US20140135886A1 - Devices, systems and methods for the treatment of medical disorders - Google Patents

Devices, systems and methods for the treatment of medical disorders Download PDF

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US20140135886A1
US20140135886A1 US13/994,541 US201113994541A US2014135886A1 US 20140135886 A1 US20140135886 A1 US 20140135886A1 US 201113994541 A US201113994541 A US 201113994541A US 2014135886 A1 US2014135886 A1 US 2014135886A1
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Prior art keywords
nerve
disorders
stimulation
trigeminal
branch
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US13/994,541
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Ian A. Cook
Christopher M. Degiorgio
Leon Ekchian
Patrick Miller
Antonio Desalles
Alejandro Covalin
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University of California
US Department of Veterans Affairs VA
Neurosigma Inc
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US Department of Veterans Affairs VA
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Assigned to NEUROSIGMA, INC. reassignment NEUROSIGMA, INC. ASSIGNMENT OF ASSIGNORS INTEREST (SEE DOCUMENT FOR DETAILS). Assignors: MILLER, PATRICK, EKCHIAN, LEON
Assigned to THE REGENTS OF THE UNIVERSITY OF CALIFORNIA reassignment THE REGENTS OF THE UNIVERSITY OF CALIFORNIA ASSIGNMENT OF ASSIGNORS INTEREST (SEE DOCUMENT FOR DETAILS). Assignors: DEGIORGIO, CHRISTOPHER M., COOK, IAN A.
Assigned to THE REGENTS OF THE UNIVERSITY OF CALIFORNIA reassignment THE REGENTS OF THE UNIVERSITY OF CALIFORNIA ASSIGNMENT OF ASSIGNORS INTEREST (SEE DOCUMENT FOR DETAILS). Assignors: COVALIN, ALEJANDRO
Assigned to THE REGENTS OF THE UNIVERSITY OF CALIFORNIA reassignment THE REGENTS OF THE UNIVERSITY OF CALIFORNIA CORRECTIVE ASSIGNMENT TO CORRECT THE APPLICATION NO. 62440784 PREVIOUSLY RECORDED AT REEL: 043059 FRAME: 0067. ASSIGNOR(S) HEREBY CONFIRMS THE ASSIGNMENT. Assignors: COVALIN, ALEJANDRO
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    • 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
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    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
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    • 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
    • A61N1/36096—Mood disorders, e.g. depression, anxiety or panic disorder
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    • 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
    • A61N1/361—Phantom sensations, e.g. tinnitus
    • A—HUMAN NECESSITIES
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    • 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
    • A61N1/36114—Cardiac control, e.g. by vagal stimulation

Definitions

  • the present disclosure generally relates to cutaneous neuromodulation devices and systems and methods of using the same. More specifically, methods, devices, and systems configured for the treatment of medical disorders, such as neuropsychiatric disorders including mood, cognitive and behavioral disorders, heart disease and other cardiac related disorders, and fatigue, via trigeminal nerve stimulation (“TNS”) are provided. Devices and systems configured for stimulation of superficial sensory branches of cranial nerves and their methods of application are described.
  • medical disorders such as neuropsychiatric disorders including mood, cognitive and behavioral disorders, heart disease and other cardiac related disorders, and fatigue
  • TNS trigeminal nerve stimulation
  • medications particularly psychostimulant medications.
  • Such medications include methylphenidate, amantadine, pemoline, and modafinil (reviewed by Peuckmann et al., Cochrane Database Syst Rev 2010, 11:CD006788).
  • These medications carry potential for side effects, such as blurred vision, depression or anxiety, liver failure, psychosis, suicidal thinking, swelling of the hands/leg/feet, shortness of breath, palpitations, elevated blood pressure, anorexia and addiction.
  • DBS deep brain stimulation
  • VNS vagus nerve stimulation
  • DBS Food and Drug Administration
  • One aspect of the subject matter of the present disclosure addresses the aforementioned needs by providing a method of treating medical disorders, and systems and devices configured to stimulate the ophthalmic (supraorbital), infraorbital and mentalis branch(es) of the trigeminal nerve to treat medical disorders.
  • an electrode assembly configured for the cutaneous stimulation of the trigeminal nerve.
  • a method of treating medical disorders using the disclosed electrode assembly is provided.
  • a system for trigeminal nerve stimulation for treatment of a medical disorder includes a pulse generator and a cutaneous electrode assembly in electrical communication with the pulse generator.
  • the assembly includes a first electrode comprising at least one contact configured for cutaneous placement at a first region of a patient's face, wherein the first electrode is configured to contact a portion of the patient's face overlying the cutaneous distribution of at least one branch of the trigeminal nerve to stimulate the trigeminal nerve to modulate at least one body system for treatment of a medical disorder, wherein the at least one branch of the trigeminal nerve is selected from the group consisting of: ophthalmic nerve, infraorbital nerve, mentalis nerve, supratrochlear nerve, supraorbital nerve, infratrochlear nerve, zygomaticotemporal nerve, zygomaticofacial nerve, zygomaticoorbital nerve, nasal nerve, and auriculotemporal nerve, and wherein the medical disorder is selected from: ophthalmic nerve, infr
  • the medical disorder is a cardiac related disorder selected from the group consisting of heart disease, cardiac arrhythmias, myocardial infarction, sudden cardiac death after myocardial infarction, heart failure, cerebral ischemia, sudden infant death syndrome (SIDS), impaired blood flow conditions, atrial fibrillation or sudden death in epilepsy.
  • the at least one branch of the trigeminal nerve is an ophthalmic nerve or an infraorbital nerve, wherein the body system is a trigeminal nerve cardiac reflex and wherein stimulation of the ophthalmic nerve or the infraorbital nerve modulates or activates the trigeminal nerve cardiac reflex to treat or prevent a cardiac related disorder.
  • the system of claim 2 wherein the body system is a vagus nerve circuit, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit to treat a cardiac related disorder.
  • the medical disorder is fatigue
  • the body system is a locus coeruleus or a reticular activating system, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the locus coeruleus or modulates the reticular activating system to treat fatigue.
  • the medical disorder is selected from the group consisting of obesity and other disorders related to weight and feeding, inflammation, disorders of regulation of breathing, disorders of gastrointestinal function, autonomic regulation in menopausal hot flashes, regulation of hemostasis and sleep/insomnia, wherein the body system is a vagus nerve circuit, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit to treat said medical disorder.
  • the medical disorder is a dementing disorder wherein the body system is a vagus nerve circuit or a trigeminal nerve cardiac reflex, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit or the trigeminal nerve cardiac reflex to treat said medical disorder.
  • the assembly further comprises a second electrode comprising at least one contact configured for cutaneous placement at a second region of the patient's face, wherein the second electrode is configured to contact a portion of the patient's face overlying the cutaneous distribution of at least one branch of the trigeminal nerve, wherein the at least one branch of the trigeminal nerve is selected from the group consisting of: ophthalmic nerve, infraorbital nerve, supraorbital nerve, mentalis nerve, supratrochlear nerve, infratrochlear nerve, zygomaticotemporal nerve, zygomaticofacial nerve, zygomaticoorbital nerve, nasal nerve, and auriculotemporal nerve.
  • first electrode and the second electrode are configured to contact a portion of the patient's face overlying the cutaneous distribution of a same branch of the trigeminal nerve. In another embodiment, the first electrode and the second electrode are configured to contact a portion of the patient's face overlying the cutaneous distribution of a different branch of the trigeminal nerve.
  • the stimulation may be provided uni- or bilaterally.
  • the system is configured for minimal current penetration into a brain of a patient.
  • the system may further include a closed loop device configured to provide self-tuning adaptive feedback control to the system.
  • stimulation of the at least one branch of the trigeminal nerve is determined based on measurement of activity in a brain region to detect an acute biological change.
  • the at least one branch of the trigeminal nerve is stimulated at a first set of stimulation parameters for a first time period, at a second set of stimulation parameters for a second time period, and at a third set of stimulation parameters for a third time period.
  • the at least one branch of the trigeminal nerve is stimulated at the first, second and third set of parameters in a cycle at least twice.
  • the pulse generator is configured to apply electrical signals at a frequency between approximately 1 and 300 Hertz, at a pulse duration between approximately 50 and 500 microseconds, at an output current density of not greater than approximately 10 mA/cm 2 and an output charge density of not greater than approximately 10 microCoulomb/cm 2 at the cerebral cortex.
  • a cutaneous electrode assembly for trigeminal nerve stimulation for treatment of a medical disorder includes a first electrode comprising at least one contact configured for cutaneous placement at a first region of the patient's face, wherein the first electrode is configured to contact a portion of the patient's face overlying the cutaneous distribution of at least one branch of the trigeminal nerve to stimulate the trigeminal nerve to modulate at least one body system for treatment of a medical disorder, wherein the at least one branch of the trigeminal nerve is selected from the group consisting of: ophthalmic nerve, infraorbital nerve, mentalis nerve, supratrochlear nerve, supraorbital nerve, infratrochlear nerve, zygomaticotemporal nerve, zygomaticofacial nerve, zygomaticoorbital nerve, nasal nerve, and auriculotemporal nerve, and wherein the medical disorder is selected from the group consisting of: cardiac related disorders, fatigue, tinnitus, obesity, diabetes, dys
  • the assembly may further include a second electrode comprising at least one contact configured for cutaneous placement at a second region of the patient's face, wherein the second electrode is configured to contact a portion of the patient's face overlying the cutaneous distribution of at least one branch of the trigeminal nerve, wherein the at least one branch of the trigeminal nerve is selected from the group consisting of: ophthalmic nerve, supraorbital nerve, infraorbital nerve, mentalis nerve, supratrochlear nerve, infratrochlear nerve, zygomaticotemporal nerve, zygomaticofacial nerve, zygomaticoorbital nerve, nasal nerve, and auriculotemporal nerve.
  • the first electrode and the second electrode are configured to contact a portion of the patient's face overlying the cutaneous distribution of a same branch of the trigeminal nerve. In some embodiments, the first electrode and the second electrode are configured to contact a portion of the patient's face overlying the cutaneous distribution of a different branch of the trigeminal nerve.
  • the medical disorder is a cardiac related disorder selected from the group consisting of heart disease, cardiac arrhythmias, myocardial infarction, sudden cardiac death after myocardial infarction, heart failure, cerebral ischemia, sudden infant death syndrome (SIDS), impaired blood flow conditions, atrial fibrillation or sudden death in epilepsy.
  • the body system is a vagus nerve circuit, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit to treat a cardiac related disorder.
  • the medical disorder is fatigue, wherein the body system is a locus coeruleus or a reticular activating system, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the locus coeruleus or modulates the reticular activating system to treat fatigue.
  • the medical disorder is selected from the group consisting of obesity and other disorders related to weight and feeding, inflammation, disorders of regulation of breathing, disorders of gastrointestinal function, autonomic regulation in menopausal hot flashes, regulation of hemostasis and sleep/insomnia, wherein the body system is a vagus nerve circuit, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit to treat said medical disorder.
  • the medical disorder is a dementing disorder wherein the body system is a vagus nerve circuit or a trigeminal nerve cardiac reflex, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit or the trigeminal nerve cardiac reflex to treat said medical disorder.
  • the assembly produces minimal current penetration into a brain of a patient.
  • a method for treating a medical disorder by trigeminal nerve stimulation includes contacting a first region of a patient's face with a cutaneous electrode assembly with at least one branch of the trigeminal nerve to stimulate the trigeminal nerve for treatment of a medical disorder and applying electrical signals to the electrode assembly to stimulate the at least one branch of the trigeminal nerve to modulate a system of the patient's body for treatment of a medical disorder.
  • the cutaneous electrode assembly includes a first electrode comprising at least one contact configured for cutaneous placement at a first region of the patient's face, wherein the first electrode contacts a portion of the patient's face overlying the cutaneous distribution of at least one branch of the trigeminal nerve.
  • the at least one branch of the trigeminal nerve is selected from the group consisting of: ophthalmic nerve, supraorbital nerve, infraorbital nerve, mentalis nerve, supratrochlear nerve, infratrochlear nerve, zygomaticotemporal nerve, zygomaticofacial nerve, zygomaticoorbital nerve, nasal nerve, and auriculotemporal nerve.
  • the medical disorder is selected from the group consisting of: cardiac related disorders, fatigue, tinnitus, obesity, diabetes, dyslipidemia, metabolic syndrome, obstructive sleep apnea, arthritis, cachexia/anorexia, inflammation, asthma, inflammatory bowel disease, atopic dermatitis, sepsis, hepatitis, disorders of regulation of breathing, disorders of gastrointestinal function, gastroesophageal reflux, diarrhea and constipation, dysphagia and other disturbances of swallowing, gastroparesis, functional bowel syndromes, post-operative ileus, dyspepsia, motion sickness, chemotherapy-related nausea and emesis, autonomic regulation in menopausal hot flashes, regulation of hemostasis, sleep/insomnia and a neuropsychiatric disorder selected from the group consisting of attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), autism and autism spectrum disorders (ASD), substance use disorders and related behavioral addictions, eating disorders and obsessive compulsive
  • the method may further include a second electrode comprising at least one contact configured for cutaneous placement at a second region of the patient's face, wherein the second electrode is configured to contact a portion of the patient's face overlying the cutaneous distribution of at least one branch of the trigeminal nerve, wherein the at least one branch of the trigeminal nerve is selected from the group consisting of: ophthalmic nerve, supraorbital nerve, infraorbital nerve, mentalis nerve, supratrochlear nerve, infratrochlear nerve, zygomaticotemporal nerve, zygomaticofacial nerve, zygomaticoorbital nerve, nasal nerve, and auriculotemporal nerve.
  • step of applying electrical signals comprises applying electrical signals at a frequency between approximately 20 and 300 Hertz, at a current of 0.05 to 5 milliamperes (mA) and at a pulse duration of less than or equal to 500 microseconds.
  • the step of applying electrical signals comprises applying electrical signals at a frequency between approximately 20 and 300 Hertz, at a pulse duration between approximately 50 and 500 microseconds, at an output current density of not greater than approximately 10 mA/cm 2 and a charge density of not greater than approximately 10 microCoulomb/cm 2 at the cerebral cortex.
  • the step of applying electrical signals comprises applying electrical signals at an output current density of not greater than approximately 10 mA/cm 2 .
  • the step of applying electrical signals comprises applying electrical signals at an output current density of between approximately 2.5 and 5 mA/cm 2 . In one embodiment, the step of applying electrical signals comprises applying electrical signals at an output current density of not greater than approximately 7 mA/cm 2 . In one embodiment, the step of applying electrical signals comprises applying electrical signals at an output current density of not greater than approximately 5 mA/cm 2 . In one embodiment, the step of applying electrical signals comprises applying electrical signals to minimize current penetration into a brain of a patient.
  • the medical disorder is a cardiac related disorder selected from the group consisting of heart disease, cardiac arrhythmias, myocardial infarction, sudden cardiac death after myocardial infarction, heart failure, cerebral ischemia, sudden infant death syndrome (SIDS), impaired blood flow conditions, atrial fibrillation or sudden death in epilepsy.
  • the body system is a vagus nerve circuit, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit to treat a cardiac related disorder.
  • the medical disorder is fatigue, wherein the body system is a locus coeruleus or a reticular activating system, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the locus coeruleus or modulates the reticular activating system to treat fatigue.
  • the medical disorder is selected from the group consisting of obesity and other disorders related to weight and feeding, inflammation, disorders of regulation of breathing, disorders of gastrointestinal function, autonomic regulation in menopausal hot flashes, regulation of hemostasis and sleep/insomnia, wherein the body system is a vagus nerve circuit, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit to treat said medical disorder.
  • the medical disorder is a dementing disorder wherein the body system is a vagus nerve circuit or a trigeminal nerve cardiac reflex, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit or the trigeminal nerve cardiac reflex to treat said medical disorder.
  • kits for trigeminal nerve stimulation for treatment of a medical disorder includes an electrode assembly as disclosed elsewhere herein and instructions for applying the electrode assembly to a patient for treatment of a medical disorder, wherein the medical disorder is selected from the group consisting of: cardiac related disorders, fatigue, tinnitus, obesity, diabetes, dyslipidemia, metabolic syndrome, obstructive sleep apnea, arthritis, cachexia/anorexia, inflammation, asthma, inflammatory bowel disease, atopic dermatitis, sepsis, hepatitis, disorders of regulation of breathing, disorders of gastrointestinal function, gastroesophageal reflux, diarrhea and constipation, dysphagia and other disturbances of swallowing, gastroparesis, functional bowel syndromes, post-operative ileus, dyspepsia, motion sickness, chemotherapy-related nausea and emesis, autonomic regulation in menopausal hot flashes, regulation of hemostasis, sleep/insomnia and a neurode
  • a method for initiation, activation or stimulation of a vagus nerve circuit by trigeminal nerve stimulation for treatment of a medical disorder may include contacting a first region of a patient's face with a cutaneous electrode assembly with at least one branch of the trigeminal nerve to stimulate the trigeminal nerve for treatment of a medical disorder and applying electrical signals to the electrode assembly to stimulate the at least one branch of the trigeminal nerve to modulate the vagus nerve circuit for treatment of a medical disorder which may benefit from vagus nerve stimulation via the trigeminal nerve.
  • the cutaneous electrode assembly includes a first electrode comprising at least one contact configured for cutaneous placement at a first region of the patient's face.
  • the at least one branch of the trigeminal nerve is an ophthalmic nerve or an infraorbital nerve.
  • the medical disorder is a cardiac related disorder selected from the group consisting of heart disease, cardiac arrhythmias, myocardial infarction, sudden cardiac death after myocardial infarction, heart failure, cerebral ischemia, sudden infant death syndrome (SIDS), impaired blood flow conditions, atrial fibrillation or sudden death in epilepsy.
  • the medical disorder is selected from the group consisting of obesity and other disorders related to weight and feeding, inflammation, disorders of regulation of breathing, disorders of gastrointestinal function, autonomic regulation in menopausal hot flashes, regulation of hemostasis and sleep/insomnia, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit to treat said medical disorder.
  • the medical disorder is a dementing disorder and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit to treat said medical disorder.
  • a behind the ear device for polycranial nerve stimulation for treatment of a medical disorder includes an external ear body including a pulse generator and a battery and an ear canal body including an electrode assembly in electrical communication with the pulse generator.
  • the electrode assembly includes at least one electrode comprising at least one contact configured to contact the cutaneous distribution of at least one branch of the trigeminal nerve at, in or about a patient's ear, and stimulation of the at least one branch of the trigeminal nerve modulates a system in the body to treat a medical disorder.
  • the at least one branch of the trigeminal nerve is selected from the group consisting of: ophthalmic nerve, infraorbital nerve, supraorbital nerve, mentalis nerve, supratrochlear nerve, infratrochlear nerve, zygomaticotemporal nerve, zygomaticofacial nerve, zygomaticoorbital nerve, nasal nerve, and auriculotemporal nerve.
  • the device further includes a second electrode comprising at least one contact configured for subcutaneous or percutaneous placement at a second region of the patient's face, wherein the second electrode is configured to be implanted in proximity to, adjacent to or in contact with at least one branch of the trigeminal nerve, wherein the at least one branch of the trigeminal nerve is selected from the group consisting of: ophthalmic nerve, infraorbital nerve, supraorbital nerve, mentalis nerve, supratrochlear nerve, infratrochlear nerve, zygomaticotemporal nerve, zygomaticofacial nerve, zygomaticoorbital nerve, nasal nerve, and auriculotemporal nerve.
  • ophthalmic nerve infraorbital nerve, supraorbital nerve, mentalis nerve, supratrochlear nerve, infratrochlear nerve, zygomaticotemporal nerve, zygomaticofacial nerve, zygomaticoorbital nerve, nasal nerve, and auriculotemporal nerve.
  • the first electrode and the second electrode are configured for implantation in proximity to, adjacent to or in contact with a same branch of the trigeminal nerve. In one embodiment, the first electrode and the second electrode are configured for implantation in proximity to, adjacent to or in contact with a different branch of the trigeminal nerve.
  • the device produces minimal current penetration into a brain of a patient.
  • the device may further include a closed loop device configured to provide self-tuning adaptive feedback control to the system. Stimulation of the at least one branch of the trigeminal nerve is determined based on measurement of activity in a brain region to detect an acute biological change.
  • the at least one branch of the trigeminal nerve is stimulated at a first set of stimulation parameters for a first time period, at a second set of stimulation parameters for a second time period, and at a third set of stimulation parameters for a third time period.
  • the at least one branch of the trigeminal nerve is stimulated at the first, second and third set of parameters in a cycle at least twice.
  • the pulse generator is configured to apply electrical signals at a frequency between approximately 1 and 300 Hertz, at a pulse duration between approximately 50 and 500 microseconds, at an output current density of not greater than approximately 10 mA/cm 2 and an output charge density of not greater than approximately 10 microCoulomb/cm 2 at the cerebral cortex.
  • the pulse generator is configured to apply electrical signals at an output current density of not greater than approximately 10 mA/cm 2 . In one embodiment, the pulse generator is configured to apply electrical signals at an output current density of between approximately 2.5 and 5 mA/cm 2 . In one embodiment, the pulse generator is configured to apply electrical signals at an output current density of not greater than approximately 7 mA/cm 2 . In one embodiment, the pulse generator is configured to apply electrical signals at an output current density of not greater than approximately 5 mA/cm 2 .
  • the medical disorder is selected from the group consisting of: neurological disorders, cardiac related disorders, fatigue, tinnitus, obesity, diabetes, dyslipidemia, metabolic syndrome, obstructive sleep apnea, arthritis, cachexia/anorexia, inflammation, asthma, inflammatory bowel disease, atopic dermatitis, sepsis, hepatitis, disorders of regulation of breathing, disorders of gastrointestinal function, gastroesophageal reflux, diarrhea and constipation, dysphagia and other disturbances of swallowing, gastroparesis, functional bowel syndromes, post-operative ileus, dyspepsia, motion sickness, chemotherapy-related nausea and emesis, autonomic regulation in menopausal hot flashes, regulation of hemostasis, sleep/insomnia and a neuropsychiatric disorder selected from the group consisting of depression, attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), autism and autism spectrum disorders (ASD), substance use disorders and related behavioral addictions, eating disorders and obs
  • the medical disorder is a cardiac related disorder selected from the group consisting of heart disease, cardiac arrhythmias, myocardial infarction, sudden cardiac death after myocardial infarction, heart failure, cerebral ischemia, sudden infant death syndrome (SIDS), impaired blood flow conditions, atrial fibrillation or sudden death in epilepsy.
  • the at least one branch of the trigeminal nerve is an ophthalmic nerve or an infraorbital nerve, wherein the body system is a trigeminal nerve cardiac reflex and wherein stimulation of the ophthalmic nerve or the infraorbital nerve modulates or activates the trigeminal nerve cardiac reflex to treat or prevent a cardiac related disorder.
  • the body system is a vagus nerve circuit, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit to treat a cardiac related disorder.
  • the medical disorder is fatigue, wherein the body system is a locus coeruleus or a reticular activating system, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the locus coeruleus or modulates the reticular activating system to treat fatigue.
  • the medical disorder is selected from the group consisting of obesity and other disorders related to weight and feeding, inflammation, disorders of regulation of breathing, disorders of gastrointestinal function, autonomic regulation in menopausal hot flashes, regulation of hemostasis and sleep/insomnia, wherein the body system is a vagus nerve circuit, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit to treat said medical disorder.
  • the medical disorder is a dementing disorder wherein the body system is a vagus nerve circuit or a trigeminal nerve cardiac reflex, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit or the trigeminal nerve cardiac reflex to treat said medical disorder.
  • a completely in canal device for polycranial nerve stimulation for treatment of a medical disorder includes an elongated body defining a lumen therethrough and further including a pulse generator and a battery housed within the body and an electrode assembly in electrical communication with the pulse generator and located about an outer circumferential surface of the elongated body.
  • the assembly includes at least one electrode comprising at least one contact configured to contact the cutaneous distribution of at least one branch of the trigeminal nerve at, in or about a patient's ear. Stimulation of the at least one branch of the trigeminal nerve modulates a system in the body to treat a medical disorder.
  • the at least one branch of the trigeminal nerve is selected from the group consisting of: ophthalmic nerve, supraorbital nerve, infraorbital nerve, mentalis nerve, supratrochlear nerve, infratrochlear nerve, zygomaticotemporal nerve, zygomaticofacial nerve, zygomaticoorbital nerve, nasal nerve, and auriculotemporal nerve.
  • the device further includes a second electrode comprising at least one contact configured for subcutaneous or percutaneous placement at a second region of the patient's face, wherein the second electrode is configured to be implanted in proximity to, adjacent to or in contact with at least one branch of the trigeminal nerve, wherein the at least one branch of the trigeminal nerve is selected from the group consisting of: ophthalmic nerve, supraorbital nerve, infraorbital nerve, mentalis nerve, supratrochlear nerve, infratrochlear nerve, zygomaticotemporal nerve, zygomaticofacial nerve, zygomaticoorbital nerve, nasal nerve, and auriculotemporal nerve.
  • ophthalmic nerve supraorbital nerve, infraorbital nerve, mentalis nerve, supratrochlear nerve, infratrochlear nerve, zygomaticotemporal nerve, zygomaticofacial nerve, zygomaticoorbital nerve, nasal nerve, and auriculotemporal nerve.
  • the first electrode and the second electrode are configured for implantation in proximity to, adjacent to or in contact with a same branch of the trigeminal nerve. In one embodiment, the first electrode and the second electrode are configured for implantation in proximity to, adjacent to or in contact with a different branch of the trigeminal nerve.
  • the device produces minimal current penetration into a brain of a patient.
  • the device may further include a closed loop device configured to provide self-tuning adaptive feedback control to the system.
  • stimulation of the at least one branch of the trigeminal nerve is determined based on measurement of activity in a brain region to detect an acute biological change.
  • the at least one branch of the trigeminal nerve is stimulated at a first set of stimulation parameters for a first time period, at a second set of stimulation parameters for a second time period, and at a third set of stimulation parameters for a third time period.
  • the at least one branch of the trigeminal nerve is stimulated at the first, second and third set of parameters in a cycle at least twice.
  • the pulse generator is configured to apply electrical signals at a frequency between approximately 1 and 300 Hertz, at a pulse duration between approximately 50 and 500 microseconds, at an output current density of not greater than approximately 10 mA/cm 2 and an output charge density of not greater than approximately 10 microCoulomb/cm 2 at the cerebral cortex.
  • the pulse generator is configured to apply electrical signals at an output current density of not greater than approximately 10 mA/cm 2 . In one embodiment, the pulse generator is configured to apply electrical signals at an output current density of between approximately 2.5 and 5 mA/cm 2 . In one embodiment, the pulse generator is configured to apply electrical signals at an output current density of not greater than approximately 7 mA/cm 2 . In one embodiment, the pulse generator is configured to apply electrical signals at an output current density of not greater than approximately 5 mA/cm 2 .
  • the medical disorder is selected from the group consisting of: neurological disorders, cardiac related disorders, fatigue, tinnitus, obesity, diabetes, dyslipidemia, metabolic syndrome, obstructive sleep apnea, arthritis, cachexia/anorexia, inflammation, asthma, inflammatory bowel disease, atopic dermatitis, sepsis, hepatitis, disorders of regulation of breathing, disorders of gastrointestinal function, gastroesophageal reflux, diarrhea and constipation, dysphagia and other disturbances of swallowing, gastroparesis, functional bowel syndromes, post-operative ileus, dyspepsia, motion sickness, chemotherapy-related nausea and emesis, autonomic regulation in menopausal hot flashes, regulation of hemostasis, sleep/insomnia and a neuropsychiatric disorder selected from the group consisting of depression, attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), autism and autism spectrum disorders (ASD), substance use disorders and related behavioral addictions, eating disorders and obs
  • the medical disorder is a cardiac related disorder selected from the group consisting of heart disease, cardiac arrhythmias, myocardial infarction, sudden cardiac death after myocardial infarction, heart failure, cerebral ischemia, sudden infant death syndrome (SIDS), impaired blood flow conditions, atrial fibrillation or sudden death in epilepsy.
  • the at least one branch of the trigeminal nerve is an ophthalmic nerve or an infraorbital nerve, wherein the body system is a trigeminal nerve cardiac reflex and wherein stimulation of the ophthalmic nerve or the infraorbital nerve modulates or activates the trigeminal nerve cardiac reflex to treat or prevent a cardiac related disorder.
  • the body system is a vagus nerve circuit, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit to treat a cardiac related disorder.
  • the medical disorder is fatigue, wherein the body system is a locus coeruleus or a reticular activating system, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the locus coeruleus or modulates the reticular activating system to treat fatigue.
  • the medical disorder is selected from the group consisting of obesity and other disorders related to weight and feeding, inflammation, disorders of regulation of breathing, disorders of gastrointestinal function, autonomic regulation in menopausal hot flashes, regulation of hemostasis and sleep/insomnia, wherein the body system is a vagus nerve circuit, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit to treat said medical disorder.
  • the medical disorder is a dementing disorder wherein the body system is a vagus nerve circuit or a trigeminal nerve cardiac reflex, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit or the trigeminal nerve cardiac reflex to treat said medical disorder.
  • the medical disorder is selected from the group consisting of: cardiac related disorders, fatigue, tinnitus, obesity, diabetes, dyslipidemia, metabolic syndrome, obstructive sleep apnea, arthritis, cachexia/anorexia, inflammation, asthma, inflammatory bowel disease, atopic dermatitis, sepsis, hepatitis, disorders of regulation of breathing, disorders of gastrointestinal function, gastroesophageal reflux, diarrhea and constipation, dysphagia and other disturbances of swallowing, gastroparesis, functional bowel syndromes, post-operative ileus, dyspepsia, motion sickness, chemotherapy-related nausea and emesis, autonomic regulation in menopausal hot flashes, regulation of hemostasis, sleep/insomnia and a neuropsychiatric disorder selected from the group consisting of attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), autism and autism spectrum
  • ADD attention deficit disorder
  • ADHD attention deficit hyperactivity disorder
  • autism autism spectrum
  • the medical disorder is a cardiac related disorder selected from the group consisting of heart disease, cardiac arrhythmias, myocardial infarction, sudden cardiac death after myocardial infarction, heart failure, cerebral ischemia, sudden infant death syndrome (SIDS), impaired blood flow conditions, atrial fibrillation or sudden death in epilepsy.
  • the at least one branch of the trigeminal nerve is an ophthalmic nerve or an infraorbital nerve, wherein the body system is a trigeminal nerve cardiac reflex and wherein stimulation of the ophthalmic nerve or the infraorbital nerve modulates or activates the trigeminal nerve cardiac reflex to treat or prevent a cardiac related disorder.
  • the body system is a vagus nerve circuit, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit to treat a cardiac related disorder.
  • the medical disorder is fatigue, wherein the body system is a locus coeruleus or a reticular activating system, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the locus coeruleus or modulates the reticular activating system to treat fatigue.
  • the medical disorder is selected from the group consisting of obesity and other disorders related to weight and feeding, inflammation, disorders of regulation of breathing, disorders of gastrointestinal function, autonomic regulation in menopausal hot flashes, regulation of hemostasis and sleep/insomnia, wherein the body system is a vagus nerve circuit, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit to treat said medical disorder.
  • the medical disorder is a dementing disorder wherein the body system is a vagus nerve circuit or a trigeminal nerve cardiac reflex, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit or the trigeminal nerve cardiac reflex to treat said medical disorder.
  • the medical disorder is selected from the group consisting of: cardiac related disorders, fatigue, tinnitus, obesity, diabetes, dyslipidemia, metabolic syndrome, obstructive sleep apnea, arthritis, cachexia/anorexia, inflammation, asthma, inflammatory bowel disease, atopic dermatitis, sepsis, hepatitis, disorders of regulation of breathing, disorders of gastrointestinal function, gastroesophageal reflux, diarrhea and constipation, dysphagia and other disturbances of swallowing, gastroparesis, functional bowel syndromes, post-operative ileus, dyspepsia, motion sickness, chemotherapy-related nausea and emesis, autonomic regulation in menopausal hot flashes, regulation of hemostasis, sleep/insomnia and a neuropsychiatric disorder selected from the group consisting of attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), autism and autism spectrum disorders (ASD),
  • ADD attention deficit disorder
  • ADHD attention deficit hyperactivity disorder
  • ASD autism and
  • the medical disorder is a cardiac related disorder selected from the group consisting of heart disease, cardiac arrhythmias, myocardial infarction, sudden cardiac death after myocardial infarction, heart failure, cerebral ischemia, sudden infant death syndrome (SIDS), impaired blood flow conditions, atrial fibrillation or sudden death in epilepsy.
  • the at least one branch of the trigeminal nerve is an ophthalmic nerve or an infraorbital nerve, wherein the body system is a trigeminal nerve cardiac reflex and wherein stimulation of the ophthalmic nerve or the infraorbital nerve modulates or activates the trigeminal nerve cardiac reflex to treat or prevent a cardiac related disorder.
  • the body system is a vagus nerve circuit, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit to treat a cardiac related disorder.
  • the medical disorder is fatigue, wherein the body system is a locus coeruleus or a reticular activating system, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the locus coeruleus or modulates the reticular activating system to treat fatigue.
  • the medical disorder is selected from the group consisting of obesity and other disorders related to weight and feeding, inflammation, disorders of regulation of breathing, disorders of gastrointestinal function, autonomic regulation in menopausal hot flashes, regulation of hemostasis and sleep/insomnia, wherein the body system is a vagus nerve circuit, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit to treat said medical disorder.
  • the medical disorder is selected from the group consisting of: cardiac related disorders, fatigue, tinnitus, obesity, diabetes, dyslipidemia, metabolic syndrome, obstructive sleep apnea, arthritis, cachexia/anorexia, inflammation, asthma, inflammatory bowel disease, atopic dermatitis, sepsis, hepatitis, disorders of regulation of breathing, disorders of gastrointestinal function, gastroesophageal reflux, diarrhea and constipation, dysphagia and other disturbances of swallowing, gastroparesis, functional bowel syndromes, post-operative ileus, dyspepsia, motion sickness, chemotherapy-related nausea and emesis, autonomic regulation in menopausal hot flashes, regulation of hemostasis, sleep/insomnia and a neuropsychiatric disorder selected from the group consisting of attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), autism and autism spectrum disorders (ASD
  • the medical disorder is a cardiac related disorder selected from the group consisting of heart disease, cardiac arrhythmias, myocardial infarction, sudden cardiac death after myocardial infarction, heart failure, cerebral ischemia, sudden infant death syndrome (SIDS), impaired blood flow conditions, atrial fibrillation or sudden death in epilepsy.
  • the at least one branch of the trigeminal nerve is an ophthalmic nerve or an infraorbital nerve, wherein the body system is a trigeminal nerve cardiac reflex and wherein stimulation of the ophthalmic nerve or the infraorbital nerve modulates or activates the trigeminal nerve cardiac reflex to treat or prevent a cardiac related disorder.
  • the body system is a vagus nerve circuit, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit to treat a cardiac related disorder.
  • the medical disorder is fatigue, wherein the body system is a locus coeruleus or a reticular activating system, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the locus coeruleus or modulates the reticular activating system to treat fatigue.
  • the medical disorder is selected from the group consisting of obesity and other disorders related to weight and feeding, inflammation, disorders of regulation of breathing, disorders of gastrointestinal function, autonomic regulation in menopausal hot flashes, regulation of hemostasis and sleep/insomnia, wherein the body system is a vagus nerve circuit, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit to treat said medical disorder.
  • the medical disorder is a dementing disorder wherein the body system is a vagus nerve circuit or a trigeminal nerve cardiac reflex, and wherein stimulation of the at least one branch of the trigeminal nerve modulates the vagus nerve circuit or the trigeminal nerve cardiac reflex to treat said medical disorder.
  • FIGS. 1A and 1B illustrate the location of several branches (nerves) of the trigeminal nerve and the location of the major foramina for the superficial branches of the trigeminal nerve;
  • FIG. 1C is a diagram of the principal afferent and efferent projections of the nucleus of the solitary tract;
  • FIG. 1D illustrates the connection between the trigeminal nerve and the vagus nerve
  • FIG. 2 shows average Positron Emission Tomography (PET) scanning data from a pair of adults being treated using aspects of the present disclosure and demonstrating brain regions with increased regional blood flow;
  • PET Positron Emission Tomography
  • FIG. 3 shows average PET scanning data from a pair of adults being treated using aspects of the present disclosure and demonstrating brain regions with decreased regional blood flow;
  • FIG. 4 shows an embodiment of a system including an electrode assembly provided according to aspects of the present disclosure
  • FIG. 5A depicts an enlarged view of the electrode assembly of FIG. 4 ;
  • FIG. 5B depicts representative dimensions of the electrode assembly of FIG. 5A ;
  • FIGS. 6A-6C depict various embodiments of the cutaneous electrode assembly of FIG. 4 ;
  • FIG. 7 shows another embodiment of an electrode assembly that may be used with the system of FIG. 4 ;
  • FIGS. 8 A to 8 C- 2 illustrate an ear and another embodiment of a system according to aspects of the present disclosure
  • FIG. 9 depicts one embodiment of the sequential employment of N sets of stimulation parameters in accordance with aspects of the present disclosure.
  • FIG. 10 depicts one embodiment of a system for determining patient specific stimulation parameters according to aspects of the present disclosure.
  • FIG. 11A is a table showing an average of the results of four assessment tests pre-treatment and post treatment of a treatment study for psychiatric disorders using aspects of the present disclosure
  • FIG. 11B is a bar graph of the data shown in FIG. 11A ;
  • FIG. 11C is a graph illustrating the change over time of the data shown in FIG. 11A ;
  • FIG. 12 summarizes one embodiment of current, charge, current density and charge density parameters for a subject exposed to cutaneous stimulation of the supraorbital nerve
  • FIG. 13 illustrates patient response to cutaneous stimulation of the supraorbital and infraorbital nerve according to one aspect of the present disclosure.
  • FIG. 14 illustrates patient response to cutaneous stimulation of the trigeminal nerve according to one aspect of the present disclosure.
  • FIGS. 15A-15B illustrates one embodiment of a protocol for mitigating potential accommodation.
  • the present disclosure relates to methods, devices and systems used for the treatment or prevention of various medical disorders via stimulation of the superficial elements of the trigeminal nerve.
  • the medical disorders may include, but are not limited to, neuropsychiatric disorders, neurological disorders, cardiac related disorders, fatigue, tinnitus, obesity, diabetes, dyslipidemia, metabolic syndrome, obstructive sleep apnea, arthritis, cachexia/anorexia, inflammation, asthma, inflammatory bowel disease, atopic dermatitis, sepsis, hepatitis, disorders of regulation of breathing, disorders of gastrointestinal function, gastroesophageal reflux, diarrhea and constipation, dysphagia and other disturbances of swallowing, gastroparesis, functional bowel syndromes, post-operative ileus, dyspepsia, motion sickness, chemotherapy-related nausea and emesis, autonomic regulation in menopausal hot flashes, regulation of hemostasis and sleep/insomnia.
  • the present disclosure also relates to methods, devices and systems used for the treatment of various medical disorders via stimulation of the superficial elements of the trigeminal nerve to modulate the activity of the vagus nerve. More specifically, cutaneous methods of stimulation of the superficial branches of the trigeminal nerve located extracranially in the face, namely the supraorbital, supratrochlear, infraorbital, auriculotemporal, zygomaticotemporal, zygomaticoorbital, zygomaticofacial, infratrochlear, nasal and mentalis nerves (also referred to collectively as the superficial trigeminal nerve) are disclosed herein.
  • eTNS extra trigeminal nerve stimulation
  • peripheral branches of the trigeminal nerve are carefully stimulated at frequencies of 1-300 Hz, at pulse durations of 50-500 usec, at output currents generally between 1 and 40 mA, or other parameters as disclosed elsewhere herein, our studies have shown selective activation or inhibition of brain structures involved in the control of various medical disorders as disclosed herein.
  • measured stimulation of branches of the trigeminal nerve at safe frequencies, pulse durations, and currents can be used to treat these medical disorders.
  • the unique anatomy of the trigeminal nerve, and its direct and indirect connections with key areas of the brainstem (including pons and medulla) and other structures of the nervous system involved with the vagus nerve may allow the use of cutaneous stimulation of the TNS as a method to modulate the vagus nerve to treat various medical disorders, including, but not limited to, obesity and other disorders related to weight and feeding, inflammation, disorders of regulation of breathing, disorders of gastrointestinal function, autonomic regulation in menopausal hot flashes, regulation of hemostasis and sleep/insomnia.
  • trigeminal nerve stimulation can be used as a safe and non-invasive method to deliver stimulation of vagus nerve circuits in the brain, without implanting a vagus nerve stimulator, and without direct stimulation of the cervical vagus nerve or its branches.
  • the methods, systems and devices described herein are noninvasive.
  • Some brain stimulation methods aim to generate currents in large volumes of the cortex and treat the brain as a bulk conductor, for example, ECT (electroconvulsive therapy) at the whole-lobe level and rTMS (repetitive transcranial magnetic stimulation) at the large regional level (i.e. dorsolateral prefrontal cortex).
  • ECT electrocatalyzed acoustic stimulation
  • rTMS repetitive transcranial magnetic stimulation
  • deep brain stimulation is generally predicated on stimulation of small but regional volumes that lead to discharges in a very large number of cells.
  • the systems, devices and methods of the present disclosure send minimal, if any, current into the brain; instead, signals are sent into the brain in order to modify the activity of relevant neuroanatomical structures.
  • the electrical pulses generate signals in the cutaneous branches of the trigeminal nerve and the electric fields are generally confined to the skin tissue and there is minimal, if any, leakage into the brain.
  • These electrical pulses traveling through the trigeminal pathways in the brain trigger a cascade of change in neuronal signaling events that involve very limited and precise recruitment of specific networks of neurons identified on figures attached that effect long lasting effects capable to modulate the diseases herein claimed.
  • the neuroanatomic pathways allow targeted modulation of activity of the trigeminal nerve and the vagus nerve and further networks.
  • minimal current penetration means (1) a charge density of approximately 0 uC/cm 2 at the cerebral cortex, or (2) calculated, measured, or modeled charge densities below the following thresholds at the cerebral cortex: (a) at currents, charge densities, or charge per phase not likely to cause direct activation of pyramidal neurons and axons; and (b) to prevent brain injury, a charge density of less than 10 uC/cm 2 in one embodiment, and, in other embodiments, a charge density of less than 1.0 uC/cm 2 and in some embodiments, a charge density of less than 0.001 to 0.1 uC/cm 2 , and at combinations of charge density and charge per phase not known to cause brain injury.
  • a lower charge density may be used when the central nervous system of an individual patient is sufficiently sensitive to lower levels of stimulation that the lower level will still permit clinical benefit to accrue.
  • the trigeminal nerve is the largest cranial nerve, and has extensive connections with brainstem and other brain structures. It is the fifth (of twelve) cranial nerves, and is often designated as Cranial Nerve V (CN V).
  • the trigeminal nerve has three major sensory branches over the face, all of which are bilateral, and highly accessible.
  • the supraorbital nerve, or ophthalmic nerve is frequently referred to as the V 1 division.
  • the infraorbital branch, or maxillary nerve is commonly referred to as the V 2 division.
  • the mandibular nerve (also known as the mentalis branch) is referred to as the V 3 division.
  • the supraorbital nerve supplies sensory information about pain, temperature, and light touch to the skin of the forehead, the upper eyelid, the anterior part of the nose, and the eye.
  • the infraorbital branch supplies sensory information about pain, temperature, and light touch sensation to the lower eyelid, cheek, and upper lip.
  • the mentalis branch supplies similar sensory modalities to the skin of the lower face (e.g. jaw and tongue) and lips.
  • the supraorbital nerve or ophthalmic nerve exits at foramen 1 (the supraorbital foramen or notch), approximately 2.1-2.6 cm from the nasal midline (in adults), and is located immediately above the orbital ridge that is located below the eyebrow.
  • the infraorbital branch or maxillary nerve exits at foramen 2 (the infraorbital foramen), approximately 2.4-3.0 cm from the nasal midline (in adults), and the mentalis nerve exits at foramen 3 (the mentalis foramen), approximately 2.0-2.3 cm from the nasal midline (in adults).
  • the nasal nerve is a division of the ophthalmic nerve.
  • Other sensory branches including the zygomaticofacial, zygomaticoorbital, zygomaticotemporal, and auriculotemporal, arise from other foramina.
  • VPM ventral posterior medial nucleus
  • Light touch sensory fibers are large myelinated fibers, which ascend to the ventral posterior lateral (VPL) nucleus of the thalamus. Afferent sensory fibers project from the trigeminal nuclei to the thalamus and the cerebral cortex.
  • the trigeminal nucleus has reciprocal projections to the nucleus tractus solitarius or nucleus of the solitary tract (NTS), the locus coeruleus, the cerebral cortex and the vagus nerve.
  • the NTS receives afferents from the vagus nerve and trigeminal nerve.
  • the NTS integrates input from multiple sources, and projects to structures in the brainstem and forebrain, including the locus coeruleus.
  • FIG. 1C which is a modified reproduction from Ruffoli, R. et al, is a diagram of the principal afferent and efferent projections of the nucleus of the solitary tract (see Ruffoli, R.
  • the NTS connects to the medulla oblongata to control blood pressure and the respiratory center.
  • the NTS projects to the dorsal motor nucleus of the vagus and the nucleus ambiguus parasympathetic pregangliar neurons and influences cardiac activity.
  • the NTS connection to the nucleus ambiguus results in innervation the striate muscles involved in swallowing and heart rate.
  • the NTS also projects to the periaqueductal grey and visceral nuclei of the spinal cord, mediating visceral sensation.
  • the locus coeruleus is a paired nuclear structure in the dorsal pons, and is located just beneath the floor of the fourth ventricle.
  • the locus coeruleus has extensive axonal projections to a broad number of brainstem, sub-cortical and cortical structures, and is an important part of the reticular activating system.
  • the locus coeruleus is a core part of the brainstem noradrenergic pathway, and produces the neurotransmitter norepinephrine. Norepinephrine plays a key role in attention, alertness, blood pressure and heart rate regulation, and mood.
  • the trigeminal nerve is also connected to the vagus nerve.
  • Afferent sensory fibers from the three trigeminal divisions (V 1 , V 2 , V 3 ) project to the Gasserian ganglion, synapse there, and then project to the main sensory nucleus of the trigeminal nerve.
  • Axons from the sensory nucleus then project via the Internucial fibers of the Reticular Formation to the Dorsal Motor Nucleus of the vagus nerve (the tenth cranial nerve, also designated as Cranial Nerve X or CN X) in the dorsal medulla.
  • Efferent fibers from each right and left vagus nerve nuclei then form the main trunk of the vagus nerve.
  • stimulation of the peripheral branches of the trigeminal nerve can be utilized to activate the vagus nerve. This results in vagus nerve stimulation from peripheral trigeminal nerve stimulation. Since trigeminal nerve activation of the vagus nerve can be performed in a non-invasive fashion, activating the vagus nerve via activation of the peripheral branches of the trigeminal nerve has advantages over direct vagus nerve stimulation, which is currently performed using a surgically implantable electrode and pulse generator attached to the vagus nerve.
  • trigeminal nerve stimulation has direct clinical application to treating medical disorders as disclosed herein, which may benefit from increased vagus nerve or parasympathetic activity.
  • the systems and methods disclosed herein for stimulation of the trigeminal nerve to activate the vagus nerve may also be relevant for neurological, psychiatric, cardiac or other medical disorders where vagus nerve stimulation is activated or provided via stimulation of the trigeminal nerve and its branches.
  • trigeminal nerve stimulation is a potential method to initiate, activate and provide stimulation of vagus nerve circuits.
  • the disclosure describes the application of trigeminal nerve stimulation to treat medical disorders including: neuropsychiatric and neurological disorders, cardiac related disorders, fatigue, tinnitus and other medical disorders.
  • Stimulation of peripheral and cutaneous branches of the trigeminal nerve in the face, ear or scalp can be applied and stimulated at safe frequencies, pulse durations and amplitudes.
  • Such treatment is advantageous over the currently used pharmacological approaches which often have undesirable side effects or lack specificity in their actions.
  • the disclosure describes the application of trigeminal nerve stimulation as a method to stimulate the vagus nerve to treat medical disorders including: neuropsychiatric and neurological disorders, cardiac related disorders, fatigue, tinnitus, obesity and other disorders related to weight and feeding, inflammation, disorders of regulation of breathing, disorders of gastrointestinal function, autonomic regulation in menopausal hot flashes, regulation of hemostasis and insomnia and disturbances of sleep.
  • trigeminal nerve projects to the dorsal motor nucleus of the vagus nerve
  • trigeminal nerve stimulation can be used as a safe and non-invasive method to deliver stimulation of vagus nerve circuits, without implanting a vagus nerve stimulator, and without direct stimulation of the cervical vagus nerve or its branches.
  • the unique anatomy of the trigeminal nerve, and its direct and indirect connections with key areas of the brainstem, thalamus, amygdala, insula, anterior cingulate and other cortical and subcortical areas involved with sensory processing, attention, emotion, cognition, and autonomic function, may allow the use of external stimulation for a variety of neuropsychiatric conditions in which stimulation may be desirable.
  • the present disclosure relates to methods, devices and systems used for the treatment of mood, anxiety, post traumatic stress disorder, neuropsychiatric disorders, including mood (such as depression), anxiety (such as post-traumatic stress disorder) and psychotic disorders (e.g. schizophrenia), and cognitive and behavioral disorders as well as attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), autism and autism spectrum disorders (ASD), substance use disorders and related behavioral addictions, eating disorders and obsessive compulsive disorder (OCD) (collectively, neuropsychiatric disorders) via stimulation of the superficial elements of the trigeminal nerve (“TNS”).
  • mood such as depression
  • anxiety such as post-traumatic stress disorder
  • psychotic disorders e.g. schizophrenia
  • ADD attention deficit disorder
  • ADHD attention deficit hyperactivity disorder
  • ASD autism and autism spectrum disorders
  • OCD obsessive compulsive disorder
  • neuropsychiatric disorders via stimulation of the superficial elements of the trigeminal nerve (“TNS”).
  • cutaneous methods of stimulation of the superficial branches of the trigeminal nerve located extracranially in the face namely the supraorbital, supratrochlear, infraorbital, auriculotemporal, zygomaticotemporal, zygomaticoorbital, zygomaticofacial, infratrochlear, nasal and mentalis nerves (also referred to collectively as the superficial trigeminal nerve) are disclosed herein.
  • eTNS attention deficit disorder
  • ADD attention deficit disorder
  • ADHD attention deficit hyperactivity disorder
  • ASD autism and autism spectrum disorders
  • Systems and devices configured for therapeutic stimulation of the trigeminal nerve or branches thereof, such as the superficial trigeminal nerve, and their methods of application are also described.
  • the connections between the trigeminal nerve and the locus coeruleus, thalamus, amygdala, anterior cingulate, and other central nervous system structures as described above may be relevant to a potential role of the trigeminal nerve in neuropsychiatric disorders, including mood (such as depression), anxiety (such as post-traumatic stress disorder), psychosis (such as schizophrenia), and other cognitive and behavioral disorders.
  • cutaneous stimulation of the trigeminal nerve can be effective in the treatment of these neuropsychiatric disorders.
  • the PET scan data of FIGS. 2 and 3 support the use of TNS in humans for treatment of neuropsychiatric disorders, namely depression and anxiety disorders, such as PTSD.
  • the PET scans show sections of the brain with increased activity ( FIG. 3 ) and decreased activity ( FIG. 3 ).
  • increased activity is seen in the medial prefrontal cortex, including the ACC, (see FIG. 2 , which is indicated by the color (darker) pixels in panels (a) and (b)).
  • Increased activity of the dorsolateral prefrontal cortex is also shown in FIG. 2 , panel c as the large colored (darker) area in the lower right of the image.
  • Increased activity is also seen in the orbitofrontal cortex, as shown in FIG.
  • FIG. 2 shows an increased activity in the medial prefrontal cortex, including the ACC, which is indicated by the color (darker) pixels in panels (a) and (b). Increased activity in the superior frontal gyrus is seen in panels (c) and (d), on the upper (superior) surface of the brain, while the increased activity in the lateral frontal cortex is seen most clearly in panel (c), in the lower-right part of that image.
  • FIG. 2 shows an increased activity in the medial prefrontal cortex, including the ACC, which is indicated by the color (darker) pixels in panels (a) and (b).
  • Increased activity in the superior frontal gyrus is seen in panels (c) and (d), on the upper (superior) surface of the brain, while the increased activity in the lateral frontal cortex is seen most clearly in panel (c), in the lower-right part of that image.
  • FIG. 3 shows a decreased activity in the superior parietal cortex which is seen in panel (a) as the colored (darker) region in the upper left of that image, panel (b) as the colored (darker) pixels in the upper right, panel (c) as the upper two regions of color (darker) pixels, and in panel (d) as the colored (darker) region near the top of the brain.
  • the decreased activity in the cortex is consistent with the antiepileptic effects of eTNS.
  • the temporal-occipital cortex is seen in panel (c) as the largest colored (darker) region, and in panel (d) as the middle of the three colored areas.
  • ADD attention deficit disorder
  • ADHD attention deficit hyperactivity disorder
  • ASD autism and autism spectrum disorders
  • substance use disorders and related behavioral addictions eating disorders, psychosis, and obsessive compulsive disorder (OCD).
  • AD Attention Deficit Disorder
  • ADHD Attention Deficit Hyperactivity Disorder
  • ASD Autism Spectrum Disorders
  • ADHD attention deficit/hyperactivity disorder
  • ACC anterior cingulate cortex
  • parietal cortex e.g., Makris et al., 2010 , J Atten Disord 13(4):407-13; Dickstein S G, et al. 2006 J Child Psychol Psychiatry. 47(10):1051-62).
  • autism also termed autistic disorder
  • ASD includes related diagnoses such as Asperger's Syndrome, in which most features are present but not a delay in language development. Regions implicated in Autism and ASD include ACC, frontal cortex, temporal cortex, and parietal cortex (e.g., Hall G B, Szechtman H, Nahmias C. 2003 . Am J Psychiatry. 160(8):1439-41; McAlonan G M, et al. 2005 . Brain. 128(Pt 2):268-76; Cherkasova M V, Hechtman L. 2009 . Can J Psychiatry. 54(10):651-64; Konrad K, et al. 2006 . Biol Psychiatry. 59(7):643-51.)
  • FIG. 2 shows areas of increased blood flow emerging after acute exposure to TNS; regions of statistically significant differences between epochs of exposure and non-exposure are indicated. Areas that exhibited significant increases in regional activation with TNS included the medial prefrontal cortex (including ACC), the superior frontal gyms, the lateral frontal cortex, and the middle temporal gyms.
  • FIG. 3 shows areas of decreased blood flow under the same conditions; significant regional inhibition was found in the superior parietal cortex temporal-occipital cortex. Modulation of the activity in these and other brain structures, which are shown to be affected by trigeminal nerve stimulation, could assist in improving the cognitive and behavioral symptoms of ADD, ADHD, Autism, and ASD.
  • Disorders of substance abuse and dependence are defined as disorders of maladaptive patterns of behavior, as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 4th edition, 2000), and include criteria such as tolerance to a substance, withdrawal upon discontinuing use, an inability to cut down or control use of the substance, and giving up important social, occupational, or recreational activities because of using the substance.
  • Behavioral addictions e.g., internet addiction, sexual addiction, pathological gambling
  • neuroimaging studies have implicated dysfunction in several brain regions in the pathophysiology and treatment response in these disorders, particularly the anterior cingulate cortex (ACC), frontal cortex, and parietal cortex (Goldstein R Z and Volkow N D. 2011 . Neuropsychopharmacology. 36(1):366-7; Vollmony-Klein S, et al., 2010 . Alcohol Clin Exp Res. 34(5):771-6; Fineberg N A, et al., 2010 . Neuropsychopharmacology. 35(3):591-604; Dannon P N, et al. 2011 . Brain Imaging Behav. 5(1):45-51, published online Nov. 16, 2010.).
  • PET scan data showed acute alterations in regional brain activity with exposure to TNS; these areas include those regions implicated in substance use disorders and in behavioral addictions. Modulation of activity in these and other brain structures, which are shown to be affected by trigeminal nerve stimulation, could assist in improving the cognitive and behavioral symptoms of substance use and behavioral addiction disorders.
  • Eating disorders include illnesses such as anorexia nervosa, bulimia nervosa, and other disorders related to eating (e.g., binge eating), as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 4th edition, 2000); in all, problems center disorders of eating behaviors, predominantly related to perceived body image, consumption of food, and/or expenditure of energy (e.g. excessive exercise); these behaviors can lead to abnormal weight and potentially life-threatening states of malnutrition or metabolic abnormalities.
  • neuroimaging studies have implicated several brain regions in these disorders, including ACC and prefrontal cortex, and abnormal afferent inputs to the brain via the vagus nerve (Joos A, et al., 2010 Psychiatry Res. 182(2):146-51; Miyake et al., 2010 . Psychiatry Res. 181(3):183-92; Faris P L, et al., 2006 J Affect Disord. 92(1):79-90.)
  • PET scan data showed acute alterations in regional brain activity with exposure to TNS; these areas include those regions implicated in eating disorders. Modulation of activity in these and other brain structures, which are shown to be affected by trigeminal nerve stimulation, could assist in improving the symptoms of eating disorders.
  • Obsessive Compulsive Disorder as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 4th edition, 2000), is marked by the presence of obsessive, ruminative thoughts (e.g. fears of contamination with dirt or germs), and compulsive behaviors (e.g., ritualized handwashing).
  • OCD Obsessive Compulsive Disorder
  • ruminative thoughts e.g. fears of contamination with dirt or germs
  • compulsive behaviors e.g., ritualized handwashing.
  • neuroimaging studies have implicated several brain regions in these disorders, including ACC, caudate nucleus, striatum, prefrontal cortex, and parietal cortex (e.g., Huyser C, et al., 2010 . J Am Acad Child Adolesc Psychiatry.
  • PET scan data showed acute alterations in regional brain activity with exposure to TNS; these areas include some of those regions implicated in OCD. Modulation of activity in these and other brain structures, which are shown to be affected by trigeminal nerve stimulation, could assist in improving the symptoms of OCD
  • TNS affects heart rate and cardiac function, physiologic measures under vagal control.
  • Trigeminal nerve stimulation thus provides non-invasive modulation of, and access to, the autonomic nervous system, including the parasympathetic pathways of the vagus system.
  • some clinical effects of TNS may be mediated by trigeminal modulation of the vagus nerve system, while other clinical effects of TNS are independent of vagal circuit modulation, and yet others may reflect a combination of direct trigeminal effects and indirect effects mediated by the vagus nerve system.
  • the clinical response to TNS can arise directly from trigeminal effects independent of the vagus nerve or mediated through, and in combination with, the vagus nerve and its circuits.
  • trigeminal nerve stimulation can be used as a safe and non-invasive method to deliver stimulation to vagus nerve circuits, without implanting a vagus nerve stimulator, and without direct stimulation of the cervical vagus nerve or its branches. Stimulation of the vagus nerve circuits via trigeminal nerve reduces seizure activity.
  • our data demonstrates a 4% reduction in heart rate via acute stimulation of the trigeminal nerve (e.g. modulation of the vagus nerve via trigeminal nerve stimulation activates the trigeminal-cardiac reflex.)
  • the cause(s) of psychotic illnesses such as schizophrenia
  • findings from neuroimaging studies implicate specific brain regions in the development of symptoms, such as hallucinations, delusions, impaired reality testing, and disorganized thought processes.
  • Areas such as the temporo-parietal cortex, bilateral prefrontal cortical regions, and the anterior cingulate cortex have been linked to psychosis (e.g., Fusar-Poli P, et al. Neuroanatomy of vulnerability to psychosis: a voxel-based meta-analysis. Neurosci Biobehav Rev. 2011. 35(5):1175-85).
  • Dementing disorders are marked by cognitive impairments, particularly problems with memory and behavior, and include specific illnesses such as Alzheimer's Disease, Vacular Dementia, and Fronto-temporal Dementia. Multiple cortical and subcortical structures may be disrupted in these disorders. Activity in many of these structures may be modulated by inputs from the locus coeruleus (e.g., Samuels E R, Szabadi E. Functional neuroanatomy of the noradrenergic locus coeruleus: its roles in the regulation of arousal and autonomic function part II: physiological and pharmacological manipulations and pathological alterations of locus coeruleus activity in humans. Curr Neuropharmacol. 2008 September; 6(3):254-85).
  • locus coeruleus e.g., Samuels E R, Szabadi E.
  • Functional neuroanatomy of the noradrenergic locus coeruleus its roles in the regulation of arousal and autonomic function part II: physiological and pharma
  • the circuitry of the trigeminal nerve system is able to send signals to the locus coeruleus, so that TNS-driven modulation of the locus coeruleus impacts these disorders.
  • stimulation of the vagus nerve has been used to treat symptoms of Alzheimer's disease (e.g., Merrill C A, et al. Vagus nerve stimulation in patients with Alzheimer's disease: Additional follow-up results of a pilot study through 1 year. J Clin Psychiatry. 2006. 67(8):1171-8). Modulation of activity in these and other brain structures can be used to treat the medical disorders as disclosed herein according to the systems, devices and methods disclosed herein.
  • the trigeminal-cardiac reflex or trigemino-cardiac reflex is a central nervous system reflex which functions to increase cerebral blood flow and provide neuroprotection when the brain is exposed to hypoxia or diminished blood flow.
  • An exaggerated form of this reflex can occur during neurosurgical, eye, or sinus procedures as the result of traction or manipulation of branches of the trigeminal nerve. Under these conditions, significant reductions in heart rate, heart block, or complete asystole have been reported. (See generally, Schaller et al., J Neurosurgical Anesthesiology, 2009; 21:187-95)
  • the TCR had been used to clinical benefit to reduce the heart rate in the setting of life threatening or severe arrhythmias.
  • physicians have utilized the TCR to slow the heart rate through application of ocular pressure during supraventricular tachycardia.
  • This primitive, poorly-controlled technique could be associated with adverse events such as excessive reductions in heart rate, and with the advent of improved drug therapy for arrhythmias, this technique is no longer in common use.
  • Reflex bradycardia, hypotension and occasionally asystole as a result of the TCR have been reported for many years as a complication encountered during ophthalmologic and neurosurgical procedures. These adverse events arise from stimulation of the TCR in an uncontrolled and nonspecific fashion.
  • the TCR can be activated (or utilized) in a controlled fashion to provide therapeutic ends including protection of the brain and the heart, as well as modulation of the activity of these organs.
  • the unique anatomy of the trigeminal nerve, and its direct and indirect connections with key areas of the brainstem (including pons and medulla) and other structures of the nervous system involved with the vagus nerve and/or the TCR may allow the use of cutaneous stimulation of the TNS as a method to activate the TCR to prevent and/or treat cardiac related disorders, including, but not limited to, preventing and/or treating cardiac arrhythmias, arrhythmias and sudden cardiac death after myocardial infarction, heart failure, SIDS, cerebral ischemia, impaired blood flow conditions, atrial fibrillation and reducing the risk of sudden death in epilepsy.
  • trigeminal nerve stimulation can be used as a safe and non-invasive method to deliver stimulation of vagus nerve circuits, without implanting a vagus nerve stimulator, and without direct stimulation of the cervical vagus nerve or its branches.
  • the TCR is the result of connections between divisions of the trigeminal nerve, the internuncial fibers of the reticular formation and the vagus nerve nuclei, including the motor nucleus of the vagus nerve. Projections from the vagus nerve innervate the heart. Stimulation of this pathway and reflex arc can cause selective reduction in heart rate. Afferent sensory fibers from the three trigeminal divisions (V 1 , V 2 , V 3 ) project to the Gasserian ganglion, synapse there, and then project to the main sensory nucleus of the trigeminal nerve.
  • Axons from the sensory nucleus then project via the Internucial fibers of the Reticular Formation to the Dorsal Motor Nucleus of the vagus nerve (Cranial Nerve X) in the dorsal medulla.
  • Efferent fibers from each right and left vagus nerve nuclei then form the main trunk of the vagus nerve.
  • Branches from the cervical portion of the vagus nerve then form the left and right cardiac nerves (both superior and inferior branches). These branches innervate the heart: the left vagus nerve projects primarily to the Atrioventricular Node (AV node), and the right vagus nerve projects to the Sinoatrial Node (SA node).
  • AV node Atrioventricular Node
  • SA node Sinoatrial Node
  • the vagus nerve acts to reduce the heart rate, modify conduction, and stabilize the myocardium in response to stress and ischemia.
  • the TCR reflex is protective. It lowers heart rate in the presence of ischemia by protecting the heart from fast cardiac arrhythmias (tachyarrhythmias), and by increasing cerebral blood flow in the setting of hypoxia.
  • stimulation of the trigeminal nerve particularly via the ophthalmic, supraorbital, supratrochlear or infraorbital branches, can be performed safely to modulate the TCR and prevent and/or treat heart disease and related cardiac disorders.
  • Proper, controlled activation of this reflex arc using a range of parameters, through cutaneous trigeminal nerve stimulation, can be used to protect the heart by reducing heart rate, reducing heart rate variability, and preventing or treating tachyarrhythmias and preventing sudden cardiac death.
  • utilization of this reflex arc through trigeminal nerve stimulation can also protect the brain by conserving oxygen and reducing the adverse effects of ischemia and seizures.
  • Conditions benefiting by measured activation of the TCR include heart failure, SIDS, supraventricular and ventricular tachycardia, acute myocardial infarction, impaired blood flow conditions, atrial fibrillation prevention of sudden cardiac death and sudden death in epilepsy, and neuroprotection.
  • vagus nerve stimulation from peripheral trigeminal nerve stimulation. Since trigeminal nerve activation of the vagus nerve can be performed in non-invasive fashion, activating the vagus nerve via activation of the peripheral branches of the trigeminal nerve has surprising advantages over direct vagus nerve stimulation, which is currently performed using a surgically implantable electrode and pulse generator attached to the vagus nerve.
  • This engagement of the vagus nerve via trigeminal nerve stimulation has direct clinical application to preventing and/or treating and/or preventing cardiac related disorders, (and other disorders as described elsewhere herein) which may benefit from increased vagus nerve or parasympathetic activity.
  • the system disclosed herein for stimulation of the trigeminal nerve to activate the TCR may also be relevant for other neurological, psychiatric, cardiac or other disorders where vagus nerve stimulation is activated or provided via stimulation of the trigeminal nerve and its branches. Since the TCR reflects vagus nerve activation via stimulation of the trigeminal nerve, trigeminal nerve stimulation is a potential method to initiate, activate and provide vagus nerve stimulation.
  • Stimulation of peripheral and cutaneous branches of the trigeminal nerve in the face, ear or scalp and the vagus nerves can be applied and stimulated at safe frequencies, pulse durations and amplitudes.
  • An external device can be applied in, for example, the ambulance, emergency room, intensive care unit or other setting, to activate the TCR (or the allied oculo-cardiac reflex in the setting of ophthalmic nerve stimulation).
  • Controlled stimulation may activate the TCR to safely reduce heart rate, and heart rate variability in acute myocardial infarction and heart failure, prevent and/or treat cardiac arrhythmias, protect the heart and brain from injury and ischemia, and reduce the risk of sudden death from heart disease, SIDS and epilepsy, help stabilize cardiac rhythm and prevent sudden cardiac death and treatment of impaired blood flow conditions and atrial fibrillation.
  • Such treatment may be used to reduce mortality in heart disease.
  • Such treatment and prevention is advantageous over the currently used pharmacological approaches which often have undesirable side effects or lack specificity in their actions.
  • the ability to peripherally and bilaterally stimulate the vagal nerve circuits through the trigeminal pathways connection in the brainstem provides possibility of strong effects, not obtained with unilateral stimulation of the vagal nerve.
  • the disclosure describes the application of trigeminal nerve stimulation as a method to activate the trigeminal cardiac reflex (TCR) to prevent and treat cardiac arrhythmias; prevent arrhythmias and sudden cardiac death after myocardial infarction; treat heart failure; treat cerebral ischemia; treat impaired blood flow conditions and atrial fibrillation; and reduce the risk of sudden death in epilepsy and SIDS.
  • TCR trigeminal cardiac reflex
  • trigeminal nerve stimulation can be used as a safe and non-invasive method to deliver stimulation of vagus nerve circuits, without implanting a vagus nerve stimulator, and without direct stimulation of the cervical vagus nerve or its branches.
  • Heart Failure is characterized by an increase in heart rate in response to diminished ventricular function.
  • the increased heart rate results in increased energy demands upon an injured and dysfunctional myocardium.
  • there is abnormal parasympathetic control of the heart as measured by a depressed baro-receptor reflex, which can lead to arrhythmias, and is associated with increased mortality.
  • Vagus nerve stimulation using implantable electrodes attached to the cervical portion of the vagus nerve, reduces heart rate and improves left ventricular function in animals and humans. (De Ferrari et al. 2010; Schwartz et al. 2009; Annegers et al., Epilepsia 2000; 41:549-53).
  • vagus nerve stimulation was evaluated to determine its effects on heart rate and outcome.
  • a 10-15% reduction in heart rate was associated with significant improvement in survival from heart failure.
  • Rats that underwent vagus nerve stimulation had a mortality of only 14%, versus 50% mortality among untreated rats: a 73% relative reduction in death rate.
  • Vagus nerve activity is significantly reduced and impaired after myocardial infarction.
  • Myocardial infarction As a result, there is reduced protection against severe life threatening arrhythmias and an increased risk of sudden death.
  • Immediately after myocardial infarction there is a surge in sympathetic activity, resulting in an increased heart rate, and increased stress on the myocardium.
  • Unopposed sympathetic activity can result in worsening of the infarction, and the propensity for lethal arrhythmias.
  • implanted vagus nerve stimulation significantly reduced the risk of lethal arrhythmias (e.g.
  • trigeminal nerve stimulation represents a novel method of increasing vagus nerve activity, reducing heart rate, and counteracting the undesired effects of sympathetic activity on the heart.
  • Paramedics, emergency room, and intensive care staff can apply trigeminal nerve stimulation using external electrodes, reducing the heart rate via controlled engagement of the trigeminal-cardiac reflex, and protect the heart from excessive sympathetic activity. This may improve outcome after myocardial infarction and reduce the risk of sudden cardiac death and lethal arrhythmias. (Schwartz et al., 2009)
  • Sudden unexpected death in epilepsy is a major cause of death in people with epilepsy, accounting for 20-30% of the mortality associated with epilepsy.
  • Sudden Unexpected Death in Epilepsy is generally defined as: “sudden, unexpected, witnessed, or unwitnessed, non-traumatic, and non-drowning death in an individual with epilepsy, with or without evidence of a seizure . . .
  • trigeminal nerve stimulation represents a novel and less invasive method to improve parasympathetic autonomic function, reduce heart rate variability, and protect the brain and heart. Therefore, trigeminal nerve stimulation can be utilized to improve the degree of vagus nerve-mediated autonomic control of the heart, and help to prevent sudden death in epilepsy.
  • the TCR is a cerebral protective reflex, which protects the brain during hypoxia, utilizing it in patients at risk for sudden death in epilepsy may protect brain and heart function during and after seizures, when hypoxia may commonly occur.
  • a sensing element may detect a change in the condition of a patient (e.g., an electrocardiographic monitor would detect the onset of a potentially-dangerous heart rhythm) and automatically initiate trigeminal nerve stimulation.
  • the use of trigeminal nerve stimulation may also include conditions in which impairment of blood flow to the brain may cause and/or worsen the progression of these conditions (collectively, “impaired blood flow conditions”).
  • impaired blood flow conditions many forms of dementia (e.g., Alzheimer's Disease, Vascular Dementia, Frontotemporal Dementia) are associated with impairments in blood flow to the brain, and interventions which may enhance delivery of blood to the brain may be clinically useful.
  • other conditions of the brain such as multiple sclerosis, Pick's disease, the transient hypoxia produced by sleep apnea, or infectious disease of the brain (e.g. Lyme Disease, HIV/AIDS) may also have a course which may be worsened by impairments in blood flow and may be improved through the neuroprotective actions of the TCR, and therefore could benefit from TNS.
  • Stimulation of a specific cranial nerve, the trigeminal nerve has been found to reduce symptoms of fatigue in patients with major depressive disorder or with epilepsy. Stimulation of the trigeminal nerve to modulate activity of the vagus nerve has, surprisingly, also been found to treat other medical disorders.
  • This non-pharmacological treatment for fatigue and other medical disorders may reduce the disability experienced by individuals with fatigue or other medical disorders, by addressing impairments from the medical condition while reducing or minimizing the side effects (including interaction with other medications and risk of addiction) posed by psychostimulants or other medications conventionally used to treat these conditions.
  • the unique anatomy of the trigeminal nerve, and its direct and indirect connections with key areas of the brainstem (including pons and medulla) and other structures of the nervous system involved with the vagus nerve may allow the use of cutaneous stimulation of the TNS as a method to modulate the vagus nerve or vagus nerve circuits to, surprisingly, treat various medical disorders, including, but not limited to, neurological disorders such as epilepsy, seizure related disorders, acute brain injury, chronic brain injury, chronic daily headache, migraine, disorders related to migraine and headache and movement disorders, and neuropsychiatric disorders, such as depression, mood disorders, cognitive disorders, behavioral disorders and anxiety disorders and others as disclosed elsewhere herein, obesity and other disorders related to weight and feeding, inflammation, disorders of regulation of breathing, disorders of gastrointestinal function, autonomic regulation in menopausal hot flashes, regulation of hemostasis and sleep/insomnia.
  • neurological disorders such as epilepsy, seizure related disorders, acute brain injury, chronic brain injury, chronic daily headache, migraine, disorders related to migraine
  • trigeminal nerve stimulation can be used as a safe and non-invasive method to deliver stimulation of vagus nerve circuits, without implanting a vagus nerve stimulator, and without direct stimulation of the cervical vagus nerve or its branches.
  • the present disclosure relates to methods, devices and systems used for the treatment of fatigue via stimulation of the superficial elements of the trigeminal nerve (“TNS”) to modulate the locus coeruleus or modulate the reticular activating system.
  • TNS trigeminal nerve
  • mechanisms of action by which TNS may counter fatigue include, but are not limited to: (a) influence on the activity of the locus coeruleus, a brain center involved in the production and regulation of the neurotransmitter norepinephrine, and (b) influence on the activity of the reticular activating system (RAS), a brain system involved in regulating levels of consciousness, arousal, wakefulness and attention, and (c) influence on activity of the vagus nerve, which allows for signaling between the brain and multiple internal organs and body systems (e.g. immune), as detailed below.
  • RAS reticular activating system
  • Tinnitus sometimes called “ringing in the ears,” is a condition in which a person has the experience of hearing a sound in the absence of corresponding external sound. Tinnitus is common, affecting 20% of the population above the age of 55. It is commonly associated with injury to the auditory system and it can arise in many contexts, including exposure to abnormally loud sounds, ear infections, foreign objects in the ear, nose allergies that prevent (or induce) fluid drain, as a side effect of some medications, as a part of aging, or as a part of a congenital hearing loss. Without wishing to be bound by any particular theory, stimulation of the trigeminal nerve may be able to treat the symptoms of tinnitus.
  • the cochlear nuclei are the principal brainstem structures responsible for hearing.
  • the paired cochlear nuclei are located in the dorsal and lateral portions of the right and left medulla.
  • the cochlear nuclei are divided into two predominant regions, the dorsal cochlear nucleus (DCN) and the ventral cochlear nucleus (VCN).
  • DCN dorsal cochlear nucleus
  • VCN ventral cochlear nucleus
  • the cochlear nuclei receive auditory (hearing) input from the cochlear nerves, which receives its input from the ear, specifically the cochlea. Fibers from the cochlear nuclei project to the central auditory pathways, including the lateral lemniscus, inferior colliculus, medical geniculate body, and finally to the primary auditory cortex.
  • the cochlear nuclei receive input from both the cochlear (auditory) nerve, and other pathways, including the trigeminal nerve, which provides somatosensory information from the face.
  • the trigeminal nerve which provides somatosensory information from the face.
  • Trigeminal nerve input serves to modulate the response of the two cochlear nuclei, and can inhibit or increase the response of the cochlear nuclei to auditory input (sound).
  • the cochlear nuclei When the cochlear nerve is injured, the cochlear nuclei (especially the DCN) exhibit enhanced sensitivity to trigeminal input, and increased inhibition of the cochlear nuclei. (Shore et al. 2008) This enhanced sensitivity may play a role in the pathogenesis of tinnitus. (Shore et al. 2008)
  • stimulation of the trigeminal nerve may result in reducing tinnitus by modulating trigeminal input to the cochlear nuclei. Since the cochlea exhibit heightened sensitivity to trigeminal input, stimulation of the trigeminal nerve can be performed to reduce or modulate trigeminal enhanced inhibition of the cochlear nuclei after injury, or increase or modulate trigeminal activation of the cochlear nuclei after cochlear nerve injury.
  • trigeminal nerve stimulation can be delivered via stimulation of auricular branches located over the anterior auditory canal, or by stimulating cutaneous branches including the auriculotemporal, zygomaticotemporal, mentalis, infraorbital, or supraorbital branches via cutaneous (or transcutaneous) stimulation of these branches.
  • frequencies may range from 1-5000 Hz, at amplitudes of 0.1-40 mA. In some embodiments, frequencies may range from 1-10000 Hz, at amplitudes of 0.1-40 mA.
  • TNS may be used to calm the dorsal cochlear nucleus (or other relevant structure) with a feedback control loop that may allow the patient in real-time to provide an audiologist with information on which stimulation parameters (such as frequency, pulse width, duty cycle) best mitigate the ringing in the patient's ears.
  • stimulation parameters such as frequency, pulse width, duty cycle
  • self-tuning control algorithms can adjust the stimulation parameters to mitigate accommodation effects and changes in the ringing frequency spectrum.
  • TNS can be used to modulate vagus nerve activity to treat obesity.
  • Conditions related to obesity that may also be treated by modulating vagus nerve activity include: diabetes (worsened in obesity), metabolic syndrome (worsened in obesity), dyslipidemia (worsened in obesity), obstructive sleep apnea (precipitated by excessive soft tissue which may obstruct the airway, in obesity), arthritis (both osteoarthritis, tied to weight load on the joint, and rheumatoid arthritis, where excess weight accelerates joint destruction), and cachexia/anorexia (arising either from cancer or from a psychiatric disorder). See e.g.
  • Val-Laillet D et al., Slower eating rate is independent to gastric emptying in obese minipigs, Physiol Behav., 2010 Nov. 2; 101(4): 462-8, Epub 2010 Aug. 5.
  • Tomé D et al., Protein, amino acids, vagus nerve signaling, and the brain, Am J Clin Nutr., 2009 September; 90(3):8385-8435, Epub 2009 Jul. 29.
  • Kral J G et al., Vagal nerve function in obesity: therapeutic implications, World J Surg, 2009 October; 33(10):1995-2006.
  • Green M A et al., An association between eating disorder behaviors and autonomic dysfunction in a nonclinical population.
  • TNS can be used to modulate vagus nerve activity to treat inflammatory processes in the body.
  • Conditions related to these inflammatory processes that may also be treated by modulating vagus nerve activity include: asthma, inflammatory bowel disease, atopic dermatitis, sepsis and hepatitis.
  • journal articles may include studies that show an effect on inflammatory processes and other conditions in which inflammation plays a role, by modulating vagus nerve activity: inflammatory processes: Minutoli L, et al., Melanocortin 4 receptor stimulation decreases pancreatitis severity in rats by activation of the cholinergic anti-inflammatory pathway, Crit Care Med, 2011 May; 39(5):1089-96.; Lehrer P, et al., Voluntarily produced increases in heart rate variability modulate autonomic effects of endotoxin induced systemic inflammation: an exploratory study, Appl Psychophysiol Biofeedback, 2010 December; 35(4):303-15; Ottani A, et al., Melanocortins counteract inflammatory and apoptotic responses to prolonged myocardial ischemia/reperfusion through a vagus nerve-mediated mechanism, Eur J Pharmacol, 2010 Jul.
  • Van Der Zanden E P et al., The vagus nerve as a modulator of intestinal inflammation, Neurogastroenterol Motil, 2009 January; 21(1):6-17.; atopic dermatitis Boettger M K, et al., Increased vagal modulation in atopic dermatitis., J Dermatol Sci, 2009 January; 53(1):55-9, Epub 2008 Sep.
  • TNS can be used to modulate vagus nerve activity to treat disorders of the regulation of breathing.
  • the following link provides a journal article which may include studies that show an effect on disorders of the regulation of breathing by modulating vagus nerve activity: Tadjalli A, et al., Identification of a novel form of noradrenergic-dependent respiratory motor plasticity triggered by vagal feedback, J Neurosci, 2010 Dec. 15; 30(50):16886-95).
  • TNS can be used to modulate vagus nerve activity to treat disorders of gastrointestinal function. These disorders may include: gastroesophageal reflux, diarrhea and constipation, gastrointestinal pain syndromes (“functional bowel syndromes”), post-operative ileus, dyspepsia, motion sickness, and chemotherapy-related nausea and emesis.
  • disorders of gastrointestinal function may include: gastroesophageal reflux, diarrhea and constipation, gastrointestinal pain syndromes (“functional bowel syndromes”), post-operative ileus, dyspepsia, motion sickness, and chemotherapy-related nausea and emesis.
  • journal articles may include studies that show an effect on disorders of gastrointestinal function by modulating vagus nerve activity: gastroesophageal reflux: Niedringhaus M, et al., “Dorsal motor nucleus of the vagus: a site for evoking simultaneous changes in crural diaphragm activity, lower esophageal sphincter pressure, and fundus tone,” Am J Physiol Regul Integr Comp Physiol. (2008) 294(1):R121-31; diarrhea and constipation; dysphagia and other disturbances of swallowing (e.g. following a stroke or traumatic brain injury (TBI)):Bansal V, et al., “Stimulating the central nervous system to prevent intestinal dysfunction after traumatic brain injury,” J.
  • TBI traumatic brain injury
  • TNS can be used to modulate vagus nerve activity to treat autonomic instability of menopausal hot flashes.
  • the following journal article may include studies that show an effect on autonomic instability of menopausal hot flashes by modulating vagus nerve activity: Thurston R C, et al., “Hot flashes and cardiac vagal control: a link to cardiovascular risk?,” Menopause (2010) 17(3):456-61.
  • TNS can be used to modulate vagus nerve activity to regulation hemostasis (blood clotting).
  • the following links provide journal articles which may include studies that show an effect on hemostasis by modulating vagus nerve activity: Czura C J, et al., “Vagus nerve stimulation regulates hemostasis in swine,” Shock (2010) 33(6):608-13; Kraemer M, et al., “The influence of vasovagal response on the coagulation system,” Clin Auton Res. (2010) 20(2):105-11.
  • Sleep disturbances can arise in a range of conditions, including sleep apnea, hyperthyroidism, depression, and primary insomnia. Stimulation of the trigeminal nerve may be able to treat sleep disturbances by means of its influences on brain systems related to wake/sleep cycles and arousal.
  • projections from the trigeminal nerve to the nucleus of the tractus solitarius (NTS) convey signals to the NTS and then to other brain regions involved in the regulation of sleep and wakefulness, for example, via the parabrachial nucleus, to the hypothalamus, amygdala, insula, lateral prefrontal cortex, and other regions of relevance (A. Jean.
  • the scores on the insomnia items of the Quick Inventory of Depressive Symptomatology (www.ids-qids.org) for ten adults with major depression who participated in a clinical trial of TNS were examined.
  • the first three questions assess (a) sleep onset insomnia (i.e., delay in falling asleep), (b) nocturnal insomnia (awakening during the night), and (c) early morning insomnia (awakening earlier than intended and being unable to return to sleep).
  • Summarizing the responses to these three items gives an index of severity of insomnia in these subjects, ranging from zero (no symptoms) to six (maximal disturbance across all three types of insomnia symptom). Over the course of this 8 week trial, this measure of insomnia severity fell from an average of 2.5 (1.8 s.d.) to 1.2 (1.0 s.d.), a decrease of over 50% which achieved statistical significance (2-tail paired t-test p ⁇ 0.05).
  • the neuroanatomic pathways allow targeted modulation of activity in areas involved in epilepsy and other neurological conditions and disorders (e.g. locus coeruleus, anterior cingulate, insular cortex).
  • the systems, devices and methods as disclosed herein utilize the brain's existing infrastructure to transmit signals to the targets of interest.
  • Example conditions and disorders include: coma and vegetative State, headache and migraine, movement disorders, include, but are not limited to, tremors, twitches, and spasms, involuntary increases in tone of muscles, such as dystonias, and complex movements, such as dyskinesias and choreas, tardive and other dyskinesias.
  • FIGS. 4-7 show various embodiments of the systems and devices that may be used for the cutaneous stimulation of the superficial branches of the trigeminal nerve and methods of using the same.
  • the method of treating medical disorders by TNS comprises positioning external electrodes over or near at least one of the foramina or branches of the trigeminal nerve ( FIGS. 1A and 1B ), and stimulating the electrodes using a stimulator for a fixed time at specified operational parameters.
  • the electrodes need not be applied at the main branch of the nerve; they can be applied in the area of the skin supplied by that nerve, which may be inches away from the main branch of the nerve.
  • the external electrodes are positioned over the foramina of the supraorbital or ophthalmic nerves ( FIG.
  • the electrode assembly is configured for unilateral stimulation.
  • the electrode assembly is configured for bilateral stimulation.
  • bilateral stimulation may offer similar or better efficacy than unilateral stimulation because the function of different brain structures may not be the same on right and left. There may also be synergistic effects that arise with bilateral stimulation.
  • two separate electrodes or a single paired electrode may be placed over the forehead.
  • the electrode can be positioned over the foramina of the infraorbital foramen (infraorbital or maxillary nerves) ( FIG. 1A , Foramen 2) or the mentalis foramen (mentalis or mandibular nerves) ( FIG. 1B , Foramen 3).
  • the stimulation can be unilaterally applied to one foramen of the trigeminal nerves.
  • the method of treating fatigue and other medical disorders includes positioning external electrodes over a plurality of foramina and simultaneously stimulating different trigeminal nerves.
  • electrodes may be positioned at a region of the patient's face (on the right and/or left side) corresponding with the supratrochlear nerve, infratrochlear nerve, zygomaticotemporal, zygomaticofacial, zygomaticoorbital, nasal, and/or auriculotemporal nerves and/or their respective foramina.
  • the operations/steps of the methods described herein may be performed in the order illustrated, in another suitable order and/or one or more operations may be performed simultaneously.
  • the methods may include more or fewer operations/steps than those illustrated/described elsewhere herein.
  • the method of treating fatigue and other medical disorders by TNS comprises selecting patient specific values for the operational parameters for the stimulation of each individual patient within a defined range.
  • the values of the operational parameters are selected such that a patient will experience a stimulation sensation, such as a mild tingling over the forehead and scalp without being in discomfort or in pain.
  • the values of the operational parameters are selected such that skin irritation, burns or other skin injury, pain, headache, and undesired effects on the brain (e.g. inducing seizures), and/or the cranial nerves are minimized or reduced.
  • the method of selecting operational parameters comprises evaluating variables such as the configuration and size of the electrode, the pulse duration, the electrode current, the duty cycle and the stimulation frequency; which are important factors in ensuring that the total charge, the charge density, and charge per phase are well within accepted limits for the skin, nerve and brain. For example, to minimize skin irritation, it is not sufficient to merely state the total current, but the current density needs to be defined.
  • selection of the electrical stimulation parameters, electrode design, and inter-electrode distance are chosen such that the electrical stimulation zone includes the ophthalmic or other cutaneous nerve branches (approximately 3-4 mm below the skin surface), while preventing or minimizing current penetration beneath the skull bone as described above.
  • the electrodes connect to leads for conveying the electrical stimuli from a neurostimulator.
  • the neurostimulation may be provided using an electrical neurostimulator at the following exemplary settings: frequency 1-300 Hz, current 1-40 mA, pulse duration (pulse width) of 50-500 microseconds, a duty cycle of up to 50%, for at least one hour per day.
  • the neurostimulation may be provided using an electrical neurostimulator at the following exemplary settings: frequency 120 Hz, current up to 25 mA, pulse duration (pulse width) of 250 microseconds, a duty cycle of 30 seconds on/30 seconds off, for at least eight hours per day.
  • the current amplitudes are less than 7 mA, or less than 6 mA, depending on the size, impedance, resistance, or configuration of the electrode(s). In some embodiments, the current amplitude is between about 2.5 mA and about 5 mA. In still another embodiment, the output current may be limited to an exact current, e.g. 5 mA, up to a maximum of a fixed current of 7 mA, depending on the size, resistance, or impedance of the electrode. In another embodiment, the output current is limited to a range not to exceed 10 mA, or 7 mA, or 5 mA.
  • stimulation parameters at the lower end of these ranges may be used, but this may be balanced with differences in clinical effect which may vary over the range of stimulation parameters.
  • different values of the operational parameters may be used.
  • a single external electrode can be used.
  • a portable external stimulator which can be attached to a patient's clothing, is used.
  • a system 200 for treatment of various medical disorders via TNS includes an electrode assembly 100 , electrical cable or wire 120 and an external neurostimulator or pulse generator 122 .
  • the electrode assembly may be configured for the bilateral simultaneous and asynchronous stimulation of the ophthalmic nerves.
  • the neurostimulator or pulse generator may be any type of appropriate stimulating, signal-generating device.
  • the generator 122 is portable and attached to the belt of a patient 20 . However, either a portable or non-portable pulse generator may be used.
  • the electrode assembly 100 is connectable to an external stimulator 122 either by lead wires 124 connected to an electrical cable 120 or wirelessly.
  • the electrical cable or wire 120 is configured to provide a physical and electrical link between the generator 122 and the electrode assembly 100 via lead wires 124 .
  • the generator 122 and the electrode assembly 100 communicate wirelessly (i.e. the wire 120 and leads 124 are not used).
  • the system 200 or elements thereof, such as the electrode assembly 100 may be part of a kit.
  • the kit may also include instructions for placement of the electrode assembly and/or system to stimulate the trigeminal nerve to activate the vagus nerve to treat or prevent various medical disorders as disclosed herein.
  • the kit may also include instructions for placement of the electrode assembly and/or system to stimulate the trigeminal nerve to activate the TCR to treat or prevent a cardiac related disorder.
  • the kit may also include instructions for monitoring the clinical effects of the stimulation to ensure proper adjustment of stimulation parameters and system configuration.
  • the kit may also include instructions for treatment of various medical disorders as disclosed herein according to a method as disclosed herein.
  • the instructions may be provided in any readable format or as a link to a website.
  • the system 200 may also include a regulation device to ensure safe use of the system.
  • the regulation device is configured to be attached to the pulse generator 122 and, in some embodiments, is configured to govern the maximum charge balanced output current below approximately 1-25 mA to minimize current penetration to the brain and increase patient tolerance. In some embodiments, the regulation device is configured to govern the maximum charge balanced output current below approximately 40 mA.
  • the regulation device may be internally programmed to range from 0.25-5.0 mA, 0-10 mA, 0-15 mA, depending on the surface area, placement, and orientation of the electrode, and whether the electrode is stimulating near or adjacent to the skull, or away from the skull, (mentalis), where current ranges may be higher or lower.
  • Current TENS units stimulate with maximum output currents of up to 100 mA's, which result in currents which may penetrate the skull and which may not be well tolerated.
  • the electrode assembly 100 further includes a retainer element 130 configured to secure the electrode assembly to a patient's forehead.
  • the retainer element 130 can be an elastic band or strap.
  • the electrode assembly 100 can be secured in place by a hat or a cap which also serves to conceal the electrode assembly from view.
  • the electrode assembly may be secured by adhesive, such as an adhesive strip, an adhesive backing surrounding the conducting area, or an adhesive conductive gel.
  • the system may utilize a closed loop design and may include a closed loop or sensing device.
  • the closed loop device may include the stimulating electrode or additional set of electrodes, indwelling catheters, or cutaneous or implantable physiologic monitors.
  • the device may be configured to detect heart rate, pulse oximetry, cerebral blood flow, systolic, diastolic blood pressure, or mean arterial pressure, transcranial Doppler, cardiac parameters (ejection fraction, pulmonary, atrial, or ventricular pressures), heart rate variability (using time, frequency, or non-linear or other measures of heart rate variability), the presence of molecules that could signify a potentially-dangerous condition (e.g., tropinin in the bloodstream, a biomaker that may indicate injury to the heart muscle tissue, as might be treated in an ambulance, an emergency room, and/or an intensive care unit) or the achievement of a desired clinical effect (e.g., levels of pro-inflammatory cytokines), or other physiologic parameters to provide self-tuning adaptive feedback control for the neurostimulator including, but not limited to, fuzzy controllers, LQG controllers and artificial neural networks (ANN).
  • ANN artificial neural networks
  • Adaptive learning controllers can learn from the previous response of a particular patient or similar patients to stimulation settings which helped alleviate conditions being treated, such as tachycardia or atrial fibrillation.
  • a closed loop device may detect heart rate and adjust the output current or voltage or other parameter to limit heart rate reductions to a prescribed level.
  • this qualitative and/or quantitative feedback may be used by the system to automatically or otherwise adjust the stimulation parameters in a closed-loop fashion to optimize the clinical effects of the stimulation.
  • the electrode assembly comprises an electrode with at least one contact. In some embodiments, a single electrode may have a plurality of contacts. In some embodiments, the electrode assembly comprises pair of electrodes with a pair of contacts. In some embodiments, the electrode assembly may be a strip electrode with at least one contact. In some embodiments, the strip electrode may include a plurality of contacts.
  • the electrode assembly 100 shown in FIGS. 4-5B is also referred to as a bilateral supraorbital electrode.
  • the electrode assembly 100 includes a first pair of contacts 112 a , 112 b for placement on a first region of the patient's face, and a second pair of contacts 114 a , 114 b for placement on a second region of the patient's face.
  • the first region is the right side of the patient's face and the second region is the left side of the patient's face.
  • the first pair of contacts comprises a first upper contact 112 a and a first lower contact 112 b
  • the second pair of contacts comprises a second upper contact 114 a and a second lower contact 114 b .
  • the first and second contact pairs are connected to each other by an insulative connection region 116 .
  • the electrode assembly 100 comprises an inner contact surface 118 that comes into contact with a patient's skin at four contact areas, each corresponding to one of the four contacts 112 a , 112 b , 114 a , 114 b .
  • the inner contact surface 118 comprising the four contact areas includes a buffered gel-like adhesive that provides good electrical conductivity with minimum skin irritation, an example of such gel includes the commercially available hydrogels from AmGel Technologies (AmGel Technologies, Fallbrook, C A, USA).
  • the electrode assembly 100 is configured to stimulate both the right and left ophthalmic nerves either simultaneously or asynchronously.
  • the insulative connection region 116 serves to assist a patient in lining up the electrode assembly 100 with the midline of the nose to ensure proper placement of the electrode assembly 100 over both ophthalmic nerves, which lie on the average about 2.1 to 2.6 cm from the nasal midline of an adult patient.
  • the electrode assembly can be placed accurately (e.g. by the patient) without knowledge of the location of the ophthalmic nerve or key landmarks relative to the nerve, thereby reducing the possibility of inadequate stimulation due to errors in positioning of the electrodes.
  • first contact pair 112 a , 112 b and the second contact pair 114 a , 114 b are placed on opposite sides of the nasal midline assures that stimulation current moves orthodromically or in the direction of the afferent ophthalmic or supraorbital nerve.
  • this configuration of the electrode assembly 100 allows the contact pairs 112 a / 112 b and 114 a / 114 b to be stimulated independently and/or unilaterally, as the response to stimulus may be localized and thus varied from one side of the midline to the other side. That is, the presently disclosed electrode assembly permits individual adjustment of current for the first and second regions or right and left sides, as applicable, thereby reducing asymmetric stimulation and/or perceived asymmetric stimulation.
  • 6A-6C illustrate other embodiments of the electrode assembly 100 , which configurations may be used to stimulate the right and/or left ophthalmic nerve and/or other branches of the trigeminal nerve as disclosed herein, such as the infraorbital nerve branch. It can be appreciated that a single electrode with one or more contacts or multiple electrodes with one or more contacts may be used.
  • the bilateral supraorbital electrode is specially configured for bilateral supraorbital stimulation. In some embodiments, it is scalable based on the location of use, stimulation parameters and input from computer modeling so as to negate or minimize or render safe, current penetration into the brain. As skin irritation may occur, a similar configuration could be applied unilaterally, so as to provide relief to one side of the forehead, to promote skin tolerability and to reduce the risk of irritation.
  • a strip electrode with at least two contacts may be used to stimulate the infraorbital nerve.
  • two separate electrodes may be used to stimulate the infraorbital nerve.
  • a strip electrode with at least two contacts may be used to stimulate the auriculotemporal and/or zygomaticofacial nerve.
  • two separate electrodes may be used to stimulate the auriculotemporal and/or zygomaticofacial nerve.
  • the upper contacts 112 a , 114 a and lower contacts 112 b , 114 have fixed polarities.
  • the upper contacts 112 a , 114 a and lower contacts 112 b , 114 b have alternating polarities.
  • the inferior electrode typically serves as the cathode for the leading phase of the stimulating pulse. In the case of a monophasic stimulation, the inferior electrode generally becomes the cathode.
  • each of the contacts 112 a , 112 b , 114 a , 114 b is sized to deliver an electrical pulse over a large enough surface area to minimize any skin injury due to excess current density and/or charge density, and to minimize or eliminate current penetration beyond the inner surface of the skull bone.
  • the distance between the first contact pair 112 a , 112 b and the second contact pair 114 a , 114 b is configured to stimulate the ophthalmic nerves while minimizing or eliminating current delivery to the surface of the brain.
  • the mid-point of each of the contacts is approximately 2.5 cm (range 1.5 cm to 3.5 cm) from the nasal midline.
  • the electrode size and the inter-electrode distance may vary for children and adults, males and females based on anatomical differences.
  • the electrode is approximately 32.5 mm in length by 12.5 mm in height and the inter-electrode distance between, for example, the upper pair of electrodes 112 a , 114 a is 17.5 mm and the inter-electrode distance between, for example, the upper electrode 112 a and the lower electrode 112 b is 20 mm.
  • the length of the electrode may be greater than or less than 32.5 mm and greater than or less than 12.5 mm in height.
  • the inter electrode distance can be in a range greater than 20 mm and/or less than 17.5 mm.
  • the surface area of each of the contacts 112 a , 112 b , 114 a , and 114 b can be within a range of about 0.5 cm 2 to about 20 cm 2 .
  • the distance between the contacts 112 a and 112 b and the distance between contacts 114 a , and 114 b can be in a range of about 0.5 cm to about 10 cm. Those of skill in the art will recognize that one or more of the above distances can be used as a border of a range of distances.
  • FIG. 7 illustrates another embodiment of the electrode assembly 100 .
  • a patient 10 is wearing two separate electrodes 12 on the forehead, one over each eyebrow, corresponding to the foramina of the ophthalmic nerves.
  • stimulation in another aspect of the present disclosure, embodiments in which stimulation is applied to fibers of multiple cranial nerves (“polycranial nerve stimulation”) are disclosed.
  • stimulation can be applied to aspects of the trigeminal nerve which innervate portions of the ear, particularly the auricle (external ear) and the ear canal (see e.g. FIGS. 8A and 8B ).
  • more than one nerve may supply adjacent and/or overlapping areas of a single anatomical structure.
  • Sensory signals from these skin areas may be conveyed to centers in the brain by nerves including the auriculotemporal nerve, a branch of the trigeminal nerve, and also by other nerves (e.g., posterior auricular nerve, from the facial nerve, or the auricular branch of the vagus nerve).
  • nerves including the auriculotemporal nerve, a branch of the trigeminal nerve, and also by other nerves (e.g., posterior auricular nerve, from the facial nerve, or the auricular branch of the vagus nerve).
  • electrodes may be placed on the skin of the auricle and/or of the ear canal. Such embodiments are less noticeable when worn by a patient and may increase patient use and/or compliance.
  • a “completely in the canal” or “CIC” system 300 may include a CIC device 302 .
  • the CIC device 302 includes electrodes or an electrode assembly 100 which may be configured as conductive rings or spots 310 placed on an outer circumferential surface of an elongated body or cylindrical device 305 .
  • the CIC device 302 may also include a pulse generator and a battery located within the elongated body 305 of the device 302 .
  • the battery may be a non-rechargeable zinc air battery or other rechargeable battery known in the art.
  • the electrode(s) or electrode assembly 100 and the pulse generator may be connected via a wire or similar connection, or may communicate wirelessly. Such communication may employ radio frequency, ultrasound, or other methods as may be apparent to one skilled in the art.
  • the CIC device 302 is configured to be received in the ear canal 315 .
  • the elongated body 305 may have a hollow channel or a lumen 320 defined therethrough such that the ear canal 315 is not occluded and hearing is not reduced.
  • the device 302 allows sound waves to propagate through the ear canal so the patient can still hear while wearing the device.
  • the CIC device 302 may include tabs 304 extending from a proximal end 306 of the elongated body 305 .
  • the tabs 304 are configured to be received in the entrance 314 of the canal 315 and aid the user in removing the device 302 from the ear canal 315 .
  • the system 300 may further include a charging device, such as a charging stand or base 322 .
  • the base 322 may include an elongated plunger body 327 to remove cerumen (earwax).
  • the base 322 may further include an inductive coupling coil 325 for charging.
  • the device 302 can be removed from the stand 322 .
  • the plunger body 327 of the stand 322 may be inserted into the ear to remove any ear wax.
  • the stand and plunger body are removed.
  • the CIC device 302 can then be inserted into the ear canal 315 and secured in place by resting the tabs 302 at the entrance 314 of the ear canal 315 .
  • Stimulation is provided to the target nerve(s) at operational parameters as disclosed herein upon communication between the pulse generator and the electrode assembly.
  • the CIC device 302 can be removed by grasping the tabs 304 and removing the device 305 from the ear canal 315 and placing it in a charging stand 322 .
  • the CIC device may be worn in one or both ear canals and for any prescribed length of time (or time of day) depending upon the indication to be treated.
  • a “behind the ear” or “BTE” system 400 may include a BTE device 402 including an ear canal body 405 and an external ear body 410 .
  • the ear canal body 405 includes electrode(s) or an electrode assembly 100 configured to contact the surface of the skin within the ear canal 315 , at the opening of the ear canal 316 or at/about another surface of the external ear 317 .
  • the electrode(s) or electrode assembly 100 may be located on an external surface of the ear canal body 405 .
  • the ear canal body 405 is configured to be received at the opening of the ear canal and/or in the canal.
  • the external ear body 410 may also include a pulse generator and a battery located within the external ear body 410 of the device 402 .
  • the electrode(s) or electrode assembly 100 may be located on an external surface of the external ear body 410 .
  • the battery may be a non-rechargeable zinc air battery or other rechargeable battery known in the art.
  • the electrode(s) or electrode assembly 100 and the pulse generator may be connected via a wire or similar connection, or may communicate wirelessly. Such communication may employ radio frequency, ultrasound, or other methods as may be apparent to one skilled in the art.
  • the external ear body 410 is configured to be received and/or secured behind the ear, similar to an external hearing aid device.
  • the system 400 may also include a charging stand (not shown).
  • the BTE device 402 is inserted into the ear canal 315 or about the ear 330 and secured by placing the external ear body behind the ear 330 . Stimulation is provided to the target nerve(s) at operational parameters as disclosed herein upon communication between the pulse generator and the electrode assembly.
  • the BTE device 402 can be removed from the ear 330 and placed in the charging stand.
  • the BTE device may be worn on one or both ears and for any prescribed length of time (or time of day) depending upon the indication to be treated.
  • FIGS. 8 B- 8 C- 2 there may be various adaptations of the embodiments shown in FIGS. 8 B- 8 C- 2 .
  • other devices such as the ear piece of eyeglasses, in-ear headphones or headphones adapted to be placed outside the ear may include an electrode assembly 100 , pulse generator and battery configured for use as described above with respect to FIGS. 8 B- 8 C- 2 .
  • Such devices may be configured to stimulate the trigeminal nerve by methods and for treatment of disorders as disclosed elsewhere herein.
  • Such devices may increase patient use and/or compliance by camouflaging the TNS device.
  • one embodiment of the present device comprises a unilateral electrode assembly configured for the unilateral stimulation of ophthalmic nerves.
  • the electrode assembly can also be configured for the stimulation of the maxillary nerves or the mandibular nerves.
  • an electrode assembly configured for the simultaneous stimulation of a plurality of trigeminal nerve branches is also within the scope of the present disclosure.
  • the system or electrode assembly as disclosed herein may be configured to stimulate the infraorbital nerve branch.
  • the electrode assembly 100 is positioned over the forehead of the patient 20 such that the centerline of the insulative connection region 116 lines up with the midline of the patient's nose. In some embodiments, the electrode assembly 100 is placed over the supraorbital foramina, located over the orbital ridge approximately 2.1-2.6 cm lateral to nasal midline. The electrode assembly 100 may then be connected to the external neurostimulator 122 via lead wires 124 and the electrical cable 120 . In other embodiments, the electrode assembly 100 is connected to the neurostimulator 122 via a wireless connection. Stimulation according to patient specific operational parameters as determined according to the methods described herein is then applied.
  • the method of treating medical disorders comprises positioning the electrode assembly 100 to the forehead of a patient, connecting the electrode assembly 100 to an external stimulator 122 , and stimulating the electrode assembly 100 at defined values of the operational parameters as disclosed herein.
  • the method of treating medical disorders comprises positioning the electrode assembly at a first region of a face of a patient, connecting the electrode assembly to an external stimulator, and stimulating the electrode assembly at defined values of the operational parameters as disclosed herein.
  • the first region is a region corresponding to the auriculotemporal nerve.
  • the first region is a region corresponding to the zygomaticofacial nerve.
  • the first region is a region corresponding to the supraorbital nerve.
  • the bilateral supraorbital electrode 100 illustrated in FIGS. 4-5A is stimulated at a stimulus frequency between about 1 Hz and about 300 Hz, at a pulse duration between 50 microseconds ( ⁇ sec) and 500 ⁇ sec, at an output current density of less than 40 mA/cm 2 and an output charge density of less than 10 ⁇ Coulomb/cm 2 at the cerebral cortex for at least one-half to one hour per day.
  • the output current density is less than 7 mA, or less than 6 mA, depending on the size, impedance, resistance, or configuration of the electrode(s). In some embodiments, the output current density is between about 2.5 mA and about 5 mA. In still another embodiment, the output current may be limited to an exact current, e.g.
  • the output current is limited to a range not to exceed 10 mA, or 7 mA, or 5 mA.
  • the stimulation would yield no or negligible charge densities at the cerebral cortex. In some cases, stimulation can be provided for less than one-half hour per day.
  • the electrodes are arrayed in pairs, arranged as two pairs (4-contact), three pairs (six contact), or four pairs (eight contact), with current moving orthodromically (toward the proximal trigeminal ganglion).
  • the electrodes are ⁇ than 50 mm 2 and ⁇ 450 mm 2 . In some embodiments, the electrodes are between approximately 50 mm 2 and 450 mm 2 .
  • the current amplitude provided by the system/electrode assembly is ⁇ 2.5 mA, ⁇ 5.0 mA, ⁇ 7.5 mA, or not greater than 10 mA's). Such low current may reduce or minimize pain felt by the patient.
  • the specific limits to output current may be a function of physician programming, or automatically adjusted or programmed to the type, number of contacts, surface area, or impedance/resistance of the device.
  • the stimulation is delivered at a specific pulse width or range of pulse widths (or pulse duration).
  • the stimulation can be set to deliver pulse widths in any range within a lower limit of about 10 microseconds and an upper limit of about 3 seconds.
  • the stimulation can be set to deliver pulse widths in the range greater than and/or less than one or more of 10 ⁇ s, 20 ⁇ s, 30 ⁇ s, 40 ⁇ s, 50 ⁇ s, 60 ⁇ s, 70 ⁇ s, 80 ⁇ s, 90 ⁇ s, 100 ⁇ s, 120 ⁇ s, 125 ⁇ s, 150 ⁇ s, 175 ⁇ s, 200 ⁇ s, 225 ⁇ s, 250 ⁇ s, up to 500 ⁇ s.
  • Those of skill in the art will recognized that one or more of the above times can be used as a border of a range of pulse widths.
  • the stimulation amplitude is delivered as a voltage or current controlled stimulation. In other embodiments it can be delivered as a capacitive discharge.
  • the current amplitude can be in any range within a lower limit of about 300 ⁇ A and an upper limit of about 30 mA-40 mA, depending on the surface area of the electrodes, inter-electrode distance, the branch(es) stimulated, and the modeling data as described above.
  • the amplitude can be in a range greater than and/or less than one or more of 50 ⁇ A, 75 ⁇ A, 100 ⁇ A, 125 ⁇ A, 150 ⁇ A, 175 ⁇ A, 200 ⁇ A, 225 ⁇ A, 250 ⁇ A, 275 ⁇ A, 300 ⁇ A, 325 ⁇ A, 350 ⁇ A, 375 ⁇ A, 400 ⁇ A, 425 ⁇ A, 450 ⁇ A, 475 ⁇ A, 500 ⁇ A, 525 ⁇ A, 550 ⁇ A, 575 ⁇ A, 600 ⁇ A, 625 ⁇ A, 650 ⁇ A, 675 ⁇ A, 700 ⁇ A, 725 ⁇ A, 850 ⁇ A, 875 ⁇ A, 900 ⁇ A, 925 ⁇ A, 950 ⁇ A, 975 ⁇ A, 1 mA, 2 mA, 3 mA, 4 mA, 5 mA, 6 mA, 7 mA, 875 ⁇ A,
  • the output current is less than 7 mA, or less than 6 mA, depending on the size, impedance, resistance, or configuration of the electrode(s). In some embodiments, the current amplitude is between about 2.5 mA and about 5 mA. In still another embodiment, the output current may be limited to an exact current, e.g. 5 mA, up to a maximum of a fixed current of 7 mA, depending on the size, resistance, or impedance of the electrode. In another embodiment, the output current is limited to a range not to exceed 10 mA, or 7 mA, or 5 mA.
  • amplitudes can be used as a border of a range of amplitudes, and that devices which use a voltage-based output can deliver a voltage output which at a range of electrode impedances would yield similar currents.
  • the stimulation can be delivered at one or more frequencies, or within a range of frequencies.
  • the stimulation can be set to be delivered at frequencies in any range within an upper limit of about 150 Hz and a lower limit of about 1 Hz.
  • the stimulation can be set to be delivered at frequencies less than, and/or greater than one or more of 50 Hz, 45 Hz, 40 Hz, 35 Hz, 30 Hz, 25 Hz, 20 Hz, 15 Hz, or 10 Hz.
  • the stimulation can be set to be delivered at frequencies greater than, and/or less than, one or more of 20 Hz, 30 Hz, 40 Hz, 50 Hz, 60 Hz, 70 Hz, 80 Hz, 90 Hz, 100 Hz, 120 Hz, 125 Hz, 150 Hz, up to 300 Hz.
  • the upper bound of the frequency may be 10,000 Hz (10 kHz).
  • the stimulation is delivered at a specific duty cycle or range of duty cycles within a range from 100% down to about 5%.
  • the stimulation can be set to be delivered at a duty cycle in the range greater than and/or less than one or more of 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100%.
  • a duty cycle of 10% to 50% may be preferable.
  • duty cycles up to 100% may be useful in particular circumstances. Those of skill in the art will recognize that one or more of the above percentages can be used as a border of a range of duty cycles.
  • the values of the operational parameters are selected such that a patient will experience a stimulation sensation, such as a mild tingling over the forehead and scalp without being in discomfort or in pain.
  • the neurostimulation parameters are important factors in the treatment method.
  • the values of the operational parameters are selected to minimize skin irritation, burns, undesired effects on the brain and/or the ophthalmic nerves.
  • the method of selecting operational parameters comprises evaluating variables such as the configuration and size of the electrode, the pulse duration, the electrode current, the duty cycle and the stimulation frequency, each of which are important factors in ensuring that the total charge, the charge density, and charge per phase are well within accepted safety limits for the skin, nerve and brain.
  • the electrical stimulation zone includes the ophthalmic nerve (approximately 3-4 mm deep), or other target nerve, while preventing or minimizing current penetration beneath the skull bone.
  • the stimulation is carried out at the above-described values of the operational parameters.
  • the values of the operational parameters are advantageously selected such that a patient will experience a stimulation sensation, such as mild tingling over the forehead and scalp, without causing the patient marked discomfort or pain. These values may vary according to the treatment of interest; however, the systems and devices disclosed herein stimulate at parameters where current penetration below the surface of the skull and/or into the brain is prevented or minimized.
  • interferential stimulation two (or more) signals are applied to the tissue of the body, and these signals are designed to differ from each other in such a way that when they combine (“heterodyne” or “interfere”) within the tissue, they produce the desired signal (interference signal).
  • This approach to creating a desired signal within nerve tissue may be advantageous in some clinical circumstances because the impedance of skin and adjacent tissue depends upon frequency, and this approach may allow for application of lower amounts of energy of the tissue to accomplish a clinically-effective level of nerve stimulation.
  • nerves when nerves are stimulated with a constant signal, at times they may accommodate to the presence of that stimulation and their response to the stimulation may decline over time.
  • it may be desirable in some circumstances to vary the specific details of the stimulus within ranges though such means as sweeping the frequency of stimulation within a range of frequencies (e.g., rather than stimulate only at 120 Hz, the frequency of the signal may be varied by a specific range or frequencies over a programmable, pre-determined or random amount, for example a protocol as follows: 20 Hz for 10-60 minutes, 30 Hz for 10-60 minutes, 60 Hz for 10-60 minutes, 120 Hz for 10-60 minutes, 240 Hz for 10-60 minutes) or hopping from one discrete frequency of stimulation to another from time to time, or varying the width a stimulus pulse either continuously (swept within a range) or discretely (selected from a set of discrete pulse widths).
  • the varying may take on a variety of patterns, such as a triangular or trapezoidal ramp or a sinusoidal or similar modulation pattern. Also, varying the duty cycle or on-off times, for example ranging the duty cycle from 10% to 50% over 1-24 hours, 50% to 10% over 1-24 hours, than 50% to 100%, or other intervals and time periods so as to prevent or respond to accommodation of the nerve or its related target brainstem, brain structures, and associated brain regions.
  • an external device may be used to identify the location of the branch or branches of the trigeminal nerve that will be targeted in an individual patient for stimulation by an implanted electrode assembly.
  • the external device may be used for mapping and targeting the desired branch or branches of the trigeminal nerve and for identifying the individual stimulation parameters that are optimal for efficacy and safety.
  • the device may include a plurality of external (transcutaneous) TNS electrodes. The practitioner approximates the location of the target branch and affixes the electrodes to the patient's skin above the target location. Stimulation may be applied and the actual location or preferred (optimal) stimulation location of the target branch or branches may be determined. Stimulation parameters may also be established. Once the location and/or stimulation parameters have been established via the external device, that data may be used to help guide the placement of the implanted electrodes for an individual patient and to establish the customized stimulation parameters for that patient.
  • the use of external electrodes for stimulation of the trigeminal nerve may identify individuals who are likely to derive therapeutic benefit from a minimally invasive system in addition to the optimal specific locations and parameters of stimulation based on person-to-person variability.
  • Various neurodiagnostic, imaging, or cutaneous nerve mapping methods may be able to delineate differences in individual anatomy to optimize stimulation for efficacy and/or safety.
  • the use of a minimally invasive system may allow screening and identification of those individuals who are likely to derive benefit from other implantable systems. This can be conceptualized as linking the two approaches as stage I (external TNS of the trigeminal nerve), and stage II (implanted TNS of the superficial trigeminal nerve), such that stage I can screen for stage II.
  • stage I external TNS of the trigeminal nerve
  • stage II implantanted TNS of the superficial trigeminal nerve
  • externally applied electrodes are placed on the skin over the trigeminal nerve dermatomes (e.g., forehead), and gentle electrical signals are used to stimulate the nerve, typically for 8 hours (while sleeping), using stimulation parameters such as a pulse width of 250 microsec, repetition rate of 120 Hz, duty cycle of 30 s on then 30 s off, and current of up to 25 mA.
  • the electrical signals have been shown to lead to selective activation or inhibition of a set of brain structures, such as the locus coeruleus and the anterior cingulate.
  • Data indicates that stimulation at other parameters may have clinical effects as well, such as a frequency in the range of 1 to 10 Hz, a cycle of 2 seconds on and 90 seconds off, and pulse widths between 100 to 500 microseconds.
  • the system may deliver stimulation at one set of parameters (e.g., 120 Hz, 250 microsec) for a period of time (e.g., several minutes) followed by a different set of parameters (such as 60 Hz, 200 microsec) for a period of time, then other additional parameter sets (e.g. 2 Hz, 250 microsec) before cycling back to the first set.
  • one set of parameters e.g., 120 Hz, 250 microsec
  • a different set of parameters such as 60 Hz, 200 microsec
  • other additional parameter sets e.g. 2 Hz, 250 microsec
  • FIG. 9 illustrates the sequential employment of N sets of parameters, with Parameter Set 1 500 , Parameter Set 2 501 , on through the final, Nth set 502 Parameter Set N.
  • the first parameter set 500 (Parameter Set 1) is employed by the stimulation generator for the duration specified in the parameter set.
  • a second parameter set 501 (Parameter Set 2) is employed, and this sequential utilization of different parameter sets continues until the final (Nth) parameter set 502 (Parameter Set N) is employed, after which the sequence may begin again. This cycling through the N different parameter sets may occur repeatedly during the treatment administration.
  • a plurality of stimulation parameters may be used to improve the clinical treatment effects.
  • several sets of parameters are utilized and the system may automatically vary the stimulation among the sets of parameters.
  • This plurality of sets is intended to avoid any adaptation of the patient's nervous system to repeated exposure to the same unvarying stimulation pattern.
  • the stimulation pattern is selected to prevent or minimize current penetration into the brain.
  • a system and method in which measurement of a biological feature is used to detect an acute biological change which may be used to select a personalized set of parameters (such as repetition frequency, pulse width, or duty cycle) which are predicted to produce an intended clinical effect (or the absence of that effect for use as a sham (placebo) control condition).
  • a biological feature e.g., activity in a brain region
  • a personalized set of parameters such as repetition frequency, pulse width, or duty cycle
  • the treating physician may monitor the individual patient's biological response to stimulation, such as with a PET neuroimaging scan (see description related to FIGS. 2 and 3 above), an EEG-derived value of current density in the brain, a fMRI scan, measures of heart activity or blood pressure, or other such measure, to select personalized parameters that produce an acute change in a biological measure which is linked to and may be predictive of later clinical outcomes.
  • a PET neuroimaging scan see description related to FIGS. 2 and 3 above
  • EEG-derived value of current density in the brain e.g., a fMRI scan, measures of heart activity or blood pressure, or other such measure
  • parameters may be selected for use in a clinical research study in order to have a set of parameters which is unlikely to produce the desired clinical effect (i.e., for use as a sham (placebo) control condition). Additionally, this approach may be used to determine if there is penetration of current into the brain tissue directly from the stimulating electrodes.
  • FIG. 10 depicts a system 610 for determining patient specific stimulation parameters.
  • the system 610 includes a biological sensing device 601 , a measurement or measuring device 602 and a stimulation generator 604 .
  • the biological sensing device may be a neuroimaging device, such as a magnetic resonance imaging (MRI) scanner, a positron emission tomography (PET) scanner, or similar device; or a physiologic device, such as an electroencephalograph (EEG), an electrocardiograph (ECG or EKG), a blood pressure sensory, pulse oximeter, or other similar device.
  • MRI magnetic resonance imaging
  • PET positron emission tomography
  • EEG electroencephalograph
  • EKG electrocardiograph
  • FIG. 10 depicts a system 610 for determining patient specific stimulation parameters.
  • the system 610 includes a biological sensing device 601 , a measurement or measuring device 602 and a stimulation generator 604 .
  • the biological sensing device may be a neuroimaging device, such as a magnetic resonance imaging
  • the data from the sensing device is provided to a measurement or measuring device 602 such as an imaging workstation, a computer to perform quantitative analysis of EEG signals, a graphical display of electrocardiographic data, or similar system.
  • the information from the measurements is interpreted by the prescribing physician 603 or other clinician, and is used to make adjustments to the stimulation parameters of the generator 604 to achieve a personalized setting which may lead to a desired clinical effect.
  • aspects of the adjustments may be made through an automated device in lieu of the person 603 .
  • a patient 600 is placed in proximity to a biological sensing device 601 , which is coupled, either directly or indirectly to a measurement or measuring device 602 .
  • Output from the measuring device 602 is observed by the prescribing physician or other clinician 603 and adjustments may be made to the stimulation parameters as disclosed elsewhere herein that are supplied by the stimulation generator 604 to the trigeminal nerve of patient 600 .
  • FIGS. 11A-11C illustrate the results from a pilot study of external trigeminal nerve stimulation for the treatment of depression. Subjects with major depression who met inclusion and exclusion criteria were followed for 8-weeks in an open label (unblinded) study conducted at UCLA.
  • Inclusion Criteria were: Age 18-65 years old who met DSM-IV criteria for an acute, recurrent episode of Major Depressive Disorder (MDD) and were in a major depressive episode (MDE) of moderate severity. Other inclusion criteria were: the current MDE must be ⁇ 4 months in duration, no response to at least one antidepressant over at least six weeks during the current MDE, and concomitant use of at least one antidepressant. All had prominent residual symptoms, with mean Hamilton Depression Rating Scale (HDRS-28) scores at study entry of 25.4 (3.9 s.d.), range 19 to 29. Subjects placed stimulating electrodes over the supraorbital branches of the trigeminal nerve for at least 8 hours per day (primarily while asleep), with current adjusted to maintain comfortable levels. Five subjects completed the trial. Primary outcome was change in HDRS at 8 weeks.
  • HDRS-28 Hamilton Depression Rating Scale
  • Exclusion criteria were: current pregnancy; meeting DSM-IV criteria for atypical or psychotic or bipolar depression; a history of schizophrenia, schizoaffective disorder, or other non-mood disorder psychosis; a current secondary DSM-IV diagnosis (or signs) of delirium, dementia, amnestic disorder or other cognitive disorder; clinically significant current suicidal intent; significant cardiac, medical or progressive neurological or medical illness; facial pain or trigeminal neuralgia; a VNS or other implantable electrical device such as a pacemaker; current use of a TENS or VNS unit, or history of non-compliance.
  • Subjects underwent stimulation using an electrical stimulator such as for example the EMS Model 7500 commercially available from TENS Products, Inc. (www.tensproducts.com) operated at a frequency of 120 Hertz, a current less than 20 mA, a pulse duration of 250 ⁇ sec, and a duty cycle at 30 seconds on and 30 seconds off, for a minimum of 8 hours per day.
  • an electrical stimulator such as for example the EMS Model 7500 commercially available from TENS Products, Inc. (www.tensproducts.com) operated at a frequency of 120 Hertz, a current less than 20 mA, a pulse duration of 250 ⁇ sec, and a duty cycle at 30 seconds on and 30 seconds off, for a minimum of 8 hours per day.
  • the symptom severity of each subject was quantified using the Hamilton Depression Rating Scale (HDRS, scored using both 17- and 28-item versions), the Beck Depression Inventory (BDI), and the Quick Inventory of Depressive Symptomatology (QIDS), with the group average values on each of these scales being tabulated in the table shown in FIG. 6A . All three are assessment instruments designed to measure the severity of depression.
  • HDRS Hamilton Depression Rating Scale
  • BDI Beck Depression Inventory
  • QIDS Quick Inventory of Depressive Symptomatology
  • the HDRS is a well-established rating scale instrument which is filled out by a clinician after interviewing and observing the individual subject in order to measure the severity of depression; in this study, ratings on all 28 items (questions) were made, and the scale was scored according to standard methods using all items (HDRS 28 ) and the standard subset of 17 items (HDRS 17 ).
  • the BDI is a 21-question multiple choice self-report survey that is used to measure the severity of depression.
  • the QIDS-C 16 is a 16-question clinician-rated survey that is used to measure the severity of depression.
  • BDI emphasizes cognitive symptoms of depression, while the HDRS weights neurovegetative symptoms prominently), and all are commonly used in clinical trials in major depression; the use of multiple scales allowed a more comprehensive assessment of the effects of trigeminal nerve stimulation than any single scale in this initial study of this treatment for major depression.
  • FIG. 12 summarizes current, charge, current density and charge density recorded in a subject during exposure to cutaneous stimulation of the supraorbital nerve.
  • Cutaneous electrical stimulation of the supraorbital branch of the trigeminal nerve with round 1.25-inch TENS patch electrodes results in current densities and charge density/phase that are well within the limits of safety.
  • the maximum current comfortably tolerated by TNS patients studied previously is approximately 25 mA, and patients typically are stimulated at an amplitude setting well below 25 mA (6-10 mA).
  • the 1.25-inch TENS electrodes are circular electrodes with a radius of 1.59 cm.
  • typical stimulation current ranges from 6-10 mA at pulse durations of 150-250 usec.
  • the charge density is generally 12 to 120 fold less at the stimulating electrode than the maximum allowed at the cerebral cortex. Since the cortex is a minimum of 10-13 mm from the stimulating electrodes, and given the interposed layers of skin, fat, bone, dura, and CSF, the actual charge densities will be significantly lower. This is of importance in avoiding the undesired passage of current directly through brain tissue as a bulk conductor.
  • FIG. 13 illustrates the response to TNS at 120 Hz, 10-30 seconds on/30 seconds off, infraorbital or supraorbital stimulation in patients with epilepsy. Note the measured and mild reductions in heart rate, consistent with activation of the Trigeminal Cardiac Reflex. This reflects the effects of vagus nerve stimulation from Trigeminal Nerve Stimulation. Mild reductions in heart rate occur without significant changes in systolic or diastolic blood pressure. The reduction in heart rate is protective in the setting of myocardial infarction, heart failure, tachyarrhythmia's, and conditions associated with the risk of sudden death.
  • FIG. 14 illustrates the changes in fatigue scores with trigeminal nerve stimulation.
  • FIGS. 15A-15B illustrate a sample protocol for mitigating the potential effects of accommodation.

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