Transcranial Stimulation Treatments (rTMS & tDCS & tACS)

Discussion in 'Treatments' started by exodus, Apr 18, 2012.

    1. exodus
      Cold

      exodus Member

      Tinnitus Since:
      05/2008
      hello there

      does anyone know if there is any center in uk or in europe that is using rTMS / Transcranial Magnetic Stimulation to treat tinnitus?

      if yes please let me know

      thanks
       
    2. jazz
      No Mood

      jazz Member Benefactor

      Location:
      US
      Tinnitus Since:
      8/2012
      Cause of Tinnitus:
      eardrum rupture from virus; barotrauma from ETD
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    3. Jason White

      Jason White Member

      Location:
      Los Angeles
      Tinnitus Since:
      2012
      Well, at the suggestion of my ear doctor at UCLA, I called the office of Dr. Stubbeman (in West LA) to see what rTMS treatment involves and how much it costs.

      Basically, it's 3 treatments per day (they treat 3 separate parts of the brain back-to-back), for about 1-1/2 hours total, 5 days per week. There's also a weekly "motor threshold" test and a weekly meeting with Dr. Stubbeman himself. They also want you to get a special type of MRI done, which insurance may or may not cover.

      So, guess how much you're going to spend on all this stuff each week?

      Go on, take a wild guess...

      $6075 per week!!!!

      And NONE of it is covered by health insurance!

      So, for 8 weeks of treatment, tests, and meetings, you're looking almost $50,000. Then, once you're in "remission"... they start to taper you off, to the tune of several thousand dollars more.

      Fuck them!!
       
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    4. daedalus

      daedalus Member

      Location:
      Brussels
      Tinnitus Since:
      04/2007
      You would pay a fraction of this in Europe. I don't know yet the whereabouts of the BRAI2N clinic Antwerp but i paid around 100 € for a rTMS test and another 100 € for a week of daily stimulations there. Even with an airplane ticket and an hotel this would have been way cheaper.

      Glad to know tDCS is being tested outside Belgium. Hope it works out.
       
    5. michalCZ

      michalCZ Member

      Tinnitus Since:
      2008
      Hi,
      I´m in trial rTMS in Prague. I´m going for 10 session this and next week. One session is 30 minutes, 1800 pulses, 1Hz and 65% of power of rTMS machine. One site protokol - the left temporal part of the brain.
      I noticed a change in perception and type of tinnitus. The whistling becomes effervescence of lower intensity, and continues until the next day. I experienced a similar effect in ACR NM (homemade of this forum). However, he lasted about two minutes.
      What surprises me more is that the last four days do not perceive tinnitus negatively. I do not suppose my tinnitus disappears, but rTMS is after the ACR NM homemade is the second method, which immediately do something with my tinnitus.
      I'll know more next week. However, for further research tinnitus is good that after rTMS my tinnitus changes.
       
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    6. jazz
      No Mood

      jazz Member Benefactor

      Location:
      US
      Tinnitus Since:
      8/2012
      Cause of Tinnitus:
      eardrum rupture from virus; barotrauma from ETD
      @michalCZ Yes, please keep us posted on your progress! There's lots of interest in these technologies on this board.
       
    7. Leo1994
      Suicidal

      Leo1994 Member

      Location:
      Sweden
      Tinnitus Since:
      2005
    8. daedalus

      daedalus Member

      Location:
      Brussels
      Tinnitus Since:
      04/2007
      Yes, toying with tDCS is dangerous. There are internet forums devoted to self experimentation with tDCS. I haven't looked but i wouldn't touch them with a large pole. Some guy went blind for two weeks after a tDCS experiment which went wrong.

      You could go to a physician with a few pubmed papers but honestly i doubt he or she would comply. ;)

      A quick pubmed search: http://www.ncbi.nlm.nih.gov/pubmed/?term=tdcs+tinnitus
       
    9. Hopeful
      Wishful

      Hopeful Member Benefactor

      Tinnitus Since:
      06/13
      From https://www.researchgate.net/public..._superficial_brain_stimulation?ev=contentfeed:

      ABSTRACT (...) Single sessions of rTMS over the temporal or temporoparietal cortex have been successful in transiently reducing tinnitus perception. Repeated sessions of rTMS have resulted in tinnitus relief in a subgroup of patients, lasting from several days to several months. However, effect sizes of rTMS in the treatment of tinnitus are only moderate, and interindividual variability is high. Larger and longer lasting effects have been observed with direct electrical stimulation of the auditory cortex via implanted epidural electrodes. Transcranial direct current stimulation (tDCS) has also shown potential for the treatment of tinnitus. Both auditory and frontal tDCS have shown tinnitus reduction in a subgroup of patients. In spite of the promising results of the different brain stimulation approaches, further research is needed before these techniques can be recommended for routine clinical use.
       
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    10. just1morething
      Benevolent

      just1morething Member Benefactor

      Location:
      U.S.
      Tinnitus Since:
      2008
      Cause of Tinnitus:
      barotrauma, noise exposure, TMJ, neck?
      @Jason White - Thanks for your research on Dr. Stubbeman and rTMS. Your straightforward honesty and candor are very much appreciated!
       
    11. DebInAustralia
      Fine

      DebInAustralia Member Benefactor Advocate

      Location:
      Geelong, Victoria
      Tinnitus Since:
      30/12/13
      Has anyone actually tried TMS for the treatment of somatic tinnitus?
       
    12. hermes

      hermes Member

      Location:
      Canada / Southeast Asia
      Tinnitus Since:
      1967/2001/2007/ 2011 / 2017
      Cause of Tinnitus:
      brain concussion/otitis media/head trauma/audio trauma X 2
      In January 2012 I participated in a research study at University of Singapore using transcranial magnetic stimulation. Zero positive effect for me during and after the 8 (?) treatments. And one negative one: it always put me in a bad mood after.
       
    13. jazz
      No Mood

      jazz Member Benefactor

      Location:
      US
      Tinnitus Since:
      8/2012
      Cause of Tinnitus:
      eardrum rupture from virus; barotrauma from ETD
      Researchers are currently still working on the correct protocols for the rTMS.

      In a few years, the treatment should become standardized. It does hold promise for many illness, including tinnitus. Right now, however, I would not try it, especially with chronic tinnitus. In general, chronic tinnitus has been more difficult to treat with rTMS. This may change in the future.

      A recent evidence-based review for rTMS rated the modality a C for tinnitus, meaning possibly effective.

      Clin Neurophysiol. 2014 Jun 5. pii: S1388-2457(14)00296-X. doi: 10.1016/j.clinph.2014.05.021. [Epub ahead of print]

      Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS)

      Abstract

      A group of European experts was commissioned to establish guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS) from evidence published up until March 2014, regarding pain, movement disorders, stroke, amyotrophic lateral sclerosis, multiple sclerosis, epilepsy, consciousness disorders, tinnitus, depression, anxiety disorders, obsessive-compulsive disorder, schizophrenia, craving/addiction, and conversion. Despite unavoidable inhomogeneities, there is a sufficient body of evidence to accept with level A (definite efficacy) the analgesic effect of high-frequency (HF) rTMS of the primary motor cortex (M1) contralateral to the pain and the antidepressant effect of HF-rTMS of the left dorsolateral prefrontal cortex (DLPFC). A Level B recommendation (probable efficacy) is proposed for the antidepressant effect of low-frequency (LF) rTMS of the right DLPFC, HF-rTMS of the left DLPFC for the negative symptoms of schizophrenia, and LF-rTMS of contralesional M1 in chronic motor stroke. The effects of rTMS in a number of indications reach level C (possible efficacy), including LF-rTMS of the left temporoparietal cortex in tinnitus and auditory hallucinations. [emphasis added] It remains to determine how to optimize rTMS protocols and techniques to give them relevance in routine clinical practice. In addition, professionals carrying out rTMS protocols should undergo rigorous training to ensure the quality of the technical realization, guarantee the proper care of patients, and maximize the chances of success. Under these conditions, the therapeutic use of rTMS should be able to develop in the coming years.

      Copyright © 2014 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.​


      Reference:
       
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    14. Solate
      Worried

      Solate Member

      Tinnitus Since:
      11/2012
      Just wanted to add my experience with tDCS:

      After a couple of months of tinnitus (and it getting worse for no reason), I went to UZA (Antwerp, Belgium) where they ruled out a somatic cause for my tinnitus (had an MRI). I had an EEG, which suggested I had elevated brain-activity in a couple of areas (don't really remember which) of interest, so neuromodulation was an option.

      I did 8 sessions of tDCS (2x every week for 20 min.). I did not have any side-effects of the treatment, but also no positive effects on my tinnitus. It might have been a little unstable for a couple of weeks, but that settled down again.

      They did however gave me the feeling of being a guinea-pig: of the 8 sessions I did, I think I received the real treatment only 5 times. There were three times where the direct effects of Tdcs (tingling feeling at scalp and big red spot on the head where the electrode used to be afterwards) were not present and I did not feel any current running.

      So for anyone who wants to try: it didn't work for me, but I also had no negative effects afterwards either so no harm there. Just a waste of my time and money (like many so-called tinnitus-treatments..)
       
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    15. snow86
      Surrender

      snow86 Member Benefactor

      Location:
      Germany
      Tinnitus Since:
      2006 - Extreme T since 12/2013
      Cause of Tinnitus:
      see "information" on profile page. Crippled by extreme T
      I just did 10 day of rTMS with the guys of Tinnitus Research Initiative (2 weeks ago).

      Somebody here wrote that rTMS looks like the best treatment right now, with 0 side effects.

      That's simply wrong, I'm going to clear that up.

      I'm probably the first person with the most extreme tinnitus possible to do rTMS.
      Prior to rTMS I had about 8 different sounds in music volume + hyperacusis + occasional vibrating feeling in the head + severe hearing loss.
      Very deep frequency sounds, about 100 Hz. Like running washing machine, electric kettle bell, engine sounds, refrigerator humming etc. + high frequency sounds like 6 kHz... the usual EEEEEE sounds... Those are easy.

      It was/is an absolute nightmare everyday because the sounds are always changing and over the day they get louder and louder and more and more...It's nothing less than suicidal torture. Masking is impossible because deep sounds are not maskable. You hear it all the time. Your head is so full, you can't stay calm inside. It's like chronic pain or worse.

      NOW rTMS made everything worse, like 500% worse. I got additional deep frequency sounds, even deeper than 100 Hz. Everything intensified and got even louder after the first day of treatment. My head is vibrating more often. After waking up the sounds are already worse than the sounds I had weeks ago in the evening.
      I have about 10 sounds when I go to sleep. It's very difficult to fall asleep.

      I was told by the doctors that the tinnitus can get worse after TMS before it gets better.
      So basically what it does, it fries and overstimulates your brain areas (including auditory cortex) so the neurons or something will get agitated and make new connections after some weeks.
      They told me it can get better even after weeks, but since my tinnitus is progressively worsening I don't think that's the case here.

      So it's actually pretty logical that everything will get worse.
      I would not call this a therapy, it's more like an experiment of "let's overstimulate the brain and see what happens"
      Maybe sometimes it will help or bring some placebo effects or it will further crush you, like it did for me. Lottery.

      I still did this because I had nothing left to lose because I was already at a point of killing myself before TMS. That's how bad my tinnitus is and no drugs or therapies helped.

      Now rTMS was my (expensive) nail in the coffin. Wish I hadn´t tried this. I have no more illusions about therapies.

      I would not recommend this treatment because of the risk that the tinnitus can get worse.
      If you have a "normal" high frequency tinnitus and you're pretty new to it, stay away from rTMS. Normal tinnitus is very tolerable after some time. (I had it for more than 8 years, those high sounds).

      Probably one of my last posts, I hope some of the fellow extreme sufferers will see their way through this garbage and people who are new to normal tinnitus (without hearing loss) will realize that after some time they don't need hopes of Autifony to deal with tinnitus. Hell, what would I give for having a normal tinnitus back and a good hearing ability.
       
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    16. Martin69
      Artistic

      Martin69 Member Benefactor

      Location:
      Germany
      Tinnitus Since:
      10/2013
      Cause of Tinnitus:
      (Health) Anxiety
    17. Aaron123

      Aaron123 Member

      Tinnitus Since:
      00/0000
      Cause of Tinnitus:
      Irrelevant
      snow,

      I am very sorry to hear about your experience. Which TRI clinic did you go to? Do you know anything about the protocol that they used?
       
    18. bjks82

      bjks82 Member

      Tinnitus Since:
      01/2015
      Has anyone else seen this paper that was published in August? Randomized, double-blind trial of rTMS with ~50% of the treatment group showing improvement. Unfortunately I dont have access to the full paper (if anyone else does and is able to forward it to me it would be appreciated).

      Repetitive Transcranial Magnetic Stimulation Treatment for Chronic Tinnitus

      Importance Chronic tinnitus negatively affects the quality of life for millions of people. This clinical trial assesses a potential treatment for tinnitus.

      Objectives To determine if repetitive transcranial magnetic stimulation (rTMS) can reduce the perception or severity of tinnitus and to test the hypothesis that rTMS will result in a statistically significantly greater percentage of responders to treatment in an active rTMS group compared with a placebo rTMS group.

      Design, Setting, and Participants A randomized, participant and clinician or observer–blinded, placebo-controlled clinical trial of rTMS involving individuals who experience chronic tinnitus. Follow-up assessments were conducted at 1, 2, 4, 13, and 26 weeks after the last treatment session. The trial was conducted between April 2011 and December 2014 at Portland Veterans Affairs Medical Center among 348 individuals with chronic tinnitus who were initially screened for participation. Of those, 92 provided informed consent and underwent more detailed assessments. Seventy individuals met criteria for inclusion and were randomized to receive active or placebo rTMS. Sixty-four participants (51 men and 13 women, with a mean [SD] age of 60.6 [8.9] years) were included in the data analyses. No participants withdrew because of adverse effects of rTMS.

      Interventions Participants received 2000 pulses per session of active or placebo rTMS at a rate of 1-Hz rTMS daily on 10 consecutive workdays.

      Main Outcomes and Measures The Tinnitus Functional Index (TFI) was the main study outcome. Our hypothesis was tested by comparing baseline and posttreatment TFIs for each participant and group.

      Results Overall, 18 of 32 participants (56%) in the active rTMS group and 7 of 32 participants (22%) in the placebo rTMS group were responders to rTMS treatment. The difference in the percentage of responders to treatment in each group was statistically significant (χ21 = 7.94, P < .005).

      Conclusions and Relevance Application of 1-Hz rTMS daily for 10 consecutive workdays resulted in a statistically significantly greater percentage of responders to treatment in the active rTMS group compared with the placebo rTMS group. Improvements in tinnitus severity experienced by responders were sustained during the 26-week follow-up period. Before this procedure can be implemented clinically, larger studies should be conducted to refine treatment protocols.
       
    19. Leon909
      Ape-like

      Leon909 Member

      Tinnitus Since:
      09/2015
      The university of Regensburg in Germany is doing a clinical trial using tRNS and I think another one using rTMS. In case you are a resident in Germany, it's pretty easy to sign up for it. They do a ca. 40-minute session 10x in a row for two weeks.

      When I called them they said that the treatment helps about 40% of the patients. According to this "head-to-head" study tRNS can reduce t by ca. 20-40%.

      The theory behind this type of treatment, to my understanding, is that it increases bain plasticity. It makes you think and learn faster.
       
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    20. Leon909
      Ape-like

      Leon909 Member

      Tinnitus Since:
      09/2015
      Yesterday I spent an hour talking to a doctor at the clinic in Regensburg, Germany. Here's a summary of what he said:

      - Ca. 40% of the patients get an improvement. The other 60% experience zero changes.
      - The scale of the improvement is roughly 20%-40%.
      - Treatment takes 2 weeks (10 days), 1 hour per day. However, they recommend doing the treatment for 4 weeks in a row.
      - Apparently some patients come back after 3-5 years, when the effects wear off.
      - It can take a couple of weeks until the effects take shape.
      - The treatment is free for German citizens, covered by health insurance.
      - They're been treating >3,000 patients in the past couple of years.
      - They were not able to find any predicting factors that could predict for which type of t the treatments works better or worse.

      My general impression:
      I've never talked to any other doctor who's had even closely as much knowledge about treatments, research and off-label treatments for t.

      I forgot to ask about adverse effects or patients where the t has become worse. I'm gonna call them next week and ask about it.

      Additional info: apparently they treat some patients where the t is related to issues in the cervical spine off-label with cyclobenzaprine, a muscle relaxant. They even sometimes inject botox into the masticatory muscles to relieve t for patients that grind their teeth.

      He also mentioned that some studies suggested that t doesn't suddenly become chronic after 3 or 6 months. Apparently there was a study where the brains of people with t were analysed after 1 year and 5 years and there were a lot of changes in the brain (I'm paraphrasing here).

      I asked him about tRNS. His response: they offer it as well, but they don't have that much experience with it. Hence, his recommendation was to go with rTMS first.
       
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    21. linearb
      Psychedelic

      linearb Member Benefactor Hall of Fame

      Location:
      temporarily banished from this plane of existence.
      Tinnitus Since:
      1999
      Cause of Tinnitus:
      karma
      I talked to Dr. Stubbeman's clinic at one point at was quoted $40,000 for a course of treatment. Plus the cost of being in LA for 2-3 months if you don't already live there ;)
       
    22. Champ
      Woot

      Champ Member Benefactor

      Location:
      Boston, MA
      Tinnitus Since:
      01/2013
      Cause of Tinnitus:
      Acoustic trauma from headphones
      My cousin's girlfriend, who is a Harvard PhD neuroscientist working on brain disorders, vouched for this treatment for tinnitus. She said the clinical trials they are involved with show real improvement in over 30% of patients.

      Apparently I'm going to be informed when a new trial is up. She told me it takes weeks and a session everyday. Seems like a small price to pay for some relief.
       
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    23. SilverSpiral
      Sad

      SilverSpiral Member

      Tinnitus Since:
      2016
      Cause of Tinnitus:
      ACOUSTIC TRAUMA
      40k at ~30% success rate kind of does seem like more than a small price to pay for some relief. Depends on your income I guess.

      If the harvard trials are free or lower cost than obviously it's much more worthwhile, even for the data it provides the researchers.
       
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    24. linearb
      Psychedelic

      linearb Member Benefactor Hall of Fame

      Location:
      temporarily banished from this plane of existence.
      Tinnitus Since:
      1999
      Cause of Tinnitus:
      karma
      It's one of those things where the price tag is what makes me skeptical. If this is something that really works, we'll figure that out in the next 5-10 years, and then insurance will pay for some of it. Stubbeman is a luxury doctor for the ultra-rich or desperate. Given that I'm only comfortably middle class, it doesn't seem like a useful thing for me to consider right now.

      I spoke with a couple different local TMS practitioners in the Virginia area after the TMS/tinnitus research from the VA was published last spring; ultimately, neither of them were very enthusiastic about that study. So, "more data needed" is where I sit on TMS right now.

      Also -- if there are protocols which can work, or work for some people, it would be naive to assume that we can't potentially be harmed. There is at least one poster here (is it you, @snow86?) who reported significant worsening in T as a result of TMS.
       
    25. Champ
      Woot

      Champ Member Benefactor

      Location:
      Boston, MA
      Tinnitus Since:
      01/2013
      Cause of Tinnitus:
      Acoustic trauma from headphones
      Hey gang.

      I talked to my cousin's girlfriend a bit more today. She's been really awesome trying to help me find a clinical trial to get enrolled in. I was talking to her more about rTMS (since she's a supervisor at a major lab that does neuroscience research) and she actually had some incredibly insightful information for me.

      The 30-40% number you hear is real. However, the FDA requires a consistent > 40% improvement in the sample population for a treatment to be qualified for mass consumption, and no researchers could modify their treatment protocols well enough to get that number up high enough. While this was going on, rTMS was showing great promise for treating depression, and many labs dropped tinnitus to focus on improving depression symptoms. This all occurred starting back in the late '90s.

      Now, here we are, in a society where earbuds/concerts/sports events are giving people tinnitus left and right. Many tinnitus researchers are looking into other ways solving it (hearing restoration via gene therapy, pharmaceuticals, implants) with much fewer research being put into rTMS treatment for tinnitus. It has a lot of promise, but not enough researchers are looking into it nowadays to get the protocol to where it needs to be for it to be a treatment for mass consumption.

      Just wanted to give you all an update :)
       
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    26. Pleasure_Paulie

      Pleasure_Paulie Member

      Location:
      Australia
      Tinnitus Since:
      06/2016
      Cause of Tinnitus:
      Noise or maybe... unicorns!
      Thanks for the update @Champ I'm trying a few things such as CBT and a few more pharmaceuticals, but my Psychiatrist is willing to give rTMS a go with him as a last ditch.
       
    27. Dr. Jay Hobbs
      Studious

      Dr. Jay Hobbs Member Benefactor

      Location:
      central valley California
      Tinnitus Since:
      Blessed to not have...often
      Cause of Tinnitus:
      NA
      I was not familiar with this technique, but I did a little reading, and I'll share my initial analysis.

      One 2013 study (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3866637/)compared THREE transcranial electrical stimulation (tES) techniques:
      • transcranial direct current stimulation (tDCS),
      • transcranial alternating current stimulation (tACS) and
      • transcranial random noise stimulation (tRNS)
      The only one that had any statistically significant effect was tRNS.
      The average VAS for LOUDNESS went from 7.0 to 6.25
      The average VAS for DISTRESS went from 6.75 to 6.15​
      It was only one session, so it wasn't a study to see the full potential effect.

      A 2014 study (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4283418/) at the SAME Belgium clinic using (tACS) and (tRNS) for 8 sessions delivered over 4 weeks demonstrated:
      No statistical benefit from single or multiple sessions of tACS.
      A statistical benefit from single and multiple sessions of tRNS was demonstrated:
      Multiple sessions of tRNS -->
      • tinnitus loudness went from 7.20 to 5.70 a 21% improvement, and
      • tinnitus annoyance went from from 6.20 to 5.40, a 13% improvement.
      There was no long-term follow-up to see how well it stuck, but it does show a little promise.

      A different group did a study in 2017 (https://www.ncbi.nlm.nih.gov/pubmed/27761741) comparing tDCS and tDCS + tRNS, with multi-site treatment.
      Not surprisingly, after reading the studies above, they found that the group that included tRNS saw an added benefit over tDCS alone. I only read the abstract, so I don't know the results. I expect they were similar to the ones above.​
       
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    28. linearb
      Psychedelic

      linearb Member Benefactor Hall of Fame

      Location:
      temporarily banished from this plane of existence.
      Tinnitus Since:
      1999
      Cause of Tinnitus:
      karma
      @Dr. Jay Hobbs thanks for the insight, it's great to have an MD venturing into the broader forum here.

      I'm curious if you personally have tinnitus, or if your interest in it is just compassion/professional? No reason for asking other than simple curiosity.
       
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    29. Dr. Jay Hobbs
      Studious

      Dr. Jay Hobbs Member Benefactor

      Location:
      central valley California
      Tinnitus Since:
      Blessed to not have...often
      Cause of Tinnitus:
      NA
      I am blessed to NOT have tinnitus.

      Oh, just to be clear, I am a DC, DACNB, not a MD.

      Since 8th grade, I have felt compelled to help others restore their health and performance in a natural, holistic way. Of course, I didn't know the word "holistic" back then, but I knew that just doing ONE thing to address a problem that had THREE causes was not going to get the best results.

      I came to tinnitus SPECIFICALLY by way of chronic pain studies. As a chiropractic neurologist and nutritionist, pain was a more likely target for my efforts. I continued running across mentions of tinnitus in the chronic pain, especially phantom limb and Complex Regional pain, literature. I brushed it off for a couple years while I developed protocols for those conditions.

      After reaching a level of completion with those topics, I turned to investigate tinnitus. I found that there was some good work going on with auditory discrimination, but that the researchers eventually moved on to other topics, presumably because they had to follow the grant money. I thought, "This is doable, as a functional neurologist, I am uniquely equipped to add insight to this approach, and no one is really pursuing this aggressively." I ended up testing some theories in an online research project. I got some promising results, but I am convinced that we can do considerably better.

      ...That's my interest.
       
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    30. Paulmanlike

      Paulmanlike Member Hall of Fame

      Tinnitus Since:
      2008
      Cause of Tinnitus:
      Noise
      Dr Hobbs,

      I read that rTMS is still very much in a testing stage with mixed results, however, the researchers think that it's only a matter of time before they work out where to place it, how long, the dose for it to have its full effect? Is this true and do you think it soon Ben clinical practice for rTMS to be a standard treatment for tinnitus?
       
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