EP2766087A2 - Motifs de stimulation électrique non réguliers pour le traitement de troubles neurologiques - Google Patents

Motifs de stimulation électrique non réguliers pour le traitement de troubles neurologiques

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Publication number
EP2766087A2
EP2766087A2 EP12839657.9A EP12839657A EP2766087A2 EP 2766087 A2 EP2766087 A2 EP 2766087A2 EP 12839657 A EP12839657 A EP 12839657A EP 2766087 A2 EP2766087 A2 EP 2766087A2
Authority
EP
European Patent Office
Prior art keywords
pulse
stimulation
regular
frequency
patterns
Prior art date
Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
Ceased
Application number
EP12839657.9A
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German (de)
English (en)
Other versions
EP2766087A4 (fr
Inventor
Warren M. Grill
David T. Brocker
Merill J. BIRDNO
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Duke University
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Duke University
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Publication date
Application filed by Duke University filed Critical Duke University
Priority to EP20175204.5A priority Critical patent/EP3718596B1/fr
Priority to EP18167953.1A priority patent/EP3372274B1/fr
Publication of EP2766087A2 publication Critical patent/EP2766087A2/fr
Publication of EP2766087A4 publication Critical patent/EP2766087A4/fr
Ceased legal-status Critical Current

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Classifications

    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/3605—Implantable neurostimulators for stimulating central or peripheral nerve system
    • A61N1/36128—Control systems
    • A61N1/36146—Control systems specified by the stimulation parameters
    • A61N1/36167—Timing, e.g. stimulation onset
    • A61N1/36178—Burst or pulse train parameters
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/02—Details
    • A61N1/04—Electrodes
    • A61N1/05—Electrodes for implantation or insertion into the body, e.g. heart electrode
    • A61N1/0526—Head electrodes
    • A61N1/0529—Electrodes for brain stimulation
    • A61N1/0534—Electrodes for deep brain stimulation
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/3605—Implantable neurostimulators for stimulating central or peripheral nerve system
    • A61N1/3606—Implantable neurostimulators for stimulating central or peripheral nerve system adapted for a particular treatment
    • A61N1/36067—Movement disorders, e.g. tremor or Parkinson disease
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/3605—Implantable neurostimulators for stimulating central or peripheral nerve system
    • A61N1/3606—Implantable neurostimulators for stimulating central or peripheral nerve system adapted for a particular treatment
    • A61N1/36082—Cognitive or psychiatric applications, e.g. dementia or Alzheimer's disease
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/3605—Implantable neurostimulators for stimulating central or peripheral nerve system
    • A61N1/36128—Control systems
    • A61N1/36189—Control systems using modulation techniques
    • A61N1/36196—Frequency modulation

Definitions

  • DBS Deep Brain Stimulation
  • GPi globus pallidus
  • STN subthalamic nucleus
  • DBS reduces tremor, rigidity, akinesia, and postural instability, and allows levodopa doses to be decreased.
  • Patients clinically diagnosed with idiopathic PD suffering from the cardinal motor symptoms are likely to receive benefit from DBS, with levodopa responsiveness predictive of its efficacy.
  • DBS in the ventral intermediate nucleus (Vim) of the thalamus is an effective and adjustable surgical treatment for tremor in persons with essential tremor or multiple sclerosis.
  • DBS is used to treat a broad range of neurological and psychiatric disorders including but not limited to epilepsy, dystonia, obsessive compulsive disorder, depression, Tourette's syndrome, addiction, and Alzheimer's disease.
  • DBS type lead into a targeted region of the brain through a burr hole drilled in the patient's skull, and the application of appropriate stimulation through the lead to the targeted region.
  • DBS beneficial (symptom-relieving) effects are observed primarily at high stimulation frequencies above 100 Hz that are delivered in stimulation patterns or trains in which the interval between electrical pulses (the inter-pulse intervals) is constant over time.
  • the trace of a conventional stimulation train for DBS is shown in Figure 2.
  • the beneficial effects of DBS on symptoms are only observed at high frequencies, while low frequency stimulation may exacerbate symptoms.
  • Thalamic DBS at less than or equal to 50 Hz has been shown to increase tremor in patients with essential tremor (ET) .
  • 50 Hz DBS has been shown to produce tremor in pain patients receiving simulation of the ventral posterior medial nucleus of the thalamus (VPM) , but the tremor disappears when the frequency is increased.
  • VPM ventral posterior medial nucleus of the thalamus
  • DBS of the subthalamic nucleus (STN) at 10 Hz has been shown to worsen akinesia in patients with PD while DBS at 130 Hz has been shown to improve motor function.
  • stimulation of the globus pallidus (GPi) at or above 130 Hz has been shown to improve dystonia, whereas stimulation at either 5 or 50 Hz leads to significant worsening.
  • non-regular stimulation patterns are less effective at suppressing tremor than temporally regular stimulation because sufficiently long gaps in the stimulation train allow pathological activity to propagate through the stimulated nucleus.
  • the features of non-regular stimulation patterns that influence clinical efficacy in PD are unknown.
  • Model studies also indicate that the masking of pathological burst activity occurs only with sufficiently high stimulation frequencies. Responsiveness of tremor to changes in DBS amplitude and frequency are strongly correlated with the ability of applied stimuli to mask neuronal bursting.
  • One aspect of the present invention is to provide a temporal pattern of stimulation for application to targeted neurological tissue comprising a repeating succession of non-regular pulse trains, each pulse train comprising a plurality of evenly spaced pulses and at least one pulse feature.
  • Another aspect of the present invention is to provide a method of generating a series of stimulation signals for the treatment of a neurological disorder comprising: selecting a neurological disorder with one or more symptoms to be treated by the stimulation signals; identifying pulse features of the stimulation signals that suppress one or more symptoms of the neurological disorder when applied to specific areas of a neurological tissue; selecting one or more patterns of non-regular stimulation signals comprised of the pulse features; and generating a pulse train of stimulation signals including the one or more selected patterns .
  • An additional aspect of the invention is to provide a method for stimulation of a targeted neurological tissue region comprising applying a non-regular pulse train, each pulse train comprising a plurality of evenly spaced pulses and at least one pulse feature and repeating the pulse train in succession.
  • Figure 1 is an anatomic view of a system for stimulating tissue of the central nervous system that includes an lead implanted in brain tissue coupled to a pulse generator that is programmed to provide non-regular (i.e., not constant) pulse patterns or trains, in which the interval between electrical pulses (the inter-pulse intervals) changes or varies over time.
  • a pulse generator that is programmed to provide non-regular (i.e., not constant) pulse patterns or trains, in which the interval between electrical pulses (the inter-pulse intervals) changes or varies over time.
  • Figure 2 is a diagrammatic trace that shows a conventional regular high frequency stimulation train, in which the interval between electrical pulses (the inter- pulse intervals) is constant.
  • Figure 3 is a diagrammatic trace showing a representative example of a repeating non-regular pulse pattern or train in which the inter-pulse intervals are linearly cyclically ramped over time.
  • Figures 4 and 5 are diagrammatic traces showing other representative examples of repeating non-regular pulse patterns or trains comprising within, a single pulse train, a combination of single pulses (singlets) and embedded multiple pulse groups (n-lets) , with non- regular inter-pulse intervals between singlets and n-lets as well as non-regular inter-pulse intervals within the multiple pulse n-lets.
  • Figure 6 depicts prior experimentation showing decreased efficacy in reducing symptoms as the variability of random patterns of DBS increases, which is modified from Dorval et al . (2010) .
  • Figure 7A depicts a "Uniform" stimulation pattern train according to the present invention.
  • Figure 7B depicts a "Unipeak" stimulation pattern train according to the present invention.
  • Figure 7C depicts an "Absence" stimulation pattern train according to the present invention.
  • Figure 7D depicts a "Presence" stimulation pattern train according to the present invention.
  • Figure 8 is a table of stimulation pattern train parameters .
  • Figure 9 is a table of patient data.
  • Figure 10A is a timeline depicting stimulation response data collection.
  • Figure 10B is a timeline depicting stimulation response data analysis.
  • Figure 11 depicts prior stimulation experimentation establishing key depression duration as being statistically significantly correlated to motor symptom severity.
  • Figure 12 depicts an exemplary embodiment of a portion of a stimulation response data collection system and associated method.
  • Figure 13A depicts a histogram of click or button depression durations of a patient.
  • Figure 13B is a bar plot indicating a statistically significant per patient finger effect.
  • Figure 14 is a timeline of button depression or click durations for two patients, one along the top line and one along the bottom line, while DBS is off (left) and while DBS is on (right), respectively.
  • Figure 15 is a bar graph showing statistically significant changes motor symptom severity as assessed through the coefficient of variation of click duration across different temporal patterns of stimulation according to the present invention.
  • Figure 16A depicts a generally accepted model used to generate thalamic neural responses to DBS and sensorimotor input (left) and types of errors that may be generated by such model (right) .
  • Figure 16B depicts the DBS frequency-dependence of the model outcome measure, the error fraction, which mirrors the DBS frequency-dependence of motor symptoms.
  • Figure 17A is a graph of an average error fraction generated by the model of Figure 16A when presented with the different temporal patterns of stimulation according to the present invention listed along the x-axis .
  • Figure 17B is a graph of power of beta band oscillations in the GPi neurons of the model of Figure 16A when presented with the different temporal patterns of stimulation according to the present invention listed along the x-axis .
  • Figure 17C is a graph of the percentage of errors generated grouped by type of error by the model of Figure 16A when presented with the different temporal patterns of stimulation according to the present invention listed along the x-axis .
  • Figure 18A is a graph of the log CV Duration during stimulation when presented with log CV Duration pre- stimulation listed along the x-axis.
  • Figure 18B is a graph of the log CV Duration post- stimulation when presented with log CV Duration during stimulation listed along the x-axis .
  • Figure 19A is a graph of the log CV Interval when presented with the different temporal patterns of stimulation according to the present invention listed along the x-axis .
  • Figure 19B is a graph of the log number of clicks when presented with the different temporal patterns of stimulation according to the present invention listed along the x-axis .
  • Figure 20 is a graph depicting prior stimulation experimentation establishing log CV Duration as being statistically significantly correlated to UPDRS, or motor symptom severity.
  • Figure 21A is a series of charts showing power density for the different temporal patterns of stimulation according to the present invention.
  • Figure 2 IB is a graph showing beta band power for the different temporal patterns of stimulation according to the present invention.
  • Figure 21C is a graph depicting the log CV duration being correlated to beta power.
  • Figure 1 is a system 10 for stimulating tissue of the central nervous system.
  • the system includes a lead 12 placed in a desired position in contact with central nervous system tissue.
  • the lead 12 is implanted in a region of the brain, such as the thalamus, subthalamus, or globus pallidus for the purpose of deep brain stimulation.
  • the lead 12 could be implanted in, on, or near the spinal cord; or in, on, or near a peripheral nerve (sensory or motor) for the purpose of selective stimulation to achieve a therapeutic purpose.
  • the distal end of the lead 12 carries one or more electrodes 14 to apply electrical pulses to the targeted tissue region.
  • the electrical pulses are supplied by a pulse generator 16 coupled to the lead 12.
  • the pulse generator 16 is implanted in a suitable location remote from the lead 12, e.g., in the shoulder region. It should be appreciated, however, that the pulse generator 16 could be placed in other regions of the body or externally.
  • the case of the pulse generator can serve as a reference or return electrode.
  • the lead 12 can include a reference or return electrode (comprising a bi-polar arrangement) , or a separate reference or return electrode can be implanted or attached elsewhere on the body (comprising a mono-polar arrangement) .
  • the pulse generator 16 includes an on-board, programmable microprocessor 18, which carries embedded code.
  • the code expresses pre-programmed rules or algorithms under which a desired electrical stimulation waveform pattern or train is generated and distributed to the electrode (s) 14 on the lead 12. According to these programmed rules, the pulse generator 16 directs the prescribed stimulation waveform patterns or trains through the lead 12 to the electrode (s) 14, which serve to stimulate selectively the targeted tissue region.
  • the code is preprogrammed by a clinician to achieve the particular physiologic response desired.
  • an on-board battery 20 supplies power to the microprocessor 18.
  • batteries 20 must be replaced every 1 to 9 years, depending on the stimulation parameters needed to treat a disorder.
  • the replacement of batteries requires another invasive surgical procedure to gain access to the implanted pulse generator.
  • the system 10 makes possible, among its several benefits, an increase in battery life.
  • the stimulation waveform pattern or train generated by the pulse generator differs from convention pulse patterns or trains in that the temporal pattern of stimulation comprises repeating non-regular (i.e., not constant) pulse patterns or trains, in which the interval between electrical pulses (the inter-pulse intervals or IPI) changes or varies over time.
  • the non-regular pulse patterns or trains provide a lower average frequency for a given pulse pattern or train, where the average frequency for a given pulse train (expressed in hertz or Hz) is defined as the sum of the inter-pulse intervals for the pulse train in seconds ( ⁇ ) divided by the number of pulses (n) in the given pulse train, or ( ⁇ iPi)/n.
  • a lower average frequency makes possible a reduction in the intensity of side effects, as well as an increase in the dynamic range between the onset of the desired clinical effect (s) and side effects, thereby increasing the clinical efficacy and reducing sensitivity to the position of the electrode (s) .
  • a lower average frequency brought about by a non-regular pulse pattern or train also leads to a decrease in power consumption, thereby prolonging battery life and reducing battery size .
  • the repeating non-regular (i.e., not constant) pulse patterns or trains can take a variety of different forms.
  • the inter-pulse intervals can be linearly cyclically ramped over time in non-regular temporal patterns (growing larger and/or smaller or a combination of each over time) ; or be periodically embedded in non- regular temporal patterns comprising clusters or groups of multiple pulses (called n-lets) , wherein n is two or more.
  • n-lets comprising clusters or groups of multiple pulses
  • the repeating non-regular pulse patterns or trains can comprise combinations of single pulses (called singlets) spaced apart by varying non-regular inter-pulse intervals and n-lets interspersed among the singlets, the n-lets themselves being spaced apart by varying non-regular inter-pulse intervals both between adjacent n-lets and between the n pulses embedded in the n-let.
  • the non-regularity of the pulse pattern or train can be accompanied by concomitant changes in waveform and/or amplitude, and/or duration in each pulse pattern or train or in successive pulse patterns or trains.
  • Each pulse comprising a singlet or imbedded in an n- let in a given train comprises a waveform that can be monophasic, biphasic, or multiphasic.
  • Each waveform possesses a given amplitude (expressed, e.g., in amperes or volts) that can, by way of example, range from 10 ⁇ ia (E ⁇ 6 ) to 10 ma (E ⁇ 3 ) .
  • the amplitude of a given phase in a waveform can be the same or differ among the phases.
  • Each waveform also possesses a duration (expressed, e.g., in seconds) that can, by way of example, range from 10 ⁇ (E ⁇ 6 ) to 2 ms (E ⁇ 3 ) .
  • the duration of the phases in a given waveform can likewise be the same or different. It is emphasized that all numerical values expressed herein are given by way of example only. They can be varied, increased or decreased, according to the clinical objectives.
  • repeating stimulation patterns or trains applied with non-regular inter-pulse intervals can regularize the output of disordered neuronal firing, to thereby prevent the generation and propagation of bursting activity with a lower average stimulation frequency than required with conventional constant frequency trains, i.e., with a lower average frequency than about 100 Hz.
  • Figure 3 shows a representative example of a repeating non-regular pulse pattern or train in which the inter- pulse intervals are linearly cyclically ramped over time.
  • the pulse pattern or train includes singlet pulses (singlets) spaced apart by progressively increasing inter-pulse intervals providing a decrease in frequency over time, e.g., having an initial instantaneous frequency of 140 Hz, decreasing with doubling inter-pulse intervals, to a final instantaneous frequency of 40 Hz.
  • the inter-pulse intervals can vary within a specified range selected based upon clinical objectives, e.g., not to exceed 25 ms, or not to exceed 100 ms, or not to exceed 200 ms, to take into account burst responses and subsequent disruption of thalamic fidelity. ) .
  • the non-regular pulse trains repeat themselves for a clinically appropriate period of time. As shown in Figure 3, the first pulse train comprises progressively increasing inter-pulse intervals from smallest to largest, followed immediately by another essentially identical second pulse train comprising progressively increasing inter-pulse intervals from smallest to largest, followed immediately by an essentially identical third pulse train, and so on.
  • the train shown in Figure 3 has an average frequency of 85 Hz and is highly non-regular, with a coefficient of variation (CV) of about 0.5.
  • CV coefficient of variation
  • the train shown in Figure 3 exploits the dynamics of burst generation in thalamic neurons .
  • the early high frequency phase of the train masks intrinsic activity in subthalamic nucleus (STN) neurons, and the inter-pulse interval increases reduce the average frequency.
  • a family of trains can be provided by varying the initial frequency, final frequency, and rate of change within the train, with the objective to prevent thalamic bursting with a lower average stimulation frequency than required with constant frequency trains.
  • Figs. 4 and 5 show other representative examples of repeating non-regular pulse patterns or trains .
  • the pulse trains in Figs. 4 and 5 comprise within, a single pulse train, a combination of single pulses (singlets) and embedded multiple pulse groups (n-lets) , with non-regular inter-pulse intervals between singlets and n-lets, as well as non-regular inter-pulse intervals within the n- lets themselves .
  • the non-regular pulse trains repeat themselves for a clinically appropriate period of time.
  • the non-regular pulse train can be characterized as comprising one or more singlets spaced apart by a minimum inter-pulse singlet interval and one or more n-lets comprising, for each n-let, two or more pulses spaced apart by an inter-pulse interval (called the "n-let inter-pulse interval") that is less than the minimum singlet inter-pulse interval.
  • the n-let inter-pulse interval can itself vary within the train, as can the interval between successive n-lets or a successive n-lets and singlets.
  • the non-regular pulse trains comprising singlets and n-lets repeat themselves for a clinically appropriate period of time.
  • each pulse train comprises four singlets in succession (with non-regular inter-pulse intervals there between) ; followed by four doublets in succession (with non-regular inter-doublet pulse intervals there between and non-regular inter-pulse intervals within each n-let) ; followed by a singlet, three doublets, and a singlet (with non-regular inter- pulse intervals there between and non-regular inter-pulse intervals within each n-let) .
  • the temporal pattern of this pulse train repeats itself in succession for a clinically appropriate period of time.
  • the non-regular temporal pulse pattern shown in Figure 4 has an average frequency of 67.82 Hz without loss of efficacy.
  • each pulse train comprises four singlets in succession (with non-regular inter-pulse intervals there between) ; followed by three doublets in succession (with non-regular inter-doublet pulse intervals there between and non-regular inter-pulse intervals within each n-let) .
  • the temporal pattern of this pulse train repeats itself in succession for a clinically appropriate period of time.
  • the non-regular temporal pulse pattern shown in Figure 5 has an average frequency of 87.62 Hz without loss of efficacy.
  • DBS can be used with genetic-algorithm-based optimization (GA) to design non-regular stimulation patterns or trains that produce desired relief of symptoms with a lower average stimulation frequency than regular, high-rate stimulation.
  • GA genetic-algorithm-based optimization
  • non-regular stimulation of the nervous system may rely on the possibility that neurons are sensitive to the specific timing of the stimulation pulses.
  • specific timing of the stimulation is important to individual neurons or even a population of neurons, it may be advantageous for DBS systems to use non-regular temporal patterns of stimulation to exploit this sensitivity and/or reactivity.
  • the importance of the timing of inputs to a neuron as it relates to information transfer in the system is a common idea that is termed temporal (or spatiotemporal) coding.
  • a non-regular stimulation pattern could be more effective than regular stimulation at disrupting or reversing pathological features of a neurological disorder such as Parkinson's disease.
  • a non-regular pattern of stimulation may be able effectively to break up pathological synchronization and oscillations that are common in systems affected by PD. Exploiting the neural coding by taking advantage of the brain's sensitivity, at any level, to the temporal structure of stimulation makes the technology described herein different than any other stimulation protocol ever developed to treat neurological disorders .
  • the technology described herein differs from prior systems and methods by utilizing non-regular stimulation with a higher average frequency (greater than about 100 Hz, and preferably less than about 250 Hz) to gain a clinical benefit greater than what can be elicited with regular high frequency stimulation.
  • a higher average frequency greater than about 100 Hz, and preferably less than about 250 Hz
  • results showed that the more non-regular you made randomly generated patterns of stimulation, the more ineffective that stimulation became at suppressing motor symptoms in Parkinson's disease patients ( Figure 6) . It was not until more structured patterns of stimulation designed to expose the effects of certain characteristics of the stimulation were tested that non-regular, higher frequency patterns of stimulation that were found to improve significantly a measure of motor performance when compared to regular stimulation at a comparable frequency ( Figure 15) .
  • non-regular patterns of stimulation (generated from non-linear dynamics) in mammals, and such methods seem to be effective in a mouse model of a minimally conscious state. While such results may be interesting, they are not in human patients, and the stimulation patterns were generated through different means . Indeed, results in human patients with ET and in human patients with PD show that such random patterns of stimulation are not effective in relieving symptoms. Patterns of stimulation according to the present invention are generated in a different way and are preferably structured and repeating. It has been found that features of non-regular patterns of DBS may need to be carefully chosen for the treatment of a specific neurological disorder in order to have the desired effects. For instance, a stimulation pattern that works for the treatment of PD may not be efficacious in treating essential tremor (ET) and/or vice versa.
  • ET essential tremor
  • Stimulation pulses and methods according to the present invention may be implemented in an implantable pulse generator capable of producing desirable patterns of the non-regular stimulation.
  • Known DBS devices, or similar variations thereof, may be used and programmed to generate the novel stimulation patterns described here herein.
  • This invention has been used in treating or relieving symptoms of Parkinson's disease.
  • the patterns of stimulation were designed to expose the effects of certain characteristics of the stimulation and yielded non-regular, high-frequency patterns of stimulation that significantly improved motor performance when compared to regular stimulation at a comparable frequency.
  • non-regular patterns of stimulation were designed and/or configured for the present working example differentiates the present methodology from all previous work regarding electrical stimulation for the treatment of PD.
  • the non-regular patterns of stimulation were chosen because they contained features that may be important to the neural code in the DBS target area. These features included: bursts, pauses, gradual increments and/or decrements in the interpulse interval, and other pulse structures thought to be important for communicating information between neurons in the brain.
  • non-regular patterns of stimulation were designed to elucidate the effects of certain characteristics of the stimulation pattern.
  • a stimulation pattern was created, wherein such pattern included bursts of stimulation pulses in rapid succession separated by groups of evenly spaced stimulation pulses (see Figure 7D) .
  • These novel patterns of stimulation where tested using intraoperative experiments . These intraoperative experiments were conducted by connecting to an exposed lead of DBS electrodes implanted in a human, then delivering the patterns of stimulation. Motor impairment was then quantified while delivering the patterns of stimulation using a finger-tapping task.
  • FIGS 7A-7D depict various non-regular stimulation patterns applied to humans according to the present invention.
  • the first stimulation pattern in Figure 7A, may be referred to as a Uniform temporally non-regular stimulation.
  • the Uniform stimulation pulse train includes non-regular timing between stimulation pulses, but does not include stimulation bursts or pauses .
  • a stimulation pulse burst is defined as an occurrence of at least two consecutive instantaneous pulse frequencies (IPF's) (IPFi and IPF 1+1 ) greater than 2*IPF m , where IPF m is the average IPF over some period of time preceding IPFi, such as about 125 milliseconds.
  • a stimulation pulse pause is defined as an IPF that is lower than a desired frequency, such as lower than the minimum frequency at which DBS effectively suppresses tremor, which may be about 90 Hz.
  • a desired frequency such as lower than the minimum frequency at which DBS effectively suppresses tremor
  • Another way of explaining a pulse pause is a desirable period of time, such as about 11 milliseconds, that passes without the initiation of a stimulation pulse.
  • the Uniform pulse train may be saidto be characterized by a log-uniform distribution of instantaneous pulse frequencies (IPFs) .
  • Figure 7B depicts what may be referred to as a Unipeak stimulation pulse train, which includes a wider log-uniform distribution of instantaneous pulse frequencies, including some pulse train bursts and some pulse train pauses .
  • Figure 7C depicts a stimulation pulse train, which may be termed the Absence train, which included a regular, periodic stimulation, but including pulse train pauses, but no pulse train bursts.
  • Figure 7D shows another stimulation pulse train, which may be referred to as the Presence train, which included a regular, periodic stimulation, and further including pulse train bursts, but no pulse train pauses.
  • Figure 8 provides a summary table of the properties of the above-discussed stimulation trains, as well as a Regular stimulation train of periodic stimulation provided at 185 Hz.
  • MPR refers to mean pulse rate, expressed in Hertz.
  • Mean(IPF) is the mean instantaneous pulse frequency, calculated by the following equation:
  • n the number of stimulation pulses in the pulse train
  • IPI the inter-pulse interval, or time between the start of pulse number i and pulse number i+1 in the pulse train.
  • the coefficient of variation of the stimulation pulse trains' IPF and IPI is provided, where the coefficient of variation is defined by the standard deviation of the respective variable (IPF or IPI) divided by the mean of the respective variable.
  • STN refers to a target site of stimulation including the patient's subthalamic nucleus
  • GPi refers to a target site of stimulation including the patient's globus pallidus interna.
  • the Absence and Presence patterns were both periodic with low entropy ( ⁇ 1 bits/pulse) and characterized by either short periods absent of pulses or the presence of short bursts of pulses, respectively. The pauses and bursts both occurred at 4.4 Hz.
  • the Uniform and Unipeak patterns were highly irregular (high entropy: -5.5-5.6 bits/pulse) and were created from log-uniform distributions of IPFs. Although the Unipeak pattern was created from a wider log-uniform distribution of IPFs (44-720 Hz) than the Uniform pattern (90-360 Hz), the two patterns had the same entropy.
  • Figure 10A provides the stimulation delivery and data collection timeline.
  • Each black box rectangle indicates a period of four minutes during which either stimulation is turned off (DBS OFF) or turned on (DBS ON) .
  • DBS OFF driven off
  • DBS ON turned on
  • data collection occurred during two time periods of twenty seconds each. First, at about two minutes into the 4-minute window, data collection period "a" started, and second, at about three minutes and thirty seconds into the 4-minute window, data collection period "b" started .
  • Figure 10B provides an overview of which data was analyzed.
  • baseline data was obtained. This data was taken from data collection time period "b" in the "Pre-Baseline” 4-minute window.
  • trial “b” data collected during DBS ON times was analyzed and compared to the baseline data. If a certain period of trial "b” data collection was not completed, then trial "a” data was analyzed for that window for that patient .
  • Figure 14 depicts click duration data collected from a first patient (on top) and a second patient (on bottom) .
  • DBS OFF times there was great variation in the click durations for each finger.
  • stimulation patterns according to the present invention were applied, improvements can be seen both in click duration consistency, as well as reduced simultaneous clicking .
  • stimulation patterns and methods according to the present invention have been shown to increase the efficacy of such stimulation, preferably without substantially increasing the mean frequency of the stimulation over a generally accepted frequency range, and maintaining a constant geometric mean frequency. Smaller values on the bar graph's y-axis indicate better performance on a motor task executed during the application of the DBS patterns. Bars not labeled with the same letter are significantly different from one another.
  • Figure 16A depicts, on the left, a generally accepted computer model from which thalamic neurological errors may be modeled. On the right, Figure 16A shows examples of such errors.
  • a "miss" error 212 is shown. That is, when a sensorimotor input is provided to the thalamus, a corresponding thalamic neuron response is expected, but does not show.
  • a "burst" error 214 is shown. A burst error occurs when more than one thalamic neuron response is generated in a short time window after a sensorimotor input.
  • a "spurious" error 216 is a thalamic neuron response that is generated without the thalamus receiving a sensorimotor input.
  • the computer model is a biophysical model of the basal ganglia in a PD state including the STN, GPi, and external globus pallidus (GPe) .
  • Each nucleus of the basal ganglia model contains 10 single compartment neurons.
  • Each GPe neuron sends inhibitory projections to two STN neurons, two GPi neurons, and two other GPe neurons.
  • STN neurons may send excitatory projections to two GPe neurons and two GPi neurons.
  • the biophysical properties of each neuron type were validated against experimental data and are described in detail elsewhere.
  • Constant currents were applied to neurons in each nucleus to represent inputs from afferent projections that were not included in the model and produced firing rates that were consistent with observations in non-human primate models of PD and human patients with PD .
  • STN and GPi neurons received applied current of 33 ⁇ /cm 2 and 21 ⁇ /cm 2 , respectively.
  • Variability was added to the model by delivering a constant current to each GPe neuron randomly drawn from a normal distribution centered around 8 ⁇ /cm 2 with a standard deviation of 2 ⁇ /cm 2 .
  • STN DBS was applied by delivering the desired pattern of current pulses (amplitude 300 ⁇ /cm 2 ; pulse width 0.3 ms) to each STN neuron.
  • DBS delivered to the model may reduce the error fraction, as defined, along a stimulation frequency range between about 100 Hz to about 200 Hz.
  • This tuning curve of error fraction as a function of DBS frequency in the biophysical model parallels strongly the tuning curve of symptoms as a function of DBS frequency in patients with PD.
  • Figure 15 shows average error fraction data generated by a generally accepted computer model. A lower average error fraction would seem to indicate an expected lower motor symptom severity as measured by click duration. As can be seen, the Regular stimulation pattern would be expected to generate a lower motor symptom severity than the patterns according to the present invention. However, as explained above and with reference to Figure 15, the stimulation patterns according to the present invention performed better.
  • stimulation patterns according to the present invention were expected to perform worse than previous Regular DBS trains based on an analysis of expected beta band oscillations generated by the model, as seen in Figure 17B.
  • beta band oscillations There is some conventionally accepted correlation between beta band oscillations and slower motor response. That is, an increased strength or power of beta band oscillations is generally correlated to a higher motor symptom severity, or slower motor response.
  • the prior Regular stimulation patterns would be expected to perform better than the stimulation patterns according to the present invention.
  • the stimulation patterns according to the present invention performed better.
  • the success of the stimulation pattern trains according to the present invention does not appear to be explainable or correlated to the types of errors expected, or as generated by the model, as seen in Figure 17C.
  • Motor performance during the stimulation patterns was weakly correlated with motor performance during the preceding stimulation off period, see Figure 18A. This suggested that changes in finger tap duration variability between stimulation patterns were caused by the stimulation patterns themselves, and were not a reflection of fluctuations in baseline motor performance. Instead, and consistent with the time course of the action of DBS in PD, motor performance during the stimulation off period following each stimulation pattern reflected the motor performance during the preceding pattern of stimulation, as demonstrated by significant correlations between finger tap duration variability during the stimulation pattern and during the subsequent stimulation off periods, see Figure 18B.
  • log CV Interval The log-transformed coefficient of variation of the intervals between finger taps (log CV Interval) exhibited the same pattern of motor performance across stimulation patterns as log CV Duration, See Figure 19A.
  • the finger tap timing was the most irregular, on average, during Baseline and the Unipeak pattern of stimulation, and the average log CV Interval during Absence, Presence, and Uniform DBS was lower than it was during Regular DBS.
  • the log-transformed rate of finger tapping exhibited a similar dependence on stimulation pattern. The fewest button presses occurred during Baseline (stimulation off) , and the most occurred during the Presence pattern of stimulation, see Figure 19B.
  • the present invention shows that different temporal patterns of DBS differentially suppressed oscillatory activity in a computational model of the basal ganglia.
  • Figure 21A shows spectrograms of GPi spike times from the computational model of the basal ganglia in the PD state across stimulation conditions.
  • Figure 21B shows that changes in beta band oscillatory power during delivery in the biophysical model of different temporal patterns of DBS were strongly correlated with changes in symptoms when the same patterns of stimulation were delivered to human patients with PD .
  • Figure 21C shows the correlation between the log CV Duration and beta power in arbitrary units .
  • Oscillatory and synchronized neural activity in specific frequency bands appear to be related to motor performance in patients with PD, and the non-regular patterns of stimulation that were most effective may be most able to override or otherwise disrupt pathological oscillations or synchronization in the basal ganglia.
  • the degree of suppression of the oscillatory activity in the model neurons matched the clinical efficacy of the patterns during the finger tapping task remarkably well, suggesting that the efficacy of these patterns of DBS depended on their ability to suppress, disrupt, or otherwise regularize pathological activity in the basal ganglia.
  • the frequency or the amplitude of the DBS is increased when a patient or clinician desires a more pronounced effect from the stimulation.
  • this inevitably leads to a shorter battery life for the implantable pulse generator system because of the higher demands placed on it.
  • This calls for more frequent battery recharging or surgery to replace non-rechargeable implantable pulse generator.
  • it is beneficial to increase the efficacy of the stimulation by simply changing the pattern of stimulation. That is exactly what the technology described in this invention does. It provides a greater level of symptom suppression for the patient while using an average frequency of stimulation similar to frequencies previously used in standard practice .
  • non-regular stimulation patterns or trains can be readily applied to deep brain stimulation, to treat a variety of neurological disorders, such as Parkinson's disease, movement disorders, epilepsy, and psychiatric disorders such as obsessive-compulsion disorder and depression.
  • the non- regular stimulation patterns or trains can also be readily applied to other classes electrical stimulation of the nervous system including, but not limited to, cortical stimulation, spinal cord stimulation, and peripheral nerve stimulation (including sensory and motor) , to provide the attendant benefits described above and to treat diseases such as but not limited to Parkinson's Disease, Essential Tremor, Movement Disorders, Dystonia, Epilepsy, Pain, psychiatric disorders such as Obsessive Compulsive Disorder, Depression, and Tourette's Symdrome .
  • the systems and methodologies make it possible to determine the effects of the temporal pattern of DBS on simulated and measured neuronal activity, as well as motor symptoms in both animals and humans.
  • the methodologies make possible the qualitative determination of the temporal features of stimulation trains .
  • stimulation having a pattern, preferably a repeating pattern, of non-regular stimulation at a high average frequency may increase the efficacy of electrical stimulation provided to relieve symptoms of neurological disorders, such as those treated with DBS.
  • a system or method according to the present invention may generate or utilize a higher frequency (about 100 to about 200 Hertz) non-regular pattern of DBS for the treatment or alleviation of symptoms of neurological disorders.

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Abstract

L'invention concerne des systèmes et des procédés pour la stimulation d'un tissu neurologique et la génération de trains de stimulation présentant des motifs temporels de stimulation, l'intervalle entre des impulsions électriques (les intervalles inter-impulsion) changeant ou variant avec le temps. Les caractéristiques des trains de stimulation peuvent être choisies et agencées de manière algorithmique selon un essai clinique. Ces trains de stimulation sont générés pour cibler un trouble neurologique spécifique, par agencement d'ensembles de caractéristiques qui réduisent les symptômes de ce trouble neurologique selon un motif qui est efficace pour réduire ces symptômes tout en maintenant ou en réduisant la consommation d'énergie en comparaison des signaux de stimulation réguliers. En comparaison de trains d'impulsions continus classiques de cadence élevée présentant des intervalles inter-impulsions réguliers (c.-à-d. constants), les motifs ou trains d'impulsions non réguliers (c.-à-d. non constants) qui constituent des caractéristiques de l'invention permettent d'obtenir une efficacité augmentée et/ou une fréquence inférieure à la moyenne.
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US9572988B2 (en) 2008-10-03 2017-02-21 Duke University Non-regular electrical stimulation patterns designed with a cost function for treating neurological disorders
US10716943B2 (en) 2008-10-03 2020-07-21 Duke University Non-regular electrical stimulation patterns for treating neurological disorders
US10773084B2 (en) 2008-10-03 2020-09-15 Duke University Non-regular electrical stimulation patterns designed with a cost function for treating neurological disorders
US11013924B2 (en) 2008-10-03 2021-05-25 Duke University Non-regular electrical stimulation patterns for treating neurological disorders
US11458318B2 (en) 2008-10-03 2022-10-04 Duke University Non-regular electrical stimulation patterns for treating neurological disorders
US11633605B2 (en) 2008-10-03 2023-04-25 Duke University Non-regular electrical stimulation patterns for treating neurological disorders
US11878173B2 (en) 2008-10-03 2024-01-23 Duke University Non-regular electrical stimulation patterns designed with a cost function for treating neurological disorders
US11975194B2 (en) 2008-10-03 2024-05-07 Duke University Non-regular electrical stimulation patterns for improved efficiency in treating Parkinson's disease
US10744328B2 (en) 2010-05-27 2020-08-18 Duke University System for generating and applying waveform shapes for treating neurological disorders optimized for energy efficiency
US11583680B2 (en) 2013-05-22 2023-02-21 Deep Brain Innovations LLC Deep brain stimulator and method of use
US10688306B2 (en) 2013-12-23 2020-06-23 Deep Brain Innovations LLC Programming systems for deep brain stimulator system

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AU2019205970A1 (en) 2019-08-01
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