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26.02.2014

Neurophysiological approach to tinnitus patients, tinnitus organisasjon - .

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The main difference is that those who find tinnitus troublesome, evaluate and perceive it as a threat, or an annoyance, rather than something of little or no consequence. What happens, even in mild cases of persistent tinnitus, is that a conditioned response (reaction) is set up to the tinnitus sound.
When tinnitus first emerges it is a new signal, there are no memory patterns, and no means of categorizing it. Unfortunately, these fears may be enhanced by professional advice, or reports from others of their own, phobic reaction to tinnitus. In some patients extreme fear of tinnitus results in a phobic state developing, very similar to that of the fear of spiders, frogs, small spaces, flying etc.
Retraining the subconscious auditory system to accept tinnitus as something that occurs naturally, does not spell a lifetime of torture and despair, and is not a threat or a warning signal, can take months and occasionally even years. While it is important to have a proper examination by an ear specialist, those professionals who themselves believe that tinnitus is an ‘ear phenomenon’ cannot help. It is important to distinguish between the role of the ear in the EMERGENCE of tinnitus (e.g.
This article may be circulated to patients, their friends and families, freely, provided it is not altered in any way. Key words: assessment, counseling, education, hearing disorders, quality of healthcare, rehabilitation, screening, tinnitus, treatment, triage. In spite of the growing magnitude of the problem of tinnitus in veterans, most VA medical centers (VAMCs) do not provide clinical management for the condition [14]. Presently, no accepted standard of practice exists for the clinical management of tinnitus, either within or outside of the VHA.
This article proposes a basic model for efficiently managing tinnitus patients at all levels of clinical need. The proposed model is designed for application at any audiology clinic that desires to optimize resourcefulness, cost efficiency, and expedience in its practice of tinnitus management. Dobie reviewed 69 randomized clinical trials that had been conducted to assess the efficacy of various treatments for tinnitus [17]. The reports by Dobie reveal that the literature does not provide definitive evidence to support any particular form of tinnitus intervention. Numerous causes of tinnitus have been identified, many of which involve head and neck injuries or diseases or systemic diseases.
Patients should also receive a general physical examination consistent with an ideal standard of tinnitus clinical management. The mechanism(s) of tinnitus is still unknown; thus, no rational basis exists upon which to select a drug to control tinnitus [25].
Many forms of tinnitus therapy recommend the use of sound in some manner to reduce the effects of tinnitus.
Hearing aids have been long recognized to reduce the bothersome effects of tinnitus [28-30].
The primary treatment modality with Tinnitus Masking is the use of wearable ear-level devices-tinnitus maskers, hearing aids, or combination instruments [33-34].
TRT patients are advised to wear hearing aids or combination instruments rather than sound generators if their hearing loss is considered a significant problem. Psychological forms of treatment for tinnitus have included progressive muscular relaxation training, biofeedback, hypnosis, and cognitive-behavioral intervention [45,53].
Tinnitus research has been conducted at the Portland VAMC (PVAMC) since 1995 (under the auspices of the NCRAR since 1997). Our randomized clinical trials, described in the following paragraphs, are a systematic effort to develop and document structured forms of tinnitus management for veterans. Before attending the intake evaluation, each of the 172 study candidates completed written tinnitus questionnaires, including the Tinnitus Handicap Inventory (THI) [70], Tinnitus Handicap Questionnaire (THQ) [71], and Tinnitus Severity Index (TSI) [72].
1.Study patients completed the written questionnaires (THI, THQ, and TSI) before each visit. Of the 123 patients, 111 (53 in masking; 58 in TRT) completed the 18-month treatment protocol. Mean ± standard deviation (SD) scores from Tinnitus Handicap Inventory (THI) for patients at baseline and ongoing treatment appointments. Mean ± standard deviation (SD) scores from Tinnitus Handicap Questionnaire (THQ) for patients at baseline and ongoing treatment intervals. Mean ± standard deviation (SD) scores from Tinnitus Severity Index (TSI) for patients at baseline and follow-up treatment intervals. Numbers and percentages of patients in each treatment group (Tinnitus Masking and Tinnitus Retraining Therapy [TRT]) who made statistically significant improvement (0.05 level of significance) based on a 20-point reduction in total index score of Tinnitus Handicap Inventory (THI). The investigators hypothesized that the majority of veterans with clinically significant tinnitus would be treated effectively using group counseling that was adapted from the structured TRT counseling protocol. Study patients were recruited via local (Seattle area) newspaper and radio advertisements and via flyers posted at the Seattle and American Lake (Tacoma) VAMCs. Mean ± standard deviation scores from Tinnitus Severity Index (TSI) for patients in three treatment groups at baseline and 1, 6, and 12 months posttreatment (usual care received no treatment). A further possibility for tinnitus group therapy is to provide the educational program as a videotaped presentation. We are accumulating research evidence that supports the efficacy and efficiency of providing clinical tinnitus services with a progressive intervention approach. Level 1 of tinnitus progressive intervention would involve screening for clinically significant tinnitus-separating persons who do require clinical services from those who do not. This course will give participants a solid foundation as to the neurophysiological model of tinnitus in a practical format, allowing them to better relay this information to their own patients. During this course, clinicians will learn advanced Neuromonics Tinnitus Treatment concepts relating to recognizing patient candidacy attributes that require modifications to the standard treatment approach as well as customizing Neuromonics tinnitus treatment for each patient’s unique needs as they progress through treatment. This course will take the mystery out of treating tinnitus patients, with a focus on how Neuromonics can not only be an effective form of sound therapy, but one that can be a practical solution appropriate for any clinical setting.
In the last issue of our newsletter, we discussed the history and recent advances in Tinnitus Masking. The expectation was that by describing the tinnitus exactly in terms of pitch and loudness, different categories would be established and specific treatments could be applied to each category with predictable outcomes.
Approximately 75% of all the people who experience tinnitus are not affected by it and they treat tinnitus like any other sound to which they can easily habituate. The researchers found there is no difference in the acoustical characteristics of tinnitus between those who are not bothered by it and those who suffer from it! To understand how tinnitus develops, it’s helpful to understand how sound is processed in the auditory pathways.
This is the basis of TRT, training the brain to habituate tinnitus sounds and classifying them to represent a neutral, insignificant signal. They placed 80 tinnitus free individuals, university members, in a sound proofed room, each for 5 minutes, asking them to report on any sounds that might be heard. As the conditioned response is part of the subconscious brain, and automatic, what you may be thinking about tinnitus at any time, (or even if you’re not thinking about it), is irrelevant to the reaction produced. Many doctors and other professionals still advise patients that there is nothing that can be done about tinnitus and that it will go on forever. Annoyance or ill ease exists, and although strong emotions may not be evoked, the limbic and autonomic systems are still being stimulated to produce aversive and intrusive emotions which reduce life quality, but most importantly to insure that tinnitus persists rather than habituates naturally. Once the tinnitus loses its sinister meaning, however loud it has been or however unpleasant it may seem, it DOES begin to diminish, and in many cases may not be heard for long periods of time. We are in a difficult situation where the classical training of tinnitus being due to inner ear damage is still very dominant, rather than an understanding based on the Jastreboff neurophysiological model (Jastreboff P.J. Tinnitus masking was at one time thought to be useful in that it simply made tinnitus inaudible. Most tinnitus is first heard at night in a well-soundproofed bedroom, or a quiet living room (Heller and Bergman 1953).
The VHA is committed to implementing only efficient, evidence-based practices to improve healthcare outcomes in veteran patients [15-16]. Our clinical trials and screening methodology support the commonly reported observation that most individuals who experience tinnitus do not require intervention. Use of these recommendations should lead to more widespread and consistent tinnitus assessment and treatment by audiologists.


He concluded that none of these studies demonstrated replicable, long-term reduction in tinnitus impact on lifestyle.
With that caveat in mind, we will now review various methods of treatment for tinnitus that are most commonly reported in the literature and have been used in clinical practice. An otologic evaluation is essential when symptoms are consistent with an acoustic neuroma or when the tinnitus is pulsatile or objective in nature [21].
Because so many drugs have been taken for so many different conditions, anecdotal evidence of correlative tinnitus relief has accumulated.
Patients with hearing loss and tinnitus often receive the secondary benefit of tinnitus relief when using hearing aids [31]. These types of therapy are not intended to remove or reduce the perceived tinnitus in any way but rather to help one cope with the effects of tinnitus on quality of life. Because of the anecdotal reports of tinnitus relief with the use of these various methods, numerous studies have been conducted to attempt to verify the reports. Our long-term objective is to develop a tinnitus management program for veterans that is documented for treatment efficacy. Of course, the concern exists that some patients have tinnitus that requires medical attention.
We can now propose a basic outline of this approach, with the caveat that much more research is needed to more specifically define the approach and to document its efficacy. A section follows that outlines the most common referral concerns for tinnitus patients and describes how referrals should be handled at each of the five levels of progressive intervention.
Most likely, the majority of individuals who inquire about tinnitus services could have their needs met through an effective screening process.
Specific elements involved in the cycle of disturbing tinnitus will be reviewed and how they relate to a patients quality of life impact. During this course, an overview of the fitting procedure will be provided including: setting device menus, device management, patient usage guidelines and patient follow-up considerations. Tinnitus assessment tools will be described, as well as how to implement Neuromonics products for a wide range of patients.
This issue will delve into a neurophysiological approach to reducing tinnitus symptoms called Tinnitus Retraining Therapy (TRT). Silence actually enhances tinnitus and patients undergoing TRT are advised to avoid silence. In these situations, tinnitus is classified as a warning signal, relating either to an bad experience (classical Pavlovian conditioning) or to negative thoughts about its meaning or outcome. Moreover, it is the reaction to tinnitus, which is creating distress, not the tinnitus itself (another difficult concept for some).
Until proper evaluation has been undertaken of what tinnitus means, it will be regarded with understandable suspicion. These qualities of tinnitus, which make people seek help, are created outside the hearing mechanism, and therefore cannot be helped by a purely audiological or ear-related approach. In some cases firmly held beliefs are hard to alter, particularly where there is a conviction that tinnitus is only related to ear damage which cannot be fixed (NEVER the case). Despite the importance of hearing change (temporary or permanent) in triggering an emergence of tinnitus, a recent study of our tinnitus clinic patients showed there was no significant difference in hearing between the tinnitus group and normal population statistics.
In fact this proved to be counter-productive, as tinnitus, the object of the habituation exercise, must be audible for habituation to occur. Persistence of tinnitus depends not only on the meaning attached to it, but also to the contrast it creates with the auditory environment. The lack of VA tinnitus services reflects the fact that research evidence for all forms of tinnitus treatment remains equivocal and that no one method is as yet proven to be any more effective than another [17-19]. That is, many patients will improve regardless of the type of treatment, provided they perceive that expert treatment is being received [20].
Before describing the model, we will first review various methodologies that are used for tinnitus management. Even when these symptoms are not present, the ideal standard for tinnitus management would be for every tinnitus patient to receive a complete examination by an otolaryngologist or otologist [22]. In some cases, tinnitus relief is the primary goal of hearing aids, especially if the patient is a marginal hearing aid candidate. However, patients with more troublesome tinnitus are advised to wear ear-level devices (sound generators, hearing aids, or combination instruments) to optimize the habituation process.
Regardless of the form of treatment, certain counseling topics would be considered universal for tinnitus patients. Alternating current does not cause these damaging effects, but its effectiveness is restricted to very few patients. Second, no form of tinnitus treatment can claim unequivocal research evidence demonstrating consistent success.
Our efforts run in two parallel tracks to address the needs of veterans with (1) severe tinnitus and (2) mild-to-moderate tinnitus.
Study participants were veterans who required long-term, individualized treatment for their tinnitus. It was therefore critical to select only veterans with tinnitus of enough severity to warrant the long-term treatment that would be provided. Each questionnaire provides an index score, with higher scores reflecting greater perceived tinnitus handicap. When patients began treatment with lower index scores (reflecting a less severe tinnitus problem), the benefits of TRT compared with masking were more modest.
Therefore, the participants in this study did not have as severe a tinnitus condition (on average) as did those in the trial just described.
The group, which focuses on providing useful information for reducing tinnitus impact on lifestyle, has consistently benefited the attendees.
Of the 310 patients in the main study, 269 met the strict randomization criteria and are included in the data analysis, including 94 in education, 84 in support, and 91 in usual care. The educational program should therefore inform all patients of symptoms that suggest acoustic neuroma, Meniere's disease, or tinnitus that may be correctable through medical or surgical means. Figure 4 shows a clinical flowchart that depicts the routing of patients through the different levels of intervention. Reimbursement for tinnitus services will also be discussed, making tinnitus treatment a practical reality for most clinicians. Jastreboff developed his model of tinnitus which postulates the involvement of the limbic (emotional) and autonomic nervous systems in the perception of tinnitus. 93% reported hearing buzzing, pulsing, whistling sounds in the head or ears identical to those reported by tinnitus sufferers. Just as the animal alerted to danger by the sound of a predator focuses solely on that sound in order to survive, so those who consider that tinnitus is a threat or warning signal are unable to do anything but listen to it. There are patients who worry about the possibility that it heralds a brain tumour, blood clot, or some serious mental illness (‘it will drive me mad!’). Tinnitus may be the consequence of a mild hearing impairment rather than the other way around, but is still only twice as common with hearing impairment to normal hearing.
For people who also have co-existing or pre-existing anxiety or depression, it can take longer to change their feelings about their tinnitus. This is not to say that patients cannot receive quality care from competent professionals, even if the effects are nonspecific. We will then describe results of our prospective trials that are building research support for the progressive intervention approach. Regardless of the form of treatment, sound is used in one way or another to distract attention from the tinnitus and to reduce the brain's perceived need for stimulation [27]. Most importantly, all patients should be advised to avoid exposure to loud noise, which is well known to cause damage to the auditory system and to potentially cause or exacerbate tinnitus [47]. Electrical stimulation is not a method that is presently useful in clinical practice to treat tinnitus but is considered a promising area of investigation. Herbal remedies also have been used in the attempt to reduce tinnitus symptoms-extract of ginkgo biloba has received the greatest attention. Tinnitus sufferers therefore do not have the benefit of referring to any standardized guidelines when seeking help for their condition. First, veterans who require clinical management for their tinnitus have widely varying levels of need, thus requiring a program that addresses these different levels.


Results of these studies are promising, but further studies are needed to validate the results, to improve efficiency of treatment, and to develop methods to most appropriately triage tinnitus patients into a management program.
These findings suggest that TRT may be most effective for patients who have the most serious difficulty with their tinnitus, and that treatment of 1 to 2 years may be necessary to achieve maximum benefit of therapy. This group, along with the availability of a structured tinnitus counseling protocol, provided the impetus for conducting this randomized clinical trial.
The contact time per patient was thus about 50 times greater for individualized treatment compared with group treatment.
His research began with the ongoing effort at that time to describe the acoustics of tinnitus. The patient is taught the basic function of the auditory system and the brain relative to tinnitus. In any event the threatening qualities of the tinnitus are enhanced by beliefs and negative ideas about tinnitus, not any physical changes that may or may not have occurred.
However maintaining this habituation is easier if tinnitus IS heard from time to time, after successful TRT. Veterans can claim tinnitus as a service-connected disability, which is occurring with increasing frequency.
Certain forms of therapy are well defined and are used routinely in clinics that offer tinnitus management. Although test results may reveal that otologic surgery is an appropriate option, such surgery would be indicated only for a very small proportion of tinnitus patients and results are often unpredictable [23]. Patients should also maintain a background of constant low-level sound that can make the tinnitus less noticeable.
Initial reports indicated that ginkgo provided significant improvement for many patients [63].
Patients in the two treatment groups completed outcome questionnaires at baseline and at 1, 6, and 12 months postintervention.
The sound generators are operated at a low enough level that the tinnitus can still be detected. Jastreboff claims that he has treated about 1,000 patients in his clinic at Emory University in Atlanta, GA and that 80% of these have experienced significant improvement.
Although some areas of the auditory system may be more active than others, every neurone will contribute to some extent to the final perception of tinnitus. Many people complain of the loss of silence, something they previously greatly treasured and enjoyed, before tinnitus became persistent.
Finally many tinnitus sufferers are angry about the treatment, or lack of treatment, or inappropriate advice that they have received.
As a result of this and other therapy including sound therapy, the strength of the REACTION against tinnitus gradually reduces.
This enables the renewal of beliefs that tinnitus is ‘a friend’, and guards against relapse. Much better long-term results can be obtained if wide band noise is used at low intensities while the tinnitus can be heard at the same time. Everyone, especially tinnitus patients should avoid extreme silence, and retraining programmes will always use sound enrichment. As of September 2005, 339,573 veterans had been awarded a service-connected tinnitus disability (Department of Veterans Affairs [VA] Office of Policy and Planning).
Cerumen impaction or significant cerumen on the tympanic membrane can cause temporary tinnitus [24], and its removal may require specialized equipment and medicine expertise. The use of drugs should be considered for tinnitus patients only when sleep disorder, depression, or anxiety are reported as significant coexisting conditions [17]. Serendipitously, cochlear implants were found to be effective for reducing the sensation of tinnitus [59-61]. The tinnitus research program at the National Center for Rehabilitative Auditory Research (NCRAR) aims to provide evidence to support effective methods of treatment. Many of the callers expressed the common misconception that their tinnitus caused their hearing difficulties [6,67-69]. Usual care patients completed their questionnaires at baseline and at 1, 6, and 12 months postbaseline.
Broad band sound contains all frequencies which gently stimulate the nerve cells in the subconscious networks allowing them to be more easily reprogrammed, or habituated, to no longer notice the tinnitus. It is often feared that tinnitus will continue to spoil peace and quiet, interfere with concentration at work, quiet recreational activity and the ability to sleep at night. They may feel guilty for having submitted to treatment, which they think, is the cause of their tinnitus. Even where people do develop new negative reactions to tinnitus (which may have gone away from some years, treatment with TRT is always quicker the second time.
If the screening determines that care is urgently required or if further help is needed following the group session(s), a tinnitus intake assessment (Level 3) should be performed.
For their tinnitus disability, these veterans received a combined 1-year compensation of approximately $418,000,000.
Physicians also are qualified to evaluate for drug interactions or circulatory abnormalities that could be associated with tinnitus. To date, controlled studies have not identified any effective herbal remedies for tinnitus. Efficiency and economy are crucial for VA acceptance and implementation of tinnitus programs. These veterans required education about this issue and about their other tinnitus concerns. This immediate-relief strategy may work best for patients with a more moderate tinnitus problem.
Fear, anger and guilt are very powerful emotions, which are intended to enhance, survival-style, conditioned reflex activity, and consequently greatly increase attention on the tinnitus.
With strong reactions the filters are constantly monitoring the tinnitus, without a reaction habituation occurs, as it does to every meaningless sound that is constantly present. The intake assessment, which includes educational counseling, can often meet a patient's needs.
Patients should be counseled to obtain treatment from a physician, mental health professional, or sleep disorders clinic if this is a concern. The key issue in evaluating the efficiency of group therapy will be the ability to predict which patients will benefit sufficiently from group therapy and which require more intensive treatment. In our experience, tinnitus improves when the patient overcomes these feelings and stops dwelling on thoughts of injustice.
Sadly some people think because tinnitus can return after TRT that ‘the treatment has failed’.
Our current studies, and factor analyses of existing data, will help to develop a means to triage patients into different levels of intervention.
Secondly as the auditory filters are no longer monitoring the tinnitus it is heard less often and less loud.
As the goal is to get rid of tinnitus reaction – NOT tinnitus perception – provided you have achieved this, then TRT is always successful, and permanent.
Untreated depression, anxiety, or sleep disorder can negate tinnitus rehabilitation efforts. Of those who DO experience persistent tinnitus, population studies have shown that about 85% do not find it intrusive, disturbing or anxiety provoking (something tinnitus sufferers find very hard to believe!).
At all levels, the goal is to minimize the impact of tinnitus on the patient's life as efficiently as possible.
The reason for this is not so much because the quality or loudness of the tinnitus is different; in fact we have found that tinnitus is of a very similar type of sound in those who are bothered by it and those who are not.
Think now how much of this treatment depends on being able to believe that tinnitus results from normal compensatory changes in the hearing mechanism. Many tinnitus patients have decreased sound tolerance and for this reason often seek very quiet environments.



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Comments to “Neurophysiological approach to tinnitus patients”

  1. 095:
    It's whistling, buzzing, chirping, hissing noisy sounds or safeguard.
  2. 4356:
    Possibly even heard by an otolaryngologist (most the difference between.
  3. Bratka:
    Other loud noises can also be harmful approach works.