FAQs on ET127 and The eToims Technique

1. What is eToims? eToims is an advanced diagnostic therapy for individuals suffering from chronic pain, as well as individuals desiring general physical health improvement and enhancement. eToims is the only treatment that is able to provide objective pain diagnosis by locating injured or irritable nerve-muscle meeting areas, while simultaneously seeking to end pain and stimulate muscle re-education by inducing deep muscle twitches at damaged trigger points. For those in pain who can benefit from The eToims Technique, pain relief may be experienced simultaneously with trigger point localization. 2. What is The eToims Technique?

The eToims Technique is the technique to locate and diagnose presence of irritable motor points. Very brief, low frequency repetitive stimulation is targeted to fatigue irritable neuromuscular junctions and focuses the stimuli to reach only the motor point (trigger point). The motor point is where the most peripheral nerve terminal meets the muscle fiber (the nerve-muscle junction) and is very electrically sensitive to stimulation.
eToims is the only available surface stimulation that induces deep twitches from neuromuscular junctions of muscles closest to the bone and joints to relieve pain by enabling muscles to relax: ! ! ! Releasing tightness and tension on affected body areas, Increasing intramuscular blood flow which improves tissue oxygenation, while Concomitantly increasing outflow of pain-producing muscle tissue wastes

The ability of eToims to allow tight muscle spasms to fatigue and relax removes the vice-like effect of these tight muscles on entrapped nerves and blood vessels within the muscles as well as to remove the pulling effects that these tight muscles have on underlying pain sensitive receptors of bone and joints. 3. Is ET127 a pain-relieving device? Yes. ET127 is a pain-relieving device. ET127 is used in: ! Symptomatic relief of chronic intractable pain ! Post-traumatic pain ! Post-surgical pain It is available for prescription use only. 4. Is ET127 used only for pain relief? No. ET127 is used to facilitate the evoking of muscle twitch responses to assess electrical activity of potentially involved peripheral nerve and skeletal muscle tissue in muscle pain and/or discomfort, muscle weakness, muscle spasm or aberrant sensation such as tingling and numbness. It can be used in hospitals or in an outpatient setting.

5. What is a twitch? A twitch is a characteristic, brisk muscle contraction followed by relaxation from stimulation at the neuromuscular junctions. Twitches contract, stretch and release muscular tension in areas of muscle pain and tightness, essentially massaging sore muscles from within the afflicted area. 6. How is ET127 different from TENS units and muscle stimulators? TENS units and muscle stimulators can be used by the patient in order to relieve pain, unattended by the clinician. Patch electrodes are used with these devices and usually placed on muscles for an arbitrary period of 30 minutes. In TENS, the electrodes may be placed over the motor points to induce superficial twitches and also used for blocking pain signals from reaching the brain. Muscle stimulators are used for the relaxation of muscle spasms, to improve local circulation and to maintain or improve range of motion. Although these devices can stimulate to induce twitches, they are unable to have sufficient current penetration to stimulate deep motor points that elicit strong force muscle twitches. ET127 is not for use by patients and must be used by clinicians. The clinician using ET127 must be trained and certified in The eToims Technique and must work one-on-one with the patient. ET127 is essential to aid the clinician to identify and briefly stimulate irritable motor points of deep muscle fibers closest to the bone and joints. The irritable motor points are stimulated only for 1-3 seconds, since fatigue of the muscle fibers at these points can occur within 1-3 seconds. The ET127 hand-held probe is then moved to another area in the same muscle or to other muscles to locate and stimulate motor points in each muscle within the same stimulus session. 7. How does one identify irritable motor points? The ease by which nerves are easily stimulated, resulting in muscle contraction to obtain large force twitches, is diagnostic of the presence of acute irritation of the spinal nerve root(s) supplying these muscles. These motor (trigger) points will fatigue rapidly (usually within 1-3 seconds) with use of 3 Hz stimulation. The twitch contractions that can initially respond rapidly to 3 Hz stimulation can be seen to become weaker and slower as the muscle becomes fatigued and unable to respond to the 3 Hz stimulation. If the twitches could lift the limb in an anti-gravity fashion at the beginning of the stimulation, as the muscle fatigues, such anti-gravity movements will not be possible. The motor points are also painless and can provide a pleasurable feeling. 8. What is the endpoint indication for stimulating a motor point? Stimulation of an irritable motor point can stop as soon as the muscle fatigues, usually within 1-3 seconds (see explanation above in FAQ #7 also). However, in patients with chronic pain, irritable trigger point localization is very difficult due to the filtering effect of tight and shortened muscles that prevent the electricity from deep penetration. Therefore, significant skill is needed to quickly and sequentially stimulate many points in many individual muscles in order to find the zones that will evoke twitch responses that have enough force to move the joint in the direction of action of the tested muscle or at least be able to shake or rock the joint. If fatiguing contractions cannot be elicited, it is essential to stimulate each point in the zone for at least 10 twitches per point. Try to stimulate at least 5-10 points in each zone to cause enough softening of the tissues in the stimulated area. Finding the most active motor (trigger) points in these zones is a necessity for pain relief and as many such zones as possible must be found within the allotted treatment session time to provide optimal pain-relieving results.

9. What conditions can The eToims Technique help?

The eToims Technique can help the following conditions:

! ! ! ! ! ! ! ! ! ! ! ! ! ! Neck muscle pain Mid-back muscle pain Arm pain Shoulder pain Elbow pain Wrist pain Hip pain Knee pain Ankle pain Foot pain Tension headaches Myofascial pain syndrome Fibromyalgia Whiplash of the spine or whiplash ! ! ! ! ! ! ! ! ! ! ! ! ! Repetitive strain injuries Tendonitis Bursitis Rotator cuff injuries Tennis elbow Early carpal tunnel syndrome Musculoskeletal pain Musculoskeletal discomfort Sports injuries Degenerative disc Bulging disc Herniated disc Spinal stenosis

10. When is the best time to begin treatments with The eToims Technique?

The eToims Technique is best applied when the muscles are not as short and tight as well as in situations when pain levels are not too high. For best results in preventing pain or keeping the patient's pain at levels that they can manage to tolerate, treatments should occur when there is low pain or no pain. Generally, patients with high pain levels of 7 or higher on a scale of 1 to 10 (7/10) are not ready for stimulation using The eToims Technique. The underlying pain must be managed by a pain specialist with medications to control this pain or such patients may need to take pre-treatment medications to be able to tolerate the pain during The eToims Technique. Such patients should not be selected for The eToims Technique unless the clinician is very experienced and skillful since these patients will experience pain during the treatment and has a tendency to suffer from post-treatment pain.
Patients will usually tolerate The eToims Technique well when their highest pain is at the level of 5/10 or less. Experienced eToims patients with chronic pain learn this paradigm well and they maintain their treatments weekly in order that muscle pain is removed with The eToims Technique as soon as it is formed. 11. Should a patient receive The eToims Technique only when he or she is experiencing pain? No. Often one has heard of or experienced progression from muscle tightness, through spasm, then discomfort, to tenderness and pain. If one has this pattern, early intervention with The eToims Technique is beneficial, even before onset of overt pain. It is common for those with chronic or relapsing pain to recognize that the earlier the intervention at a lower pain level by eToims, medications or whatever mechanism that has worked in the past, the more efficacious it seems. Many times with early intervention, pain progression can be halted and/or reversed. When the pain level is high, eToims sessions will not be able to locate motor (trigger) points effectively, due to severe muscle tightness. That tightness appears to exert a dampening effect on the involved muscle fibers directly affected by that trigger point, impairing resultant generation of a twitch of sufficient force that either shakes the joint or preferably moves the joint from those fibers. Therefore, experience has taught patients undergoing The eToims Technique to schedule weekly sessions or even daily sessions when pain free and involved muscle characteristics are commensurate

with the ability of The eToims Technique to generate adequate force twitches. This tends to preclude pain escalation over time, which parallels precluding escalation of muscle spasm over time. By relieving muscle spasm, The eToims Technique increases range of motion, which analgesics such as narcotics cannot provide. Increasing range of motion increases function. 12. What outcome should a patient expect from The eToims Technique? A patients results will depend on the ease or difficulty in finding trigger points within a given time frame and the force of twitches generated. If trigger points cannot be stimulated and the twitch forces produced are weak, there may be no relief of discomfort and/or pain, or the relief will not be as substantial. Muscles become tight and may impair trigger point localization depending on: (1) the extent and duration of nerve root involvement and degeneration, (2) age of patient, (3) obesity, and (4) any other medical conditions that can affect nerve and muscle function. 13. How many eToims Technique sessions are necessary for discomfort/pain relief?

The eToims Technique can produce pain relief when trigger points can be stimulated to produce characteristic twitches of adequate strength. With mild acute partial nerve root irritation, trigger points are easier to locate for stimulation to produce the essential twitches. This leads to more significant relief of discomfort and/or pain with one or a limited number of eToims Technique sessions. With chronic nerve root irritation, trigger point localization is difficult due to chronic tightness of the muscles. Ongoing weekly sessions can maintain the pain relief achieved, and improve mobility and function for a progressive return to moderate activity. Patients with chronic pain have a tendency for re-injury to nerve roots with formation of additional new trigger points even with activities of daily living. These new trigger points are easier to be healed with ongoing eToims Technique sessions, allowing patients to have a stable or progressive improvement in quality of life.
14. How often can I provide The eToims Technique? How many sessions are needed before results can be obtained?

The eToims Technique is best performed preferably within 1- 4 days of new nerve irritation since there is the potential for cure depending on the degree and type of nerve damage. If the nerve damage is temporary and reversible, eToims can aid full nerve recovery with 1-3 treatments. Usually, once per week stimulation is recommended as a convenience schedule for patients with chronic pain due to permanent nerve damage to aid in nerve regeneration. Regular sessions with The eToims Technique will prevent the muscles from tightening further so that the pain escalation is prevented.
Since nerve related muscle pain is primarily ischemic pain and twitch movements restore circulation to areas where the muscles are tight, eToims can be done daily and also multiple times per day. Frequent and regular eToims sessions allow for pain-relieving results to be cumulative. 15. How soon after an injury should a patient receive The eToims Technique?

The eToims Technique is best applied before muscles become shortened and tight, which is usually associated with the highest pain levels. Therefore, in order to obtain the best results with The eToims Technique, the sessions should begin preferably within 24 hours of an injury and certainly before the pain escalates.
16. Can there be overstimulation of nerves with The eToims Technique? Overstimulation does not occur with The eToims Technique if you perform the technique as trained. The principle in The eToims Technique is to find the irritable motor (trigger) point in each major muscle at, above and below the myotomes (group of muscles supplied by one spinal nerve root) involved. There is no need to stay on one muscle for 30 minutes like in TENS or muscle stimulation. Every active motor point has to be searched for and stimulated and there is such a point in many

muscles surrounding the area of the painful myotome. When we obtain such an irritable motor point, we can tire (fatigue) the nerve in 1 sec in more healthy muscles whereas in very tight muscles, we have to wait longer (maximum 60 seconds). Motor points are not painful; if the patient complains of pain, you are not stimulating the motor point and therefore must move away immediately from that point. 17. Can there be understimulation of nerves with The eToims Technique? Understimulation of nerves is possible when the muscles are very tight. While searching for the location of a motor point, you must decide immediately which points are motor points and which are not. Do not stimulate with long pulse widths and strong current strength at non-motor point areas because you can induce spasm of the deep muscle layers which will give post-treatment pain since they are under stimulated because you are performing muscle stimulation rather than motor point stimulation. The motor point will twitch with a narrow pulse width and low current strength. That is the definition of the motor point. Since nerves are very susceptible to electrical stimulation at the motor point, the following characteristics will occur: 1. The twitch will be very fast and will be able to respond to the 3Hz stimulation. 2. Since the motor points of the deepest muscles apposed to the bone and joint will contract, there will be movements of the joint in the direction of action of the treated muscle. 3. The motor point stimulation will be painless for the patient. 4. The motor point stimulation will be pleasurable for the patient. The true motor point stimulation will give very fast twitches with strong forces. If you are obtaining very strong force twitches, you may be using too much current if it is not accompanied by rapidly occurring twitches that are responding to the stimulation at 3 Hz. In that situation, you need to reduce the current so that you can stimulate only the motor point and not multiple peripheral nerves due to using very high current that spreads to other bigger nerves. In patients with very tight muscles, you may be able to identify the motor point only by at the recoil effect on the probe. This is because only submaximal current can reach the motor point due to the filtering effect of the overlying tight muscles. Therefore, in tight muscles, the recoil or bouncing effect on the probe will never stop because the nerve cannot fatigue since is not getting the maximal stimulus to induce it to fatigue. Submaximal stimulation can cause muscle contraction without relaxation and therefore muscle spasms can be induced. So there is a need to stimulate longer at these bouncy sites so that you can tire out some of the motor points. Otherwise, the patient will have no pain relief or they may even have post-treatment pain from the contractions that build up into a spasm without the ability to relax. At bouncy points, you should move the probe only ! centimeter so that you can locate the best point that produces contractions that can at least shake the joint. Shaking of the joint does produce therapeutic pain relieving effects but are not as good as muscle contractions that can move the joint in the direction of action of the stimulated muscle. Additionally, true motor point stimulation is also accompanied by rapidly occurring twitches since the nerve can respond to 3Hz stimulation whereas muscle stimulation cannot respond to 3Hz stimulation. It is essential to learn how to do The eToims Technique well with less involved cases before attempting to treat patients with significant muscle tightness and severe chronic pain since you can induce post-treatment pain from submaximal stimulation. 18. How can I avoid giving post-treatment pain to patients? For patients who have significant muscle tightness, post treatment pain may last for approximately 1-2 days especially when the muscles do not twitch well due to insufficient penetration of the electrical current form the buffering effect of the tight tissues. However, if some areas did produce sufficient depolarization with elicitation of strong force twitches that move or shake the joint during the stimulation, pain relief may be noted on the 2 or 3 day after the treatment. If motor points were not located and strong force twitches were not elicited during the stimulation session, there will be no pain
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relief even on the third day and the patient may just suffer from more pain for two days after the treatment. Such patients may not return for further eToims unless the practitioner explains these side effects to the patient in advance. It is a pre-requisite on the part of the eToims clinician to prevent post-stimulation pain. If motor points are difficult to locate, it is essential to focus the stimulation only to the muscles surrounding the region of pain than to treat diffusely. This allows more treatment time to be directed to elicit the correct twitches from the most involved muscles. It is most important that when the out of compliance signals are noted on ET127, the stimulus strength (milliamps) is reduced rather than increased. Also, it is important for the electrodes to be wet so that stimulation conditions are optimal. (Refer also to FAQ #14). 19. What are the contraindications to The eToims Technique? We have avoided use of The eToims Technique in patients with implantable cardioverter defibrillators and recommend that presence of such implanted devices and stimulators, be considered a contraindication for the use of The eToims Technique. Other contraindications include patients with pacemakers, seizure disorders, history of cerebrovascular accidents including transient ischemic attacks, bleeding disorders, therapeutically anticoagulated, active infections, active inflammations, fractures, acute illnesses, organ failures, neuroendocrine disorders (e.g. pheochromocytoma), hyperkinetic heart syndrome, coronary artery disease with angina, debilitation, significant profound psychiatric disorder, suicidal or homicidal ideas, inability to follow commands, disruptive or noncooperative patients and pregnant patients. Those patients with very severe and high levels of pain, pain associated with significant denervation, failed multiple spinal surgeries, need for multiple narcotics for pain control, pain due autoimmune diseases, central pain or sympathetically maintained pain, those with thickened and scarred skin, oedema, and obesity are not candidates for The eToims Technique. 20. Why does ET127 require system activation? Repurchasing system activation via www.etoims.com automatically triggers a shipment of 125 pairs of eToims conduction mediums (250 total) for use with the ET127 device and The eToims Technique. The system activation ET127 requires the ongoing usage of only eToims electrodes. Non-eToims electrodes can be painful and dangerous to the patient, as only eToims electrodes have undergone FDA clearance for biocompatibility testing. Intensive R&D was performed on these conduction mediums to assure clinicians that they are safe, efficacious, and are capable of producing the highest eToims brand results. eToims conduction mediums are made of high-quality specialty imported medical grade fabric. 21. Are eToims conduction mediums necessary for the practice of The eToims Technique? Yes. The FDA-approved biocompatible eToims conduction mediums are specific for the practice of The eToims Technique. Only eToims electrodes have undergone strict testing and intensive R&D to obtain FDA approval for safety and efficacy to be used specifically in The eToims Technique. eToims electrodes are made of high-quality specialty medical grade imported fabric. Use of unauthorized electrodes will result in bio-incompatibility issues, pain during stimulation due to uneven electrical distribution and inability to get branded eToims results due to inadequate electrical penetration into the deeper tissues. These conduction mediums provide the most optimal, painless penetration to the deepest trigger points in muscle fibers closest to the bone and joints. 22. Who can I call to have technical questions answered? You can also e-mail us directly at: technical@etoims.com or call +1 (215) 387-0550.