tms

Repetitive Transcranial Magnetic Stimulation

Repetitive Transcranial Magnetic Stimulation (rTMS) is a non-surgical brain stimulation method used to treat various mental and neurological conditions. Introduced in 1985, it gained FDA approval in 2008 for treating severe depression. rTMS uses electromagnetic pulses to activate brain nerve cells, and is often paired with cognitive behavioral therapy (CBT). It’s helpful for conditions like bipolar disorder, depression, OCD, epilepsy, migraines, and nicotine addiction, and is now being explored for tinnitus treatment. Conducted in a clinic, it’s a convenient option for patients. Magnets are crucial in rTMS, similar to their use in MRI machines for detecting cancer and injuries. These strong magnets in rTMS influence brain activity, showing promise in treating various conditions, including tinnitus.

During TMS Treatment

During TMS, patients sit comfortably as an electromagnetic coil is placed on their head, targeting specific brain areas. Jewelry and other metallic items must be removed to avoid interference. The process, known as rTMS, is non-invasive and doesn’t require anesthesia, often completed within 20 to 30 minutes. Patients may feel a tapping sensation and hear clicking noises, similar to an MRI machine, and are provided earplugs for comfort and hearing protection – it is important to note that failure to protect the ears during TMS can affect normal hearing and result in permanent hearing loss. To make the experience as easy as possible, the treatment intensity is adjusted based on the patient’s response.

After TMS Treatment

Post-TMS, patients can immediately resume normal activities and drive themselves home. However, some patients may experience temporary discomfort at the treatment site, headaches, lightheadedness, tingling, or facial muscle spasms. Following initial sessions, subsequent treatments are typically shorter, with the entire process spanning 6 weeks of daily stimulation. Maintenance treatments may be necessary after symptom recovery.

Who Can Benefit From TMS?

Transcranial Magnetic Stimulation (TMS) therapy is primarily for adults (18 and older) with mental health conditions like depression and OCD, especially those resistant to medications and other treatments. However, it’s not suitable for everyone. Patients with metal implants, such as bullet fragments in the head, or those with a history of seizures are typically ineligible. Cost is also a consideration, as TMS therapy can be expensive and insurance coverage is not guaranteed. Most insurance companies only cover TMS for Major Depressive Disorder, often after other treatments have been tried. The financial aspect can be a barrier for uninsured patients, limiting their access to this therapy. Despite these limitations, there are more affordable and effective alternatives available for treating these conditions.

Safety Features For TMS Treatment

One of the most important safety considerations for rTMS devices is how well they’re able to consistently deliver the pulses. The output should be consistent throughout treatment, and it’s very possible for component failure or drift to affect efficacy. Every TMS device must demonstrate its ability to indicate it’s functioning optimally. Since the same therapy is provided at every session, the device must be able to recreate the same conditions throughout the treatment process. The initial rTMS session is the longest, and patients aren’t expected to go through finding their motor threshold and coil placement every single session. The FDA deems recalling these presets an important safety feature for rTMS devices. rTMS devices should also have some type of features or components to prevent overheating. The risk of burns, though rare, is still a real possibility and should be disclosed to patients receiving TMS. Alarms should also be present to alert the treatment administrator of any problems with the device.

Types Of TMS

Before we explore how TMS can help with the treatment of tinnitus, we have to understand what the treatment entails. This will make connecting those complicated dots easier.  TMS treatments can take different approaches to treat specific conditions. This can involve using a different pulse pattern, or magnetic coils. rTMS is TMS that involves using repetitive pulses during treatment at low-frequency 1Hz (1 pulse/second) or high-frequency 5-10Hz (5-10 pulses/second). Theta-burst stimulation or TBS is an accelerated form of TMS. TBS uses triple bursts, emitting 15 pulses in a single second, with sessions lasting as little as 1 to 3 minutes. dTMS or Deep TMS uses H-shaped helmed coils to penetrate deeper into the brain. This makes it more effective at treating OCD and other conditions such as autism and PTSD.

rTMS Treatment For Tinnitus

For chronic tinnitus, patients often explore various treatments before finding relief. Repetitive Transcranial Magnetic Stimulation (rTMS) has emerged as a potential therapy, with its effectiveness still under study. This non-invasive method is being researched for its ability to reduce tinnitus severity. Patients considering rTMS can expect a thorough medical review, including lifestyle, family history, and any conditions like high blood pressure or mental illness that might relate to tinnitus. A physical exam focuses on identifying any external causes of tinnitus, examining the inner ear, head, and neck. The American Tinnitus Association recognizes rTMS as a promising treatment. It’s thought to work similarly to how it helps in depression, targeting brain areas linked to tinnitus perception like the primary auditory cortex, dorsomedial prefrontal cortex, and anterior cingulate cortex. These brain regions, along with the amygdala, anterior insula, and hippocampus, are associated with tinnitus-related symptoms like stress and sleep disturbances. Studies show mixed results, but some indicate that rTMS can decrease tinnitus severity. A significant aspect is the oscillatory activity in the auditory cortex and other brain regions. Increases in alpha power in the auditory cortex have been linked to reduced tinnitus severity, while decreases can intensify it. Research suggests that a series of 10 rTMS sessions might aid tinnitus management for up to four years. However, the effectiveness depends on the correct stimulation protocol, as incorrect application could worsen symptoms.

So Far, The Science Says:

Transcranial magnetic stimulation, or TMS can be used to treat many conditions. High-frequency rTMS targeting the left dorsolateral prefrontal cortex is the acceptable TMS treatment for depression. However, the TMS settings and protocols differ when dealing with chronic tinnitus. Administrators of repetitive transcranial magnetic stimulation must understand the importance of making the necessary adjustments on a case-by-case basis. Studies on rTMS treatment for tinnitus that show promise have some similarities, but there is a glaring difference in protocol parameters. This is what we know so far from the information collected from several randomized controlled studies:

- Frequency
Low frequency rTMS can reduce activity in the auditory cortex and other non-auditory areas related to tinnitus perception.
- Pulse rate
Overstimulating the auditory cortex during TMS therapy can have the opposite effect, increasing tinnitus loudness or intensity
- Treatment location
Most of these studies involve single-site therapy at the auditory cortex, however, two randomized controlled studies have investigated triple-site therapy. The studies that treated the temporoparietal junction (TPJ) showed no clinical efficacy. Single-site therapy that targeted the auditory cortex (AC) and posterior superior temporal gyrus (STG) shows potential in reducing tinnitus loudness.
There is no significant difference when triple-site therapy is used. Dual-site therapy of the left dorsolateral prefrontal cortex (DLPFC) and left temporal cortex (TC) is more effective than single-site DLPFC therapy. In one placebo controlled study, bilateral DMPFC stimulation had made a significant difference in the lives of patients with chronic tinnitus.
- Baseline and outcome measures
Tinnitus questionnaires are useful tools for establishing clinical efficacy, as they’re used to measure tinnitus perception, severity, impact, and its characteristics. Two of the most commonly used questionnaires are the Tinnitus Functional Index (TFI) and the Tinnitus Handicap Inventory (THI).
PET and MRI imagining are useful tools for highlighting the metabolic and functional changes of repetitive transcranial magnetic stimulation treatment. Electroencephalography (EEG) is useful for observing differences in VAS scores and brain wave frequencies.

The majority of clinical trials we’ve studied say repetitive transcranial magnetic stimulation rTMS has the potential to be worthwhile for the treatment of tinnitus. Stimulating the auditory cortex and other non-auditory parts of the brain may be just the thing. The current obstacle is the standardization of rTMS treatment for tinnitus. Further clinical trials should establish protocol for chronic tinnitus treatment and open the doors for futuristic treatments.

Is TMS For Tinnitus Safe?

The safety and efficacy of Transcranial Magnetic Stimulation (TMS) for tinnitus are still under FDA review, with over two decades of studies and clinical trials. Despite its potential, there are unresolved issues and concerns regarding the treatment’s application. One major factor is the type or brand of the TMS system. Effective treatment relies on specific characteristics of the magnetic fields, including size, penetration, and shape. Accurate coil placement, current direction, and coil type are crucial for successful treatment outcomes. Another area of debate is the stimulation parameters. While the standard frequency for rTMS is 1Hz, higher frequencies may be more effective for tinnitus. Continuous theta burst stimulation (cTBS) is being explored, but its efficacy remains uncertain. Determining the correct stimulation intensity is critical. This involves establishing the patient’s resting motor threshold (rMT), a process not uniformly addressed in existing studies, leading to uncertainty in treatment protocols. Large-scale, multi-site studies are needed to fully understand rTMS’s safety and effectiveness in treating tinnitus. These studies would help answer important questions about how factors like tinnitus duration, cause, patient age, and age-related hearing loss impact treatment outcomes, as well as determining the best measures for evaluating treatment success.

(Source : TrebleHealth)

People with tinnitus - a ringing or other "phantom" sounds in their ears - may benefit from a treatment that sends electromagnetic pulses into the brain, suggests a new study.

Transcranial magnetic simulation (TMS) is not currently available for the average person with tinnitus, but the study's lead author hopes it will someday be used along with existing therapies like hearing aids and symptom management strategies.

"I don’t see TMS replacing all that, but I see it as another option for helping some patients," said Robert Folmer of Portland Veterans Affairs Medical Center and Oregon Health and Science University.
"Tinnitus is more likely to occur in people with hearing loss or people who had a lot of noise exposure," he said. "So it’s usually associated with damage to the auditory system."

For the treatment, electric current running through a coil placed on the scalp generates a magnetic field that affects nearby brain cells.

"It’s the magnetic field that penetrates the scalp and skull and interacts with brain tissue," Folmer told Reuters Health. The therapy is already approved in the U.S. for treatment of depression, he added.
Past studies have found that people with tinnitus have increased neural activity in regions of the brain associated with hearing even when there is no sound, Folmer said.

"When we deliver one pulse per second of TMS, that low rate of TMS stimulation can suppress neural activity in that region," he said.

For the new study of 64 people with significant ringing in their ears, the researchers randomly assigned half the participants to receive 2,000 TMS pulses during sessions over 10 consecutive business days. The other half of the participants received sham TMS. The sessions lasted approximately 35 minutes each.

The participants then periodically filled out questionnaires about the severity of their tinnitus over the next six months.

Overall, 56 percent of participants receiving TMS improved by the end of the 10 sessions, compared to 22 percent of the participants who received sham TMS.

"Some people responded quite well," Folmer said. "We were surprised they maintained their improvement throughout the six months of follow-up. I thought if people showed an improvement it would be short-lived."

By the end of the six months, 66 percent of the TMS group had improved, compared to 38 percent of the sham group.

None of the participants dropped out of the trial because of side effects, but Folmer said sometimes TMS can cause jaw movement or eye twitching. In those cases, he said the intensity of the pulses is turned down.

While people who responded to the treatment typically sustained their improvements over the six months, larger studies are needed before TMS is offered to people with tinnitus, the researchers write in JAMA Otolaryngology-Head and Neck Surgery.

In a previous study, Dr. Jay Piccirillo from the Washington University School of Medicine in St. Louis found that TMS did not help tinnitus, but he told Reuters Health that the difference in results between the two studies may be due to differences in the groups studied.

For example, the participants in his study were younger, had more severe tinnitus and had very low depression scores.

"There is probably some effect," said Piccirillo, who wasn't involved in the new study. "We just don’t know in whom and what place to stimulate and how much."

Folmer said it's difficult to say how much a TMS session for tinnitus would cost, because it's not approved to treat that condition.

"For people with tinnitus, they should try the management strategies that are available now," he advised.

(Source : Reuters)

In the largest US clinical trial of its kind funded by the Veterans Affairs (VA) Rehabilitation Research and Development Service, the VA Portland Medical Center and Oregon Health & Science University (OHSU) report that researchers have found that transcranial magnetic stimulation (TMS) significantly improved tinnitus symptoms for more than half of study participants. Their findings were published in an article in the July 16 online edition of the journal JAMA Otolaryngology – Head & Neck Surgery.

“For some study participants, this was the first time in years that they experienced any relief in symptoms,” said Robert L. Folmer, PhD, research investigator with the National Center for Rehabilitative Auditory Research at the VA Portland Health Care System, and associate professor of Otolarynology – Head and Neck Surgery in the OHSU School of Medicine. “These promising results bring us closer to developing a long-sought treatment for this condition that affects an enormous number of Americans, including many men and women who have served in our armed forces.”

According to the announcement from OHSU, tinnitus (ringing, buzzing, or hissing in the ears) affects nearly 45 million Americans, and the distraction can impair people’s ability to sleep or concentrate. Statistics from the Centers for Disease Control and Prevention show that nearly 15% of Americans experience some degree of tinnitus. Currently, there are no proven treatments available, so patients with the condition often develop coping strategies to manage their reaction to tinnitus. Military veterans are at greater risk of developing the condition, and tinnitus is the most prevalent service connected disability in the VA health system. Study participants were a mix of veterans and non-veterans.

“We applaud the work of Dr Folmer and his colleagues,” said Melanie West, chair of the American Tinnitus Association’s Board of Directors. “The results of the joint National Center for Rehabilitative Auditory Research/OHSU study are promising for tinnitus patients everywhere. “We are committed to finding solutions for tinnitus and excited to see the progression of TMS clinical trials producing positive results for some patients.”

For the research, Folmer and colleagues reportedly used a TMS system that generates a cone-shaped magnetic field that penetrates the participant’s scalp and skull to interact with brain tissue. The higher the stimulation intensity, the deeper the magnetic field can penetrate and affect neural activity. Currently, the Food and Drug Administration has approved transcranial magnetic stimulation only for treatment of depression.

All 64 participants enrolled in the tinnitus study received one pulse of TMS per second to their skull just above the ear to target the auditory cortex in the brain. The researchers had participants undergo TMS sessions on 10 consecutive workdays, during which they received 2,000 pulses of TMS. Of the 32 participants who received the “active” TMS treatment, 18 people found their tinnitus symptoms were alleviated for at least six months. To participate in the study, patients were required to have had tinnitus for at least a year or more. A significant number of participants who had tinnitus for more than 20 years reported receiving some relief from TMS treatment.

Dr Folmer hopes to conduct a larger clinical trial to refine protocols for the eventual clinical use of TMS for tinnitus.

(Source : TheHearingReview)