Patent Publication Number: US-11638825-B2

Title: Adaptive electrical neurostimulation treatment to reduce pain perception

Description:
CLAIM OF PRIORITY 
     This application is a continuation of U.S. application Ser. No. 16/417,476, filed May 20, 2019, which claims the benefit of priority under 35 U.S.C. § 119(e) of U.S. Provisional Patent Application Ser. No. 62/675,014, filed on May 22, 2018, and titled “ADAPTIVE ELECTRICAL NEUROSTIMULATION TREATMENT TO REDUCE PAIN PERCEPTION”, each of which are incorporated by reference herein in their entireties. 
    
    
     DISCLAIMER 
     The claims and scope of the subject application, and any continuation, divisional or continuation-in-part applications claiming priority to the subject application, are solely limited to embodiments (e.g., systems, apparatus, methodologies, computer program products and computer readable storage media) directed to implanted electrical stimulation for pain treatment and/or management. 
     STATEMENT REGARDING JOINT RESEARCH AND DEVELOPMENT 
     The present subject matter was developed and the claimed invention was made by or on behalf of Boston Scientific Neuromodulation Corporation and International Business Machines Corporation, parties to a joint research agreement that was in effect on or before the effective filing date of the claimed invention, and the claimed invention was made as a result of activities undertaken within the scope of the joint research agreement. 
     TECHNICAL FIELD 
     The present disclosure relates generally to medical devices, and more particularly, to systems, devices, and methods for electrical stimulation programming techniques, to perform implanted electrical stimulation for pain treatment and/or management. 
     BACKGROUND 
     Neurostimulation, also referred to as neuromodulation, has been proposed as a therapy for a number of conditions. Examples of neurostimulation include Spinal Cord Stimulation (SCS), Deep Brain Stimulation (DBS), Peripheral Nerve Stimulation (PNS), and Functional Electrical Stimulation (FES). Implantable neurostimulation systems have been applied to deliver such a therapy. An implantable neurostimulation system may include an implantable electrical neurostimulator, also referred to as an implantable pulse generator (IPG), and one or more implantable leads each including one or more electrodes. The implantable electrical neurostimulator delivers neurostimulation energy through one or more electrodes placed on or near a target site in the nervous system. 
     A neuromodulation system can be used to electrically stimulate tissue or nerve centers to treat nervous or muscular disorders. For example, an SCS system may be configured to deliver electrical pulses to a specified region of a patient&#39;s spinal cord, such as particular spinal nerve roots or nerve bundles, to create an analgesic effect that masks pain sensation. While modern electronics can accommodate the need for generating and delivering stimulation energy in a variety of forms, the capability of a neurostimulation system depends on its post-manufacturing programmability to a great extent. For example, a sophisticated neurostimulation program may only benefit a patient when it is customized for that patient, and stimulation patterns or programs of patterns that are predetermined at the time of manufacturing may substantially limit the potential for the customization. 
     SUMMARY 
     This Summary includes examples that provide an overview of some of the teachings of the present application and not intended to be an exclusive or exhaustive treatment of the present subject matter. Further details about the present subject matter are found in the detailed description and appended claims. Other aspects of the disclosure will be apparent to persons skilled in the art upon reading and understanding the following detailed description and viewing the drawings that form a part thereof, each of which are not to be taken in a limiting sense. The scope of the present disclosure is defined by the appended claims and their legal equivalents. 
     Example 1 is a system for use to establish programming of an implantable electrical neurostimulation device for treating chronic pain of a human subject, the system comprising: at least one processor; and at least one memory device comprising instructions, which when executed by the processor, cause the processor to perform operations that: obtain state data, the state data indicating a measured value that is correlated to pain experienced by the human subject; determine a plurality of neurostimulation programming parameters, using a dynamic model, for pain treatment in the human subject, the dynamic model adapted to identify values of the neurostimulation programming parameters which predict an improvement to the measured value; and indicate a neurostimulation program that includes, the neurostimulation programming parameters for the implantable electrical neurostimulation device. 
     In Example 2, the subject matter of Example 1 includes, the dynamic model utilizing a plurality of model parameters that are specific to the human subject, wherein the identified values of the neurostimulation programming parameters are determined by the dynamic model based on a plurality of neurostimulation treatment constraints for the human subject. 
     In Example 3, the subject matter of Examples 1-2 includes, the measured value being a pain measurement for the human subject, with operations that evaluate a benefit of the neurostimulation program in use with the implantable electrical neurostimulation device of the human subject, using a reward function in the dynamic model, wherein the dynamic model is adapted to identify a projected use of the neurostimulation programming parameters that provides a reduction in the pain measurement with the human subject. 
     In Example 4, the subject matter of Example 3 includes, the neurostimulation program being subsequently deployed to the implantable electrical neurostimulation device, with operations that identify changes to the neurostimulation programming parameters for pain treatment in the human subject using the dynamic model, wherein the dynamic model is adapted to change values of the neurostimulation programming parameters; and modify the neurostimulation program to include the changes to the neurostimulation programming parameters. 
     In Example 5, the subject matter of Examples 1-4 includes, the dynamic model being further adapted to establish the values of the neurostimulation programming parameters using model parameters generated from prior state data, wherein the prior state data indicates another value of at least one measured value at a prior time. 
     In Example 6, the subject matter of Examples 1-5 includes, the dynamic model being a continuous time model or a discrete time model, wherein the dynamic model predicts the improvement to the measured value over a time period based on: predicted pain of the human subject, observed pain of the human subject, dynamic model parameters, and operational data of the implantable electrical neurostimulation device. 
     In Example 7, the subject matter of Examples 1-6 includes, the dynamic model being further adapted to use reinforcement to increase or decrease values associated with the neurostimulation programming parameters based on changes to the measured value. 
     In Example 8, the subject matter of Examples 1-7 includes, the neurostimulation programming parameters being stored by a data service, wherein subsequent operations using the dynamic model obtain the neurostimulation programming parameters from the data service and evaluate the neurostimulation programming parameters obtained from the data service. 
     In Example 9, the subject matter of Examples 1-8 includes, a user interface being used to receive at least one of: at least a portion of the state data related to the measured value, or a command to cause selection or deployment of the neurostimulation program to the implantable electrical neurostimulation device. 
     In Example 10, the subject matter of Examples 1-9 includes, deployment of the neurostimulation programming parameters with the neurostimulation program causing a change in operation of the implantable electrical neurostimulation device, that corresponds to an observed change in the measured value as experienced by the human subject. 
     In Example 11, the subject matter of Examples 1-10 includes, the neurostimulation programming parameters of the neurostimulation program specifying a change in programming for the implantable electrical neurostimulation device for one or more of: pulse patterns, pulse shapes, a spatial location of pulses, waveform shapes, or a spatial location of waveform shapes, for modulated energy provided with a plurality of leads of the implantable electrical neurostimulation device. 
     In Example 12, the subject matter of Examples 1-11 includes, the implantable electrical neurostimulation device being further configured to treat pain by delivering at least one of: an electrical spinal cord stimulation, an electrical brain stimulation, or an electrical peripheral nerve stimulation, in the human subject. 
     In Example 13, the subject matter of Examples 1-12 includes, the instructions further to cause the processor to: provide instructions to cause the implantable electrical neurostimulation device to implement the neurostimulation program. 
     Example 14 is a machine-readable medium including instructions, which when executed by a machine, cause the machine to perform the operations of the system of any of the Examples 1 to 13. 
     Example 15 is a method to perform the operations of the system of any of the Examples 1 to 13. 
     Example 16 is a device to establish programming of an implantable electrical neurostimulation device for treating chronic pain of a human subject, the device comprising: at least one processor and at least one memory; patient state determination circuitry, operable with the processor and the memory, configured to process patient state data, the patient state data indicating at least one measured value that is correlated to pain experienced by the human subject; neurostimulation programming circuitry, in operation with the at least one processor and the at least one memory, configured to: determine a plurality of neurostimulation programming parameters, using a dynamic model, for pain treatment in the human subject, the dynamic model adapted to identify values of the neurostimulation programming parameters which predict an improvement to the measured value; and identify a neurostimulation program that includes, the neurostimulation programming parameters for the implantable electrical neurostimulation device. 
     In Example 17, the subject matter of Example 16 includes, the dynamic model utilizing a plurality of model parameters that are specific to the human subject, wherein the identified values of the neurostimulation programming parameters are determined by the dynamic model based on a plurality of neurostimulation treatment constraints for the human subject. 
     In Example 18, the subject matter of Examples 16-17 includes, the measured value being a pain measurement for the human subject, the patient state determination circuitry further configured to: evaluate a benefit of the neurostimulation program in use with the implantable electrical neurostimulation device of the human subject, using a reward function in the dynamic model, wherein the dynamic model is adapted to identify a projected use of the neurostimulation programming parameters that provides a reduction in the pain measurement with the human subject. 
     In Example 19, the subject matter of Example 18 includes, the neurostimulation program being subsequently deployed to the implantable electrical neurostimulation device, the patient state determination circuitry further configured to: identify changes to the neurostimulation programming parameters for pain treatment in the human subject using the dynamic model, wherein the dynamic model is adapted to change values of the neurostimulation programming parameters; and modify the neurostimulation program to include the changes to the neurostimulation programming parameters. 
     In Example 20, the subject matter of Examples 16-19 includes, the dynamic model being a continuous time model or a discrete time model, wherein the dynamic model predicts the improvement to the measured value over a time period based on: predicted pain of the human subject, observed pain of the human subject, dynamic model parameters, and operational data of the implantable electrical neurostimulation device. 
     In Example 21, the subject matter of Examples 16-20 includes, the dynamic model being further adapted to use reinforcement to increase or decrease values associated with the neurostimulation programming parameters based on changes to the measured value. 
     In Example 22, the subject matter of Example 21 includes, the neurostimulation programming parameters being stored by a data service, wherein subsequent operations using the dynamic model obtain the neurostimulation programming parameters from the data service and evaluate the neurostimulation programming parameters obtained from the data service. 
     In Example 23, the subject matter of Examples 16-22 includes, a user interface being used to receive at least one of: at least a portion of the patient state data related to the measured value, or a command to cause selection or deployment of the neurostimulation program to the implantable electrical neurostimulation device. 
     In Example 24, the subject matter of Examples 16-23 includes, deployment of the neurostimulation programming parameters with the neurostimulation program causing a change in operation of the implantable electrical neurostimulation device, that corresponds to an observed change in the measured value as experienced by the human subject, wherein the neurostimulation programming parameters of the neurostimulation program specifies a change in programming for the implantable electrical neurostimulation device for one or more of: pulse patterns, pulse shapes, a spatial location of pulses, waveform shapes, or a spatial location of waveform shapes, for modulated energy provided with a plurality of leads of the implantable electrical neurostimulation device. 
     In Example 25, the subject matter of Examples 16-24 includes, the neurostimulation programming circuitry further configured to: provide programming instructions to cause the implantable electrical neurostimulation device to implement the neurostimulation program. 
     Example 26 is a method, for establishing programming of an implantable electrical neurostimulation device for treating chronic pain of a human subject, the method comprising a plurality of operations executed with at least one processor of an electronic device, the plurality of operations comprising: obtaining state data, the state data indicating a measured value that is correlated to pain experienced by the human subject; determining a plurality of neurostimulation programming parameters, using a dynamic model, for pain treatment in the human subject, the dynamic model adapted to identify values of the neurostimulation programming parameters which predict an improvement to the measured value; and outputting a neurostimulation program that includes, the neurostimulation programming parameters for the implantable electrical neurostimulation device. 
     In Example 27, the subject matter of Example 26 includes, the dynamic model utilizing a plurality of model parameters that are specific to the human subject, wherein the identified values of the neurostimulation programming parameters are determined by the dynamic model based on a plurality of neurostimulation treatment constraints for the human subject. 
     In Example 28, the subject matter of Examples 26-27 includes, the measured value being a pain measurement for the human subject, and evaluating a benefit of the neurostimulation program in use with the implantable electrical neurostimulation device of the human subject, using a reward function in the dynamic model, wherein the dynamic model is adapted to identify a projected use of the neurostimulation programming parameters that provides a reduction in the pain measurement with the human subject. 
     In Example 29, the subject matter of Example 28 includes, wherein the neurostimulation program is subsequently deployed to the implantable electrical neurostimulation device, with operations that: identify changes to the neurostimulation programming parameters for pain treatment in the human subject using the dynamic model, wherein the dynamic model is adapted to change values of the neurostimulation programming parameters; and modify the neurostimulation program to include the changes to the neurostimulation programming parameters. 
     In Example 30, the subject matter of Examples 26-29 includes, the dynamic model with a continuous time model or a discrete time model, wherein the dynamic model predicts the improvement to the measured value over a time period based on: predicted pain of the human subject, observed pain of the human subject, dynamic model parameters, and operational data of the implantable electrical neurostimulation device. 
     In Example 31, the subject matter of Examples 26-30 includes, the dynamic model being further adapted to use reinforcement to increase or decrease values associated with the neurostimulation programming parameters based on changes to the measured value. 
     In Example 32, the subject matter of Examples 26-31 includes, the neurostimulation programming parameters being stored by a data service, wherein subsequent operations using the dynamic model obtain the neurostimulation programming parameters from the data service and evaluate the neurostimulation programming parameters obtained from the data service. 
     In Example 33, the subject matter of Examples 26-32 includes, a user interface being used to receive at least one of: at least a portion of the state data related to the measured value, or a command to cause selection or deployment of the neurostimulation program to the implantable electrical neurostimulation device. 
     In Example 34, the subject matter of Examples 26-33 includes, deployment of the neurostimulation programming parameters with the neurostimulation program causing a change in operation of the implantable electrical neurostimulation device, that corresponds to an observed change in the measured value as experienced by the human subject, wherein the neurostimulation programming parameters of the neurostimulation program specifies a change in programming for the implantable electrical neurostimulation device for one or more of: pulse patterns, pulse shapes, a spatial location of pulses, waveform shapes, or a spatial location of waveform shapes, for modulated energy provided with a plurality of leads of the implantable electrical neurostimulation device. 
     In Example 35, the subject matter of Examples 26-34 includes, providing programming instructions to cause the implantable electrical neurostimulation device to implement the neurostimulation program. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       Various embodiments are illustrated by way of example in the figures of the accompanying drawings. Such embodiments are demonstrative and not intended to be exhaustive or exclusive embodiments of the present subject matter. 
         FIG.  1    illustrates, by way of example, an embodiment of a neurostimulation system. 
         FIG.  2    illustrates, by way of example, an embodiment of a stimulation device and a lead system, such as may be implemented in the neurostimulation system of  FIG.  1   . 
         FIG.  3    illustrates, by way of example, an embodiment of a programming device, such as may be implemented in the neurostimulation system of  FIG.  1   . 
         FIG.  4    illustrates, by way of example, an implantable neurostimulation system and portions of an environment in which the system may be used. 
         FIG.  5    illustrates, by way of example, an embodiment of an implantable stimulator and one or more leads of a neurostimulation system, such as the implantable neurostimulation system of  FIG.  4   . 
         FIG.  6    illustrates, by way of example, an embodiment of a patient programming device for a neurostimulation system, such as the implantable neurostimulation system of  FIG.  4   . 
         FIG.  7    illustrates, by way of example, an embodiment of data interactions among a clinician programmer device, a patient programming device, a program modeling system, and a data service for generating and implementing respective programs of defined parameter settings for operation of a neurostimulation device. 
         FIG.  8    illustrates, by way of example, an embodiment of a program modeling system adapted for recommending and controlling programming parameters of a neurostimulation treatment. 
         FIG.  9    illustrates, by way of example, an embodiment of a data and control flow between a dynamical system data processing model and programming determination logic, used to explore and exploit programming parameters of a neurostimulation treatment. 
         FIG.  10    illustrates, by way of example, an embodiment of a processing method implemented by a system or device for use to establish programming of an implantable electrical neurostimulation device for treating chronic pain of a human subject. 
         FIG.  11    illustrates, by way of example, a block diagram of an embodiment of a computing system implementing patient state determination circuitry for use to establish programming of an implantable electrical neurostimulation device for treating chronic pain of a human subject. 
         FIG.  12    illustrates, by way of example, a block diagram of an embodiment of a computing system implementing neurostimulation programming circuitry for use to establish programming of an implantable electrical neurostimulation device for treating chronic pain of a human subject. 
         FIG.  13    is a block diagram illustrating a machine in the example form of a computer system, within which a set or sequence of instructions may be executed to cause the machine to perform any one of the methodologies discussed herein, according to an example embodiment. 
     
    
    
     DETAILED DESCRIPTION 
     The following detailed description of the present subject matter refers to the accompanying drawings which show, by way of illustration, specific aspects and embodiments in which the present subject matter may be practiced. These embodiments are described in sufficient detail to enable those skilled in the art to practice the present subject matter. Other embodiments may be utilized and structural, logical, and electrical changes may be made without departing from the scope of the present subject matter. References to “an”, “one”, or “various” embodiments in this disclosure are not necessarily to the same embodiment, and such references contemplate more than one embodiment. The following detailed description is, therefore, not to be taken in a limiting sense, and the scope is defined only by the appended claims, along with the full scope of legal equivalents to which such claims are entitled. 
     This document discusses various techniques that can generate programming of an implantable electrical neurostimulation device, for the treatment of chronic pain of a human subject (e.g., a patient). As an example, various systems and methods are described to identify, given a time series of quantity of interest conditions (e.g., conditions relating to or suggestive of pain), a dynamical system (e.g., model) of arbitrary order that relates a proposed treatment to the quantity of interest. This quantity of interest may be a measurement of pain or one of its correlates, such as quality of sleep, quality of life, patient satisfaction, or the like. Based on the dynamical system, the various systems and methods discussed herein are configured to implement a real time closed loop adaptive system that computes and delivers a best neurostimulation treatment for the patient, to directly improve the quantity of interest. 
     The dynamics applied in this model are associated with a set of model parameters to explore variations in pain treatments. As the model changes over time, further uses allow the model to re-identify the set of model parameters, even as the model parameters provided as input adapt in real time based on their evolution. Based on the identified dynamics, the dynamic information system can generate a recommendation for a new program (or the selection of an existing program), as the system recommends a treatment that best suits the patient given the known quantity of interest, the physiological condition of the patient, and other parameters such as environment conditions. Based on the identified dynamics, the dynamic information system can also begin control of the neurostimulator device using the new program (or the selection of an existing program), including in scenarios where the new program is automatically delivered and started once a best program has been identified. Accordingly, the exploration and exploitation of a best program within this dynamic model is designed to be customized to the current and a predicted state of the patient, with the ultimate goal to provide improvement in the treatment of chronic pain. 
     Chronic pain is a common condition for many patients, but which may be addressed through the use of neurostimulation therapy (e.g., electrical spinal cord stimulation, electrical peripheral nerve stimulation, or electrical brain stimulation) to deliver treatment. One limiting factor for existing applications of neurostimulation therapies is that, even if a number of advanced programs can be applied by an neurostimulation device, patients often only end up to use a few of the available treatments (e.g., two or three programs). As a result, the treatment results are often not effective and the patient ends up applying programs that are not customized to the patient or a best fit for the patient. The present inventive techniques and systems improve this scenario through the use of a dynamic information system built around the patient, which is able to learn and implement new programs that the patient should apply given his or her specific conditions, predicted conditions, and relevant constraints and uncertainties of the operation of the neurostimulation device. 
     The dynamic information system discussed herein enables the analysis of multiple aspects of relevant treatment inputs, to enable a patient, caregiver, or medical professional to generate, evaluate, modify, and implement certain programming parameters (e.g., settings) for a neurostimulator, based on a measure of pain or one of its correlates (e.g., quality of sleep, quality of life, satisfaction) being experienced by the human subject. In an example, the dynamic information system applies a dynamic model that evaluates dynamic equations within a continuous time or a discrete time based on system inputs including: patient pain, predicted pain, model parameters, model time, stimulator input (e.g., predefined programs available for use by the stimulator, and programs computed for use at a future time), and model uncertainty that is learned at every time step. This stimulator input includes exploration of a set of possible neurostimulation programs that is expanded with time, as new programs are created and explored for the particular patient. The dynamic information system operates the dynamic model to provide, from the continuous-time or discrete-time evaluation, a recommendation of which the parameters are applicable to provide an improvement to the evaluated patient state (e.g., to improve the patient treatment of chronic pain). These programming parameters may be arranged or defined (e.g., created, modified, activated, etc.) into new or updated sets of neurostimulation operational programs (also plainly referred to as “programs” in this document), resulting in an identification of a particular neurostimulation program that includes at least a portion of the pain treatment parameters identified as a best-fit for the human patient in the dynamic model. 
     The techniques of this document can enable a human subject (e.g., patient) to create, establish, activate, select, modify, update, or adapt a program for a device (or to re-program a device) within an expanded set of programs and program settings, to improve chronic pain treatment and treatment efficacy of neurostimulation device uses. Given the large number of permutations in neurostimulation output available in any given program (and the wide variation among different types of programs) the exploration and exploitation of these combinations in a fashion that is specific to a particular patient or patient&#39;s state is not feasible with existing approaches. In an example, programming determination logic operates within the dynamic information system to obtain state data of some measured value that is correlated to pain experienced by a human subject. The programming creation and determination logic operates to determine neurostimulation programming parameters using the previously described dynamic model, to identify values of the programming parameters which predict an improvement to the measured value and effect pain treatment. Finally, the programming creation and determination logic operates to indicate a program which includes the pain treatment parameters for the neurostimulation device, to provide a best fit for the predicted state of the patient and the patient&#39;s chronic pain state. 
     By way of example, operational parameters of the electrical neurostimulation device may include amplitude, frequency, duration, pulse width, pulse type, patterns of neurostimulation pulses, waveforms in the patterns of pulses, and like settings with respect to the intensity, type, and location of neurostimulator output on individual or a plurality of respective leads. The electrical neurostimulator may use current or voltage sources to provide the neurostimulator output, and apply any number of control techniques to modify the electrical simulation applied to anatomical sites or systems related to chronic pain. In various embodiments, a neurostimulator program may include parameters that define spatial, temporal, and informational characteristics for the delivery of modulated energy, including the definitions or parameters of pulses of modulated energy, waveforms of pulses, pulse blocks each including a burst of pulses, pulse trains each including a sequence of pulse blocks, train groups each including a sequence of pulse trains, and programs of such definitions or parameters, each including one or more train groups scheduled for delivery. Characteristics of the waveform that are defined in the program may include, but are not limited to the following: amplitude, pulse width, frequency, total charge injected per unit time, cycling (e.g., on/off time), pulse shape, number of phases, phase order, interphase time, charge balance, ramping, as well as spatial variance (e.g., electrode configuration changes over time). It will be understood that based on the many characteristics of the waveform itself, a program may have many parameter setting combinations that would be potentially available for use. 
     In various embodiments, the present subject matter may be implemented using a combination of hardware and software designed to provide users such as patients, caregivers, clinicians, researchers, physicians, or others with the ability to generate, identify, select, implement, and update neurostimulation programs that specifically model aspects of chronic pain in a human subject. The adaptation of neurostimulation programs may provide variation in the location, intensity, and type of defined waveforms and patterns in an effort to increase therapeutic efficacy and/or patient satisfaction for neurostimulation therapies, including but not being limited to SCS and DBS therapies. While neurostimulation is specifically discussed as an example, the present subject matter may apply to any therapy that employs stimulation pulses of electrical or other forms of energy for treating chronic pain. 
     The delivery of neurostimulation energy that is discussed herein may be delivered in the form of electrical neurostimulation pulses. The delivery is controlled using stimulation parameters that specify spatial (where to stimulate), temporal (when to stimulate), and informational (patterns of pulses directing the nervous system to respond as desired) aspects of a pattern of neurostimulation pulses. Many current neurostimulation systems are programmed to deliver periodic pulses with one or a few uniform waveforms continuously or in bursts. However, neural signals may include more sophisticated patterns to communicate various types of information, including sensations of pain, pressure, temperature, etc. Accordingly, the following drawings provide an introduction to the features of an example neurostimulation system and how such programming may be accomplished through neurostimulation systems. 
       FIG.  1    illustrates an embodiment of an electrical neurostimulation system  100 . System  100  includes electrodes  106 , a stimulation device  104 , and a programming device  102 . Electrodes  106  are configured to be placed on or near one or more neural targets in a patient. Stimulation device  104  is configured to be electrically connected to electrodes  106  and deliver neurostimulation energy, such as in the form of electrical pulses, to the one or more neural targets though electrodes  106 . The delivery of the neurostimulation is controlled by using a plurality of stimulation parameters, such as stimulation parameters specifying a pattern of the electrical pulses and a selection of electrodes through which each of the electrical pulses is delivered. In various embodiments, at least some parameters of the plurality of stimulation parameters are programmable by a clinical user, such as a physician or other caregiver who treats the patient using system  100 . Programming device  102  provides the user with accessibility to the user-programmable parameters. In various embodiments, programming device  102  is configured to be communicatively coupled to stimulation device  104  via a wired or wireless link. 
     In various embodiments, programming device  102  includes a user interface  110  (e.g., a user interface embodied by a graphical, text, voice, or hardware-based user interface) that allows the user to set and/or adjust values of the user-programmable parameters by creating, editing, loading, and removing programs that include parameter combinations such as patterns and waveforms. These adjustments may also include changing and editing values for the user-programmable parameters or sets of the user-programmable parameters individually (including values set in response to a therapy efficacy indication). Such waveforms may include, for example, the waveform of a pattern of neurostimulation pulses to be delivered to the patient as well as individual waveforms that are used as building blocks of the pattern of neurostimulation pulses. Examples of such individual waveforms include pulses, pulse groups, and groups of pulse groups. The program and respective sets of parameters may also define an electrode selection specific to each individually defined waveform. 
     As described in more detail below with respect to  FIGS.  7  to  9   , a user, e.g., the patient, or a clinician or other medical professional associated with the patient can select, load, modify, and implement one or more parameters of a defined program for neurostimulation treatment, based on programming determination logic that identifies the defined program using a dynamic model. Based on a modeling of pain, the programming determination logic can determine which program is likely to produce an improvement for a predetermined condition involving chronic pain. Example parameters that can be implemented by a selected program include, but are not limited to the following: amplitude, pulse width, frequency, duration, total charge injected per unit time, cycling (e.g., on/off time), pulse shape, number of phases, phase order, interphase time, charge balance, ramping, as well as spatial variance (e.g., electrode configuration changes over time). 
     As detailed in  FIG.  6   , a controller, e.g., controller  650  of  FIG.  6   , can implement program(s) and parameter setting(s) to implement a specific neurostimulation waveform, pattern, or energy output, using a program or setting in storage, e.g., external storage device  618  of  FIG.  6   , or using settings communicated via an external communication device  620  of  FIG.  6    corresponding to the selected program. The implementation of such program(s) or setting(s) may further define a therapy strength and treatment type corresponding to a specific pulse group, or a specific group of pulse groups, based on the specific program(s) or setting(s). As also described in more detail below with respect to  FIG.  7    and thereafter, a program modeling system and program determination logic (operating as an implementation of a dynamic information system) may operate to produce this information based on operation of the presently described dynamic model. As also described, a clinician or the patient may also affect use and implementation of such programs or settings, including in settings where a combination of dynamic and manual control are involved. 
     Portions of the stimulation device  104 , e.g., implantable medical device, or the programming device  102  can be implemented using hardware, software, or any combination of hardware and software. Portions of the stimulation device  104  or the programming device  102  may be implemented using an application-specific circuit that can be constructed or configured to perform one or more particular functions, or can be implemented using a general-purpose circuit that can be programmed or otherwise configured to perform one or more particular functions. Such a general-purpose circuit can include a microprocessor or a portion thereof, a microcontroller or a portion thereof, or a programmable logic circuit, or a portion thereof. The system  100  could also include a subcutaneous medical device (e.g., subcutaneous ICD, subcutaneous diagnostic device), wearable medical devices (e.g., patch based sensing device), or other external medical devices. 
       FIG.  2    illustrates an embodiment of a stimulation device  204  and a lead system  208 , such as may be implemented in neurostimulation system  100  of  FIG.  1   . Stimulation device  204  represents an embodiment of stimulation device  104  and includes a stimulation output circuit  212  and a stimulation control circuit  214 . Stimulation output circuit  212  produces and delivers neurostimulation pulses, including the neurostimulation waveform and parameter settings implemented via a program selected or implemented with the user interface  110 . Stimulation control circuit  214  controls the delivery of the neurostimulation pulses using the plurality of stimulation parameters, which specifies a pattern of the neurostimulation pulses. Lead system  208  includes one or more leads each configured to be electrically connected to stimulation device  204  and a plurality of electrodes  206  distributed in the one or more leads. The plurality of electrodes  206  includes electrode  206 - 1 , electrode  206 - 2 , . . . electrode  206 -N, each a single electrically conductive contact providing for an electrical interface between stimulation output circuit  212  and tissue of the patient, where N≥2. The neurostimulation pulses are each delivered from stimulation output circuit  212  through a set of electrodes selected from electrodes  206 . In various embodiments, the neurostimulation pulses may include one or more individually defined pulses, and the set of electrodes may be individually definable by the user for each of the individually defined pulses. 
     In various embodiments, the number of leads and the number of electrodes on each lead depend on, for example, the distribution of target(s) of the neurostimulation and the need for controlling the distribution of electric field at each target. In one embodiment, lead system  208  includes 2 leads each having 8 electrodes. Those of ordinary skill in the art will understand that the neurostimulation system  100  may include additional components such as sensing circuitry for patient monitoring and/or feedback control of the therapy, telemetry circuitry, and power. 
     The neurostimulation system may be configured to modulate spinal target tissue or other neural tissue. The configuration of electrodes used to deliver electrical pulses to the targeted tissue constitutes an electrode configuration, with the electrodes capable of being selectively programmed to act as anodes (positive), cathodes (negative), or left off (zero). In other words, an electrode configuration represents the polarity being positive, negative, or zero. Other parameters that may be controlled or varied include the amplitude, pulse width, and rate (or frequency) of the electrical pulses. Each electrode configuration, along with the electrical pulse parameters, can be referred to as a “modulation parameter” set. Each set of modulation parameters, including fractionalized current distribution to the electrodes (as percentage cathodic current, percentage anodic current, or off), may be stored and combined into a program that can then be used to modulate multiple regions within the patient. 
     The neurostimulation system may be configured to deliver different electrical fields to achieve a temporal summation of modulation. The electrical fields can be generated respectively on a pulse-by-pulse basis. For example, a first electrical field can be generated by the electrodes (using a first current fractionalization) during a first electrical pulse of the pulsed waveform, a second different electrical field can be generated by the electrodes (using a second different current fractionalization) during a second electrical pulse of the pulsed waveform, a third different electrical field can be generated by the electrodes (using a third different current fractionalization) during a third electrical pulse of the pulsed waveform, a fourth different electrical field can be generated by the electrodes (using a fourth different current fractionalized) during a fourth electrical pulse of the pulsed waveform, and so forth. These electrical fields can be rotated or cycled through multiple times under a timing scheme, where each field is implemented using a timing channel. The electrical fields may be generated at a continuous pulse rate, or as bursts of pulses. Furthermore, the interpulse interval (i.e., the time between adjacent pulses), pulse amplitude, and pulse duration during the electrical field cycles may be uniform or may vary within the electrical field cycle. Some examples are configured to determine a modulation parameter set to create a field shape to provide a broad and uniform modulation field such as may be useful to prime targeted neural tissue with sub-perception modulation. Some examples are configured to determine a modulation parameter set to create a field shape to reduce or minimize modulation of non-targeted tissue (e.g., dorsal column tissue). Various examples disclosed herein are directed to shaping the modulation field to enhance modulation of some neural structures and diminish modulation at other neural structures. The modulation field may be shaped by using multiple independent current control (MICC) or multiple independent voltage control to guide the estimate of current fractionalization among multiple electrodes and estimate a total amplitude that provide a desired strength. For example, the modulation field may be shaped to enhance the modulation of dorsal horn neural tissue and to minimize the modulation of dorsal column tissue. A benefit of MICC is that MICC accounts for various in electrode-tissue coupling efficiency and perception threshold at each individual contact, so that “hotspot” stimulation is eliminated. 
     The number of electrodes available combined with the ability to generate a variety of complex electrical pulses, presents a huge selection of available modulation parameter sets to the clinician or patient. For example, if the neurostimulation system to be programmed has sixteen electrodes, millions of modulation parameter value combinations may be available for programming into the neurostimulation system. Furthermore, SCS systems may have as many as thirty-two electrodes, which exponentially increases the number of modulation parameter value combinations available for programming. To facilitate such programming, a clinician often initially programs and modifies the modulation parameters through a computerized programming system, to allow the modulation parameters to be established from starting parameter sets (programs) and patient and clinician feedback. In addition, the patient often is provided with a limited set of controls to switch from a first program to a second program, based on user preferences and the subjective amount of pain or discomfort that the patient is treating. However, the implementation and use of a program modeling system and program determination logic as described further in  FIGS.  7  to  9    and thereafter provides a mechanism for recommending and controlling programs with new combinations of parameter settings, in a fashion that emphasizes chronic pain improvement from use of a new or changed program with the neurostimulator deployment. 
       FIG.  3    illustrates an embodiment of a programming device  302 , such as may be implemented in neurostimulation system  100 . Programming device  302  represents an embodiment of programming device  102  and includes a storage device  318 , a programming control circuit  316 , and a user interface device  310 . Programming control circuit  316  generates the plurality of stimulation parameters that controls the delivery of the neurostimulation pulses according to the pattern of the neurostimulation pulses. The user interface device  310  represents an embodiment to implement the user interface  110 . 
     In various embodiments, the user interface device  310  includes an input/output device  320  that is capable to receive user interaction and commands to load, modify, and implement neurostimulation programs and schedule delivery of the neurostimulation programs. In various embodiments, the input/output device  320  allows the user to create, establish, access, and implement respective parameter values of a neurostimulation program through graphical selection (e.g., in a graphical user interface output with the input/output device  320 ), including values of a therapeutic neurostimulation field. In some examples, the user interface device  310  can receive user input to initiate the implementation of the programs which are recommended, modified, selected, or loaded through use of a program modeling system, which are described in more detail below. 
     In various embodiments, the input/output device  320  allows the patient user to apply, change, modify, or discontinue certain building blocks of a program and a frequency at which a selected program is delivered. In various embodiments, the input/output device  320  can allow the patient user to save, retrieve, and modify programs (and program settings) loaded from a clinical encounter, managed from the patient feedback computing device, or stored in storage device  318  as templates. In various embodiments, the input/output device  320  and accompanying software on the user interface device  310  allows newly created building blocks, program components, programs, and program modifications to be saved, stored, or otherwise persisted in storage device  318 . 
     In one embodiment, the input/output device  320  includes a touchscreen. In various embodiments, the input/output device  320  includes any type of presentation device, such as interactive or non-interactive screens, and any type of user input device that allows the user to interact with a user interface to implement, remove, or schedule the programs, and as applicable, to edit or modify waveforms, building blocks, and program components. Thus, the input/output device  320  may include one or more of a touchscreen, keyboard, keypad, touchpad, trackball, joystick, and mouse. In various embodiments, circuits of the neurostimulation system  100 , including its various embodiments discussed in this document, may be implemented using a combination of hardware and software. For example, the logic of the user interface  110 , the stimulation control circuit  214 , and the programming control circuit  316 , including their various embodiments discussed in this document, may be implemented using an application-specific circuit constructed to perform one or more particular functions or a general-purpose circuit programmed to perform such function(s). Such a general-purpose circuit includes, but is not limited to, a microprocessor or a portion thereof, a microcontroller or portions thereof, and a programmable logic circuit or a portion thereof. 
       FIG.  4    illustrates an implantable neurostimulation system  400  and portions of an environment in which system  400  may be used. System  400  includes an implantable system  422 , an external system  402 , and a telemetry link  426  providing for wireless communication between an implantable system  422  and an external system  402 . Implantable system  422  is illustrated in  FIG.  4    as being implanted in the patient&#39;s body  499 . The system is illustrated for implantation near the spinal cord. However, the neuromodulation system may be configured to modulate other neural targets. 
     Implantable system  422  includes an implantable stimulator  404  (also referred to as an implantable pulse generator, or IPG), a lead system  424 , and electrodes  406 , which represent an embodiment of the stimulation device  204 , the lead system  208 , and the electrodes  206 , respectively. The external system  402  represents an embodiment of the programming device  302 . 
     In various embodiments, the external system  402  includes one or more external (non-implantable) devices each allowing the user and/or the patient to communicate with the implantable system  422 . In some embodiments, the external system  402  includes a programming device intended for the user to initialize and adjust settings for the implantable stimulator  404  and a remote control device intended for use by the patient. For example, the remote control device may allow the patient to turn the implantable stimulator  404  on and off and/or adjust certain patient-programmable parameters of the plurality of stimulation parameters. The remote control device may also provide a mechanism to receive and process feedback on the operation of the implantable neuromodulation system. Feedback may include metrics or an efficacy indication reflecting perceived pain, effectiveness of therapies, or other aspects of patient comfort or condition. Such feedback may be automatically detected from a patient&#39;s physiological state, or manually obtained from user input entered in a user interface. 
     For the purposes of this specification, the terms “neurostimulator,” “stimulator,” “neurostimulation,” and “stimulation” generally refer to the delivery of electrical energy that affects the neuronal activity of neural tissue, which may be excitatory or inhibitory; for example by initiating an action potential, inhibiting or blocking the propagation of action potentials, affecting changes in neurotransmitter/neuromodulator release or uptake, and inducing changes in neuro-plasticity or neurogenesis of tissue. It will be understood that other clinical effects and physiological mechanisms may also be provided through use of such stimulation techniques. 
       FIG.  5    illustrates an embodiment of the implantable stimulator  404  and the one or more leads  424  of an implantable neurostimulation system, such as the implantable system  422 . The implantable stimulator  404  may include a sensing circuit  530  that is optional and required only when the stimulator has a sensing capability, stimulation output circuit  212 , a stimulation control circuit  514 , an implant storage device  532 , an implant telemetry circuit  534 , and a power source  536 . The sensing circuit  530 , when included and needed, senses one or more physiological signals for purposes of patient monitoring and/or feedback control of the neurostimulation. Examples of the one or more physiological signals includes neural and other signals each indicative of a condition of the patient that is treated by the neurostimulation and/or a response of the patient to the delivery of the neurostimulation. 
     The stimulation output circuit  212  is electrically connected to electrodes  406  through the one or more leads  424 , and delivers each of the neurostimulation pulses through a set of electrodes selected from the electrodes  406 . The stimulation output circuit  212  can implement, for example, the generating and delivery of a customized neurostimulation waveform (e.g., implemented from a parameter of a program selected with the present dynamic model or dynamical information system) to an anatomical target of a patient. 
     The stimulation control circuit  514  represents an embodiment of the stimulation control circuit  214  and controls the delivery of the neurostimulation pulses using the plurality of stimulation parameters specifying the pattern of the neurostimulation pulses. In one embodiment, the stimulation control circuit  514  controls the delivery of the neurostimulation pulses using the one or more sensed physiological signals and processed input from patient feedback interfaces. The implant telemetry circuit  534  provides the implantable stimulator  404  with wireless communication with another device such as a device of the external system  402 , including receiving values of the plurality of stimulation parameters from the external system  402 . The implant storage device  532  stores values of the plurality of stimulation parameters, including parameters from one or more programs obtained using the patient feedback and the programming modification logic techniques disclosed herein. 
     The power source  536  provides the implantable stimulator  404  with energy for its operation. In one embodiment, the power source  536  includes a battery. In one embodiment, the power source  536  includes a rechargeable battery and a battery charging circuit for charging the rechargeable battery. The implant telemetry circuit  534  may also function as a power receiver that receives power transmitted from external system  402  through an inductive couple. 
     In various embodiments, the sensing circuit  530  (if included), the stimulation output circuit  212 , the stimulation control circuit  514 , the implant telemetry circuit  534 , the implant storage device  532 , and the power source  536  are encapsulated in a hermetically sealed implantable housing. In various embodiments, the lead(s)  424  are implanted such that the electrodes  406  are placed on and/or around one or more targets to which the neurostimulation pulses are to be delivered, while the implantable stimulator  404  is subcutaneously implanted and connected to the lead(s)  424  at the time of implantation. 
       FIG.  6    illustrates an embodiment of an external patient programming device  602  of an implantable neurostimulation system, such as the external system  402 , with the external patient programming device  602  illustrated to receive commands (e.g., program selections, information) directly or indirectly from a dynamical information system and the dynamic models (not shown in  FIG.  6   , but discussed with reference to  FIGS.  7  to  9   , below). The external patient programming device  602  represents an embodiment of the programming device  302 , and includes an external telemetry circuit  640 , an external storage device  618 , a programming control circuit  616 , a user interface device  610 , a controller  650 , and an external communication device  620 . 
     The external telemetry circuit  640  provides the external patient programming device  602  with wireless communication to and from another controllable device such as the implantable stimulator  404  via the telemetry link  426 , including transmitting one or a plurality of stimulation parameters (including changed stimulation parameters of a selected program) to the implantable stimulator  404 . In one embodiment, the external telemetry circuit  640  also transmits power to the implantable stimulator  404  through inductive coupling. 
     The external communication device  620  provides a mechanism to conduct communications with a programming information source, such as a data service, program modeling system, or other aspects of a dynamic information system, to receive program information via an external communication link (not shown). As described in the following paragraphs, the program modeling system may be used to identify a program or program data to the external patient programming device  602  that corresponds to a new or different neurostimulation program or characteristics of a neurostimulation program (which is, in turn, selected to provide an improved treatment of a chronic pain condition by the dynamic model). The external communication device  620  and the programming information source may communicate using any number of wired or wireless communication mechanisms described in this document, including but not limited to an IEEE 802.11 (Wi-Fi), Bluetooth, Infrared, and like standardized and proprietary wireless communications implementations. Although the external telemetry circuit  640  and the external communication device  620  are depicted as separate components within the external patient programming device  602 , the functionality of both of these components may be integrated into a single communication chipset, circuitry, or device. 
     The external storage device  618  stores a plurality of existing neurostimulation waveforms, including definable waveforms for use as a portion of the pattern of the neurostimulation pulses, settings and setting values, other portions of a program, and related treatment efficacy indication values. In various embodiments, each waveform of the plurality of individually definable waveforms includes one or more pulses of the neurostimulation pulses, and may include one or more other waveforms of the plurality of individually definable waveforms. Examples of such waveforms include pulses, pulse blocks, pulse trains, and train groupings, and programs. The existing waveforms stored in the external storage device  618  can be definable at least in part by one or more parameters including, but not limited to the following: amplitude, pulse width, frequency, duration(s), electrode configurations, total charge injected per unit time, cycling (e.g., on/off time), waveform shapes, spatial locations of waveform shapes, pulse shapes, number of phases, phase order, interphase time, charge balance, and ramping. 
     The external storage device  618  also stores a plurality of individually definable fields that may be implemented as part of a program. Each waveform of the plurality of individually definable waveforms is associated with one or more fields of the plurality of individually definable fields. Each field of the plurality of individually definable fields is defined by one or more electrodes of the plurality of electrodes through which a pulse of the neurostimulation pulses is delivered and a current distribution of the pulse over the one or more electrodes. A variety of settings in a program (including settings changed as a result of evaluation with the dynamical information system and the dynamic models) may be correlated to the control of these waveforms and definable fields. 
     The programming control circuit  616  represents an embodiment of a programming control circuit  316  and generates the plurality of stimulation parameters, which is to be transmitted to the implantable stimulator  404 , based on the pattern of the neurostimulation pulses. The pattern is defined using one or more waveforms selected from the plurality of individually definable waveforms (e.g., defined by a program) stored in an external storage device  618 . In various embodiments, a programming control circuit  616  checks values of the plurality of stimulation parameters against safety rules to limit these values within constraints of the safety rules. In one embodiment, the safety rules are heuristic rules. 
     The user interface device  610  represents an embodiment of the user interface device  310  and allows the user (including a patient or clinician) to select, modify, enable, disable, activate, schedule, or otherwise define a program or sets of programs for use with the neurostimulation device and perform various other monitoring and programming tasks for operation of the neurostimulation device. The user interface device  610  can enable a user to implement, save, persist, or update a program including the program or program parameters recommended or indicated by the programming information source, such as a data service or program modeling system. The user interface device  610  includes a display screen  642 , a user input device  644 , and an interface control circuit  646 . The display screen  642  may include any type of interactive or non-interactive screens, and the user input device  644  may include any type of user input devices that supports the various functions discussed in this document, such as a touchscreen, keyboard, keypad, touchpad, trackball, joystick, and mouse. The user interface device  610  may also allow the user to perform any other functions discussed in this document where user interface input is suitable. 
     Interface control circuit  646  controls the operation of the user interface device  610  including responding to various inputs received by the user input device  644  that define or modify characteristics of implementation (including conditions, schedules, and variations) of one or more programs, parameters within the program, characteristics of one or more stimulation waveforms within a program, and like neurostimulator operational values that may be entered or selected with the external patient programming device  602 , or obtained from the programming information source, such as the data service, or the program modeling system. Interface control circuit  646  includes a neurostimulation program circuit  660  that may generate a visualization of such characteristics of implementation, and receive and implement commands to implement the program and the neurostimulator operational values (including a status of implementation for such operational values). These commands and visualization may be performed in a review and guidance mode, status mode, or in a real-time programming mode. 
     The controller  650  can be a microprocessor that communicates with the external telemetry circuit  640 , the external communication device  620 , the external storage device  618 , the programming control circuit  616 , and the user interface device  610 , via a bidirectional data bus. The controller  650  can be implemented by other types of logic circuitry (e.g., discrete components or programmable logic arrays) using a state machine type of design. As used in this disclosure, the term “circuitry” should be taken to refer to either discrete logic circuitry, firmware, or to the programming of a microprocessor. 
     As will be understood, the variety of settings for a neurostimulation device may be provided by many variations of programming parameter settings within programs. Existing patient programmers only provide a limited ability for a patient to cycle through programs that have defined programming parameters, with hundreds or thousands of specific settings often being rolled up into a single program. The following system and methods provide technical mechanisms to generate and recommend new programs and parameters for chronic pain therapy in response to operation of a dynamical model. This dynamical model may operate to explore a prediction or recommendation of a program, based on factors such as user decisions, feedback on applied programs, pain level observations, and other observations of values that are correlated to pain experienced by a human subject. The dynamical model may generate new combinations of one or more settings in a new program, implement modifications to one or more settings in an existing program, and provide indications of new or different programs, recommended or suggested adjustments or modifications to an existing program, and like variations. 
     In an example, a dynamical model for the creation of a new program may be implemented in continuous time or discrete time, as modeled with the following equations: 
     
       
         
           
             
               
                 
                   
                     
                       
                         
                           x 
                           ^ 
                         
                         := 
                           
                         
                           patient 
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                   EQUATION 
                   ⁢ 
                       
                   1 
                 
               
             
           
         
       
     
     In an example, the set of possible programs available on the neurostimulation device is expanded with time, as new programs are created (up to time t). As noted in these equations, the model may be evaluated in either a continuous time or discrete time, depending on the available data. 
     Also in an example, the model is adapted to learn new programs and then evaluate the benefits of the program based on some reward function. In a first phase, this evaluation may occur as part of an exploration process, modeled with the following equation in continuous time:
 
 u   q(t)+1 = ( U   t ,past actions) with  u   q(t)+1  belonging to a safe set, for any uncertainty,  r ( t )  EQUATION 2
 
     Also in an example, the model is adapted to deploy a new program in a second phase as part of an exploitation process, which operates a provides a modified model predictive control algorithm, with the model being uncertain modeled. This form of inputs exploitation may be modeled with the following equation in continuous time: 
     
       
         
           
             
               
                 
                   
                     
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                   EQUATION 
                   ⁢ 
                       
                   3 
                 
               
             
           
         
       
     
     Although continuous time models are illustrated in Equations 2 and 3, it will be understood that discrete time models may be represented by similar equations. 
     With implementation of these dynamical equations, a control system may operate a predictive control-like algorithm that generates new programs for future use cases based on prior activities and the universe of settings available to use. Further, this control system is adaptive in the sense that the model may be “trained” over time based on prior operations and how a patient directly responds to the changes in programming. Accordingly, with suitable patient and medical professional oversight and guidance, a neurostimulation program may be optimized for treatment of chronic pain using the presently disclosed dynamical models. 
     The following drawings illustrate example implementations of systems utilizing these or similar dynamical models for the purpose of chronic pain treatment. It will be understood that variations to the parameters and dynamic equations listed above, as used for the treatment of chronic pain with neurostimulation programs, are within the scope of the present disclosure. 
       FIG.  7    illustrates, by way of example, an embodiment of data interactions among a clinician programmer device  710 , a program modeling system  720 , an external patient programming device  602 , and a programming data service  770  for generating and implementing respective programs of defined parameter settings of a neurostimulation device, in connection with dynamic models of chronic pain treatments. The program modeling system  720  is shown in  FIG.  7    in the form of a computing device (e.g., a server) with the computing device being specially programmed to communicate over a network the results of the dynamic modeling logic  724  (e.g., with an algorithm implemented in software that is executed on the computing device). The program modeling system  720  may also include a user interface  722  (e.g., in a software app interface, or an application programming interface) which provides the similar results to another system or to a human user. It will be understood that other form factors and embodiments of the program modeling system  720 , including in the integration of other programming devices, data services, or information services, may also be deployed. 
     The program modeling system  720  and the clinician programmer device  710  may communicate to a programming data service  770  via a network  740  (e.g., a private local area network, public wide area network, the Internet, and the like) to obtain pre-defined programs, program settings, program modifications, constraints, rules, or like information related to programming (programs  776 ) or device operations (e.g., operational data  778 ). The programming data service  770  serves as a data service to host program information for a plurality of neurostimulation programs (e.g., across multiple patients, facilities, or facility locations) and model parameters. In an example, the programming data service  770  may be operated or hosted by a research institution, medical service provider, or a medical device provider (e.g., a manufacturer of the neurostimulation device) for managing data and settings for respective programs  776  and operational data  778  among a plurality of clinical deployments or device types. The programming data service  770  may provide an interface to backend data components such as a data processing server  772  and a database  774 , to provide a plurality of programs  776  and operational data  778  and related settings. For instance, the programming data service  770  may be accessed using an application programming interface (API) or other remotely accessible interface accessible via the network  740 . 
     In an example, the program settings  752  to update the parameter(s) or program(s) of the neurostimulation device  750  are generated by the program modeling system  720 , and then communicated to the neurostimulation device  750  by the external patient programming device  602 . In a further example, the dynamic modeling logic  724  results in selection of an entirely new program, or a customized or modified program, which may be communicated in the program settings  752 . The clinician programmer device  710  can operate in a similar fashion, with use of a user interface  712  and program implementation logic  714  to activate, deploy, select, define, edit, and modify parameter(s) or program(s) in a clinical setting through use of the program modeling system. Finally, in some examples, the program settings  752  may be directly communicated from the clinician programmer device  710  rather than a patient programming device  602 . 
     The external patient programming device  602  is illustrated in the form factor of a patient-operable remote control, but may be embodied in a number of other form factors. The external patient programming device  602  operates to communicate program data to the neurostimulation device  750  through use of program implementation logic  734  and a user interface  732  (e.g., a user interface provided by the user interface device  610  discussed in  FIG.  6   ). In an example, a neurostimulation program or set of programming parameters are transmitted to the external patient programming device  602  (or clinician programmer device  710 ) from the program modeling system  720 , and is processed by the program implementation logic  734  (or program implementation logic  714 ) to determine an appropriate operational change to the neurostimulation device  750 . 
       FIG.  8    illustrates, by way of example, a block diagram  800  of an embodiment of the program modeling system  720  adapted for recommending and controlling programming parameters of a neurostimulation treatment. As shown, the block diagram  800  illustrates data flows among the data service  770 , the program modeling system  720 , and the neurostimulation device  750 , as a result of program creation and determination logic  840  which identifies an appropriate program selection using dynamic models. It will be understood that additional features and data flows may occur in connection with the use of the program determination logic  840  and the dynamic models described herein. 
     The program modeling system  720  is depicted as receiving user input and program feedback  802 , for use in determining operative values of parameters in the dynamic model to experiment and explore for pain treatment. In an example, this user input and program feedback  802  is received in a user interface  850  (e.g., a graphical user interface, an application programming interface, etc.). The user interface  850  may also receive additional settings (not shown), constraints, and conditions for operation and use of a dynamic model. For instance, these constraints and conditions may be safety or regulatory operation conditions, device engineering or operational limits, comfort or preference settings, or the like. 
     The program modeling system  720  is also depicted as outputting treatment recommendations  804 , for user control (e.g., by a patient, a clinician, a caregiver, etc.). These treatment recommendations  804  may include a set of suggested program characteristics or parameter settings as newly determined by the dynamic model. During the exploration phase of the program modeling, the treatment recommendations  804  may be used to identify new options and permutations of programs to the patient, clinician, or another interested party. 
     The program modeling system  720  performs coordination of the parameter determination operations, and the execution of one or more dynamic models (and associated dynamic equation algorithms) through the user of operational logic  820  that coordinates with the program creation and determination logic  840 . In an example, the operational logic  820  interfaces with a data repository  860  to access and obtain historical data relevant to the dynamic model, programs, pain information, or other aspects relevant to neurostimulation treatment or the program modeling. 
     The program modeling system  720  also coordinates the selection of parameters for use in program generation based on model calculation data  830 , which provides model calculations in a similar fashion as reinforcement learning. IN an example, the model calculation data is provided from learning data  870  obtained or derived from the operation of the neurostimulation device  750  or respective treatment operations  890 . 
     In an example, the program creation and determination logic  840  evaluates the user input and program feedback  802  and the model calculation data  830 , and identifies relevant data parameters for evaluation in a dynamical model. The program modeling system  720  then generates treatment recommendations  804  (e.g., through the user interface  850 ), or facilitates the generation of a program with a relevant selection of relevant treatment parameters  880 , for control of the neurostimulation device  750 . The operation of the neurostimulation device  750  with the selected program and parameters results in treatment operations  890  for chronic pain relief. Again, as previously discussed, the results of the treatment operations  890  or operation of the neurostimulation device  750  provides learning data that reinforces (emphasizes, de-emphasizes) certain outcomes and selections by the dynamical model. 
       FIG.  9    illustrates, by way of example, an embodiment of a data and control flow between a dynamical system data processing model  902  and programming generation logic  910 , used to explore and exploit programming parameters  930  of a neurostimulation treatment (e.g., implemented for the neurostimulation device  750 ). As illustrated, the data and control flow may include a plurality of inputs  900  that are provided as part of a dynamical system data processing  902 , which may implement a dynamic model (e.g., in the form of an algorithm including the dynamic equations discussed above) or other aspects of dynamical modeling (e.g., in connection with the program modeling system  720 ). As also illustrated, the dynamical system data processing  902  provides control and operation of programming generation logic  910 , which utilizes the dynamic modeling results to perform aspects of program parameter identification  920 , program selection  912 , and program generation  914 , using the dynamic models discussed herein. 
     The output of the programming determination logic may identify and effect the use of programming parameters  930  (e.g., treatment parameters  880 ) as part of treatment for a chronic pain condition using the neurostimulation device  750 . As illustrated, the programming parameters  930  may include defined aspects such as amplitude, pulse type, pulse pattern, duration, and frequency, among other aspects described herein. 
     The inputs that can be provided to the dynamical system data processing  902  as part of a program generation process (e.g., with use of a dynamical model) may include: model parameters and constraints  900 - 1 , relevant to the operation of the dynamic modeling and the bounds in which new programs can be explored and created; predicted pain  900 - 2 , relevant to the particular predicted pain condition of the human subject; and observed patient pain  900 - 3 , relevant to the current, historical, or previously observed pain condition of the patient. The predicted pain  900 - 2  and the observed patient pain  900 - 3  may be derived from other quantities of interest, such as other measurements of physiologic data (including patient sensor data  940 , in the form of activity data, behavior data, or physiologic data). In an example, the observed patient pain  900 - 3  may be represented by a data value, measurement, or as a result of other data types, including values that indicate scale or changes in pain level, pain area, spread of pain, or other pain characteristics. 
     Further parameters provided to the dynamical system data processing  902  include model time data  900 - 4 , indicating time increments, measurements, or values relevant to the dynamical model; and stimulator input  900 - 5 , which define the applicable universe or set of stimulator operations to be modeled. In an example, the parameters of the stimulator input  900 - 5  include a set of predefined stimulator programs  904 , which may include previously generated programs that have associated feedback and results; and computed stimulator programs  906 , which define new calculations of parameter combinations in programs computed up to time t. As a result, many program types and feedback on these various program types may be collected and considered. Finally, the parameters provided to the dynamical system data processing  902  may also include time-based model uncertainty, which may be various values to represent model uncertainty learned at every time step that the system attempts to unveil. 
     As discussed above, the pain values (including observed patient pain  900 - 3 ) may be determined from various forms and types of patient sensor data  940 , such as activity data, behavior data, or physiologic data. In an example, physiological data includes values to indicate at least one of: autonomic tone, heart rate, respiratory rate, or blood pressure, for the human subject. In another example, activity data includes values to indicate of at least one of: movement or gait for the human subject. Finally, in another example, behavior data includes values to indicate at least one of: a psychological state of the human subject or social activities performed by the human subject. Any combination of these data values may also be considered and used as part of the patient pain measurements  900 - 3  or the dynamical system data processing  902 . 
     The programming generation logic  910  operates to perform program generation  914  in connection with inputs exploration  922  with use of the dynamic model, including the selection or specification of various parameters with program parameter identification  920 . The programming generation logic  910  may further operate to perform program selection  912  in connection with inputs exploitation with use of results from the dynamic model, including the selection or modification of parameters with the program selection  912 . For instance, inputs exploration  922  may generate a new program that includes the generated program parameters  930 ; this new program may be deployed and controlled as a result of inputs exploitation  924 . 
       FIG.  10    illustrates, by way of example, an embodiment of a processing method  1000  implemented by a system or device for use to establish programming of an implantable electrical neurostimulation device for treating chronic pain of a human subject. For example, the processing method  1000  can be embodied by electronic operations performed by one or more computing systems or devices that are specially programmed to implement the pain determination, program modeling, and neurostimulation programming functions described herein. 
     For example, the method  1000  includes the obtaining (e.g., receiving, requesting, extracting, processing) of patient state data for a condition of a human subject (e.g., patient) in connection with chronic pain treatment with a neurostimulation treatment (or series of treatments) (operation  1002 ). This data may represent or correspond to various forms of values, sensor measurements, device operational details, user input, indicated above for  FIG.  9   , although other formats and forms of data may also be may be used. This data may specifically indicate a measured value that is correlated to (or indicative of) pain experienced by the human subject. Further, this data may include prior (e.g., historical, previously observed) state data that indicates at least one measured value at a prior time. 
     The method  1000  continues, in an optional example, with the identification of various measured data values, from patient state data (operation  1004 ). Accordingly, in this optional example, operations that identify a pain state may utilize the dynamic model to evaluate at least the measured pain level and the predicted pain level as part of determining pain treatment parameters or an appropriate program (further discussed below). In a further example (not depicted), the dynamic model is one of a plurality of dynamic models available for identification of the pain treatment parameters, such as in a case where the particular utilized dynamic model is selected from a dynamic model data source based on the measured data values or a particular state of pain. 
     The method  1000  continues to determine one or more neurostimulation programming parameters, using exploration in a dynamic model (operation  1006 ). The parameters of the dynamic model may include those described above in  FIG.  9    (e.g., parameters  900 - 1  to  900 - 5 ). In an example, the dynamic model is a continuous time model or a discrete time model, such that the dynamic model evaluates the pain treatment parameters in the human subject over the time period based on: predicted pain of the human subject, observed pain of the human subject, dynamic model parameters, and operational data of the implantable electrical neurostimulation device (including predefined programs and programs computed forward in time). In a further example, the dynamic model is adapted to evaluate the pain treatment parameters in the human subject based on operational data obtained from use or programming of the implantable electrical neurostimulation device, including from feedback from previous program definitions and recommendations. In a further example, the model parameters that are specific to the human subject. 
     The method  1000  continues to indicate a neurostimulation program corresponding to the pain treatment parameters, such as through the establishing or creation of the program (operation  1008 ) and the output and/or implementation of the neurostimulation (operation  1010 ). The indication of the neurostimulation program may be implemented within the dynamic model, programming determination logic, or other aspects of a programming or information system. In an example, the generated neurostimulation program is one of a plurality of predefined neurostimulation programs made available for use in the implantable electrical neurostimulation device. 
     In an example, the generated neurostimulation program causes a change in operation of the implantable electrical neurostimulation device with the identified parameters, with such change corresponding to a change in the state for the human subject. Also in an example, deployment of the neurostimulation programming parameters with the neurostimulation program causes a change in operation of the implantable electrical neurostimulation device, that corresponds to an observed change in a measured value. Also in an example, the generated neurostimulation program specifies a change in programming for the implantable electrical neurostimulation device, with the identified parameters, for one or more of: pulse patterns, pulse shapes, a spatial location of pulses, waveform shapes, or a spatial location of waveform shapes, for modulated energy provided with a plurality of leads of the implantable electrical neurostimulation device. 
     The method  1000  may continue with additional operations (not depicted) to effect or modify the programming of the neurostimulation device with the generated program or the identified parameters. Such programming may be implemented in the manner as described with  FIG.  7    above, or with other variations involving the use of patient, clinician, or administrator involvement. 
     Finally, the method  1000  may conclude with the evaluation of the benefit of the implemented neurostimulation program (operation  1012 ), conducted in connection with the collection of additional patient state data and the identification of additional measured data values (repeating operations  1002 ,  1004 ). For example, operations to evaluate the benefit may include using a reward function in the dynamic model, where the dynamic model is adapted to identify a projected use of the neurostimulation programming parameters that provides a reduction in the pain measurement with the human subject. Other variations to repeat the selection operations, incorporate patient feedback or clinician observations, or adapt the treatment with the use of new or modified programs with the dynamic model, may be utilized. 
       FIG.  11    illustrates, by way of example, a block diagram of an embodiment of a system  1100  (e.g., a computing system) implementing patient state determination circuitry for use to establish programming of an implantable electrical neurostimulation device for treating chronic pain of a human subject. The system  1100  may be a remote control device, patient programmer device, clinician programmer device, program modeling system, or other external device, usable for the determination of a pain state in connection with dynamical modeling discussed herein. In some examples, the system  1100  may be a networked device connected via a network (or combination of networks) to a programming device or programming service using a communication interface  1108 , with the programming device or programming service providing output content for the graphical user interface or responding to input of the graphical user interface. The network may include local, short-range, or long-range networks, such as Bluetooth, cellular, IEEE 802.11 (Wi-Fi), or other wired or wireless networks. 
     The system  1100  includes a processor  1102  and a memory  1104 , which can be optionally included as part of pain determination circuitry  1106 . The processor  1102  may be any single processor or group of processors that act cooperatively. The memory  1104  may be any type of memory, including volatile or non-volatile memory. The memory  1104  may include instructions, which when executed by the processor  1102 , cause the processor  1102  to implement the features of the user interface, or to enable other features of the pain determination circuitry  1106 . Thus, electronic operations in the system  1100  may be performed by the processor  1102  or the circuitry  1106 . 
     For example, the processor  1102  or circuitry  1106  may implement any of the features of the method  1000  (including operations  1002 ,  1004 ,  1006 ,  1012 ) to obtain data related to a patient state (e.g., a state of pain, or another quantity of interest relating to chronic pain), identify data values correlated to a chronic pain condition and the pain state, and determine neurostimulation parameters which predict an improvement to the identified data values, in connection with a neurostimulation program or treatment. The processor  1102  or circuitry  1106  may further establish a new neurostimulation program, based on the determined programming parameters and any constraints, rules, settings, or preferences of the target neurostimulation device; and the processor  1102  or circuitry  1106  may further evaluate or compare the benefit of any implemented neurostimulation program. The system  1100  may save, output, or cause implementation of this new neurostimulation program, directly or indirectly (e.g., via a programming device or system that in turn communicates and implements the new program to the neurostimulation device). It will be understood that the processor  1102  or circuitry  1106  may also implement other aspects of the logic and processing described above with reference to  FIGS.  7 - 9   . 
       FIG.  12    illustrates, by way of example, a block diagram of an embodiment of a system  1200  (e.g., a computing system) for use to establish programming of an implantable electrical neurostimulation device for treating chronic pain of a human subject. The system  1200  may be operated by a clinician, a patient, a caregiver, a medical facility, a research institution, a medical device manufacturer or distributor, and embodied in a number of different computing platforms. The system  1200  may be a remote control device, patient programmer device, program modeling system, or other external device, including a regulated device used to directly implement programming commands and modification with a neurostimulation device. In some examples, the system  1200  may be a networked device connected via a network (or combination of networks) to a computing system operating a user interface computing system using a communication interface  1208 . The network may include local, short-range, or long-range networks, such as Bluetooth, cellular, IEEE 802.11 (Wi-Fi), or other wired or wireless networks. 
     The system  1200  includes a processor  1202  and a memory  1204 , which can be optionally included as part of neurostimulation programming circuitry  1206 . The processor  1202  may be any single processor or group of processors that act cooperatively. The memory  1204  may be any type of memory, including volatile or non-volatile memory. The memory  1204  may include instructions, which when executed by the processor  1202 , cause the processor  1202  to implement the features of the programming device, or to enable other features of the programming modification logic and programming circuitry  1206 . Thus, the following references to electronic operations in the system  1200  may be performed by the processor  1202  or the circuitry  1206 . 
     For example, the processor  1202  or circuitry  1206  may implement any of the features of the method  1000  (including operations  1008 ,  1010 ) to establish a neurostimulation program, transmit the program to the neurostimulation device, implement (e.g., save, persist, activate, control) the program in the neurostimulation device, and receive feedback for use of the neurostimulation program, all with use of a neurostimulation device interface  1210 . The processor  1202  or circuitry  1206  may further provide data and commands to assist the processing and implementation of the programming using communication interface  1208 . It will be understood that the processor  1202  or circuitry  1206  may also implement other aspects of the programming devices and device interfaces described above with reference to  FIGS.  7 - 9   . 
       FIG.  13    is a block diagram illustrating a machine in the example form of a computer system  1300 , within which a set or sequence of instructions may be executed to cause the machine to perform any one of the methodologies discussed herein, according to an example embodiment. In alternative embodiments, the machine operates as a standalone device or may be connected (e.g., networked) to other machines. In a networked deployment, the machine may operate in the capacity of either a server or a client machine in server-client network environments, or it may act as a peer machine in peer-to-peer (or distributed) network environments. The machine may be a personal computer (PC), a tablet PC, a hybrid tablet, a personal digital assistant (PDA), a mobile telephone, an implantable pulse generator (IPG), an external remote control (RC), a User&#39;s Programmer (CP), or any machine capable of executing instructions (sequential or otherwise) that specify actions to be taken by that machine. Further, while only a single machine is illustrated, the term “machine” shall also be taken to include any collection of machines that individually or jointly execute a set (or multiple sets) of instructions to perform any one or more of the methodologies discussed herein. Similarly, the term “processor-based system” shall be taken to include any set of one or more machines that are controlled by or operated by a processor (e.g., a computer) to individually or jointly execute instructions to perform any one or more of the methodologies discussed herein. 
     Example computer system  1300  includes at least one processor  1302  (e.g., a central processing unit (CPU), a graphics processing unit (GPU) or both, processor cores, compute nodes, etc.), a main memory  1304  and a static memory  1306 , which communicate with each other via a link  1308  (e.g., bus). The computer system  1300  may further include a video display unit  1310 , an alphanumeric input device  1312  (e.g., a keyboard), and a user interface (UI) navigation device  1314  (e.g., a mouse). In one embodiment, the video display unit  1310 , input device  1312  and UI navigation device  1314  are incorporated into a touch screen display. The computer system  1300  may additionally include a storage device  1316  (e.g., a drive unit), a signal generation device  1318  (e.g., a speaker), a network interface device  1320 , and one or more sensors (not shown), such as a global positioning system (GPS) sensor, compass, accelerometer, or other sensor. It will be understood that other forms of machines or apparatuses (such as PIG, RC, CP devices, and the like) that are capable of implementing the methodologies discussed in this disclosure may not incorporate or utilize every component depicted in  FIG.  13    (such as a GPU, video display unit, keyboard, etc.). 
     The storage device  1316  includes a machine-readable medium  1322  on which is stored one or more sets of data structures and instructions  1324  (e.g., software) embodying or utilized by any one or more of the methodologies or functions described herein. The instructions  1324  may also reside, completely or at least partially, within the main memory  1304 , static memory  1306 , and/or within the processor  1302  during execution thereof by the computer system  1300 , with the main memory  1304 , static memory  1306 , and the processor  1302  also constituting machine-readable media. 
     While the machine-readable medium  1322  is illustrated in an example embodiment to be a single medium, the term “machine-readable medium” may include a single medium or multiple media (e.g., a centralized or distributed database, and/or associated caches and servers) that store the one or more instructions  1324 . The term “machine-readable medium” shall also be taken to include any tangible (e.g., non-transitory) medium that is capable of storing, encoding or carrying instructions for execution by the machine and that cause the machine to perform any one or more of the methodologies of the present disclosure or that is capable of storing, encoding or carrying data structures utilized by or associated with such instructions. The term “machine-readable medium” shall accordingly be taken to include, but not be limited to, solid-state memories, and optical and magnetic media. Specific examples of machine-readable media include non-volatile memory, including but not limited to, by way of example, semiconductor memory devices (e.g., electrically programmable read-only memory (EPROM), electrically erasable programmable read-only memory (EEPROM)) and flash memory devices; magnetic disks such as internal hard disks and removable disks; magneto-optical disks; and CD-ROM and DVD-ROM disks. 
     The instructions  1324  may further be transmitted or received over a communications network  1326  using a transmission medium via the network interface device  1320  utilizing any one of a number of well-known transfer protocols (e.g., HTTP). Examples of communication networks include a local area network (LAN), a wide area network (WAN), the Internet, mobile telephone networks, plain old telephone (POTS) networks, and wireless data networks (e.g., Wi-Fi, 3G, and 4G LTE/LTE-A or 5G networks). The term “transmission medium” shall be taken to include any intangible medium that is capable of storing, encoding, or carrying instructions for execution by the machine, and includes digital or analog communications signals or other intangible medium to facilitate communication of such software. 
     The above detailed description is intended to be illustrative, and not restrictive. The scope of the disclosure should, therefore, be determined with references to the appended claims, along with the full scope of equivalents to which such claims are entitled.