Transcranial Stimulation Treatments (rTMS & tDCS & tACS)

It's supposed to reduce tinnitus distress, not loudness.

 

I completely forgot about the webinar! @Autumnly, do you happen to have a link to the webinar? Can't find it anywhere. If not, I hope they will put the video on the website.

Interestingly, I had a discussion with Dr. Jacquemin a week ago about the tDCS programme and she told me that she works closely with Dr. Shekhawat, who did a successful study in HD-tDCS intervention (decrease in loudness, link: https://link.springer.com/article/10.1007/s00702-017-1808-6). So I assume she would also be informed about the probable benefit that tDCS intervention could entail when it concerns tinnitus loudness, not only tinnitus annoyance.

 

I only know about the link I posted above, I'm not sure if they're going to upload the webinar. Yes, she mentioned that other researchers saw a reduction in tinnitus loudness in tDCS trials.

 

Why are we not so postive about these studies? I mean this study shows a lot of promise (see link, below)? Or do I miss something?

This study was the first attempt to optimize the settings of tDCS for DLPFC stimulation to modulate tinnitus, especially to optimize the number of sessions needed for tinnitus suppression. TDCS of DLPFC resulted in a significant reduction of tinnitus loudness.


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5974180/

 

I tried it. No change.

 

An up to date overview:

Non-Invasive Neuromodulation for Tinnitus

Tinnitus is a prevalent disorder that has no cure currently. Within the last two decades, neuroscientific research has facilitated a better understanding of the pathophysiological mechanisms that underlie the generation and maintenance of tinnitus, and the brain and nerves have been identified as potential targets for its treatment using non-invasive brain stimulation methods. This article reviews studies on tinnitus patients using transcranial magnetic stimulation, transcranial electrical stimulation, such as transcranial direct current stimulation, alternating current stimulation, transcranial random noise stimulation as well as transcutaneous vagus nerve stimulation and bimodal combined auditory and somatosensory stimulation. Although none of these approaches has demonstrated effects that would justify its use in routine treatment, the studies have provided important insights into tinnitus pathophysiology. Moreover bimodal stimulation, which has only been developed recently, has shown promising results in pilot trials and is a candidate for further development into a valuable treatment procedure.

Full article: https://www.ejao.org/journal/view.php?number=734

 

A Systematic Review and Meta-analysis of Randomized Controlled Trials on the Effect of Transcranial Magnetic Stimulation on Tinnitus Management
Salma Galal, Naema Ismail, Ghada Niel

Abstract

Introduction: Tinnitus occurs in 10-15% of the world’s population. It may lead to hearing loss, depression, and suicidal tendencies, as well as reduced quality of life. The aim of this study was to assess whether Transcranial Magnetic Stimulation (TMS) effectively reduces tinnitus handicapping after six months or more of follow-up.

Methods: A systematic review of randomized controlled trials with follow-up of six months was undertaken. The review took place through searching Medline, Science Direct, and Google Scholar databases using the keywords “tinnitus” and “Transcranial Magnetic Stimulation” and limiting the search results to randomized controlled trials (RCTs) conducted on adults (19 years and older) published between 2005-2015. Meta-analysis was performed on the similarly designed studies.

Results: Five RCTs with six month follow-up were found conforming to the inclusion criteria. In total, there were 119 patients in the TMS arms and 115 in the placebo arms. However, designs were different between the studies and were therefore not all comparable. Different parameters were used to measure the severity of tinnitus and depression scores. Tinnitus handicapped inventory (THI) was the common measured outcome parameter used in all studies. THI score decreased after the TMS in four studies. Meta-analysis was performed on three similarly designed RCTs with the overall effect being insignificant.

Conclusion: TMS reduced the THI score and decreased the severity of tinnitus in 45% of patients and lead to a complete recovery in 32% of cases in one study. However, the meta-analysis demonstrated lack of significant effect of TMS on tinnitus management.

Full article: http://cajgh.pitt.edu/ojs/index.php/cajgh/article/view/356

 

Dorsomedial Prefrontal Cortex Repetitive Transcranial Magnetic Stimulation for Tinnitus
Promising Results of a Blinded, Randomized, Sham-Controlled Study

Objectives:
Tinnitus is the perception of sound in ears or head without corresponding external stimulus. Despite the great amount of literature concerning tinnitus treatment, there are still no evidence-based established treatments for curing or for effectively reducing tinnitus intensity. Sham-controlled studies revealed beneficial effects using repetitive transcranial magnetic stimulation (rTMS). Still, results show moderate, temporary improvement and high individual variability. Subcallosal area (ventral and dorsomedial prefrontal and anterior cingulate cortices) has been implicated in tinnitus pathophysiology. Our objective is to evaluate the use of bilateral, high frequency, dorsomedial prefrontal cortex (DMPFC) rTMS in treatment of chronic subjective tinnitus.

Design:
Randomized placebo-controlled, single-blinded clinical trial. Twenty sessions of bilateral, 10 Hz rTMS at 120% of resting motor threshold of extensor hallucis longus were applied over the DMPFC. Fourteen patients underwent sham rTMS and 15 were submitted to active stimulation. Tinnitus Handicap Inventory (THI), visual analog scale, and tinnitus loudness matching were obtained at baseline and on follow-up visits. The impact of intervention on outcome measures was evaluated using mixed-effects restricted maximum likelihood regression model for longitudinal data.

Results:
A difference of 11.53 points in the THI score was found, favoring the intervention group (p = 0.05). The difference for tinnitus loudness matching was of 4.46 dB also favoring the intervention group (p = 0.09).

Conclusions:
Tinnitus treatment with high frequency, bilateral, DMPFC rTMS was effective in reducing tinnitus severity measured by THI and matched tinnitus loudness when compared to sham stimulation.

Source: https://journals.lww.com/ear-hearin...edial_Prefrontal_Cortex_Repetitive.98636.aspx

 

I wonder what their criteria for "chronic" tinnitus is?

 

Association of Central Noninvasive Brain Stimulation Interventions With Efficacy and Safety in Tinnitus Management: A Meta-analysis

Question Which noninvasive brain stimulation treatment was associated with the best efficacy and acceptability in tinnitus management?

Findings In this meta-analysis of 32 unique studies including 1458 unique participants, the cathodal transcranial direct current stimulation over the left dorsolateral prefrontal cortex combined with transcranial random noise stimulation over the bilateral auditory cortex was associated with the greatest improvement in both tinnitus severity and quality of life. Continuous theta-burst stimulation over both auditory cortices ranked more favorably than that over the left auditory cortex only.

Meaning Regarding the efficacy and acceptability for tinnitus treatment, these findings suggest that the cathodal transcranial direct current stimulation over the left dorsolateral prefrontal cortex combined with transcranial random noise stimulation over the bilateral auditory cortex is preferable.

Abstract
Importance Tinnitus has a prevalence of 10% to 25% and is frequently associated with numerous complications, such as neuropsychiatric disease. Traditional treatments have failed to meet the needs of patients with tinnitus. Noninvasive brain stimulation (NIBS) can focally modify cortical functioning and has been proposed as a strategy for reducing tinnitus severity. However, the results have been inconclusive.

Objective To evaluate the association between different central NIBS therapies and efficacy and acceptability for treatment of tinnitus.

Data Sources ClinicalKey, Cochrane CENTRAL, Embase, ProQuest, PubMed, ScienceDirect, and Web of Science databases were searched from inception to August 4, 2019. No language restriction was applied. Manual searches were performed for potentially eligible articles selected from the reference lists of review articles and pairwise meta-analyses.

Study Selection Randomized clinical trials (RCTs) examining the central NIBS method used in patients with unilateral or bilateral tinnitus were included in the current network meta-analysis. The central NIBS method was compared with sham, waiting list, or active controls. Studies that were not clinical trials or RCTs and did not report the outcome of interest were excluded.

Data Extraction and Synthesis Two authors independently screened the studies, extracted the relevant information, and evaluated the risk of bias in the included studies. In cases of discrepancy, a third author became involved. If manuscript data were not available, the corresponding authors or coauthors were approached to obtain the original data. This network meta-analysis was based on the frequentist model.

Main Outcomes and Measures The primary outcome was change in the severity of tinnitus. Secondary outcomes were changes in quality of life and the response rate related to the NIBS method in patients with tinnitus.

Results Overall, 32 unique RCTs were included with 1458 unique participants (mean female proportion, 34.4% [range, 0%-81.2%]; mean age, 49.6 [range, 40.0-62.8] years; median age, 49.8 [interquartile range, 48.1-52.4] years). The results of the network meta-analysis revealed that cathodal transcranial direct current stimulation over the left dorsolateral prefrontal cortex combined with transcranial random noise stimulation over the bilateral auditory cortex was associated with the greatest improvement in tinnitus severity (standardized mean difference [SMD], –1.89; 95% CI, –3.00 to –0.78) and quality of life (SMD, –1.24; 95% CI, –2.02 to –0.45) compared with the controls. Improvement in tinnitus severity ranked more favorably for continuous theta-burst stimulation (cTBS) over both auditory cortices (SMD, −0.79; 95% CI = −1.57 to −0.01) than cTBS over only the left auditory cortex (SMD, −0.30; 95% CI, −0.87 to 0.28), compared with controls. Repetitive transcranial magnetic stimulation with priming had a superior beneficial association with tinnitus severity compared with the strategies without priming. None of the investigated NIBS types had a significantly different dropout rate compared with that of the control group.

Conclusions and Relevance This network meta-analysis suggests a potential role of NIBS interventions in tinnitus management. Future large-scale RCTs focusing on longer follow-up and different priming procedure NIBS are warranted to confirm these findings.

Source: https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2767836

 

Question: What is the placebo?

Transcranial direct current stimulation improves tinnitus perception and modulates cortical electrical activity in patients with tinnitus: A randomized clinical trial

Objectives
This study aims to determine whether transcranial direct current stimulation (tDCS): a) is effective in the treatment of tinnitus by decreasing its annoyance and severity; b) modulates the cortical electrical activity of such individuals.

Methods
A double-blind, placebo-controlled clinical trial was conducted with 24 patients with tinnitus, randomized into two groups: Group 1 (n = 12) received anodal tDCS over the left temporoparietal area (LTA) and cathodal tDCS over the right dorsolateral prefrontal cortex (DLPFC) and Group 2 (n = 12) received placebo intervention. Tinnitus perception using a visual analog scale (VAS) and the Tinnitus Handicap Inventory (THI) questionnaire, in addition to electroencephalogram (EEG) was measured with eyes opened and closed at baseline and after the intervention. For the treatment, patients were subjected to five consecutive sessions of tDCS with the anodal electrode over the LTA and cathodal electrode over the right DLPFC (7 × 5 cm, 2 mA for 20 min). tDCS was turned off after 30 s in the sham group.

Results
Active tDCS significantly improved tinnitus annoyance and severity. It was associated with decreased beta and theta EEG frequency bands with eyes opened and decreased alpha frequency with eyes closed. sLORETA identified changes in frequency bands in the frontal, temporoparietal, and limbic regions. Finally, there were negative correlations between baseline EEG frequency bands and tDCS-induced change in tinnitus annoyance and severity.

Conclusions
These results demonstrate that tDCS modulates the EEG activity and alleviates tinnitus perception. This effect may be related to baseline EEG activity.

Source: https://www.sciencedirect.com/science/article/abs/pii/S0987705320300769

 

Is there any good tDCS device available for purchase already? I've come across a couple while googling tDCS, but I don't know if they actually do anything or if you need to find a hospital that provides this kind of brain stimulation.

 

There is Brai3n in Belgium where they have been doing this for a long time. I'm not sure about portable versions.

EDIT: Interested in portable devices, but I only found some tDCS devices for depression and it's dangerous, as those are configured to excite neurons rather than calming them down. It's similar to rTMS: if you do sessions that have been configured for depression you may end up worsening tinnitus. I haven't found portable tDCS devices on sale for tinnitus specifically. Also, one should have a qEEG to configure the treatment, that's what they do in Belgium.

Found this: https://flowneuroscience.com/home/. One can rent the device in the UK. I'm going to email them to see if they have versions configured for tinnitus but without a EEG I'm skeptical, it reminds me of the Parasym which I tried and was a fiasco.

EDIT 2: Emailed them, but found this in the handbook:
Possible Adverse Reactions
[...] Discontinue treatment if you experience tinnitus (noise or ringing in the ears) during or after using the device.

This is not encouraging but could be due to the fact that this is stimulant, as it is configured for depression.

 

Can you keep us updated if they reply to you regarding tinnitus?

 

Will do if my brain keeps on working, the tinnitus is horrid.

In the meantime, as in my last edit above, I checked the manual that is available online and it says

"Possible Adverse Reactions
[...] Discontinue treatment if you experience tinnitus (noise or ringing in the ears) during or after using the device."

This is not encouraging but could be due to the fact that this is stimulant, as it is configured for depression.

Anyway I'll let you know. I had planned to go to Ghent and get a qEEG plus tDCS (or rTMS according to their recommendations) but then the whole COVID-19 nightmare started.

 

They are aware of the research on tinnitus but their device cannot be re-configured at the moment. It cannot be used, as is, for tinnitus because it could worsen it.

Unfortunately it looks like the only way to try tDCS is Brai3n in Ghent, Belgium, which poses a lot of logistical problems, especially under COVID-19.

 

Thanks for letting me know. I guess the answer will be the same for all the other available portable devices out there.

It seems complicated to go to Belgium right now, but I believe it won't be an issue as soon as they let go of the travel restrictions.

In which country do you live?

 

I'm in the UK. I was thinking of traveling to Ghent by train (Eurostar to Brussels is slightly more than 2h plus local train) and then stay in an AirBnb for 1 month. I hope I'll have the strength to try this.

Could you go to Belgium? Where do you live?

 

I could, I live in France, but that would take me more time than it would take you haha

 

Dual-site rTMS is More Effective than Single-site rTMS in Tinnitus Patients: A Blinded Randomized Controlled Trial

Repetitive transcranial magnetic stimulation (rTMS) has been proposed as an alternative option for treating tinnitus. rTMS is a noninvasive method in which repetitive magnetic stimulation is applied to the cortex; it is considered a therapeutic strategy that modulates the loudness of tinnitus. In this study, we performed a double-blind randomized clinical trial to compare the outcome of tinnitus treatment among (1) dual-site (auditory + prefrontal) rTMS stimulation, (2) auditory cortex only rTMS stimulation (AC), and (3) sham stimulation. The left primary auditory cortex and left dorsolateral prefrontal cortex (DLPFC) were targeted independently of handedness or tinnitus laterality. Dual-site and auditory only groups were treated with a total of 12,000 pulses, 2000 pulses over the AC and 1000 pulses over the DLPFC (group 1), 3000 pulses over the AC only (group 2), and daily for 4 consecutive days. Dual-site group exhibited a significantly better ΔTinnitus Handicap Inventory (ΔTHI) score at 4, 8 weeks and 12 weeks after rTMS treatments compared with pre-treatment. However, there was no effect in the auditory only group. Also, there was no effect in sham group when THI scores were compared with that of the pre-treatment. These results are in line with the former studies that reported a better treatment effect by multiple site rTMS.

Source:
https://link.springer.com/article/10.1007/s10548-020-00797-y

 

Thought I'd tag on to this convo.

I've been to UZA for a tinnitus checkup (and frankly to get a 3rd opinion).
Immediately after my consultation they advised me to get on the waiting list for the neurostimulation device (as mentioned here before) by Laure Jacquemin.

There is a HUGE waiting list so I don't even have a date yet and it is 6 sessions.

Obviously I emailed Dr Jacquemin with some obvious questions like:

1) Since she has been treating a lot of people since the initial publication of her doctorate study (117 subjects mentioned and 1/3rd of them got a significant reduction) how have these numbers evolved?

2) Are there known cases that have been treated where the patient got out WORSE than they got in?

3) How does this device differ from Lenire and the pathways that it talks to to try and cure this thing?

4) Do you already have a pattern in people that are helped with this neuromodulation? Is it also helpful for people with acoustic trauma as a cause etc?


Today I got an email back from the hospital to let me know that Dr Jacquemin is not allowed to talk to me over email for privacy concerns. They immediately and correctly proposed a date for a consult with the doctor to ask all my questions.

Can't imagine why anyone would just get in there and have current put into their brain without at least asking the very basic questions I noted.

If anyone has any other questions that you want answered, tag me and let me know. I have the appointment on the 6th of January at 11am.

 

Ey @Ben Winders, please let us know! I do hope you're one of the lucky few who can get a fix with a tDCS stimulation.

I have been to Antwerp two months ago for an appointment at UZA, though I had to stop partaking in this study temporally given the current COVID-19 situation in Belgium.

I also talked to Dr. Laure Jacquemin and she seems like someone who is really on top of her game given her vast knowledge of current tinnitus research. Anyway, if I recall it correctly, I remember that Dr. Jacquemin told me that out of 120 +/- peeps there was just one person who had a worsening, which may be more related to stress than to her own study.

Could you ask her if she's aware of Susan Shore's bimodal study and in particular if she's considering combining DCN stimulation + sound stimulation (Dr. Shore's study) with HD-tDCS?

 

I already asked this in my initial email to her (which remained unanswered for reasons of the aforementioned privacy issues.)

To be honest - it would astound me that she is not aware of Susan Shore.
I cannot - for the life of me - figure out why NONE of the so called specialists I was referred to have heard of FX-322... I mean just google "tinnitus meds in the pipeline" ONCE and you at least have the notion.

These are the doctors that see X number of new tinnitus patients daily and they don't even know about research that could potentially give at least some portion of their patients some glimmer of hope.

 

Little update here:

I also made an appointment at Brai3n - they do qEEG and then, based on their assessment, therapy with either/or:

NFB (Neurofeedback)
TES (Transcranial Electrical Stimulation)
TMS (Transcranial Magnetic Stimulation)
Lenire

That appointment is on January 7h - appointment at UZA is at January 6th.

I will keep everyone up to date.

 

@Ben Winders

Yes please, keep us updated.

I exchanged emails with people at "Brai3n" clinic in Belgium too.

My main questions were about Lenire. I asked them how the process worked with the clinic and how much it cost.

At this time, I was not sure yet if I should go with Lenire.

And I saw that the Brai3n offered different treatments as well, tDCS, TMS etc...

So I asked them if it would be a good option to go there, do a full panel of tests, and then, based on the qEEG result, decide what would be the best treatment option for my particular case.

They answered me that it would be very hard to tell me what would be the best option. So I would have to choose first (before visiting the clinic) what I wanted to do.

That last answer left me a bit in doubt despite the fact that I know Lenire is new and of course nothing is 100% guaranteed to work. I was expecting a little bit of help from them to make my decision.

Thus I am wondering if they answered you differently?
Because when reading your post, it seems like you have the choice to go there, do a qEEG and then choose your therapy? Is that right?

Looking forward to your feedback.

Cheers.

 

The University of California, Los Angeles (UCLA) has a TMS clinic and advertises treatment for tinnitus. I inquired about whether they noted a certain tinnitus subtype that responded to treatment better. I got the following response from them:

"Studies have not found clear and consistent predictors of who is most likely to benefit from tinnitus treatment. One study has shown that better results were associated with younger age, male gender, shorter duration of tinnitus, a central location of tinnitus in the head, normal hearing, and no sleep disturbance. It seems like pitch differences in tinnitus and the presence of accompanying symptoms or underlying medical conditions do not seem to predict response or lack of response.

Another study suggested that people with more severe tinnitus and who also had TMJ complaints were more likely to benefit.

Per the clinical impression of one of our attending physicians, people who are more distressed, upset, and distracted by their tinnitus tend to respond better than people who are not particularly upset by it. Overall, it is estimated that after about 10 treatments, approximately 25% of patients get benefit from the treatment, with a good result being a 30-50% decrease in how bothersome tinnitus is."​

I associate TMJ with being able to somatically modulate your tinnitus so it's interesting that they're similar to the best responders for Lenire and Susan Shore's device.

I do have hearing loss and can't modulate my tinnitus and even with that, a 25% chance at improvement seems pretty slim for how much it'll cost to do 10 treatments.

 

How much does it cost for 10 treatments?

 

They didn't provide an actual number but TMS is only FDA approved for treating depression. Therefore, insurance won't cover TMS for tinnitus so I'd have to pay out of pocket.

 

So far I only got the introductory email (the one where they attach PDFs with all the possible treatments).

Email is as follows (loose translation):

"We start with an intake consult and a qEEG.
A qEEG is a kind of test that measures your brain activity and that is being compared to other men of your age group.

On the basis of your story and the qEEG we will look at which types of neuromodulation would be able to be applied.​

(Keep in mind that neuromodulation is not being covered by your health insurance)"

 

No problem. I'm pretty sure it's expensive, but I'm going to call and find out. My other concern is the loudness. When I was at a neurologist's office that offered TMS, I remember hearing a treatment session in progress. It's not quiet. Maybe not MRI loudness but enough that I would ask about using hearing protection.