Patent Publication Number: US-2020297992-A1

Title: Primary Dysmenorrhea Pain Reduction

Description:
CROSS REFERENCE TO RELATED APPLICATIONS 
     This application claims priority to U.S. Provisional Patent Application Ser. No. 62/822,262, filed Mar. 22, 2019, the disclosure of which is hereby incorporated by reference. 
    
    
     FIELD 
     This invention is directed to primary dysmenorrhea (PD), and more particularly to reducing pain experienced during PD using externally applied electrical stimulation. 
     BACKGROUND INFORMATION 
     Primary dysmenorrhea (PD) is pain experienced during a woman&#39;s menstrual cycle, occurring principally in the lower abdomen, lower back and thighs. Symptoms include nausea and vomiting, diarrhea, headache, dizziness, disorientation, fainting and fatigue. Symptoms of PD often begin immediately after ovulation and can last until the end of menstruation. This is because PD is often associated with changes in hormonal levels in the body that occur with ovulation. In particular, prostaglandins induce abdominal contractions that can cause pain and gastrointestinal symptoms. The use of certain types of birth control pills can prevent the symptoms of PD because they stop ovulation from occurring. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  is a depiction of a neuron activating a muscle by electrical impulse. 
         FIG. 2  is a representation of the electrical potential activation time of an electrical impulse in a nerve. 
         FIG. 3  is a cross section of a penis. 
         FIG. 4  is an illustration of a Topical Nerve Stimulator/Sensor (TNSS) component configuration. 
         FIG. 5  is an illustration of the upper side of a Smart Band Aid implementation of a TNSS showing location of battery, which may be of various types. 
         FIG. 6  is an illustration of the lower side of the SBA of  FIG. 5 . 
         FIG. 7  is TNSS components incorporated into a SBA. 
         FIG. 8  is examples of optional neural stimulator and sensor chip sets incorporated into a SBA. 
         FIG. 9  is examples of optional electrode configurations for a SBA. 
         FIG. 10  is an example of the use of TNSS with a Control Unit as a System, in a population of Systems and software applications. 
         FIG. 11  shows a method for forming and steering a beam by the user of a plurality of radiators. 
         FIG. 12  is an exemplary beam forming and steering mechanism. 
         FIG. 13  illustrates exemplary Control Units for activating a nerve stimulation device. 
         FIG. 14  are exemplary software platforms for communicating between the Control Units and the TNSS, gathering data, networking with other TNSSs, and external communications. 
         FIG. 15  represents TNSS applications for patients with a wide range of medical indications such as Spinal Cord Injury, chronic and acute Pain including Migraine, Arthritis and Dysmenorrhea, Ulcers and Wounds, Thrombosis and Circulatory problems, Sexual Dysfunction, Bladder and Bowel conditions, Respiratory problems, Movement and Gait issues, Osteoporosis and Bone Problems, Skin Conditions, and many others. 
         FIG. 16  shows an example of multiple TNSS units deployed at various locations on the human body, with inter-TNSS and direct-to-controller communications. 
         FIG. 17  shows communications among the TNSS devices, the control unit, a user, and the cloud. 
         FIG. 18  shows an example electrode configuration for electric field steering and sensing. 
         FIG. 19  shows an example of stimulating and sensing patterns of signals in a volume of tissue. 
         FIG. 20  is a graph showing pulses applied to the skin. 
         FIG. 21  is a graph showing symmetrical and asymmetrical pulses applied to the skin. 
         FIG. 22  is a cross-sectional diagram showing a field in underlying tissue produced by application of two electrodes to the skin. 
         FIG. 23  is a cross-sectional diagram showing a field in underlying tissue produced by application of two electrodes to the skin, with two layers of tissue of different electrical resistivity. 
         FIG. 24  is a cross-sectional diagram showing a field in underlying tissue when the stimulating pulse is turned off. 
         FIG. 25A  is a system diagram of an example software and hardware components showing an example of a Topical Nerve Stimulator/Sensor (TNSS) interpreting a data stream from a control device in accordance with one example. 
         FIG. 25B  is a flow chart showing an example of a function of a master control program in accordance with one example. 
         FIG. 26  is a block diagram of an example TNSS component configuration including a system on a chip (SOC) in accordance with one example. 
         FIG. 27  is a flow diagram of the protocol for adaptive current control in accordance with one example. 
         FIG. 28  is a Differential Integrator Circuit used in the Adaptive Current Protocol in accordance with one example. 
         FIG. 29  is a table relating charge duration vs. frequency to provide feedback to the Adaptive Current Protocol in accordance with one example. 
         FIG. 30  illustrates components of a PD pain suppression system for a user in accordance to example inventions. 
         FIG. 31A  illustrates a user with an abdomen, a navel, a mons pubis, a lower back, and thighs. 
         FIGS. 31B-C  illustrate the internal physiology pertinent to primary dysmenorrhea. 
         FIG. 32A  illustrates how the patch is designed to be placed on the front of the abdomen in accordance to example inventions. 
         FIG. 32B  illustrates how the patch is designed to be placed on the lower back in accordance to example inventions. 
         FIG. 32C  illustrates how the patch is designed to be placed on one or both of the thighs in accordance to example inventions. 
         FIGS. 33A-B  illustrate other possible locations on the body for patches in example inventions. 
     
    
    
     DETAILED DESCRIPTION 
     Example inventions reduce pain associated with PD by applying electrical stimulation to nerves using patches applied to one or more of a user&#39;s abdomen, lower back, thighs, calves, or feet. 
     The body is controlled by a chemical system and a nervous system. Nerves and muscles produce and respond to electrical voltages and currents. Electrical stimulation of these tissues can restore movement or feeling when these have been lost, or can modify the behavior of the nervous system, a process known as neuro modulation. Recording of the electrical activity of nerves and muscles is widely used for diagnosis, as in the electrocardiogram, electromyogram, electroencephalogram, etc. Electrical stimulation and recording require electrical interfaces for input and output of information. Electrical interfaces between tissues and electronic systems are usually one of three types: 
     a. Devices implanted surgically into the body, such as pacemakers. These are being developed for a variety of functions, such as restoring movement to paralyzed muscles or restoring hearing, and can potentially be applied to any nerve or muscle. These are typically specialized and somewhat expensive devices. 
     b. Devices inserted temporarily into the tissues, such as needles or catheters, connected to other equipment outside the body. Health care practitioners use these devices for diagnosis or short-term treatment. 
     c. Devices that record voltage from the surface of the skin for diagnosis and data collection, or apply electrical stimuli to the surface of the skin using adhesive patches connected to a stimulator. Portable battery-powered stimulators have typically been simple devices operated by a patient, for example for pain relief. Their use has been limited by; 
     i. The inconvenience of chronically managing wires, patches and stimulator, particularly if there are interfaces to more than one site, and 
     ii. The difficulty for patients to control a variety of stimulus parameters such as amplitude, frequency, pulse width, duty cycle, etc. 
     Nerves can also be stimulated mechanically to produce sensation or provoke or alter reflexes; this is the basis of touch sensation and tactile feedback. Nerves can also be affected chemically by medications delivered locally or systemically and sometimes targeted to particular nerves on the basis of location or chemical type. Nerves can also be stimulated or inhibited optically if they have had genes inserted to make them light sensitive like some of the nerves in the eye. The actions of nerves also produce electrical, mechanical and chemical changes that can be sensed. 
     The topical nerve stimulator/sensor (TNSS) is a device to stimulate nerves and sense the actions of the body that can be placed on the skin of a human or mammal to act on and respond to a nerve, muscle or tissue. One implementation of the TNSS is the Smart Band Aid™ (SBA). A system, incorporating a SBA, controls neuro modulation and neuro stimulation activities. It consists of one or more controllers or Control Units, one or more TNSS modules, software that resides in Control Units and TNSS modules, wireless communication between these components, and a data managing platform. The controller hosts software that will control the functions of the TNSS. The controller takes inputs from the TNSS of data or image data for analysis by said software, The controller provides a physical user interface for display to and recording from the user, such as activating or disabling the TNSS, logging of data and usage statistics, generating reporting data. Finally, the controller provides communications with other Controllers or the Internet cloud. 
     The controller communicates with the Neurostim module, also called TNSS module or SBA or patch, and also communicates with the user. In at least one example, both of these communications can go in both directions, so each set of communications is a control loop. Optionally, there may also be a control loop directly between the TNSS module and the body. So the system optionally may be a hierarchical control system with at least four control loops. One loop is between the TNSS and the body; another loop is between the TNSS and the controller; another loop is between the controller and the user; and another loop is between the controller and other users via the cloud. Each control loop has several functions including: (1) sending activation or disablement signals between the controller and the TNSS via a local network such as Bluetooth; (2) driving the user interface, as when the controller receives commands from the user and provides visual, auditory or tactile feedback to the user; (3) analyzing TNSS data, as well as other feedback data such as from the user, within the TNSS, and/or the controller and/or or the cloud; (4) making decisions about the appropriate treatment; (5) system diagnostics for operational correctness; and (6) communications with other controllers or users via the Internet cloud for data transmission or exchange, or to interact with apps residing in the Internet cloud. 
     The control loop is closed. This is as a result of having both stimulating and sensing. The sensing provides information about the effects of stimulation, allowing the stimulation to be adjusted to a desired level or improved automatically. 
     Typically, stimulation will be applied. Sensing will be used to measure the effects of stimulation. The measurements sensed will be used to specify the next stimulation. This process can be repeated indefinitely with various durations of each part. For example (where “a” is applying stimulation, “b” is sensing the results of stimulation, and “c” is correcting or revising the stimulation based on the applying and sensing): rapid cycling through the process (a-b-c-a-b-c-a-b-c); prolonged stimulation, occasional sensing (aaaa-b-c-aaaa-b-c-aaaa-b-c); or prolonged sensing, occasional stimulation (a-bbbb-c-a-bbbb-c-a-bbbb). The process may also start with sensing, and when an event in the body is detected this information is used to specify stimulation to treat or correct the event, for example, (bbbbbbbbb-c-a-bbbbbbbb-c-a-bbbbbbbbb). Other patterns are possible and contemplated within the scope of the application. 
     The same components can be used for stimulating and sensing alternately, by switching their connection between the stimulating circuits and the sensing circuits. The switching can be done by standard electronic components. In the case of electrical stimulating and sensing, the same electrodes can be used for both. An electronic switch is used to connect stimulating circuits to the electrodes and electric stimulation is applied to the tissues. Then the electronic switch disconnects the stimulating circuits from the electrodes and connects the sensing circuits to the electrodes and electrical signals from the tissues are recorded. 
     In the case of acoustic stimulating and sensing, the same ultrasonic transducers can be used for both (as in ultrasound imaging or radar). An electronic switch is used to connect circuits to the transducers to send acoustic signals (sound waves) into the tissues. Then the electronic switch disconnects these circuits from the transducers and connects other circuits to the transducers (to listen for reflected sound waves) and these acoustic signals from the tissues are recorded. 
     Other modalities of stimulation and sensing may be used (e.g. light, magnetic fields, etc.) The closed loop control may be implemented autonomously by an individual TNSS or by multiple TNSS modules operating in a system such as that shown below in  FIG. 16 . Sensing might be carried out by some TNSSs and stimulation by others. 
     Stimulators are protocol controlled initiators of electrical stimulation, where such protocol may reside in either the TNSS and/or the controller and/or the cloud. Stimulators interact with associated sensors or activators, such as electrodes or MEMS devices. 
     The protocol, which may be located in the TNSS, the controller or the cloud, has several functions including: 
     (1) Sending activation or disablement signals between the controller and the TNSS via a local network such as Bluetooth. The protocol sends a signal by Bluetooth radio waves from the smartphone to the TNSS module on the skin, telling it to start or stop stimulating or sensing. Other wireless communication types are possible. 
     (2) Driving the user interface, as when the controller receives commands from the user and provides visual, auditory or tactile feedback to the user. The protocol receives a command from the user when the user touches an icon on the smartphone screen, and provides feedback to the user by displaying information on the smartphone screen, or causing the smartphone to beep or buzz. 
     (3) Analyzing TNSS data, as well as other feedback data such as from the user, within the TNSS, and/or the controller and/or or the cloud. The protocol analyzes data sensed by the TNSS, such as the position of a muscle, and data from the user such as the user&#39;s desires as expressed when the user touches an icon on the smartphone; this analysis can be done in the TNSS, in the smartphone, and/or in the cloud. 
     (4) Making decisions about the appropriate treatment. The protocol uses the data it analyzes to decide what stimulation to apply. 
     (5) System diagnostics for operational correctness. The protocol checks that the TNSS system is operating correctly. 
     (6) Communications with other controllers or users via the Internet cloud for data transmission or exchange, or to interact with apps residing in the Internet cloud. The protocol communicates with other smartphones or people via the internet wirelessly; this may include sending data over the internet, or using computer programs that are operating elsewhere on the internet. 
     A neurological control system, method and apparatus are configured in an ecosystem or modular platform that uses potentially disposable topical devices to provide interfaces between electronic computing systems and neural systems. These interfaces may be direct electrical connections via electrodes or may be indirect via transducers (sensors and actuators). It may have the following elements in various configurations: electrodes for sensing or activating electrical events in the body; actuators of various modalities; sensors of various modalities; wireless networking; and protocol applications, e.g. for data processing, recording, control systems. These components are integrated within the disposable topical device. This integration allows the topical device to function autonomously. It also allows the topical device along with a remote control unit (communicating wirelessly via an antenna, transmitter and receiver) to function autonomously. 
     Referring to  FIG. 1 , nerve cells are normally electrically polarized with the interior of the nerve being at an electric potential 70 mV negative relative to the exterior of the cell. Application of a suitable electric voltage to a nerve cell (raising the resting potential of the cell from −70 mV to above the firing threshold of −55 mV) can initiate a sequence of events in which this polarization is temporarily reversed in one region of the cell membrane and the change in polarization spreads along the length of the cell to influence other cells at a distance, e.g. to communicate with other nerve cells or to cause or prevent muscle contraction. 
     Referring to  FIG. 2 , a nerve impulse is graphically represented from a point of stimulation resulting in a wave of depolarization followed by a repolarization that travels along the membrane of a neuron during the measured period. This spreading action potential is a nerve impulse. It is this phenomenon that allows for external electrical nerve stimulation. 
     Referring to  FIG. 3 , the dorsal genital nerve on the back of the penis or clitoris just under the skin is a purely sensory nerve that is involved in normal inhibition of the activity of the bladder during sexual activity, and electrical stimulation of this nerve has been shown to reduce the symptoms of the Over Active Bladder. Stimulation of the underside of the penis may cause sexual arousal, erection, ejaculation and orgasm. 
     A Topical nerve stimulator/sensor (TNSS) is used to stimulate these nerves and is convenient, unobtrusive, self-powered, controlled from a smartphone or other control device. This has the advantage of being non-invasive, controlled by consumers themselves, and potentially distributed over the counter without a prescription. 
     Referring to  FIG. 4 , the TNSS has one or more electronic circuits or chips that perform the functions of: communications with the controller, nerve stimulation via electrodes  408  that produce a wide range of electric field(s) according to treatment regimen, one or more antennae  410  that may also serve as electrodes and communication pathways, and a wide range of sensors  406  such as, but not limited to, mechanical motion and pressure, temperature, humidity, chemical and positioning sensors. One arrangement would be to integrate a wide variety of these functions into an SOC, system on chip  400 . Within this is shown a control unit  402  for data processing, communications and storage and one or more stimulators  404  and sensors  406  that are connected to electrodes  408 . An antenna  410  is incorporated for external communications by the control unit. Also present is an internal power supply  412 , which may be, for example, a battery. An external power supply is another variation of the chip configuration. It may be necessary to include more than one chip to accommodate a wide range of voltages for data processing and stimulation. Electronic circuits and chips will communicate with each other via conductive tracks within the device capable of transferring data and/or power. 
     In one or more examples, a Smart Band Aid™ incorporating a battery and electronic circuit and electrodes in the form of adhesive conductive pads may be applied to the skin, and electrical stimuli is passed from the adhesive pads into the tissues. Stimuli may typically be trains of voltage-regulated square waves at frequencies between 15 and 50 Hz with currents between 20 and 100 mA. In other examples, the stimuli includes square waves having an amplitude between 10 and 100 volts, pulse widths between 100 and 500 microseconds, and a pulse repetition rate of between 3 and 30 pulses per second. The trains of stimuli are controlled from a smartphone operated by the user. Stimuli may be either initiated by the user when desired, or programmed according to a timed schedule, or initiated in response to an event detected by a sensor on the Smart Band Aid™ or elsewhere. Another implementation for males may be a TNSS incorporated in a ring that locates a stimulator conductively to selected nerves in a penis to be stimulated. 
     Referring to  FIG. 5 , limited lifetime battery sources will be employed as internal power supply  412 , to power the TNSS deployed in this illustration as a Smart Band Aid™. These may take the form of Lithium Ion technology or traditional non-toxic Mn02 technologies.  FIG. 5  illustrates different battery options such as a printable Manganese Oxide battery  516  and a button battery  518 . A TNSS of different shapes may require different battery packaging. 
       FIG. 6  shows an alternate arrangement of these components where the batteries  616 - 618  are positioned on the bottom side of the SBA between the electrodes  610  and  620 . In this example, battery  616  is a lithium ion battery, battery  617  is a Mn02 battery and battery  618  is a button battery. Other types of batteries and other battery configurations are possible within the scope of this application in other examples. 
     Aside from the Controller, the Smart Band Aid™ Packaging Platform (also referred to as a “smart patch” or “patch”) consists of an assembly of an adhesive patch capable of being applied to the skin and containing the TNSS Electronics, protocol, and power described above. 
     Referring to  FIG. 7  is a TNSS deployed as a Smart Band Aid™  414 . The Smart Band Aid™ has a substrate with adhesive on a side for adherence to skin, the SOC  400  previously described in  FIG. 4 , or electronic package, and electrodes  408  disposed between the dermis and the adhesive surface. The electrodes provide electrical stimuli through the dermis to nerves and other tissue and in turn may collect electrical signals from the body, such as the electrical signals produced by muscles when they contract (the electromyogram) to provide data about body functions such as muscle actions. 
     Referring to  FIG. 8 , different chips may be employed to design requirements. Shown are sample chips for packaging in a TNSS in this instance deployed as a SBA. For example, neural stimulator  800 , sensor  802 , processor/communications  804  are represented. The chips can be packaged separately on a substrate, including a flexible material, or as a system-on-chip (SOC)  400  or as an ASIC. The chip connections and electronics package are not shown but are known in the art. 
     Referring to  FIG. 9 , SBAs with variations on arrangements of electrodes are shown. Each electrode may consist of a plurality of conductive contacts that give the electrode abilities to adjust the depth, directionality, and spatial distribution of the applied electric field. For all the example electrode configurations shown,  901 - 904 , the depth of the electrical stimulation can be controlled by the voltage and power applied to the electrode contacts. Electric current can be applied to various electrode contacts at opposite end of the SBA, or within a plurality of electrode contacts on a single end of the SBA. The phase relationship of the signals applied to the electrode contacts can vary the directionality of the electric field. For all configurations of electrodes, the applied signals can vary over time and spatial dimensions. The configuration on the left,  901 , shows a plurality of concentric electrode contacts at either end of the SBA. This configuration can be used to apply an electric stimulating field at various tissue depths by varying the power introduced to the electrode contacts. The next configuration,  902 , shows electrodes  404  that are arranged in a plurality of parallel strips of electrical contacts. This allows the electric field to be oriented perpendicular or parallel to the SBA. The next configuration,  903 , shows an example matrix of electrode contacts where the applied signal can generate a stimulating field between any two or more electrode contacts at either end of the SBA, or between two or more electrode contacts within a single matrix at one end of the SBA. Finally, the next configuration on the far right,  904 , also shows electrodes that are arranged in a plurality of parallel strips of electrical contacts. As with the second configuration, this allows the electric field to be oriented perpendicular or parallel to the SBA. There may be many other arrangements of electrodes and contacts. 
     One or more TNSSs with one or more Controllers form a System. Systems can communicate and interact with each other and with distributed virtualized processing and storage services. This enables the gathering, exchange, and analysis of data among populations of systems for medical and non-medical applications. 
     Referring to  FIG. 10 , a system is shown with two TNSS units  1006 , with one on the wrist, one on the leg, communicating with its controller, a smartphone  1000  or other control device. The TNSS units can be both sensing and stimulating and can act independently and also work together in a Body Area Network (BAN). Systems communicate with each other over a communication bridge or network such as a cellular network. Systems also communicate with applications running in a distributed virtualized processing and storage environment generally via the Internet  1002 . The purpose for communications with the distributed virtualized processing and storage environment is to communicate large amounts of user data for analysis and networking with other third parties such as hospitals, doctors, insurance companies, researchers, and others. There are applications that gather, exchange, and analyze data from multiple Systems  1004 . Third party application developers can access TNSS systems and their data to deliver a wide range of applications. These applications can return data or control signals to the individual wearing the TNSS unit  1006 . These applications can also send data or control signals to other members of the population who employ systems  1008 . This may represent an individual&#39;s data, aggregated data from a population of users, data analyses, or supplementary data from other sources. 
     Referring to  FIG. 11 , shown is an example of an electrode array to affect beam forming and beam steering. Beam forming and steering allows a more selective application of stimulation energy by a TNSS to nerves and tissue. Beam steering also provides the opportunity for lower power for stimulation of cells including nerves by applying the stimulating mechanism directionally to a target. In the use of an electrical beam lower power demand lengthens battery life and allows for use of low power chip sets. Beam steering may be accomplished in multiple ways for instance by magnetic fields and formed gates.  FIG. 11  shows a method for forming and steering a beam by the use of a plurality of radiators  1102  which are activated out of phase with each other by a plurality of phase shifters  1103  that are supplied power from a common source  1104 . Because the radiated signals are out of phase they produce an interference pattern  1105  that results in the beam being formed and steered in varying controlled directions  1106 . An example is the use of interferential fields. Electromagnetic radiation like light shows some properties of waves and can be focused on certain locations. This provides the opportunity to stimulate tissues such as nerves selectively. It also provides the opportunity to focus the transmission of energy and data on certain objects, including topical or implanted electronic devices, thereby not only improving the selectivity of activating or controlling those objects but also reducing the overall power required to operate them. 
       FIG. 12  is another example of a gating structure  1200  used for beam shaping and steering  1202 . The gating structure  1200  shows an example of an interlocked pair of electrodes that can be used for simple beam forming through the application of time-varying voltages. The steering  1202  shows a generic picture of the main field lobes and how such beam steering works in this example.  FIG. 12  is illustrative of a possible example that may be used. 
     The human and mammal body is an anisotropic medium with multiple layers of tissue of varying electrical properties. Steering of an electric field may be accomplished using multiple electrodes, or multiple SBAs, using the human or mammal body as an anisotropic volume conductor. Electric field steering will discussed below with reference to  FIGS. 18 and 19 . 
     Referring to  FIG. 13 , the controller is an electronics platform that is a smartphone  1300 , tablet  1302 , personal computer  1304 , or dedicated module  1306  that hosts wireless communications capabilities, such as Near Field Communications, Bluetooth, Adaptive Network Topology (ANT) or Wi-Fi technologies as enabled by the current set of communications chips, e.g. Broadcom BCM4334, TI WiLink 8 and others, and a wide range of protocol apps that can communicate with the TNSSs. There may be more than one controller, acting together. This may occur, for example, if the user has both a smartphone control app running, and a key fob controller in his/her pocket/purse. 
     TNSS protocol performs the functions of communications with the controller including transmitting and receiving of control and data signals, activation and control of the neural stimulation, data gathering from on board sensors, communications and coordination with other TNSSs, and data analysis. Typically the TNSS may receive commands from the controller, generate stimuli and apply these to the tissues, sense signals from the tissues, and transmit these to the controller. It may also analyze the signals sensed and use this information to modify the stimulation applied. In addition to communicating with the controller it may also communicate with other TNSSs using electrical or radio signals via a body area network. 
     Referring to  FIG. 14 , controller protocol executed and/or displayed on a smartphone  1400 , tablet  1402  or other computing platform or mobile device, will perform the functions of communications with TNSS modules including transmitting and receiving of control and data signals, activation and control of the neuro modulation regimens, data gathering from on board sensors, communications and coordination with other controllers, and data analysis. In some cases local control of the neuro modulation regimens may be conducted by controller protocol without communications with the user. 
       FIG. 15  shows potential applications of electrical stimulation and sensing for the body, particularly for users who may suffer from paralysis or loss of sensation or altered reflexes such as spasticity or tremor due to neurological disorders and their complications, as well as users suffering from incontinence, pain, immobility and aging. Different example medical uses of the present system are discussed below. 
       FIG. 16  shows the components of one example of a typical TNSS system  1600 . TNSS devices  1610  are responsible for stimulation of nerves and for receiving data in the form of electrical, acoustic, imaging, chemical and other signals which then can be processed locally in the TNSS or passed to the Control Unit  1620 . TNSS devices  1610  are also responsible for analysis and action. The TNSS device  1610  may contain a plurality of electrodes for stimulation and for sensing. The same electrodes may be used for both functions, but this is not required. The TNSS device  1610  may contain an imaging device, such as an ultrasonic transducer to create acoustic images of the structure beneath the electrodes or elsewhere in the body that may be affected by the neural stimulation. 
     In this example TNSS system, most of the data gathering and analysis is performed in the Control Unit  1620 . The Control Unit  1620  may be a cellular telephone or a dedicated hardware device. The Control Unit  1620  runs an app that controls the local functions of the TNSS System  1600 . The protocol app also communicates via the Internet or wireless networks  1630  with other TNSS systems and/or with 3rd party software applications. 
       FIG. 17  shows the communications among the components of the TNSS system  1600  and the user. In this example, TNSS  1610  is capable of applying stimuli to nerves  1640  to produce action potentials in the nerves  1640  to produce actions in muscles  1670  or other organs such as the brain  1650 . These actions may be sensed by the TNSS  1610 , which may act on the information to modify the stimulation it provides. This closed loop constitutes the first level of the system  1600  in this example. 
     The TNSS  1610  may also be caused to operate by signals received from a Control Unit  1620  such as a cellphone, laptop, key fob, tablet, or other handheld device and may transmit information that it senses back to the Control Unit  1620 . This constitutes the second level of the system  1600  in this example. 
     The Control Unit  1620  is caused to operate by commands from a user, who also receives information from the Control Unit  1620 . The user may also receive information about actions of the body via natural senses such as vision or touch via sensory nerves and the spinal cord, and may in some cases cause actions in the body via natural pathways through the spinal cord to the muscles. 
     The Control Unit  1620  may also communicate information to other users, experts, or application programs via the Internet  1630 , and receive information from them via the Internet  1630 . 
     The user may choose to initiate or modify these processes, sometimes using protocol applications residing in the TNSS  1610 , the Control Unit  1620 , the Internet  1630 , or wireless networks. This software may assist the user, for example by processing the stimulation to be delivered to the body to render it more selective or effective for the user, and/or by processing and displaying data received from the body or from the Internet  1630  or wireless networks to make it more intelligible or useful to the user. 
       FIG. 18  shows an example electrode configuration  1800  for Electric Field Steering. The application of an appropriate electric field to the body can cause a nerve to produce an electrical pulse known as an action potential. The shape of the electric field is influenced by the electrical properties of the different tissue through which it passes and the size, number and position of the electrodes used to apply it. The electrodes can therefore be designed to shape or steer or focus the electric field on some nerves more than on others, thereby providing more selective stimulation. 
     An example 10×10 matrix of electrical contacts  1860  is shown. By varying the pattern of electrical contacts  1860  employed to cause an electric field  1820  to form and by time varying the applied electrical power to this pattern of contacts  1860 , it is possible to steer the field  1820  across different parts of the body, which may include muscle  1870 , bone, fat, and other tissue, in three dimensions. This electric field  1820  can activate specific nerves or nerve bundles  1880  while sensing the electrical and mechanical actions produced  1890 , and thereby enabling the TNSS to discover more effective or the most effective pattern of stimulation for producing the desired action. 
       FIG. 19  shows an example of stimulating and sensing patterns of signals in a volume of tissue. Electrodes  1910  as part of a cuff arrangement are placed around limb  1915 . The electrodes  1910  are external to a layer of skin  1916  on limb  1915 . Internal components of the limb  1915  include muscle  1917 , bone  1918 , nerves  1919 , and other tissues. By using electric field steering for stimulation, as described with reference to  FIG. 18 , the electrodes  1910  can activate nerves  1919  selectively. An array of sensors (e.g., piezoelectric sensors or micro-electro-mechanical sensors) in a TNSS can act as a phased array antenna for receiving ultrasound signals, to acquire ultrasonic images of body tissues. Electrodes  1910  may act as an array of electrodes sensing voltages at different times and locations on the surface of the body, with software processing this information to display information about the activity in body tissues, e.g., which muscles are activated by different patterns of stimulation. 
     The SBA&#39;s ability to stimulate and collect organic data has multiple applications including bladder control, reflex incontinence, sexual stimulations, pain control and wound healing among others. Examples of SBA&#39;s application for medical and other uses follow. 
     Sample Modes of Operation 
     An SBA system consists of at least a single Controller and a single SBA. Following application of the SBA to the user&#39;s skin, the user controls it via the Controller&#39;s app using Near Field Communications. The app appears on a smartphone screen and can be touch controlled by the user; for ‘key fob’ type Controllers. The SBA is controlled by pressing buttons on the key fob. 
     When the user feels the need to activate the SBA s/he presses the “go” button two or more times to prevent false triggering, thus delivering the neuro stimulation. The neuro stimulation may be delivered in a variety of patterns of frequency, duration, and strength and may continue until a button is pressed by the user or may be delivered for a length of time set in the application. 
     Sensor capabilities in the TNSS, are enabled to start collecting/analyzing data and communicating with the controller when activated. 
     The level of functionality in the protocol app, and the protocol embedded in the TNSS, will depend upon the neuro modulation or neuro stimulation regimen being employed. 
     In some cases there will be multiple TNSSs employed for the neuro modulation or neuro stimulation regimen. The basic activation will be the same for each TNSS. 
     However, once activated multiple TNSSs will automatically form a network of neuro modulation/stimulation points with communications enabled with the controller. 
     The need for multiple TNSSs arises from the fact that treatment regimens may need several points of access to be effective. 
     Controlling the Stimulation 
     In general, advantages of a wireless TNSS system as disclosed herein over existing transcutaneous electrical nerve stimulation devices include: (1) fine control of all stimulation parameters from a remote device such as a smartphone, either directly by the user or by stored programs; (2) multiple electrodes of a TNSS can form an array to shape an electric field in the tissues; (3) multiple TNSS devices can form an array to shape an electric field in the tissues; (4) multiple TNSS devices can stimulate multiple structures, coordinated by a smartphone; (5) selective stimulation of nerves and other structures at different locations and depths in a volume of tissue; (6) mechanical, acoustic or optical stimulation in addition to electrical stimulation; (7) the transmitting antenna of TNSS device can focus a beam of electromagnetic energy within tissues in short bursts to activate nerves directly without implanted devices; (8) inclusion of multiple sensors of multiple modalities, including but not limited to position, orientation, force, distance, acceleration, pressure, temperature, voltage, light and other electromagnetic radiation, sound, ions or chemical compounds, making it possible to sense electrical activities of muscles (EMG, EKG), mechanical effects of muscle contraction, chemical composition of body fluids, location or dimensions or shape of an organ or tissue by transmission and receiving of ultrasound. 
     Further advantages of the wireless TNSS system include: (1) TNSS devices are expected to have service lifetimes of days to weeks and their disposability places less demand on power sources and battery requirements; (2) the combination of stimulation with feedback from artificial or natural sensors for closed loop control of muscle contraction and force, position or orientation of parts of the body, pressure within organs, and concentrations of ions and chemical compounds in the tissues; (3) multiple TNSS devices can form a network with each other, with remote controllers, with other devices, with the Internet and with other users; (4) a collection of large amounts of data from one or many TNSS devices and one or many users regarding sensing and stimulation, collected and stored locally or through the internet; (5) analysis of large amounts of data to detect patterns of sensing and stimulation, apply machine learning, and improve algorithms and functions; (6) creation of databases and knowledge bases of value; (7) convenience, including the absence of wires to become entangled in clothing, showerproof and sweat proof, low profile, flexible, camouflaged or skin colored, (8) integrated power, communications, sensing and stimulating inexpensive disposable TNSS, consumable electronics; (9) power management that utilizes both hardware and software functions will be critical to the convenience factor and widespread deployment of TNSS device. 
     Referring again to  FIG. 1 , a nerve cell normally has a voltage across the cell membrane of 70 millivolts with the interior of the cell at a negative voltage with respect to the exterior of the cell. This is known as the resting potential and it is normally maintained by metabolic reactions which maintain different concentrations of electrical ions in the inside of the cell compared to the outside. Ions can be actively “pumped” across the cell membrane through ion channels in the membrane that are selective for different types of ion, such as sodium and potassium. The channels are voltage sensitive and can be opened or closed depending on the voltage across the membrane. An electric field produced within the tissues by a stimulator can change the normal resting voltage across the membrane, either increasing or decreasing the voltage from its resting voltage. 
     Referring again to  FIG. 2 , a decrease in voltage across the cell membrane to about 55 millivolts opens certain ion channels, allowing ions to flow through the membrane in a self-catalyzing but self-limited process which results in a transient decrease of the trans membrane potential to zero, and even positive, known as depolarization followed by a rapid restoration of the resting potential as a result of active pumping of ions across the membrane to restore the resting situation which is known as repolarization. This transient change of voltage is known as an action potential and it typically spreads over the entire surface of the cell. If the shape of the cell is such that it has a long extension known as an axon, the action potential spreads along the length of the axon. Axons that have insulating myelin sheaths propagate action potentials at much higher speeds than those axons without myelin sheaths or with damaged myelin sheaths. 
     If the action potential reaches a junction, known as a synapse, with another nerve cell, the transient change in membrane voltage results in the release of chemicals known as neuro-transmitters that can initiate an action potential in the other cell. This provides a means of rapid electrical communication between cells, analogous to passing a digital pulse from one cell to another. 
     If the action potential reaches a synapse with a muscle cell it can initiate an action potential that spreads over the surface of the muscle cell. This voltage change across the membrane of the muscle cell opens ion channels in the membrane that allow ions such as sodium, potassium and calcium to flow across the membrane, and can result in contraction of the muscle cell. 
     Increasing the voltage across the membrane of a cell below −70 millivolts is known as hyper-polarization and reduces the probability of an action potential being generated in the cell. This can be useful for reducing nerve activity and thereby reducing unwanted symptoms such as pain and spasticity 
     The voltage across the membrane of a cell can be changed by creating an electric field in the tissues with a stimulator. It is important to note that action potentials are created within the mammalian nervous system by the brain, the sensory nervous system or other internal means. These action potentials travel along the body&#39;s nerve “highways”. The TNSS creates an action potential through an externally applied electric field from outside the body. This is very different than how action potentials are naturally created within the body. 
     Electric Fields that can Cause Action Potentials 
     Referring to  FIG. 2 , electric fields capable of causing action potentials can be generated by electronic stimulators connected to electrodes that are implanted surgically in close proximity to the target nerves. To avoid the many issues associated with implanted devices, it is desirable to generate the required electric fields by electronic devices located on the surface of the skin. Such devices typically use square wave pulse trains of the form shown in  FIG. 20 . Such devices may be used instead of implants and/or with implants such as reflectors, conductors, refractors, or markers for tagging target nerves and the like, so as to shape electric fields to enhance nerve targeting and/or selectivity. 
     Referring to  FIG. 20 , the amplitude of the pulses “A”, applied to the skin, may vary between 1 and 100 Volts, pulse width “t”, between 100 microseconds and 10 milliseconds, duty cycle (t/T) between 0.1% and 50%, the frequency of the pulses within a group between 1 and 100/sec, and the number of pulses per group “n”, between 1 and several hundred. Typically, pulses applied to the skin will have an amplitude of up to 60 volts, a pulse width of 250 microseconds and a frequency of 20 per second, resulting in a duty cycle of 0.5%. In some cases balanced-charge biphasic pulses will be used to avoid net current flow. Referring to  FIG. 21 , these pulses may be symmetrical, with the shape of the first part of the pulse similar to that of the second part of the pulse, or asymmetrical, in which the second part of the pulse has lower amplitude and a longer pulse width in order to avoid canceling the stimulatory effect of the first part of the pulse. 
     Formation of Electric Fields by Stimulators 
     The location and magnitude of the electric potential applied to the tissues by electrodes provides a method of shaping the electrical field. For example, applying two electrodes to the skin, one at a positive electrical potential with respect to the other, can produce a field in the underlying tissues such as that shown in the cross-sectional diagram of  FIG. 22 . 
     The diagram in  FIG. 22  assumes homogeneous tissue. The voltage gradient is highest close to the electrodes and lower at a distance from the electrodes. Nerves are more likely to be activated close to the electrodes than at a distance. For a given voltage gradient, nerves of large diameter are more likely to be activated than nerves of smaller diameter. Nerves whose long axis is aligned with the voltage gradient are more likely to be activated than nerves whose long axis is at right angles to the voltage gradient. 
     Applying similar electrodes to a part of the body in which there are two layers of tissue of different electrical resistivity, such as fat and muscle, can produce a field such as that shown in  FIG. 23 . Layers of different tissue may act to refract and direct energy waves and be used for beam aiming and steering. An individual&#39;s tissue parameters may be measured and used to characterize the appropriate energy stimulation for a selected nerve. 
     Referring to  FIG. 24 , when the stimulating pulse is turned off the electric field will collapse and the fields will be absent as shown. It is the change in electric field that will cause an action potential to be created in a nerve cell, provided sufficient voltage and the correct orientation of the electric field occurs. More complex three-dimensional arrangements of tissues with different electrical properties can result in more complex three-dimensional electric fields, particularly since tissues have different electrical properties and these properties are different along the length of a tissue and across it, as shown in Table 1. 
     
       
         
           
               
               
               
               
             
               
                   
                 TABLE 1 
               
               
                   
                   
               
               
                   
                 Electrical 
                   
                   
               
               
                   
                 Conductivity 
               
               
                   
                 (siemens/m) 
                 Direction 
                 Average 
               
               
                   
                   
               
             
            
               
                   
               
            
           
           
               
               
               
               
            
               
                   
                 Blood 
                   
                 .65 
               
               
                   
                 Bone 
                 Along 
                 .17 
               
               
                   
                 Bone 
                 Mixed 
                 .095 
               
               
                   
                 Fat 
                   
                 .05 
               
               
                   
                 Muscle 
                 Along 
                 .127 
               
               
                   
                 Muscle 
                 Across 
                 .45 
               
               
                   
                 Muscle 
                 Mixed 
                 .286 
               
               
                   
                 Skin (Dry) 
                   
                 .000125 
               
               
                   
                 Skin (Wet) 
                   
                 .00121 
               
               
                   
                   
               
            
           
         
       
     
     Modification of Electric Fields by Tissue 
     An important factor in the formation of electric fields used to create action potentials in nerve cells is the medium through which the electric fields must penetrate. For the human body this medium includes various types of tissue including bone, fat, muscle, and skin. Each of these tissues possesses different electrical resistivity or conductivity and different capacitance and these properties are anisotropic. They are not uniform in all directions within the tissues. For example, an axon has lower electrical resistivity along its axis than perpendicular to its axis. The wide range of conductivities is shown in Table 1. The three-dimensional structure and resistivity of the tissues will therefore affect the orientation and magnitude of the electric field at any given point in the body. 
     Modification of Electric Fields by Multiple Electrodes 
     Applying a larger number of electrodes to the skin can also produce more complex three-dimensional electrical fields that can be shaped by the location of the electrodes and the potential applied to each of them. Referring to  FIG. 20 , the pulse trains can differ from one another indicated by A, t/T, n, and f as well as have different phase relationships between the pulse trains. For example with an 8×8 array of electrodes, combinations of electrodes can be utilized ranging from simple dipoles, to quadripoles, to linear arrangements, to approximately circular configurations, to produce desired electric fields within tissues. 
     Applying multiple electrodes to a part of the body with complex tissue geometry will thus result in an electric field of a complex shape. The interaction of electrode arrangement and tissue geometry can be modeled using Finite Element Modeling, which is a mathematical method of dividing the tissues into many small elements in order to calculate the shape of a complex electric field. This can be used to design an electric field of a desired shape and orientation to a particular nerve. 
     High frequency techniques known for modifying an electric field, such as the relation between phases of a beam, cancelling and reinforcing by using phase shifts, may not apply to application of electric fields by TNSSs because they use low frequencies. Instead, examples use beam selection to move or shift or shape an electric field, also described as field steering or field shaping, by activating different electrodes, such as from an array of electrodes, to move the field. Selecting different combinations of electrodes from an array may result in beam or field steering. A particular combination of electrodes may shape a beam and/or change the direction of a beam by steering. This may shape the electric field to reach a target nerve selected for stimulation. 
     Activation of Nerves by Electric Fields 
     Typically, selectivity in activating nerves has required electrodes to be implanted surgically on or near nerves. Using electrodes on the surface of the skin to focus activation selectively on nerves deep in the tissues, as with examples of the invention, has many advantages. These include avoidance of surgery, avoidance of the cost of developing complex implants and gaining regulatory approval for them, and avoidance of the risks of long-term implants. 
     The features of the electric field that determine whether a nerve will be activated to produce an action potential can be modeled mathematically by the “Activating Function” disclosed in Rattay F., “The basic mechanism for the electrical stimulation of the nervous system”,  Neuroscience  Vol. 89, No. 2, pp. 335-346 (1999). The electric field can produce a voltage, or extracellular potential, within the tissues that varies along the length of a nerve. If the voltage is proportional to distance along the nerve, the first order spatial derivative will be constant and the second order spatial derivative will be zero. If the voltage is not proportional to distance along the nerve, the first order spatial derivative will not be constant and the second order spatial derivative will not be zero. The Activating Function is proportional to the second-order spatial derivative of the extracellular potential along the nerve. If it is sufficiently greater than zero at a given point it predicts whether the electric field will produce an action potential in the nerve at that point. This prediction may be input to a nerve signature. 
     In practice, this means that electric fields that are varying sufficiently greatly in space or time can produce action potentials in nerves. These action potentials are also most likely to be produced where the orientation of the nerves to the fields change, either because the nerve or the field changes direction. The direction of the nerve can be determined from anatomical studies and imaging studies such as MRI scans. The direction of the field can be determined by the positions and configurations of electrodes and the voltages applied to them, together with the electrical properties of the tissues. As a result, it is possible to activate certain nerves at certain tissue locations selectively while not activating others. 
     To accurately control an organ or muscle, the nerve to be activated must be accurately selected. This selectivity may be improved by using examples disclosed herein as a nerve signature, in several ways, as follows:
         (1) Improved algorithms to control the effects when a nerve is stimulated, for example, by measuring the resulting electrical or mechanical activity of muscles and feeding back this information to modify the stimulation and measuring the effects again. Repeated iterations of this process can result in optimizing the selectivity of the stimulation, either by classical closed loop control or by machine learning techniques such as pattern recognition and artificial intelligence;   (2) Improving nerve selectivity by labeling or tagging nerves chemically; for example, introduction of genes into some nerves to render them responsive to light or other electromagnetic radiation can result in the ability to activate these nerves and not others when light or electromagnetic radiation is applied from outside the body;   (3) Improving nerve selectivity by the use of electrical conductors to focus an electric field on a nerve; these conductors might be implanted, but could be passive and much simpler than the active implantable medical devices currently used;   (4) The use of reflectors or refractors, either outside or inside the body, is used to focus a beam of electromagnetic radiation on a nerve to improve nerve selectivity. If these reflectors or refractors are implanted, they may be passive and much simpler than the active implantable medical devices currently used;   (5) Improving nerve selectivity by the use of feedback from the person upon whom the stimulation is being performed; this may be an action taken by the person in response to a physical indication such as a muscle activation or a feeling from one or more nerve activations;   (6) Improving nerve selectivity by the use of feedback from sensors associated with the TNSS, or separately from other sensors, that monitor electrical activity associated with the stimulation; and   (7) Improving nerve selectivity by the combination of feedback from both the person or sensors and the TNSS that may be used to create a unique profile of the user&#39;s nerve physiology for selected nerve stimulation.       

     Potential applications of electrical stimulation to the body, as previously disclosed, are shown in  FIG. 15 . 
     Referring to  FIG. 25A , a TNSS  934  human and mammalian interface and its method of operation and supporting system are managed by a Master Control Program (“MCP”)  910  represented in function format as block diagrams. It provides the logic for the nerve stimulator system in accordance to one example. 
     In one example, MCP  910  and other components shown in  FIG. 25A  are implemented by one or more processors that are executing instructions. The processor may be any type of general or specific purpose processor. Memory is included for storing information and instructions to be executed by the processor. The memory can be comprised of any combination of random access memory (“RAM”), read only memory (“ROM”), static storage such as a magnetic or optical disk, or any other type of computer readable media. 
     Master Control Program 
     The primary responsibility of MCP  910  is to coordinate the activities and communications among the various control programs, a Data Manager  920 , a User  932 , and the external ecosystem and to execute the appropriate response algorithms in each situation. The MCP  910  accomplishes electric field shaping and/or beam steering by providing an electrode activation pattern to TNSS device  934  to selectively stimulate a target nerve. For example, upon notification by a Communications Controller  930  of an external event or request, the MCP  910  is responsible for executing the appropriate response, and working with the Data Manager  920  to formulate the correct response and actions. It integrates data from various sources such as Sensors  938  and external inputs such as TNSS devices  934 , and applies the correct security and privacy policies, such as encryption and HIPAA required protocols. It will also manage the User Interface (UI)  912  and the various Application Program Interfaces (APIs)  914  that provide access to external programs. 
     MCP  910  is also responsible for effectively managing power consumption by TNSS device  934  through a combination of software algorithms and hardware components that may include, among other things: computing, communications, and stimulating electronics, antenna, electrodes, sensors, and power sources in the form of conventional or printed batteries. 
     Communications Controller 
     Communications controller  930  is responsible for receiving inputs from the User  932 , from a plurality of TNSS devices  934 , and from 3rd party apps  936  via communications sources such as the Internet or cellular networks. The format of such inputs will vary by source and must be received, consolidated, possibly reformatted, and packaged for the Data Manager  920 . 
     User inputs may include simple requests for activation of TNSS devices  934  to status and information concerning the User&#39;s  932  situation or needs. TNSS devices  934  will provide signaling data that may include voltage readings, TNSS  934  status data, responses to control program inquiries, and other signals. Communications Controller  930  is also responsible for sending data and control requests to the plurality of TNSS devices  934 . 3rd party applications  936  can send data, requests, or instructions for the Master Control Program  910  or User  932  via the Internet or cellular networks. Communications Controller  930  is also responsible for communications via the cloud where various software applications may reside. 
     In one example, a user can control one or more TNSS devices using a remote fob or other type of remote device and a communication protocol such as Bluetooth. In one example, a mobile phone is also in communication and functions as a central device while the fob and TNSS device function as peripheral devices. In another example, the TNSS device functions as the central device and the fob is a peripheral device that communicates directly with the TNSS device (i.e., a mobile phone or other device is not needed). 
     Data Manager 
     The Data Manager (DM)  920  has primary responsibility for the storage and movement of data to and from the Communications Controller  930 , Sensors  938 , Actuators  940 , and the Master Control Program  910 . The DM  920  has the capability to analyze and correlate any of the data under its control. It provides logic to select and activate nerves. Examples of such operations upon the data include: statistical analysis and trend identification; machine learning algorithms; signature analysis and pattern recognition, correlations among the data within the Data Warehouse  926 , the Therapy Library  922 , the Tissue Models  924 , and the Electrode Placement Models  928 , and other operations. There are several components to the data that is under its control as disclosed below. 
     The Data Warehouse (DW)  926  is where incoming data is stored; examples of this data can be real-time measurements from TNSS devices  934  or from Sensors ( 938 ), data streams from the Internet, or control and instructional data from various sources. The DM  920  will analyze data, as described above, that is held in the DW  926  and cause actions, including the export of data, under MCP  910  control. Certain decision making processes implemented by the DM  920  will identify data patterns both in time, frequency, and spatial domains and store them as signatures for reference by other programs. Techniques such as EMG, or multi-electrode EMG, gather a large amount of data that is the sum of hundreds to thousands of individual motor units and the typical procedure is to perform complex decomposition analysis on the total signal to attempt to tease out individual motor units and their behavior. The DM  920  will perform big data analysis over the total signal and recognize patterns that relate to specific actions or even individual nerves or motor units. This analysis can be performed over data gathered in time from an individual, or over a population of TNSS Users. 
     The Therapy Library  922  contains various control regimens for the TNSS devices  934 . Regimens specify the parameters and patterns of pulses to be applied by the TNSS devices  934 . The width and amplitude of individual pulses may be specified to stimulate nerve axons of a particular size selectively without stimulating nerve axons of other sizes. The frequency of pulses applied may be specified to modulate some reflexes selectively without modulating other reflexes. There are preset regimens that may be loaded from the Cloud  942  or 3rd party apps  936 . The regimens may be static read-only as well as adaptive with read-write capabilities so they can be modified in real-time responding to control signals or feedback signals or software updates. Referring to  FIG. 3 , one such example of a regimen has parameters A=40 volts, t=500 microseconds, T=1 Millisecond, n=100 pulses per group, and f=20 per second. Other examples of regimens will vary the parameters within ranges previously specified. 
     The Tissue Models  924  is specific to the electrical properties of particular body locations where TNSS devices  934  may be placed. As previously disclosed, electric fields for production of action potentials will be affected by the different electrical properties of the various tissues that they encounter. Tissue Models  924  are combined with regimens from the Therapy Library  922  and Electrode Placement Models  928  to produce desired actions. Tissue Models  924  may be developed by MRI, Ultrasound or other imaging or measurement of tissue of a body or particular part of a body. This may be accomplished for a particular User  932  and/or based upon a body norm. One such example of a desired action is the use of a Tissue Model  924  together with a particular Electrode Placement Model  928  to determine how to focus the electric field from electrodes on the surface of the body on a specific deep location corresponding to the pudendal nerve in order to stimulate that nerve selectively to reduce incontinence of urine. Other examples of desired actions may occur when a Tissue Model  924  in combination with regimens from the Therapy Library  22  and Electrode Placement Models  928  produce an electric field that stimulates a sacral nerve. Many other examples of desired actions follow for the stimulation of other nerves. 
     Electrode Placement Models  928  specify electrode configurations that the TNSS devices  934  may apply and activate in particular locations of the body. For example, a TNSS device  934  may have multiple electrodes and the Electrode Placement Model  928  specifies where these electrodes should be placed on the body and which of these electrodes should be active in order to stimulate a specific structure selectively without stimulating other structures, or to focus an electric field on a deep structure. An example of an electrode configuration is a 4 by 4 set of electrodes within a larger array of multiple electrodes, such as an 8 by 8 array. This 4 by 4 set of electrodes may be specified anywhere within the larger array such as the upper right corner of the 8 by 8 array. Other examples of electrode configurations may be circular electrodes that may even include concentric circular electrodes. The TNSS device  934  may contain a wide range of multiple electrodes of which the Electrode Placement Models  928  will specify which subset will be activated. The Electrode Placement Models  928  complement the regimens in the Therapy Library  922  and the Tissue Models  924  and are used together with these other data components to control the electric fields and their interactions with nerves, muscles, tissues and other organs. Other examples may include TNSS devices  934  having merely one or two electrodes, such as but not limited to those utilizing a closed circuit. 
     Sensor/Actuator Control 
     Independent sensors  938  and actuators  940  can be part of the TNSS system. Its functions can complement the electrical stimulation and electrical feedback that the TNSS devices  934  provide. An example of such a sensor  938  and actuator  940  include, but are not limited to, an ultrasonic actuator and an ultrasonic receiver that can provide real-time image data of nerves, muscles, bones, and other tissues. Other examples include electrical sensors that detect signals from stimulated tissues or muscles. The Sensor/Actuator Control module  950  provides the ability to control both the actuation and pickup of such signals, all under control of the MCP  910 . 
     Application Program Interfaces 
     The MCP  910  is also responsible for supervising the various Application Program Interfaces (APIs) that will be made available for 3rd party developers. There may exist more than one API  914  depending upon the specific developer audience to be enabled. For example many statistical focused apps will desire access to the Data Warehouse  926  and its cumulative store of data recorded from TNSS  934  and User  932  inputs. Another group of healthcare professionals may desire access to the Therapy Library  922  and Tissue Models  924  to construct better regimens for addressing specific diseases or disabilities. In each case a different specific API  914  may be appropriate. 
     The MCP  910  is responsible for many software functions of the TNSS system including system maintenance, debugging and troubleshooting functions, resource and device management, data preparation, analysis, and communications to external devices or programs that exist on the smart phone or in the cloud, and other functions. However, one of its primary functions is to serve as a global request handler taking inputs from devices handled by the Communications Controller  930 , external requests from the Sensor Control Actuator Module ( 950 ), and 3rd party requests  936 . Examples of High Level Master Control Program (MCP) functions are disclosed below. 
     The manner in which the MCP handles these requests is shown in  FIG. 25B . The Request Handler (RH)  960  accepts inputs from the User  932 , TNSS devices  934 , 3rd party apps  936 , sensors  938  and other sources. It determines the type of request and dispatches the appropriate response as set forth in the following paragraphs. 
     User Request: The RH  960  will determine which of the plurality of User Requests  961  is present such as: activation; display status, deactivation, or data input, e.g. specific User condition. Shown in  FIG. 25B  is the RH&#39;s  960  response to an activation request. As shown in block  962 , RH  960  will access the Therapy Library  922  and cause the appropriate regimen to be sent to the correct TNSS  934  for execution, as shown at block  964  labeled “Action.” 
     TNSS/Sensor Inputs: The RH  960  will perform data analysis over TNSS  934  or Sensor inputs  965 . As shown at block  966 , it employs data analysis, which may include techniques ranging from DSP decision-making processes, image processing algorithms, statistical analysis and other algorithms to analyze the inputs. In  FIG. 25B  two such analysis results are shown; conditions which cause a User Alarm  970  to be generated and conditions which create an Adaptive Action  980  such as causing a control feedback loop for specific TNSS  934  functions, which can iteratively generate further TNSS  934  or Sensor inputs  965  in a closed feedback loop. 
     3rd Party Apps: Applications can communicate with the MCP  910 , both sending and receiving communications. A typical communication would be to send informational data or commands to a TNSS  934 . The RH  960  will analyze the incoming application data, as shown at block  972 .  FIG. 25B  shows two such actions that result. One action, shown at block  974  would be the presentation of the application data, possibly reformatted, to the User  932  through the MCP User Interface  912 . Another result would be to perform a User  932  permitted action, as shown at  976 , such as requesting a regimen from the Therapy Library  922 . 
     Referring to  FIG. 26 , an example TNSS in accordance to one example is shown. The TNSS has one or more electronic circuits or chips  2600  that perform the functions of: communications with the controller, nerve stimulation via electrodes  2608  that produce a wide range of electric field(s) according to treatment regimen, one or more antennae  2610  that may also serve as electrodes and communication pathways, and a wide range of sensors  2606  such as, but not limited to, mechanical motion and pressure, temperature, humidity, chemical and positioning sensors. In another example, TNSS interfaces to transducers  2614  to transmit signals to the tissue or to receive signals from the tissue. 
     One arrangement is to integrate a wide variety of these functions into an SOC, system on chip  2600 . Within this is shown a control unit  2602  for data processing, communications, transducer interface and storage and one or more stimulators  2604  and sensors  2606  that are connected to electrodes  2608 . An antenna  2610  is incorporated for external communications by the control unit. Also present is an internal power supply  2612 , which may be, for example, a battery. An external power supply is another variation of the chip configuration. It may be necessary to include more than one chip to accommodate a wide range of voltages for data processing and stimulation. Electronic circuits and chips will communicate with each other via conductive tracks within the device capable of transferring data and/or power. 
     The TNSS interprets a data stream from the control device, such as that shown in  FIG. 25A , to separate out message headers and delimiters from control instructions. In one example, control instructions contain information such as voltage level and pulse pattern. The TNSS activates the stimulator  2604  to generate a stimulation signal to the electrodes  2608  placed on the tissue according to the control instructions. In another example the TNSS activates a transducer  2614  to send a signal to the tissue. In another example, control instructions cause information such as voltage level and pulse pattern to be retrieved from a library stored in the TNSS. 
     The TNSS receives sensory signals from the tissue and translates them to a data stream that is recognized by the control device, such as the example in  FIG. 25A . Sensory signals include electrical, mechanical, acoustic, optical and chemical signals among others. Sensory signals come to the TNSS through the electrodes  2608  or from other inputs originating from mechanical, acoustic, optical, or chemical transducers. For example, an electrical signal from the tissue is introduced to the TNSS through the electrodes  2608 , is converted from an analog signal to a digital signal and then inserted into a data stream that is sent through the antenna  2610  to the control device. In another example an acoustic signal is received by a transducer  2614  in the TNSS, converted from an analog signal to a digital signal and then inserted into a data stream that is sent through the antenna  2610  to the control device. In certain examples sensory signals from the tissue are directly interfaced to the control device for processing. 
     An open loop protocol to control current to electrodes in known neural stimulation devices does not have feedback controls. It commands a voltage to be set, but does not check the actual Voltage. Voltage control is a safety feature. A stimulation pulse is sent based on preset parameters and cannot be modified based on feedback from the patient&#39;s anatomy. When the device is removed and repositioned, the electrode placement varies. Also the humidity and temperature of the anatomy changes throughout the day. All these factors affect the actual charge delivery if the voltage is preset. 
     In contrast, examples of the TNSS stimulation device have features that address these shortcomings using the Nordic Semiconductor nRF52832 microcontroller to regulate charge in a TNSS. The High Voltage Supply is implemented using a LED driver chip combined with a Computer controlled Digital Potentiometer to produce a variable voltage. A 3-1 step up Transformer then provides the desired High Voltage, “VBOOST”, which is sampled to assure that no failure causes an incorrect Voltage level as follows. The nRF52832 Microcontroller samples the voltage of the stimulation waveform providing feedback and impedance calculations for an adaptive protocol to modify the waveform in real time. The Current delivered to the anatomy by the stimulation waveform is integrated using a differential integrator and sampled and then summed to determine actual charge delivered to the user for a Treatment. After every pulse in a Stimulation event, this measurement is analyzed and used to modify, in real time, subsequent pulses. 
     This hardware adaptation allows a firmware protocol to implement the adaptive protocol. This protocol regulates the charge applied to the body by changing VBOOST. A treatment is performed by a sequence of periodic pulses, which insert charge into the body through the electrodes. Some of the parameters of the treatment are fixed and some are user adjustable. The strength, duration and frequency may be user adjustable. The user may adjust these parameters as necessary for comfort and efficacy. The strength may be lowered if there is discomfort and raised if nothing is felt. The duration will be increased if the maximum acceptable strength results in an ineffective treatment. 
     A flow diagram in accordance with one example of the Adaptive Protocol disclosed above is shown in  FIG. 27 . The Adaptive Protocol strives to repeatedly and reliably deliver a target charge (“Q target ”) during a treatment and to account for any environmental changes. Therefore, the functionality of  FIG. 27  is to adjust the charge level applied to a user based on feedback, rather than use a constant level. 
     The mathematical expression of this protocol is as follows: Q target =Q target  (A*dS+B*dT), where A is the Strength Coefficient—determined empirically, dS is the user change in Strength, B is the Duration Coefficient—determined empirically, and dT is the user change in Duration. 
     The Adaptive Protocol includes two phases in one example: Acquisition  2700  and Reproduction  2720 . Any change in user parameters places the Adaptive Protocol in the Acquisition phase. When the first treatment is started, a new baseline charge is computed based on the new parameters. At a new acquisition phase at  2702 , all data from the previous charge application is discarded. In one example,  2702  indicates the first time for the current usage where the user places the TNSS device on a portion of the body and manually adjusts the charge level, which is a series of charge pulses, until it feels suitable, or any time the charge level is changed, either manually or automatically. The treatment then starts. The mathematical expression of this function of the application of a charge is as follows: 
     The charge delivered in a treatment is 
     
       
         
           
             
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     Where T is the duration; f is the frequency of “Rep Rate”; Q pulse  (i) is the measured charge delivered by Pulse (i) in the treatment pulse train provided as a voltage MON_CURRENT that is the result of a Differential Integrator circuit shown in  FIG. 28  (i.e., the average amount of charge per pulse). The Nordic microcontroller of  FIG. 28  is an example of an Analog to Digital Conversion feature used to quantify voltage into a number representing the delivered charge and therefore determine the charge output. The number of pulses in the treatment is T*f. 
     At  2704  and  2706 , every pulse is sampled. In one example, the functionality of  2704  and  2706  lasts for 10 seconds with a pulse rate of 20 Hz, which can be considered a full treatment cycle. The result of phase  2700  is the target pulse charge of Q target . 
       FIG. 29  is a table in accordance with one example showing the number of pulses per treatment measured against two parameters, frequency and duration. Frequency is shown on the Y-axis and duration on the X-axis. The Adaptive Current protocol in general performs better when using more pulses. One example uses a minimum of 100 pulses to provide for solid convergence of charge data feedback. Referring to the  FIG. 29 , a frequency setting of 20 Hz and duration of 10 seconds produces 200 pulses, which is desirable to allow the Adaptive Current Protocol to reproduce a previous charge. 
     The reproduction phase  2720  begins in one example when the user initiates another subsequent treatment after acquisition phase  2700  and the resulting acquisition of the baseline charge, Q target . For example, a full treatment cycle, as discussed above, may take 10 seconds. After, for example, a two-hour pause as shown at wait period  2722 , the user may then initiate another treatment. During this phase, the Adaptive Current Protocol attempts to deliver Q target  for each subsequent treatment. The functionality of phase  2720  is needed because, during the wait period  2722 , conditions such as the impedance of the user&#39;s body due to sweat or air humidity may have changed. The differential integrator is sampled at the end of each Pulse in the Treatment. At that point, the next treatment is started and the differential integrator is sampled for each pulse at  2724  for purposes of comparison to the acquisition phase Q target . Sampling the pulse includes measuring the output of the pulse in coulombs. The output of the integrator of  FIG. 28  in voltage, referred to as Mon_Current  2801 , is a direct linear relationship to the delivered charge in micro-coulombs and provides a reading of how much charge is leaving the device and entering the user. At  2726 , each single pulse is compared to the charge value determined in phase  2700  (i.e., the target charge) and the next pulse will be adjusted in the direction of the difference. 
       NUM_PULSES=( T*f ) 
     After each pulse, the observed charge, Q pulse (i), is compared to the expected charge per pulse. 
         Q   pulse ( i )&gt; Q   target /NUM_PULSES? 
     The output charge or “VBOOST” is then modified at either  2728  (decreasing) or  2730  (increasing) for the subsequent pulse by: 
         dV ( i )= G [ Q   target /NUM_PULSES− Q   pulse ( i )]
 
     where G is the Voltage adjustment Coefficient—determined empirically. The process continues until the last pulse at  2732 . 
     A safety feature assures that the VBOOST will never be adjusted higher by more than 10%. If more charge is necessary, then the repetition rate or duration can be increased. 
     In one example, in general, the current is sampled for every pulse during acquisition phase  2700  to establish target charge for reproduction. The voltage is then adjusted via a digital potentiometer, herein referred to as “Pot”, during reproduction phase  2720  to achieve the established target_charge. 
     The digital Pot is calibrated with the actual voltage at startup. A table is generated with sampled voltage for each wiper value. Tables are also precomputed storing the Pot wiper increment needed for 1 v and 5 v output delta at each pot level. This enables quick reference for voltage adjustments during the reproduction phase. The tables may need periodic recalibration due to battery level. 
     In one example, during acquisition phase  2700 , the minimum data set=100 pulses and every pulse is sampled and the average is used as the target_charge for reproduction phase  2720 . In general, less than 100 pulses may provide an insufficient data sample to use as a basis for reproduction phase  2720 . In one example, the default treatment is 200 pulses (i.e., 20 Hz for 10 seconds). In one example, a user can adjust both duration and frequency manually. 
     In one example, during acquisition phase  2700 , the maximum data set=1000 pulses. The maximum is used to avoid overflow of 32 bit integers in accumulating the sum of samples. Further, 1000 pulses in one example is a sufficiently large data set and collecting more is likely unnecessary. 
     After 1000 pulses for the above example, the target_charge is computed. Additional pulses beyond 1000 in the acquisition phase do not contribute to the computation of the target charge. 
     In one example, the first 3-4 pulses are generally higher than the rest so these are not used in acquisition phase  2700 . This is also accounted for in reproduction phase  2720 . Using these too high values can result in target charge being set too high and over stimulating on the subsequent treatments in reproduction phase  2720 . In other examples, more advanced averaging algorithms could be applied to eliminating high and low values. 
     In an example, there may be a safety concern about automatically increasing the voltage. For example, if there is poor connection between the device and the user&#39;s skin, the voltage may auto-adjust at  2730  up to the max. The impedance may then be reduced, for example by the user pressing the device firmly, which may result in a sudden high current. Therefore, in one example, if the sample is 500 mv or more higher than the target, it immediately adjusts to the minimum voltage. This example then remains in reproduction phase  2720  and should adjust back to the target current/charge level. In another example, the maximum voltage increase is set for a single treatment (e.g., 10V). More than that should not be needed in normal situations to achieve the established target_charge. In another example, a max is set for VBOOST (e.g., 80V). 
     In various examples, it is desired to have stability during reproduction phase  2720 . In one example, this is accomplished by adjusting the voltage by steps. However, a relatively large step adjustment can result in oscillation or over stimulation. Therefore, voltage adjustments may be made in smaller steps. The step size may be based on both the delta between the target and sample current as well as on the actual VBOOST voltage level. This facilitates a quick and stable/smooth convergence to the target charge and uses a more gradual adjustments at lower voltages for more sensitive users. 
     The following are the conditions that may be evaluated to determine the adjustment step.
         delta-mon_current=abs(sample_mon_current−target_charge)   If delta_mon_current&gt;500 mv and VBOOST&gt;20V then step=5V for increase adjustments   (For decrease adjustments a 500 mv delta triggers emergency decrease to minimum Voltage)   If delta_mon_current&gt;200 mv then step=1V   If delta_mon_current&gt;100 mv and delta_mon_current&gt;5%*sample_mon_current then step=1V       

     In other examples, new treatments are started with voltage lower than target voltage with a voltage buffer of approximately 10%. The impedance is unknown at the treatment start. These examples save the target_voltage in use at the end of a treatment. If the user has not adjusted the strength parameter manually, it starts a new treatment with saved target_voltage with the 10% buffer. This achieves target current quickly with the 10% buffer to avoid possible over stimulation in case impedance has been reduced. This also compensates for the first 3-4 pulses that are generally higher. 
     As disclosed, examples apply an initial charge level, and then automatically adjust based on feedback of the amount of current being applied. The charge amount can be varied up or down while being applied. Therefore, rather than setting and then applying a fixed voltage level throughout a treatment cycle, implementations of the invention measure the amount of charge that is being input to the user, and adjust accordingly throughout the treatment to maintain a target charge level that is suitable for the current environment. 
     Primary Dysmenorrhea Pain Reduction 
     Example inventions reduce the pain experienced during primary dysmenorrhea (PD), thereby allowing activity levels and function not achievable because of pain experienced and also improving quality of life for the individual. Example inventions are an integrated system which may be placed on the skin of the user, and activated and used without the help of a medical professional. The integrated system includes hardware and software to selectively stimulate nerves in the abdomen, lower back, thighs, calves or feet related to PD. 
       FIG. 30  illustrates components of a PD pain suppression system  3001  for a user  3000  in accordance to example inventions. System  3001  includes a Primary Dysmenorrhea Abdominal Topical Nerve Activator (ATNA) Device  3010  (or “patch  3010 ”) that includes a securing mechanism  3012  (e.g., adhesive layer), one or more electrode pairs  3014  with each pair having a positive electrode and a negative electrode, an optional heating element (not shown), a power source  3016 , a processor/controller  3018  and an antenna (not shown). System  3001  further includes a Primary Dysmenorrhea Lumbar Topical Nerve Activator (LTNA) Device  3020  (or “patch  3020 ”) that includes a securing mechanism  3022  (e.g., adhesive layer), one or more electrode pairs  3024  with each pair having a positive electrode and a negative electrode, an optional heating element (not shown), a power source  3026 , a processor/controller  3028  and an antenna (not shown). 
     System  3001  further includes a Primary Dysmenorrhea Lumbar Topical Nerve Activator (LTNA) Device  3030  (or “patch  3030 ”) that includes a securing mechanism  3032  (e.g., adhesive layer), one or more electrode pairs  3034  with each pair having a positive electrode and a negative electrode, an optional heating element (not shown), a power source  3036 , a processor/controller  3038  and an antenna (not shown). System  3001  further includes an optional smart controller  3040 , with a display  3042  and an acknowledgment button  3044 . System  3001  further includes an optional fob  3050  with one or more buttons  3052  or visual indicators, and an antenna (not shown). Smart controller  3040  is implemented by a smartphone in example inventions. 
     Patches  3010 ,  3020  and  3030  are used by user  3000  either singly or in combination to reduce pain symptoms of primary dysmenorrhea. One patch optionally communicates wirelessly to one or more other patches on the body of the same user  3000 , to coordinate the timing of the stimulations. Further, sensors (not shown) on patches  3010 ,  3020  and  3030  can be used to detect the effectiveness of the stimulations and then adjust the duration or intensity of stimulations among the various patches  3010 ,  3020  and  3030 . 
     In examples, the electronic components on each of the patches, such as those on patch  3010 , including electrodes  3014 , power source  3016 , processor  3018 , and an antenna, and similarly for patches  3020  and  3030 , are mounted on a common substrate or like suitable support structure, which is typically flexible to be able to conform to the human dermis. The antenna may also be associated with the electronics providing a communication link to a control mechanism such as fob  3050 , smart controller  3040  or like devices. In examples, patches  3010 ,  3020  and  3030  can include all elements and functionalities disclosed herein in conjunction with any disclosed patch/TNSS/Smart Band Aid™/SBA. 
     Each of patches  3010 ,  3020  and  3030  has a design optimized for the placement on a particular part of the body. The processor in each patch executes software designed to control its corresponding patch, and to communicate to patches on the same body, as well as to one or both of fob  3050  or smart controller  3040 . Smart controller  3040  is used by user  3000  to adjust settings, such as waveform, frequency, and signal strength, to perform effective nerve activation for that specific user. Smart controller  3040  stores these settings internally, to facilitate the repeated use the patches on the same user, and optionally logs data related to the use of the patches for that user. Fob  3050  is used by user  3000  to initiate a nerve activation by neurostimulation, and optionally is used to adjust the settings on one patch at a time, or on multiple patches, while such device or devices are worn by user  3000 . 
     The transcutaneous nerve stimulation is adjusted on each patch according to the settings defined by the user. Pulse waveform, frequency and voltage are set to affect the potential at the target nerve or nerves for each patch, such that the patch creates an adequate action potential at the nerve to send a nerve signal toward the spine. Due to the variation in depth of each nerve, the intervening tissues, and the sensitivity to signal through the skin and tissue, the nerve stimulation is optimized for each patch location, on each user, and for each use. Each patch adapts the voltage applied to the skin to deliver a constant amount of energy into the tissue, adapting that voltage according to the impedance of the tissues. This adaptive application of voltage provides a consistent level of stimulation. Such optimization allows for variation in impedance of the skin and tissues, such as dry versus damp skin. 
     In one example, one patch mounted to the skin controls all of the other patches mounted to the skin of the same user. The “master” patch uses its processor to send and receive signals to and from the other patches. In examples, the software in the processor of the master patch is different from the software in the other patches to facilitate the master functionality. 
       FIG. 31A  illustrates user  3000  with an abdomen  3110 , a navel  3112 , a mons pubis  3114 , a lower back  3120 , and thighs  3130 , including a left thigh  3132  and a right thigh  3134 . 
       FIGS. 31B-C  illustrate the internal physiology pertinent to primary dysmenorrhea. As shown, the physiology includes a uterus  3140 , a uterovaginal plexus  3150 , a lumbar nerve  3160 , lumbar muscles  3170  with a quadratus lumborum muscle  3174 . The physiology further includes a thigh area, with thigh muscles  3180 , with a genitofemoral nerve  3192 , and muscular branches of femoral nerve  3194 . 
       FIG. 32A  illustrates how patch  3010 —shown partially transparent—is designed to be placed on the front of the abdomen, between navel  3112  and mons pubis  3114  in accordance to example inventions. Patch  3010  is situated such that electrical stimulation may activate one or more branches of the uterovaginal plexus  3150  on one or both sides of the uterus  3140  using electrical fields. Patch  3010  affects other nervous system structures in the abdomen, thereby assisting in the relief of primary dysmenorrhea symptoms. 
       FIG. 32B  illustrates how patch  3020  is designed to be placed on the lower back  3120  in accordance to example inventions. Patch  3020  is situated such that electrical stimulation activates the nerves in the lumbar muscles  3170  using electrical fields. Patch  3020  affects other nervous system structures in the lumbar region, thereby assisting in the relief of primary dysmenorrhea symptoms. 
       FIG. 32C  illustrates how patch  3030  is designed to be placed on one or both of the left thigh  3132  and the right thigh  3134  in accordance to example inventions. Patch  3030  is situated such that electrical stimulation may activate one or more branches of genitofemoral nerve  3182 , or one or more of the muscular branches of the femoral nerve  3194 , or both, using electrical fields. Patch  3030  affects other nervous system structures in the thighs and hips, thereby assisting in the relief of primary dysmenorrhea symptoms. Patch  3030  can be used in a single mode, on one of the left thigh and right thigh, or in pairs, with one on each thigh, according to the locations at which the user senses PD pain. 
     Each of patches  3010 ,  3020 ,  3030 , is designed in a shape to conform to the skin when affixed to the skin to be electronically effective. When targeting a nerve fiber, such as the femoral nerve  3194  with patch  3030 , the patch is electronically most effective when the positive and negative electrodes are placed axially along the path of the target nerve fiber in contrast to transversely across the path of the nerve fiber, which is not as electronically effective. When targeting a nerve plexus, such as the uterovaginal plexus  3150  with the patch  3010 , the positive and negative electrodes are placed over the plexus. 
     In example inventions, each of patches  3010 ,  3020 ,  3030  uses neurostimulation to effect one or more of the following physiological mechanisms to reduce the sensation of pain in the area associated with the placement of each TNA Device. 
     A first mechanism for pain reduction, as described in the “Gate Theory of Pain,” targets the larger A beta (Aβ) afferent fibers which have a lower threshold of activation, causing more activation through those Aβ fibers to the dorsal horn than the activations from the pain-sensing A delta (Aδ) afferent fibers. The Aβ activations work through the interneurons to block pain sensed by the Aδ fibers. 
     A second mechanism uses nerve stimulation to create endogenous morphines, or endorphins, such as dopamine, in the area of nerve stimulation. The endorphins reduce the sensation of pain in the local area. 
     A third mechanism uses nerve stimulation to increase blood flow local to the stimulation. The blood flow improvement relieves pain from organs such as the uterus and muscles. 
     In one example, patch  3010  uses one electrode pair  3014  to activate the uterovaginal plexus  3150  on one of the distal or lateral sides of the abdomen  3110 . 
     In one example, patch  3010  uses two electrode pairs  3014  to activate both the distal and lateral branches the uterovaginal plexus  3150  on the abdomen  3110 . 
     In one example, patch  3010  uses multiple positive electrodes and one or more negative electrodes to activate one or both of the distal and lateral branches of the uterovaginal plexus  3150 , modifying the waveshapes or timings or both of the activation pulses from the multiple electrodes to direct the waveform energy at one or more specific points on the target nerves. 
     In one example, patch  3010  includes one or more sensors which measure internal features or biometrics of the user in the abdominal area, these measurements used to help the user to orient and place the patch most accurately in the target location. The sensor data is communicated to one or more of fob  3050 , smart controller  3040  and the patch. Biometric measurements through the patch sensors are also used to monitor uterine contractions and quantify blood flow to the uterine area, to provide a closed-loop mechanism for adjusting the patch settings. 
     In connection with positioning, the sensor data is communicated to one or more of smart controller  3040 , fob  3050  and patch  3010  (or any of the other patches), and an indication such as an LED or vibration is sent to the user to assist them in placing the device. 
     For example, the orientation vertically or horizontally of the patch  3010  itself is determined by a 9-axis accelerometer on the patch. The smart phone app informs the user in real-time to rotate the patch to the proper orientation before sticking it to the skin. The shape of patch  3010  is designed in a shape to assist the user in orienting it properly. Further, a marking (e.g., an arrow meant to be vertical) is printed on the patch or on a removable paper liner (so that the arrow is removed when the patch is actually applied). 
     Further, patch  3010  (or any of the other patches) is designed to accommodate multiple orientations. For example, the electrodes is an array or series or matrix of sub-electrodes, and the patch selects which to use for effective stimulation based on the position and orientation of the patch. Similarly, patch  3010  includes two microphones which have their roles reversed if the patch were placed “upside down” on the skin. 
     In some examples, patch  3030  uses one electrode pair  3034  to activate the genitofemoral nerve  3192  or the femoral nerve  3194 , or both, on one of the left thigh  3132  or the right thigh  3134 . 
     In some examples, patch  3030  uses two electrode pairs  3034  to activate the genitofemoral nerve  3192  or the femoral nerve  3194 , or both, from both the distal and lateral sides on one of the left thigh  3132  or the right thigh  3134 . 
     In some examples, patch  3030  uses multiple positive electrodes and one or more negative electrodes to activate the genitofemoral nerve  3192  or the femoral nerve  3194 , or both, from one or both of the distal and lateral sides on one of the left thigh  3132  or the right thigh  3134 , modifying the waveshapes or timings or both of the activation pulses from the multiple electrodes to direct the waveform energy at one or more specific points on the target nerves. 
     Patches  3010 ,  3020  and  3030 , fob  3050  and smart controller  3040  may be combined in a variety of ways to implement system  3001 . 
     In some examples, user  3000  uses fob  3050  to send data and controls to smart controller  3040 . In some examples, user  3000  uses fob  3050  to send data and controls to the patches. In some examples, user  3000  uses smart controller  3040  directly, and fob  3050  is not used. 
     In some examples, each of patches  3010 ,  3020  and  3030  send a status signal to fob  3050 , or to smart controller  3040 , or both. The status signal includes an indication of the remaining power in each patch being used, and the user is informed by audible or visual signal from fob  3050  or smart controller  3040  of any patch which has insufficient power to perform any additional activations. 
     In some examples, each of patches  3010 ,  3020  and  3030  adjust the intensity of the neural stimulation during the course of treatment over a duration of one or more minutes, to optimize the blocking of pain. 
     In some examples, each of patches  3010 ,  3020  and  3030  include a heating element which applies heat to the skin when the patch is activated, and under the control of fob  3050  or smart controller  3040 . The heat acts to relieve pain in the tissues to supplement the actions of the neurostimulation. The heating elements are designed into the patch to provide heat for a duration consistent with the duration of use of the patch&#39;s neurostimulation circuitry. 
     In some examples, fob  3050  communicates data and controls with smart controller  3040  or to the patches, or both, through wireless means. In some examples, the wireless means is through the use of Bluetooth Low Energy (BLE), Wi-Fi, or other means, with the antennas. 
     In some examples, the power sources of each patch, fob  3050  and smart controller  3040  may be powered by battery or rechargeable means. 
     In some examples, each of patches  3010 ,  3020  and  3030  send an activation signal to the relevant nerve or nerves, and repeats this signal according to a timer preset by user  3000 . The interval between each patch&#39;s activations is selected to effectively suppress pain episodes according to the user&#39;s preference. The user selects the duration of each patch activation, and the number of repetitions of each patch activation. The user selects a strength level for each patch under use, as instructed in user instructions for system  3001 , using fob  3050  or smart controller  3040 . 
     In some examples, analysis of measurements from smart controller  3040  may be performed by processing in a remote server, in the cloud, or on a computer separate from smart controller  3040  but local to the user, such as a personal computer. 
     In some examples, system  3001  collects time-based records of a user&#39;s dysmenorrhea cycle. These records are used to build a database of anonymized dysmenorrhea information from large populations of patch users, or with recordings of dysmenorrhea from other detection systems. The time-based records of dysmenorrhea may be supplemented with data entered manually by the user. The data recorded in the time-based database is sent to the cloud through a local network, such as a home mesh network, or directly over the Internet. The time based records can be used to automatically activate stimulation from one or more of the patches. 
     The shape of patches  3010 ,  3020  and  3030  are designed to minimize discomfort for the user  3000  when affixed in the target location. In some examples, the patches use adhesive surfaces to attach to the skin. In some examples, the patches use an adhesive selected to attach to the skin more than once, to allow the patch to be removed from the skin, repositioned for improvement of effectiveness, and reaffixed to the skin. 
     Other patches similar to patches  3010 ,  3020  and  3030  are designed to be applied to other locations on the body, such as the medial side of one or both the left and right mid-calf, to stimulate the underlying nerve or nerves to relieve the pain of dysmenorrhea.  FIGS. 33A-B  illustrate other possible locations on the body for patches in example inventions. As shown below, these locations are on the calf, of either or both legs above the ankle bone near the midline of the leg, both laterally topical to the fibula bone and the fibularis brevis muscle ( 3302 ,  3303 ), and medially topical to the tibia bone and flexor digitorum longus muscle ( 3304 ,  3305 ). These locations are also indicated by A, B, C, and D in  FIGS. 33A-B . The nerves that are activated by stimulators at  3302 ,  3303  are the sural and fibular nerves and their branches. The nerves that are activated by stimulators at  3304 ,  3305  are the saphenous nerve and its branches. 
     These points can be activated singly or in any combination. For example, C alone ipsilateral to perceived pain on that side; D alone or the combination of C D. Further, A alone ipsilateral to perceived pain on one side, or A, B together. In some cases A, C or B, D will be appropriate, or all points together will be appropriate. The patch stimulator system is capable of activating these various combinations. Form factors ranges from individual patches to combined form factors of A, C and B, D. Control is exercised individually for each patch, or in any combination as outlined above. 
     As disclosed, example inventions reduce pain associated with PD by applying electrical stimulation to nerves using patches applied to one or more of a user&#39;s abdomen, lower back, thighs, calves or feet. 
     Several examples are specifically illustrated and/or described herein. However, it will be appreciated that modifications and variations of the disclosed examples are covered by the above teachings and within the purview of the appended claims without departing from the spirit and intended scope of the invention.