1. RTOG 0537 ALTENS vs Pilocarpine in Treating Early Radiation-Induced Xerostomia ALTENS Treatment Instruction Raimond Wong, MD Principal Investigator

2. Delivering ALTENS treatment is a simple process. Please also consult the accompanying user manual!

3. Step 1 Make sure patient is comfortable, e.g., lying down or reclining slightly. Each patient must have his/her own set of reusable electrodes; include the patient’s name on each set. The electrodes are large, so you will be able to access the acupuncture points easily.

4. Step 2 Place electrodes on the specific acupuncture points: CV24, LI4, Sp6, St36 The electrodes are self-adhesive. Wetting the electrode sticky surface with distilled (not mineral) water will help to maintain stickiness. If necessary, taping the electrode to the patient’s skin will help.

5. CV24: In the groove of the chin below the middle of the lower lip CV24

6. LI4 (both sides): On the dorsal side of the hand. On the thumb side of the middle of the 2 nd metacarpal bone

7. St36 (both sides): 4 finger breath (patient’s finger breath) below lower border of patella and one finger breath lateral to anterior tibial crest

8. Sp6 (both sides): On the medial (inner) side of the calf, 4 finger breath superior to the tip of the medial malleolus and just posterior to the tibial bone Patient may feel ‘bruised’ when the point is pressed

9. Step 3: Step 3: Check the machine before connecting the electrodes Machine should be turned off Charger is removed Code setting is III In Adjust Mode All Output Intensity knobs are set to zero. Wires connected. Green wire to green connector.

10. Step 4: Step 4: Connect the electrodes Bring the machine closer to the patient. Separate wires into left and right sets.

11. Step 5: Step 5: Adjust output intensity one electrode at a time 1) Turn on machine 2) Keep in Adjust Mode 3) Green light of each electrode will, in turn, be on for 10 seconds. For each electrode, adjust the intensity slowly until patient feels strong but comfortable stimulation.

12. Step 6: Step 6: Start treatment after finished intensity adjustment Switch to Treat Mode Each electrode will be on randomly for 10 seconds each time. This randomized stimulation process will reduce brain habituation, resulting in more effective stimulation.

13. Step 7: Step 7: Set timer for 20 minutes Each treatment session is 20 minutes.

14. Step 8: Step 8: When session is finished, turn machine off and reset all settings Machine should be turned off Code setting is III In Adjust mode All Output Intensity knobs are set to zero Charge machine

15. Step 9 Put electrodes back on the plastic sheets. Wet with distilled water from time to time to maintain stickiness.

16. Done! If you have questions, please do not hesitate to contact the Principal Investigator, Raimond Wong, MD Phone: 905-387-9495, x64704 E-mail: raimond.wong@jcc.hhsc.ca Thank you for joining RTOG 0537!