P309 Tinnitus rTMS Treatment Guided by Local Synchronicity of the Resting State fMRI

Objectives
In tinnitus rTMS treatment, the inhibitory 1 Hz stimulation is commonly delivered to left auditory cortex and/or left temporoparietal junction (TPJ). We aimed to improve rTMS-targeting with fMRI measurements.

Methods
A patient with whiplash and head trauma originated brain injury leading to constant headache, bilateral tinnitus and hearing deficit, and depression. Tinnitus handicap index (0–100) (THI) was 74 before therapy.

The patient received two 4-week rTMS therapy series. Primary treatment side was left based on literature and MRI perfusion images. Targets were on primary auditory cortex bilaterally and on left TPJ. Several adjustments to target locations were tested in chasing of the positive patient feedback. Inhibitory TMS-parameters for each target were 1 Hz and 1000–1500 pulses.

Before and after treatment series resting-state fMRI was acquired and a local synchrony measure (ReHo) was computed.

Results
After the first treatment series the left side tinnitus was relieved (THI dropped from 74 to 22) but right side tinnitus remained and later THI got back to 74. After three months, patient received the second series and left side tinnitus was again attenuated, but right side tinnitus remained. Then fMRI ReHo analysis was re-checked and a hypersyncronous right posterior temporal cortex spot was noticed. Using that as an rTMS-target led to a quick attenuation of the remaining right side tinnitus. THI dropped to 12 and the treatment effect has persisted.

Conclusions
fMRI informed personalized rTMS-treatment has the potential to target the correct gyrus and hemisphere without extensive trial and error, at least in tinnitus.

 

Is this new?

Too bad it's only one case report, that happens not to be noise induced-tinnitus. However this looks something that I would like to try.

 

It is from a poster session from the 16th European Congress of Clinical Neurophysiology, Budapest, Hungary. The journal Clinical Neurophysiology printed the poster session abstracts. So this is not a regular paper that has gone through peer review. Here is a link to the abstract from the journal:
http://www.clinph-journal.com/article/S1388-2457(17)30804-0/abstract

 

@HomeoHebbian thoughts?

 

Are you aware of any other studies on fMRI guided rTMS?

 

I've read a few rTMS treatments for tinnitus with mixed to positive results.

Does anybody know of any upcoming trials for rTMS to best find the right protocols to enhance efficacy of treatment? Or any idea how long it will be before it will be established to use this method of treatment?

It seems rTMS has been considered for tinnitus for years but yet there is still not conclusive evidence it works, you would think with the prevaleanve of tinnitus researchers would be keen to pursue it more...?

 

I'm not, so I did a little digging. There are a number of papers on fMRI and tinnitus or rTMS and tinnitus, but I only turned up 1 that includes all three. In that paper it looks like fMRI was used to look at what happened rather than to guide the rTMS: http://www.sciencedirect.com/science/article/pii/S0987705311002358?via=ihub

 

Regardless of the cause this shows that it can be cured. I need this

 

There are 4 trials listed in clinicaltrials.gov that are recruiting:

https://clinicaltrials.gov/ct2/show/NCT00926237?term=rtms&cond=tinnitus&draw=3&rank=4
https://clinicaltrials.gov/ct2/show/NCT02653547?term=rtms&cond=tinnitus&draw=1&rank=17
https://clinicaltrials.gov/ct2/show/NCT02071732?term=rtms&cond=tinnitus&draw=1&rank=18
https://clinicaltrials.gov/ct2/show/NCT02617953?term=rtms&cond=tinnitus&draw=1&rank=20

There may be others that are not listed at clinicaltrials.gov.

 

Thanks for your time @Aaron123.

 

http://www.psychiatrycentre.co.uk/

Here they offer rTMS for £2,000 a week and there is a systematic review of journals 'proving' its efficacious.

However I found some studies that showed it no better than a placebo.

It will be interesting when these results are published @Aaron123 - what's your take on RTMS?

 

The systematic review/meta-analysis is not very convincing.

My view is that too little is known about where and how to use rTMS that it is unlikely to be useful in the foreseeable future.

I am more excited about the possibility of non-invasive deep brain stimulation (http://www.cell.com/cell/abstract/S0092-8674(17)30584-6). It is still not a near-term solution since it is much newer, but it would seem to have the potential to be very powerful if it can be well targeted deep into the brain.

 

there is a clinic in sussex uk offering rtms for tinnitus

 

Is this treatment invasive? And also, what are the side-effects that are commonly associated with this treatment?

 

I discussed it with my phychiarst who does it often (for depression) and he said side effects are rare, but it is loud so if you’re considering wear ear plugs

 

Like Aaron said, it's a poster abstract. No peer review. I think non-invasive direct brain stimulation has potential, though it's hard to control and the parameter space to be explored with respect to tinnitus mitigation is too large for any careful, exhaustive study. Most of the research in this area is being done by hacks, but one exception is the work of Amber Leaver at UCLA, who is using fMRI to guide positioning of stimulation electrodes.

The neurobiology of direct brain stim is fascinating, as at least one nice recent paper shows that it induces metaplastic states predominantly by changing the physiology of glia, not neurons.

 

Yep, I totally agree. There is an amazing pod cast by ATA about Neurmodulation and the science behind it from a well known Neurologist who studies tinnitus.
https://www.ata.org/podcasts/episode-3-neuromodulation-suppress-tinnitus. I really think its worth your time listening if you want the most update to research on this.

 

It is not so loud. Just a 'clac' sound, like a little hammer hit a nail. And that's how it feels too. A little hammer hitting your brain.

 

Thank you for updating me. I've not tried it as of yet, but appreciate your feedback. Did you have any success or science with it?

 

RTMS parameters in tinnitus trials: a systematic review

Abstract
Over the past few years extensive body of research was produced investigating the effects of repetitive transcranial magnetic stimulation (rTMS) for the treatment of chronic tinnitus with heterogeneous results. This heterogeneity is exemplified by two recently published large-scale clinical trials reporting different outcomes. Technical aspects of rTMS were suspected as a potential source for this incongruency. The aim of this systematic review is to examine the overall efficacy as well as to identify possible technical factors relevant for the effectiveness of rTMS tinnitus trials. Via a literature search appropriate original research papers were identified and rTMS parameters were extracted from each study arm for subsequent statistical analysis with respect to observed effects (significant vs. not significant pre-post rTMS effects). Our findings indicate that verum rTMS is superior to sham rTMS as demonstrated by the proportion of significant pre-post contrasts. Some relevant rTMS parameters (e.g., pulse waveform) are not reported. Lower rTMS stimulation intensity was associated with significant effects in verum rTMS arms. An additional stimulation of the DLPFC to the temporal cortex was not found to promote efficacy. Future research should consider differential effects of rTMS induced by technical parameters and strive for an exhaustive reporting of relevant rTMS parameters.

Conclusion
The present systematic review demonstrates a higher efficacy of verum rTMS in contrast to sham rTMS. In verum arms, technical parameters such as stimulation intensity and number of pulses or restrictive stimulation of the auditory cortex were identified as relevant factors for clinical efficacy in a dose-dependent manner – less might be more. The impact of technical parameters in interaction with neurophysiological parameters (e.g., brain state before stimulation72,73,74) highlights the capability of rTMS in treating chronic tinnitus based on the premise to identify optimal stimulation protocols for single patients by means of personalized medical approaches75. In order to understand the consequences of considerable rTMS parameters in detail, standardized and sufficient reporting is highly required. As of yet, this is not the case – neither in tinnitus research nor in any other field utilizing rTMS