with the patient data currently in the computer's memory, while the USEDATA program can work only with data recorded on disks. Therefore, since we are selecting stored data, there are four new selection elements:
Specify the Patient's Name
Specify the Dates - both starting and ending dates for the session
Specify Auxiliary Field
Specify Main Menu Entry.
When any option is selected, any "to be specified" parameters will be presented in a window box to be chosen for this one time. Based on the particular data file(s) that you are looking for, you must construct a "search criteria" that will find exactly what you want. This takes a bit of thinking, but really isn't as bad as it first seems.
For example, if you only treated one patient on May 25, 1841, you can leave "any and all" for patient name, "any and all" for auxiliary field, and simply specify May 25, 1841 as both the starting and ending dates. The program then searches your disk, and pulls up all data files that match the criteria-in this case, the one (or more) file(s) for the one patient seen on that date.
Another example: the NAME field allow "wild-cards" (question marks). You might locate a particular patient, Sally, by specifying "SAL??????" as the first name (provided you don't have any "Salvadore's" on the same disk!) Similarly, if your patient's middle initial is unique, that would be all it would require to find that patient. (Note that the other fields should be left as wildcards (?????????????).
Two of the prepared "jobs" will locate and display (J) or print (K) the single most recent datafile. These were designed for situations where the patient has to leave before you have time to do the printout, but you immediately sit down afterwards and process it (or, in any case, before any additional data is stored on that disk.)
Jobs S and T are included for special purposes, and should be used with great caution. Job T permits direct editing of previously stored data; for example, removal (zeroing) of known aberrant data glitches in order to print nicer graphs. A more common use is correcting the mis-spelling of a patient's name. (When storing patient data after the very first time, you should always select from the computer-generated list of existing patients, rather than entering a NEW name, to avoid spelling it even slightly differently. Names must be absolutely identical, right down to the spaces, initials, and punctuation, to be sorted and grouped together on data retrieval.)
Job S performs a similar function; it allows the editing (and printing) of any Patient Report Forms previously created using the <ALT>+R function (described in another chapter).
2. The PerryMeter Report - Standardized Evaluation Summary.
The stylized PerryMeter Report was created by popular demand to provide IBM users with the same standardized interpretive report that was first introduced in our Commodore computer program in 1985. It is written in BASIC, and is automatically accessed from the Grey J&J System Management Menu as option "F".
About the PerryMeter Report Option. The program is distributed as a stand-alone "EXE" program. It runs independently of the USE language and system to provide a highly stylized Perineometer Evaluation Report which is much more suitable for distribution to third parties, such as insurance companies. The program name is "PMREPORT.EXE" and it should have been transfered to your USEA directory in the installation process. This program was written by Dr. Perry in direct response to many, many requests from IBM users who wanted the same kind of report that is available on Commodore and Orion/Perry Teacher systems.
NOTE: PMREPORT will only process diagnostic evaluations that have been saved to disk in the high resolution format. Moreover, you must have run a complete evaluation (Flicks, Holds, and Timing) in order for the program to work. The complete evaluation (obtained by running Main Menu choices E, F, G or J, K, L) is saved in (normal and) high resolution form by Volume K, resulting in a data file that is exactly 220 lines long. Each Hi-Res file has a name beginning with "JJDF", a four digit number, and ends with ".HIR".
The PerryMeter Report is option "F" on the Grey and Red J&J System Management Menu. To use it, simply press "F", and the program opens by asking you to specify the drive for the data disk. You can select "a", "b", or "c" for drives A:, B:, and D:\USEA. If your data is elsewhere, you can select "d" and you will have a chance to type the actual path (e.g., "e:\clinical\patients\data")
The Program then looks for a file called "JJDFDIR.HIR" on the specified drive and path. If not found, it asks for the drive and path again. If found, the contents of the file are displayed. Each (numbered) line of the file represents a specific "saved" data session. You are presented with the patient name, ID, Auxiliary field, and date. (If there is more than one per date, they will still be in chronological order.)
Type a number corresponding to the line number of the data file (person, date, and session) that you wish to process and the program will search the specified directory for the corresponding data file. While the program reads the file and crunches the numbers, it begins sending header information to the printer to speed up the process.
The header consists of five lines. The first two identify the Evaluation Report and carry the Copyright notice. Three lines are available for the (1) Facility Name, (2) the Responsible Professional (including B/C & Medicare Numbers, etc.) and lastly (3) for the Address and Telephone numbers. (See the "Personalizing the Program" section for instructions on how to do this.)
The data of the report is intentionally printed along the left margin to leave plenty of room for hand-written comments, especially those that point out areas of improvement or concern, to be sure the patient understands what is says. (Did you ever try to read a lab report on a blood test? It seems written only for the professional to read!)
Two kinds of hand-written notes are especially common in our practice. First, we always identify (circle) aberrant scores at the initial evaluation, and write "This high resting tension probably accounts for your pelvic pain." or "Your weak contractions are probably the cause of your Stress Incontinence." At subsequent sessions, we always try to find something to congratulate: "Your contractions are 50% better than last week-Keep up the Good Work!" The hard empirical data (computer-printed) and strong emotional subjective comments (hand-written) balance each other in a "be wise as serpents and gentle as doves" way. This combination of art and science helps to set perineometry apart from disciplines that err in either direction alone.
The first part of the report describes resting levels-before and after the short contraction test, and also calculates the difference between them (a new feature). Resting levels above 2 µVolts should always be noted. (See The Perry Protocol for additional information about norms for perineometry.)
The first test summarizes the Short Contractions. Short contractions, which measure the phasic or fast twitch muscle fibers, are not much interest in urinary or fecal incontinence (or sexual response), except as they may be significantly different from the Ten-Second Contractions which follow. If the "Average Phasic Maximum" is much higher than the "Net Tonic Strength" (in Test 2), we know that the patient has been doing no exercise or only very brief contractions.
The second test summarizes Ten Second Contractions. The "Net Tonic Strength" is the best single predictor of bowel and bladder control. The score obtained during contractions is reduced by the score obtained during relaxation periods, in order to ensure that patients are not rewarded merely for becoming tense (which can raise both resting and contracting levels). Almost all investigators agree that the 10-Second strength is the most important index of patient condition.
Theoretical Note: The PerryMeter Program calculates 10-Second Strength by providing a ten-second "window of opportunity" and measuring what the patient does (the contraction) during that 10 seconds. It should be obvious that if the patient has difficulty locating the muscle (as many elderly and incontinent patients do) that interval will reduce the contraction "score". (I.e., the first two seconds might be zero, for example, with only eight seconds at higher values; but we still divide by "10" to get the average.) Thus the "tonic strength" score actually represents both "strength" and "control".
V. Common Questions and Answers:
1. What's the difference between "USEDATA" reports and the "F4" Data Options?
The primary difference is when they are used. The F4 data saving options are only for use with data that is currently still in the computer's RAM memory, while USEDATA works only with data that has already been stored to a floppy or hard disk. In general, one uses the F4 options while the patient is in the chair, and the USEDATA program after the patient has departed, but that isn't necessarily so. For example, one could leave the computer waiting at the F4 screen, dismiss the patient, and then return to finish processing the data (although this isn't recommended). Likewise, one could, while the patient is still present, terminate the program, and then invoke USEDATA and process a report.
There is one subtle difference of which you should be aware. The F4 options operate on all the data in the computer's memory, which means all of the individual data points that make up the "trial" and "period" averages. Thus F4 history reports can include the "minimum" and "maximum" values within an individual "trial". On the other hand, when data is saved from RAM memory to floppy or hard disk in "normal" or "USEDATA" resolution, only the Trial averages (and not the individual data points that make up those averages) are saved. To be specific, a bar graph of a 10-second contraction (which is one "trial") would be composed of 10 1-second data points if printed by the F4 option; but only one data point (the average of the 10 original data points) if printed by USEDATA. Thus F4 graphs can have one grade higher resolution than USEDATA graphs.
2. What's the difference between USEDATA Reports and the PerryMeter Report?
The USEDATA reports are "generic" reports that present statistics and pictures of individual trials and periods without any understanding of what the data means. The PM Report, like the Glazer and Anismus reports on the other hand, select data that is of special interest in a pelvic muscle evaluation. For instance, in the short contraction test for phasic muscle strength, the "peak" or maximum is reported, but in the 10-second test for tonic strength, the average or mean is reported. instead. Also, the PM Report organizes the data into meaningful tables and summaries that are more readily understood by both patients and third parties, such as referring physicians and insurance companies. USEDATA reports generally require additional documentation to be comprehensible, whereas the PM Report was designed to be used by itself.
3. Where should I save my patient data-on Floppy or Hard Disk?
The answer depends on several factors. Most important is the number of patients you expect to see per month or season. If you store data from several dozen patients in the same disk or directory, you will have to wait for the computer to read each and every data file, each and every time you invoke a USEDATA or PM Report command. If you have a 486DX running at 60 MegaHertz, this may not be a concern; but on an AT at 8 MH, it can become tedious to downright irritating.
The most time-effective solution is to make an individual data diskette for each patient, and store it in the patient's chart between sessions. A low-density (360K) costs less than 50 cents in bulk, and should store over a dozen evaluation sessions. Be aware that under Medicare regulations, you may be called upon to document sessions many months or even years later, so you can't just erase the patient after therapy is completed.
An intermediate solution is to create and use a set of 26 alphabetical disks, and file each patient according to last name. (Actually, about 23 disks will do the job, since you can combine P-Q and X-Y-Z.) If you do this, use only high density (1.2 or 1.4 Meg) diskettes.
If you have exclusive use of a big, fast harddisk, you can keep your patient data there, but you will probably need to weed out inactive patients at regular intervals. See Section 4.3.14 of the J&J Manual for details on how this is done; you can't just thrown the "data" files away, since the "directory" file must also be updated. And remember that you must still save patient records for several years for legal purposes. Even if your hard disk is backed up regularly (and few are), it will be a lot easier to reconstruct your patient files for an audit if the diskette is filed in the patient chart.
4. None of your reports meet my research needs-what can I do?
The F4 and USEDATA menus have been pre-programmed to provide the most useful statistical reports and graphs for most practitioners, but you are free to create and save additional options, or alternative options, if the present choices are not adequate.
In addition, the program automatically saves all evaluation data in both "normal" and "high-resolution" formats (unless you intentionally disable one or both features.) The "normal" files ("JJDFXXXX.PRN") and "high-res" files ("JJDFXXXX.HIR") can be easily imported into any spreadsheet or statistical database program for whatever type of analysis you wish to devise. Many of the latest spreadsheet programs include very smart graphing capabilities, for example.
Research Hint: The PerryMeter Program does not calculate "latency to contract" and "latency to relax" scores. However, you could create a spreadsheet with macros to perform such calculations automatically. You would probably want to modify the data sampling rate (on the F5 screens) from its present 1-second intervals to 0.1 seconds intervals, and use the high-res data files. You can save a modified version of Volume C in the un-used Volume L slot. If you have a 386 computer with extended memory, and you need more memory to store the data (ten times as much), you can move USEPRINT, DOS, and your MOUSE driver to high memory, for example.)
5. I can't afford to buy PIZZAZ PLUS or SNAPSHOT; is there any other way to get screen dumps?
It isn't supposed to work, but we get excellent graphics screen dumps from our VGA monitor unto our Epson LX-800 printer, just by pressing Shift+ PrintScrn on the keyboard. Compared with dumping text screens, it takes a long time (there is a 10-15 second pause between each printed line) but the output is excellent. So always try this method before concluding that it can't be done.
Screen dumps of muscle spasms are the only way to document the presence of tiny, short individual spasms, which may be the cause of chronic pelvic pain. By any other test, the spasms will be averaged out, and the patient will unjustly be accused of malingering!
SNAPSHOT is a utility program written by Bill Stewart, the chief programmer of the USE language, and distributed by David Mars, Ph.D., in California. (It is available for purchase through Synectics Medical and PerryMeter Systems.) SNAPSHOT is installed as a resident program when you load USE. At any time while USE is running you can press <ALT>+G and "grab" whatever is currently displayed on the screen. The screen display at that instant will be saved as a disk file. Snapshots are indexed, and may be retrieved, viewed, printed, or erased at any time in the future from a Snapshot Menu screen. The most important difference between using Snapshot and any other method of capturing screens is that Snapshot only requires 8 seconds to store the file, whereas other screen capture methods can interrupt the therapy process for as much as ten minutes.
Comments, Criticism and Suggestions - for future revisions of the PerryMeter Software and/or Instruction Manual may be given to the biofeedback instrument dealer from whom you purchased the software, or better, sent directly to the Author: John D. Perry, PhD, PerryMeter Systems, 3620 Sunrise Drive, Key West, Florida 33040 USA
If the above address becomes invalid, just call 1-800-JD-PERRY, which is now (1995) being used for the PerryMeter Home Trainer Rental program in Dallas. Kim should always know how to locate Dr. Perry. Besides, you should contact her anyway to find out how easy it is to rent home trainers for your patients. A major bank credit card is all that is required. Research shows clearly that patients who use at-home trainers for daily practice get more better faster! Your patients deserve the best professional care possible.
A metaphor may help to visualize the process of making temporary and permanent changes in the J&J USE Language. Imagine that a USE Application, such as the PerryMeter Pelvic Muscle Rehabilitation Program, is a Confederation of autonomous States. Each State has its own laws governing behavior inside its borders. Laws in one State don't effect activity in any other State. Each State has its own traditions and customs-dress codes-which specify how things appear, in terms of colors, shapes, etc.
It is possible to travel from one state to another. A "Main Menu" item is like an airline ticket, which specifies which states (volumes) you will visit and in what order.
The rules of behavior in each state are specified in the Programing and Timing Page, which is visible when you press the <F5> key. If you want to make changes in these rules you must then press the "P" key (for programing). These rules govern how life is organized; into a number of "trials", which are grouped into "periods"; up to 10 periods may specified in each volume. Thru the programing screen, you can also specify the automatic association of particular set-ups, and other features, such as audio feedback and branching to other activities on specified conditions, with each "period".
The Dress Code-how (and what) things appear on the screen-is specified through the "Set-Up" menu, which is visible when you press <Alt>+S. Within each State (volume) up to 10 standard appearances may be specified from a list of nearly 100 potential designs, and these can be brought up on the screen by pressing <ALT>+(a number key, 1 thru 0). In addition to the basic design of a set-up (line graphs, bars, circles, pyramids, etc.) you can also control all of the colors used to display the basic design, as well as sweep times, etc.
Two of the 10 possible set-ups are given a special status-they can be assigned to the <F2> or <F3> key. The one associated with <F2> will always start up automatically; and the one associated with <F3> is always standing in the wings ready to take over. Each period (<F5>, above) can have its own favorite two setups among the 10 setups that are defined for each volume.
In addition to the <F2> and <F3> setups there is a "Master Setup" associated with the <F1> key. This <F1> master page isn't very useful for biofeedback, but it does help the programer or operator because it shows the status of almost everything involved in Setups at a glance. It contains horizontal bar graphs for each active channel; numbers and letters above and below each bar show the status of each channel in a coded form. (You will need to study the J&J USE Language Manual carefully to understand these codes, and to learn how to change them.)
Any of the many parameters defining Setups may be temporarily changed by executing the key-stroke sequences described in the USE Manual. For example, pressing the 6 or 7 keys will increase or decrease the "gain" of the channel marked by the "happyface" symbol. It is important to understand that any such change in the setup is only "temporary", unless you explicitly make that change permanent. The process of saving your changes in a bit complicated, because there are two steps involved. You must first design your screens (up to 10 of them) and, as you go along, individually save each one as a specific numbered "setup". This is accomplished by arranging the "setup" exactly as you want, then press <F6> for the Utility Menu, and <1> for Setups. Save your screens (including not only the <F2> screen you are probably watching but also <F3> screen which you can't see) by following the on-screen instructions. If you are making a replacement screen, save it to the "old" name; if you are adding a new alternative, save it to a blank location and give it a new name.
These changes to "Setups" still aren't permanent until these new setups are recorded in the volume itself. Theoretically you could make a lot of Setup changes before accomplishing the second step, but we recommend against that. It is too easy to get lost, distracted, or confused. We proceed immediately to the second step after each little setup change. Press <F6> again, and then select item #2, Volume changes. If you are constructing a replacement, save it to the old volume name and slot; if you are adding an alternative, save it to a new volume name and slot. [There are only two blank volumes in the PerryMeter program, but you can always create a second installation of the whole PerryMeter application, throw out unnecessary volumes, and have a lot of room to experiment.] After you specify changes to the volume, you are given one last chance: the program asks "Are You Sure Y/N". If you say <N>, nothing will be permanently changed; if you say <Y>, your new settings will replace what was there before.
So far we have only described changes to the "Setups". All of the other parameters, such as <F4> history (data storage and report printing), <F5> programing and timing, <ALT>+A Audio feedback, <ALT>+B Branching conditions, are adjusted on their individual menus and saved as part of the Volume rules only (F6, 2).
Important Tip: Before making any setup changes, or any other changes for that matter, you should consider the problem of timing and sequences. Many of our volumes are designed for rapid evaluation and processing, and jumping automatically from one volume to the next. But when you are making changes, you need plenty of time to consider each parameter, make adjustments, and then save your results. Therefore, you need to "disable" the programmed timing. Here's how to do that.
First, don't use a "main menu" key to access the system. While the main menu is displayed, press <ALT>+V to access the purple Volume Menu window, and Load the appropriate Volume by selecting its letter. [The appropriate one is the one most like you want to end up with; i.e., the fewest changes required.]
Start the volume, and press <F5> to bring up the Timing and Programing Window. Use the cursor key to move the white pointer down to an inactive period (which will probably be called "manual"). This is provide an un-ending loop, during which you can make whatever screen setup changes you want to make without being rushed. [If there is no inactive period, you could temporarily change the number of Trials in a period to "99"; make your setup changes, and save them; then change the Trials back to the original number before you re-save everything to a "Volume".]
After you have made and saved (to both Setups and to the Volume itself) all the Setup changes you want, then go back (with the cursor arrows) and make any changes to the Periods and their programing. Be aware that there is only one Programing (Periods and Timing) menu in each volume, so things like the number of samples per second, for example, can only be set once, globally, for each volume.
One way to organize your changes is to group together similar activities; study the present organization of the PerryMeter Program to see how this is done. For example, all of the "game" screens have a similar (10-minute period) structure ending in a data review and/or save option; the various games themselves are included as alternative "Setups" within the "Game" volume.
The Perry Protocol For Treatment of Incontinence Using EMG Biofeedback Version 1.1 2/95 Normally published as a part of the manual, it is available on IncontiNet for separate downloading/reading by clicking on the name.
The portable, battery operated I-400 interface box is an economical and convenient alternative to the full-sized I-330 system, which is capable of using 16 modalities or channels. The I-400 includes only 2 EMG channels, and is not expandable. The I-400 was designed for incontinence work, for PerryMeter Systems.
The Interface box is connected to the computer's serial (RS-232) port through a standard serial cable (supplied) connected to the DIN-25 plug on the right end of the box. Note that if used with a one-port laptop computer, you will probably need to change the default COM2 port setting to COM1. See the discussion on page 13.
The special Perry™ sensor cable should be inserted into sensor input jack "A" on the left side of the I-400. No external ground is required for Perry sensors. The Perry sensor is plugged into the jack on the short pigtail lead coming from the "sugar cube" in-line EMG preamplifier.
If and when the accessory monitoring EMG sensor MA-3 (supplied) is used, it should be plugged into sensor input jack "B", and the ground reference electrode lead plugged into jack "D". Insert the three cup electrodes into the three snaps (2 on MA-3, one on Ground), affix double-sided adhesive rings, and fill level with the supplied electrode paste. Addition supplies can be obtained from many dealers, or J&J.
A standard nine-volt battery is housed in a compartment on the bottom of the I-400 box. A quality alkaline battery should be used. Use a coin or screwdriver to open the battery compartment. ALWAYS operate and store the I-400 right-side up, to avoid the possibility that a leaky battery could damage the circuits inside and create a potential shock hazard.
There is very little battery drain when the interface is not actively sending data to the computer; nevertheless, it is recommended that the serial cable be disconnected from the I-400 box when it is not in use.
BATTERY MONITOR: The I-400 version differs from that described in the manual only by the inclusion of a Battery Monitor Channel "D1" on the opening screen of Main Menu option "B" (setup and confirm for regular evaluations) and option "S" (setup for anismus evaluation). You should always confirm that the battery level is above 6.5 volts at the same time you confirm other aspects of the patient hook-up, before starting to use the program.
[Note that on the "B" setup, the battery graph (brown line) is "correct", but on the "S" setup, which shows a 0-20 scale for the sake of the sensor, the battery graph (dashed-green) is not "correct", since the battery scale is really 0-10. In other words, a 7 volt battery level, which is graphed on its own "7" line, appears to be on the "14" line, since only the sensor's scale is actually shown. Watch the number at the right end of the line - that's the actual battery voltage.]