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17.01.2014

Chronic intrusive tinnitus, spring fatigue life equation - Reviews

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Mark Williams, principal scientific audiologist at the private Tinnitus Clinic in London, which is already offering the treatment, said the trial results were ‘extremely encouraging’.
The findings now need to be replicated by an independent research group.‘A randomised-controlled trial is required to assess whether this new intervention is a viable and effective treatment for tinnitus patients.
In conjunction with therapy and support materials, Tinnitus SoundSupport (TSS) encompasses ease of use along with flexibility and variety to promote an uncomplicated fitting process for the audiologist and significant relief for the tinnitus patient. As mentioned in previous literature, tinnitus can have a significant effect on an individual, including loss of sleep, depression, social isolation, and general well-being, and it can be so severe that it can affect job performance or cause suicidal thoughts.3 Most veterans report tinnitus following exposure to loud sounds, usually while on active duty, and is usually observed alongside hearing loss. Although there are many solutions available for tinnitus relief, not all provide ample flexibility to the hearing care professional or preferred sounds to the patient. In Figure 5, results were tabulated indirectly from the patients by the audiologists during the follow-up visit with their devices, based on how beneficial the patients found TSS for relief of their tinnitus. Each year, it is reported that tinnitus-related disability increases at a rate of approximately 15% across the veteran population. Sound generators have been used clinically to provide relief since the 1980s; however, limitations involving sound choices and sound shaping have been difficult to overcome in some products, leaving tinnitus patients less than satisfied. Patients who were fit with TSS ranged in age from 24 to 95 (average age of 58), were either experienced (n=10) or new users (n=24), had hearing loss that ranged from mild to severe (Figure 2), and reported tinnitus between 6 months and over 40 years (Figure 3). Rate how beneficial your client found the Tinnitus SoundSupport for relief of their tinnitus. Of those who commented on TSS itself, patients found it helpful for easing tinnitus, especially when the tinnitus was bothersome. The tinnitus functional index: Development of a new clinical measure for chronic, intrusive tinnitus.
Tinnitus SoundSupport: A flexible solution for both patients and hearing care professionals. Not only is it important to have the flexibility and control to create an ideal setting to best assist a tinnitus patient, but it is paramount to ensure ease of use and confidence while creating a tinnitus solution specific to your patient. The Tinnitus Functional Index (TFI)5 provides hearing care professionals with a better understanding of the severity and negative impact that the tinnitus patient is experiencing.
The average pre-score was 75.6% and the average post-score was 45%, yielding an average improvement in tinnitus relief of 30%.
This hierarchal approach provides a path for clinicians to follow when managing a tinnitus patient, with each step providing more support to the patient as needed. Using a number of tinnitus severity domains, the patient completes the index prior to treatment and then at follow-up appointments (eg, at 3 or 6 months). Some models of tinnitus pathophysiology suggest that networks associated with attention, memory, distress and multisensory experience are involved in tinnitus perception. The aim of this study was to evaluate whether a multisensory attention training paradigm which used audio, visual, and somatosensory stimulation would reduce tinnitus.
Eighteen participants with predominantly unilateral chronic tinnitus were randomized between two groups receiving 20 daily sessions of either integration (attempting to reduce salience to tinnitus by binding with multisensory stimuli) or attention diversion (multisensory stimuli opposite side to tinnitus) training.
The training resulted in small but statistically significant reductions in Tinnitus Functional Index and Tinnitus Severity Numeric Scale scores and improved attentional abilities. No statistically significant improvements in tinnitus were found between the training groups.
This study demonstrated that a short period of multisensory attention training reduced unilateral tinnitus, but directing attention toward or away from the tinnitus side did not differentiate this effect.IntroductionTinnitus is the conscious awareness of sound without an external driving sound. There is often little direct relationship between the subjectively reported severity of tinnitus and the psychoacoustic matches such as loudness and sensation level3,4 suggesting the involvement of processes related to attention, emotion, and memory in tinnitus pathophysiology5.
Support for this assumption is the observation showing that unilateral tinnitus is associated with a marked attention shift towards the tinnitus ear6.


Participants with a unilateral tinnitus were able to detect target sounds more accurately in the tinnitus ear than the opposite ear but this did not occur in a simulated tinnitus group6. Although the evidence is not univocal7 and many of the methods used are still under development, the majority of recent studies using electroencephalography (EEG)8 resting state functional magnetic resonance imaging (fMRI)9,10, and positron emission tomography (PET) scans11 have shown altered brain connectivity in tinnitus patients. PET in tinnitus patients has revealed increased resting state activity in limbic, frontal and parietal regions and a positive correlation between tinnitus duration and the activity in the right inferior frontal, right ventro-medial prefrontal, and the right posterior cingulate cortices11.Multisensory interactions appear to be a ubiquitous property of information processing within the central nervous system.
There is evidence indicating involvement of multisensory interactions in tinnitus19,20,21,22,23,24,25. For example, jaw movements may elicit an increase in tinnitus loudness21 that is associated with increased activation of the auditory brain areas22. Another intriguing, although rare, example is a form of tinnitus that can be modulated upon peripheral eye gaze23,24,25. These changes in tinnitus perception have been associated with reduced inhibition and increased activity within the central auditory system24.
Tinnitus is unusual because, in addition to the strong emotional response it elicits, it does not have a localizable external source and therefore violates the rules of auditory scene analysis28. This may result in attentional resources being directed towards the tinnitus sound in order to validate its ecological relevance and purpose28 which prevents habituation30. A potential dissociation between auditory cortex and visual cortex in tinnitus patients has also recently been demonstrated in MRI, raising further questions to the role of sensory integration and tinnitus31.Considering the research described, an intervention targeting attention and the multisensory interactions may represent a promising tool for the treatment of tinnitus. Here, we introduce a novel approach to tinnitus treatment which involves combining attention training with multisensory (auditory, visual and somatosensory) stimulation. We hypothesize that multisensory attentional training will reduce tinnitus within multiple tinnitus severity domains as measured with the Tinnitus Functional Index (TFI)34. Two possible approaches emerge in light of the proposed role of auditory scene analysis in the pathophysiology of tinnitus28,35. Multisensory stimulation could be used to divert attention away from tinnitus (an attention diversion approach) to reduce its salience, or to integrate the sound of tinnitus with other sensory modalities (an integration approach).
Putatively, both approaches have the potential to relieve the attentional load towards tinnitus and reduce subjective tinnitus annoyance28.The primary aim of this study was to assess whether multisensory attention training would reduce the impact of tinnitus (as measured by the Tinnitus Functional Index (TFI)34 on participants. All participants had constant, subjective, predominantly unilateral tinnitus without any active external or middle ear pathology. The detailed methodology of the audiometry examination and tinnitus assessment are described in supplementary methods. In the integration group, all three lateralized stimuli (auditory, visual and tactile) were presented when the central cue indicated a saccade towards the tinnitus side. Prior to each daily session, participants performed a rapid computer based self-assessment of their tinnitus using a custom software utility within the training program. In addition, it was completed at the initial audiology assessment (Baseline) in order to provide a measure of test-retest reliability within our cohort and to match the two experimental groups for tinnitus severity.
Secondary outcome measures consisted of other standardized questionnaires evaluating tinnitus, mental state, and a variety of attentional measures.QuestionnairesAll participants completed the Tinnitus Handicap Inventory (THI)41 and Tinnitus Severity Numeric Scale (TSNS)42.
Previous studies from our group have shown that attention-based perceptual training in tinnitus had the greatest effect on a subset of CAB measures, specifically the Discriminate Reaction Time (DRT) and Auditory-Visual Multiprocessing Tests (AVMT)35. Subsequently, they were instructed to match the intensity level of a sound at the tinnitus pitch to the perceived loudness of their tinnitus.
These data allowed for the auditory stimulus to be matched to the tinnitus sound during training. The secondary measures CAB (number of hits and reaction time of hits separately for each test) and eye tracking (saccadic latency and percent of correct saccades separately for tinnitus dominant and non-dominant side), and tinnitus characteristics (pitch and loudness) were also assessed using the Wilcoxon signed rank test comparing the Pre and Post values.In order to examine potential mechanisms of the training, we conducted secondary analyses. Panel (b) shows the mean saccadic latency of correctly initiated saccades towards tinnitus dominant (white circles) and non-dominant (black circles) sides.


On average, tinnitus loudness also tended to drop over the course of treatment by an average of 5 dB. Our findings are in agreement with previous data showing that attentional training can improve symptoms of tinnitus35,36 and attentional abilities in people with tinnitus35.The design of the task was motivated by the following requirements. The attention diversion approach has been used in previous studies aiming to divert attention away from the tinnitus sound35,36. The integration approach, however, is a novel strategy designed to integrate the tinnitus sound with visual and somatosensory stimuli. The aim of the integration approach was to reduce the conflict between the phantom auditory perception and the lack of input from other sensory modalities which has been suggested as a possible source of salience for the tinnitus sound11,35,48.
Previous studies showed that a cognitively demanding task irrelevant to tinnitus can temporarily decrease tinnitus49, although other results imply that tasks relevant to tinnitus may be more efficient36.
This may have provided another competing source of limbic and autonomic system activation whereby the improvement in the reaction time acted as a positive reinforcement which superseded the negative reinforcement originating from tinnitus. It is therefore possible that the multisensory training reduced the negative emotions associated with tinnitus independently from performance on the CAB tests that reflect conscious top-down processes51.
A study breaking down the individual sensory modalities and comparing their effects alone to the multisensory approach would shed more light on this question.Lastly, we were interested whether altered attention in tinnitus affects saccadic eye movements. In light of the results of their study, one would expect that the saccadic measures, error rate, latency and velocity would be imbalanced in favour of the tinnitus side45. Our eye tracking data, however, revealed no baseline difference between the tinnitus and non-tinnitus side in any of the saccadic measures. This finding indicates that chronic unilateral tinnitus does not affect performance on a visual attention task relying on a purely oculomotor response. This is in agreement with recent evidence showing a lack of a left-right saccadic asymmetry in unilateral tinnitus participants52. Interestingly, in the integration (but not diversion) group, we revealed a decreased number of correct saccades directed towards tinnitus side. However, the overall improvement in the tinnitus questionnaires (approximately 20%) was achieved in considerably shorter time that in other studies.
For example, tinnitus retraining therapy has shown 20% - 33% improvement in questionnaires and visual analogue scale in one year53, listening to notched music is associated with 20% - 30% decrease in tinnitus loudness in 6 to 12 months54, and cognitive behavioural thereby can decrease tinnitus loudness by 16% and annoyance by 37% in 6 weeks55. Participants self-reported modest differences in their tinnitus which were consistent with the improvement in the questionnaires and psychoacoustic measures performed each day before the training session.
Participants were exposed to the procedure of tinnitus pitch (and loudness) matching at the initial audiology examination as well as the study admission appointment. It is therefore possible that the pitch change after the first day may reflect a combination of the multisensory training and gained confidence in their tinnitus assessment.In summary, there is a growing body of evidence that attention training may be an effective therapeutic approach for a variety of cortically based disorders such as amblyopia56,57, stroke58, and tinnitus35,36. Our preliminary results indicate that multisensory attention training may be a viable therapeutic approach for the management of tinnitus. Although the primary outcome measure (TFI) does not directly address the question whether the training acts upon improvement in emotional state or by changing tinnitus percept, the psychoacoustic data suggest the latter.
Changes in spontaneous neural activity immediately after an acoustic trauma: implications for neural correlates of tinnitus. An integrative model of auditory phantom perception: Tinnitus as a unified percept of interacting separable subnetworks. The neural network of phantom sound changes over time: a comparison between recent-onset and chronic tinnitus patients.



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