# Patent

## Title
Method, apparatus and system for bipolar charge utilization during stimulation by an implantable medical device

## Abstract

We disclose a method, apparatus, and system of treating a medical condition in a patient using an implantable medical device. A first electrode is coupled to a first portion of a cranial nerve of the patient. A second electrode is coupled to a second portion of the cranial nerve of the patient. A first electrical signal is provided to the first and second electrodes. The first electrical signal is provided in a first polarity configuration in which the first electrode functions as an anode and the second electrode functions as a cathode. Upon termination of the first electrical signal, the anode and cathode each comprise a first accumulated energy. A second electrical signal is provided to the first and second electrodes, in which the second electrical signal includes at least a portion of the first accumulated energy.

## Background
BACKGROUND OF THE INVENTION
1. Field of the Invention
This invention relates generally to medical devices, and, more particularly, to methods, apparatus, and systems for providing improved charge utilization when providing an electrical signal therapy by a medical device.
2. Description of the Related Art
There have been many improvements over the last several decades in medical treatments for disorders of the nervous system, such as epilepsy and other motor disorders, and abnormal neural discharge disorders. One of the more recently available treatments involves the application of an electrical signal to reduce various symptoms or effects caused by such neural disorders. For example, electrical signals have been successfully applied at strategic locations in the human body to provide various benefits, including reducing occurrences of seizures and/or improving or ameliorating other conditions. A particular example of such a treatment regimen involves applying an electrical signal to the vagus nerve of the human body to reduce or eliminate epileptic seizures, as described in U.S. Pat. Nos. 4,702,254, 4,867,164, and 5,025,807 to Dr. Jacob Zabara, which are hereby incorporated in this specification in their entirety by reference.
More generally, the endogenous electrical activity (i.e., activity attributable to the natural functioning of the patient's own body) of a neural structure of a patient may be modulated in a variety of ways. In particular, the electrical activity may be modulated by exogenously applied (i.e., from a source other than the patient's own body) electrical, chemical, or mechanical signals applied to the neural structure. The modulation (hereinafter referred to generally as “neurostimulation” or “neuromodulation”) may involve the induction of afferent action potentials, efferent action potentials, or both, in the neural structure, and may also involve blocking or interrupting the transmission of endogenous electrical activity traveling along the nerve. Electrical signal therapy or electrical modulation of a neural structure (also known as “electrical signal therapy”) refers to the application of an exogenous therapeutic electrical signal (as opposed to a chemical or mechanical signal), to the neural structure. Electrical signal therapy may be provided by implanting an electrical device underneath the skin of a patient and delivering an electrical signal to a nerve such as a cranial nerve. The electrical signal therapy may involve performing a detection step, with the electrical signal being delivered in response to a detected body parameter. This type of stimulation is generally referred to as “active,” “feedback,” or “triggered” stimulation. Alternatively, the system may operate without a detection system once the patient has been diagnosed with epilepsy (or another medical condition), and may periodically apply a series of electrical pulses to the nerve (e.g., a cranial nerve such as a vagus nerve) intermittently throughout the day, or over another predetermined time interval. This type of stimulation is generally referred to as “passive,” “non-feedback,” or “prophylactic,” stimulation. The stimulation may be applied by an implantable medical device that is implanted within the patient's body.
A number of medical conditions that are amenable to electrical signal therapy via cranial nerve stimulation present symptoms in regions outside the brain. For example, disorders of the neurological system, the gastrointestinal system, the pancreas, or the kidneys, feature impaired or improper function of those organs. Diabetes, particularly type I diabetes, often features impaired production of insulin by the islets of Langerhans in the pancreas. Electrical signal stimulation of either the brain alone or the organ alone may have some efficacy in treating such medical conditions, but may not have maximal efficacy.
Therefore, a need exists for apparatus and methods for performing electrical signal stimulation of both the brain and an organ outside the brain. A need also exists for apparatus and methods for performing electrical signal stimulation with increased efficacy.
SUMMARY OF THE INVENTION
In one aspect, the present invention relates to a method of treating a medical condition in a patient using an implantable medical device. A first electrode is coupled to a first portion of a cranial nerve of the patient. A second electrode is coupled to a second portion of the cranial nerve of the patient. A first electrical pulse is provided to the first and second electrodes. The first electrical pulse is provided in a first configuration in which the first electrode functions as an anode and the second electrode functions as a cathode. Upon termination of the first signal pulse, the anode and cathode each comprises an accumulated energy. A second electrical pulse is provided to the first and second electrodes. The second electrical pulse comprises at least a portion of the accumulated energy.
In another aspect, the present invention relates to another method for treating a medical condition in a patient using an implantable medical device. A first electrical signal is provided to a first electrode coupled to a first portion of a cranial nerve of the patient, as well as to a second electrode coupled to a second portion of a cranial nerve of the patient. The first electrical signal is provided in a first configuration in which the first electrode functions as an anode and the second electrode functions as a cathode. The anode and cathode each comprises an accumulated energy based upon the first signal pulse. A second configuration of the electrodes is provided upon termination of the first electrical signal. In the second configuration, the first electrode functions as the cathode and the second electrode function as the anode. A second electrical signal is provided to the first and second electrodes in the second configuration. The second electrical signal comprises at least a portion of the accumulated energy.
In yet another aspect, the present invention relates to another method for treating a medical condition in a patient using an implantable medical device. A first electrode is coupled to a portion of a right cranial nerve of the patient. A second electrode is coupled to a portion of a left cranial nerve of the patient. A first electrical signal is provided to the first and second electrodes. The first electrical signal is provided in a first configuration in which the first electrode functions as an anode and the second electrode functions as a cathode. Upon termination of the first electrical signal, the anode and cathode each comprise an accumulated energy. A second configuration of the electrodes is provided upon termination of the first electrical signal. In the second configuration, the first electrode functions as the cathode and the second electrode function as the anode. A second electrical signal is provided to the first and second electrodes in the second configuration. The second electrical signal comprises at least a portion of the accumulated energy.
In another aspect, the present invention relates to an implantable medical device for treating a medical condition in a patient. The device includes a controller capable of receiving data and controlling the operation of the implantable medical device by providing at least one control parameter. The device also includes a stimulation unit for generating and delivering, based upon the at least one control parameter, a first electrical signal to a first electrode electrically coupled to a first portion of a cranial nerve and to a second electrode electrically coupled to a second cranial nerve. The first electrical signal is provided in a first configuration, in which the first electrode functions as an anode and the second electrode functions as a cathode. Upon termination of the first electrical signal, the anode and cathode each includes an accumulated energy resulting from the first electrical signal. The device also comprises an electrode polarity reversal unit that is capable of changing the configuration of the first and second electrodes from the first configuration to the second configuration. The stimulation unit also generates and delivers a second electrical signal to the first and second electrodes in the second configuration. The second electrical signal comprises at least a portion of the accumulated energy.
In yet another aspect, the present invention relates to a computer readable program storage device encoded with instructions that, when executed by a computer, performs a method for treating a medical condition in a patient. The method includes providing a first electrical signal to a first electrode coupled to a first portion of a cranial nerve of the patient, and to a second electrode coupled to a second portion of a cranial nerve of the patient. The first electrical signal is provided in a first configuration in which the first electrode functions as an anode and the second electrode functions as a cathode. Upon termination of the first electrical signal, the anode and cathode each includes an accumulated energy. The method also includes providing a second configuration of the electrodes upon termination of the first electrical signal. In the second configuration, the first electrode functions as the cathode and the second electrode functions as the anode. A second electrical signal is provided to the first and second electrodes in the second configuration. The second electrical signal comprises at least a portion of the accumulated energy.



BRIEF DESCRIPTION OF THE DRAWINGS
The invention may be understood by reference to the following description taken in conjunction with the accompanying drawings, in which like reference numerals identify like elements, and in which:
FIGS. 1A-1C provide stylized diagrams of an implantable medical device implanted into a patient's body for providing electrical signals to a portion of the patient's body, in accordance with one illustrative embodiment of the present invention;
FIG. 2 illustrates a block diagram depiction of the implantable medical device of FIG. 1, in accordance with one illustrative embodiment of the present invention;
FIG. 3 illustrates a block diagram depiction of an electrode polarity reversal unit shown in FIG. 2, in accordance with one illustrative embodiment of the present invention;
FIG. 4 illustrates a flowchart depiction of a method for performing limited patient-initiated electrical signal therapy, in accordance with an illustrative embodiment of the present invention;
FIG. 5 illustrates a flowchart depiction of a method for performing limited patient-initiated electrical signal therapy, in accordance with another illustrative embodiment of the present invention;
FIG. 6 illustrates an implementation of the IMD of FIG. 2 and related electrodes in an illustrative configuration, in accordance with one illustrative embodiment of the present invention;
FIGS. 7A-7D provide various diagrams illustrating electrical characteristics of signals generated by the IMD 200 in the configuration provided in FIG. 6;
FIG. 8 illustrates a reversed configuration of the IMD relative to the configuration illustrated in FIG. 6, in accordance with one illustrative embodiment of the present invention;
FIGS. 9A-9D provide various diagrams illustrating electrical characteristics of signals generated by the IMD 200 in the configuration provided in FIG. 8; and
FIGS. 10A-10D provide various electrical diagrams of signals at various nodes of the configuration illustrated in FIGS. 6 and 8, in accordance with one illustrative embodiment of the present invention.



While the invention is susceptible to various modifications and alternative forms, specific embodiments thereof have been shown by way of example in the drawings and are herein described in detail. It should be understood, however, that the description herein of specific embodiments is not intended to limit the invention to the particular forms disclosed, but on the contrary, the intention is to cover all modifications, equivalents, and alternatives falling within the spirit and scope of the invention as defined by the appended claims.
DETAILED DESCRIPTION OF SPECIFIC EMBODIMENTS
Illustrative embodiments of the invention are described herein. In the interest of clarity, not all features of an actual implementation are described in this specification. In the development of any such actual embodiment, numerous implementation-specific decisions must be made to achieve the design-specific goals, which will vary from one implementation to another. It will be appreciated that such a development effort, while possibly complex and time-consuming, would nevertheless be a routine undertaking for persons of ordinary skill in the art having the benefit of this disclosure.
This document does not intend to distinguish between components that differ in name but not function. In the following discussion and in the claims, the terms “including” and “includes” are used in an open-ended fashion, and thus should be interpreted to mean “including, but not limited to.” Also, the term “couple” or “couples” is intended to mean either a direct or an indirect electrical connection. “Direct contact,” “direct attachment,” or providing a “direct coupling” indicates that a surface of a first element contacts the surface of a second element with no substantial attenuating medium there between. The presence of small quantities of substances, such as bodily fluids, that do not substantially attenuate electrical connections does not vitiate direct contact. The word “or” is used in the inclusive sense (i.e., “and/or”) unless a specific use to the contrary is explicitly stated.
The term “electrode” or “electrodes” described herein may refer to one or more stimulation electrodes (i.e., electrodes for delivering an electrical signal generated by an IMD to a tissue), sensing electrodes (i.e., electrodes for sensing a physiological indication of a patient's body), and/or electrodes that are capable of delivering a stimulation signal, as well as performing a sensing function.
Cranial nerve stimulation, such as vagus nerve stimulation (VNS), has been proposed to treat a number of medical conditions pertaining to or mediated by one or more structures of the nervous system of the body, including epilepsy and other movement disorders, depression, anxiety disorders and other neuropsychiatric disorders, dementia, head trauma, coma, migraine headache, obesity, eating disorders, sleep disorders, cardiac disorders (such as congestive heart failure and atrial fibrillation), hypertension, endocrine disorders (such as diabetes and hypoglycemia), and pain, among others. See, e.g., U.S. Pat. Nos. 4,867,164; 5,299,569; 5,269,303; 5,571,150; 5,215,086; 5,188,104; 5,263,480; 6,587,719; 6,609,025; 5,335,657; 6,622,041; 5,916,239; 5,707,400; 5,231,988; and 5,330,515. Despite the numerous disorders for which cranial nerve stimulation has been proposed or suggested as a treatment option, the fact that detailed neural pathways for many (if not all) cranial nerves remain relatively unknown, makes predictions of efficacy for any given disorder difficult or impossible. Moreover, even if such pathways were known, the precise stimulation parameters that would modulate particular pathways relevant to a particular disorder generally cannot be predicted.
In one embodiment, the present invention provides a method of treating a medical condition. The medical condition can be selected from the group consisting of epilepsy, neuropsychiatric disorders (including but not limited to depression), eating disorders/obesity, traumatic brain injury/coma, addiction disorders, dementia, sleep disorders, pain, migraine, endocrine/pancreatic disorders (including but not limited to diabetes), motility disorders, hypertension, congestive heart failure/cardiac capillary growth, hearing disorders, angina, syncope, vocal cord disorders, thyroid disorders, pulmonary disorders, gastrointestinal disorders, kidney disorders, and reproductive endocrine disorders (including infertility).
In a further embodiment, the medical condition is selected from the group consisting of depression, epilepsy, obesity, bulimia, traumatic brain injury, congestive heart failure, stroke, coma, fibromyalgia, addiction disorders, multiple sclerosis, haring disorder, Alzheimer's disease, Parkinson's disease, gastrointestinal disorders, pancreatic disorders, kidney disorders, and diabetes.
Still further, embodiments of the present invention provide for performing a bipolar stimulation utilizing a node reversal technique. The bipolar stimulation may be implemented in a bilateral and/or a unilateral fashion, e.g., in vagus nerve stimulation, to both the left and right branches of the vagus nerve (bilateral stimulation), or to the left vagus nerve alone or the right vagus nerve alone (unilateral stimulation). Utilizing the node reversal technique of reversing the cathode and the anode of a signal delivery location, efficiency in charge usage may be realized. Embodiments of the present invention provide for utilizing the excess charges resulting from delivery of a previously applied therapeutic electrical signal. The excess charges may be used in a manner whereupon reversal of electrical nodes of electrodes associated with an IMD may be used to boost a subsequently generated and applied electrical signal, thereby realizing improved efficiencies and charge usage. Utilizing techniques provided by the present invention, increase of charge efficiency resulting in decrease of charge usage in the order of 80% or above may be realized.
Although not so limited, a system capable of implementing embodiments of the present invention is described below. FIGS. 1A-1C depict a stylized implantable medical system 100 for implementing one or more embodiments of the present invention. FIGS. 1A-1C illustrate an electrical signal generator 110 having main body 112 comprising a case or shell 121 (FIG. 1B) with a header 116 (FIG. 1A, 1B) for connecting to leads 122. The generator 110 is implanted in the patient's chest in a pocket or cavity formed by the implanting surgeon just below the skin (indicated by a line 145, FIG. 1A), similar to the implantation procedure for a pacemaker pulse generator.
A stimulating nerve electrode assembly 125, preferably comprising at least an electrode pair, is conductively connected to the distal end of an insulated, electrically conductive lead assembly 122, which preferably comprises a pair of lead wires (one wire for each electrode of an electrode pair). Lead assembly 122 is attached at its proximal end to connectors on the header 116 (FIG. 1B) on case 121. The electrode assembly 125 may be surgically coupled to a cranial nerve, such as vagus nerve 127, in the patient's neck or head, or at another location, e.g., near the patient's diaphragm. Other cranial nerves, such as the trigeminal and/or glossopharyngeal nerves, may also be used to deliver the therapeutic electrical signal. The electrode assembly 125 preferably comprises a bipolar stimulating electrode pair 125-1, 125-2 (FIG. 1C), such as the electrode pair described in U.S. Pat. No. 4,573,481 issued Mar. 4, 1986 to Bullara. Suitable electrode assemblies are available from Cyberonics, Inc., Houston, Tex., USA as the Model 302 electrode assembly. However, persons of skill in the art will appreciate that many electrode designs could be used in the present invention, including unipolar electrodes. Returning to FIGS. 1A and 1C, the two electrodes are preferably wrapped about the cranial nerve, such as vagus nerve 127, and the electrode assembly 125 may be secured to the nerve by a spiral anchoring tether 128 (FIG. 1C) such as that disclosed in U.S. Pat. No. 4,979,511 issued Dec. 25, 1990 to Reese S. Terry, Jr. and assigned to the same assignee as the instant application. Lead assembly 122 is secured, while retaining the ability to flex with movement of the chest and neck, by a suture connection 130 to nearby tissue (FIG. 1C).
In one embodiment, the open helical design of the electrode assembly 125 (described in detail in the above-cited Bullara patent), which is self-sizing and flexible, minimizes mechanical trauma to the nerve and allows body fluid interchange with the nerve. The electrode assembly 125 preferably conforms to the shape of the nerve, providing a low stimulation threshold by allowing a large stimulation contact area with the nerve. Structurally, the electrode assembly 125 comprises two electrode ribbons (not shown), of a conductive material such as platinum, iridium, platinum-iridium alloys, and/or oxides of the foregoing. The electrode ribbons are individually bonded to an inside surface of an elastomeric body portion of the two spiral electrodes 125-1 and 125-2 (FIG. 1C), which may comprise two spiral loops of a three-loop helical assembly. The lead assembly 122 may comprise two distinct lead wires or a coaxial cable whose two conductive elements are respectively coupled to one of the conductive electrode ribbons. One suitable method of coupling the lead wires or cable to the electrodes 125-1, 125-2 comprises a spacer assembly such as that disclosed in U.S. Pat. No. 5,531,778, although other known coupling techniques may be used.
The elastomeric body portion of each loop is preferably composed of silicone rubber, and the third loop 128 (which typically has no electrode) acts as the anchoring tether for the electrode assembly 125.
In one embodiment, a first electrode is coupled to a first portion of a first electrically-stimulatable structure of the patient, and a second electrode is coupled to a second portion of a second electrically-stimulatable structure of the patient. The person of ordinary skill in the art can, in light of the present disclosure, identify electrically-stimulatable structures of the patient as a matter of routine experimentation. By coupling the electrodes as described in this paragraph, electrical signal stimulation can be effected on any electrically-stimulatable structure of the patient. In one embodiment, the first electrically-stimulatable structure is selected from the group consisting of the brain, the spinal cord, the peripheral nerves, and the heart, and the second electrically-stimulatable structure is selected from the group consisting of the brain, the spinal cord, the peripheral nerves, and the heart.
In one embodiment, the pulse generator case 121 can function as an electrode. In this embodiment, one or more electrodes 125 can be coupled to a cranial nerve, such as the vagus nerve 127, for delivery of electrical signals to the cranial nerve, and the pulse generator case 121 can be located in proximity to a tissue for delivery of electrical signals to the tissue.
The electrical pulse generator 110 may be programmed with an external computer 150 using programming software of a type known in the art for stimulating neural structures, or other suitable software based on the description herein, and a programming wand 155 to facilitate radio frequency (RF) communication between the computer 150 (FIG. 1A) and the pulse generator 110. The wand 155 and software permit wireless, non-invasive communication with the generator 110 after the latter is implanted. The wand 155 is preferably powered by internal batteries, and provided with a “power on” light to indicate sufficient power for communication. Another indicator light may be provided to show that data transmission is occurring between the wand and the generator.
A variety of stimulation therapies may be provided in implantable medical systems 100 of the present invention. Different types of nerve fibers (e.g., A, B, and C-fibers being different fibers targeted for stimulation) respond differently to stimulation from electrical signals. More specifically, the different types of nerve fibers have different conduction velocities and stimulation thresholds and, therefore, differ in their responsiveness to stimulation. Certain pulses of an electrical stimulation signal, for example, may be below the stimulation threshold for a particular fiber and, therefore, may generate no action potential in the fiber. Thus, smaller or narrower pulses may be used to avoid stimulation of certain nerve fibers (such as C-fibers) and target other nerve fibers (such as A and/or B fibers, which generally have lower stimulation thresholds and higher conduction velocities than C-fibers). Additionally, techniques such as pre-polarization may be employed wherein particular nerve regions may be polarized before a more robust stimulation is delivered, which may better accommodate particular electrode materials. Furthermore, opposing polarity phases separated by a zero current phase may be used to excite particular axons or postpone nerve fatigue during long term stimulation.
As used herein, the terms “stimulating” and “stimulator” may generally refer to delivery of a signal, stimulus, or impulse to neural tissue for affecting neuronal activity of a neural tissue (e.g., a volume of neural tissue in the brain or a nerve). The effect of such stimulation on neuronal activity is termed “modulation”; however, for simplicity, the terms “stimulating” and “modulating”, and variants thereof, are sometimes used interchangeably herein. The effect of delivery of the stimulation signal to the neural tissue may be excitatory or inhibitory and may potentiate acute and/or long-term changes in neuronal activity. For example, the effect of “stimulating” or “modulating” a neural tissue may comprise one or more of the following effects: (a) changes in neural tissue to initiate an action potential (bi-directional or uni-directional); (b) inhibition of conduction of action potentials (endogenous or externally stimulated) or blocking the conduction of action potentials (hyperpolarizing or collision blocking), (c) affecting changes in neurotransmitter/neuromodulator release or uptake, and (d) changes in neuro-plasticity or neurogenesis of brain tissue. Applying an electrical signal to an autonomic nerve may comprise generating a response that includes an afferent action potential, an efferent action potential, an afferent hyperpolarization, an efferent hyperpolarization, an afferent sub-threshold depolarization, and/or an efferent sub-threshold depolarization.
In one embodiment, the stimulation method includes the steps of generating a first electrical signal with the electrical signal generator, applying the first electrical signal to the electrodes, wherein the first electrode is a cathode and the second electrode is an anode, reversing the polarity of the first electrode and the second electrode, yielding a configuration wherein the first electrode is an anode and the second electrode is a cathode, generating a second electrical signal with the electrical signal generator, applying the second electrical signal to the electrodes, reversing the polarity of the first electrode and the second electrode, yielding a configuration wherein the first electrode is a cathode and the second electrode is an anode, generating a third electrical signal with the electrical signal generator, and applying the third electrical signal to the electrodes.
In one embodiment, the first electrical signal, the second electrical signal, and the third electrical signal are substantially identical. In another embodiment, the first electrical signal may vary from the second electrical signal, the third electrical signal, or both in terms of one or more of pulse width, number of pulses, amplitude, frequency, stimulation on-time, and stimulation off-time, among other parameters.
The first electrical signal, the second electrical signal, and the third electrical signal are described herein in terms of exemplary illustrations. The person of ordinary skill in the art having benefit of the present disclosure would appreciate that more than three electrical signals, up to an nth electrical signal, can be used and are within the scope of the present invention.
“Cathode” and “anode” have their standard meanings, as the electrode at which current leaves the IMD system and the electrode at which current enters the IMD system, respectively. Reversing the polarity of the electrodes can be effected by any switching technique known in the art.
A “pulse” is used herein to refer to a single application of electrical charge from the cathode to the cranial nerve. Individual pulses are separated by a time period in which no charge is delivered to the nerve, which can be called the “interpulse interval.” A “burst” is used herein to refer to a plurality of pulses, wherein no charge is delivered to the nerve before the first pulse of the burst for a time period at least twice as long as the interpulse interval and no charge is delivered to the nerve after the last pulse of the burst for a time period at least twice as long as the interpulse interval. The time period between the end of the last pulse of a first burst and the initiation of the first pulse of the next subsequent burst can be called the “interburst interval.” In one embodiment, the interburst interval is at least 100 msec.
A plurality of pulses can refer to any of (a) a number of consecutive pulses within a burst, (b) all the pulses of a burst, or (c) a number of consecutive pulses including the final pulse of a first burst and the first pulse of the next subsequent burst.
Each of the first, second, and third electrical signals can independently contain one or more pulses. In one embodiment, the first electrical signal contains one or more pulses, the second electrical signal contains one or more pulses, and the third electrical signal contains one or more pulses. In a further embodiment, the first electrical signal contains one pulse, the second electrical signal contains one pulse, and the third electrical signal contains one pulse.
The number of pulses contained within the first and second electrical signals or the second and third electrical signals need not be equal, and can be in any ratio. In one embodiment, the ratio is from about 1:100 to about 100:1. In a further embodiment, the ratio is from about 1:10 to about 10:1.
In one embodiment, the first electrical signal contains a first number of pulses, the second electrical signal contains a second number of pulses, and the third electrical signal contains a third number of pulses, wherein the first number of pulses is not equal to the second number of pulses or the second number of pulses is not equal to the third number of pulses.
In another embodiment, the first electrical signal contains one or more bursts, the second electrical signal contains one or more bursts, and the third electrical signal contains one or more bursts. In a further embodiment, the first electrical signal contains one burst, the second electrical signal contains one burst, and the third electrical signal contains one burst.
The number of bursts contained within the first and second electrical signals or the second and third electrical signals need not be equal, and can be in any ratio. In one embodiment, the ratio is from about 1:100 to about 100:1. In a further embodiment, the ratio is from about 1:10 to about 10:1.
In one embodiment, the first electrical signal contains a first number of bursts, the second electrical signal contains a second number of bursts, and the third electrical signal contains a third number of bursts, wherein the first number of bursts is not equal to the second number of bursts or the second number of bursts is not equal to the third number of bursts.
Typical cranial nerve stimulation can be performed with an interpulse frequency of 20-30 Hz (resulting in a number of pulses per burst of 140-1800, at a burst duration from 7-60 sec). In one embodiment, at least one of the first electrical signal, the second electrical signal, and the third electrical signal delivers microbursts. Microburst neurostimulation is discussed by U.S. Ser. No. 11/693,451, filed Mar. 2, 2007 and published as United States patent Publication No. 20070233193, and incorporated herein by reference. In one embodiment, at least one of the first electrical signal, the second electrical signal, and the third electrical signal is characterized by having a number of pulses per microburst from 2 pulses to about 25 pulses, an interpulse interval of about 2 msec to about 50 msec, an interburst period of at least 100 msec, and a microburst duration of less than about 1 sec.
As stated above, different fiber types of cranial nerves propagate action potentials at different velocities. In one embodiment of the method, after performance of a prior applying step, the subsequent applying step is performed after an action potential induced by the prior applying step in A-fibers of the cranial nerve has passed the anode of the subsequent applying step and before an action potential induced by the prior applying step in C-fibers of the cranial nerve reaches the anode of the subsequent applying step. As a result, in this embodiment, an action potential induced in the A-fibers in the prior applying step can propagate along the nerve in the direction from the cathode of the prior applying step to the anode of the prior applying step and beyond to the brain or the distal terminus of the cranial nerve. Whereas, an action potential induced in the C-fibers in the prior applying step, though originally propagating along the nerve in the direction from the cathode of the prior applying step to the anode of the prior applying step, can be blocked by an electrical stimulation performed at the anode of the subsequent applying step, which was the cathode of the prior applying step. To generalize, by performing this method, particular fiber types in the cranial nerve can be selectively stimulated to propagate an action potential to either the proximal terminus (i.e., the brain) or distal terminus of the cranial nerve.
Turning now to FIG. 2, a block diagram depiction of an implantable medical device, in accordance with one illustrative embodiment of the present invention is illustrated. The IMD 200 may be coupled to various leads, e.g., 122 (FIGS. 1A, 1C). Stimulation signals used for therapy may be transmitted from the IMD 200 to target areas of the patient's body, specifically to various electrodes associated with the leads 122. Stimulation signals from the IMD 200 may be transmitted via the leads 122 to stimulation electrodes (electrodes that apply the therapeutic electrical signal to the target tissue) associated with the electrode assembly 125, e.g., 125-1, 125-2 (FIG. 1A). Further, signals from sensor electrodes (electrodes that are used to sense one or more body parameters such as temperature, heart rate, brain activity, etc.) may also traverse the leads back to the IMD 200.
The IMD 200 may comprise a controller 210 capable of controlling various aspects of the operation of the IMD 200. The controller 210 is capable of receiving internal data and/or external data and controlling the generation and delivery of a stimulation signal to target tissues of the patient's body. For example, the controller 210 may receive manual instructions from an operator externally, or may perform stimulation based on internal calculations and programming. The controller 210 is capable of affecting substantially all functions of the IMD 200.
The controller 210 may comprise various components, such as a processor 215, a memory 217, etc. The processor 215 may comprise one or more micro controllers, micro processors, etc., that are capable of executing a variety of software components. The memory 217 may comprise various memory portions, where a number of types of data (e.g., internal data, external data instructions, software codes, status data, diagnostic data, etc.) may be stored. The memory 217 may store various tables or other database content that could be used by the IMD 200 to implement the override of normal operations. The memory 217 may comprise random access memory (RAM) dynamic random access memory (DRAM), electrically erasable programmable read-only memory (EEPROM), flash memory, etc.
The IMD 200 may also comprise a stimulation unit 220. The stimulation unit 220 is capable of generating and delivering a variety of electrical signal therapy signals to one or more electrodes via leads. The stimulation unit 220 is capable of delivering a programmed, primary mode electrical signal to the leads 122 coupled to the IMD 200. The electrical signal may be delivered to the leads 122 by the stimulation unit 220 based upon instructions from the controller 210. The stimulation unit 220 may comprise various types of circuitry, such as stimulation signal generators, impedance control circuitry to control the impedance “seen” by the leads, and other circuitry that receives instructions relating to the type of stimulation to be performed.
The IMD 200 may also comprise an electrode polarity reversal unit 280. The electrode polarity reversal unit 280 is capable of reversing the polarity of electrodes associated with the electrode assembly 125. The electrode polarity reversal unit 280 is shown in more detail in FIG. 3. In preferred embodiments, the electrode polarity reversal unit is capable of reversing electrode polarity rapidly, i.e., in about 10 microseconds or less, and in any event at a sufficiently rapid rate to permit electrode polarities to be changed between adjacent pulses in a pulsed electrical signal.
The IMD 200 may also comprise a power supply 230. The power supply 230 may comprise a battery, voltage regulators, capacitors, etc., to provide power for the operation of the IMD 200, including delivering the stimulation signal. The power supply 230 comprises a power-source battery that in some embodiments may be rechargeable. In other embodiments, a non-rechargeable battery may be used. The power supply 230 provides power for the operation of the IMD 200, including electronic operations and the stimulation function. The power supply 230, may comprise a lithium/thionyl chloride cell or a lithium/carbon monofluoride (LiCFx) cell. Other battery types known in the art of implantable medical devices may also be used.
The IMD 200 also comprises a communication unit 260 capable of facilitating communications between the IMD 200 and various devices. In particular, the communication unit 260 is capable of providing transmission and reception of electronic signals to and from an external unit 270. The external unit 270 may be a device that is capable of programming various modules and stimulation parameters of the IMD 200. In one embodiment, the external unit 270 comprises a computer system that is capable of executing a data-acquisition program. The external unit 270 may be controlled by a healthcare provider, such as a physician, at a base station in, for example, a doctor's office. The external unit 270 may be a computer, preferably a handheld computer or PDA, but may alternatively comprise any other device that is capable of electronic communications and programming. The external unit 270 may download various parameters and program software into the IMD 200 for programming the operation of the implantable device. The external unit 270 may also receive and upload various status conditions and other data from the IMD 200. The communication unit 260 may be hardware, software, firmware, and/or any combination thereof. Communications between the external unit 270 and the communication unit 260 may occur via a wireless or other type of communication, illustrated generally by line 275 in FIG. 2.
In one embodiment, the communication unit 260 can transmit a log of stimulation data to the patient, a physician, or another party.
The IMD 200 is capable of delivering stimulation that can be intermittent, periodic, random, sequential, coded, and/or patterned. The stimulation signals may comprise an electrical stimulation frequency of approximately 0.1 to 2500 Hz. The stimulation signals may comprise a pulse width in the range of approximately 1-2000 micro-seconds. The stimulation signals may comprise current amplitude in the range of approximately 0.1 mA to 10 mA. The stimulation delivered by the IMD 200 according to its programming may be referred to herein as “normal operations” or as a “normal operating mode.”
The IMD 200 may also comprise a magnetic field detection unit 290. The magnetic field detection unit 290 is capable of detecting magnetic and/or electromagnetic fields of a predetermined magnitude. Whether the magnetic field results from a magnet placed proximate to the IMD 200, or whether it results from a substantial magnetic field encompassing an area, the magnetic field detection unit 290 is capable of informing the IMD of the existence of a magnetic field. The changeable electrode polarity stimulation described herein may be activated, deactivated, or alternatively activated or deactivated using a magnetic input.
The magnetic field detection unit 290 may comprise various sensors, such as a Reed Switch circuitry, a Hall Effect sensor circuitry, and/or the like. The magnetic field detection unit 290 may also comprise various registers and/or data transceiver circuits that are capable of sending signals that are indicative of various magnetic fields, the time period of such fields, etc. In this manner, the magnetic field detection unit 290 is capable of detecting whether the detected magnetic field relates to an inhibitory input or an excitory input from an external source. The inhibitory input may refer to an inhibition of, or a deviation from, normal stimulation operation. The excitory input may refer to additional stimulation or deviation from normal stimulation.
One or more of the blocks illustrated in the block diagram of the IMD 200 in FIG. 2, may comprise hardware units, software units, firmware units, or any combination thereof. Additionally, one or more blocks illustrated in FIG. 2 may be combined with other blocks, which may represent circuit hardware units, software algorithms, etc. Additionally, one or more of the circuitry and/or software units associated with the various blocks illustrated in FIG. 2 may be combined into a programmable device, such as a field programmable gate array, an ASIC device, etc.
FIG. 3 shows in greater detail the electrode polarity reversal unit 280 (FIG. 2). The electrode polarity reversal unit 280 comprises an electrode configuration switching unit 340, which includes a switching controller 345. The switching controller 345 transmits signals to one or more switches, generically, n switches 330(1), 330(2), . . . 330(n) which effect the switching of the configuration of two or more electrodes, generically, n electrodes 125(1), 125(2), . . . 125(n). Although FIG. 3 shows equal numbers of switches 330 and electrodes 125, the person of ordinary skill in the art having the benefit of the present disclosure will understand that the number of switches 330 and their connections with the various electrodes 125 can be varied as a matter of routine optimization. A switching timing unit 333 can signal to the electrode configuration switching unit 340 that a desired time for switching the electrode configuration has been reached.
Instructions for implementing a series of predetermined and/or programmable stimulation regimens may be stored in the IMD 200. These stimulation regimens may include data relating to the type of changeable electrode polarity stimulation to be implemented. For example, a first stimulation regimen may call for a particular type of pulse signal in one direction and having one electrode polarity configuration (e.g., an electrical signal in which action potentials to the brain are not blocked, and in which action potentials to a distal terminus of the nerve are partially or completely blocked or inhibited), followed by a plurality of microburst type signals during the normal off-time and delivered in the other direction (e.g., with the electrode polarities reversed such that action potentials to the brain are partially or completely blocked or inhibited, but action potentials to the distal terminus of the nerve are not blocked or inhibited). A second exemplary stimulation regimen may call for a series of pulses in a first direction, followed by an off-time, and then followed by a series of pulses in the opposite direction. A third exemplary stimulation regimen may call for switching electrode polarity in a 2-electrode configuration after each pulse, such that propagation of action potentials in each direction are sequentially permitted and then at least partially blocked, then permitted again in alternating sequence. In other embodiments, multiple pulses may be generated in a first electrode configuration, followed by switching electrode polarity to a second electrode configuration for one or a few pulses, followed by switching polarity back to the first electrode configuration. Information relating to the stimulation regimens may be used by the electrode polarity reversal unit 280 to control the operations of the first through nth switches 330(1−n).
In one embodiment, each of a plurality of stimulation regimens may respectively relate to a particular disorder. In one embodiment, different regimens relating to the same disorder may be implemented to accommodate improvements or regressions in the patient's present condition relative to his or her condition at previous times. By providing flexibility in electrode configurations nearly instantaneously, the present invention greatly expands the range of adjustments that may be made to respond to changes in the patient's underlying medical condition.
The switching controller 345 may be a processor that is capable of receiving data relating to the stimulation regimens. In an alternative embodiment, the switching controller may be a software or a firmware module. Based upon the particulars of the stimulation regimens, the switching timing unit 333 may provide timing data to the switching controller 345. The first through nth switches 330(1−n) may be electrical devices, electromechanical devices, and/or solid state devices (e.g., transistors).
FIG. 4 shows one embodiment of a method of performing changeable electrode polarity stimulation according to the present invention. In this embodiment, the IMD 200 has a first normal stimulation mode in which it performs single polarity stimulation 410, i.e., stimulation in which only one electrode 125 of the IMD 200 is the cathode for delivery of electrical signals to the cranial nerve, such as vagus nerve 127, and in which the electrode polarities are only changed by manual programming. At predetermined times during performance of single polarity stimulation 410, the IMD 200 checks 420 whether a signal to enter a changeable electrode polarity stimulation mode has been received. The signal to enter a changeable electrode polarity stimulation mode can be received, by way of nonlimiting examples, from the controller 210 (FIG. 2), from a sensor or sensors implanted in or on the patient's body which detect(s) one or more bodily parameters (e.g., heart rate, respiration rate, blood pressure, blood glucose, etc.), from a medical practitioner communicating with the device via wand 155 (FIG. 1), or a medical practitioner or patient using a magnet to provide a signal via the magnetic field detection unit 290. Regardless of the nature of the signal, if the IMD 200 does not detect it when checking 420, the IMD reverts to single polarity stimulation 410.
However, if the signal is received, the IMD 200 then implements a changeable electrode polarity stimulation mode shown in steps 430-460. Specifically, the IMD 200 delivers 430 a first predetermined number of pulses in a first polarity configuration of the electrodes. For an example, a first electrode 125(1) may be the cathode and a second electrode 125(2) may be the anode in step 430. After the first predetermined number of pulses are delivered in the first polarity configuration (step 430), the IMD 200 reverses 440 the polarity of the electrodes to a second polarity configuration. Continuing the example, the first electrode 125(1) may be switched to be the anode and the second electrode 125(2) may be switched to be the cathode. It will be appreciated that, where 3 or more electrodes are used, only some of the electrode polarities may be reversed. Step 450 resembles step 430, though it will be noted the second polarity configuration differs from the first polarity configuration and the second predetermined number of pulses may differ in number of pulses or other stimulation parameters (pulse frequency, pulse width, On Time, Off Time, interpulse interval, number of pulses per burst, or interburst interval, among others) from the first predetermined number of pulses. Step 460 resembles step 440, though it will be noted it reverts the configuration of the electrodes to the first electrode polarity configuration as of step 430.
After steps 430-460 have been performed, the IMD 200 checks 470 whether a signal to discontinue the changeable electrode polarity stimulation mode has been received. The signal to discontinue the changeable electrode polarity stimulation mode can be received from the same sources described above in the context of checking step 420. Regardless of the nature of the signal, if the IMD 200 does not detect the signal when performing checking step 470, the IMD 200 continues changeable electrode polarity stimulation by returning to step 430. If the signal is detected when performing checking step 470, the IMD 200 reverts to single polarity stimulation 410.
FIG. 5 shows another embodiment of a method according to the present invention. The method comprises steps 530-560, which resemble steps 430-460 shown in FIG. 4. The method shown in FIG. 5 does not include single polarity stimulation; after the second reversal step 560 is performed, the IMD 200 continues changeable electrode polarity stimulation by returning to step 530.
In the methods shown in FIGS. 4-5, one or more of the properties of the first predetermined number of pulses (e.g., number of pulses, pulse frequency, pulse width, On Time, Off Time, interpulse interval, number of pulses per burst, or interburst interval, among others) can be changed upon each performance of step 430 or 530. The properties can be varied in a preprogrammed fashion, following programming executed by the controller 210, or can be varied according to data retrieved from a sensor of a bodily parameter of the patient or in response to instructions received from a medical practitioner or the patient. Similarly, one or more of the properties of the second predetermined number of pulses can be changed upon each performance of step 450 or 550.
Turning now to FIG. 6, an exemplary configuration of the IMD 200 and electrodes being implemented in a patient's body, in accordance with an illustrative embodiment of the present invention, is provided. The IMD 200 provides therapeutic stimulation signals via the stimulation unit 220. The stimulation unit 220 provides signals via leads that are coupled to a first electrode 610 and a second electrode 620. The first and second electrodes 610, 620, may be coupled to a portion of a tissue in a patient. The diagram in FIG. 6 depicts a tissue impedance experienced at the nodes of the first and second electrodes 610, 620. The tissue impedance 630 may generally be constant with slight variations based on bodily changes. For example, the tissue impedance may vary based upon hydration, pH changes, tissue fibrosis around the electrodes, electrode polarization, electrode metal oxidation, scar tissue formation, injury, infection, inflammation, and other factors related to electrolyte balance, or two or more thereof. For example, the tissue impedance may vary based upon the acute-to-chronic transition from lead implant wherein the lead impedance may be 1800 Ohms soon after implant and 2800 Ohms a month after implant.
Upon delivery of an electrical pulse by the IMD 200, an electrical circuit path is completed, wherein a current (I) passes through the first electrode 610, through the tissue impedance 630, and through the second electrode 620. This results in a voltage (V) across the tissue impedance 630. The IMD 200 may also comprise a 1st capacitor (C1) in series with the first electrode 610, as well as a 2nd capacitor (C2) in series with the second electrode 620. The 1st and 2nd capacitors C1, C2 are provided for dissipating electrical charges built-up on the 1st and 2nd electrodes 610, 620 as a result of delivering therapeutic stimulation signals to the tissue impedance 630.
The diagram of FIG. 6 also illustrates a first node (i.e., first anode) at the distal end of the electrode 610 and a second node (i.e., first cathode) at the distal end of the second electrode 620. The electrode polarity reversal unit 280 is capable of switching or reversing the polarity of the first and second electrodes to provide the changeable electrode polarity stimulation provided herein. In other words, the anode and cathode functions performed by the first and second nodes, respectively, may be reversed, wherein the first node transforms from being the anode to the cathode and the second node transforms from being the cathode to the anode.
Referring simultaneously to FIGS. 6 and 7A-7D, illustrative diagrams of an exemplary signal pulse and various resultant electrical parameters related to the circuit of FIG. 6, are provided. The 1st and 2nd capacitors C1, C2 are capable of dissipating the charge build-up that results from the delivery of therapeutic electrical signal pulses to the tissue region represented by the tissue impedance 630. The stimulation unit 220 is capable of providing a controlled current signal that is exemplified in FIG. 7A, which illustrates a current pulse signal. The delivery of the current illustrated in FIG. 7A may result in a voltage, V, as illustrated in FIG. 7B. The development of the voltage V as the current passes through the tissue impedance 630 is due to the flow of the current (I). Upon termination of the current pulse I, charge build-up is dissipated by the capacitors C1 and C2 at a rate defined by the time-constant (τ) of each capacitor C1, C2. Therefore, the voltage across the capacitor C1 and C2, upon termination of the current I, will dissipate in an asymptotic fashion defined by the Equations 1 and 2:

Vfinal=Vinitial*e−t/τ;  Equation 1

τ=R*C;  Equation 2

wherein Vfinal is the steady state voltage across each capacitor C1 and C2 after the current pulse (I) is terminated. The voltage, Vinitial, is the value of the voltage across C1 and C2 induced by the current pulse (I). The time-constant τ, defines the rate of decay (or rise) of the voltage across the capacitors C1, C2. The time-constant τ, is defined by the capacitance value of C and the resistance experienced by the each capacitor C1, C2. The charges built up in the capacitors C1, C2, dissipate over time, resulting in a voltage rise from a negative level to zero in an asymptotic fashion as illustrated in FIG. 7B.

FIG. 7C illustrates the signal response relating to the capacitor C1 upon the delivery of the current I. Since instantaneous change in voltage is not possible across the capacitor C1, upon delivery of the current I, an asymptotic negative rise of voltage across C1 is realized. This voltage change is defined by the equation provided above. The voltage across the capacitor C1 is built up in the opposite polarity with reference to voltage V. Upon the termination of the pulse, the voltage stops increasing (in the negative direction) and asymptotically rises up to zero. FIG. 7D illustrates that the capacitor C2 provides a rise in positive voltage in a similar manner. Upon termination of the current pulse I, the voltage across C2 decreases asymptotically to zero. Embodiments of the present invention provide for use of the remaining charges that may exist in the capacitors C1 and C2 and/or nodes of the electrodes, after the termination of an electrical signal pulse. These remaining charges may be used in the delivery of a subsequent electrical signal pulse. This may be achieved by reversing the polarities of the respective nodes of the first and second electrodes 610-620.
FIG. 8 illustrates a second configuration of an exemplary implementation of the IMD 200, in which the polarity of the first and second electrodes have been reversed from those shown in FIG. 6. In this configuration the first anode and the first cathode nodes have been reversed wherein the first anode of FIG. 6 is now the second cathode of FIG. 8, and the first cathode of FIG. 6 is now the second anode of FIG. 8. This reversal may be performed by the electrode polarity reversal unit 220 described above. Upon reversal of the nodes, the current I flows in the opposite direction upon application of a stimulation signal provided by the stimulation unit 220. Likewise, the voltage V across the tissue impedance 630 is also reversed. Reversal of the polarities may provide for various therapeutic benefits described above. This type of reversal may be provided during changeable electrode polarity stimulation, wherein the first and the second electrode 610, are configured in a bilateral fashion (i.e., wherein first electrode may be coupled to the right vagus nerve and the second electrode 620 may be coupled to the left vagus nerve, or vice versa). In an alternative embodiment, the changeable electrode polarity system provided herein may be implemented in a unilateral configuration, such as both the first and second electrodes 610 and 620 being coupled to a single vagus nerve, such as the left vagus nerve.
In the unilateral configuration, the distance between the first and second electrodes 610, 620 may vary from 1 mm to 50 mm. For example, the electrodes may be spaced 1 cm apart for closely-spaced stimulation or 40 cm apart for distant stimulation. In an embodiment wherein the pulse generator case 121 is an electrode, the distance between an electrode 125 coupled to a cranial nerve and the pulse generator case 121 may vary from 1 mm to 300 mm.
Based upon the type of stimulation, the target tissue to be stimulated, and/or other factors, the distance between the electrodes 610, 620 may play a substantial part in targeting particular regions of a patient's body, in multiple directions. For example, the cathode may be placed strategically such that signals in both directions may propagate to a certain limit, such as to a particular plexus, and then would be blocked in one direction by the anode. In the opposite direction, a proximal cranium signal may be delivered to the brain.
Referring simultaneously to FIG. 8 and FIGS. 9A-9D, illustrative diagrams of an exemplary signal pulse and various resultant electrical parameters related to the circuit of FIG. 8, are provided. The stimulation unit 220 may provide a therapeutic electrical signal pulse having a programmed current. Due to the reversal of the cathode and the anode (in relation to the configuration of FIG. 6), the stimulation current I is represented as going from zero to a negative value and back, in a pulse form, as illustrated in FIG. 9A. During the duration of the current pulse (FIG. 9A), the voltage V (FIG. 9B) develops across the tissue impedance 630 (i.e., between the second cathode and the second anode) in the same polarity as the current I. Upon termination of the current pulse I, the voltage is reversed due to the charges accumulated in the 1st and 2nd capacitors C1, C2.
The configuration of FIG. 8 causes the accumulation of voltage shown in FIG. 9B to be in a negative direction compared to the configuration depicted and described in FIGS. 6 and 7. The discharge of the energy from the capacitors C1 and C2 provides for an asymptotic function of the voltage V as illustrated in FIG. 9B. FIG. 9C illustrates the signal-response in capacitor C1 to the electrical pulse shown in FIG. 9A. Upon assertion of the current pulse I, an asymptotical rise of voltage across the capacitor C1 in the opposite direction of the polarity of the current pulse I is produced. Similarly, an asymptotic rise in voltage in the negative direction (i.e., the same polarity of the current is generated) is produced across the capacitor C2.
Upon termination of the current pulse I, accumulated charges provide for an asymptotic decay of respective voltages across the capacitor C1 and C2, as illustrated in FIGS. 9C and 9D. Based upon the disclosure herein, those skilled in the art would not recognize that even after the termination of the current pulse I, there remains an electrical charge/energy accumulated on the capacitors C1 and C2. This charge/energy may be used to provide a subsequent pulse in the reverse polarity in a more efficient manner. In other words, using the accumulated charge/energy, which would otherwise have been simply dissipated, a subsequent stimulation pulse signal may be generated using less energy than otherwise would have been used. This is true because the remaining accumulated charges/energy (stored in the C1 and C2) may be “piggy backed” onto the driven constant current signal provided by the IMD 200 to reach the desired current amplitude based on using the electrical charge/energy that is stored in the capacitors C1 and C2.
This concept is further exemplified in an exemplary illustration provided in FIGS. 10A-10D which provide an exemplary illustration of accumulated charge/energy from one electrical signal pulse that may be used to generate a second electrical signal pulse. The solid lines in the diagrams of FIGS. 10A-10D represent the signals resulting from the delivery of an electrical signal pulse in the configuration illustrated in FIG. 6. The signal responses indicated by the dotted lines represent signals resulting from the delivery of an electrical signal pulse performed after reversal of the first and second electrodes' polarities (as illustrated in FIG. 8). FIGS. 10A-10D also define shaded regions that represents the charge/energy accumulated by a preceding therapeutic stimulation signal.
Referring simultaneously to FIGS. 6, 8 and 10A-10D, FIG. 10A illustrates a first cathode signal response based upon the configuration of FIG. 6 (i.e., with the first electrode as a first anode and the second electrode as a first cathode). The first cathode is coupled to the distal portion of the second electrode 620. When the stimulation unit 220 in FIG. 6 applies an electrical signal current pulse, the resultant signal at the first cathode provides a signal that is opposite in polarity to the current I (FIG. 10A). The capacitor C2, which in FIG. 6 is a “cathode capacitor,” provides an asymptotic rise in voltage until the termination of the current pulse, which then prompts an asymptotic decay (shaded region of FIG. 10B) of the voltage.
Similarly, during the application of the current pulse I, the first anode, which is the output of the first electrode 610 in FIG. 6, provides a signal with the same polarity as the current. An “anode capacitor” (C1 in the case of FIG. 6) provides for an asymptotic negative rise in voltage, as illustrated in FIG. 10D. Upon termination of the current pulse I, an asymptotic positive rise to zero voltage across the anode capacitor occurs (shaded region of FIG. 10D). Therefore, upon termination of the current pulse there remains a charge on the cathode capacitor (i.e., C2 in the configuration of FIG. 6) and the anode capacitor (i.e., C1 in FIG. 6). Both capacitors contain accumulated charge that may be discharged. The shaded regions in FIGS. 10B and 10D represent some lingering, accumulated charge/energy for a period of time, until they asymptotically decay.
However, if the polarity of the first anode and the first cathode are switched from the configuration of FIG. 6 to the configuration of FIG. 8, the accumulated charges in the capacitors C1 and C2 may be utilized in delivery of a subsequent electrical signal current pulse. If within the period of time in which there remains some charge/energy in the capacitors, as depicted by the shaded regions in FIGS. 10B and 10D, an electrical signal current pulse delivered in those same directions (as the available charges/energy in FIGS. 10B and 10D) would result in a boost in the signals delivered by the electrodes in the second configuration of FIG. 8. This is illustrated by the dotted lines in FIGS. 10A and 10C. While an accumulated charge/energy still exists in the capacitors C1 and C2, as indicated in the shaded region of FIGS. 10B and 10D, an electrode polarity reversal may be performed by the electrode polarity reversal unit 280. After reversing the polarity of the electrodes, the first cathode will become the second anode and the first anode will become the second cathode. In this manner, a pulse current signal in the opposite polarity is delivered, which would coincide with the polarity of the stored charges by the cathode capacitor and the anode capacitor.
As illustrated in FIG. 10A the second anode signal receives a charge boost for the portion of the pulse that overlaps the time period where there still remains stored charges/energy in the cathode capacitor. This is indicated by the shaded region (“second anode charge boost”) of FIG. 10A. Therefore, the stimulation unit 220 may generate and provide a smaller amount of energy to achieve a sufficient rise in the pulse current to obtain a desired amplitude because of the charge boost provided by the capacitor, as illustrated in FIG. 10A. Due to the feedback control current nature of the operation of the IMD 200, less charge proportionally is used than in cases where the charge on the capacitor completely decays, such that the second anode charge boost provides for a percentage of the total charge needed to provide the pulse illustrated in dotted lines in FIG. 10A.
Similarly, the second cathode also experiences a second cathode charge boost, as illustrated in FIG. 10C, due to the accumulated charge/energy remaining in the anode capacitor of FIG. 10D. While an accumulated charge is present on the anode capacitor, a portion of the negative-polarity pulse is boosted by the existing charge on the anode capacitor. In this manner, leftover charges are utilized to provide energy for subsequent pulses. This may provide considerable savings in charge usage from the battery of the IMD 200. In this manner, the anode and cathode nodes may be reversed continuously (i.e., repeating the reversals several times) to take advantage of the existing charge from the previous delivery of a pulse, while delivering changeable electrode polarity stimulation. In alternative embodiments, the polarity reversals of the cathode and the anode may only be performed periodically. In such alternative embodiments, therefore, some resident charges may be dissipated by the capacitor C1 and C2 while some charges may be utilized during those times when the anode and the cathode nodes are reversed. In this manner, substantial savings in charge-usage may be realized utilizing the changeable electrode polarity stimulation provided herein. In some cases, 80% or more of the electrical charge necessary for an electrical signal pulse may be provided by the energy stored in the capacitors. For the sake of clarity and ease of description, embodiments of the present invention were described as in a two-electrode configuration. However, those skilled in the art having benefit of the present disclosure, would readily appreciate that a variety of configurations, with any number of electrodes, may be implemented and remain within the spirit and scope of the present invention. The above-described implementations may be provided in a bilateral configuration, as well as in a unilateral configuration. Therefore, utilizing the embodiments of the present invention, substantial appreciation in efficacy and power savings may be realized.
In one embodiment, a first electrode and a second electrode, substantially as described above, are directly coupled to a first ventricle of the heart and a second ventricle of the heart. This embodiment may realize substantial appreciation in efficacy, power savings, or both in a pacemaker device.
The particular embodiments disclosed above are illustrative only, as the invention may be modified and practiced in different but equivalent manners apparent to those skilled in the art having the benefit of the teachings herein. Furthermore, no limitations are intended to the details of construction or design herein shown other than as described in the claims below. It is, therefore, evident that the particular embodiments disclosed above may be altered or modified and all such variations are considered within the scope and spirit of the invention. Accordingly, the protection sought herein is as set forth in the claims below.

## Claims

1. A method of treating a medical condition in a patient using an implantable medical device (IMD) having a first electrode coupled to a first cranial nerve structure and a second electrode coupled to a second cranial nerve structure, wherein the first cranial nerve structure is different from the second cranial nerve structure, and wherein the first cranial nerve structure is a left portion of a cranial nerve and the second cranial nerve structure is a right portion of the cranial nerve, the method comprising:
delivering a first pulse having a first charge to the first cranial nerve structure, the first pulse configured to induce action potentials in the first cranial nerve structure, wherein the first electrode is configured as a cathode and the second electrode configured as an anode during the first pulse;
storing charge accumulated at the IMD during the first pulse; and
delivering a second pulse having a second charge to the second cranial nerve structure, the second pulse configured to induce action potentials in the second cranial nerve structure, wherein the first electrode is configured as the anode and the second electrode is configured as the cathode during the second pulse, wherein the charge stored during the first pulse comprises at least a portion of the second charge.

2. The method of claim 1, wherein the cranial nerve is one of a vagus nerve, a trigeminal nerve, and a glossopharyngeal nerve.

3. The method of claim 1, wherein at least a portion of the charge is accumulated at a first capacitor associated with the first electrode.

4. The method of claim 1, wherein at least a portion of the charge is accumulated at a first capacitor associated with the first electrode and a second capacitor associated with the second electrode.

5. The method of claim 1, further comprising:
reversing the polarity of the first electrode and the second electrode to deliver the second pulse to the second cranial nerve structure such that the first electrode is configured as the anode and the second electrode is configured as the cathode.

6. The method of claim 5, further comprising:
reversing the polarity of the first electrode and the second electrode after delivering the second pulse to the second cranial nerve structure such that the first electrode is configured as the cathode and the second electrode is configured as the anode.

7. The method of claim 1, wherein the second charge of the second pulse is the stored charge.

8. A method of treating a medical condition in a patient using an implantable medical device (IMD) having a first electrode coupled to a first cranial nerve structure and a second electrode coupled to a second cranial nerve structure, wherein the first cranial nerve structure is different from the second cranial nerve structure, and wherein the first cranial nerve structure is a first cranial nerve and the second cranial nerve structure is a second cranial nerve, the method comprising:
delivering a first pulse having a first charge to the first cranial nerve structure, the first pulse configured to induce action potentials in the first cranial nerve structure, wherein the first electrode is configured as a cathode and the second electrode configured as an anode during the first pulse;
storing charge accumulated at the IMD during the first pulse; and
delivering a second pulse having a second charge to the second cranial nerve structure, the second pulse configured to induce action potentials in the second cranial nerve structure, wherein the first electrode is configured as the anode and the second electrode is configured as the cathode during the second pulse, wherein the charge stored during the first pulse comprises at least a portion of the second charge.

9. The method of claim 8, wherein the first cranial nerve structure is one of a vagus nerve, a trigeminal nerve, and a glossopharyngeal nerve.

10. A method of treating a medical condition in a patient using an implantable medical device (IMD) having a first electrode coupled to a first cranial nerve structure and a second electrode coupled to a second cranial nerve structure, wherein the first cranial nerve structure is different from the second cranial nerve structure, and wherein the first cranial nerve structure is a left portion of a cranial nerve and the second cranial nerve structure is a right portion of the cranial nerve, the method comprising:
providing a first electrical signal to the first cranial nerve structure of the patient using a first polarity configuration in which the first electrode functions as a cathode and the second electrode functions as an anode, the first electrical signal configured to induce action potentials in the first cranial nerve structure, wherein charge accumulates at the anode and the cathode as a result of the first electrical signal;
switching from the first polarity configuration to a second polarity configuration upon termination of the first electrical signal, wherein the first electrode functions as the anode and the second electrode functions as the cathode in the second polarity configuration; and
providing a second electrical signal to the second cranial nerve structure in the second polarity configuration, the second electrical signal configured to induce action potentials in the second cranial nerve structure, wherein at least a portion of the second electrical signal comprises the accumulated charge from the first electrical signal.

11. The method of claim 10, wherein second charge accumulates at the anode and the cathode as a result of the second electrical signal, further comprising:
switching from the second polarity configuration to the first polarity configuration upon termination of the second electrical signal; and
providing a third electrical signal to the first cranial nerve structure in the first polarity configuration, the third electrical signal configured to induce action potentials in the first cranial nerve structure, wherein at least a portion of the third electrical signal comprises the accumulated second charge from the second electrical signal.

12. The method of claim 10, wherein the second electrical signal comprises a feedback controlled current pulse operable to adjust the amount of energy used to provide the second electrical signal based upon an amount of the accumulated charge from the first signal.

13. The method of claim 10, wherein the medical condition is selected from the group consisting of depression, epilepsy, obesity, bulimia, traumatic brain injury, congestive heart failure, stroke, coma, fibromyalgia, addiction disorders, multiple sclerosis, haring disorder, Alzheimer's disease, Parkinson's disease, gastrointestinal disorders, pancreatic disorders, kidney disorders, and diabetes.

14. The method of claim 10, wherein the cranial nerve is one of a vagus nerve, a trigeminal nerve, and a glossopharyngeal nerve

15. The method of claim 10, wherein the first cranial nerve structure is a first cranial nerve and the second cranial nerve structure is a second cranial nerve, wherein the first cranial nerve structure is one of a vagus nerve, a trigeminal nerve, and a glossopharyngeal nerve.

16. The method of claim 8, wherein at least a portion of the charge is accumulated at a first capacitor associated with the first electrode.

17. The method of claim 8, wherein at least a portion of the charge is accumulated at a first capacitor associated with the first electrode and a second capacitor associated with the second electrode.

18. The method of claim 8, further comprising:
reversing the polarity of the first electrode and the second electrode to deliver the second pulse to the second cranial nerve structure such that the first electrode is configured as the anode and the second electrode is configured as the cathode.

19. The method of claim 18, further comprising:
reversing the polarity of the first electrode and the second electrode after delivering the second pulse to the second cranial nerve structure such that the first electrode is configured as the cathode and the second electrode is configured as the anode.

20. The method of claim 8, wherein the second charge of the second pulse is the stored charge.