US20050021106A1 - Methods and apparatus for effectuating a lasting change in a neural-function of a patient - Google Patents

Abstract

The present disclosure suggests methods of selecting a stimulation site for stimulating a patient's brain or methods of effectuating a neural-function of a patient associated with an impaired body function. In one exemplary implementation, such a neural function may be effectuated by selecting a stimulation site, positioning at least a first electrode at the stimulation site, and applying an electrical potential to pass a current through the first electrode. If one aspect, this stimulation site may be selected by a) identifying a second body function that is a corollary to the impaired body function, and b) determining a corollary location of the patient's brain that is associated with the second body function and is ipsilateral to the impaired body function.

Description

CROSS-REFERENCE TO RELATED APPLICATION(S)
• This application is a continuation-in-part of U.S. application Ser. No. 10/260,720, filed on Sep. 27, 2002, which claims the benefit of U.S. application Ser. No. 60/325,872 filed on Sep. 28, 2001 and which is a continuation-in-part of U.S. application Ser. No. 09/802,808, filed on Mar. 8, 2001, which, in turn, claims the benefit of U.S. Provisional Application No. 60/217,981, filed Jul. 31, 2000. Each of these applications is incorporated by reference herein in its entirety.
TECHNICAL FIELD
• Several embodiments of methods and apparatus in accordance with the invention are related to electrically stimulating a region in the cortex or other area of the brain to bring about a lasting change in a physiological function and/or a mental process of a patient.
BACKGROUND
• A wide variety of mental and physical processes are controlled or influenced by neural activity in particular regions of the brain. The neural-functions in some areas of the brain (i.e., the sensory or motor cortices) are organized according to physical or cognitive functions. Several other areas of the brain also appear to have distinct functions in most individuals. In the majority of people, for example, the occipital lobes relate to vision, the left interior frontal lobes relate to language, and the cerebral cortex appears to be involved with conscious awareness, memory, and intellect.
• Many problems or abnormalities can be caused by damage, disease and/or disorders in the brain. Effectively treating such abnormalities may be very difficult. For example, a stroke is a common condition that damages the brain. Strokes are generally caused by emboli (e.g., obstruction of a vessel), hemorrhages (e.g., rupture of a vessel), or thrombi (e.g., clotting) in the vascular system of a specific region of the brain. Such events generally result in a loss or impairment of a neural function (e.g., neural functions related to facial muscles, limbs, speech, etc.). Stroke patients are typically treated using various forms of physical therapy to rehabilitate the loss of function of a limb or another affected body part. Stroke patients may also be treated using physical therapy plus an adjunctive therapy such as amphetamine treatment. For most patients, however, such treatments are minimally effective and little can be done to improve the function of an affected body part beyond the recovery that occurs naturally without intervention.
• The problems or abnormalities in the brain are often related to electrical and/or chemical activity in the brain. Neural activity is governed by electrical impulses or “action potentials” generated in neurons and propagated along synaptically connected neurons. When a neuron is in a quiescent state, it is polarized negatively and exhibits a resting membrane potential typically between −70 and −60 mV. Through chemical connections known as synapses, any given neuron receives excitatory and inhibitory input signals or stimuli from other neurons. A neuron integrates the excitatory and inhibitory input signals it receives, and generates or fires a series of action potentials when the integration exceeds a threshold potential. A neural firing threshold, for example, may be approximately −55 mV.
• It follows that neural activity in the brain can be influenced by electrical energy supplied from an external source such as a waveform generator. Various neural functions can be promoted or disrupted by applying an electrical current to the cortex or other region of the brain. As a result, researchers have attempted to treat physical damage, disease and disorders in the brain using electrical or magnetic stimulation signals to control or affect brain functions.
• Transcranial electrical stimulation is one such approach that involves placing an electrode on the exterior of the scalp and delivering an electrical current to the brain through the scalp and skull. Another treatment approach, transcranial magnetic stimulation, involves producing a high-powered magnetic field adjacent to the exterior of the scalp over an area of the cortex. Yet another treatment approach involves direct electrical stimulation of neural tissue using implanted electrodes.
• The neural stimulation signals used by these approaches may comprise a series of electrical or magnetic pulses that can affect neurons within a target neural population. Stimulation signals may be defined or described in accordance with stimulation signal parameters including pulse amplitude, pulse frequency, duty cycle, stimulation signal duration, and/or other parameters. Electrical or magnetic stimulation signals applied to a population of neurons can depolarize neurons within the population toward their threshold potentials. Depending upon stimulation signal parameters, this depolarization can cause neurons to generate or fire action potentials. Neural stimulation that elicits or induces action potentials in a functionally significant proportion of the neural population to which the stimulation is applied is referred to as supra-threshold stimulation; neural stimulation that fails to elicit action potentials in a functionally significant proportion of the neural population is defined as sub-threshold stimulation. In general, supra-threshold stimulation of a neural population triggers or activates one or more functions associated with the neural population, but sub-threshold stimulation by itself does not trigger or activate such functions. Supra-threshold neural stimulation can induce various types of measurable or monitorable responses in a patient. For example, supra-threshold stimulation applied to a patient's motor cortex can induce muscle fiber contractions in an associated part of the body.
• Although electrical or magnetic stimulation of neural tissue may be directed toward producing an intended type of therapeutic, rehabilitative, or restorative neural activity, such stimulation may result in collateral neural activity. In particular, neural stimulation delivered beyond a certain intensity, period of time, level, or amplitude can give rise to seizure activity and/or other types of collateral activity. It will be appreciated that collateral neural activity may be undesirable and/or inconvenient in a neural stimulation situation.
• The human brain has two hemispheres that are connected via the corpus callosum. Each hemisphere of the brain generally exerts majority control over motor functions and/or sensory functions on the opposite or “contralateral” side of the patient's body. Hence, for example, the left hemisphere of the brain has majority control over movement of the right arm and right leg. Through transcallosal connections, though, each hemisphere of the brain exerts some degree of control over the functions on the same or “ipsilaterial” side of the patient's body. Hence, the right hemisphere of the brain may have some involvement in controlling movement of the right arm and right leg.
• Some studies have concluded that damage to or disorders of the cerebral cortex on one hemisphere can induce long-term changes in the structure and function of a homotopic location of the contralateral hemisphere, namely a location on the undamaged cortex that is at about the same position as the position of the damaged tissue in the opposite cortex. Damage to the cortex in one hemisphere may impact the contralateral homotopic cortex in a variety of fashions, including causing increased cortical thickness, dendritic growth and/or elimination, neuronal hyperexcitability, and synaptogenesis. See, e.g., Nudo, “Recovery After Damage to Motor Cortical Areas,”Current Opinion in Neurobiology, 1999, 9:740-747, the entirety of which is incorporated herein by reference. See also Keyvani et al., “Suppression of Proteasome C2 Contralateral to Ischemic Lesions in Rat Brain,”Brain Research858, (2000) 386-392.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1 is a schematic view of neurons.
• FIG. 2 is a graph illustrating firing an “action potential” associated with normal neural activity.
• FIG. 3 is a flowchart of a method for effectuating a neural-function of a patient associated with a location in the brain in accordance with one embodiment of the invention.
• FIG. 4 is a top plan view of a portion of a brain illustrating neural activity in the brain.
• FIG. 5 is a top plan image of a portion of the brain illustrating a loss of neural activity associated with the neural-function of the patient used in one stage of a method in accordance with an embodiment of the invention.
• FIG. 6 is a top plan image of the brain ofFIG. 3 showing a change in location of the neural activity associated with the neural-function of the patient at another stage of a method in accordance with an embodiment of the invention.
• FIGS. 7-10 are flow charts illustrating various embodiments of diagnostic procedures used in embodiments of methods in accordance with the invention.
• FIG. 11 is a schematic illustration of a system for carrying out the diagnostic and stimulation procedures ofFIGS. 4C and 4D.
• FIG. 12 is a flow chart illustrating another embodiment of a method in accordance with the invention.
• FIGS. 13 and 14 are schematic illustrations of an implanting procedure at a stage of a method in accordance with an embodiment of the invention.
• FIG. 15 is a graph illustrating firing an “action potential” associated with stimulated neural activity in accordance with one embodiment of the invention.
• FIG. 16 is an isometric view of an implantable stimulation apparatus in accordance with one embodiment of the invention.
• FIG. 17 is a cross-sectional view schematically illustrating a part of an implantable stimulation apparatus in accordance with an embodiment of the invention.
• FIG. 18 is a schematic illustration of a pulse system in accordance with one embodiment of the invention.
• FIG. 19 is a schematic illustration of an implanted stimulation apparatus and an external controller in accordance with an embodiment of the invention.
• FIG. 20 is a cross-sectional view schematically illustrating a portion of an implantable stimulation apparatus having an external power source and pulse generator in accordance with an embodiment of the invention.
• FIG. 21 is a schematic illustration of an implantable stimulation apparatus in accordance with an embodiment of the invention.
DETAILED DESCRIPTION
• The following disclosure describes several methods and apparatus for intracranial electrical stimulation to treat or otherwise effectuate a change in neural-functions of a patient. Several embodiments of methods in accordance with the invention are directed toward enhancing or otherwise inducing neuroplasticity to effectuate a particular neural-function. Neuroplasticity refers to the ability of the brain to change or adapt over time. It was once thought adult brains became relatively “hard wired” such that functionally significant neural networks could not change significantly over time or in response to injury. It has become increasingly more apparent that these neural networks can change and adapt over time so that meaningful function can be regained in response to brain injury. An aspect of several embodiments of methods in accordance with the invention is to provide the appropriate triggers for adaptive neuroplasticity. These appropriate triggers appear to cause or enable increased synchrony of functionally significant populations of neurons in a network.
• Electrically enhanced or induced neural stimulation in accordance with several embodiments of the invention excites a portion of a neural network involved in a functionally significant task such that a selected population of neurons can become more strongly associated with that network. Because such a network will subserve a functionally meaningful task, such as motor relearning, the changes are more likely to be lasting because they are continually being reinforced by natural use mechanisms. The nature of stimulation in accordance with several embodiments of the invention ensures that the stimulated population of neurons links to other neurons in the functional network. It is expected that this occurs because action potentials are not actually caused by the stimulation, but rather are caused by interactions with other neurons in the network. Several aspects of the electrical stimulation in accordance with selected embodiments of the invention simply allows this to happen with an increased probability when the network is activated by favorable activities, such as rehabilitation or limb use.
• The methods in accordance with the invention can be used to treat brain damage (e.g., stroke, trauma, etc.), brain disease (e.g., Alzheimer's, Pick's, Parkinson's, etc.), and/or brain disorders (e.g., epilepsy, depression, etc.). The methods in accordance with the invention can also be used to enhance functions of normal, healthy brains (e.g., learning, memory, etc.), or to control sensory functions (e.g., pain).
• Certain embodiments of methods in accordance with the invention electrically stimulate the brain at a stimulation site where neuroplasticity is occurring. The stimulation site may be different than the region in the brain where neural activity is typically present to perform the particular function according to the functional organization of the brain. In one embodiment in which neuroplasticity related to the neural-function occurs in the brain, the method can include identifying the location where such neuroplasticity is present. This particular procedure may accordingly enhance a change in the neural activity to assist the brain in performing the particular neural function. In an alternative embodiment in which neuroplasticity is not occurring in the brain, an aspect is to induce neuroplasticity at a stimulation site where it is expected to occur. This particular procedure may thus induce a change in the neural activity to instigate performance of the neural function. Several embodiments of these methods are expected to produce a lasting effect on the intended neural activity at the stimulation site.
• The specific details of certain embodiments of the invention are set forth in the following description and inFIGS. 1-21 to provide a thorough understanding of these embodiments to a person of ordinary skill in the art. More specifically, several embodiments of methods in accordance with the invention are initially described with reference toFIGS. 1-15, and then several embodiments of devices for stimulating the cortical and/or deep-brain regions of the brain are described with reference toFIGS. 16-21. A person skilled in the art will understand that the present invention may have additional embodiments, or that the invention can be practiced without several of the details described below.
A. Methods for Electrically Stimulating Regions of the Brain
• 1. Embodiments of Electrically Enhancing Neural Activity
• FIG. 1 is a schematic representation of several neurons N1-N3 andFIG. 2 is a graph illustrating an “action potential” related to neural activity in a normal neuron. Neural activity is governed by electrical impulses generated in neurons. For example, neuron N1 can send excitatory inputs to neuron N2 (e.g., times t₁, t₃and t₄inFIG. 2), and neuron N3 can send inhibitory inputs to neuron N2 (e.g., time t₂inFIG. 2). The neurons receive/send excitatory and inhibitory inputs from/to a population of other neurons. The excitatory and inhibitory inputs can produce “action potentials” in the neurons, which are electrical pulses that travel through neurons by changing the flux of sodium (Na) and potassium (K) ions across the cell membrane. An action potential occurs when the resting membrane potential of the neuron surpasses a threshold level. When this threshold level is reached, an “all-or-nothing” action potential is generated. For example, as shown inFIG. 2, the excitatory input at time t₅causes neuron N2 to “fire” an action potential because the input exceeds the threshold level for generating the action potential. The action potentials propagate down the length of the axon (the long process of the neuron that makes up nerves or neuronal tracts) to cause the release of neurotransmitters from that neuron that will further influence adjacent neurons.
• FIG. 3 is a flowchart illustrating amethod100 for effectuating a neural-function in a patient in accordance with an embodiment of the invention. The neural-function, for example, can control a specific mental process or physiological function, such as a particular motor function or sensory function (e.g., movement of a limb) that is normally associated with neural activity at a “normal” location in the brain according to the functional organization of the brain. In several embodiments of themethod100, at least some neural activity related to the neural-function can be occurring at a site in the brain. The site of the neural activity may be at the normal location where neural activity typically occurs to carry out the neural-function according to the functional organization of the brain, or the site of the neural activity may be at a different location where the brain has recruited material to perform the neural activity. One aspect of several embodiments of themethod100 includes determining the location in the brain where the neural activity related to the neural-function is present. In several other embodiments of themethod100, one need not determine where the neural activity is already present. Instead, a site may be selected where the brain is likely to recruit other neurons to perform this neural activity without actually determining that the neural activity is already present at that location.
• Themethod100 includes adiagnostic procedure102 involving identifying a stimulation site. In one approach, the stimulation site may be a location of the brain where an intended neural activity related to the neural-function is or is expected to be present. In another approach, the stimulation site may be a location of the brain that supports or is expected to support the intended neural-function.
• Thediagnostic procedure102 may include identifying one or more exterior anatomical landmarks on the patient that correspond to such neurological regions and/or structures within the brain. The external anatomical landmarks serve as reference points for locating a structure of the brain where an intended neural activity may occur. Thus, one aspect of thediagnostic procedure102 may include referencing the stimulation site on the brain relative to external anatomical landmarks.
• More specifically, identifying an anatomical landmark may include visually determining the location of one or more reference structures (e.g., visible cranial landmarks), and locating underlying brain regions or structures (e.g., the motor strip and/or the Sylvian fissure) relative to the external location of the reference structures in a manner understood by those skilled in the art. Such reference structures may include, for example, the bregma, the midsagittal suture, and/or other well-known cranial landmarks. The methods for locating the underlying brain structure typically involve measuring distances and angles relative to the cerebral topography as known in the art of neurosurgery.
• In another embodiment, thediagnostic procedure102 includes generating the intended neural activity in the brain from a “peripheral” location that is remote from the normal location, and then determining where the intended neural activity is actually present in the brain. In an alternative embodiment, thediagnostic procedure102 can be performed by identifying a stimulation site where neural activity has changed in response to a change in the neural-function. For example, the patient's brain may be scanned for neural activity associated with the impaired neural-function as the patient regains use of an affected limb or learns a task over a period of time. In yet another embodiment, thediagnostic procedure102 may involve identifying a stimulation site where a corollary neural activity is present. This corollary neural activity may correspond to an unaffected or unimpaired physiological function or mental process that is a counterpart or corollary to an impaired or affected physiological function or mental process, e.g., movement of an unimpaired limb that is contralateral to an impaired homotypic limb.
• Themethod100 continues with an implantingprocedure104 involving positioning first and second electrodes relative to the identified stimulation site, and a stimulatingprocedure106 involving applying an electrical current between the first and second electrodes. Many embodiments of the implantingprocedure104 position two or more electrodes at the stimulation site, but other embodiments of the implanting procedure involve positioning only one electrode at the stimulation site and another electrode remotely from the stimulation site. As such, the implantingprocedure104 of themethod100 can include implanting at least one electrode at the stimulation site. The procedures102-106 are described in greater detail below.
• FIGS. 4-6 illustrate a specific embodiment of thediagnostic procedure102. Thediagnostic procedure102 can be used to determine a region of the brain where stimulation will likely facilitate or effectuate the desired function, such as rehabilitating a loss of a neural-function caused by a stroke, trauma, disease or other circumstance.FIG. 4, more specifically, is an image of a normal,healthy brain200 having afirst region210 in afirst hemisphere202 where the intended neural activity occurs to effectuate a specific neural-function in accordance with the functional organization of the brain. Thefirst region210 can have a high-intensity area212 and a low-intensity area214 in which different levels of neural activity occur. It is not necessary to obtain an image of the neural activity in thefirst region210 shown inFIG. 4 to carry out thediagnostic procedure102, but rather it is provided to show an example of neural activity that typically occurs at a “normal location” according to the functional organization of thebrain200 for a large percentage of people with normal brain function. The actual location of thefirst region210 may vary somewhat between individual patients, but those skilled in the art recognize that the location of thisfirst region210 will bear a fairly predictable spatial relationship with respect to anatomical features of the patient's skull for a majority of individuals.
• Thebrain200 ofFIG. 4 also indicates neural activity in asecond region211 in asecond hemisphere204 of the brain. In general, eachhemisphere202,204 of thebrain200 is responsible for exerting primary or majority control over motor and/or sensory functions on the opposing or “contralateral” side of the patient's body. For example, the neural activity in thefirst region210 shown inFIG. 4 may be generally associated with the movement of fingers on a patient's right hand, whereas thesecond region211 in theright hemisphere204 may be generally associated with movement of fingers on the patient's left hand. Thissecond region211, like thefirst region210, may have a high-intensity area213 and a low-intensity area215 in which different levels of neural activity related to movement of the patient's left-hand fingers occur. Thefirst region210 may be associated with a body part or parts (in this example, the fingers of the right hand) and thesecond region211 may be associated with a contralateral homotypic body part (in this case the fingers of the left hand), i.e., another body part having the same or an analogous structure or function as, but contralateral to, the first body part. This is one example of a body function (movement of the left fingers) that may be a corollary to another body function (movement of the right fingers).
• The neural activity in thefirst region210, however, can be impaired. In one embodiment, thediagnostic procedure102 begins by taking an image of thebrain200 that is capable of detecting neural activity to determine whether the intended neural activity associated with the particular neural function of interest is occurring at the region of thebrain200 where it normally occurs according to the functional organization of the brain.FIG. 5 is an exemplary image of thebrain200 after thefirst region210 has been affected (e.g., from a stroke, trauma or other cause). As shown inFIG. 5, the neural activity that controlled the neural-function for moving the fingers of the right hand no longer occurs in thefirst region210. Thefirst region210 is thus “inactive,” which is expected to result in a corresponding loss of the movement and/or sensation in the fingers. In some instances, the damage to thebrain200 may result in only a partial loss of the neural activity in the damaged region. In either case, the image shown inFIG. 5 establishes that the loss of the neural-function is related to the diminished neural activity in thefirst region210. Thebrain200 may accordingly recruit other neurons to perform neural activity for the affected neural-function (i.e., neuroplasticity), or the neural activity may not be present at any location in the brain. As suggested inFIG. 5, a corollary neural function associated with the contralateral homotypic body part (in this case, movement of the fingers of the left hand), which is associated with thesecond region211, may remain largely unimpaired. It is worth noting that thesecond region211 associated with the corollary body function is at a contralateral homotopic location to thefirst region210, i.e., the location of thesecond region211 on thesecond hemisphere204 is homologous or generally corresponds to the location of thesecond region210 on thefirst hemisphere202.
• FIG. 6 is an image of thebrain200 illustrating a plurality ofpotential stimulation sites220 and230 for effectuating the neural-function that was originally performed in thefirst region210 shown inFIG. 4.FIGS. 5 and 6 show an example of neuroplasticity in which the brain compensates for a loss of neural-function in one region of the brain by recruiting other regions of the brain to perform neural activity for carrying out the affected neural-function. It is worth noting that a firstpotential stimulation site220 is in thesame hemisphere202 as thefirst region210 shown inFIG. 4. Since thisfirst stimulation site220 is on the same side of the body as thefirst region210, it may be referred to as being “ipsilateral” to thefirst region210. As thefirst region210 in theleft hemisphere202 of the brain controls movement on the right side of the body, this firstpotential stimulation site220 also may be said to be contralateral to the body function impaired by the inactive status of thefirst region210. The secondpotential stimulation site230, in contrast, is in theright hemisphere204 of thebrain200 and is therefore contralateral to thefirst region210 and ipsilateral to the impaired body function associated with thefirst region210.
• The twohemispheres202 and204 of thebrain200 are connected via the corpus callosum, which facilitates information transfer between thehemispheres202 and204. Although eachhemisphere202 or204 generally exerts majority control over motor and/or sensory functions on the opposite or contralateral side of the patient's body, each hemisphere typically also exerts some level of control and/or influence over motor and/or sensory functions on the same or ipsilateral side of the patient's body. Moreover, through transcallosal connections, neural activity in one hemisphere may influence neural activity, e.g., neuroplasticity, in the opposite hemisphere. The location in thebrain200 that exerts influence on an ipsilateral body function frequently is proximate to or subsumed within the location of the brain associated with a corollary body function. Hence, as suggested inFIG. 6, the secondpotential stimulation site230, which is ipsilateral to the body function associated with the inactivefirst region210, may lie within thesecond region211 of the brain. As discussed above in connection withFIG. 4, thissecond region211 may be associated with a corollary to the impaired body function. In the particular example mentioned above wherein the first region210 (which resides within the left hemisphere202) is associated with movement of the fingers of the patient's right hand, the secondpotential stimulation site230 may be positioned proximate to or within a region of the brain (i.e., thesecond region211, which resides within the right hemisphere204) associated with movement of the contralateral homotypic body part, namely the fingers of the patient's left hand.
• Thediagnostic procedure102 may utilize the neuroplasticity that occurs in the brain to identify the location of a stimulation site that is expected to be more responsive to the results of an electrical, magnetic, sonic, genetic, biologic, and/or pharmaceutical procedure to effectuate the desired neural-function. One embodiment of thediagnostic procedure102 involves generating the intended neural activity remotely from thefirst region210 of the brain, and then detecting or sensing the location in the brain where the intended neural activity has been generated. The intended neural activity can be generated by applying an input that causes a signal to be sent to the brain. For example, in the case of a patient having an impaired limb, the affected limb is moved and/or stimulated while the brain is scanned using a known imaging technique that can detect neural activity (e.g., functional MRI, positron emission tomography, etc.). In one specific embodiment, the affected limb can be moved by a practitioner or the patient, stimulated by sensory tests (e.g., pricking), or subject to peripheral electrical stimulation. The movement/stimulation of the affected limb produces a peripheral neural signal from the limb that is expected to generate a response neural activity in the brain. The location in the brain where this response neural activity is present can be identified using the imaging technique.FIG. 6, for example, can be created by moving the affected fingers and then noting where neural activity occurs in response to the peripheral stimulus. By peripherally generating the intended neural activity, this embodiment may accurately identify where the brain has recruited matter (i.e.,sites220 and230) to perform the intended neural activity associated with the neural-function.
• Several particular embodiments for peripherally generating the intended neural activity are expected to be useful for therapies that involve patients who have lost volitional control of a body part. Volitional movement of a body part involves several parts of the cortex. For example, the prefrontal cortex is where the decision to move the body part occurs, the pre-motor cortex then generates the particular instructions for performing the movement, and the motor cortex then uses these instructions to send the appropriate electrical pulses to the body part via the spinal cord. The loss of volitional movement of a body part is usually caused by damage to the motor cortex. Some of the following embodiments for generating the intended neural activity may locate the site on the cortex where the brain is recruiting neurons related to the functionality of the impaired body part even though the patient is incapable of moving it.
• FIG. 7 is a flow chart of one embodiment of the diagnostic procedure102 (FIG. 3) in which the intended neural activity is generated peripherally. This embodiment includes agenerating phase110 involving passively moving the impaired body part. A clinician, for example, can move the impaired body part or massage the muscles associated with the impaired body part. In an alternate embodiment, a mechanical device moves the impaired body part, such as physical therapy equipment that continually and/or intermittently moves limbs, digits and other body parts. Thediagnostic procedure102 also includes amonitoring phase112 involving detecting the location in the cortex where passive movement of the impaired limb generates neural activity. Themonitoring phase112 is typically performed before, during, and after thegenerating phase110. In one particular embodiment, themonitoring phase112 involves: (a) imaging the neural activity in the brain using functional MRI before passively moving the impaired body part to provide a baseline indication of brain activity; (b) passively moving the impaired body part in thegenerating phase110 while imaging the brain; and (c) determining the site where neural activity occurs in response to the passive movement of the impaired body part.
• The passive movement of the impaired body part is expected to provide a good indication of the location in the cortex where the brain is performing neural activity that controls the impaired body part. Passively moving the impaired body part produces neural signals that travel through the spinal cord to the cortex. The neural signals then produce neural activity at a site in the brain that is associated with the function of the impaired body part. In one embodiment, this neural activity defines the “intended neural activity.” The site of the intended neural activity generated by the passive movement of the impaired body part correlates well with active movement of the impaired body part. Thus, by passively moving an impaired body part and monitoring the intended neural activity that occurs in response to the passive motion, the location of the intended neural activity allows one to select, inselection phase114, the stimulation site for applying an electrical therapy or another type of therapy.
• As suggested inFIG. 6, neural activity may occur in more than one region of the brain in response to actively or passively moving the impaired body part. In general, the location at which this neural activity occurs may involve neural matter that is healthier than the neural matter associated with a lost or impaired neural function, e.g., theinactive region210. Stimulation at such a healthier location may enhance the rate and/or extent of functional restoration of the desired neural-function. Moreover, healthier neural matter may be more sensitive or responsive to lower intensity stimulation than is damaged, impaired, or less healthy neural matter. Thus, stimulation of such healthier tissue may provide therapeutic benefit at a lower current level than stimulation applied to or proximate damaged or impaired neural matter, such asinactive region210. As will become more evident below, the ability to employ a lower current level to achieve the same therapeutic benefit may conserve power or extend the battery life of a stimulation apparatus.
• In the particular example ofFIG. 6, a firstpotential stimulation site220 is contralateral to the impaired body part and is in thesame hemisphere202 of the brain as the damaged first region (210 inFIG. 4) of thebrain200. A secondpotential stimulation site230 is located in theother hemisphere204 and is ipsilateral to the impaired body part that is being passively moved. In many circumstances, thesecond hemisphere204 of the brain will be largely unaffected by the underlying cause of damage to thefirst region210. For example, a stroke leading to inactivity in thefirst region210 may cause little or no damage in thesecond hemisphere204.
• In circumstances where neural activity occurs at multiple locations in response to moving the impaired body part, theselection phase114 may further include selecting one or more of the areas of the brain exhibiting such neural activity as a stimulation site. In one particular embodiment, theselection phase114 includes selecting a stimulation site from a plurality of potential stimulation sites exhibiting such neural activity that is contralateral to a damaged location of the brain and ipsilateral to an impaired body function. Hence, in the specific example ofFIG. 6, theselection phase114 may comprise selecting the secondpotential stimulation site230 as the intended stimulation site. The firstpotential stimulation site220 is positioned closer to the damagedfirst region210 and may not be quite as healthy as the secondpotential stimulation site230, which is in theundamaged hemisphere204 contralateral to the damaged hemisphere. As such healthier tissue may be more responsive to neural stimulation, it is anticipated that selecting an intended stimulation site at a location that is contralateral to the damaged brain tissue may provide enhance therapeutic benefits or may provide therapeutic benefit at a lower current level.
• FIG. 8 is a flow chart of another embodiment of thediagnostic procedure102. In this embodiment, thediagnostic procedure102 includes agenerating phase140 that involves exercising a body function that is a corollary to an impaired body function. In the context of a procedure wherein the impaired body function is impaired movement of a body part, thisgenerating phase140 may include identifying a corresponding movement of a contralateral homotypic body part and moving that homotypic body part. Using the same example discussed above, if the patient is suffering from impaired function of the fingers of his or her right hand, the fingers of the left hand may be considered an appropriate contralateral homotypic body part and thegenerating phase140 may include movement of the fingers of the left hand.
• Movement of the contralateral homotypic body part can be accomplished in a variety of ways. In some of the embodiments discussed above, the patient may have little or no volitional control over movement of an impaired body part, necessitating intervention by an operator or a device to move the impaired body part. Because the contralateral homotypic body part often will have largely unimpaired function, movement of the homotypic body part in thegenerating phase140 may be volitional movement of the body part by the patient. For example, the patient may be requested to flex or otherwise move the fingers of the left hand. In another embodiment, the contralateral homotypic body part may be moved passively as discussed above in connection withFIG. 7, such as by having a clinician move the homotypic body part, stimulating the muscles associated with the homotypic body part, or by employing a mechanical device.
• Thediagnostic procedure102 ofFIG. 8 also includes amonitoring phase142. Thismonitoring phase142 includes detecting neural activity that occurs in response to movement of the contralateral homotypic body part in thegenerating phase140. This may be accomplished by monitoring neural activity in the brain while performing the generating phase in a manner analogous to themonitoring phase112 discussed above. Using the information gathered in themonitoring phase142, a suitable stimulation site may be selected in theselection phase144 ofFIG. 8. If neural activity is detected at multiple locations in the brain during themonitoring phase142, theselection phase144 may include selecting one of those locations as a stimulation site. In some circumstances, movement of the contralateral homotypic body part may generate neural activity in bothhemispheres202 and204 of the brain. In such a circumstance, theselection phase144 in some embodiments comprises selecting as a stimulation site a location on the brain that is ipsilateral to the impaired body function and contralateral to a damaged portion of the brain, e.g., thefirst region210 shown inFIGS. 4 and 5.
• In another embodiment, a generating phase (not shown) may instead comprise volitional exercise of the actual impaired body function. For example, to enhance the ability to learn a particular task (e.g., playing a musical instrument or memorizing information), the neural activity may be monitored (in a manner analogous to themonitoring phase142 ofFIG. 8) while the patient performs the task or thinks about performing the task. The potential stimulation sites can be identified in the selection phase as those areas of the brain where the neural activity has the highest intensity or the greatest increases, or those areas of the brain that other parameters indicate are being used to perform the particular task. As in the prior embodiments, the selection phase may comprise selecting a stimulation site at a location of the brain that is ipsilateral to the impaired body function (if the impaired body function is associated with one side of the body or the other) and/or contralateral to a damaged location of the brain. For example, if the deficit or impaired function is associated with a damaged area in one hemisphere of the brain, the stimulation site may be selected as a contralateral homotopic location on the opposite hemisphere of the brain.
• FIG. 9 is a flow chart of another embodiment of thediagnostic procedure102. In this embodiment, thediagnostic procedure102 includes agenerating phase120 involving electrically stimulating the muscles of the impaired body part or of a contralateral homotypic body part. The electrical stimulation can be performed using transcutaneous or subcutaneous electrodes or electrical stimulation devices. A transcutaneous device, for example, can include electrode patches that are applied to the skin and coupled to a current source. Suitable subcutaneous devices can include depth electrodes or percutaneous therapy electrodes. Such electrodes can be flexible, wire-type electrodes or rigid, needle-type electrodes. The embodiment of thediagnostic procedure102 also includes amonitoring phase122 in which the neural activity in the brain is monitored while performing thegenerating phase120. Themonitoring phase122 can be similar to themonitoring phase112 described above. Thus, themonitoring phase122 determines the site where cortical neural activity occurs in response to the electrical stimulation of the muscles.
• The embodiment of thediagnostic procedure102 shown inFIG. 9 that electrically stimulates the muscles may provide enhanced-accuracy results. One reason for this is that the electrical current can be applied to only certain muscles without having to involve other muscles. As a result, it is expected that there will be less “noise” in the image of the neural activity. Such a reduction in noise may produce a more accurate indication of where the neural response is occurring in the brain, facilitating selection of a suitable stimulation site in aselection phase124. As discussed above, in some applications the intended neural activity may occur at more than one location in the brain, identifying multiple potential stimulation sites, e.g.,potential stimulation sites220 and230 inFIG. 6. In some embodiments, theselection phase124 may, therefore, comprise selecting a stimulation site from a plurality of potential stimulation sites where the intended neural activity occurs. This selection may comprise selecting a stimulation site that is ipsilateral to the impaired body part and contralateral to a damaged first location (210 inFIG. 4) of thebrain200 that is or was associated with the impaired body function.
• In certain applications of the embodiment shown inFIG. 9, the muscles of the impaired body part are electrically stimulated. This can help give a more direct indication of where the intended neural activity is occurring in the brain. In other applications of this embodiment, the stimulated muscles are in a homotypic body part that is contralateral to the impaired body part. In the embodiment discussed above in connection withFIG. 8, the neural-function associated with the corollary of an impaired body function was determined by moving a body part that is a contralateral homotypic body part to the impaired body part in thegenerating phase140.
• FIG. 10 is a flow diagram of yet another embodiment of thediagnostic procedure102. In this embodiment, thediagnostic procedure102 includes agenerating phase130 involving electrically stimulating at least one of the nerves of the impaired body part or a contralateral homotypic body part. The electrical stimulation of the nerve can be performed using a set of electrodes that are positioned proximate to the particular nerve(s) in the selected body part, and then the electrical current is applied to the electrodes. In one application of the embodiment illustrated inFIG. 10, the electrodes are positioned proximate to the particular nerves in the impaired body part. Stimulating the nerves in the impaired body part may give a relatively direct indication of the pertinent locations of the brain in themonitoring phase132, discussed below. In another application, the electrodes may be positioned proximate to contralateral homotypic nerves in an unimpaired contralateral homotypic body part.
• Thediagnostic procedure102 inFIG. 10 can also include amonitoring phase132, which can be similar to themonitoring phase112 described above. Thus, themonitoring phase132 determines the site where cortical neural activity occurs in response to the electrical stimulation of the nerves. This determination can then be used in selecting a suitable stimulation site in aselection phase134. As discussed above in connection with the embodiments ofFIGS. 7-9, theselection phase134 may comprise selecting a stimulation site from a plurality of potential stimulation sites. In some embodiments, thisselection phase134 may comprise selecting a stimulation site within the hemisphere of the brain that is ipsilateral to the damaged body part and contralateral to a damaged region of the brain (e.g., thefirst region210 inFIG. 6) that is or was associated with the impaired body part.
• The embodiment of thediagnostic procedure102 shown inFIG. 10 is also expected to be useful for providing an accurate image of the intended neural activity in the cortex. Stimulating nerves may reduce the “noise” of neural activity in the brain correlated with an impaired body part. Additionally, stimulating the nerves in the impaired body part may provide an even more precise image of the response neural activity in the brain because it directly involves the nervous system without having to involve other features of the impaired body part.
• Another benefit of several embodiments of the diagnostic procedures described above with reference toFIGS. 9 and 10 is that they may generate the intended neural activity in highly impaired body parts. One aspect of severely impaired body parts is that passive motion of such body parts may not generate neural activity in the brain. The electrical stimulation of the muscles and/or the nerves of the impaired body part, however, may provide more stimulus than merely passively moving the muscles. The electrical stimulus may thus generate neural activity related to the impaired body part when passive movement of the impaired body part does not produce a sufficiently adequate image.
• FIG. 11 schematically illustrates asystem400 for performing particular diagnostic procedures described above. Thesystem400 includes acontroller410, animaging apparatus420 coupled to thecontroller410, and possibly apulse generator430 coupled to thecontroller410. Thesystem400 can also include a plurality ofstimulus elements432 for providing a stimulus to the affected body part of the patient P. The procedure described with respect toFIG. 9 uses thestimulus elements432 to stimulate the muscle of the affected body part, whereas the procedure described with respect toFIG. 10 uses thestimulus elements432 to stimulate the nerves of the affected body part. Thestimulus elements432 can be transcutaneous or subcutaneous electrodes or electrode devices. Thestimulus elements432 can alternatively be magnetic stimulation elements that provide magnetic stimuli to the affected body part of the patient P. In the example shown inFIG. 11, the upper arm is the affected body part of the patient P. In operation, thecontroller410 instructs thepulse generator430 to provide a stimulus to the affected body part via thestimulus elements432. As the stimulus is applied to the affected body part, theimaging apparatus420 monitors the neural activity in the patient P and generates data corresponding to the observed neural activity.
• FIG. 12 is a flow chart of still another embodiment of thediagnostic procedure102 in accordance with the invention. In this embodiment, thediagnostic procedure102 includes agenerating phase150 involving stimulating an area on the cortex at a supra-threshold level, and amonitoring phase152 involving determining whether the supra-threshold stimulation produced a response in the impaired body part. In one embodiment, thegenerating phase150 involves stimulating one or more cortical regions using a Transcranial Magnetic Stimulation (TMS) device. In another embodiment, thegenerating phase150 can include implanting an electrode array having a plurality of electrodes to which an electrical current can be applied independently. The region of the cortex for implanting the electrode array can be based upon an estimate of the area where the brain is likely to perform the neural activity to control the impaired body part. After implanting the electrode array, different configurations of electrodes can be activated to apply electrical stimulation to different areas of the cortex. Thegenerating phase150 also typically includes applying stimulation at a supra-threshold level that will cause a motor response, an electrical response, or another type of response that can be measured at the impaired body part.
• Themonitoring phase152 of this embodiment of thediagnostic procedure102 involves measuring the response to the electrical stimulation that was applied to the cortex in thegenerating phase150. The response can be detected using electrical sensors at the impaired body part or by detecting movement of the impaired body part. If no response is detected, then the particular area of the cortex to which the stimulation was applied is not likely the motor control area of the cortex associated with performing neural activity for the impaired body part. Thediagnostic procedure102 can accordingly further include adecision phase153 in which the practitioner or a computer decides to apply stimulation to another area of the cortex by moving a TMS device to another location, or selecting another electrode configuration on the electrode array. If a response is detected at the impaired body part, then the area of the cortex to which the stimulation was applied is likely involved in performing the neural function for the impaired body part. Thediagnostic procedure102 in this embodiment can also decide to test alternate cortical stimulation regions or locations at thedecision phase153 even when a response to the stimulation is detected to further refine the area of the cortex that is performing the neural activity of the impaired body part. After testing one or, more typically, several different cortical stimulation locations, thediagnostic procedure102 can proceed to theselection phase154 in which the area of the cortex that provided a desired response in the impaired body part is selected as the site to apply therapeutic electrical stimulation. If thegenerating phase150 generates neural activity at multiple locations of the brain, theselection phase154 may comprise selecting a stimulation site from these multiple potential stimulation sites. In one particular embodiment, theselection phase154 comprises selecting a stimulation site that is ipsilateral to an impaired body part and contralateral to a damaged location of thebrain200 that was formerly associated with the impaired body part.
• An alternative embodiment of thediagnostic procedure102 involves identifying a stimulation site at a second location of the brain where the neural activity has changed in response to a change in the neural-function of the patient. This embodiment of the method does not necessarily require that the intended neural activity be generated by peripherally actuating or stimulating a body part. For example, the brain can be scanned for neural activity associated with the impaired neural-function as a patient regains use of an affected limb or learns a task over a period of time. This embodiment, however, can also include peripherally generating the intended neural activity remotely from the brain explained above.
• In still another embodiment, thediagnostic procedure102 involves identifying a stimulation site at a location of the brain where the intended neural activity is developing to perform the neural-function. This embodiment is similar to the other embodiments of thediagnostic procedure102, but it can be used to identify a stimulation site at (a) the normal region of the brain where the intended neural activity is expected to occur according to the functional organization of the brain and/or (b) a different region where the neural activity occurs because the brain is recruiting additional matter to perform the neural-function. This particular embodiment of the method involves monitoring neural activity at one or more locations where the neural activity occurs in response to the particular neural-function of interest. For example, to enhance the ability to learn a particular task (e.g., playing a musical instrument, memorizing, etc.), the neural activity can be monitored while a person performs the task or thinks about performing the task. The stimulation sites can be defined by the areas of the brain where the neural activity has the highest intensity, the greatest increases, and/or other parameters that indicate areas of the brain that are being used to perform the particular task.
• FIGS. 13 and 14 are schematic illustrations of the implantingprocedure104 described above with reference toFIG. 3 for positioning the first and second electrodes relative to a portion of the brain of apatient500. Referring toFIG. 13, astimulation site502 is identified in accordance with an embodiment of thediagnostic procedure102. In one embodiment, askull section504 is removed from thepatient500 adjacent to thestimulation site502. Theskull section504 can be removed by boring a hole in the skull in a manner known in the art, or a much smaller hole can be formed in the skull using drilling techniques that are also known in the art. In general, the hole can be 0.2-4.0 cm in diameter. Referring toFIG. 14, animplantable stimulation apparatus510 having first andsecond electrodes520 can be implanted in thepatient500. Suitable techniques associated with the implantation procedure are known to practitioners skilled in the art. After thestimulation apparatus510 has been implanted in thepatient500, a pulse system generates electrical pulses that are transmitted to thestimulation site502 by the first andsecond electrodes520. Stimulation apparatus suitable for carrying out the foregoing embodiments of methods in accordance with the invention are described in more detail below with reference to theFIGS. 16-21.
• Several embodiments of methods for enhancing neural activity in accordance with the invention are expected to provide lasting results that promote the desired neural-function. Before the present invention, electrical and magnetic stimulation techniques typically stimulated the normal locations of the brain where neural activity related to the neural-functions occurred according to the functional organization of the brain. Such conventional techniques, however, may not be effective because the neurons in the “normal locations” of the brain may not be capable of carrying out the neural activity because of brain damage, disease, disorder, and/or because of variations of the location specific to individual patients. Several embodiments of methods for enhancing neural activity in accordance with the invention overcome this drawback by identifying a stimulation site based on neuroplastic activity that appears to be related to the neural-function. By first identifying a location in the brain that is being recruited to perform the neural activity, it is expected that therapies (e.g., electrical, magnetic, genetic, biologic, and/or pharmaceutical) applied to this location will be more effective than conventional techniques. This is because the location that the brain is recruiting for the neural activity may not be the “normal location” where the neuro activity would normally occur according to the functional organization of the brain. Therefore, several embodiments of methods for enhancing neural activity in accordance with the invention are expected to provide lasting results because the therapies are applied to the portion of the brain where neural activity for carrying out the neural-function actually occurs in the particular patient.
• 2. Electrically Inducing Desired Neural Activity
• Themethod100 for effectuating a neural-function can also be used to induce neural activity in a region of the brain where such neural activity is not present. As opposed to the embodiments of themethod100 described above for enhancing existing neural activity, the embodiments of themethod100 for inducing neural activity initiate the neural activity at a stimulation site where it is estimated that neuroplasticity will occur. In this particular situation, an image of the brain seeking to locate where neuroplasticity is occurring may be similar toFIG. 5. An aspect of inducing neural activity, therefore, is to develop a procedure to determine where neuroplasticity is likely to occur.
• A stimulation site may be identified by estimating where the brain will likely recruit neurons for performing the neural-function. In one embodiment, the location of the stimulation site is estimated by defining a region of the brain that is proximate to the normal location where neural activity related to the neural-function is generally present according to the functional organization of the brain. An alternative embodiment for locating the stimulation site includes determining where neuroplasticity has typically occurred in patients with similar symptoms. For example, if the brain typically recruits a second region of the cortex to compensate for a loss of neural activity in the normal region of the cortex, then the second region of the cortex can be selected as the stimulation site either with or without imaging the neural activity in the brain.
• Several embodiments of methods for inducing neural activity in accordance with the invention are also expected to provide lasting results that initiate and promote a desired neural-function. By first estimating the location of a stimulation site where desired neuroplasticity is expected to occur, therapies applied to this location may be more effective than conventional therapies for reasons that are similar to those explained above regarding enhancing neural activity. Additionally, methods for inducing neural activity may be easier and less expensive to implement because they do not require generating neural activity and/or imaging the brain to determine where the intended neural activity is occurring before applying the therapy.
• 3. Applications of Methods for Electrically Stimulating Regions of the Brain
• The foregoing methods for enhancing existing neural activity or inducing new neural activity are expected to be useful for many applications. As explained above, several embodiments of themethod100 involve determining an efficacious location of the brain to enhance or induce an intended neural activity that causes the desired neural-functions to occur. Additional therapies can also be implemented in combination with the electrical stimulation methods described above. Several specific applications using embodiments of electrical stimulation methods in accordance with the invention either alone or with adjunctive therapies will now be described, but it will be appreciated that the methods in accordance with the invention can be used in many additional applications.
• a. General Applications
• The embodiments of the electrical stimulation methods described above are expected to be particularly useful for rehabilitating a loss of mental functions, motor functions and/or sensory functions caused by damage to the brain. In a typical application, the brain has been damaged by a stroke or trauma (e.g., automobile accident). The extent of the particular brain damage can be assessed using functional MRI or another appropriate imaging technique as explained above with respect toFIG. 5. A stimulation site can then be identified by: (a) peripherally stimulating a body part that was affected by the brain damage to induce the intended neural activity and determining the location where a response neural activity occurs; (b) determining where the neural activity has changed as a patient gains more use of the affected body part; (c) estimating the location that the brain may recruit neurons to carry out the neural activity that was previously performed by the damaged portion of the brain; and/or (d) determining a location in the brain hemisphere ipsilateral to the affected body part that is associated with a function that is a corollary to an impaired function of the affected body part. An electrical stimulation therapy can then be applied to the selected stimulation site by placing the first and second electrodes relative to the stimulation site to apply an electrical current in that portion of the brain. As explained in more detail below, it is expected that applying an electrical current to the portion of the brain that has been recruited to perform the neural activity related to the affected body part will produce a lasting neurological effect for rehabilitating the affected body part.
• Several specific applications are expected to have a stimulation site in the cortex because neural activity in this part of the brain effectuates motor functions and/or sensory functions that are typically affected by a stroke or trauma. In these applications, the electrical stimulation can be applied directly to the pial surface of the brain or at least proximate to the pial surface (e.g., the dura mater, the fluid surrounding the cortex, or neurons within the cortex). Suitable devices for applying the electrical stimulation to the cortex are described in detail with reference toFIGS. 16-21.
• The electrical stimulation methods can also be used with adjunctive therapies to rehabilitate damaged portions of the brain. In one embodiment, the electrical stimulation methods can be combined with behavioral therapy and/or drug therapies to rehabilitate an affected neural function. For example, if a stroke patient has lost the use of a limb, the patient can be treated by applying the electrical therapy to a stimulation site where the intended neural activity is present while the affected limb is also subject to physical therapy. An alternative embodiment can involve applying the electrical therapy to the stimulation site and chemically treating the patient using amphetamines or other suitable drugs.
• The embodiments of the electrical stimulation methods described above are also expected to be useful for treating brain diseases, such as Alzheimer's, Parkinson's, and other brain diseases. In this application, the stimulation site can be identified by monitoring the neural activity using functional MRI or other suitable imaging techniques over a period of time to determine where the brain is recruiting material to perform the neural activity that is being affected by the disease. It may also be possible to identify the stimulation site by having the patient try to perform an act that the particular disease has affected, and monitoring the brain to determine whether any response neural activity is present in the brain. After identifying where the brain is recruiting additional matter, the electrical stimulation can be applied to this portion of the brain. It is expected that electrically stimulating the regions of the brain that have been recruited to perform the neural activity which was affected by the disease will assist the brain in offsetting the damage caused by the disease.
• The embodiments of the electrical stimulation methods described above are also expected to be useful for treating neurological disorders, such as depression, passive-aggressive behavior, weight control, and other disorders. In these applications, the electrical stimulation can be applied to a stimulation site in the cortex or another suitable part of the brain where neural activity related to the particular disorder is present. The embodiments of electrical stimulation methods for carrying out the particular therapy can be adapted to either increase or decrease the particular neural activity in a manner that produces the desired results. For example, an amputee may feel phantom sensations associated with the amputated limb. This phenomenon can be treated by applying an electrical pulse that reduces the phantom sensations. The electrical therapy can be applied so that it will modulate the ability of the neurons in that portion of the brain to execute sensory functions.
• b. Pulse Forms and Potentials
• The electrical stimulation methods in accordance with the invention can use several different pulse forms to facilitate or effectuate the desired neuroplasticity.
• The pulses can be a bi-phasic or monophasic stimulus that is applied to achieve a desired potential in a sufficient percentage of a population of neurons at the stimulation site. In one embodiment, the pulse form has a frequency of approximately 2-1000 Hz, but the frequency may be particularly useful in the range of approximately 40-200 Hz. For example, initial clinical trials are expected to use a frequency of approximately 50-100 Hz. The pulses can also have pulse widths of approximately 10 μs-100 ms, or more specifically the pulse width can be approximately 20-200 μs. For example, a pulse width of 50-100 μs may produce beneficial results.
• It is expected that one particularly useful application of the invention involves enhancing or inducing neuroplasticity by raising the membrane potential of neurons to bring the neurons closer to the threshold level for firing an action potential. Because the stimulation raises the membrane potential of the neurons, it is expected that these neurons are more likely to “fire” an action potential in response to excitatory input at a lower level.
• FIG. 15 is a graph illustrating applying a subthreshold potential to the neurons N1-N3 ofFIG. 1. At times t₁and t₂, the excitory/inhibitory inputs from other neurons do not “bridge-the-gap” from the resting potential at −X mV to the threshold potential. At time t₃, the electrical stimulation is applied to the brain to raise the potential of neurons in the stimulated population such that their potential is at −Y mV. As such, at time t₄when the neurons receive another excitatory input, even a small input exceeds the gap between the raised potential −Y mV and the threshold potential to induce action potentials in these neurons. For example, if the resting potential is approximately −70 mV and the threshold potential is approximately −50 mV, then the electrical stimulation can be applied to raise the potential of a sufficient number of neurons to approximately −52 to −60 mV.
• The actual electrical potential applied to electrodes implanted in the brain to achieve a subthreshold potential stimulation will vary according to the individual patient, the type of therapy, the type of electrodes, and other factors. In general, the pulse form of the electrical stimulation (e.g., the frequency, pulse width, wave form, and voltage potential) is selected to raise the potential in a sufficient number neurons at the stimulation site to a level that is less than a threshold potential for a statistical portion of the neurons in the population. The pulse form, for example, can be selected so that the applied voltage of the stimulus achieves a change in the potential of approximately 10%-95%, and more specifically of 60%-80%, of the difference between the unstimulated resting potential and the threshold potential.
• In one specific example of a subthreshold application for treating a patient's hand, electrical stimulation is not initially applied to the stimulation site. Although physical therapy related to the patient's hand may cause some activation of a particular population of neurons that is known to be involved in “hand function,” only a low level of activation might occur because physical therapy only produces a low level of action potential generation in that population of neurons. However, when the subthreshold electrical stimulation is applied, the membrane potentials of the neurons in the stimulated population are elevated. These neurons now are much closer to the threshold for action potential formation such that when the same type of physical therapy is given, this population of cells will have a higher level of activation because these cells are more likely to fire action potentials.
• Subthreshold stimulation may produce better results than simply stimulating the neurons with sufficient energy levels to exceed the threshold for action potential formation. One aspect of subthreshold stimulation is to increase the probability that action potentials will occur in response to the ordinary causes of activation—such as behavioral therapy. This will allow the neurons in this functional network to become entrained together, or “learn” to become associated with these types of activities. If neurons are given so much electricity that they continually fire action potentials without additional excitatory inputs (suprathreshold stimulation), this will create “noise” and disorganization that will not likely cause improvement in function. In fact, neurons that are “overdriven” soon deplete their neurotransmitters and effectively become silent.
• The application of a subthreshold stimulation is very different than suprathreshold stimulation. Subthreshold stimulation in accordance with several embodiments of the invention, for example, does not intend to directly make neurons fire action potentials with the electrical stimulation in a significant population of neurons at the stimulation site. Instead, subthreshold stimulation attempts to decrease the “activation energy” required to activate a large portion of the neurons at the stimulation site. As such, subthreshold stimulation in accordance with certain embodiments of the invention is expected to increase the probability that the neurons will fire in response to the usual intrinsic triggers, such as trying to move a limb, physical therapy, or simply thinking about movement of a limb, etc. Moreover, coincident stimulation associated with physical therapy is expected to increase the probability that the action potentials that are occurring with an increased probability due to the subthreshold stimulation will be related to meaningful triggers, and not just “noise.”
• The stimulus parameters set forth above, such as a frequency selection of approximately 50-100 Hz and an amplitude sufficient to achieve an increase of 60% to 80% of the difference between the potential and the threshold potential are specifically selected so that they will increase the resting membrane potential of the neurons, thereby increasing the likelihood that they will fire action potentials, without directly causing action potentials in most of the neuron population. In addition, and as explained in more detail below with respect toFIGS. 16-21, several embodiments of stimulation apparatus in accordance with the invention are designed to precisely apply a pulse form that produces subthreshold stimulation by selectively stimulating regions of the cerebral cortex of approximately 1-2 cm (the estimated size of a “functional unit” of cortex), directly contacting the pial surface with the electrodes to consistently create the same alterations in resting membrane potential, and/or biasing the electrodes against the pial surface to provide a positive connection between the electrodes and the cortex.
B. Devices for Electrically Stimulating Regions of the Brain
• FIGS. 16-21 illustrate stimulation apparatus in accordance with several embodiments of the invention for electrically stimulating regions of the brain in accordance with one or more of the methods described above. The devices illustrated inFIGS. 16-21 are generally used to stimulate a region of the cortex proximate to the pial surface of the brain (e.g., the dura mater, the pia mater, the fluid between the dura mater and the pia mater, and a depth in the cortex outside of the white matter of the brain). The devices can also be adapted for stimulating other portions of the brain in other embodiments. A variety of other useful stimulation apparatus are detailed in U.S. Patent Application Publication U.S. Pat. No. 2002/0087201, the entirety of which is incorporated herein by reference. In addition, other suitable stimulation apparatus may be apparent to those skilled in the art in view of the present disclosure.
• 1. Implantable Stimulation Apparatus with Integrated Pulse Systems
• FIG. 16 is an isometric view andFIG. 17 is a cross-sectional view of astimulation apparatus600 in accordance with an embodiment of the invention for stimulating a region of the cortex proximate to the pial surface. In one embodiment, thestimulation apparatus600 includes asupport member610, an integrated pulse-system630 (shown schematically) carried by thesupport member610, and first and second electrodes660 (identified individually byreference numbers660aand660b). The first and second electrodes660 are electrically coupled to thepulse system630. Thesupport member610 can be configured to be implanted into the skull or another intracranial region of a patient. In one embodiment, for example, thesupport member610 includes ahousing612 and anattachment element614 connected to thehousing612. Thehousing612 can be a molded casing formed from a biocompatible material that has an interior cavity for carrying thepulse system630. The housing can alternatively be a biocompatible metal or another suitable material. Thehousing612 can have a diameter of approximately 14 cm, and in many applications thehousing612 can be 1.5-2.5 cm in diameter. Thehousing612 can also have other shapes (e.g., rectilinear, oval, elliptical) and other surface dimensions. Thestimulation apparatus600 can weigh 35 g or less and/or occupy a volume of 20 cc or less. Theattachment element614 can be a flexible cover, a rigid plate, a contoured cap, or another suitable element for holding thesupport member610 relative to the skull or other body part of the patient. In one embodiment, theattachment element614 is a mesh, such as a biocompatible polymeric mesh, metal mesh, or other suitable woven material. Theattachment element614 can alternatively be a flexible sheet of Mylar, a polyester, or another suitable material.
• FIG. 17, more specifically, is a cross-sectional view of thestimulation apparatus600 after it has been implanted into a patient in accordance with an embodiment of the invention. In this particular embodiment, thestimulation apparatus600 is implanted into the patient by forming an opening in thescalp702 and cutting ahole704 through theskull700 and through thedura mater706. Thehole704 should be sized to receive thehousing612 of thesupport member610, and in most applications, thehole704 should be smaller than theattachment element614. A practitioner inserts thesupport member610 into thehole704 and then secures theattachment element614 to theskull700. Theattachment element614 can be secured to the skull using a plurality of fasteners618 (e.g., screws, spikes, etc.) or an adhesive. In an alternative embodiment, a plurality of downwardly depending spikes can be formed integrally with theattachment element614 to define anchors that can be driven into theskull700.
• The embodiment of thestimulation apparatus600 shown inFIG. 17 is configured to be implanted into a patient so that the electrodes660 contact a desired portion of the brain at the stimulation site. Thehousing612 and the electrodes660 can project from theattachment element614 by a distance “D” such that the electrodes660 are positioned at least proximate to thepia mater708 surrounding thecortex709. The electrodes660 can project from ahousing612 as shown inFIG. 17, or the electrodes660 can be flush with the interior surface of thehousing612. In the particular embodiment shown inFIG. 17, thehousing612 has a thickness “T” and the electrodes660 project from thehousing612 by a distance “P” so that the electrodes660 press against the surface of thepia mater708. The thickness of thehousing612 can be approximately 0.5-4 cm, and is more generally about 1-2 cm. The configuration of thestimulation apparatus600 is not limited to the embodiment shown inFIGS. 16 and 17, but rather thehousing612, theattachment element614, and the electrodes660 can be configured to position the electrodes in several different regions of the brain. For example, in an alternate embodiment, thehousing612 and the electrodes660 can be configured to position the electrodes deep within thecortex709, and/or adeep brain region710. In general, the electrodes can be flush with the housing or extend 0.1 mm to 5 cm from the housing. More specific embodiments of pulse system and electrode configurations for the stimulation apparatus will be described below.
• Several embodiments of thestimulation apparatus600 are expected to be more effective than existing transcranial electrical stimulation devices and transcranial magnetic stimulation devices. It will be appreciated that much of the power required for transcranial therapies is dissipated in the scalp and skull before it reaches the brain. In contrast to conventional transcranial stimulation devices, thestimulation apparatus600 is implanted so that the electrodes are at least proximate to the pial surface of thebrain708. Several embodiments of methods in accordance with the invention can use thestimulation apparatus600 to apply an electrical therapy directly to thepia mater708, thedura mater706, and/or another portion of thecortex709 at significantly lower power levels than existing transcranial therapies. For example, a potential of approximately 1 mV to 10 V can be applied to the electrodes660; in many instances a potential of 100 mV to 5 V can be applied to the electrodes660 for selected applications. It will also be appreciated that other potentials can be applied to the electrodes660 of thestimulation apparatus600 in accordance with other embodiments of the invention.
• Selected embodiments of thestimulation apparatus600 are also capable of applying stimulation to a precise stimulation site. Again, because thestimulation apparatus600 positions the electrodes660 at least proximate to thepial surface708, precise levels of stimulation with good pulse shape fidelity will be accurately transmitted to the stimulation site in the brain. It will be appreciated that transcranial therapies may not be able to apply stimulation to a precise stimulation site because the magnetic and electrical properties of the scalp and skull may vary from one patient to another such that an identical stimulation by the transcranial device may produce a different level of stimulation at the neurons in each patient. Moreover, the ability to focus the stimulation to a precise area is hindered by delivering the stimulation transcranially because the scalp, skull and dura all diffuse the energy from a transcranial device. Several embodiments of thestimulation apparatus600 overcome this drawback because the electrodes660 are positioned under theskull700 such that the pulses generated by thestimulation apparatus600 are not diffused by thescalp702 andskull700.
• 2. Integrated Pulse Systems for Implantable Stimulation Apparatus
• Thepulse system630 shown inFIGS. 16 and 17 generates and/or transmits electrical pulses to the electrodes660 to create an electrical field at a stimulation site in a region of the brain. The particular embodiment of thepulse system630 shown inFIG. 17 is an “integrated” unit in that is carried by thesupport member610. Thepulse system630, for example, can be housed within thehousing612 so that the electrodes660 can be connected directly to thepulse system630 without having leads outside of thestimulation apparatus600. The distance between the electrodes660 and thepulse system630 can be less than 4 cm, and it is generally 0.10 to 2.0 cm. Thestimulation apparatus600 can accordingly provide electrical pulses to the stimulation site without having to surgically create tunnels running through the patient to connect the electrodes660 to a pulse generator implanted remotely from thestimulation apparatus600. It will be appreciated, however, that alternative embodiments of stimulation apparatus in accordance with the invention can include a pulse system implanted separately from thestimulation apparatus600 in the cranium or an external pulse system. Several particular embodiments of pulse systems that are suitable for use with thestimulation apparatus600 will now be described in more detail.
• FIGS. 18 and 19 schematically illustrate anintegrated pulse system800 in accordance with one embodiment of the invention for being implanted in the cranium within thestimulation apparatus600. Referring toFIG. 18, thepulse system800 can include apower supply810, anintegrated controller820, apulse generator830, and apulse transmitter840. Thepower supply810 can be a primary battery, such as a rechargeable battery or another suitable device for storing electrical energy. In alternative embodiments, thepower supply810 can be an RF transducer or a magnetic transducer that receives broadcast energy emitted from an external power source and converts the broadcast energy into power for the electrical components of thepulse system800. Theintegrated controller820 can be a wireless device that responds to command signals sent by anexternal controller850. Theintegrated controller820, for example, can communicate with theexternal controller850 by RF ormagnetic links860. Theintegrated controller820 provides control signals to thepulse generator830 in response to the command signals sent by theexternal controller850. Thepulse generator830 can have a plurality of channels that send appropriate electrical pulses to thepulse transmitter840, which is coupled to the electrodes660. Suitable components for thepower supply810, theintegrated controller820, thepulse generator830, and thepulse transmitter840 are known to persons skilled in the art of implantable medical devices.
• Referring toFIG. 19, thepulse system800 can be carried by thesupport member610 of thestimulation apparatus600 in the manner described above with reference toFIGS. 16 and 17. Theexternal controller850 can be located externally to thepatient500 so that theexternal controller850 can be used to control thepulse system800. In one embodiment, several patients that require a common treatment can be simultaneously treated using a singleexternal controller850 by positioning the patients within the operating proximity of thecontroller850. In an alternative embodiment, theexternal controller850 can contain a plurality of operating codes and theintegrated controller820 for a particular patient can have an individual operating code. Asingle controller850 can thus be used to treat a plurality of different patients by entering the appropriate operating code into thecontroller850 corresponding to the particular operating codes of theintegrated controllers820 for the patients.
• 2. Implantable Stimulation Apparatus with External Pulse Systems
• FIG. 20 is a schematic cross-sectional view of one embodiment of animplantable stimulation apparatus3100 having external pulse systems. Thisstimulation apparatus3100 has abiasing element3150 to which a plurality ofelectrodes3160 are attached. It will be appreciated that thestimulation apparatus3100 may not include thebiasing element3150, but may instead have a less flexible arrangement similar to that of thestimulation apparatus600 ofFIGS. 16-19. Thestimulation apparatus3100 can also include anexternal receptacle3120 having anelectrical socket3122 and an implantedlead line3124 coupling theelectrodes3160 to contacts (not shown) in thesocket3122. Thelead line3124 can be implanted in a subcutaneous tunnel or other passageway in a manner known to a person skilled and art.
• Thestimulation apparatus3100, however, does not have an internal pulse system carried by the portion of the device that is implanted in theskull700 of thepatient500. Thestimulation apparatus3100 receives electrical pulses from anexternal pulse system3130. Theexternal pulse system3130 can have anelectrical connector3132 with a plurality ofcontacts3134 configured to engage the contacts within thereceptacle3120. Theexternal pulse system3130 can also have a power supply, controller, pulse generator, and pulse transmitter to generate the electrical pulses. In operation, theexternal pulse system3130 sends electrical pulses to thestimulation apparatus3100 via theconnector3132, thereceptacle3120, and thelead line3124.
• 3. Alternate Embodiments of Implantable Stimulation Apparatus
• FIG. 21 is a schematic illustration of astimulation apparatus4000 together with aninternal pulse system4030 in accordance with another embodiment of the invention. Thestimulation apparatus4000 can include asupport member4010, a biasing element4015 carried by thesupport member4010, and a plurality ofelectrodes4020 carried by the biasing element4015. Theinternal pulse system4030 can be similar to any of the integrated pulse systems described above with reference toFIGS. 16-19, but theinternal pulse system4030 is not an integrated pulse system because it is not carried by thehousing4010. Theinternal pulse system4030 can be coupled to theelectrodes4020 by acable4034. In a typical application, thecable4034 is implanted subcutaneously in a tunnel from a subclavicular region, along the back of the neck, and around the skull. Thestimulation apparatus4000 can also include any other suitable electrode configuration.
• From the foregoing, it will be appreciated that specific embodiments of the invention have been described herein for purposes of illustration, but that various modifications may be made without deviating from the spirit and scope of the invention. Accordingly, the invention is not limited except as by the appended claims. All of the U.S. Patents, U.S. Patent applications, and other references noted above are incorporated herein by reference.

Claims (25)

1-32. (Cancelled)

33. A method for effectuating a neural function related to a body part affected by a stroke, comprising:

identifying an ipsilateral hemisphere in the brain relative to the affected body part;

implanting an electrode at a cortical stimulation site selected to promote the neural function related to the affected body part, the cortical stimulation site being at least proximate to the cortex in the ipsilateral hemisphere of the brain; and

applying an ipsilateral electrical stimulation to the cortical stimulation site.

34. The method ofclaim 33, further comprising applying a contralateral electrical stimulation to a stimulation site at least proximate to the cortex in a contralateral hemisphere of the brain.

35. The method ofclaim 34 wherein the ipsilateral electrical stimulation and the contralateral electrical stimulation are applied concurrently.

36. The method ofclaim 34 wherein the ipsilateral electrical stimulation and the contralateral electrical stimulation are applied sequentially.

37. The method ofclaim 34 wherein the ipsilateral electrical stimulation and contralateral electrical stimulation have different frequencies.

38. The method ofclaim 33, further comprising performing an adjunctive therapy related to the affected body part.

39. The method ofclaim 38 wherein the adjunctive therapy comprises moving the affected body part.

40. The method ofclaim 38 wherein the adjunctive therapy comprises electrically stimulating the affected body part.

41. The method ofclaim 38, further comprising applying a contralateral electrical stimulation to a stimulation site at least proximate to the cortex in a contralateral hemisphere of the brain.

42. The method ofclaim 41 wherein the ipsilateral electrical stimulation and the contralateral electrical stimulation are applied concurrently.

43. The method ofclaim 41 wherein the ipsilateral electrical stimulation and the contralateral electrical stimulation are applied sequentially.

44. The method ofclaim 41 wherein the ipsilateral electrical stimulation and contralateral electrical stimulation have different frequencies.

45. A method for effectuating a neural function related to a body part affected by a stroke, comprising:

positioning an electrode at a cortical stimulation site selected to promote the neural function related to the affected body part, the cortical stimulation site being at least proximate to the cortex in an ipsilateral hemisphere of the brain relative to the affected body part; and

applying an ipsilateral electrical stimulation to the cortical stimulation site.

46. The method ofclaim 45, further comprising applying a contralateral electrical stimulation to a stimulation site at least proximate to the cortex in a contralateral hemisphere of the brain.

47. The method ofclaim 46 wherein the ipsilateral electrical stimulation and the contralateral electrical stimulation are applied concurrently.

48. The method ofclaim 46 wherein the ipsilateral electrical stimulation and the contralateral electrical stimulation are applied sequentially.

49. The method ofclaim 46 wherein the ipsilateral electrical stimulation and contralateral electrical stimulation have different frequencies.

50. The method ofclaim 45, further comprising performing an adjunctive therapy related to the affected body part.

51. The method ofclaim 50 wherein the adjunctive therapy comprises moving the affected body part.

52. The method ofclaim 50 wherein the adjunctive therapy comprises electrically stimulating the affected body part.

53. The method ofclaim 50, further comprising applying a contralateral electrical stimulation to a stimulation site at least proximate to the cortex in a contralateral hemisphere of the brain.

54. The method ofclaim 53 wherein the ipsilateral electrical stimulation and the contralateral electrical stimulation are applied concurrently.

55. The method ofclaim 53 wherein the ipsilateral electrical stimulation and the contralateral electrical stimulation are applied sequentially.

56. The method ofclaim 53 wherein the ipsilateral electrical stimulation and contralateral electrical stimulation have different frequencies.

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