Tinnitus retraining therapy

Tinnitus retraining therapy (TRT) is a form of habituation therapy designed to help people who suffer from tinnitus, a ringing, buzzing, hissing, or other sound in the ears when no external sound is present. Two key components of TRT directly follow from the neurophysiological model of tinnitus. One of these principles includes directive counseling aimed at reclassification of tinnitus to a category of neutral signals, while the other includes sound therapy[1] which is aimed at weakening tinnitus related neuronal activity.[2]

The goal of TRT is management of tinnitus; there is no evidence that TRT can attenuate or eliminate tinnitus. The efficacy of TRT in reducing the distress of tinnitus has not been established.

An alternative to TRT is tinnitus masking, the use of noise, music or other environmental sounds to obscure or mask the tinnitus. Hearing aids can provide a partial masking effect for the condition.[3] Results from a review of tinnitus retraining therapy trials indicate that it may be a more effective treatment than tinnitus masking.[4]

Applicability

Not everyone who experiences tinnitus is significantly bothered by it. However, some of the problems caused by tinnitus include annoyance, anxiety, panic, and loss of sleep and/or concentration.[2] The distress of tinnitus is strongly associated with various psychological factors; loudness, duration and other characteristics of the tinnitus are secondary.

TRT may offer real although moderate improvement in tinnitus suffering for adults with moderate-to-severe tinnitus, in the absence of hyperacusis, significant hearing loss and/or depression.[5] Not everyone is a good candidate for TRT. Factors associated with suitability for TRT and predisposing for favorable outcome are: lower loudness of tinnitus, higher pitch of tinnitus, shorter duration of tinnitus since onset, recognition of tinnitus attenuation by sound generator, lower hearing thresholds (i.e. better hearing), high Tinnitus Handicap Inventory (THI) score,[6] and positive attitude toward therapy.[7]

Other secondary hearing symptoms

Despite the fact that there haven't been any recent studies which concluded in its optimal treatment, tinnitus retraining therapy has been applied to treating hyperacusis, misophonia, and phonophobia.[2]

Limitations

There is no evidence that TRT or any other treatment can eliminate or decrease tinnitus. Tinnitus is a symptom, not a disease. As such, the optimal treatment strategy should be directed toward eliminating the disease, rather than simply alleviating the symptom. More than half of people with tinnitus have a comorbid psychological injury or illness (e.g., post-traumatic stress disorder, depression, anxiety, obsessive compulsive disorder, stress, dysfunction of the temporomandibular joint, etc.) that can exacerbate the tinnitus.

Cause

Physiological basis

It has been proposed that tinnitus is caused by mechanisms that generate abnormal neural activity, specifically one mechanism called discordant damage (dysfunction) of outer and inner hair cells of the cochlea.[2]

Psychological model

See also: Neuroplasticity

The psychological basis for TRT stems from the fact that the brain exhibits a high level of plasticity. In turn, this allows it to adjust to any sensory signals as long as they do not lead to negative effects. TRT is imputed to work by interfering with the neural activity causing the tinnitus at its source, in order to prevent it from spreading to other nervous systems such as the limbic and autonomic nervous systems.[2]

Methodologies

Classification

Clients are classified into 5 categories. These categories are numbered 0 to 4, and based on whether or not the patient has tinnitus with hearing loss, tinnitus with no hearing loss, tinnitus with hearing loss and hyperacusis, and tinnitus with hearing loss and hyperacusis for an extended amount of time.

Counseling

Further information: Cognitive behavior therapy

The first component of TRT, directive counseling, may change the way tinnitus is perceived. The patient is taught the basic knowledge about the auditory system and its function, the mechanism of tinnitus generation and the annoyance associated with tinnitus. The repetition of these points in the follow-up visits helps the patient to perceive the signal as a non-danger.

Sound therapy

Further information: Neurologic music therapy

The basis of sound therapy discovered over a century ago, is a psychological phenomenon known as residual inhibition: the tendency of a loud enough sound of the right pitch to damp out or inhibit the annoying ringing of tinnitus.[8] However, the phenomenon is of very short duration, seconds to a few minutes, in rare cases longer. Nor is residual inhibition progressive or cumulative: repeated application of the stimulus doesn't result in greater degree or longer duration of suppression of tinnitus. However, more modern research has found that different kinds of noise, frequency ranges, or patterns of sound may result in greater or lesser degree or duration of suppression.[9]

The psycho-physiological tenet of sound therapy is that habituation occurs as a result of the brain perceiving the tinnitus just above the threshold of the masking sound. Thus the masking sound level is set at what is called the 'mixing masking level (MML)' just below the perceived level of the tinnitus, resulting in only partial masking. However, at least one study has invalidated this tenet, finding that complete masking is just as effective as partial masking. The masker is usually worn for 8 hours a day for 6 months or longer.

The sound used in therapy is generally from a specialized sound generator, either worn on or over the ear, or on the table. The type of sound is either broadband white noise or tailored background music. The use of a portable music player as a control instrument in TRT has produced successful results in recent analysis, offering patients a more cost-efficient treatment.[10]

Efficacy

Measuring the efficacy of TRT is beset by confounding factors: tinnitus reporting is entirely subjective therefore not reliable; tinnitus or at least subjects' perception of it varies over time and repeated evaluations are not consistent. Researchers have noted that there is a large placebo component to tinnitus management. In many commercial TRT practices, there is a large proportion of dropouts; reported 'success' ratios may not take these subjects into account.

There are few available studies, but most show that tinnitus naturally declines over time (years) in a large proportion of subjects surveyed, without any treatment. The annoyance of tinnitus also tends to decline over time. In at least some, tinnitus spontaneously disappears.[1]

A Cochrane review found only one sufficiently rigorous study of TRT and noted that while the study suggested benefit in the treatment of tinnitus, the study quality was not good enough to draw firm conclusions.[11] A separate Cochrane review of sound therapy (though they called it masking), an integral part of TRT, found no convincing evidence of the efficacy of sound therapy in the treatment of tinnitus.[12]

A summary in The Lancet concluded that in the only decent study, TRT was more effective than masking; in another study in which TRT was used as a control methodology, TRT showed a small benefit. A study which compared cognitive behavior therapy (CBT) in combination with the counselling part of TRT versus standard care (ENT, audiologist, maskers, hearing aid) found that the specialized care had a positive effect on quality of life as well as specific tinnitus metrics.[13]

Clinical practice

Tinnitus activities treatment (TAT) is a clinical adaptation of TRT that focuses on four areas: thoughts and emotions, hearing and communication, sleep, and concentration.[14]

Progressive tinnitus management (PTM) is a 5-step structured clinical protocol for management of tinnitus which may include tinnitus retraining therapy. The five steps are: 1) triage - determining appropriate referral, i.e. audiology, ENT, emergency medical intervention, or mental health evaluation; 2) audiologic evaluation of hearing loss, tinnitus, hyperacusis and other symptoms; 3) group education about causes and management of tinnitus; 4) interdisciplinary evaluation of tinnitus; 5) individual management of tinnitus.[15] The U.S. Department of Veterans Affairs (VA) now employs PTM to help patients self-manage their tinnitus.[16]

Research

Alternatives

Cognitive behavior therapy

Cognitive behavior therapy (CBT), the counselling part of TRT, as a generalized type of psychological and behavioral counselling, has also been used by itself in the management of tinnitus.[20]

Hearing aids

If tinnitus is associated with hearing loss, a tuned hearing aid that amplifies sound in the frequency range of the hearing loss (usually the high frequencies) may effectively mask tinnitus by raising the level of environmental sound, in addition to the benefit of restoring hearing.

Masking

See also: Tinnitus masker

White noise generators or environmental music may be used to provide a background noise level that is of sufficient amplitude that it wholly or partially 'masks' the tinnitus (tinnitus masker). Composite hearing aids that combine amplification and white noise generation are also available.

Other

Numerous other non-TRT methods have been suggested for the treatment or management of tinnitus.

See also

References

  1. 1 2 Tinnitus Retraining Therapy Implementing the Neurophysiological Model, Jastreboff, P.J. and Hazell, J.W.P. (2004). Cambridge University Press, Cambridge
  2. 1 2 3 4 5 Jastreboff, P.J. (2007). "Tinnitus retraining therapy". Progress in Brain Research. 166: 415–423. doi:10.1016/s0079-6123(07)66040-3. ISSN 0079-6123. Retrieved 23 March 2013.
  3. ↑ Tyler et.al., R.S. (2012). "Tinnitus Retraining Therapy: Mixingpoint and Masking are Equally Effective.". Ear and Hearing. 33 (5): 588–594. doi:10.1097/aud.0b013e31824f2a6e.
  4. ↑ Phillips, John S; Don McFerran (2010). "Tinnitus Retraining Therapy (TRT) for tinnitus". Cochrane Database of Systematic Reviews (3). doi:10.1002/14651858.CD007330.pub2.
  5. ↑ Bauer, et.al., CA (2011). "Effect of Tinnitus Retraining Therapy on the Loudness and Annoyance of Tinnitus: A Controlled Trial.". Ear & Hearing. 32 (2): 145–55. doi:10.1097/aud.0b013e3181f5374f.
  6. ↑ Newman, et.al, CW (1996). "Development of the Tinnitus Handicap Inventory". Arch Otolaryngol. 122 (2): 143–148. doi:10.1001/archotol.1996.01890140029007.
  7. ↑ Ariizumi, Y (2010). "Clinical prognostic factors for tinnitus retraining therapy with a sound generator in tinnitus patients". J Med Dent Sci. 57: 45–53.
  8. ↑ Spalding, J.A. (1903). "Tinnitus, with a plea for its more accurate musical notation.". Archives of Otology. 32 (4): 263–272.
  9. ↑ Reavis, et.al, KM (2012). "Temporary Suppression of Tinnitus by Modulated Sounds". J Assoc Res Otolaryngol. 13 (4): 561–571. doi:10.1007/s10162-012-0331-6.
  10. ↑ Fukuda S, Miyashita T, Inamoto R, Mori N. (2011) "Tinnitus retraining therapy using portable music players". Auris Nasus Larynx, Volume 38, Issue 6, 692-696.
  11. ↑ Phillips, JS (2010). "Tinnitus Retraining Therapy (TRT) for tinnitus". Cochrane Review.
  12. ↑ Hobson, J (2012). "Sound therapy (masking) in the management of tinnitus in adults". Cochrane Review.
  13. ↑ Baguley, D (2013). "Tinnitus". The Lancet. 382 (9904): 1600–07. doi:10.1016/S0140-6736(13)60142-7.
  14. ↑ Tyler, et.al., RS (2007). "Tinnitus activities treatment". Prog Brain Res. 166: 425–34. doi:10.1016/S0079-6123(07)66041-5. PMID 17956807.
  15. ↑ Henry, et.al., J (2008). "Using Therapeutic Sound With Progressive Audiologic Tinnitus Management". Trends Amplif. 12 (3): 188–209. doi:10.1177/1084713808321184. PMC 4134892Freely accessible.
  16. ↑ Henry, et.al., J. "VA Clinical Practice Recommendations for Tinnitus" (PDF). National Center for Rehabilitative Auditory Research (NCRAR).
  17. ↑ Reavis, et.al., KM (2010). "Patterned sound therapy for the treatment of tinnitus. Hear Jour. 2010;60(11):21-24". Hear jour. 60 (11): 21–24.
  18. ↑ Ridder, et.al., DD (2004). "Magnetic and electrical stimulation of the auditory cortex for intractable tinnitus". J Neurosurg (100).
  19. ↑ Henning, et.al., S (2010). "Customized notched music training reduces tinnitus loudness". Commun Integr Biol. 3 (3): 274–277. PMC 2918775Freely accessible. PMID 20714412.
  20. ↑ Hyung, et.al., JJ (2013). "Cognitive Behavioral Therapy for Tinnitus: Evidence and Efficacy". Korean J Audiol. 17 (3): 101–104. doi:10.7874/kja.2013.17.3.101.
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