Electromyographic lead positioning and stimulation titration in a nerve stimulation system for treatment of overactive bladder
The present invention provides improved methods for positioning of an implantable lead in a patient with an integrated EMG and stimulation clinician programmer. The integrated clinician programmer is coupled to the implantable lead, wherein the implantable lead comprises at least four electrodes, and to at least one EMG sensing electrode minimally invasively positioned on a skin surface or within the patient. The method comprises delivering a test stimulation at a stimulation amplitude level from the integrated clinician programmer to a nerve tissue of the patient with a principal electrode of the implantable lead. Test stimulations are delivered at a same stimulation amplitude level for a same period of time sequentially to each of the four electrodes of the implantable lead. A stimulation-induced EMG motor response is recorded with the integrated clinician programmer for each test stimulation on each electrode of the implantable lead via the at least one pair of EMG sensing electrodes so as to facilitate initial positioning of the implantable lead at a target stimulation region.
1 . A system for improved positioning of an implantable lead in a patient, the system comprising:
a clinician programmer;
an implantable lead coupleable to the clinician programmer, wherein the implantable lead comprises at least four electrodes;
at least one EMG sensing electrode coupleable to the clinician programmer; wherein the clinician programmer is configured for:
selecting a principal electrode from the at least four electrodes of the implantable lead;
delivering one or more first test stimulations at one or more stimulation amplitude levels, using a first pulse width, to a nerve tissue of the patient with the principal electrode;
monitoring a stimulation-induced EMG motor response to each of the first test stimulations to identify a first stimulation amplitude level at which a desired motor response is observed;
delivering a plurality of second test stimulations at a same stimulation amplitude level equal to the first stimulation amplitude level using the first pulse width sequentially to each of the four electrodes of the implantable lead other than the principle electrode; and
monitoring a stimulation-induced EMG motor response with the clinician programmer for the second test stimulations as sensed via the at least one EMG sensing electrode so as to facilitate positioning of the implantable lead at a target stimulation region.
2 . The system of claim 1 , wherein the clinician programmer is further configured for automatically selecting the principal electrode.
3 . The system of claim 1 , wherein the clinician programmer is further configured for receiving user input related to selection of the principal electrode via a graphical user interface of the clinician programmer.
4 . The system of claim 1 , wherein the clinician programmer is further configured for automatically adjusting the stimulation amplitude level of the one or more first test stimulations until the desired stimulation-induced EMG motor response is detected.
5 . The system of claim 4 , wherein automatically adjusting comprises increasing the stimulation amplitude in increments of 0.05 mA for a test stimulation less than or equal to 1 mA.
6 . The system of claim 4 , wherein automatically adjusting comprises increasing the stimulation amplitude in increments of 0.1 mA for a test stimulation more than or equal to 1 mA and less than or equal to 2 mA.
7 . The system of claim 4 , wherein automatically adjusting comprises increasing the stimulation amplitude in increments of 0.2 mA for a test stimulation more than or equal to 2 mA and less than or equal to 3 mA.
8 . The system of claim 4 , wherein automatically adjusting comprises increasing the stimulation amplitude in increments of 0.25 mA for a test stimulation more than or equal to 3 mA.
9 . The system of claim 1 , wherein the clinician programmer is further configured for receiving user input related to adjustment of the stimulation amplitude level of the test stimulation for the principal electrode in increments in a range from about 0.05 mA to about 0.25 mA to achieve a desired stimulation-induced EMG motor response via a graphical user interface of the clinician programmer.
10 . The system of claim 1 , wherein the clinician programmer is further configured for calculating an EMG response value for each test stimulation delivered at a given stimulation amplitude level to each electrode based on a maximum EMG response amplitude associated with each electrode.
11 . The system of claim 1 , wherein the clinician programmer is further configured for calculating an EMG response value for each test stimulation delivered at a given stimulation amplitude level to each electrode based on a maximum EMG response amplitude associated with each electrode which is normalized relative to an EMG response amplitude associated with the principal electrode.
12 . A system for improved positioning of an implantable lead in a patient, the system comprising:
an electromyography (EMG) and stimulation clinician programmer;
an implantable lead coupleable to the clinician programmer, wherein the implantable lead comprises at least four electrodes;
wherein the clinician programmer is configured to deliver one or more first test stimulations at one or more stimulation amplitude levels and for a period of time to a nerve tissue of the patient via a principal electrode of the implantable lead,
wherein the clinician programmer is configured to monitor a stimulation-induced EMG motor response as the one or more first test stimulations are delivered until a desired stimulation-induced EMG motor response is observed, and record a first stimulation amplitude level in response to the desired stimulation-induced EMG motor response being observed;
wherein the principal electrode is selected from the at least four electrodes of the implantable lead,
wherein the clinician programmer is configured to deliver second test stimulations at a same stimulation amplitude level as the first stimulation amplitude level for a same period of time sequentially to each of the at least four electrodes of the implantable lead, and the clinician programmer is configured to monitor the stimulation-induced EMG motor response with the clinician programmer for the second test stimulations as sensed via at least one EMG sensing electrode positionable on a skin surface or within the patient so as to facilitate positioning of the implantable lead at a target stimulation region.
13 . The system of claim 12 , wherein the clinician programmer is further configured to calculate an EMG response value for each second test stimulation to each electrode based on a maximum EMG response amplitude associated with each electrode.
14 . The system of claim 13 , wherein the EMG response value associated with each electrode provides visual feedback to a user on how to laterally or axially position the implantable lead at the target stimulation region via a graphical user interface of the clinician programmer.
15 . The system of claim 14 , wherein the graphical user interface includes an implantable lead graphical element and the visual feedback comprises a color coding from at least three contrasting colors on a side of each associated electrode of the implantable lead graphical element.
16 . The system of claim 15 , wherein the visual feedback provides directional indication to the user to advance the implantable lead distally along an insertion axis, to retract the implantable lead proximally along the insertion axis, or to steer the implantable lead along a lateral direction from the insertion axis so that a middle of the implantable lead is positioned at the target stimulation region.
17 . The system of claim 16 , wherein the clinician programmer is further configured to repeat the delivering second test stimulations to each of the four electrodes of the implantable lead and record steps after lead re-positioning to confirm the calculated EMG response value for each electrode are within a desired value range, or the maximum EMG response amplitude for each electrode are within a desired response range and the associated simulation amplitude for each electrode is within a desired stimulation range.
18 . The system of claim 12 , wherein the clinician programmer is further configured to calculate an EMG response value for each second test stimulation delivered at a given stimulation amplitude level to each electrode based on a maximum EMG response amplitude associated with each electrode which is normalized relative to an EMG response amplitude associated with the principal electrode.
19 . The system of claim 18 , wherein the EMG response value associated with each electrode provides visual feedback to a user on how to laterally or axially position the implantable lead at the target stimulation region via a graphical user interface of the clinician programmer.
20 . The system of claim 19 , wherein the graphical user interface includes an implantable lead graphical element and the visual feedback comprises a color coding from at least three contrasting colors on a side of each associated electrode of the implantable lead graphical element.
21 . The system of claim 20 , wherein the visual feedback provides directional indication to the user to advance the implantable lead distally along an insertion axis, to retract the implantable lead proximally along the insertion axis, or to steer the implantable lead along a lateral direction from the insertion axis so that a middle of the implantable lead is positioned at the target stimulation region.
22 . The system of claim 21 , wherein the clinician programmer is further configured to repeat the delivering second test stimulations to each of the four electrodes of the implantable lead and record steps after lead re-positioning to confirm the calculated EMG response value for each electrode are within a desired value range, or the maximum EMG response amplitude for each electrode are within a desired response range and the associated simulation amplitude for each electrode is within a desired stimulation range.
23 . A system for improved positioning of an implantable lead in a patient, the system comprising:
an electromyography (EMG) and stimulation clinician programmer;
an implantable lead coupleable to the clinician programmer, wherein the implantable lead comprises at least four electrodes;
at least one EMG sensing electrode minimally invasively positionable on a skin surface or within the patient, the EMG sensing electrode coupleable to the clinician programmer;
wherein the clinician programmer is configured to deliver one or more first test stimulations at one or more stimulation amplitude levels and for a period of time to a nerve tissue of the patient with a principal electrode of the implantable lead,
wherein the clinician programmer is configured to monitor a stimulation-induced EMG motor response as the one or more first test stimulations are delivered until a desired stimulation-induced EMG motor response is observed, and record a first stimulation amplitude level in response to the desired stimulation-induced EMG motor response being observed;
wherein the principal electrode is selected from the at least four electrodes of the implantable lead,
wherein the clinician programmer is configured to deliver second test stimulations at a same stimulation amplitude level as the first stimulation amplitude level for a same period of time sequentially to each of the at least four electrodes of the implantable lead, and the clinician programmer is configured to monitor the stimulation-induced EMG motor response with the clinician programmer for the second test stimulations as sensed via the at least one EMG sensing electrode so as to facilitate positioning of the implantable lead at a target stimulation region.