US20090030263A1 - Sensitivity analysis for selecting therapy parameter sets - Google Patents

Abstract

Techniques for controlling delivery of a therapy to a patient by a medical device, such as an implantable medical device (IMD), involve a sensitivity analysis of a performance metric. The performance metric may relate to efficacy or side effects of the therapy. For example, the performance metric may comprise a sleep quality metric, an activity level metric, a movement disorder metric for patients with Parkinson's disease, or the like. The sensitivity analysis identifies values of therapy parameters that defines a substantially maximum or minimum value of the performance metric. The identified therapy parameters are a baseline therapy parameter set, and a medical device may control delivery of the therapy based on the baseline therapy parameter set.

Description

• This application is a divisional of U.S. patent application Ser. No. 11/081,873, filed Mar. 16, 2005, which claims the benefit of U.S. Provisional Application Ser. No. 60/553,769, filed Mar. 16, 2004, the entire content of both which is incorporated herein by reference.
TECHNICAL FIELD
• The invention relates to medical devices and, more particularly, to medical devices that deliver a therapy.
BACKGROUND
• In some cases, an ailment may affect a patient's sleep quality or physical activity level, or a therapy delivered to the patient to treat the ailment may produce undesirable side effects. For example, chronic pain may cause a patient to have difficulty falling asleep, and may disturb the patient's sleep, e.g., causing the patient to wake. Further, chronic pain may cause the patient to have difficulty achieving deeper sleep states, such as one of the nonrapid eye movement (NREM) sleep states associated with deeper sleep. Other ailments that may negatively affect patient sleep quality include movement disorders, psychological disorders, sleep apnea, congestive heart failure, gastrointestinal disorders and incontinence. As another example, chronic pain may cause a patient to avoid particular physical activities, or activity in general, where such activities increase the pain experienced by the patient. Movement disorders and congestive heart failure may also affect patient activity level.
• Furthermore, in some cases, poor sleep quality may increase the symptoms experienced by a patient due to an ailment. For example, poor sleep quality has been linked to increased pain symptoms in chronic pain patients. The link between poor sleep quality and increased symptoms is not limited to ailments that negatively impact sleep quality, such as those listed above. Nonetheless, the condition of a patient with such an ailment may progressively worsen when symptoms disturb sleep quality, which in turn increases the frequency and/or intensity of symptoms.
• In some cases, these ailments are treated via a medical device, such as an implantable medical device (IMD). For example, patients may receive an implantable neurostimulator or drug delivery device to treat chronic pain or a movement disorder. Congestive heart failure may be treated by, for example, a cardiac pacemaker.
SUMMARY
• In general, the invention is directed to systems, devices and techniques for controlling delivery of a therapy to a patient by a medical device, such as an implantable medical device (IMD), based on a sensitivity analysis of a performance metric. The performance metric may relate to efficacy or side effects associated with a particular therapy. For example, the performance metric may comprise a sleep quality metric, an activity level metric, a posture metric, a movement disorder metric for patients with Parkinson's disease, a side-effects metric, or the like. The sensitivity analysis facilitates generation of a therapy parameter set that defines a substantially maximum or minimum value of the performance metric. A medical device according to an embodiment of the invention may conduct the sensitivity analysis for the performance metric, and identify values for each of a plurality of physiological parameters based on the sensitivity analysis. A system according to an embodiment of the invention may include a monitor, a programmer, and a therapy device to conduct the sensitivity analysis for the performance metric, and determine a baseline therapy parameter set based on the sensitivity analysis. In either case, the medical device or another medical device may control delivery of the therapy based on a baseline therapy parameter set that includes the identified values. The baseline therapy parameter set may be a therapy parameter set found to be most efficacious or to result in the least side effects, as indicated by the performance metric value associated with that therapy parameter set.
• For the sensitivity analysis, a medical device may deliver therapy according to a plurality of different therapy parameter sets. Each of the therapy parameter sets comprises a value for each of a plurality of therapy parameters. The plurality of therapy parameter sets for the sensitivity analysis encompass a range of therapy parameter values. The therapy parameter sets may be generated either randomly or non-randomly. The therapy parameter sets may be defined, for example, by the medical device or an external programming device. The medical device, programming device, or another device may monitor performance metric values for each therapy parameter set in order to conduct the sensitivity analysis.
• Furthermore, after a baseline therapy parameter set has been identified, the medical device that delivers therapy according to the baseline therapy parameter set may periodically perturb at least one therapy parameter value of the baseline therapy parameter set to determine whether the performance metric value has changed over time. The therapy parameter may be increased or decreased in small increments relative to the range values. If perturbing the therapy parameter improves the performance metric, the therapy parameter value is further increased or decreased to again define a substantially maximum or minimum performance metric value. The baseline therapy parameter set is then updated to correspond to the therapy parameter set with the perturbed therapy parameter value or values. If changing the therapy parameter worsens the performance metric, the baseline therapy parameter set is maintained. The medical device that delivers therapy according to the baseline therapy parameter set, a programming device, or another device may determine the performance metric values for each perturbation, and update the baseline therapy parameter set if indicated by the comparison to the performance metric value for the baseline therapy parameter set.
• The medical device or a separate monitor, as examples, may monitor one or more physiological parameters of the patient in order to determine values for the one or more performance metrics. Example physiological parameters that the medical device may monitor include activity level, posture, heart rate, ECG morphology, respiration rate, respiratory volume, blood pressure, blood oxygen saturation, partial pressure of oxygen within blood, partial pressure of oxygen within cerebrospinal fluid, muscular activity and tone, core temperature, subcutaneous temperature, arterial blood flow, brain electrical activity, eye motion, and galvanic skin response. These parameters may be indicative of sleep quality and activity level, and therefore may be useful in determining the performance metric values for different therapy parameter sets. In some embodiments, the medical device additionally or alternatively monitors the variability of one or more of these parameters. In order to monitor one or more of these parameters, the medical device may include, be coupled to, or be in wireless communication with one or more sensors, each of which outputs a signal as a function of one or more of these physiological parameters.
• In one embodiment, the invention is directed to a method comprising delivering a therapy to a patient via a medical device according to each of a plurality of therapy parameter sets, each of the therapy parameter sets including a value for each of a plurality of therapy parameters, and monitoring a value of a performance metric of a patient in response to therapy delivered according to each of a plurality of therapy parameter sets. The method further comprises conducting a sensitivity analysis of the performance metric for each of the plurality of therapy parameter sets, and identifying a baseline value for each of the therapy parameters based on the sensitivity analysis to form a baseline therapy parameter set.
• In another embodiment, the invention is directed to a medical device that includes a therapy module and a processor. The therapy module delivers a therapy to a patient according to each of a plurality of therapy parameter sets, each of the therapy parameter sets including a value for each of a plurality of therapy parameters. The processor monitors a value of a performance metric of the patient in response to therapy delivered according to each of a plurality of therapy parameter sets. The processor further conducts a sensitivity analysis of the performance metric for each of the plurality of therapy parameter sets, and identifies a baseline value for each of the therapy parameters based on the sensitivity analysis to form a baseline therapy parameter set.
• In another embodiment, the invention is directed to a computer-readable medium containing instructions. The instructions cause a programmable processor to monitor a value of a performance metric of a patient for each of a plurality of therapy parameter sets, wherein a medical device delivers a therapy to the patient according to each of the therapy parameters sets, and each of the parameter sets includes a value for each of a plurality of therapy parameters. The instructions further cause the processor to conduct a sensitivity analysis of the performance metric for each of the plurality of therapy parameter sets, and identify a baseline value for each of the plurality of therapy parameters based on the sensitivity analysis to form a baseline therapy parameter set.
• In another embodiment, the invention is directed to a system comprising a therapy device, a monitor, and a computing device. The therapy device delivers therapy to a patient according to each of a plurality of therapy parameter sets, each of the therapy parameter sets including a value for each of a plurality of therapy parameters. The monitor monitors values of at least one physiological parameter of a patient in response to therapy delivered according to each of the plurality of therapy parameter sets. The computing device receives the physiological parameter values from the monitor, identifies values of a performance metric of the patient for each of the plurality of parameter sets based on the physiological parameter values monitored during delivery of therapy according to each of the plurality of therapy parameter sets, conducts a sensitivity analysis of the performance metric for each of the plurality of therapy parameter sets, and identifies a baseline value for each of the therapy parameters based on the sensitivity analysis to form a baseline therapy parameter set.
• The invention is capable of providing one or more advantages. For example, through the sensitivity analysis of the performance metric, a baseline therapy parameter set that provides substantially maximum or minimum value of the performance metric may be identified. A medical device may provide therapy according to the baseline therapy parameter set.
• Further, the medical device may be able to adjust therapy to produce an improved performance metric value. In particular, the adjustments may address symptoms that cause a poor performance metric value or symptoms that are worsened by a poor performance metric value. Adjusting therapy based on the performance metric value information may significantly improve the patient's performance quality and condition. The ability of a medical device to periodically check performance metric values and adjust therapy parameters based on the performance metric values may reduce the need for the patient to make time consuming and expensive clinic visits when the patient's sleep is disturbed, physical activity level has decreased, or symptoms have worsened.
• The details of one or more embodiments of the invention are set forth in the accompanying drawings and the description below. Other features, objects, and advantages of the invention will be apparent from the description and drawings, and from the claims.
BRIEF DESCRIPTION OF DRAWINGS
• FIG. 1 is a conceptual diagram illustrating an example system that includes an implantable medical device that controls delivery of therapy based on a sensitivity analysis of a performance metric.
• FIG. 2 is a block diagram further illustrating the example system and implantable medical device ofFIG. 1.
• FIG. 3 is a block diagram illustrating an example memory of the implantable medical device ofFIG. 1.
• FIG. 4 is a flow diagram illustrating an example method for collecting sleep quality information that may be employed by an implantable medical device.
• FIG. 5 is a flow diagram illustrating an example method for identifying and modifying a baseline therapy parameter set based on a sensitivity analysis of a sleep quality metric, which is an example of a performance metric.
• FIG. 6 is a conceptual diagram illustrating a monitor that monitors values of one or more physiological parameters of a patient.
DETAILED DESCRIPTION
• FIG. 1 is a conceptual diagram illustrating anexample system10 that includes an implantable medical device (IMD)14 that controls delivery of a therapy to a patient12 based on a sensitivity analysis of a performance metric. The performance metric may relate to efficacy or side effects. For example, the performance metric may comprise a sleep quality metric, a physical activity level metric, a posture metric, a movement disorder metric for patients with Parkinson's disease, or the like. The sensitivity analysis determines values of a therapy parameter set that define a substantially maximum or minimum value of the performance metric. In particular, as will be described in greater detail below,IMD14 or another device conducts the sensitivity analysis of the performance metric, and determines a baseline therapy parameter set based on the sensitivity analysis.IMD14 controls delivery of the therapy based on the baseline therapy parameter set. Furthermore,IMD14 or another device may periodically perturb at least one therapy parameter value of the baseline therapy parameter set to determine whether the performance metric value has changed over time.
• Feedback entered bypatient12, such as comments and/or a pain level value, may also be used as a performance metric to determine the baseline therapy parameter set. In some cases, a clinician or physician may determine a weighting scheme to provide more or less significance to the patient's feedback, i.e., the physician may choose to give the patient feedback zero weight and instead rely completely on other performance metric values, or the physician may judge that the patient has enough perspective to be able to competently gage pain levels and input substantially objective feedback into the sensitivity analysis.
• Although the invention may use any performance metric, for purposes of illustration, the invention will be described herein as using a sleep quality metric to control the delivery of therapy to a patient.IMD14 may be able to adjust the therapy to address symptoms causing disturbed sleep, or symptoms that are worsened by disturbed sleep. In exemplary embodiments,IMD14 delivers a therapy to treat chronic pain, which may both negatively impact the quality of sleep experienced bypatient12, and be worsened by inadequate sleep quality.
• In the illustrated example system,IMD14 takes the form of an implantable neurostimulator that delivers neurostimulation therapy in the form of electrical pulses topatient12.IMD14 delivers neurostimulation therapy topatient12 vialeads16A and16B (collectively “leads16”). Leads16 may, as shown inFIG. 1, be implanted proximate to thespinal cord18 ofpatient12, andIMD14 may deliver spinal cord stimulation (SCS) therapy topatient12 in order to, for example, reduce pain experienced bypatient12.
• However, the invention is not limited to the configuration of leads16 shown inFIG. 1, or to the delivery of SCS therapy. For example, one or more leads16 may extend fromIMD14 to the brain (not shown) ofpatient12, andIMD14 may deliver deep brain stimulation (DBS) therapy topatient12 to, for example, treat tremor or epilepsy. As further examples, one or more leads16 may be implanted proximate to the pelvic nerves (not shown) or stomach (not shown), andIMD14 may deliver neurostimulation therapy to treat incontinence, sexual dysfunction, or gastroparesis.
• Moreover, the invention is not limited to implementation via an implantable neurostimulator, or even implementation via an IMD. In other words, any implantable or external medical device that delivers a therapy may control delivery of the therapy based on performance metric information, such as sleep quality information, according to the invention.
• Further, the invention is not limited to embodiments in which the therapy-delivering medical device performs the sensitivity analysis. For example, in some embodiments, a computing device, such as a programming device, controls testing of therapy parameter sets by a therapy-delivering medical device, receives performance metric values from the medical device, performs the sensitivity analysis, and provides a baseline therapy parameter set to the therapy-delivering medical device. In some embodiments, multiple computing devices may cooperate to perform these functions. For example, a programming device may control testing of therapy parameter sets by the therapy-delivering medical device and receive performance metric values from the medical device, while another computing device performs the sensitivity analysis on the performance metric values, and identifies the baseline therapy parameter set. The other computing device may provide the baseline therapy parameter set to the programming device, which may in turn provide the baseline therapy parameter set to the medical device. The other computing device may have a greater computing capacity than the programming device, which may allow it to more easily perform the sensitivity analysis, and may, for example, be a server coupled to the programming device by a network, such as a local area network (LAN), wide area network (WAN), or the Internet.
• As another example, in some embodiments, the programming device or other computing device may receive values for one or more physiological parameters from the medical device, and may determine values for the performance metric based on the physiological parameter values. Further, in some embodiments of the invention, an implantable or external monitor separate from the therapy-delivering medical device may monitor physiological parameters of the patient instead of, or in addition to the therapy-delivering medical device. The monitor may determine values of the performance metric based on values of the physiological parameters, or transmit the physiological parameter values to a programming device or other computing device that determines the values of the performance metric. In some embodiments, the programming device and the monitor may be embodied within a single device.
• Additionally, in some embodiments, a therapy device other thanIMD14 may deliver therapy during the process of determining the baseline therapy parameter sets. The other therapy device may be an external or implantable trialing device, such as a trial neurostimulator or trial pump. The other therapy delivery device may monitor physiological parameter values ofpatient12, determine performance metric values, and perform the sensitivity analysis, as described herein with reference toIMD14. In other embodiments, some or all of these functions may be performed by a monitor, programming device, or other computing device, as described above. In such embodiments,IMD14 may deliver therapy according to a baseline therapy parameter set determined by a sensitivity analysis during a trialing period, and may perturb the therapy parameters for continued refinement of the baseline therapy parameter set, as will be described in greater detail below
• In the illustrated embodiment,IMD14 delivers therapy according to a set of therapy parameters, i.e., a set of values for a number of parameters that define the therapy delivered according to that therapy parameter set. In embodiments whereIMD14 delivers neurostimulation therapy in the form of electrical pulses, the parameters may include voltage or current pulse amplitudes, pulse widths, pulse rates, duty cycles, durations, and the like. Further, each of leads16 includes electrodes (not shown inFIG. 1), and a therapy parameter set may include information identifying which electrodes have been selected for delivery of pulses, and the polarities of the selected electrodes. Therapy parameter sets used byIMD14 may include a number of parameter sets programmed by a clinician (not shown), and parameter sets representing adjustments made bypatient12 to these preprogrammed sets.
• In other non-neurostimulator embodiments of the invention, theIMD14 may still deliver therapy according to a different type of therapy parameter set. For example, implantable pump IMD embodiments may deliver a therapeutic agent to a patient according to a therapy parameter set that includes, for example, a dosage, an infusion rate, and/or a duty cycle.
• System10 also includes aclinician programmer20, which is an example of a programming device that may determine values of a performance metric and/or perform a sensitivity analysis, as described above. A clinician (not shown) may useclinician programmer20 to program therapy forpatient12, e.g., specify a number of therapy parameter sets and provide the parameter sets toIMD14. The clinician may also useclinician programmer20 to retrieve information collected byIMD14. The clinician may useclinician programmer20 to communicate withIMD14 both during initial programming ofIMD14, and for collection of information and further programming during follow-up visits.
• Clinician programmer20 may, as shown inFIG. 1, be a handheld computing device.Clinician programmer20 includes adisplay22, such as a LCD or LED display, to display information to a user.Clinician programmer20 may also includekeypad24, which may be used by a user to interact withclinician programmer20. In some embodiments,display22 may be a touch screen display, and a user may interact withclinician programmer20 viadisplay22. A user may also interact withclinician programmer20 using peripheral pointing devices, such as a stylus, mouse, or the like.Keypad24 may take the form of a complete keyboard, an alphanumeric keypad or a reduced set of keys associated with particular functions.
• System10 also includes apatient programmer26, which also may, as shown inFIG. 1, be a handheld computing device.Patient12 may usepatient programmer26 to control the delivery of therapy byIMD14. For example, usingpatient programmer26,patient12 may select a current therapy parameter set from among the therapy parameter sets preprogrammed by the clinician, or may adjust one or more parameters of a preprogrammed therapy parameter set to arrive at the current therapy parameter set. As an example,patient12 may increase or decrease stimulation pulse amplitude usingpatient programmer26.Patient programmer26 is also an example of a programming device that may determine values of a performance metric and/or perform a sensitivity analysis, as described above.Patient programmer26 may also include adisplay28 and akeypad30 to allowpatient12 to interact withpatient programmer26. In some embodiments,display28 may be a touch screen display, andpatient12 may interact withpatient programmer26 viadisplay28.Patient12 may also interact withpatient programmer26 using peripheral pointing devices, such as a stylus, mouse, or the like.
• However, clinician andpatient programmers20,26 are not limited to the hand-held computer embodiments illustrated inFIG. 1.Programmers20,26 according to the invention may be any sort of computing device. For example, aprogrammer20,26 according to the invention may a tablet-based computing device, a desktop computing device, or a workstation.
• IMD14,clinician programmer20 andpatient programmer26 may, as shown inFIG. 1, communicate via wireless communication.Clinician programmer20 andpatient programmer26 may, for example, communicate via wireless communication withIMD14 using radio frequency (RF) or infrared telemetry techniques known in the art.Clinician programmer20 andpatient programmer26 may communicate with each other using any of a variety of local wireless communication techniques, such as RF communication according to the 802.11 or Bluetooth specification sets, infrared communication according to the IRDA specification set, or other standard or proprietary telemetry protocols.
• Clinician programmer20 andpatient programmer26 need not communicate wirelessly, however. For example,programmers20 and26 may communicate via a wired connection, such as via a serial communication cable, or via exchange of removable media, such as magnetic or optical disks, or memory cards or sticks. Further,clinician programmer20 may communicate with one or both ofIMD14 andpatient programmer26 via remote telemetry techniques known in the art, communicating via a local area network (LAN), wide area network (WAN), public switched telephone network (PSTN), or cellular telephone network, for example.
• As mentioned above,IMD14 controls delivery of a therapy, e.g., neurostimulation, to patient12 based on a sensitivity analysis of the sleep quality experienced by the patient. In some embodiments, as will be described in greater detail below,IMD14 conducts the sensitivity analysis to determine values of a therapy parameter set that defines a substantially maximum value of a sleep quality metric that indicates the quality of sleep experienced bypatient12.IMD14 determines a baseline therapy parameter set based on the sensitivity analysis and controls delivery of the therapy topatient12, e.g., adjusts the therapy, based on the baseline therapy parameter set. Furthermore,IMD14 may periodically perturb at least one therapy parameter value of the baseline therapy parameter set to determine whether the response of the sleep quality metric value to perturbation has changed over time. The perturbation may occur at a preset time, in response to a change in a physiological parameter of a patient, or in response to a signal from a patient or a clinician. The therapy parameter values may be increased or decreased in small increments relative the therapy parameter range.
• In some embodiments,IMD14 compares the sleep quality metric value defined by the baseline therapy parameter set to a sleep quality metric value defined by the perturbed therapy parameter values.IMD14 then adjusts the therapy delivered topatient12 based on the comparison. For example,IMD14 may maintain the baseline therapy parameter set when the comparison shows no improvement in the value of the sleep quality metric during perturbation. When the comparison shows improvement in the sleep quality metric value during perturbation,IMD14 updates the baseline therapy parameter set based on the one or more perturbed therapy parameter values.
• In other embodiments, an implantable or external programmer, such asprogrammers20 and26, may perturb at least one therapy parameter value of the baseline therapy parameter set and an implantable or external monitoring device may monitor the sleep quality metric value. The programmer may also conduct the comparison and update the baseline parameter set based on the comparison. An implantable or external therapy device, such asIMD14, may then alter the therapy provided to the patient based on the updated baseline parameter set.
• IMD14 may monitor one or more physiological parameters of the patient in order to determine values for one or more sleep quality metrics. Example physiological parameters that IMD14 may monitor include activity level, posture, heart rate, ECG morphology, respiration rate, respiratory volume, blood pressure, blood oxygen saturation, partial pressure of oxygen within blood, partial pressure of oxygen within cerebrospinal fluid, muscular activity and tone, core temperature, subcutaneous temperature, arterial blood flow, brain electrical activity, and eye motion. Some external medical device embodiments of the invention may additionally or alternatively monitor galvanic skin response. Further, in some embodiments,IMD14 additionally or alternatively monitors the variability of one or more of these parameters. In order to monitor one or more of these parameters,IMD14 may include, be coupled to, or be in wireless communication with one or more sensors (not shown inFIG. 1), each of which outputs a signal as a function of one or more of these physiological parameters.
• For example,IMD14 may determine sleep efficiency and/or sleep latency values. Sleep efficiency and sleep latency are example sleep quality metrics.IMD14 may measure sleep efficiency as the percentage of time whilepatient12 is attempting to sleep thatpatient12 is actually asleep.IMD14 may measure sleep latency as the amount of time between a first time whenpatient12 begins attempting to sleep and a second time whenpatient12 falls asleep, e.g., as an indication of how long it takes patient12 to fall asleep.
• IMD14 may identify the time at which patient begins attempting to fall asleep in a variety of ways. For example,IMD14 may receive an indication from the patient that the patient is trying to fall asleep viapatient programmer26. In other embodiments,IMD14 may monitor the activity level ofpatient12, and identify the time whenpatient12 is attempting to fall asleep by determining whetherpatient12 has remained inactive for a threshold period of time, and identifying the time at whichpatient12 became inactive. In still other embodiments,IMD14 may monitor the posture ofpatient12, and may identify the time when thepatient12 becomes recumbent, e.g., lies down, as the time whenpatient12 is attempting to fall asleep. In these embodiments,IMD14 may also monitor the activity level ofpatient12, and confirm thatpatient12 is attempting to sleep based on the activity level.
• IMD14 may identify the time at whichpatient12 has fallen asleep based on the activity level of the patient and/or one or more of the other physiological parameters that may be monitored byIMD14 as indicated above. For example,IMD14 may identify a discernable change, e.g., a decrease, in one or more physiological parameters, or the variability of one or more physiological parameters, which may indicate thatpatient12 has fallen asleep. In some embodiments,IMD14 determines a sleep probability metric value based on a value of a physiological parameter monitored by the medical device. In such embodiments, the sleep probability metric value may be compared to a threshold to identify when the patient has fallen asleep. In some embodiments, a sleep probability metric value is determined based on a value of each of a plurality of physiological parameters, the sleep probability values are averaged or otherwise combined to provide an overall sleep probability metric value, and the overall sleep probability metric value is compared to a threshold to identify the time that the patient falls asleep.
• Other sleep quality metrics include total time sleeping per day, and the amount or percentage of time sleeping during nighttime or daytime hours per day. In some embodiments,IMD14 may be able to detect arousal events and apneas occurring during sleep based on one or more monitored physiological parameters, and the number of apnea and/or arousal events per night may be determined as a sleep quality metric. Further, in some embodiments,IMD14 may be able to determine which sleepstate patient12 is in based on one or more monitored physiological parameters, e.g., rapid eye movement (REM), S1, S2, S3, or S4, and the amount of time per day spent in these various sleep states may be a sleep quality metric.
• FIG. 2 is a block diagram further illustratingsystem10. In particular,FIG. 2 illustrates an example configuration ofIMD14 and leads16A and16B.FIG. 2 also illustratessensors40A and40B (collectively “sensors40”) that output signals as a function of one or more physiological parameters ofpatient12.
• IMD14 may deliver neurostimulation therapy viaelectrodes42A-D oflead16A andelectrodes42E-H oflead16B (collectively “electrodes42”). Electrodes42 may be ring electrodes. The configuration, type and number of electrodes42 illustrated inFIG. 2 are exemplary. For example, leads16A and16B may each include eight electrodes42, and the electrodes42 need not be arranged linearly on each of leads16A and16B.
• Electrodes42 are electrically coupled to atherapy delivery module44 vialeads16A and16B.Therapy delivery module44 may, for example, include an output pulse generator coupled to a power source such as a battery.Therapy delivery module44 may deliver electrical pulses topatient12 via at least some of electrodes42 under the control of aprocessor46, which controlstherapy delivery module44 to deliver neurostimulation therapy according to one or more neurostimulation therapy programs selected from available programs stored in amemory48. However, the invention is not limited to implantable neurostimulator embodiments or even to IMDs that deliver electrical stimulation. For example, in some embodiments, a therapy delivery module of an IMD may include a pump, circuitry to control the pump, and a reservoir to store a therapeutic agent for delivery via the pump, and a processor of the IMD may control delivery of a therapeutic agent by the pump according to an infusion program selected from among a plurality of infusion programs stored in a memory.
• IMD14 may also include atelemetry circuit50 that enablesprocessor46 to communicate withprogrammers20,26. Viatelemetry circuit50,processor46 may receive therapy programs specified by a clinician fromclinician programmer20 for storage inmemory48.Processor46 may also receive program selections and therapy adjustments made bypatient12 usingpatient programmer26 viatelemetry circuit50. In some embodiments,processor46 may provide diagnostic information recorded byprocessor46 and stored inmemory48 to one ofprogrammers20,26 viatelemetry circuit50.
• Processor46 may include a microprocessor, a controller, a digital signal processor (DSP), an application specific integrated circuit (ASIC), a field-programmable gate array (FPGA), discrete logic circuitry, or the like.Memory48 may include any volatile, non-volatile, magnetic, optical, or electrical media, such as a random access memory (RAM), read-only memory (ROM), non-volatile RAM (NVRAM), electrically-erasable programmable ROM (EEPROM), flash memory, and the like. In some embodiments,memory48 stores program instructions that, when executed byprocessor46,cause IMD14 andprocessor46 to perform the functions attributed to them herein.
• Each of sensors40 outputs a signal as a function of one or more physiological parameters ofpatient12.IMD14 may include circuitry (not shown) that conditions the signals output by sensors40 such that they may be analyzed byprocessor46. For example,IMD14 may include one or more analog to digital converters to convert analog signals output by sensors40 into digital signals usable byprocessor46, as well as suitable filter and amplifier circuitry. Although shown as including two sensors40,system10 may include any number of sensors.
• Further, as illustrated inFIG. 2, sensors40 may be included as part ofIMD14, or coupled toIMD14 via leads16. Sensors40 may be coupled toIMD14 via therapy leads16A and16B, or via other leads16, such aslead16C depicted inFIG. 2. In some embodiments, a sensor located outside ofIMD14 may be in wireless communication withprocessor46.
• As discussed above, exemplary physiological parameters ofpatient12 that may be monitored byIMD14 to determine values of one or more sleep quality metrics include activity level, posture, heart rate, ECG morphology, respiration rate, respiratory volume, blood pressure, blood oxygen saturation, partial pressure of oxygen within blood, partial pressure of oxygen within cerebrospinal fluid, muscular activity and tone, core temperature, subcutaneous temperature, arterial blood flow, brain electrical activity, and eye motion. Further, as discussed above, external medical device embodiments of the invention may additionally or alternatively monitor galvanic skin response. Sensors40 may be of any type known in the art capable of outputting a signal as a function of one or more of these parameters.
• In some embodiments, in order to determine one or more sleep quality metric values,processor46 determines whenpatient12 is attempting to fall asleep. For example,processor46 may identify the time that patient begins attempting to fall asleep based on an indication received frompatient12, e.g., viaclinician programmer20 and atelemetry circuit50. In other embodiments,processor46 identifies the time thatpatient12 begins attempting to fall asleep based on the activity level ofpatient12.
• In such embodiments,IMD14 may include one or more sensors40 that generate a signal as a function of patient activity. For example, sensors40 may include one or more accelerometers, gyros, mercury switches, or bonded piezoelectric crystals that generates a signal as a function of patient activity, e.g., body motion, footfalls or other impact events, and the like. Additionally or alternatively, sensors40 may include one or more electrodes that generate an electromyogram (EMG) signal as a function of muscle electrical activity, which may indicate the activity level of a patient. The electrodes may be, for example, located in the legs, abdomen, chest, back or buttocks ofpatient12 to detect muscle activity associated with walking, running, or the like. The electrodes may be coupled toIMD14 by leads16 or wirelessly, or, ifIMD14 is implanted in these locations, integrated with a housing ofIMD14.
• However, bonded piezoelectric crystals located in these areas generate signals as a function of muscle contraction in addition to body motion, footfalls or other impact events. Consequently, use of bonded piezoelectric crystals to detect activity ofpatient12 may be preferred in some embodiments in which it is desired to detect muscle activity in addition to body motion, footfalls, or other impact events. Bonded piezoelectric crystals may be coupled toIMD14 via leads16 or wirelessly, or piezoelectric crystals may be bonded to the can ofIMD14 when the IMD is implanted in these areas, e.g., in the back, chest, buttocks or abdomen ofpatient12.
• Processor46 may identify a time when the activity level ofpatient12 falls below a threshold activity level value stored inmemory48, and may determine whether the activity level remains substantially below the threshold activity level value for a threshold amount of time stored inmemory48. In other words,patient12 remaining inactive for a sufficient period of time may indicate thatpatient12 is attempting to fall asleep. Ifprocessor46 determines that the threshold amount of time is exceeded,processor46 may identify the time at which the activity level fell below the threshold activity level value as the time thatpatient12 began attempting to fall asleep.
• In some embodiments,processor46 determines whetherpatient12 is attempting to fall asleep based on whetherpatient12 is or is not recumbent, e.g., lying down. In such embodiments, sensors40 may include a plurality of accelerometers, gyros, or magnetometers oriented orthogonally that generate signals which indicate the posture ofpatient12. In addition to being oriented orthogonally with respect to each other, each of sensors40 used to detect the posture ofpatient12 may be generally aligned with an axis of the body ofpatient12. In exemplary embodiments,IMD14 includes three orthogonally oriented posture sensors40.
• When sensors40 include accelerometers, for example, that are aligned in this manner,processor46 may monitor the magnitude and polarity of DC components of the signals generated by the accelerometers to determine the orientation ofpatient12 relative to the Earth's gravity, e.g., the posture ofpatient12. In particular, theprocessor46 may compare the DC components of the signals to respective threshold values stored inmemory48 to determine whetherpatient12 is or is not recumbent. Further information regarding use of orthogonally aligned accelerometers to determine patient posture may be found in a commonly assigned U.S. Pat. No. 5,593,431, which issued to Todd J. Sheldon. Other sensors40 that may generate a signal that indicates the posture ofpatient12 include electrodes that generate an electromyogram (EMG) signal, or bonded piezoelectric crystals that generate a signal as a function of contraction of muscles. Such sensors40 may be implanted in the legs, buttocks, abdomen, or back ofpatient12, as described above. The signals generated by such sensors when implanted in these locations may vary based on the posture ofpatient12, e.g., may vary based on whether the patient is standing, sitting, or laying down.
• Further, the posture ofpatient12 may affect the thoracic impedance of the patient. Consequently, sensors40 may include an electrode pair, such as one electrode integrated with the housing ofIMD14 and one of electrodes42, that generates a signal as a function of the thoracic impedance ofpatient12, andprocessor46 may detect the posture or posture changes ofpatient12 based on the signal. The electrodes of the pair may be located on opposite sides of the patient's thorax. For example, the electrode pair may include one of electrodes42 located proximate to the spine of a patient for delivery of SCS therapy, andIMD14 with an electrode integrated in its housing may be implanted in the abdomen ofpatient12.
• Additionally, changes of the posture ofpatient12 may cause pressure changes with the cerebrospinal fluid (CSF) of the patient. Consequently, sensors40 may include pressure sensors coupled to one or more intrathecal or intracerebroventricular catheters, or pressure sensors coupled toIMD14 wirelessly or via lead16. CSF pressure changes associated with posture changes may be particularly evident within the brain of the patient, e.g., may be particularly apparent in an intracranial pressure (ICP) waveform.
• In some embodiments,processor46 considers both the posture and the activity level ofpatient12 when determining whetherpatient12 is attempting to fall asleep. For example,processor46 may determine whetherpatient12 is attempting to fall asleep based on a sufficiently long period of sub-threshold activity, as described above, and may identify the time that patient began attempting to fall asleep as the time whenpatient12 became recumbent. Any of a variety of combinations or variations of these techniques may be used to determine whenpatient12 is attempting to fall asleep, and a specific one or more techniques may be selected based on the sleeping and activity habits of a particular patient.
• Processor46 may also determine whenpatient12 is asleep, e.g., identify the times thatpatient12 falls asleep and wakes up, in order to determine one or more sleep quality metric values. The detected values of physiological parameters ofpatient12, such as activity level, heart rate, values of ECG morphological features, respiration rate, respiratory volume, blood pressure, blood oxygen saturation, partial pressure of oxygen within blood, partial pressure of oxygen within cerebrospinal fluid, muscular activity and tone, core temperature, subcutaneous temperature, arterial blood flow, brain electrical activity, eye motion, and galvanic skin response may discernibly change when patient12 falls asleep or wakes up. In particular, these physiological parameters may be at low values whenpatient12 is asleep. Further, the variability of at least some of these parameters, such as heart rate and respiration rate, may be at a low value when the patient is asleep.
• Consequently, in order to detect when patient12 falls asleep and wakes up,processor46 may monitor one or more of these physiological parameters, or the variability of these physiological parameters, and detect the discernable changes in their values associated with a transition between a sleeping state and an awake state.
• In some embodiments, in order to determine whetherpatient12 is asleep,processor46 monitors a plurality of physiological parameters, and determines a value of a metric that indicates the probability thatpatient12 is asleep for each of the parameters based on a value of the parameter. In particular, theprocessor46 may apply a function or look-up table to the current value, and/or the variability of each of a plurality of physiological parameters to determine a sleep probability metric value for each of the plurality of physiological parameters. A sleep probability metric value may be a numeric value, and in some embodiments may be a probability value, e.g., a number within the range from 0 to 1, or a percentage level.
• Processor46 may average or otherwise combine the plurality of sleep probability metric values to provide an overall sleep probability metric value. In some embodiments,processor46 may apply a weighting factor to one or more of the sleep probability metric values prior to combination.Processor46 may compare the overall sleep probability metric value to one or more threshold values stored inmemory48 to determine when patient12 falls asleep or awakes. Use of sleep probability metric values to determine when a patient is asleep based on a plurality of monitored physiological parameters is described in greater detail in a commonly assigned and copending U.S. patent application Ser. No. 11/081,786, by Ken Heruth and Keith Miesel, entitled “DETECTING SLEEP,” bearing Attorney Docket No. 1023-360US02 and filed on Mar. 16, 2005, which is incorporated herein by reference in its entirety.
• To enableprocessor46 to determine whenpatient12 is asleep or awake, sensors40 may include, for example, activity sensors as described above. In some embodiments, the activity sensors may include electrodes or bonded piezoelectric crystals, which may be implanted in the back, buttocks, chest, or abdomen ofpatient12 as described above. In such embodiments,processor46 may detect the electrical activation and contractions of muscles associated with gross motor activity of the patient, e.g., walking, running or the like via the signals generated by such sensors.Processor46 may also detect spasmodic or pain related muscle activation via the signals generated by such sensors. Spasmodic or pain related muscle activation may indicate thatpatient12 is not sleeping, e.g., unable to sleep, or ifpatient12 is sleeping, may indicate a lower level of sleep quality.
• As another example, sensors40 may include electrodes located on leads or integrated as part of the housing ofIMD14 that output an electrogram signal as a function of electrical activity of the heart ofpatient12, andprocessor46 may monitor the heart rate ofpatient12 based on the electrogram signal. In other embodiments, a sensor may include an acoustic sensor withinIMD14, a pressure sensor within the bloodstream or cerebrospinal fluid ofpatient12, or a temperature sensor located within the bloodstream ofpatient12. The signals output by such sensors may vary as a function of contraction of the heart ofpatient12, and can be used byIMD14 to monitor the heart rate ofpatient12.
• In some embodiments,processor46 may detect, and measure values for one or more ECG morphological features within an electrogram generated by electrodes as described above. ECG morphological features may vary in a manner that indicates whetherpatient12 is asleep or awake. For example, the amplitude of the ST segment of the ECG may decrease whenpatient12 is asleep. Further, the amplitude of QRS complex or T-wave may decrease, and the widths of the QRS complex and T-wave may increase whenpatient12 is asleep. The QT interval and the latency of an evoked response may increase whenpatient12 is asleep, and the amplitude of the evoked response may decrease whenpatient12 is asleep.
• In some embodiments, sensors40 may include an electrode pair, including one electrode integrated with the housing ofIMD14 and one of electrodes16, that output a signal as a function of the thoracic impedance ofpatient12 as described above, which varies as a function of respiration bypatient12. In other embodiments, sensors40 may include a strain gauge, bonded piezoelectric element, or pressure sensor within the blood or CSF that outputs a signal that varies based on patient respiration. An electrogram output by electrodes as discussed above may also be modulated by patient respiration, and may be used as an indirect representation of respiration rate.
• Sensors40 may include electrodes that output an electromyogram (EMG) signal as a function of muscle electrical activity, as described above, or may include any of a variety of known temperature sensors to output a signal as a function of a core or subcutaneous temperature ofpatient12. Such electrodes and temperature sensors may be incorporated within the housing ofIMD14, or coupled toIMD14 wirelessly or via leads. Sensors40 may also include a pressure sensor within, or in contact with, a blood vessel. The pressure sensor may output a signal as a function of the blood pressure ofpatient12, and may, for example, comprise a Chronicle Hemodynamic Monitor™ commercially available from Medtronic, Inc. of Minneapolis, Minn. Further, certain muscles ofpatient12, such as the muscles of the patient's neck, may discernibly relax whenpatient12 is asleep or within certain sleep states. Consequently, sensors40 may include strain gauges or EMG electrodes implanted in such locations that generate a signal as a function of muscle tone.
• Sensors40 may also include optical pulse oximetry sensors or Clark dissolved oxygen sensors located within, as part of a housing of, or outside ofIMD14, which output signals as a function blood oxygen saturation and blood oxygen partial pressure respectively. In some embodiments,system10 may include a catheter with a distal portion located within the cerebrospinal fluid ofpatient12, and the distal end may include a Clark dissolved oxygen sensor to output a signal as a function of the partial pressure of oxygen within the cerebrospinal fluid. Embodiments in which an IMD comprises an implantable pump, for example, may include a catheter with a distal portion located in the cerebrospinal fluid.
• In some embodiments, sensors40 may include one or more intraluminal, extraluminal, or external flow sensors positioned to output a signal as a function of arterial blood flow. A flow sensor may be, for example, an electromagnetic, thermal convection, ultrasonic-Doppler, or laser-Doppler flow sensor. Further, in some external medical device embodiments of the invention, sensors40 may include one or more electrodes positioned on the skin ofpatient12 to output a signal as a function of galvanic skin response.
• Additionally, in some embodiments, sensors40 may include one or more electrodes positioned within or proximate to the brain of patient, which detect electrical activity of the brain. For example, in embodiments in whichIMD14 delivers stimulation or other therapy to the brain,processor46 may be coupled to electrodes implanted on or within the brain via a lead16. In other embodiments,processor46 may be wirelessly coupled to electrodes that detect brain electrical activity.
• For example, one or more modules may be implanted beneath the scalp of the patient, each module including a housing, one or more electrodes, and circuitry to wirelessly transmit the signals detected by the one or more electrodes toIMD14. In other embodiments, the electrodes may be applied to the patient's scalp, and electrically coupled to a module that includes circuitry for wirelessly transmitting the signals detected by the electrodes toIMD14. The electrodes may be glued to the scalp, or a headband, hair net, cap, or the like may incorporate the electrodes and the module, and may be worn bypatient12 to apply the electrodes to the patient's scalp when, for example, the patient is attempting to sleep. The signals detected by the electrodes and transmitted toIMD14 may be electroencephalogram (EEG) signals, andprocessor46 may process the EEG signals to detect whenpatient12 is asleep using any of a variety of known techniques, such as techniques that identify whether a patient is asleep based on the amplitude and/or frequency of the EEG signals.
• Also, the motion of the eyes ofpatient12 may vary depending on whether the patient is sleeping and which sleep state the patient is in. Consequently, sensors40 may include electrodes place proximate to the eyes ofpatient12 to detect electrical activity associated with motion of the eyes, e.g., to generate an electro-oculography (EOG) signal. Such electrodes may be coupled toIMD14 via one or more leads16, or may be included within modules that include circuitry to wirelessly transmit detected signals toIMD14. Wirelessly coupled modules incorporating electrodes to detect eye motion may be worn externally bypatient12, e.g., attached to the skin ofpatient12 proximate to the eyes by an adhesive when the patient is attempting to sleep.
• Processor46 may also detect arousals and/or apneas that occur whenpatient12 is asleep based on one or more of the above-identified physiological parameters. For example,processor46 may detect an arousal based on an increase or sudden increase in one or more of heart rate, heart rate variability, respiration rate, respiration rate variability, blood pressure, or muscular activity as the occurrence of an arousal.Processor46 may detect an apnea based on a disturbance in the respiration rate ofpatient12, e.g., a period with no respiration.
• Processor46 may also detect arousals or apneas based on sudden changes in one or more of the ECG morphological features identified above. For example, a sudden elevation of the ST segment within the ECG may indicate an arousal or an apnea. Further, sudden changes in the amplitude or frequency of an EEG signal, EOG signal, or muscle tone signal may indicate an apnea or arousal.Memory48 may store thresholds used byprocessor46 to detect arousals and apneas.Processor46 may determine, as a sleep quality metric value, the number of apnea events and/or arousals during a night.
• Further, in some embodiments,processor46 may determine which sleepstate patient12 is in during sleep, e.g., REM, S1, S2, S3, or S4, based on one or more of the monitored physiological parameters. In some embodiments,memory48 may store one or more thresholds for each of sleep states, andprocessor46 may compare physiological parameter or sleep probability metric values to the thresholds to determine which sleepstate patient12 is currently in.Processor46 may determine, as sleep quality metric values, the amounts of time per night spent in the various sleep states. Further, in some embodiments,processor46 may use any of a variety of known techniques for determining which sleep state patient is in based on an EEG signal, whichprocessor46 may receive via electrodes as described above, such as techniques that identify sleep state based on the amplitude and/or frequency of the EEG signals. In some embodiments,processor46 may also determine which sleep state patient is in based on an EOG signal, whichprocessor46 may receive via electrodes as described above, either alone or in combination with an EEG signal, using any of a variety of techniques known in the art. Inadequate time spent in deeper sleep states, e.g., S3 and S4, is an indicator of poor sleep quality.
• FIG. 3 further illustratesmemory48 ofIMD14. As illustrated inFIG. 3,memory48 stores a plurality of therapy parameter sets60. Therapy parameter sets60 may include parameter sets randomly or non-randomly generated byprocessor46 over therapy parameter ranges68 set by a clinician usingclinician programmer20. Therapy parameter sets60 may also include parameter sets specified by a clinician usingclinician programmer20 and preprogrammed therapy parameter sets.
• Memory48 may also includeparameter data62 recorded byprocessor46, e.g., physiological parameter values, or mean or median physiological parameter values.Memory48 stores threshold values64 used byprocessor46 in the collection of sleep quality metric values, as discussed above. In some embodiments,memory48 also stores one or more functions or look-up tables (not shown) used byprocessor46 to determine sleep probability metric values, or to determine an overall sleep quality metric value.
• Further,processor46 stores determined sleep qualitymetric values66 for each of the plurality of therapy parameter sets60 withinmemory48.Processor46 conducts a sensitivity analysis of the sleep quality metric values for each therapy parameter. The sensitivity analysis determines a value for each therapy parameter that defines a substantially maximum sleep quality metric value. In other words, the sensitivity analysis identifies parameter values that yield the best sleep quality metric values.Processor46 then determines a baseline therapy parameter set based on the sensitivity analysis and stores the baseline therapy parameter set with therapy parameter set66 or separately withinmemory48. The baseline therapy parameter set may be identical to a single one of therapy parameter sets60, or may be a new therapy parameter set that includes one or more therapy parameter values from a plurality of therapy parameter sets60. The baseline therapy parameter set includes the values for respective therapy parameters that produced the best sleep quality metric values.
• Processor46 may collect sleep qualitymetric values66 eachtime patient12 sleeps, or only during selected times thatpatient12 is asleep.Processor46 may store each sleep quality metric value determined withinmemory48 as a sleep qualitymetric value66. Further,processor46 may apply a function or look-up table to a plurality of sleep quality metric values to determine overall sleep quality metric value, and may store the overall sleep quality metric values withinmemory48. The application of a function or look-up table byprocessor46 for this purpose may involve the use of weighting factors for one or more of the individual sleep quality metric values.
• In some embodiments, as discussed above,processor46 may adjust the therapy delivered bytherapy module44 based on a change in the sleep quality metric value. In particular,processor46 may perturb one or more therapy parameters of the baseline therapy parameter set, such as pulse amplitude, pulse width, pulse rate, duty cycle, and duration to determine if the current sleep quality metric value improves or worsens during perturbation. In some embodiments,processor46 may iteratively and incrementally increase or decrease values of the therapy parameters until a substantially maximum value of the sleep quality metric value is again determined.
• FIG. 4 is a flow diagram illustrating an example method for collecting sleep quality information that may be employed byIMD14 alone, or in combination with a computing device and/or a monitor. In some embodiments, as discussed above, a computing device, such as one ofprogrammers20 and26, may determine sleep quality metric values based on monitored physiological parameter values, rather thanIMD14. Further, in some embodiments, a monitor may monitor physiological parameter values instead of, or in addition to,IMD14.
• In the illustrated example, however,IMD14 monitors the posture and/or activity level ofpatient12, or monitors for an indication frompatient12, e.g., via patient programmer26 (70), and determines whetherpatient12 is attempting to fall asleep based on the posture, activity level, and/or a patient indication, as described above (72). IfIMD14 determines thatpatient12 is attempting to fall asleep,IMD14 identifies the time thatpatient12 began attempting to fall asleep using any of the techniques described above (74), and monitors one or more of the various physiological parameters ofpatient12 discussed above to determine whetherpatient12 is asleep (76,78).
• In some embodiments,IMD14 compares parameter values or parameter variability values to one or more threshold values64 to determine whetherpatient12 is asleep. In other embodiments,IMD14 applies one or more functions or look-up tables to determine one or more sleep probability metric values based on the physiological parameter values, and compares the sleep probability metric values to one or more threshold values64 to determine whetherpatient12 is asleep. While monitoring physiological parameters (76) to determine whetherpatient12 is asleep (78),IMD14 may continue to monitor the posture and/or activity level of patient12 (70) to confirm thatpatient12 is still attempting to fall asleep (72).
• WhenIMD14 determines thatpatient12 is asleep, e.g., by analysis of the various parameters contemplated herein,IMD14 will identify the time thatpatient12 fell asleep (80). Whilepatient12 is sleeping,IMD14 will continue to monitor physiological parameters of patient12 (82). As discussed above,IMD14 may identify the occurrence of arousals and/or apneas based on the monitored physiological parameters (84). Further,IMD14 may identify the time that transitions between sleep states, e.g., REM, S1, S2, S3, and S4, occur based on the monitored physiological parameters (84).
• Additionally, whilepatient12 is sleeping,IMD14 monitors physiological parameters of patient12 (82) to determine whetherpatient12 has woken up (86). WhenIMD14 determines thatpatient12 is awake,IMD14 identifies the time thatpatient12 awoke (88), and determines sleep quality metric values based on the information collected whilepatient12 was asleep (90).
• For example, one sleep quality metric value that IMD14 may calculate is sleep efficiency, whichIMD14 may calculate as a percentage of time during whichpatient12 is attempting to sleep thatpatient12 is actually asleep.IMD14 may determine a first amount of time between thetime IMD14 identified thatpatient12 fell asleep and thetime IMD14 identified thatpatient12 awoke. IMD may also determine a second amount of time between thetime IMD14 identified thatpatient12 began attempting to fall asleep and thetime IMD14 identified thatpatient12 awoke. To calculate the sleep efficiency,IMD14 may divide the first time by the second time.
• Another sleep quality metric value that IMD14 may calculate is sleep latency, whichIMD14 may calculate as the amount of time between thetime IMD14 identified thatpatient12 was attempting to fall asleep and thetime IMD14 identified thatpatient12 fell asleep. Other sleep quality metrics with values determined byIMD14 based on the information collected byIMD14 in the illustrated example include: total time sleeping per day, at night, and during daytime hours; number of apnea and arousal events per occurrence of sleep; and amount of time spent in the various sleep states.IMD14 may store the determined values as sleep qualitymetric values66 withinmemory48.
• IMD14 may perform the example method illustrated inFIG. 4 continuously. For example,IMD14 may monitor to identify whenpatient12 is attempting to sleep and asleep any time of day, each day. In other embodiments,IMD14 may only perform the method during evening hours and/or once every N days to conserve battery and memory resources. Further, in some embodiments,IMD14 may only perform the method in response to receiving a command frompatient12 or a clinician via one ofprogrammers20,26. For example,patient12 may directIMD14 to collect sleep quality information at times when the patient believes that his or her sleep quality is low or therapy is ineffective.
• FIG. 5 is a flow diagram illustrating an example method for identifying and modifying a baseline therapy parameter set based on a sensitivity analysis of a sleep quality metric, which is an example of a performance metric. In the illustrated example, the method is employed byIMD14. However, in other embodiments, a system including one or more ofIMD14, a physiological parameter monitor, a trial therapy device, and a programmer and/or other computing device may perform the example method, as described above.
• IMD14 receives atherapy parameter range68 for therapy parameters (100) from a clinician usingclinician programmer20 viatelemetry circuit50. Therange68 may include minimum and maximum values for each of one or more individual therapy parameters, such as pulse amplitude, pulse width, pulse rate, duty cycle, duration, dosage, infusion rate, electrode placement, and electrode selection.Range68 may be stored inmemory48, as described in reference toFIG. 3.Processor46 then randomly or non-randomly generates a plurality of therapy parameter sets60 with individual parameter values selected from the range68 (102). The generated therapy parameter sets60 may substantially coverrange68, but do not necessarily include each and every therapy parameter value withinrange68, or every possible combination of therapy parameters withinrange68. Therapy parameter sets60 may also be stored inmemory48.
• IMD14 monitors a sleep quality metric ofpatient12 for each of the randomly or non-randomly generated therapy parameter sets60 spanning range68 (104). The values of the sleep quality metric66 corresponding to each of the therapy parameter sets60 may be stored inmemory48 ofIMD14.IMD14 then conducts a sensitivity analysis of the sleep quality metric for each of the therapy parameters (106). The sensitivity analysis determines a value for each of the therapy parameters that produced a substantially maximum value of the sleep quality metric. A baseline therapy parameter set is then determined based on the therapy parameter values from the sensitivity analysis (108). The baseline therapy parameter set includes a combination of the therapy parameter values individually observed to produce a substantially maximum sleep quality metric. In some embodiments, the patient may enter comments, a pain value from a scale, or other feedback used along with the sensitivity analysis to determine the baseline parameter set. The baseline therapy parameter set may also be stored with therapy parameters sets60 inmemory48. In some embodiments, the baseline therapy parameter set may be stored separately from the generated therapy parameter sets.
• IMD14 controls delivery of the therapy based on the baseline therapy parameter set. Periodically during the therapy,IMD14 checks to ensure that the baseline therapy parameter continues to define a substantially maximum sleep quality metric value forpatient12.IMD14 first perturbs at least one of the therapy parameter values of the baseline therapy parameter set (110). The perturbation comprises incrementally increasing and/or decreasing the therapy parameter value. A perturbation period may be preset to occur at a specific time, in response to a physiological parameter monitored by the IMD, or in response to a signal from the patient or clinician. The perturbation may be applied for a single selected parameter or two or more parameters, or all parameters in the baseline therapy parameter set. Hence, numerous parameters may be perturbed in sequence. For example, upon perturbing a first parameter and identifying a value that produces a maximum metric value, a second parameter may be perturbed with the first parameter value fixed at the identified value. This process may continue for each of the parameters in the therapy parameter set.
• Upon perturbing a parameter value,IMD14 then compares a value of the sleep quality metric defined by the perturbed therapy parameter set to the value of the sleep quality metric defined by the baseline therapy parameter set (112). If the sleep quality metric value does not improve with the perturbation,IMD14 maintains the unperturbed baseline therapy parameter set values (114). If the sleep quality metric value does improve with the perturbation,IMD14 perturbs the therapy parameter value again (116) in the same direction that defined the previous improvement in the sleep quality metric value.IMD14 compares a value of the sleep quality metric defined by the currently perturbed therapy parameter set and the sleep quality metric value defined by the previously perturbed therapy parameter set (118). If the sleep metric value does not improve,IMD14 updates the baseline therapy parameter set based on the therapy parameter values from the previous perturbation (120). If the sleep metric value improves again,IMD14 continues to perturb the therapy parameter value (116).
• Periodically checking the value of the sleep quality metric for the baseline therapy parameter set allowsIMD14 to consistently deliver a therapy topatient12 that defines a substantially maximum sleep quality metric value ofpatient12. This allows the patient's symptoms to be continually managed even as the patient's physiological parameters change.
• In some embodiments, an external computing device, such asclinician programmer20, may generate the plurality of therapy parameter sets over the range. A clinician may then provide the therapy parameter sets toIMD14 viaclinician programmer20. The computing device may provide individual therapy parameter sets to be tested, and may thus control the testing byIMD14, or may provide a listing of therapy parameter sets to be tested.
• Furthermore, an external computing device, such asprogrammer20, a separate desktop computer, or server, may receive the sleep quality metric values collected by the IMD for the plurality of therapy parameter sets. The external computing device may then conduct the sensitivity analysis to determine the baseline therapy parameter set. The external computing device may also control the subsequent perturbations. In some embodiments, the external computing device may receive physiological parameter values fromIMD14, and, rather thatIMD14, the external computing device may determine values of the sleep quality or other performance metric based on the physiological parameter values received fromIMD14.
• In some embodiments, the sensitivity analysis and determination of a baseline therapy parameter set may be performed as part of a trialing process. In such embodiments, an external or implanted trial therapy device, such as a trial neurostimulator, may perform the functions ascribed toIMD14 above that are associated with performing the sensitivity analysis and determination of a baseline therapy parameter set. The trial therapy device may include atherapy module44,processor46, andmemory48, and may be coupled to sensors40 and leads16, as described above with reference toIMD14 andFIGS. 2 and 3.
• IMD14 may then be implanted inpatient12, and programmed to deliver therapy according to the baseline therapy parameter set. In such embodiments,IMD14 may perform the perturbation and updating functions of the example method illustrated byFIG. 5. In some embodiments, an external computing device may control delivery of a plurality of therapy parameter sets by the trial device, determine performance metric values based on physiological parameter values received from the trial device, and/or perform the sensitivity analysis.
• FIG. 6 illustrates, aseparate monitor130 that monitors values of one or more physiological parameters ofpatient12 instead of, or in addition to the trial device orIMD14.Monitor130 may include aprocessor46 andmemory48, and may be coupled to sensors40, as illustrated above with reference toIMD14 andFIGS. 2 and 3.Monitor130 may identify performance metric values based on the values of the monitored physiological parameter values, or may transmit the physiological parameter values to a computing device for determination of the performance metric values. In some embodiments, an external computing device, such as a programming device, may incorporate monitor130. In the illustrated embodiment, monitor130 is portable, and is configured to be attached to or otherwise carried by abelt132, and may thereby be worn bypatient12.
• FIG. 6 also illustrates various sensors40 that may be coupled to monitor130 by leads, wires, cables, or wireless connections, such asEEG electrodes134A-C placed on the scalp ofpatient12, a plurality ofEOG electrodes136A and136B placed proximate to the eyes ofpatient12, and one ormore EMG electrodes138 placed on the chin or jaw the patient. The number and positions ofelectrodes134,136 and138 illustrated inFIG. 6 are exemplary. For example, although only three EEG electrodes13 are illustrated inFIG. 1, an array of between 16 and 25 EEG electrodes143 may be placed on the scalp ofpatient12, as is known in the art. EEG electrodes134 may be individually placed onpatient12, or integrated within a cap or hair net worn by the patient.
• In the illustrated example,patient12 wears anECG belt140.ECG belt140 incorporates a plurality of electrodes for sensing the electrical activity of the heart ofpatient12. The heart rate and, in some embodiments, ECG morphology ofpatient12 may monitored bymonitor130 based on the signal provided byECG belt140. Examples ofsuitable belts140 for sensing the heart rate ofpatient12 are the “M” and “F” heart rate monitor models commercially available from Polar Electro. In some embodiments, instead ofbelt140,patient12 may wear a plurality of ECG electrodes attached, e.g., via adhesive patches, at various locations on the chest of the patient, as is known in the art. An ECG signal derived from the signals sensed by such an array of electrodes may enable both heart rate and ECG morphology monitoring, as is known in the art.
• As shown inFIG. 6,patient12 may also wear arespiration belt142 that outputs a signal that varies as a function of respiration of the patient.Respiration belt142 may be a plethysmograpy belt, and the signal output byrespiration belt142 may vary as a function of the changes in the thoracic or abdominal circumference ofpatient12 that accompany breathing by the patient. An example of asuitable belt142 is the TSD201 Respiratory Effort Transducer commercially available from Biopac Systems, Inc. Alternatively,respiration belt142 may incorporate or be replaced by a plurality of electrodes that direct an electrical signal through the thorax of the patient, and circuitry to sense the impedance of the thorax, which varies as a function of respiration of the patient, based on the signal. In some embodiments, ECG andrespiration belts140 and142 may be a common belt worn bypatient12, and the relative locations ofbelts140 and142 depicted inFIG. 6 are exemplary.
• In the example illustrated byFIG. 1,patient12 also wears atransducer144 that outputs a signal as a function of the oxygen saturation of the blood ofpatient12.Transducer144 may be an infrared transducer.Transducer144 may be located on one of the fingers or earlobes ofpatient12. Sensors40 coupled to monitor130 may additionally or alternatively include any of the variety of sensors described above that monitor any one or more of activity level, posture, heart rate, ECG morphology, respiration rate, respiratory volume, blood pressure, blood oxygen saturation, partial pressure of oxygen within blood, partial pressure of oxygen within cerebrospinal fluid, muscular activity and tone, core temperature, subcutaneous temperature, arterial blood flow, brain electrical activity, eye motion, and galvanic skin response.
• FIG. 6 also illustrates an external trial therapy device146 in conjunction withpatient12. In the illustrated example,patient12 wears trial therapy device146 withmonitor130 onbelt132. The trial therapy device146 may be coupled to one or more transcutaneoulsy implanted leads or catheters for delivery of therapy, such as neurostimulation or a drug, topatient12. As described above, trial therapy device146 may deliver therapy topatient12 during the sensitivity analysis and baseline therapy parameter set determination portion of the method illustrated inFIG. 5 and, in some embodiments, may also monitor physiological parameters ofpatient12, determine performance metric values, and/or perform the sensitivity analysis to determine the baseline therapy parameter set for use byIMD14.
• Various embodiments of the invention have been described. However one skilled in the art will appreciate, however, that various modifications may be made to the described embodiments without departing from the scope of the invention. For example, although described herein primarily in the context of treatment of pain with an implantable neurostimulator or implantable pump, the invention is not so limited. Moreover, the invention is not limited to implantable medical devices. The invention may be embodied in any implantable or external medical device that delivers therapy to treat any ailment of symptom of a patient.
• As another example, the invention has been primarily described in the context of monitoring a sleep quality metric; however the invention is not so limited. The invention may monitor any performance metric, such as an activity metric, posture metric, a movement disorder metric, or other metrics that indicate the efficacy or degree of side effects associated a therapy delivered to a patient.
• In some embodiments, for example,IMD14 or any of the other devices described herein may periodically determine an activity level ofpatient12 during delivery of therapy to the patient according to a plurality of parameter sets by monitoring at least one signal that is generated by a sensor40 and varies as a function of patient activity, as described above. A value of at least one activity metric for each of a plurality of therapy parameter sets may be determined based on the activity levels associated with that parameter set. An activity metric value may be, for example, a mean or median activity level, such as an average number of activity counts per unit time. In other embodiments, an activity metric value may be chosen from a predetermined scale of activity metric values based on comparison of a mean or median activity level to one or more threshold values. The scale may be numeric, such as activity metric values from 1-10, or qualitative, such as low, medium or high activity.
• In some embodiments, each activity level associated with a therapy parameter set is compared with the one or more thresholds, and percentages of time above and/or below the thresholds are determined as one or more activity metric values for that therapy parameter set. In other embodiments, each activity level associated with a therapy parameter set is compared with a threshold, and an average length of time that consecutively determined activity levels remain above the threshold is determined as an activity metric value for that therapy parameter set. One or both of the medical device or a programming device may determine the activity metric values as described herein.
• As another example, the device may monitor one or more signals that are generated by respective sensors40 and vary as a function of patient posture, as described above. Posture events are identified based on the posture of the patient, e.g., the patient's posture and/or posture transitions are periodically identified, and each identified posture event is associated with the current therapy parameter set.
• A value of at least one posture metric is determined for each of the therapy parameter sets based on the posture events associated with that parameter set. A posture metric value may be, for example, an amount or percentage of time spent in a posture while a therapy parameter set is active, e.g., average amount of time over a period of time, such as an hour, that a patient was within a particular posture. In some embodiments, a posture metric value may be an average number of posture transitions over a period of time, e.g., an hour, that a particular therapy parameter sets was active.
• In embodiments in which a plurality of posture metrics are determined for each therapy parameter set, an overall posture metric may be determined based on the plurality of posture metrics. The plurality of posture metrics may be used as indices to select an overall posture metric from a look-up table comprising a scale of potential overall posture metrics. The scale may be numeric, such as overall posture metric values from 1-10.
• Similarly, a device may sense physiological parameter values of a patient indicative of movement disorders, such as tremor, via one or more sensors40, such as one or more accelerometers. Movement disorder metrics values that may be determined include mean or median values output by the sensors, amounts of time the sensor signal is above or below a threshold, or frequency of episodes above or below a threshold.
• Further details regarding activity and posture metric values may be found in U.S. patent application Ser. No. 11/081,785, by Ken Heruth and Keith Miesel, entitled “COLLECTING ACTIVITY INFORMATION TO EVALUATE THERAPY,” bearing Attorney Docket No. 1023-361US02 and filed on Mar. 16, 2005, and U.S. patent application Ser. No. 11/081,872, by Ken Heruth and Keith Miesel, entitled “COLLECTING POSTURE INFORMATION TO EVALUATE THERAPY,” bearing Attorney Docket No. 1023-359US02 and filed on Mar. 16, 2005. The content of these applications is incorporated herein by reference in its entirety.
• Additionally, as discussed above, feedback entered bypatient12, may be used as a performance metric instead of, or in addition to, the other performance metrics described herein. One ofprogramming devices20,26 may receive the feedback frompatient12. In embodiments in which another device, such as a medical device or other computing device, performs the sensitivity analysis, the programming device may provide the feedback or performance metric values derived from the feedback to the other device. As examples, the feedback may include comments, or numeric values for pain, efficacy, or side effect levels.
• For example, theprogramming device20,26 may promptpatient12 for feedback after a new or modified program is delivered by a therapy-delivering medical device during the sensitivity analysis or perturbation portions of the method illustrated byFIG. 5. Additionally or alternatively, ifpatient12 experiences discomfort, the patient could cause the sensitivity analysis or perturbation to “step backward” to the most recent setting before the setting was changed by the algorithm via the programming device. A perturbation of a therapy parameter may produce results, either related or unrelated to the performance metric, that the patient does not like. For example, a perturbation to a higher drug dosage may result in somnolence, or a perturbation to a higher SCS amplitude may painfully stimulate ribs or abdominal muscles. The patient may cause the sensitivity analysis or perturbation to “step backward” to the most recent setting to rapidly stop the undesirably results
• When the patient causes the algorithm to step backward, the device performing the sensitivity analysis or perturbation may record this as a low performance metric value for the avoided program, or may prevent further program testing, perturbation, or other program selection of the avoided program, or within in a zone of therapy parameters determined based on the avoided program. In embodiments in which feedback is used in addition to one or more other performance metrics, a clinician or physician may determine a weighting scheme to provide more or less significance to the patient's feedback, i.e., the physician may choose to give the patient feedback zero weight and instead rely completely on other performance metric values, or the physician may judge that the patient has enough perspective to be able to competently gage pain levels and input substantially objective feedback into the sensitivity analysis.
• These and other embodiments are within the scope of the following claims.

Claims (16)

1. A computer-readable medium comprising instructions that cause a programmable processor to:

monitor a value of a performance metric of a patient for each of a plurality of therapy parameter sets, wherein a medical device delivers a therapy to the patient according to each of the therapy parameter sets, each of the therapy parameter sets includes a value for each of a plurality of therapy parameters, and the performance metric comprises a sleep quality metric;

conduct a sensitivity analysis of the performance metric for each of the plurality of therapy parameters based on the monitored values of the performance metric; and

identify a baseline value for each of the plurality of therapy parameters based on the sensitivity analysis to form a baseline therapy parameter set.

2. The medium ofclaim 1, further comprising instructions that cause the processor to receive a range for at least one therapy parameter in the therapy parameter sets and generate the plurality of therapy parameter sets with different values of the therapy parameter distributed over the range.

3. The medium ofclaim 1, further comprising instructions that cause the processor to perturb at least one therapy parameter value of a baseline therapy parameter set that includes the identified therapy parameter values, monitor a perturbed value of the performance metric in response to the perturbed therapy parameter value, compare the perturbed value of the performance metric to the value of the performance metric for the baseline therapy parameter set and adjust the baseline therapy parameter set based on the comparison.

4. The medium ofclaim 1, wherein the performance metric comprises a patient feedback metric.

5. A system comprising:

a therapy device that delivers a therapy to a patient according to each of a plurality of therapy parameter sets, each of the therapy parameter sets including a value for each of a plurality of therapy parameters;

a monitor that monitors values of at least one physiological parameter of a patient during delivery of therapy according to each of the plurality of therapy parameter sets; and

a computing device that receives the physiological parameter values from the monitor, identifies a value of a performance metric of the patient for each of the plurality of parameter sets based on the physiological parameter values monitored during delivery of therapy according to each of the plurality of therapy parameter sets, conducts a sensitivity analysis of the performance metric for each of the plurality of therapy parameters based on the monitored values of the performance metric, and identifies a baseline value for each of the therapy parameters based on the sensitivity analysis to form a baseline therapy parameter set.

6. The system ofclaim 5, wherein one of the therapy device and the computing device comprises the monitor.

7. The system ofclaim 5, wherein the computing device comprises a programming device.

8. The system ofclaim 5, wherein the computing device receives a range for at least one therapy parameter in the therapy parameter sets and generates the plurality of therapy parameter sets with different values of the therapy parameter distributed over the range.

9. The system ofclaim 5, wherein the computing device conducts the sensitivity analysis to determine a value for at least one therapy parameter corresponding to one of a maximum value and a minimum value of the performance metric.

10. The system ofclaim 5, wherein one of the therapy device or another therapy device receives a baseline therapy parameter set that includes the identified baseline therapy parameter values from the computing device, and delivers the therapy to the patient according to the baseline therapy parameter set.

11. The system ofclaim 10, wherein the computing device directs the therapy device or the other therapy device to perturb at least one therapy parameter value of the baseline therapy parameter set and monitors a perturbed value of the performance metric in response to the perturbed therapy parameter value.

12. The system ofclaim 11, wherein the computing device compares the perturbed value of the performance metric to the value of the performance metric for the baseline therapy parameter set and updates the baseline therapy parameter set based on the comparison, and one of the therapy device or the other therapy device receives the updated baseline therapy parameter set from the computing device to adjust the therapy based on the updated baseline therapy parameter set.

13. The system, ofclaim 5, wherein the performance metric comprises a patient feedback metric.

14. The system ofclaim 5, wherein the therapy device comprises an implantable medical device.

15. The system ofclaim 5, wherein the therapy device comprises at least one of a neurostimulator or a pump.

16. The system ofclaim 5, wherein the therapy device comprises at least one of a trial neurostimulator or a trial pump.

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