Functional MRI Neurofeedback Outperforms CBT for Reducing Tinnitus Distress

[Adaś]

FYI, I just came across this one. This is some great progress, even if it took years (2017-2021). Of course if you read what Neurofeedback is, and if I got it right, it still relies on individual adjusting her/his response to tinnitus distress, so it is some improved CBT with visual feedback performed inside of an MRI (pretty loud) device. I still need to get access to the full article to read through the details. I hope that an fMRI may provide some way also to measure tinnitus objectively.

→ Functional MRI Neurofeedback Outperforms Cognitive Behavioral Therapy for Reducing Tinnitus Distress: A Prospective Randomized Clinical Trial

Abstract
Patients with severe chronic tinnitus who underwent real-time functional MRI neurofeedback therapy showed reduced tinnitus burden 6 months after intervention compared with patients who received group cognitive behavioral therapy.

Background
Cognitive behavioral therapy (CBT) is the current standard treatment for chronic severe tinnitus; however, preliminary evidence suggests that real-time functional MRI (fMRI) neurofeedback therapy may be more effective.

Purpose
To compare the efficacy of real-time fMRI neurofeedback against CBT for reducing chronic tinnitus distress.

Materials and Methods
In this prospective controlled trial, participants with chronic severe tinnitus were randomized from December 2017 to December 2021 to receive either CBT (CBT group) for 10 weekly group sessions or real-time fMRI neurofeedback (fMRI group) individually during 15 weekly sessions. Change in the Tinnitus Handicap Inventory (THI) score (range, 0–100) from baseline to 6 or 12 months was assessed. Secondary outcomes included four quality-of-life questionnaires (Beck Depression Inventory, Pittsburgh Sleep Quality Index, State-Trait Anxiety Inventory, and World Health Organization Disability Assessment Schedule). Questionnaire scores between treatment groups and between time points were assessed using repeated measures analysis of variance and the nonparametric Wilcoxon signed rank test.

Results
The fMRI group included 21 participants (mean age, 49 years ± 11.4 [SD]; 16 male participants) and the CBT group included 22 participants (mean age, 53.6 years ± 8.8; 16 male participants). The fMRI group showed a greater reduction in THI scores compared with the CBT group at both 6 months (mean score change, −28.21 points ± 18.66 vs −12.09 points ± 18.86; P = .005) and 12 months (mean score change, −30 points ± 25.44 vs −4 points ± 17.2; P = .01). Compared with baseline, the fMRI group showed improved sleep (mean score, 8.62 points ± 4.59 vs 7.25 points ± 3.61; P = .006) and trait anxiety (mean score, 44 points ± 11.5 vs 39.84 points ± 10.5; P = .02) at 1 month and improved depression (mean score, 13.71 points ± 9.27 vs 6.53 points ± 5.17; P = .01) and general functioning (mean score, 24.91 points ± 17.05 vs 13.06 points ± 10.1; P = .01) at 6 months. No difference in these metrics over time was observed for the CBT group (P value range, .14 to >.99).

Conclusion
Real-time fMRI neurofeedback therapy led to a greater reduction in tinnitus distress than the current standard treatment of CBT.

 

[annV]

I still need to get access to the full article to read through the details.

Here's the full article.

 

[IYIiKe]

It will be a hard sell since the cost will be prohibitive, in my opinion. Insurers will just laugh at us.

 

[AfroSnowman]

It will be a hard sell since the cost will be prohibitive, in my opinion. Insurers will just laugh at us.

I don't think insurance in the US approves any tinnitus treatment at the moment. So they always laugh at us.

How much does this cost? I looked online and couldn't find anywhere that it is publicly available, much less pricing.

 

[IYIiKe]

How much does this cost? I looked online and couldn't find anywhere that it is publicly available, much less pricing.

Probably $500-600 USD for the fMRI only, plus any other ancillary BS fees per treatment.

 

[Jammer]

Probably $500-600 USD for the fMRI only, plus any other ancillary BS fees per treatment.

Probably more like $2000+.

 

[EDDTEKK]

There was a study on classic Neurofeedback in Marburg (Germany) for tinnitus with many participants in 2019. I talked after the study to the responsible person - Cornelia Weise (Psychologist).

She said that it did, unfortunately, absolutely nothing in regards to tinnitus or distress, etc.

It's useless. It seemed to be hyped some years ago. Even with fMRI, don't expect any positive results. This paper is bullshit.

I personally had around 60 classic Neurofeedback sessions in 2017 aligned to my EEG results - it did nothing for my condition.

Forget this approach.

 

[Adaś]

Forget this approach.

I don't think there ever was expectation that fMRI + Neurofeedback would be any good solution anyway. MRI is loud and expensive. I think the point was that there's something that can be done at all and objectively measure tinnitus and its changes (improvements?), and later be used to conduct research on more robust treatment techniques.

See here:

To mark the #TinnitusAwarenessWeek at Neurosoft Bioelectronics, we are proud to highlight our hard work towards the development of a minimally invasive soft brain interface aimed at reducing tinnitus. By leveraging insights from recent #fMRI research and accumulating knowledge from invasive electrical stimulation in the past 20 years, we aim to bring novel precise individual #neuromodulation strategies one step closer to reality!

I know the pace of the tinnitus research is (extremely) disappointing, but at least there is some motion and a will to invest in building some proper treatments, and these fMRI measurements are evidence for potential investors that some solution is even possible, producing incentive to invest more money, expecting possible returns. Before, there was hardly any good evidence anything could be done, except all these CBT folks producing numerous articles trying to prove it works, but IMHO, just conjuring the reality to keep the business running. But nothing is simple in this world.

Fortunately, we have Tinnitus Talk and the folks behind it on our side.

 

[Jammer]

I don't think there ever was expectation that fMRI + Neurofeedback would be any good solution anyway. MRI is loud and expensive.

I've had an fMRI and it was noiseless; didn't hear a thing.

 

[mrpetrov]

The paper alludes to silent fMRI being available towards the end.

I expect this treatment has legs. Anecdotally, I am able to semi-influence my tinnitus through mental exercises, so it feels intuitively correct to me that with fMRI some people (not all) could "learn" how to adjust the auditory precept and dampen their tinnitus.

 

[Stayinghopeful]

I've had an fMRI and it was noiseless; didn't hear a thing.

Doesn't the "f" stand for "fucking quiet"?

 

[IYIiKe]

Doesn't the "f" stand for "fucking quiet"?

I think it's "f$%^&^$yourwallet"

 

[Adaś]

I've had an fMRI and it was noiseless; didn't hear a thing.

Was it noiseless with or without hearing protection?

The paper alludes to silent fMRI being available towards the end.

It depends on the definition of "silent." I can read in some places that "Looping Star is a near-silent, multi-echo, 3D functional magnetic resonance imaging (fMRI) technique. It reduces acoustic noise by at least 25dBA, with respect to gradient-recalled echo echo-planar imaging (GRE-EPI)-based fMRI."

The question is, what was the previous acoustic noise level? If I assume 105 dB for GRE (I can find such number in some papers), we have 80 dBA after "reduction," which is not even close to silent. Maybe it is silent with earplugs and pads.

 

[Jammer]

Was it noiseless with or without hearing protection?

It depends on the definition of "silent." I can read in some places that "Looping Star is a near-silent, multi-echo, 3D functional magnetic resonance imaging (fMRI) technique. It reduces acoustic noise by at least 25dBA, with respect to gradient-recalled echo echo-planar imaging (GRE-EPI)-based fMRI."

The question is, what was the previous acoustic noise level? If I assume 105 dB for GRE (I can find such number in some papers), we have 80 dBA after "reduction," which is not even close to silent. Maybe it is silent with earplugs and pads.

I didn't need any hearing protection. Note that the machine looked more like a CT scanner than a traditional MRI.

 

[Adaś]

I didn't need any hearing protection. Note that the machine looked more like a CT scanner than a traditional MRI.

Do you happen to remember the brand? GE or Siemens? Was it regular or research protocol?

If indeed ZTE and/or Looping Star are becoming the gold standard, then yeah, it seems silent fMRI is possible. I found a fresh article that summarizes the state of silent MRI well and have some good references to prior art:

Zero Acoustic Noise with Zero TE MRI

Unlike common magnetic resonance imaging (MRI) acquisitions and due to extremely soft gradient switching, zero echo time (ZTE) acquisitions are intrinsically silent. In this chapter, this unique acoustic characteristic of ZTE is elaborated in detail. It is shown that ZTE-based sequences, in combination with acoustic noise reduction techniques applied to conventional sequences, enable complete quiet examinations, which is a big step forward in overall patient comfort, examination of hyperacusis patients, and research studies sensitive to acoustic noise.

I think it would be nice to learn if there's any reason to fall back to loud protocols. I found an older article stating that silent protocols may produce under-sampling artifacts, but maybe this is solved by now.

Model-based reconstruction for looping-star MRI

Looping star is a silent MRI pulse sequence that can be used for quantitative susceptibility mapping (QSM), T2*-weighted imaging and fMRI. However, the sparse radial sampling of looping-star limits its spatial and temporal resolution in fMRI studies. This work proposes a customized looping-star fMRI protocol and a spatial temporal reconstruction method that removes the undersampling artifact from the repeating sampling pattern and improves the temporal resolution and quality of the time course and activation map.

 

[momus]

I would be hesitant to put my faith in a machine that is so loud it could give someone tinnitus w/o proper ear safety protection.

 

[rei]

What doesn't outperform CBT?