Patent Application
20210236824
The present disclosure provides systems and methods relating to neuromodulation. In particular, the present disclosure provides systems and methods for eliminating the onset response when blocking nerve conduction. The various embodiments disclosed herein include methods for designing waveforms that block nerve conduction without inducing an onset response, and systems for delivering treatment based on these waveforms to subjects with pathological neural activity.
Many neurological disorders, including pain and spasticity, are characterized by undesirable increases in sensory, motor, or autonomic nerve activity. Local application of kilohertz frequency alternating currents (KHFAC) can effectively and completely block the conduction of undesired hyperactivity through peripheral nerves and could be a therapeutic approach for alleviating disease symptoms. However, KHFAC nerve block produces an undesirable initial burst of action potentials (APs) prior to achieving block, known as onset response. This onset firing may result in muscle contraction and pain and is a significant impediment to potential clinical applications of KHFAC nerve block. There are some existing approaches to reduce or eliminate the onset response, such as electrode geometry design and amplitude and frequency modulation of the applied signal. However, these approaches are often unable to completely eliminate the onset firing and can be challenging for clinical implementation. Hence, there is an ongoing need for improved methods of KHFAC treatment.
Embodiments of the present disclosure include a method of designing a waveform shape for blocking neural conduction without inducing an onset response. In accordance with these embodiments, the method includes identifying an optimized transmembrane voltage trajectory sufficient to induce closed-state inactivation (CSI) in a plurality of voltage-gated sodium channels, identifying at least one DC blocking waveform from a plurality of candidate waveforms using a global optimization algorithm, and designing a waveform that blocks neural conduction without inducing an onset response based on the at least one DC blocking waveform. In some embodiments, the at least one DC blocking waveform drives a voltage profile corresponding to the optimized transmembrane voltage trajectory.
In some embodiments, the waveform that blocks neural conduction without inducing an onset response is an AC blocking waveform. In some embodiments, the AC blocking waveform comprises an amplitude envelope defined by the least one DC blocking waveform.
In some embodiments, the optimized transmembrane voltage trajectory is identified using a computation model comprising characteristics of a nerve fiber. In some embodiments, the characteristics of the nerve fiber are selected from the group consisting of number of nodes of Ranvier, nerve fiber diameter, nerve fiber length, nerve fiber location, types of sodium channels, number of sodium channels, types of potassium channels, number of potassium channels, and degree of myelination.
In some embodiments, the optimized transmembrane voltage trajectory is identified using a global optimization algorithm. In some embodiments, the global optimization algorithm is selected from the group consisting of a genetic algorithm, a particle swarm algorithm, a simulated annealing algorithm, an ant colony algorithm, an estimation of distribution algorithm, and any combinations and derivations thereof.
In some embodiments, the global optimization algorithm used to identify the at least one DC blocking waveform is selected from the group consisting of a genetic algorithm, a particle swarm algorithm, a simulated annealing algorithm, an ant colony algorithm, an estimation of distribution algorithm, and any combinations and derivations thereof. In some embodiments, the optimized transmembrane voltage trajectory increases nonlinearly from a resting potential to a suprathreshold level.
In some embodiments, the AC blocking waveform is applied at increasing amplitude over time. In some embodiments, the AC blocking waveform is charge-balanced. In some embodiments, the AC blocking waveform is biphasic, monophasic, or multiphasic. In some embodiments, the AC blocking waveform is applied at a frequency of about 5 kHz to about 90 kHz. In some embodiments, the AC blocking waveform is symmetric and/or rectangular.
Embodiments of the present disclosure also include an AC conduction block waveform that eliminates onset response. In accordance with these embodiments, the waveform is applied at increasing amplitude over time, and the waveform blocks neural conduction and induces closed-state inactivation (CSI) of voltage-gated sodium channels prior to activation.
Embodiments of the present disclosure also include a system for blocking neural conduction without inducing an onset response. In accordance with these embodiments, the system includes an electrode sized and configured for implantation in proximity to neural tissue, and a pulse generator coupled to the electrode. In some embodiments, the pulse generator includes a power source comprising a battery and a microprocessor coupled to the battery. In some embodiments, the pulse generator is capable of applying to the electrode an AC waveform capable of blocking neural conduction and eliminating onset response by inducing closed-state inactivation (CSI) of voltage-gated sodium channels prior to activation.
In some embodiments, the AC blocking waveform is applied at increasing amplitude over time. In some embodiments, the AC blocking waveform is charge-balanced. In some embodiments, the AC blocking waveform is biphasic, monophasic, or multiphasic. In some embodiments, the AC blocking waveform is applied at a frequency of about 5 kHz to about 90 kHz. In some embodiments, the AC blocking waveform is symmetric and/or rectangular.
Embodiments of the present disclosure also include a method for blocking neural conduction in a subject using any of the systems described herein. In accordance with these embodiments, the method includes programming the pulse generator to output the blocking waveform at increasing amplitude over time, and delivering the blocking waveform to the subject without inducing an onset response.
The present disclosure provides systems and methods relating to neuromodulation. In particular, the present disclosure provides systems and methods for eliminating the onset response when blocking nerve conduction. The various embodiments disclosed herein include methods for designing waveforms that block nerve conduction without inducing an onset response, and systems for delivering treatment based on these waveforms to subjects with pathological neural activity.
In accordance with these embodiments, the present disclosure provides optimized waveforms for administering nerve blocking in a subject, and method for designing optimized waveforms. In some embodiments, the present disclosure provides a novel engineering optimization approach for designing a blocking waveform to completely eliminate onset firing in peripheral axons by moving voltage-gated Na+ channels (VGSCs) to closed-state inactivation (CSI). The resulting KHFAC waveforms of the present disclosure can generate electric nerve block without inducing an onset response. The methods and systems provided herein for optimizing blocking waveforms represents a novel engineering design methodology with myriad potential applications and has relevance for the conduction block of peripheral nerve hyperactivity.
As described further herein, a hybrid axon model was created to develop and test candidate waveforms. In one embodiment, a Markov-type kinetic model was used to simulate Na+ channel CSI; this model was previously validated with electrophysiological data from all VGSC isoforms. In another embodiment, a McIntyre-Richardson-Grill (MRG) model of a mammalian peripheral myelinated axon was modified to incorporate Markov-type Nav 1.1 and Nav 1.6 channels. In accordance with these embodiments, the methods and systems of the present disclosure include the use of such models to design and test optimized waveforms using various input parameters, such as electrode type, axon diameter, electrode position, and the like. In some embodiments, an optimized waveform includes waveforms that maximize the number of VGSCs in a CSI state so as to eliminate the onset response resulting from KHFAC block.
In some embodiments, methods of the present disclosure include the use of a optimization algorithm to design an optimized transmembrane voltage trajectory to drive VGSCs to CSI without first causing activation of the VGSCs. In some embodiments, the same or similar algorithm can then be used to generate an extracellular DC stimulation waveform to drive the voltage profile to follow the optimized trajectory. In some embodiments, an AC waveform is generated based on the generated DC waveform and is administered to a subject using a neuromodulation system, for example, to treat pathological neural activity. In some embodiments, the optimization algorithm is a particle swarm optimization (PSO), and the method includes a multi-objective optimization to find a voltage trajectory that maximizes the fractions of Nav 1.1 and Nav 1.6 channels in inactivated states while minimizing the fractions of the two VGSCs in open states.
In some embodiments, after a voltage trajectory is identified, the optimization algorithm is used to generate a plurality of candidate waveforms for driving the optimized voltage trajectory in an axon. In some embodiments, the optimization algorithm (e.g., PSO) is again applied, with the particles defined as the electrode currents at each time step, to design an extracellular stimulation waveform to drive PSO-generated voltage profile. In this case, the goal of the PSO is to minimize the difference between the membrane voltage recorded in a particular node and the optimized voltage profile. In some embodiments, this can be applied to a single axon, or two or more axons (e.g., a population of axons). In some embodiments, the waveform can be designed for driving the voltage profile in a group of axons, where the axons may have different properties, including but not limited to, diameter and distance from the electrode.
Results provided herein demonstrate that a PSO-based KHFAC waveform produces robust conduction block without activating an onset response. Thus, it is anticipated that the disclosed waveform can be useful in applying a therapeutic nerve block to a subject. It is additionally noted that the example PSO-based KHFAC waveform completely prevented the onset firing in the axon model for a prescribed set of parameters. For example, as described further herein, the electrode was assumed to be at a specific distance from a nerve fiber, and that the nerve fiber had a specific diameter. However, it is within the scope of the disclosure to design an optimized waveform based on different values of these and other input parameters.
Embodiments of the present disclosure also include a method of using a computationally optimized stimulation waveform to block neural activity in a subject without inducing an onset response. In some embodiments, the waveform can be delivered to the subject as an electrical stimulus using a neuromodulation device.
Section headings as used in this section and the entire disclosure herein are merely for organizational purposes and are not intended to be limiting.
Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art. In case of conflict, the present document, including definitions, will control. Preferred methods and materials are described below, although methods and materials similar or equivalent to those described herein can be used in practice or testing of the present disclosure. All publications, patent applications, patents and other references mentioned herein are incorporated by reference in their entirety. The materials, methods, and examples disclosed herein are illustrative only and not intended to be limiting.
The terms “comprise(s),” “include(s),” “having,” “has,” “can,” “contain(s),” and variants thereof, as used herein, are intended to be open-ended transitional phrases, terms, or words that do not preclude the possibility of additional acts or structures. The singular forms “a,” “and” and “the” include plural references unless the context clearly dictates otherwise. The present disclosure also contemplates other embodiments “comprising,” “consisting of” and “consisting essentially of,” the embodiments or elements presented herein, whether explicitly set forth or not.
“About” is used to provide flexibility to a numerical range endpoint by providing that a given value may be “slightly above” or “slightly below” the endpoint without affecting the desired result.
For the recitation of numeric ranges herein, each intervening number there between with the same degree of precision is explicitly contemplated. For example, for the range of 6-9, the numbers 7 and 8 are contemplated in addition to 6 and 9, and for the range 6.0-7.0, the number 6.0, 6.1, 6.2, 6.3, 6.4, 6.5, 6.6, 6.7, 6.8, 6.9, and 7.0 are explicitly contemplated. Recitation of ranges of values herein are merely intended to serve as a shorthand method of referring individually to each separate value falling within the range, unless otherwise-Indicated herein, and each separate value is incorporated into the specification as if it were individually recited herein. For example, if a concentration range is stated as 1% to 50%, it is intended that values such as 2% to 40%, 10% to 30%, or 1% to 3%, etc., are expressly enumerated in this specification. These are only examples of what is specifically intended, and all possible combinations of numerical values between and including the lowest value and the highest value enumerated are to be considered to be expressly stated in this disclosure.
“Pain” generally refers to the basic bodily sensation induced by a noxious stimulus, received by naked nerve endings, characterized by physical discomfort (e.g., pricking, throbbing, aching, etc.) and typically leading to an evasive action by the individual. As used herein, the term pain also includes chronic and acute neuropathic pain. The term “chronic neuropathic pain” refers to a complex, chronic pain state that is usually accompanied by tissue injury wherein the nerve fibers themselves may be damaged, dysfunctional or injured. These damaged nerve fibers send incorrect signals to other pain centers. The impact of nerve fiber injury includes a change in nerve function both at the site of injury and areas around the injury. The term “acute neuropathic pain” refers to self-limiting pain that serves a protective biological function by acting as a warning of on-going tissue damage. Acute neuropathic pain is typically a symptom of a disease process experienced in or around the injured or diseased tissue.
“Subject” and “patient” as used herein interchangeably refers to any vertebrate, including, but not limited to, a mammal (e.g., cow, pig, camel, llama, horse, goat, rabbit, sheep, hamsters, guinea pig, cat, dog, rat, and mouse, a non-human primate (e.g., a monkey, such as a cynomolgus or rhesus monkey, chimpanzee, etc.) and a human). In some embodiments, the subject may be a human or a non-human. In one embodiment, the subject is a human. The subject or patient may be undergoing various forms of treatment.
“Treat,” “treating” or “treatment” are each used interchangeably herein to describe reversing, alleviating, or inhibiting the progress of a disease and/or injury, or one or more symptoms of such disease, to which such term applies. Depending on the condition of the subject, the term also refers to preventing a disease, and includes preventing the onset of a disease, or preventing the symptoms associated with a disease. A treatment may be either performed in an acute or chronic way. The term also refers to reducing the severity of a disease or symptoms associated with such disease prior to affliction with the disease. Such prevention or reduction of the severity of a disease prior to affliction refers to administration of a treatment to a subject that is not at the time of administration afflicted with the disease. “Preventing” also refers to preventing the recurrence of a disease or of one or more symptoms associated with such disease.
The term “effective amount” or “therapeutically effective amount” refers to an amount sufficient to effect beneficial or desirable biological and/or clinical results.
Unless otherwise defined herein, scientific and technical terms used in connection with the present disclosure shall have the meanings that are commonly understood by those of ordinary skill in the art. For example, any nomenclatures used in connection with, and techniques of, cell and tissue culture, molecular biology, neurobiology, microbiology, genetics, electrical stimulation, neural stimulation, neural modulation, and neural prosthesis described herein are those that are well known and commonly used in the art. The meaning and scope of the terms should be clear; in the event, however of any latent ambiguity, definitions provided herein take precedent over any dictionary or extrinsic definition. Further, unless otherwise required by context, singular terms shall include pluralities and plural terms shall include the singular.
Multiple neurological disorders are characterized by undesirable increases in sensory, motor, or autonomic nerve activity, for example pain and spasticity. Blocking the conduction of activity in nerves has the potential to alleviate disease symptoms. Kilohertz frequency alternating current (KHFAC) stimulation is an effective method for producing a rapid, controlled, and locally-acting conduction block. KHFAC nerve block is quickly reversible, and thus enables both temporal and spatial control of the target tissue with minimal side effects. However, an important drawback of KHFAC block is the transient burst of action potentials (APs) activated at the onset of blocking currents. This onset firing is likely to lead to intense muscle contraction and or painful sensations, and/or other unwanted physiological responses, and is a significant impediment to potential clinical applications of KHFAC nerve block. Several approaches are proposed to reduce or eliminate the onset response, including transitioning KHFAC waveform from a high amplitude and high frequency to a low amplitude and low frequency, slowly increasing the amplitude of the KHFAC waveform, introducing direct current (DC) nerve block, and modifying electrode geometries. However, these approaches are either unable to eliminate completely the onset firing or are challenging for clinical implementation. As described further herein, engineering optimization was used to design a stimulus waveform to achieve conduction block while preventing the onset responses.
Nerve excitation is regulated by voltage-gated Na+ channels (VGSCs). During an AP, the VGSCs first activate from non-conducting closed states to open states when membrane depolarization exceeds a threshold. The open channels allow influx of Na+ ions, which further depolarizes the cell and drives the upstroke of the AP. Membrane depolarization also causes inactivation of VGSCs, which prevents Na+ influx and facilitates repolarization to the resting potential. Na+ inactivation is coupled to activation, and typically occurs from the open state at strongly depolarized membrane potentials, also called open-state inactivation (OSI). However, recordings in cardiac cells, skeletal muscle, neuroblastoma cells, squid giant axon, medullary raphe neurons, and dorsal root ganglion neurons confirm that VGSCs can also inactivate from pre-open closed states without first opening, called closed-state inactivation (CSI). This path occurs at hyperpolarized and modestly depolarized potentials without generation of an AP.
Thus, as described further herein, experiments were conducted to investigate whether moving VGSCs into CSI without first causing activation could eliminate the initiation of APs and thus prevent the onset response. Embodiments of the present disclosure used Markov-type kinetic models to simulate Na+ channel CSI, and the models were previously validated with electrophysiological data from all VGSC isoforms. The McIntyre-Richardson-Grill (MRG) model of a mammalian peripheral myelinated axon was modified to incorporate Markov-type Nav 1.1 and Nav 1.6 channels. Additionally, particle swarm optimization (PSO) was used to design the profile of membrane voltage required to move the two types of VGSCs into CSI, and, subsequently, to determine the stimulation waveform shape required to drive that voltage profile. PSO is an effective search method for dealing with non-linear optimization problems by moving the particles to a “preferred” position in their constrained domains. It is effective for determining sequences of real numbers in non-linear systems, and was well suited to designing the voltage and current waveforms of the present disclosure; however, as would be recognized by one of ordinary skill in the art based on the present disclosure, other optimization algorithms can also be used. The outcome of the engineering optimization was a KHFAC current waveform that produced nerve conduction block without generating an onset response. The results provided herein revealed that moving VGSCs into the CSI without first opening completely suppressed the onset firing and demonstrated that using this novel approach for designing blocking waveforms may have relevance for the conduction block of peripheral nerve hyperactivity.
In accordance with these embodiments, a novel design process was used to develop a KHFAC stimulus waveform to enable nerve conduction block without the onset response that occurs with conventional KHFAC waveforms. In some embodiments, a charge-balanced 10 kHz biphasic waveform based on the PSO-generated DC waveform was designed, and this PSO-based KHFAC waveform produced robust conduction block without an onset response.
In in vivo experiments, a KHFAC waveform is commonly delivered using an extracellular electrode and can affect a number of axons with different electrode-fiber distances. The PSO-based biphasic waveform IBI was calculated in a 21-node model at distance of 1 mm, and this waveform did not produce onset firing. The block threshold increases with increasing electrode-fiber distance, and it was examined whether the PSO-based KHFAC waveform optimized at a specific location produced onset-free conduction block in the axon at other locations. Applying IBI with same plateau amplitude generated an onset response in the model at an electrode-fiber distance of 0.3 mm (
In in vivo experiments, a KHFAC waveform delivered using an extracellular electrode can also affect axons with different fiber diameters. The block threshold decreases with increasing fiber diameter, and it was examined whether the PSO-based KHFAC waveform produced onset-free conduction block in smaller diameter (2 μm and 8.7 μm) model axons. The internodal lengths of 2 μm or 8.7 μm axons are much shorter than those of the 10 μm fiber (Table 1), which significantly reduced the total length of the 21-node model axon. Since the electrode-fiber distance was a fixed value (1 mm), the number of nodes was increased to 251 to examine conduction block using the PSO-based KHFAC waveform and to avoid potential end effects, as the ends of the 21-node model axons with shorter intermodal lengths were much closer to the electrode. When scaling the plateau amplitude of IBI to the block threshold of a 251-node model at a diameter of 2 μm, two APs were generated as the KHFAC amplitude approached the block threshold (
The original MRG models used the HH-type formalism to describe fast Na+ and persistent Na+ channels in each node, and the waveform was designed using the hybrid model incorporating Markov-type channels. Applying the PSO-based biphasic waveform to a 21-node 10 μm HH-type MRG axon (e.g., without the Markov-type VGSCs in the central nodes) generated eight APs as KHFAC amplitude approached the block threshold (
An earlier study of somatic voltage clamp reported that applying a voltage pre-pulse inactivated axonal channels after evoking an axonal spike, and the voltage steps following the pulse no longer triggered axonal spikes. The present disclosure showed that directly applying voltage clamp of the PSO-generated voltage profile VPSO at the central node generated CSI of VGSCs, and no APs were escaped from the node. Further, a monopolar point source electrode was used to design PSO-based DC and KHFAC waveforms in the hybrid MRG model, while bipolar and tripolar cuff electrodes are commonly used in vivo. Linearly ramping KHFAC amplitude from zero to block threshold in rat sciatic nerve did not eliminate the onset response with a tripolar electrode, while linearly ramping KHFAC waveforms from non-zero amplitudes reduced the onset response with a bipolar electrode. Using representations of bipolar and tripolar cuff electrodes, the PSO-generated DC and biphasic waveforms were re-calculated, and the resulting KHFAC waveform was similar for each of three electrodes. Using a bipolar cuff, there was onset firing activated in the 21-node hybrid model as the KHFAC amplitude approached the block threshold (
Other waveforms were proposed to eliminate the onset response. For example, Miles et al. showed that the KHFAC ramp that started from zero amplitude did not eliminate the onset response in either the HH-type MRG model or in experiments on rat sciatic nerve. Additionally, in vivo recordings demonstrated that the onset response was minimized with high amplitudes and high frequencies, and Gerges et al. showed that a transition from a high amplitude and high frequency to a low amplitude and low frequency during KHFAC nerve block minimized or eliminated the onset response with longer transition times. A DC block was also introduced to eliminate the onset response. Ackermann et al. reported that a brief DC block in combination with KHFAC prevented the onset firing, but such DC was found to produce nerve damage and prolonged conduction failure. Subsequently, Franke et al. suggested that combining KHFAC and charge-balanced DC block significantly reduced or completely prevented the onset response without a change in nerve conduction by using a block electrode of high capacitance materials.
Thus, embodiments of the present disclosure provide an engineering optimization method to design a charge-balanced biphasic current waveform that eliminates the onset response during KHFAC nerve block. Surprisingly, embodiments of the PSO-based KHFAC waveforms described herein completely eliminated or prevented the onset firing in axons at specific locations and with specific diameters, which demonstrates somewhat unexpectedly that it is possible to achieve KHFAC nerve block without an onset response by moving VGSCs to CSI.
In accordance with the above, embodiments of the present disclosure include a method of designing a waveform shape for blocking neural conduction without inducing an onset response. In some embodiments, the method includes identifying an optimized transmembrane voltage trajectory sufficient to induce closed-state inactivation (CSI) in a plurality of voltage-gated sodium channels, identifying at least one DC blocking waveform from a plurality of candidate waveforms using a global optimization algorithm, and designing a waveform that blocks neural conduction without inducing an onset response based on the at least one DC blocking waveform. In some embodiments, the at least one DC blocking waveform drives a voltage profile corresponding to the optimized transmembrane voltage trajectory.
In some embodiments, the waveform that blocks neural conduction without inducing an onset response is an AC blocking waveform. In some embodiments, the AC blocking waveform comprises an amplitude envelope defined by the least one DC blocking waveform (see, e.g.,
In some embodiments, the optimized transmembrane voltage trajectory is identified using a computation model comprising characteristics of a nerve fiber. In some embodiments, these characteristics include, but are not limited to, the number of nodes of Ranvier, nerve fiber diameter, nerve fiber length, nerve fiber location, types of sodium channels, number of sodium channels, types of potassium channels, number of potassium channels, and degree of myelination. Other characteristics can also be included in the computational model, as would be recognized by one of ordinary skill in the art based on the present disclosure.
In some embodiments, the optimized transmembrane voltage trajectory is identified using a global optimization algorithm. In some embodiments, the global optimization algorithm includes, but is not limited to, a genetic algorithm, a particle swarm algorithm, a simulated annealing algorithm, an ant colony algorithm, an estimation of distribution algorithm, and any combinations and derivations thereof. In some embodiments, the optimized transmembrane voltage trajectory increases nonlinearly from a resting potential to a suprathreshold level, as described further herein.
In some embodiments, after a voltage trajectory is identified, the optimization algorithm is used to generate a plurality of candidate waveforms for driving the optimized voltage trajectory in an axon. In some embodiments, the optimization algorithm (e.g., PSO) is again applied, with the particles defined as the electrode currents at each time step, to design an extracellular stimulation waveform to drive PSO-generated voltage profile. The purpose of the PSO is to minimize the difference between the membrane voltage recorded in a particular node and the optimized voltage profile, as described further herein. As would be recognized by one of skill in the art based on the present disclosure, the optimized transmembrane voltage trajectory can also be identified using a global optimization algorithm. In some embodiments, the global optimization algorithm used to identify the at least one DC blocking waveform includes, but is not limited to, a genetic algorithm, a particle swarm algorithm, a simulated annealing algorithm, an ant colony algorithm, an estimation of distribution algorithm, and any combinations and derivations thereof.
In some embodiments, the AC blocking waveform can be applied at increasing amplitude over time (see, e.g., 4), which in part facilitates the elimination of the onset response. In some embodiments, the AC blocking waveform can be applied at increasing amplitude over a time period of 5 ms, 10 ms, 15 ms, 20 ms, 25 ms, 30 ms, 35 ms, 40 ms, 45 ms, 50 ms, 55 ms, 60 ms, 70 ms, 80 ms, 90 ms or 100 ms. In some embodiments, the AC blocking waveform can be applied at increasing amplitude over any time period after the initial application of the waveform (time 0) up until about 100 ms.
In some embodiments, the AC blocking waveform can be charge-balanced. In some embodiments, the AC blocking waveform can be biphasic, monophasic, or multiphasic. In other embodiments, the AC waveform can be multiphasic, including a waveform that is charge-balanced and/or biphasic. In some embodiments, the AC blocking waveform is symmetric and/or rectangular. In some embodiments, the AC blocking waveform can be sinusoidal. In some embodiments, the AC blocking waveform is a sawtooth. In some embodiments, the AC blocking waveform is triangular.
In some embodiments, the AC blocking waveform can be applied at a frequency of at least about 5 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of at least about 10 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of at least about 20 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of at least about 40 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of at least about 60 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of at least about 80 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of at least about 90 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of about 5 kHz to about 90 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of about 5 kHz to about 80 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of about 5 kHz to about 70 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of about 5 kHz to about 60 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of about 5 kHz to about 50 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of about 5 kHz to about 40 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of about 5 kHz to about 30 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of about 5 kHz to about 20 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of about 5 kHz to about 10 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of about 10 kHz to about 90 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of about 20 kHz to about 90 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of about 30 kHz to about 90 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of about 40 kHz to about 90 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of about 50 kHz to about 90 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of about 60 kHz to about 90 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of about 70 kHz to about 90 kHz. In some embodiments, the AC blocking waveform can be applied at a frequency of about 80 kHz to about 90 kHz.
Embodiments of the present disclosure also include the various AC conduction block waveforms described herein, as well as systems for blocking neural conduction without inducing an onset response in a subject using the AC blocking waveforms. In accordance with these embodiments, the AC blocking waveform can applied at increasing amplitude over time, which blocks neural conduction and induces closed-state inactivation (CSI) of voltage-gated sodium channels prior to activation. The application of the AC blocking waveform using these systems eliminates onset firing that often causes muscle contraction and pain in a subject, which is a significant impediment to potential clinical applications of KHFAC nerve block.
In some embodiments, the system includes an electrode sized and configured for implantation in proximity to neural tissue, and a pulse generator coupled to the electrode. In some embodiments, the pulse generator includes a power source comprising a battery and a microprocessor coupled to the battery. In some embodiments, the pulse generator is capable of applying to the electrode an AC waveform capable of blocking neural conduction and eliminating onset response by inducing closed-state inactivation (CSI) of voltage-gated sodium channels prior to activation.
In some embodiments, the AC blocking waveform is applied at increasing amplitude over time, as described further herein. In some embodiments, the AC blocking waveform is charge-balanced. In some embodiments, the AC blocking waveform is biphasic, monophasic, or multiphasic. In some embodiments, the AC blocking waveform is symmetric and/or rectangular. In some embodiments, the AC blocking waveform is applied at a frequency of about 5 kHz to about 90 kHz, as described further herein.
Embodiments of the present disclosure also include a method for blocking neural conduction in a subject using any of the systems described herein. In accordance with these embodiments, the method includes programming the pulse generator to output the blocking waveform at increasing amplitude over time, and delivering the blocking waveform to the subject without inducing an onset response.
Embodiments of the present disclosure also include methods for blocking neural conduction without inducing onset response using embodiments of the systems and methods as described above. In accordance with these embodiments, the methods include programming the pulse generator to output the waveform (e.g., on a graphical user interface (GUI)). In some embodiments, the waveform is an AC blocking waveform with an amplitude envelope that is defined by a DC stimulation waveform. In some embodiments, the AC waveform blocks neural conduction without inducing an onset response when delivered by the pulse generator.
In some embodiments, the electrode or lead can be placed in a desired position in contact with nervous system tissue of a subject receiving neural block conduction treatment. In one embodiment, the electrode can be implanted in a region of the brain, such as the thalamus, subthalamus, subthalamic nucleus, or globus pallidus for the purpose of deep brain stimulation. However, as would be recognized by one of ordinary skill in the art based on the present disclosure, the electrode can be implanted in, on, or near the spinal cord; or in, on, or near a peripheral nerve (sensory or motor or mixed; somatic or autonomic); or in, or, or near a neural plexus; or in, on, or near any subcutaneous tissue such as muscle tissue (including cardiac tissue) or adipose tissue or other organ tissue for the purpose of stimulation to achieve a therapeutic purpose. In addition, the electrode may be utilized for transcutaneous stimulation where electrodes are placed, not subcutaneous, but on an outer skin surface. Further, the electrode may be utilized for percutaneous stimulation where electrodes are placed through the skin but the pulse generator remains outside the skin.
The electrode can be one or more electrodes configured as part of the distal end of a lead or be one or more electrodes configured as part of a leadless system to apply electrical pulses to the targeted tissue region. Electrical pulses can be supplied by a pulse generator coupled to the electrode/lead. In one embodiment, the pulse generator can be implanted in a suitable location remote from the electrode/lead (e.g., in the shoulder region); however, that the pulse generator could be placed in other regions of the body or externally to the body.
When implanted, at least a portion of the case or housing of the pulse generator can serve as a reference or return electrode. Alternatively, the lead can include a reference or return electrode (comprising a multipolar (such as bipolar) arrangement), or a separate reference or return electrode can be implanted or attached elsewhere on the body (comprising a monopolar arrangement).
The pulse generator can include stimulation generation circuitry, which can include an on-board, programmable microprocessor, which has access to and/or carries embedded code. The code expresses pre-programmed rules or algorithms under which desired electrical stimulation is generated, having desirable electrical stimulation parameters that may also be calculated by the microprocessor, and distributed to the electrode(s) on the lead. According to these programmed rules, the pulse generator directs the stimulation through the lead to the electrode(s), which serve to selectively stimulate the targeted tissue region. The code may be programmed, altered or selected by a clinician to achieve the particular physiologic response desired. Additionally or alternatively to the microprocessor, stimulation generation circuitry may include discrete electrical components operative to generate electrical stimulation having desirable stimulation parameters, as described further herein (e.g., input to generate an optimized waveform shape, which can include a pulse amplitude; a pulse width (PW) or duration; a frequency of stimulation pulses applied over time; and a shape or waveform of the stimulation pulses). One or more of the parameters may be prescribed or predetermined as associated with a particular treatment regime or indication. In some embodiments, the pulse generator can be programed to output a stimulation waveform (e.g., on a graphical user interface (GUI)), and the stimulation waveform can represent a waveform having an optimized shape capable of blocking neural conduction without inducing onset response, as described further herein. In some embodiments, programming the pulse generator includes setting the amplitude of the stimulation waveform, such that the stimulation waveform blocks neural conduction when delivered by the pulse generator.
Additionally, the neuromodulation systems and methods of the present disclosure include a system for delivering neuromodulation therapy to a subject in order to reduce, treat, or prevent the subject's neuropathic pain. In accordance with these embodiments, the system includes an electrode sized and configured for implantation in proximity to neural tissue. For example, the system can include a stimulation device, an electrical connection lead, and at least one electrode or electrode array operatively positioned in the epidural space of a vertebral column of a subject that is experiencing neuropathic pain. The electrode or electrode array can be positioned at the site of nerves that are the target of stimulation (e.g., along the spinal cord), or positioned in any suitable location that allows for the delivery of electrical stimulation to the targeted neural tissue.
In some embodiments, the system includes a pulse generator coupled to the electrode. The pulse generator can include a power source comprising a battery and a microprocessor coupled to the battery, and the pulse generator is generally configured to generate electrical signals for delivering neuromodulation therapy. In some embodiments, the system further includes a controller comprising hardware, software, firmware, or combinations thereof for implementing functionality described herein. For example, the controller can be implemented by one or more processors and memory. The controller can be operatively connected to the pulse generator to facilitate the generation of electrical signals and applying temporal patterns of electrical stimulation to targeted neurological tissue. The output signals may be received by the connection lead and carried to the electrode or electrode array for the delivery of electrical stimulation to targeted neurological tissue. The system can include a power source, such as a battery, for supplying power to the controller and the pulse generator.
In some embodiments, the system also includes an external computing device that is not implanted within the subject. The computing device can communicate with a stimulation device or system via any suitable communication link (e.g., a wired, wireless, or optical communication link). The communication link may also facility battery recharge. A clinician may interact with a user interface of the computing device for programming the output of the implanted pulse generator, including the electrodes that are active, the stimulation pulse amplitude, the stimulation pulse duration, the stimulation pattern (including pulse repetition frequency), and the like applied via each electrode contact to each sub-population. In accordance with these embodiments, systems and methods of the present disclosure can be used to deliver an AC blocking waveform, as described herein, to reduce pain in a plurality of subjects with different pain states without inducing onset response.
In some embodiments, systems and methods of the present disclosure can be implemented as an algorithm within a pulse generator device. An on-board controller can deliver multiple frequencies and patterns through different output channels to different contacts on an electrode, including delivering any of the AC blocking waveforms of the present disclosure. Values of the stimulation frequencies and patterns of stimulation and the electrodes through which these frequencies and patterns are delivered can be input by either a physician or a patient through a user interface. Alternatively, the device can be pre-programmed with specific combinations of frequencies and patterns to use. The applied frequencies and patterns may or may not be offset from each other at the start of stimulation. The algorithm can be toggled on and off (e.g., between multi-frequency and single frequency) by either the physician or patient, or it can be coupled to an internal feedback-driven algorithm for automatic control.
Axon Model.
The MRG double-cable myelinated axon model was used to simulate KHFAC conduction block, and this model was originally developed to reproduce a wide range of excitation properties of mammalian peripheral nerve fibers. The model was composed of equivalent electrical circuits for both nodal and internodal segments (
Markov-Type Models of VGSCs.
There are two types of models commonly used to reproduce the electrophysiological behaviors of VGSCs, i.e., HH- and Markov-type models. The HH-type models represent an ionic channel as an assembly of several independent gating particles, which are not sufficient to capture specific kinetics of VGSCs. Unlike the HH formalism, Markov-type models represent an ion channel as a series of conformational states of the channel protein and a collection of transitions between them, which allowed for reproducing the dependence of Na+ inactivation on activation. Markov-type kinetic models of VGSCs were used to design the transmembrane voltage trajectory for causing Na+ CSI.
The Markov-type models used in the simulations were developed by Balbi et al. and were validated against electrophysiological data from all VGSC isoforms. The model framework was detailed, unifying, and computationally efficient, and can account for different features of each human VGSC isoform with a minimal set of states and transitions. The model included six states, and the state diagram and transitions of the Markov-type channels are shown in
dC1/dt=AI1C1I1+AC2C1C2−(AC1C2+AC1I1)C1 (1)
dC2/dt=AC1C2C1+AO1C2O1+AO2C2O2−(AC2C1+AC2O1+AC2O2)C2 (2)
dO1/dt=AC2O1C2+AI1O1I1−(AO1C2+AO1I1)O1 (3)
dO2/dt=AC2O2C2−AO2C2O2 (4)
dI1/dt=AI2I1I2+AC1I1C1+AO1I1O1−(AI1C1+AI1I2+AI1O1)I1 (5)
dI2/dt=AI1I2I1−AI2I1I2 (6)
Here Aw1w2 was the transition rate from state w1 to state w2, which was computed by
The Na+ conductance was determined by the fraction of open channels, and the Na+ current was computed by
I
Nav
=
Nav(O1+O2)(V−ENa) (8)
where
Implementation of Markov-Type VGSCs.
KHFAC waveforms are applied in practice using comparatively small electrodes and generate a locally-acting conduction block in peripheral nerves. In the simulations, there were 21 nodes in the model axon and the simulated block electrode was placed above the central node (i.e. node 10). To reduce overall computational demands, Markov-type VGSCs were implemented in the central nine nodes, which were closest to the block electrode. The other nodes far away from the site of block were modeled with HH-type VGSCs. Note that the specific number of Markov-type nodes did not alter the block threshold or lack of onset response in the hybrid model (
Experimental data indicated that the Nav 1.1 and Nav 1.6 channels are preferentially expressed in the nodes of mammalian peripheral nerve fibers. The HH-type models of/Naf and INap were substituted in node 6 to node 14 with the Markov-type models of Nav 1.1 and Nav 1.6 channels, respectively. The parameters of each transition rate for two VGSCs are provided in Table 3. Only the maximum conductances of INav11 and INav16 were modified, and this did not change any parameter of their transition rates between consecutive states. The maximum conductance of Nav 1.6 channels was set to a
Particle Swarm Optimization.
PSO algorithms were applied to design the transmembrane voltage trajectory for causing Na+ CSI and to generate current waveform to drive this voltage trajectory, which were implemented in Matlab (version R2016a). PSO is a meta-heuristic optimization method inspired by the information circulation and social behavior of swarms. It uses a population-based search strategy to solve nonlinear optimization problems, based on cooperation and competition among the particles of a swarm. In PSO, each particle is a point in the search space, which represents a candidate solution of the optimization problem. The movement of a particle in the search space is driven by its own fitness as well as the highest fitness in the swarm. The algorithm iteratively updates the velocity of each particle towards the position of the highest fitness. Through communication between particles over multiple iterations, the particles explore the problem space to identify the optimal solution of the problem.
Mathematically, the position of particle i (1≤i≤M) at the kth iteration was described by a vector {right arrow over (X)}i(k)=[xi,1(k), xi,2(k), . . . , xi,D(k)], where M was the number of particles and D was the dimension of the search space. Each dimension of the particle was bounded between xmin and xmax. The personal best position previously found by particle i was {right arrow over (P)}i=[pi,1, pi,2, . . . , pi,D], and the best position experienced by all particles in the whole swarm was indicated by {right arrow over (G)}=[g1, g2, . . . , gD]. The velocity of particle i in the kth iteration was {right arrow over (V)}i(t)=[vi,1(k), vi,2(k), . . . , vi,D(k)], which determined the movement direction of the particle through the search space. At the kth iteration, the d-dimension (1≤d≤D) of particle i was updated based on following equations
v
i,d(k+1)=c{r1[pi,d−xi,d(k)]+r2[gd−xi,d(k)]} (9)
x
i,d(k+1)=xi,d(k)+vi,d(k+1) (10)
where c=1.5 was a learning coefficient, and r1 and r2 were uniform random numbers within [0, 1] used to help promote exploration.
Implementation of PSO.
PSO was applied to generate an optimized voltage trajectory VPSO for causing the CSI of Nav 1.1 and Nav 1.6 channels in the 21-node model (
Minimize ƒt=Σj=1N[B(O11j+O12j+O61j+O62j)−(I12j+I62j)] (11)
where O11, O12, and I12 were the fractions of Nav 1.1 channels in states O1, O2 and I2, O61, O62, and I62 were the fractions of Nav 1.6 channels in states O1, O2 and 12, j corresponded to the time point, and B=20000 was a weight used to reduce the fractions in open states. The lower bound of each particle was xmin=−80 mV (i.e., resting potential), and the upper bound was xmax=−10 mV. The time constant of inactivation state I1 was smaller than I2, and the optimization results were sensitive to the changes in I1. Thus, the fraction of state I1 was excluded from the fitness function ƒ1. The initial positions of 50 particles were defined to be randomly distributed around a straight line, which linearly increased from xmin to xmax.
Subsequently, PSO was used to generate a current waveform for driving the optimized voltage trajectory in the central node of the 21-node model (
where Iext was the amplitude of electrode current, and (x0, y0, z0) was the location of the point source electrode. The resulting transmembrane voltage was recorded in node 10 at each iteration. VPSO was set as the desired voltage trajectory, and defined an one-objective optimization problem: find electrode currents to minimize the difference between transmembrane voltage Vnode 10 recorded in node 10 and desired voltage trajectory VPSO. Mathematically, the following cost function ƒ2 was defined to evaluate the quality of this problem solution
Minimize ƒ2=Σj=1N(vnode 10,j−VPSO,j)2 (13)
where j corresponded to the time point. By using the point source electrode, cathodic stimulus depolarized node 10 and anodic stimulus hyperpolarized node 10. Since VPSO started from the resting potential, the upper bound of each particle was xmax=0 mA. The lower bound was defined to xmin=−0.7 mA, which was sufficient to drive transmembrane voltage in node 10 to a plateau level higher than −10 mV. The initial positions of particles were defined to be randomly distributed around a straight line from the xmin to xmax.
When solving the optimal solutions for ƒt and ƒ2, the time step of PSO was 2 ms and the search space dimension was D=50. The termination criterion was that the algorithm generation reached a limit of 1000, which was sufficient for convergence. When designing the optimized voltage trajectory VPSO for causing Na+ CSI, the minimum ƒi converged to within 1% of the final iteration by 330 iterations (
Simulation Protocols for KHFAC Conduction Block.
After generating PSO-based DC and KHFAC waveforms for conduction block, experiments were conducted to examine whether they activated onset responses. An extracellular point source electrode was used to deliver blocking currents to the central node (10) of the model, and the electrode-fiber distance was 1 mm. Subsequently, it was determined whether the PSO-generated waveform blocked nerve conduction. An intracellular monopolar electrode was applied to deliver suprathreshold test pulses (width: 0.1 ms and amplitude: 2.5Ith) at one end of the axon (node 0), which was used to stimulate APs in node 0 after the onset of blocking currents and test whether these APs propagated through the site of the block electrode. Ith=0.43 mA was the threshold of intracellular test pulse for activation of an AP in node 0.
A 251-node model was used to examine the conduction block at the fiber diameters (2 μm and 8.7 μm) less than 10 μm using PSO-based KHFAC waveform. Each fiber diameter had specific lengths for all segments (Table 1), which were identified based on experimental data. The Markov-type Nav 1.1 and Nav 1.6 channels were implemented in node 121 to node 129, and the block electrode was placed 1 mm above node 125.
It will be readily apparent to those skilled in the art that other suitable modifications and adaptations of the methods of the present disclosure described herein are readily applicable and appreciable, and may be made using suitable equivalents without departing from the scope of the present disclosure or the aspects and embodiments disclosed herein. Having now described the present disclosure in detail, the same will be more clearly understood by reference to the following examples, which are merely intended only to illustrate some aspects and embodiments of the disclosure, and should not be viewed as limiting to the scope of the disclosure. The disclosures of all journal references, U.S. patents, and publications referred to herein are hereby incorporated by reference in their entireties.
The present disclosure has multiple aspects, illustrated by the following non-limiting examples.
Design of Transmembrane Voltage Trajectory to Generate Closed-State Inactivation of VGSCs.
The first step was to design a voltage trajectory that generated CSI of VGSCs. A 21-node 10 μm diameter MRG myelinated axon model of mammalian peripheral nerve fiber was used (
The responses in Nav 1.1 and Nav 1.6 channels were first examined when a standard voltage step (from −80 mV to −10 mV) was applied to the central node as a voltage clamp (
Subsequently, PSO was applied to design an optimized trajectory of transmembrane voltage to drive transitions along the CSI path. PSO is a search algorithm inspired by the social behavior of swarms. It finds the optimal or near-optimal solutions to numerical and qualitative problems by adjusting the trajectories of individual particles in the defined search space of an objective function, and is particularly applicable to addressing waveform optimization. A population of 50 particles was designed as the membrane voltages that were used as the voltage profile to control a series of voltage clamps at node 10. The objective of the PSO was to maximize the fractions of Nav 1.1 and Nav 1.6 channels in the inactivated states while minimizing the fractions in the open states. The PSO-generated voltage profile VPSO increased nonlinearly from the resting potential (−80 mV) to a suprathreshold level (−10 mV) over a duration of 46 ms (
The transitions from the closed states to the inactivated states caused by voltage profile VPSO were similar for Nav 1.1 and Nav 1.6 channels. At the resting potential, VGSCs were in C1 state. After depolarization, the fraction of either channel in C1 was gradually reduced (
PSO-Generated DC Waveform Drives VPSO and Generates Onset-Free Conduction Block.
Having generated a transmembrane voltage trajectory that caused CSI of Nav 1.1 and Nav 1.6 channels, the next step was to design a stimulus waveform to drive this voltage profile in the axon. PSO was again applied, with the particles defined as the electrode currents at each time step, to design an extracellular stimulus to drive VPSO in node 10 using an extracellular monopolar electrode placed 1 mm above the central node (
KHFAC Waveform for Onset-Free Conduction Block.
The DC IPSO waveform was not charge-balanced, and thus can cause irreversible faradaic reactions at the electrode-electrolyte interface, and these may result in electrode and or nerve damage when applied for long periods of time. Therefore, a scaled version of the DC IPSO waveform was used as the envelope of symmetric rectangular charge-balanced biphasic pulses, applied at 10 kHz to block nerve conduction (
The KHFAC waveform IBI, delivered using a monopolar electrode placed 1 mm over node 10, generated passive oscillations in transmembrane voltage at node 10, and the upper envelope of the transmembrane voltage response followed the optimized voltage profile VPSO (
Additional support for the various embodiments described herein can be found in the following tables.
One skilled in the art will readily appreciate that the present disclosure is well adapted to carry out the objects and obtain the ends and advantages mentioned, as well as those inherent therein. The present disclosure described herein are presently representative of preferred embodiments, are exemplary, and are not intended as limitations on the scope of the present disclosure. Changes therein and other uses will occur to those skilled in the art which are encompassed within the spirit of the present disclosure as defined by the scope of the claims.
No admission is made that any reference, including any non-patent or patent document cited in this specification, constitutes prior art. In particular, it will be understood that, unless otherwise stated, reference to any document herein does not constitute an admission that any of these documents forms part of the common general knowledge in the art in the United States or in any other country. Any discussion of the references states what their authors assert, and the applicant reserves the right to challenge the accuracy and pertinence of any of the documents cited herein. All references cited herein are fully incorporated by reference, unless explicitly indicated otherwise. The present disclosure shall control in the event there are any disparities between any definitions and/or description found in the cited references.
The This application claims priority to and the benefit of U.S. Provisional Patent Application No. 62/970,303 filed Feb. 12, 2020, which is incorporated herein by reference in its entirety for all purposes.
This invention was made with government support under Federal Grant No. OT2 OD025340 awarded by the National Institutes of Health. The Federal Government has certain rights to the invention.
| Number | Date | Country | |
|---|---|---|---|
| 62970303 | Feb 2020 | US |
