4 – Tinnitus Treatment – Flashcards

Psychological contributions: - Cognition: maladaptive cognitive strategies "The reaction is the key to whether a person with tinnitus becomes a tinnitus patient" (Sweetow, 1986; 2000) - Habituation: intolerance results from individual's failure to adapt (Hallamet al, 1984; 2006) - Attention: failure to shift attention away from tinnitus (Hallam and McKenna, 2006) - Enhanced tinnitus perception is learned response resulting from "negative" emotional reinforcement involving limbic system and autonomic activation (Hallum; Jastreboff and Hazell, 1993; McKenna, 2004).....de-emphasizes connection with peripheral hearing loss

- Sleep - Persistence - Speech understanding - Despair, frustration, depression - Annoyance, irritation, stress - Concentration, confusion - Drug dependence - Pain/headaches

- 53% of tinnitus patients report sleep disturbance (Meikle and Taylor-Walsh (1984) - 2/3 require more than 30 minutes to fall asleep (less frequently a problem for people with normal hearing (Hallum 1996) - Alster, et al (1993) indicate tinnitus severity increases with sleep problems ^many people who have trouble sleeping start taking medications to help sleep

- Severity of TRQ was shown to be a good predictor of sleep disturbance and of group association, especially the "emotional" sub score component (sensitivity 96.9% and specificity 55.3 % for identifying tinnitus patients with insomnia). - The greater the insomnia disability, the more severe the patient's complaints were regarding the tinnitus ^nature sounds are more relaxing ^need to consider pt partners when thinking about noise generators especially at night ^consider mindfulness to help sleep

Reduce Contrast Mask Phantom Percept Suppress Hyperactivity - Examples: ~ Maskers ~ Hearing aids ~ Neuromonics ~ Zen Fractal tones ~ Sound cure: S-tones ~ Cochlear Implants ^main goal of therapy is to reduce the contrast between tinnitus and silence ^full masking of the tinnitus isn't the best option usually Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress - Examples: ~ TRT ~ Neuromonics ~ Zen Therapy ^ relaxation techniques ~ CB-intervention ~ MBSR (Mindfulness Based Stress Reduction) ~ Antidepressants Disrupt Information Conveyance Avoid Interference with Audition - Examples: ~Striatal Neuromodulation ~Vagal nerve stimulation-releases neurotransmitters to drive reorganization ~Cortical Stimulation (rTMS) ~Drug Therapies

Progressive Tinnitus Management (Henry, et al) - hearing aids, masking, TRT, and CBT. - stepped-care approach - telephone screen - informational counseling - intake assessment - Basic treatment - extended treatment

Tinnitus Retraining Therapy - directive counseling - auditory (low level noise) therapy

- the process of "ignoring" (or becoming accustomed to) a stimulus without exerting any conscious effort. - from a psychological perspective, it is defined as the adaptation, or decline of a conditioned response, to a stimulus following repeated exposure to that stimulus.

- ring on your finder - clothing - refrigerator humming - rear end (buttocks) in your chair ^tinnitus patients do not think that they have the ability to habituate to their tinnitus

A simple structure for remembering the sequence of the brain's analysis of the tinnitus - the auditory cortex analyzes - the hippocampus identifies - the amygdala determines salience - thunder versus a pin drop... ^it doesn't really matter the volume of the sound ^in tinnitus, the info sent to the brain that the sound is a danger to the person's well being

- Maskers - Noise generators (unfiltered, filtered, modulated) - Music (unfiltered, filtered, fractal) - Hearing aids (effective in over 60% of cases) - Combination instruments - Home based sounds - CDs/internet ^music - neuromonics ^sound cure = noise generator

- Goddard, et al 2009 reported 78% success with Neuromonics; but only 14 of initial 47 subjects completed the study - If 100 subjects enroll, but only 60 complete the study, and 40 of those 60 are successful, what is the success rate, 66%, or 40%? - Research design - Risk of bias assessment tools consist of five domains: population, outcome, exposure, statistical analysis, and for random control trials, randomization, blinding, and withdrawals

- The limited data from the included studies failed to show strong evidence of the efficacy of sound therapy in tinnitus management. - The absence of conclusive evidence should not be interpreted as evidence of lack of effectiveness. - "The lack of quality research in this area, in addition to the common use of combined approaches (hearing therapy plus counseling) in the management of tinnitus are, in part, responsible for the lack of conclusive evidence. ^how can you separate out benefits from counseling, HA, and sound therapy from each other?

- Of the nine tinnitus treatment methods assessed, none were tried by more than 7% of the subjects. - Treatment methods rated with substantial tinnitus amelioration were hearing aids (34%) and music (30%). - *Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols.* - This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus. This fact should be more widely acknowledged in both the audiological and medical communities ^couldn't get enough ppl to stay in the plan ^ppl could the best with the retraining if they had HA and music

WIDEX-Zen (all models) - Fractal tones plus white noise - Additional Zen therapy guide with relaxation exercises ^ the first purpose of zen tones was relaxation ^widex is the only company that has a unique of sounds as zen tones PHONAK -Audeo Q - Adjustable tinnitus balance noise generator -App of sounds and music for smart phones STARKEY-Xino and Z-Series - Adjustable sound generator -patient can customize sound using sound point OTICON-Alta Ti products - Adjustable sound generator-can customize for sound preference, can modulate RESOUND-Verso TS (Alera TS ) - Adjustable sound generator -can customize for sound preference SIEMENS -Ace ™, Pure®, Life™, Pure Carat® - Adjustable signal generator with 4 preprogrammed sounds: white noise, pink noise, speech noise, and high-tone noise; can modulate ^app vs HA tinnitus - app you cant shape the sound - more customization VC with sound therapy that cant do with app Siemens and Oticon - tinnitus comes in all levels of HA technology

If tinnitus and hearing loss is present in both ears: - Use binaural amplification. Monaural amplification may draw attention to the tinnitus in the non-amplified ear. If tinnitus is present in one ear and hearing loss in both ears: - Use binaural amplification. Previously undetected tinnitus may become apparent in the unamplified ear when it is suppressed in the amplified ear, In addition, an unpleasant imbalance in hearing may occur if only one hearing aid is used. If tinnitus is present in both ears and hearing loss in only one ear: - Your patient may benefit from binaural devices, but turn off the microphone in the normal hearing ear ^I would rather see a pt with a lower level of technology in both ears than a higher level technology in one ear

- Your patient may benefit from binaural devices with sound therapy only, use open fit style. - Use Neuromonics or Soundcure - Sound therapy app ^1st option is the route to go if patient has insurance that covers HA ^Neuromonics and souncure are not covered by insurance b/c they arent HAs and are considered DME ^Adv of HA vs neuromonics/soundcure - Can use HA if HL progresses in future - HA is less noticeable than other device (HA more descrete) ^Diff b/w neuromonics and app - Can personalize and shape the neuromonics and not the app

- Greater neural activity allows brain to correct for abnormal reduced inhibition - Enriched sound environment may prevent maladaptive cortical reorganization - Alter production peripherally and/or centrally - Reduce contrast to quiet - Partially mask tinnitus - Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight - All of the above may facilitate habituation and - The majority of tinnitus sufferers have at least some degree of hearing loss

- Complete masking - Partial masking - Mix - Habituate - Distract - Suppress

Music has been shown to activate the limbic system and other brain structures (including the frontal lobe and cerebellum) and has been shown to produce physiologic changes associated with relaxation and stress relief. - Widex sounds are like "wind chimes"

- Home - Work - Celebrations - Advertising - Romance - Movies - Athletic locker rooms - Shopping malls - Hospitals - Therapies - Relaxation

- Home stereo - iPod - Neuromonics - Hearing aids

Slow onset, long, quiet sounds -calming Music with a slow tempo (i.e. near natural heart rate (60 -72 beats per minute) -relaxing Repetition -emotionally satisfying evokes positive feelings - without vocals - no pronounced bass beat - pleasant, but not too interesting or compelling (though for short term relief attention capturing music can be beneficial) - induces relaxation while reducing tinnitus audibility (best for long term relief) - Play at low levels where music blends with tinnitus

- An integrated program addressing all 3 major components of tinnitus distress; auditory, attention, and emotion; as well as stress and sleep management - Many patients will be adequately served by counseling and sound therapy (hearing aids, fractal or S tones, or noise) alone; - Patients with negative reactions treated with a comprehensive program integrating *cognitive-behavioral concepts and relaxation exercises along with the counseling, sleep management, and acoustic tools.* ^have to remember to address the times when HAs aren't on i.e. at night and in the morning when tinnitus tends to be the most bothersome

- Helps the patient recognize aspects about how the tinnitus is affecting him or her, and the cognitive and behavioral implications. It is designed to : - Address the emotional sequelae of tinnitus, including fear, anxiety and depression; - Identify and correct maladaptive thoughts and behaviors; - Understand the relationship between tinnitus, stress, fear, behaviors, thoughts, and quality of life.

changing maladaptive thinking leads to change in affect and behavior, but recent variants emphasize changes in one's relationship to maladaptive thinking rather than changes in thinking itself

not to diagnose a person with a particular disease, but to look at them as a whole and decide what needs to be fixed.

- Identify troubling situations or conditions in your life. - Become aware of your thoughts, emotions and beliefs about these situations or conditions. - Identify negative or inaccurate thinking. - Challenge negative or inaccurate thinking

- The therapeutic effort to modify maladaptive thoughts and behaviors by applying systematic, measurable implementation of strategies designed to alter unproductive actions - CBT gives patients hypotheses that can be self-tested - Focuses on using a wide range of strategies to help clients overcome maladaptive thoughts and behaviors - Cognitive restructuring, dissociation of negative emotional association, attention control, modification of avoidance behavior, journaling, role-playing, thought stopping, relaxation techniques and mental distractions, coping strategies

Event: Awareness of tinnitus - cognitions (Automatic thoughts) Emotions - anger, depression, anxiety Emotional response is the result of the thoughts, not the event (awareness of the tinnitus) itself.

- N = 12, 166 ; N with tinnitus) = 2,024 (16%) - Exposure to noise and stress were important for the probability and level of discomfort from tinnitus. However, for the transition from mild to severe tinnitus, stress turned out to be more important. - Reduction of likelihood of tinnitus if noise is removed = 27%, if stress is removed =19%), if both removed = 42%. - *Conclusions:* Stress management strategies should be included in hearing conservation programs, especially for individuals with mild tinnitus who report a high stress load. Baigi, et al; Ear and Hearing 2011. 32, 6:787-789

- N= 492 in Netherlands - Primary outcomes were health-related quality of life (assessed by the health utilities index core), tinnitus severity (tinnitus questionnaire score), and tinnitus impairment (tinnitus handicap inventory) at 3 months, 8 months, and 12 months - Usual care group: Full audio work up and basic instructional counseling, Sound-generators when specifically asked for by the patient, adjusted to produce a small band noise around the pitch match frequency and slightly below the tinnitus masking level. Follow up. - Health-related quality of life increased with specialized care compared with usual care at 8 months and 12 months). - Tinnitus severity and impairment related to tinnitus were reduced by specialized care compared with usual care at all three follow-ups - Specialized care reduced negative affect at 8 months and 12 months, and tinnitus catastrophizing and fear related to tinnitus at all three follow-ups. - The difference between specialized care and usual care that occurred by 8 months seemed to persist to 12 months, and was larger than that noted at 3 months. Patients with mild or severe tinnitus seemed to benefit equally

*CBT* - but can we use portions of it??? Most reactions are learned processes - subject to behavioral and cognitive modifications ^what we are doing is cognitive behavioral intervention

- Don't do it if you have no confidence in your communication skills - Remember, nearly all successful audiologists are good counselors - Try it, you will see how natural it is - Your advantage is, you know counseling AND tinnitus - Basically, you are just telling the truth! - AAO-HNS 2015 guidelines call for this approach

- Address the emotions of tinnitus - Explain the relationship between tinnitus, thoughts, and emotions - Identify maladaptive thoughts and behaviors - Provide strategies for alternative thoughts and behaviors

All or nothing thinking - I still hear my tinnitus, so therapy isn't working Mind reading and labeling - If I wear these devices, people will think I'm stupid Jumping to conclusions - I will have a terrible day if I hear my tinnitus in the morning

- What is the evidence that this is true? - Are there any facts that I am forgetting? - Has this ever happened before and what was the outcome? - Are there any alternative ways of thinking about this? - What is the worst that can happen? How likely is this? What is most likely to happen?

Stone and Olswang, 1989 Within boundaries - Rehabilitative counseling - Dealing with feelings and attitudes related to communication - Mutual respect - Active patient participation and empowerment

Outside of boundaries - Psychotherapy - Changing basic ways of relating - Overly dependent patient - Unstable patient - Emotional personal relationship