Navigating the FDA regulatory landscape.

Recent research and technological developments have led to an expanding number of novel and rapidly acting therapeutics being developed across a variety of neuropsychiatric disorders. Novel medical devices range from implantable and non-invasive brain stimulating and recording technologies to digital therapeutics. This perspective provides an overview of FDA regulatory oversight for medical devices, including a discussion of regulatory pathways and the review of neuromodulation devices for psychiatric disorders. We highlight the importance of early engagement with FDA and special programs that may be useful to device developers participating in interactions with the FDA that are solution focused. We explore current novel and rapid treatments for psychiatric disorders and those on the horizon. Lastly, we provide considerations for developers in navigating the regulatory landscape for neuromodulation devices intended for psychiatric disorders, including approaches to incorporating patient perspectives.

Perceived timing of cutaneous vibration and intracortical microstimulation of human somatosensory cortex.

BACKGROUND: Intracortical microstimulation (ICMS) of somatosensory cortex can partially restore the sense of touch. Though ICMS bypasses much of the neuraxis, prior studies have found that conscious detection of touch elicited by ICMS lags behind the detection of cutaneous vibration. These findings may have been influenced by mismatched stimulus intensities, which can impact temporal perception. OBJECTIVE: Evaluate the relative latency at which intensity-matched vibration and ICMS are perceived by a human participant. METHODS: One person implanted with microelectrode arrays in somatosensory cortex performed reaction time and temporal order judgment (TOJ) tasks. To measure reaction time, the participant reported when he perceived vibration or ICMS. In the TOJ task, vibration and ICMS were sequentially presented and the participant reported which stimulus occurred first. To verify that the participant could distinguish between stimuli, he also performed a modality discrimination task, in which he indicated if he felt vibration, ICMS, or both. RESULTS: When vibration was matched in perceived intensity to high-amplitude ICMS, vibration was perceived, on average, 48 ms faster than ICMS. However, in the TOJ task, both sensations arose at comparable latencies, with points of subjective simultaneity not significantly different from zero. The participant could discriminate between tactile modalities above chance level but was more inclined to report feeling vibration than ICMS. CONCLUSIONS: The latencies of ICMS-evoked percepts are slower than their mechanical counterparts. However, differences in latencies are small, particularly when stimuli are matched for intensity, implying that ICMS-based somatosensory feedback is rapid enough to be effective in neuroprosthetic applications.

Characteristics and stability of sensorimotor activity driven by isolated-muscle group activation in a human with tetraplegia.

Understanding the cortical representations of movements and their stability can shed light on improved brain-machine interface (BMI) approaches to decode these representations without frequent recalibration. Here, we characterize the spatial organization (somatotopy) and stability of the bilateral sensorimotor map of forearm muscles in an incomplete-high spinal-cord injury study participant implanted bilaterally in the primary motor and sensory cortices with Utah microelectrode arrays (MEAs). We built representation maps by recording bilateral multiunit activity (MUA) and surface electromyography (EMG) as the participant executed voluntary contractions of the extensor carpi radialis (ECR), and attempted motions in the flexor carpi radialis (FCR), which was paralytic. To assess stability, we repeatedly mapped and compared left- and right-wrist-extensor-related activity throughout several sessions, comparing somatotopy of active electrodes, as well as neural signals both at the within-electrode (multiunit) and cross-electrode (network) levels. Wrist motions showed significant activation in motor and sensory cortical electrodes. Within electrodes, firing strength stability diminished as the time increased between consecutive measurements (hours within a session, or days across sessions), with higher stability observed in sensory cortex than in motor, and in the contralateral hemisphere than in the ipsilateral. However, we observed no differences at network level, and no evidence of decoding instabilities for wrist EMG, either across timespans of hours or days, or across recording area. While map stability differs between brain area and hemisphere at multiunit/electrode level, these differences are nullified at ensemble level.

Intracortical Somatosensory Stimulation to Elicit Fingertip Sensations in an Individual With Spinal Cord Injury.

BACKGROUND AND OBJECTIVES: The restoration of touch to fingers and fingertips is critical to achieving dexterous neuroprosthetic control for individuals with sensorimotor dysfunction. However, localized fingertip sensations have not been evoked via intracortical microstimulation (ICMS). METHODS: Using a novel intraoperative mapping approach, we implanted electrode arrays in the finger areas of left and right somatosensory cortex and delivered ICMS over a 2-year period in a human participant with spinal cord injury. RESULTS: Stimulation evoked tactile sensations in 8 fingers, including fingertips, spanning both hands. Evoked percepts followed expected somatotopic arrangements. The subject was able to reliably identify up to 7 finger-specific sites spanning both hands in a finger discrimination task. The size of the evoked percepts was on average 33% larger than a finger pad, as assessed via manual markings of a hand image. The size of the evoked percepts increased modestly with increased stimulation intensity, growing 21% as pulse amplitude increased from 20 to 80 µA. Detection thresholds were estimated on a subset of electrodes, with estimates of 9.2 to 35 µA observed, roughly consistent with prior studies. DISCUSSION: These results suggest that ICMS can enable the delivery of consistent and localized fingertip sensations during object manipulation by neuroprostheses for individuals with somatosensory deficits. CLINICALTRIALSGOV IDENTIFIER: NCT03161067.

Intracortical microstimulation of somatosensory cortex enables object identification through perceived sensations.

Advances in brain-machine interfaces have helped restore function and independence for individuals with sensorimotor deficits; however, providing efficient and effective sensory feedback remains challenging. Intracortical microstimulation (ICMS) of sensorimotor brain regions is a promising technique for providing bioinspired sensory feedback. In a human participant with chronically-implanted microelectrode arrays, we provided ICMS to the primary somatosensory cortex to generate tactile percepts in his hand. In a 3-choice object identification task, the participant identified virtual objects using tactile sensory feedback and no visual information. We evaluated three different stimulation paradigms, each with a different weighting of the grip force and its derivative, to explore the potential benefits of a more bioinspired stimulation strategy. In all paradigms, the participant's ability to identify the objects was above-chance, with object identification accuracy reaching 80% correct when using only sustained grip force feedback and 76.7% when using equal weighting of both sustained grip force and its derivative. These results demonstrate that bioinspired ICMS can provide sensory feedback that is functionally beneficial in sensorimotor tasks. Designing more efficient stimulation paradigms is important because it will allow us to 1) provide safer stimulation delivery methods that reduce overall injected charge without sacrificing function and 2) more effectively transmit sensory information to promote intuitive integration and usage by the human body.

Novel intraoperative online functional mapping of somatosensory finger representations for targeted stimulating electrode placement: technical note.

Defining eloquent cortex intraoperatively, traditionally performed by neurosurgeons to preserve patient function, can now help target electrode implantation for restoring function. Brain-machine interfaces (BMIs) have the potential to restore upper-limb motor control to paralyzed patients but require accurate placement of recording and stimulating electrodes to enable functional control of a prosthetic limb. Beyond motor decoding from recording arrays, precise placement of stimulating electrodes in cortical areas associated with finger and fingertip sensations allows for the delivery of sensory feedback that could improve dexterous control of prosthetic hands. In this study, the authors demonstrated the use of a novel intraoperative online functional mapping (OFM) technique with high-density electrocorticography to localize finger representations in human primary somatosensory cortex. In conjunction with traditional pre- and intraoperative targeting approaches, this technique enabled accurate implantation of stimulating microelectrodes, which was confirmed by postimplantation intracortical stimulation of finger and fingertip sensations. This work demonstrates the utility of intraoperative OFM and will inform future studies of closed-loop BMIs in humans.

Decoding Native Cortical Representations for Flexion and Extension at Upper Limb Joints Using Electrocorticography.

Brain-machine interface (BMI) researchers have traditionally focused on modeling endpoint reaching tasks to provide the control of neurally driven prosthetic arms. Most previous research has focused on achieving an endpoint control through a Cartesian-coordinate-centered approach. However, a joint-centered approach could potentially be used to intuitively control a wide range of limb movements. We systematically investigated the feasibility of discriminating between flexion and extension of different upper limb joints using electrocorticography(ECoG) recordings from sensorimotor cortex. Four subjects implanted with macro-ECoG (10-mm spacing), high-density ECoG (5-mm spacing), and/or micro-ECoG arrays (0.9-mm spacing and 4 mm × 4 mm coverage), performed randomly cued flexions or extensions of the fingers, wrist, or elbow contralateral to the implanted hemisphere. We trained a linear model to classify six movements using averaged high-gamma power (70-110 Hz) modulations at different latencies with respect to movement onset, and within a time interval restricted to flexion or extension at each joint. Offline decoding models for each subject classified these movements with accuracies of 62%-83%. Our results suggest that the widespread ECoG coverage of sensorimotor cortex could allow a whole limb BMI to sample native cortical representations in order to control flexion and extension at multiple joints.

Rigor and reproducibility in research with transcranial electrical stimulation: An NIMH-sponsored workshop.

BACKGROUND: Neuropsychiatric disorders are a leading source of disability and require novel treatments that target mechanisms of disease. As such disorders are thought to result from aberrant neuronal circuit activity, neuromodulation approaches are of increasing interest given their potential for manipulating circuits directly. Low intensity transcranial electrical stimulation (tES) with direct currents (transcranial direct current stimulation, tDCS) or alternating currents (transcranial alternating current stimulation, tACS) represent novel, safe, well-tolerated, and relatively inexpensive putative treatment modalities. OBJECTIVE: This report seeks to promote the science, technology and effective clinical applications of these modalities, identify research challenges, and suggest approaches for addressing these needs in order to achieve rigorous, reproducible findings that can advance clinical treatment. METHODS: The National Institute of Mental Health (NIMH) convened a workshop in September 2016 that brought together experts in basic and human neuroscience, electrical stimulation biophysics and devices, and clinical trial methods to examine the physiological mechanisms underlying tDCS/tACS, technologies and technical strategies for optimizing stimulation protocols, and the state of the science with respect to therapeutic applications and trial designs. RESULTS: Advances in understanding mechanisms, methodological and technological improvements (e.g., electronics, computational models to facilitate proper dosing), and improved clinical trial designs are poised to advance rigorous, reproducible therapeutic applications of these techniques. A number of challenges were identified and meeting participants made recommendations made to address them. CONCLUSIONS: These recommendations align with requirements in NIMH funding opportunity announcements to, among other needs, define dosimetry, demonstrate dose/response relationships, implement rigorous blinded trial designs, employ computational modeling, and demonstrate target engagement when testing stimulation-based interventions for the treatment of mental disorders.

Cortical subnetwork dynamics during human language tasks.

Language tasks require the coordinated activation of multiple subnetworks-groups of related cortical interactions involved in specific components of task processing. Although electrocorticography (ECoG) has sufficient temporal and spatial resolution to capture the dynamics of event-related interactions between cortical sites, it is difficult to decompose these complex spatiotemporal patterns into functionally discrete subnetworks without explicit knowledge of each subnetwork's timing. We hypothesized that subnetworks corresponding to distinct components of task-related processing could be identified as groups of interactions with co-varying strengths. In this study, five subjects implanted with ECoG grids over language areas performed word repetition and picture naming. We estimated the interaction strength between each pair of electrodes during each task using a time-varying dynamic Bayesian network (tvDBN) model constructed from the power of high gamma (70-110Hz) activity, a surrogate for population firing rates. We then reduced the dimensionality of this model using principal component analysis (PCA) to identify groups of interactions with co-varying strengths, which we term functional network components (FNCs). This data-driven technique estimates both the weight of each interaction's contribution to a particular subnetwork, and the temporal profile of each subnetwork's activation during the task. We found FNCs with temporal and anatomical features consistent with articulatory preparation in both tasks, and with auditory and visual processing in the word repetition and picture naming tasks, respectively. These FNCs were highly consistent between subjects with similar electrode placement, and were robust enough to be characterized in single trials. Furthermore, the interaction patterns uncovered by FNC analysis correlated well with recent literature suggesting important functional-anatomical distinctions between processing external and self-produced speech. Our results demonstrate that subnetwork decomposition of event-related cortical interactions is a powerful paradigm for interpreting the rich dynamics of large-scale, distributed cortical networks during human cognitive tasks.

Individual finger control of a modular prosthetic limb using high-density electrocorticography in a human subject.

OBJECTIVE: We used native sensorimotor representations of fingers in a brain-machine interface (BMI) to achieve immediate online control of individual prosthetic fingers. APPROACH: Using high gamma responses recorded with a high-density electrocorticography (ECoG) array, we rapidly mapped the functional anatomy of cued finger movements. We used these cortical maps to select ECoG electrodes for a hierarchical linear discriminant analysis classification scheme to predict: (1) if any finger was moving, and, if so, (2) which digit was moving. To account for sensory feedback, we also mapped the spatiotemporal activation elicited by vibrotactile stimulation. Finally, we used this prediction framework to provide immediate online control over individual fingers of the Johns Hopkins University Applied Physics Laboratory modular prosthetic limb. MAIN RESULTS: The balanced classification accuracy for detection of movements during the online control session was 92% (chance: 50%). At the onset of movement, finger classification was 76% (chance: 20%), and 88% (chance: 25%) if the pinky and ring finger movements were coupled. Balanced accuracy of fully flexing the cued finger was 64%, and 77% had we combined pinky and ring commands. Offline decoding yielded a peak finger decoding accuracy of 96.5% (chance: 20%) when using an optimized selection of electrodes. Offline analysis demonstrated significant finger-specific activations throughout sensorimotor cortex. Activations either prior to movement onset or during sensory feedback led to discriminable finger control. SIGNIFICANCE: Our results demonstrate the ability of ECoG-based BMIs to leverage the native functional anatomy of sensorimotor cortical populations to immediately control individual finger movements in real time.

Demonstration of a semi-autonomous hybrid brain-machine interface using human intracranial EEG, eye tracking, and computer vision to control a robotic upper limb prosthetic.

To increase the ability of brain-machine interfaces (BMIs) to control advanced prostheses such as the modular prosthetic limb (MPL), we are developing a novel system: the Hybrid Augmented Reality Multimodal Operation Neural Integration Environment (HARMONIE). This system utilizes hybrid input, supervisory control, and intelligent robotics to allow users to identify an object (via eye tracking and computer vision) and initiate (via brain-control) a semi-autonomous reach-grasp-and-drop of the object by the MPL. Sequential iterations of HARMONIE were tested in two pilot subjects implanted with electrocorticographic (ECoG) and depth electrodes within motor areas. The subjects performed the complex task in 71.4% (20/28) and 67.7% (21/31) of trials after minimal training. Balanced accuracy for detecting movements was 91.1% and 92.9%, significantly greater than chance accuracies (p < 0.05). After BMI-based initiation, the MPL completed the entire task 100% (one object) and 70% (three objects) of the time. The MPL took approximately 12.2 s for task completion after system improvements implemented for the second subject. Our hybrid-BMI design prevented all but one baseline false positive from initiating the system. The novel approach demonstrated in this proof-of-principle study, using hybrid input, supervisory control, and intelligent robotics, addresses limitations of current BMIs.

Simultaneous neural control of simple reaching and grasping with the modular prosthetic limb using intracranial EEG.

Intracranial electroencephalographic (iEEG) signals from two human subjects were used to achieve simultaneous neural control of reaching and grasping movements with the Johns Hopkins University Applied Physics Lab (JHU/APL) Modular Prosthetic Limb (MPL), a dexterous robotic prosthetic arm. We performed functional mapping of high gamma activity while the subject made reaching and grasping movements to identify task-selective electrodes. Independent, online control of reaching and grasping was then achieved using high gamma activity from a small subset of electrodes with a model trained on short blocks of reaching and grasping with no further adaptation. Classification accuracy did not decline (p < 0.05, one-way ANOVA) over three blocks of testing in either subject. Mean classification accuracy during independently executed overt reach and grasp movements for (Subject 1, Subject 2) were (0.85, 0.81) and (0.80, 0.96), respectively, and during simultaneous execution they were (0.83, 0.88) and (0.58, 0.88), respectively. Our models leveraged knowledge of the subject's individual functional neuroanatomy for reaching and grasping movements, allowing rapid acquisition of control in a time-sensitive clinical setting. We demonstrate the potential feasibility of verifying functionally meaningful iEEG-based control of the MPL prior to chronic implantation, during which additional capabilities of the MPL might be exploited with further training.