TINNITUS REHABILITATION (TRT)
TINNITUS REHABILITATION (TRT)
Tinnitus Retraining Therapy
John Philips and Don McFerran
Published in 2010.
A single, low-quality RCT suggests that TRT is much more effective as a treatment for patients with tinnitus than tinnitus masking.
Repetitive Transcranial Magnetic Stimulation for Tinnitus
There is very limited support for low-freq rTmS for tinnitus treatment. rTMS seems to be a safe treatment for tinnitus short-term however insufficient data to provide support for safety of this treatment in the long-term.
More prospective, randomised, placebo-controlled, double-blind studies with larger sample sizes are needed.
Transcranial Magnetic Stimuation for treatment of epilepsy
Adverse effects were uncommon among studies and involved headache, dizziness, and tinnitus. No sig changes in medication use was found in the trials.
Conlusions: there is evidence that rTMS is safe and is not associated with any adverse effects, but given the variability in technique and outcome reporting that prevented menta-analysis.
Hyperbaric Oxygen therapy for Idiopathic sudden SNHL
No evidence of beneficial effect of HBOT for chronic ISSHL
Antidepressants for Tinnitus
Insufficient evidence to suggest that antidepressants improve tinnitus
Anticonvulsants for Tinnitus
No evidence that anticonvulsants help
Amplification with Hearing Aids for Tinnitus & co-existing Hearing Loss
Limited evidence. No evidence to support or refute HA use. (2014)
Ginkgo Biloba for Tinnitus
Limited evidence (2013)
The Jastreboff Neurophysiological Model.....
*Devised by Professort P. Jastreboff in the 1980s.
First proposed in 1990 by Dr J. Hazell & Prof P Jastreboff
Works on the principal that areas of the brain outside the auditory system influence the severity of tinnitus.
Our auditory system is highly sophisticated and is designed to detect sounds of special importance.
These can be extremely weak signals that are hidden amongst numerous stronger signals.
The auditory system therefore has to furiously suppress and filter out meaningless signals and simultaneously enhance important ones.
The Limbic System
Comprises of >> The Amygdala (Emotional Centre), Hippocampus (formation of new memories and past experiences), thalamus, hypothalamus, basal ganglia and cingulate gyrus.
Songs you like
Songs you dislike
Banging noises in the night
Favourite sports team
Sirens in the distance
Your own breathing
Living near a main road
living under a flight path
Our footsteps when walking
All the other conversations in a restaurant
What other Neuro model does this remind us of?
Social, cultural, economic, and historical factors create social roles >>
Social roles are assigned to groups >>
Group members perform role appropriate behaviours >>
Through correspondence bias, role associated behaviours are attributed to personality characteristics. >>
Stereotypes of groups are formed.
(Smith and Mackie, 2000)
Source (Cochlea or Brainstem) & Body (Autonomic Nervous System ANS) >>
Detection (Subcortical) >> & <<
& Emotional Associations (Limbic System) >> Perception & Evaluation (Auditory & other cortical areas)
occurs from the auditory periphery > It is new and needs to be "labelled".
occurs for new/ meaningful sounds in the auditory cortex. If Tinnitus is unimportant then > Auditory filters detune it at a subconscious level - Heller and Bergman.
If Tinnitus is classified as -ve or +ve this leads to activation of the limbic system and the ANS.
occurs if a threat is perceived....and then the filters tune to the signal and a conditioned aversive response is set up.
Vicious cycle enhances the perception and distress due to the tinnitus despite no change in the original generation.
A new sound includes a pattern of activity in the auditory pathways.
Detection will occur if the sound is 'important'
Perception occurs in the higher cognitive centres.
Sounds are classified as having Neutral, Positive or Negative meaning.
For +ve or -ve sounds the limbic system and ANS are activated.
For a neutral sound these are not activated.
If the sound illicits a mild limbic and ANS response then repeated exposure to the sound will lead to HABITUATION.
Then: Heller and Bergman (1953)
80 subjects with normal hearing and no tinnitus
Placed in a sound-proof booth for 5 minutes.
Asked to report "any sounds they might hear"
94% reported a buzzing, pulsing and whistling etc.
Conclusion: Almost everyone can perceive tinnitus in the right conditions.
: Normal neural activity. "Individual nerve fibres in the auditory nervous system discharge spontaneously 50 to 100 times each second (Henry et al., 2007)
: A change in hearing or emotional state causes auditory filters to widen and tune into the tinnitus so we conscious perceive it.
Perception & Evaluation
: The tinnitus signal reaches the auditory cortex where we perceive it for the first time and classify it. New and unclassified sounds are prioritized and are always passed on to the auditory cortex for evaluation. >>>
: The limbic system (responsible for emotions) labels the tinnitus with a negative emotion.
Body: The Sympathetic Division of the Autonomic Nervous
System (ANS) prepares the body for the fight-or-flight response when exposed to the threatening situation:
-Increased adrenaline release
-Increased heart rate.
-Digestive system inhibition
Stress Levels can be indicated by the body's state of arousal, and there can be a biological vulnerability and particular events of conditions can trigger the expression, early definitions link it to the "fight" or "flight" mechanisms. Stress can be thought of as an automatic response, but can have 4 types of effects:
Physiological stress can cause prolonged production of adrenalin, from longstanding sympathetic activation, but also increased cortisol levels, both which can resut in physiological harm - particularly in the areas of the heart, the kidneys and the immune system.
Limbic System and ANS Involvement:
Negative emotional and bodily reactions cause tinnitus to be classified as important & a threatening signal >> therefore an aversive conditioned response is produced.
Subconscious filters widen and enhance the tinnitus signal so it appears louder and may be heard above other sounds.
Greater awareness of tinnitus can cause an increase in the activation of the limbic and ANS, further enhancing the tinnitus, resulting in a vicious cycle.
1 more item...
"The prevalence of frequent tinnitus is highest among older adults, non-Hispanic whites, former smokers, and adults with hypertension, hearing impairment, loud noise exposure, or generalised anxiety disorder"
Tinnitus and its risk factors
Beaver Dam Offspring Study of 3267 participants, aged 21-84, The prevalence of tinnius was 10.6%. And factors associated with having tinnitus: hearing impairment, currenty having a loud job, history of head injury, depressive symptoms, history of ear infection, history of target shooting, arthritis and se of NSAID medications
What do we do?
What do we ask?
How do we ask it?
Who do we include?
Consider Possible Causes:
: To enrich the auditory system and in turn to reduce the tinnitus signal strength by reducing the contrast between the tinnitus and environmental noise.
: Results in increased auditory gain and heightened tinnitus awareness.
Avoid situations where the hearing system has nothing to do
Reduce the contrast between tinnitus and the outside sounds
Reprogramme the central gain "volume control"
Environmental sound is preferred
Environmental Sound Enrichment
-Open a window
-Under pillow speaker
-Fountains and fans
-Tapes and bedside maskers
-What appeals to the patient?
White Noise Generators
Concept of sound that follows you rather like tinnitus.
Preferably BTE on an open mould.
Maybe use ITE
....consider use of a Walkman or MP3 Player or other like Apps?
The Models of Stages of Change
Ethical & Spiritual
Pupil sees no problem but others disapprove
Weighing up the pros and cons of changing
To carry on as before or to change >> (Might EXIT)
Putting the decision into practice
Actively maintaining change
Return to previous behaviour
Unconscious classical conditioning paradigm
Passive extinction of association
Stage 1: Decrease the magnitude of the negative reinforcement
Stage 2: Sound therapy
Emergent evidence of efficacy
Sounds have positive, neutral or negative meanings....educational counselling provides the backdrop - but has the patient actually heard what you have been saying? ..Sound therapy enriches the auditory system. It suppresses the tinnitus signal by decreasing the contrast to the environment. Leading to more neutral reactions.therefore the patient can gain greater control..is that enough?
Tinnitus is very common in the general population and is associated with gender, smoking, stress, sleep, hearing loss, hyperlipidemia, osteoarthritis, rheumatoid arthritis, asthma, depression and thyroid disease history (2015)
*Environment -Setting up the room (avoid physical obstacles!)
Preparation- Know your patient history
Time boundaries - explain the parameters
Introductions - Reinforce links with previous encounters, explain yourself, check their details, find out / explain / agree expectations of the appointment (Williams, 2002)
Exclusive vs Incusive setting up of the room...can be semi-inclusive too (either clinician-controlled, or patient-controlled). The clinician can control the screen access of the patient may be able to see the screen.
Advice on how to manage Tinnitus:
From HearingLink (online, 2016) the basics:
Learn to relax
Protect your hearing but avoid overuse of earplugs.
But: What if that is not enough?
The severity of tinnitus is important but it is mainly the IMPACT of tinnitus on an individual's life:
-Lack of understanding?
What do these feelings described remind you of?
Aims & Objectives
To develop an understanding of:
-Tinnitus definitions and current understanding
-Tinnitus Retraining Therapy (TRT) - The Jastreboff Neurophysiological Model of Tinnitus Perception & Distress.
-TRT in practice.
Interventions for Tinnitus in Adults
An Overview of Ongoing Systematic Reviews
Tinnitus retraining therapy (TRT) (neurophysiological mode-based treatment)
Sound therapy (masking)
Amplification with hearing aids
Electrical stimulation of the ochlea
Cochlear implants (intra-cochlear electrical stimulation)
External electrical stimulation
Repetititive Transcranial Magnetic Stimulation
Cognitive Behavioural Therapy (CBT)
Mindfulness: Mindfulness meditation is a process of purposefully paying attention to what is happening at the present moment without being distracted by associations attached to those thoughts or sensations. Sensations, ideas or feelings that come to mind are not judged or repressed, but are observed in a detached manner (Sadlier, 2007)
Low-level laser therapy
Calcium channel blockers
AIM: To promote understanding of the true mechanisms behind tinnitus and why it becomes distressing >> To facilitate reclassification of the tinnitus signal and the habituation process.
Components of Educational Counselling:
Anatomy & Physiology of Auditory System
Explain normal functioning and the condition of the patient's auditory system
Tinnitus source and why it is now being heard
Pattern recognition - enhancement and suppression of sounds (patient examples from their lifestyle / living area -i.e. suburb etc)
Auditory Nervous System (fight-or-flight)
The Vicious Cycle
Tailored to patient's problems e.g. sleep, concentration etc
The habituation process
BIOPSYCHOSOCIAL MODEL (WHO-ICF)
Disease >>> Impairments >>> External and Internal Biological & Physical Factors >>> Activity Limitations >>> Participation Restrictions >>> Quality of Life "Wellness" >>> (Contextual Factors) = (Personality, Mental State, Positiveness, Sense of Coherence, Communication Partners etc).
Delivering your content
Choose your words carefully
Be fluent and make it clear
Use words to structure your presentation
Consider impact words
Pace your delivery (especially for unexpected or important news)
Support what you say....with handouts and non-verbal communication.
& Deal with Questions: do not ignore them- however: clarify/speak to the room, keep responses brief and relate back to the topic in hand! (Williams, 2002)
CREATING A HELPING RELATIONSHIP
Carl Rogers defines this as a trustworthy, dependable, positive attitudes demonstrated, with appropriate boundaries to the relationship which provided in a secure atmosphere, and an empathetic and non-judgemental clinician (Rogers, 2004)
At a minimum, troublesome tinnitus is present in about 1% of the population.
There are currently 4 research studies recruiting in the UK:
-Internet based versus face to face clinical care for tinnitus
-Manualisaion and feasibility study of audiologist delivered counsellling for tinnitus
-A clinical trial investigating the effect of tinted light on tinnitus perception
-Efficacy of a combination hearing aid and sound generator.
To demonstrate 0.1% of populace for HIV/AIDS there are currently 45 studies. (as a comparison)