Stimulator design and subsequent stimulation parameter optimization for controlling micturition and reducing urethral resistance

Measurement of block thresholds in kiloHertz frequency alternating current peripheral nerve block

BACKGROUND

Kilohertz frequency alternating currents (KHFAC) produce rapid nerve conduction block of mammalian peripheral nerve and have potential clinical applications in reducing peripheral nerve hyperactivity. The experimental investigation of KHFAC nerve block requires a robust output measure and this has proven to be the block threshold (BT), the lowest current or voltage at which the axons of interest are completely blocked. All significant literature in KHFAC nerve block, both simulations and experimental, were reviewed to determine the block threshold method that was used. The two common methods used are the High-Low method experimentally and the Binary search method for simulations.

NEW METHOD

Four methods to measure the block threshold (High-Low, High-Low-High, Binary and Random) at three frequencies (10, 20 and 30 kHz) were compared through randomized repeated experiments in the in-vivo rodent sciatic nerve-gastrocnemius model.

RESULTS

The literature review showed that more than 50% of publications did not measure the block threshold. The experimental results showed no statistical difference in the BT value between the four methods.

COMPARISON WITH EXISTING METHOD(S)

However, there were differences in the number of significant onset responses, depending on the method. The run time for the BT determination was the shortest for the High-Low method.

CONCLUSIONS

It is recommended that all research in electrical nerve block, including KHFAC, should include measurement of the BT. The High-Low method is recommended for most experimental situations but the Binary method could also be a viable option, especially where onset responses are minimal.

Effects of Acute Sacral Neuromodulation at Different Frequencies on Bladder Overactivity in Pigs

Purpose

We investigated the effects of different stimulation frequencies on the inhibition of bladder overactivity by sacral neuromodulation (SNM) in pigs.

Methods

Implant-driven stimulators were used to stimulate the S3 spinal nerve in 13 pigs. Cystometry was performed by infusing normal saline (NS) or acetic acid (AA). SNM (pulse width, 210 µsec) at frequencies ranging from 5 to 50 Hz was conducted at the intensity threshold at which observable perianal and/or tail movement was induced. Multiple cystometrograms were performed to determine the effects of different frequencies on the micturition reflex.

Results

AA-induced bladder overactivity significantly reduced the bladder capacity (BC) to 34.4%±4.7% of the NS control level (354.4±35.9 mL) (P<0.05). During AA infusion, SNM at 5 Hz did not significantly change the BC (48.1%±6.9% of the NS control level) (P>0.05), but SNM at 15, 30, and 50 Hz significantly increased the BC to 54.5%±7.1%, 55.2%±6.5%, and 57.2%±6.1% of the NS control level (P<0.05), respectively. No significant differences were found among the results obtained using frequencies of 15, 30, and 50 Hz (P>0.05).

Conclusions

This study demonstrated that 15 Hz was an appropriate frequency for SNM and that frequencies higher than 15 Hz did not lead to better surgical outcomes.

Impact of direct epispinal stimulation on bladder and bowel functions in pigs: A feasibility study

AIMS

This study assesses the potential of epispinal (subdural) stimulation application in the treatment of urinary and bowel neurological disorders. Acute experiments were performed on a large animal model - the domestic pig - to develop a new methodology facilitating future results and technology transfers to human.

METHODS

After rectal and bladder catheterization, four Landrace pigs (45-50 kg) underwent spinal cord surgery - that is, lumbosacral incision, laminectomy [L4-S4], dural opening and microsurgical arachnoid dissection. Three successive electrical stimulation sessions were carried out: 1) nerve roots stimulation, 2) epispinal stimulation with a matrix electrode, 3) epispinal stimulation with a small diameter needle electrode. Changes in rectal and bladder pressures were monitored throughout the various procedures to identify spinal areas inducing responses while evaluating the influence of electrode contacts size in the measured responses amplitudes.

RESULTS

An interesting area was identified in the upper portion of the spinal myelomeres (ie, spinal cord segment delimited by two successive pairs of spinal roots) directly adjoining root with best pressures (either rectal or vesical). Significant responses (up to 40 cmH₂ O) were also obtained with a needle electrode. Furthermore, bowel evacuation was triggered in one of the animals. Despite the use of smaller electrode contacts, no detrusor or rectum selective responses were observed in none of the sessions.

CONCLUSION

This study showed, for the first time, that epispinal stimulation causes significant detrusor and rectal responses in pigs and allows considering further studies with the objective of treating urinary and rectal disorders in spinal cord injury patients.

Electrical stimulation for the treatment of lower urinary tract dysfunction after spinal cord injury

Electrical stimulation for bladder control is an alternative to traditional methods of treating neurogenic lower urinary tract dysfunction (NLUTD) resulting from spinal cord injury (SCI). In this review, we systematically discuss the neurophysiology of bladder dysfunction following SCI and the applications of electrical stimulation for bladder control following SCI, spanning from historic clinical approaches to recent pre-clinical studies that offer promising new strategies that may improve the feasibility and success of electrical stimulation therapy in patients with SCI. Electrical stimulation provides a unique opportunity to control bladder function by exploiting neural control mechanisms. Our understanding of the applications and limitations of electrical stimulation for bladder control has improved due to many pre-clinical studies performed in animals and translational clinical studies. Techniques that have emerged as possible opportunities to control bladder function include pudendal nerve stimulation and novel methods of stimulation, such as high frequency nerve block. Further development of novel applications of electrical stimulation will drive progress towards effective therapy for SCI. The optimal solution for restoration of bladder control may encompass a combination of efficient, targeted electrical stimulation, possibly at multiple locations, and pharmacological treatment to enhance symptom control.

Reversible nerve conduction block using kilohertz frequency alternating current

OBJECTIVES

The features and clinical applications of balanced-charge kilohertz frequency alternating currents (KHFAC) are reviewed. Preclinical studies of KHFAC block have demonstrated that it can produce an extremely rapid and reversible block of nerve conduction. Recent systematic analysis and experimentation utilizing KHFAC block have resulted in a significant increase in interest in KHFAC block, both scientifically and clinically.

MATERIALS AND METHODS

We review the history and characteristics of KHFAC block, the methods used to investigate this type of block, the experimental evaluation of block, and the electrical parameters and electrode designs needed to achieve successful block. We then analyze the existing clinical applications of high-frequency currents, comparing the early results with the known features of KHFAC block.

RESULTS

Although many features of KHFAC block have been characterized, there is still much that is unknown regarding the response of neural structures to rapidly fluctuating electrical fields. The clinical reports to date do not provide sufficient information to properly evaluate the mechanisms that result in successful or unsuccessful treatment.

CONCLUSIONS

KHFAC nerve block has significant potential as a means of controlling nerve activity for the purpose of treating disease. However, early clinical studies in the use of high-frequency currents for the treatment of pain have not been designed to elucidate mechanisms or allow direct comparisons to preclinical data. We strongly encourage the careful reporting of the parameters utilized in these clinical studies, as well as the development of outcome measures that could illuminate the mechanisms of this modality.

Electrical stimulation using kilohertz-frequency alternating current

Transcutaneous electrical stimulation using kilohertz-frequency alternating current (AC) became popular in the 1950s with the introduction of "interferential currents," promoted as a means of producing depth-efficient stimulation of nerve and muscle. Later, "Russian current" was adopted as a means of muscle strengthening. This article reviews some clinically relevant, laboratory-based studies that offer an insight into the mechanism of action of kilohertz-frequency AC. It provides some answers to the question: "What are the optimal stimulus parameters for eliciting forceful, yet comfortable, electrically induced muscle contractions?" It is concluded that the stimulation parameters commonly used clinically (Russian and interferential currents) are suboptimal for achieving their stated goals and that greater benefit would be obtained using short-duration (2-4 millisecond), rectangular bursts of kilohertz-frequency AC with a frequency chosen to maximize the desired outcome.

Voiding reflex in chronic spinal cord injured cats induced by stimulating and blocking pudendal nerves

AIMS

To induce efficient voiding in chronic spinal cord injured (SCI) cats.

METHODS

Voiding reflexes induced by bladder distension or by electrical stimulation and block of pudendal nerves were investigated in chronic SCI cats under alpha-chloralose anesthesia.

RESULTS

The voiding efficiency in chronic SCI cats induced by bladder distension was very poor compared to that in spinal intact cats (7.3 +/- 0.9% vs. 93.6 +/- 2.0%, P < 0.05). In chronic SCI cats continuous stimulation of the pudendal nerve on one side at 20 Hz induced large amplitude bladder contractions, but failed to induce voiding. However, continuous pudendal nerve stimulation (20 Hz) combined with high-frequency (10 kHz) distal blockade of the ipsilateral pudendal nerve elicited efficient (73.2 +/- 10.7%) voiding. Blocking the pudendal nerves bilaterally produced voiding efficiency (82.5 +/- 4.8%) comparable to the efficiency during voidings induced by bladder distension in spinal intact cats, indicating that the external urethral sphincter (EUS) contraction was caused not only by direct activation of the pudendal efferent fibers, but also by spinal reflex activation of the EUS through the contralateral pudendal nerve. The maximal bladder pressure and average flow rate induced by stimulation and bilateral pudendal nerve block in chronic SCI cats were also comparable to those in spinal intact cats.

CONCLUSIONS

This study shows that after the spinal cord is chronically isolated from the pontine micturition center, bladder distension evokes a transient, inefficient voiding reflex, whereas stimulation of somatic afferent fibers evokes a strong, long duration, spinal bladder reflex that elicits efficient voiding when combined with blockade of somatic efferent fibers in the pudendal nerves.

Simulation of high-frequency sinusoidal electrical block of mammalian myelinated axons

High frequency alternating current (HFAC) sinusoidal waveforms can block conduction in mammalian peripheral nerves. A mammalian axon model was used to simulate the response of nerves to HFAC conduction block. Sinusoidal waveforms from 1 to 40 kHz were delivered to eight simulated axon diameters ranging from 7.3 to 16 microm. Conduction block was obtained between 3 to 40 kHz. The minimum peak to peak current at which block was obtained, defined as the block threshold, increased with increasing frequency. Block threshold varied inversely with axon diameter. Upon initiation, the HFAC waveform produced one or more action potentials. These simulation results closely parallel previous experimental results of high frequency motor block of the rat sciatic and cat pudendal nerve. During HFAC block, the axons showed a dynamic steady state depolarization of multiple nodes, strongly suggesting a depolarization mechanism for HFAC conduction block.

Nerve conduction block utilising high-frequency alternating current

High-frequency alternating current (AC) waveforms have been shown to produce a quickly reversible nerve block in animal models, but the parameters and mechanism of this block are not well understood. A frog sciatic nerve/gastrocnemius muscle preparation was used to examine the parameters for nerve conduction block in vivo, and a computer simulation of the nerve membrane was used to identify the mechanism for block. The results indicated that a 100% block of motor activity can be accomplished with a variety of waveform parameters, including sinusoidal and rectangular waveforms at frequencies from 2 kHz to 20 kHz. A complete and reversible block was achieved in 34 out of 34 nerve preparations tested. The most efficient waveform for conduction block was a 3-5 kHz constant-current biphasic sinusoid, where block could be achieved with stimulus levels as low as 0.01 microCphase(-1). It was demonstrated that the block was not produced indirectly through fatigue. Computer simulation of high-frequency AC demonstrated a steady-state depolarisation of the nerve membrane, and it is hypothesised that the conduction block was due to this tonic depolarisation. The precise relationship between the steady-state depolarisation and the conduction block requires further analysis. The results of this study demonstrated that high-frequency AC can be used to produce a fast-acting, and quickly reversible nerve conduction block that may have multiple applications in the treatment of unwanted neural activity.

Spinal cord neural organization controlling the urinary bladder and striated sphincter

The storage and elimination of urine requires the coordination of activity between the autonomic nervous system (thoracolumbar sympathetic and sacral parasympathetic divisions) controlling the urinary bladder and urethra and the lumbosacral somatic motoneurons innervating the striated sphincter and pelvic floor muscles. These three efferent systems involved in the control of lower urinary tract function receive segmental sensory information from various visceral organs and the perineum, as well as inputs from supraspinal regions. Ascending and descending connections between the various spinal segments levels and supraspinal regions provide the reflex substrates participating in normal bladder continence and micturition reflexes. Many of the actions of descending and segmental reflexes are mediated by excitatory and inhibitory sacral spinal interneurons located within the region of the parasympathetic preganglionic autonomic neurons and the sphincter ventral horn motoneurons. This review will: (1) discuss the basic organization and spinal elements of the reflex pathways subserving continence and micturition; (2) describe features of the identified sacral interneuronal circuitry contributing to the control of the bladder and sphincter function; and (3) discuss how changes in the control of these reflex pathways and neurons may contribute to abnormal patterns of bladder and sphincter function commonly observed following spinal cord injury.

Implantable selective stimulator to improve bladder voiding: design and chronic experiments in dogs

Among the treatments to enhance the bladder voiding, the sacral roots neurostimulation is one of the most promising techniques. The electrostimulation of sacral nerves provokes a simultaneous contraction of the detrusor muscle as well as the external urethral sphincter (EUS). A new simplified-architecture implantable stimulator with its wireless controller have been designed to investigate high-frequency inhibition stimulation strategies. This innovative technique based on high-frequency inhibition reduces sphincter activity during stimulation. Low-frequency current pulses also applied to the sacral roots induces contraction of the detrusor muscle resulting in low pressure voiding. Chronic experiments were carried out on ten male mongrel paraplegic dogs. One cuff electrode was implanted along with each stimulator for eight months. The animals were stimulated twice a day using the prototypes of our implantable selective stimulator while voided and residual urine volume were measured during the procedure. These experiments revealed that the proposed stimulation strategy enhances bladder voiding by more than 50% in comparison with low-frequency only stimulation. The residual urine volume was reduced to an average of 9% and low pressure micturition was achieved as shown by weekly cystourethrogram.

Implantable measurement technique dedicated to the monitoring of electrode-nerve contact in bladder stimulators

A fully integrated electrode-nerve contact monitoring circuit intended to increase safety and reliability in implantable bladder stimulators is described. The proposed integrated circuit converts a measurement of the impedance of two electrode-nerve contacts into frequency. The measurement is derived from a test current generated by the stimulation current source. The obtained results is the frequency of a square wave signal. This frequency is then converted into 8-bit data, which are serially transmitted to an external controller through an inductive link. The whole circuit can be set in idle model during stimulation, ensuring low energy consumption. It is fully testable, and an internal calibration technique makes it possible to reduce errors due to temperature and process variations. The total area of the proposed monitoring circuit is 0.1 mm2 when fabricated with a 0.35 micron technology, including a digitally controlled, current source. The design has been fabricated and successfully tested.

Design of low-cost general purpose microcontroller based neuromuscular stimulator

In this study, a general purpose, low-cost, programmable, portable and high performance stimulator is designed and implemented. For this purpose, a microcontroller is used in the design of the stimulator. The duty cycle and amplitude of the designed system can be controlled using a keyboard. The performance test of the system has shown that the results are reliable. The overall system can be used as the neuromuscular stimulator under safe conditions.

Electronic design of a multichannel programmable implant for neuromuscular electrical stimulation

An advanced stimulator for neuromuscular stimulation of spinal cord injured patients has been developed. The stimulator is externally controlled and powered by a single encoded radio frequency carrier and has four independently controlled bipolar stimulation channels. It offers a wide range of reprogrammability and flexibility, and can be used in many neuromuscular electrical stimulation applications. The implant system is adaptable to patient's needs and to future developments in stimulation algorithms by reprogramming the stimulator. The stimulator is capable of generating a wide range of stimulation waveforms and stimulation patterns and therefore is very suitable for selective nerve stimulation techniques. The reliability of the implant has been increased by using a forward error detection and correction communication protocol and by designing the chip for structural testability based on scan test approach. Implemented testability scheme makes it possible to verify the complete functionality of the implant before and after implantation. The stimulators architecture is designed to be modular and therefore its different blocks can be reused as standard building blocks in the design and implementation of other neuromuscular prostheses. Design for low-power techniques have also been employed to reduce power consumption of the electronic circuitry.

New easy to install nerve cuff electrode using shape memory alloy armature

This paper presents an easy to install nerve cuff electrode dedicated to functional electrical stimulation (FES). In this new device, a shape memory alloy (SMA) armature is used to perform the closing of the electrode. This technique makes the electrode installation around the nerve much easier, quicker, and safer. Both remarkable mechanical properties of SMA materials, namely, shape memory effect and superelasticity, can be used to obtain the desired mode of electrode closing. The fabrication procedure of the new electrode is described. It does not require any expensive or complex techniques. Bipolar and tripolar electrodes have been manufactured with an inner diameter of 1.6 mm and a cuff wall thickness of 0.8 mm. These electrodes are to be used for FES of the bladder in spinal cord injured patients. Acute studies in dogs are being carried out to validate the device and the implantation procedure.

Implantable bioelectric interfaces for lost nerve functions

Neuronal cells are unique within the organism. In addition to forming long-distance connections with other nerve cells and non-neuronal targets, they lose the ability to regenerate their neurites and to divide during maturation. Consequently, external violations like trauma or disease frequently lead to their disappearance and replacement by non-neuronal, and thus not properly functioning cells. The advent of microtechnology and construction of artificial implants prompted to create particular devices for specialised regions of the nervous system, in order to compensate for the loss of function. The scope of the present work is to review the current devices in connection with their applicability and functional perspectives. (1) Successful implants like the cochlea implant and peripherally implantable stimulators are discussed. (2) Less developed and not yet applicable devices like retinal or cortical implants are introduced, with particular emphasis given to the reasons for their failure to replace very complex functions like vision. (3) Material research is presented both from the technological aspect and from their biocompatibility as prerequisite of any implantation. (4) Finally, basic studies are presented, which deal with methods of shaping the implants, procedures of testing biocompatibility and modification of improving the interfaces between a technical device and the biological environment. The review ends by pointing to future perspectives in neuroimplantation and restoration of interrupted neuronal pathways.

Implantable stimulation system dedicated for neural selective stimulation

A functional electrical stimulation system is presented, which is dedicated for the selective neural stimulation of the bladder. The proposed system is composed of an internal stimulator (implant) and an external controller. The system is used to produce low-pressure voiding of the bladder in spinal cord injured patients. The implant is powered and operated by the external controller via radio-frequency electromagnetic coupling. All stimulation parameters are chosen externally using the controller and are sent to the implant, which produces the desired stimuli. These stimuli are applied directly to the S2 nerve which is linked to the sphincter and bladder muscles. A high-frequency signal is used to inhibit the contraction of the sphincter muscle, and low-frequency pulses stimulate the bladder muscle (the detrusor). Dedicated computer software is used by the physician to select the optimal parameters for each patient and to activate the implant through a parallel port interface with built-in transmitter. The parameters are then transferred to a hand-held controller which is used by the technical staff and by the patients themselves. Acute studies have been performed to validate the selective stimulation strategy, and chronic experimentation is currently underway in dogs.

Design of a miniaturized ultrasonic bladder volume monitor and subsequent preliminary evaluation on 41 enuretic patients

Nocturnal incontinence (enuresis) affects 20% of children over four years old, and this figure typically decreases by 15% each year. At the age of 18, 1% of those people remain enuretic. Nocturnal enuresis can be treated by means of a conditioning device that awakens the patient once the urine level has reached a preestablished threshold of the capacity of his or her bladder. We have designed and implemented a portable miniaturized ultrasonic monitor, which permits estimation of the urine volume with an accuracy of 75%. Prototypes have been completed and validated on 41 patients (children) at Ste. Justine Hospital (Montréal). On the first group of 33 patients, we used a hand-held transducer to determine the volume detection range, which is accurate for volumes between 40 and 400 mL. With the second group of 8 patients, the device was mounted on an elastic belt around the abdomen. Measurements were taken in order to validate the accuracy of urine threshold detection and the activation of the corresponding alarm.

Proposed new bladder volume monitoring device based on impedance measurement

A new implantable bladder volume-monitoring device based on the impedance measurement of the detrusor muscle is described. The system is completely autonomous and forms a mixed-signal (analogue/digital) feedback loop with a neuro-stimulator to rectify bladder dysfunctions (incontinence and retention) through neuromuscular stimulation techniques. A programmable instrumentation amplifier and a signal processing block, to eliminate the artefacts caused by the patient's movements, have been designed and tested. The layout for the signal processing block has been realised in 0.8 micron BiCMOS technology.