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The leading causes of traumatic brain injury (TBI) in civilians are motor vehicle accidents, falls, and assaults. Mild TBI, particularly for those with closed head injuries, may not be immediately obvious. While the nature and outcomes of brain injuries resulting from blast exposure are not yet fully understood, it is known that TBI causes both acute and delayed symptoms.
We have described audiologic tinnitus management (ATM) previously (Henry, Zaugg, & Schechter, 2005a, 2005b). PATM uses therapeutic sound as the primary intervention modality, and it is distinguished from other sound-based methods (neuromonics tinnitus treatment, tinnitus masking, and tinnitus retraining therapy) in that the sound-management protocol is adaptive to address patients' unique needs.
The focus of patient education is to provide patients with the knowledge and skills to use sound in adaptive ways to manage their tinnitus in any life situation disrupted by tinnitus.
The Tinnitus Pyramid illustrated in Figure 1 is a way of visualizing how people who experience chronic tinnitus are affected differently. The overall goal of PATM's hierarchical approach is to minimize the impact of tinnitus on patients' lives as efficiently as possible.
Because tinnitus can affect many aspects of health, a team approach to tinnitus management is the ideal. Both TBI and tinnitus often are associated with mental health disorders, including PTSD, depression, and anxiety. Mild TBI, particularly for patients with closed head injuries, may not be immediately obvious. Some tinnitus patients present with behaviors that indicate the need for an evaluation by a psychiatrist, psychologist, or other licensed mental health professional. Tinnitus is a symptom of dysfunction within the auditory system and usually is associated with some degree of hearing loss. The Level 2 evaluation includes a standard audiologic evaluation and brief written questionnaires to assess the relative impact of hearing problems and tinnitus problems. For each of the three types of sound for managing tinnitus (soothing, background, and interesting), patients are taught that environmental sound, music, or speech can be applied. Intervention with PATM focuses on assisting patients in learning how to self-manage their tinnitus using therapeutic sound in adaptive ways.
CBT has been shown to be effective in reducing the annoyance of tinnitus and is an adjunct to the sound-based PATM counseling to address emotional difficulties by teaching patients to learn ways to change their thoughts and feelings about tinnitus. Each participant uses a worksheet to develop an individualized "plan of action" to change their negative thoughts and feelings about tinnitus-see Figure 6, PATM Changing Thoughts and Feelings Worksheet [PDF]. Most patients can satisfactorily self-manage their tinnitus after participating in Level 3-Group Education. No program currently exists to provide clinical management for military personnel and veterans who have tinnitus associated with TBI. The PATM model is designed for implementation at any audiology clinic that desires to optimize resourcefulness, cost efficiency, and expedience in its practice of tinnitus management. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
For more details about the diagnosis and treatment of TBI, see Veterans Health Initiative, Traumatic Brain Injury: A CME Program [PDF].
James Henry, PhD, has been working at the VA at the National Center for Rehabilitative Auditory Research (NCRAR) in Portland, Oregon, for the past 22 years and has conducted tinnitus research for 16 years. Tinnitus is the perception of sound heard within the human ear, when there isn’t any outside noise that others can hear.
Tinnitus can occur in one or both ears, constantly or intermittently, be perceived to come from inside or outside of the ear(s), be progressive, pulsing, or vary in intensity and pitch. Most of the individuals that seek help suffer from constant tinnitus, or tinnitus that lasts 24 hours a day, seven days a week. Withdrawal from benzodiazepines and in-ear earphones, whose sound enters directly into the ear canal without any opportunity to be deflected or absorbed elsewhere, are common causes of tinnitus.
Feelings of pressure (aural fullness) or pain in or around the ears may accompany tinnitus. Individuals with more severe cases of tinnitus may find it difficult to hear, work, or sleep.
Although tinnitus does not cause hearing loss, it can interfere with the ability to communicate. For the most part, tinnitus usually goes away by itself without treatment, but it is permanent in about 25% of all cases. Because tinnitus is usually a symptom of a problem, such as an illness, treating the initial cause should help get rid of, or at least lessen, the sounds.
And last, but not least, if you suffer from tinnitus, you join some pretty high profile people throughout history known to have had it too. Key words: blast injury, clinical trial, cognitive-behavioral therapy, education, hearing disorders, military Veterans, rehabilitation, telehealth, tinnitus, traumatic brain injury. Traumatic brain injury (TBI), defined generally as a traumatically induced structural injury or physiological disruption of brain function resulting from external forces to the head, is a leading cause of death and disability in the United States, with an estimated incidence of 1.4 million persons per year--excluding war [1-2]. Our research has focused on developing effective, evidence-based methods of tinnitus management for Veterans. The objective of this pilot study was to develop and test the feasibility and potential efficacy of a telehealth tinnitus-management approach for Veterans and military personnel with TBI.
PTM is a hierarchical method of providing clinical services for patients who complain of tinnitus.
The study team included (but was not limited to) a neuropsychologist (DMS) with expertise in TBI, an audiologist (PJM) with expertise in TBI and patient health education, and a research psychologist (CJS) with expertise in using CBT for tinnitus management.
Before this pilot study, psychological concerns associated with tinnitus were not specifically addressed by the PTM intervention. The THI provides an index score, ranging from 0 to 100, with higher scores reflecting greater perceived functional limitations due to tinnitus [39-40]. The ATM method provided specific guidelines for audiologists to implement a well-defined program of tinnitus management. The base of the pyramid reveals that most persons who experience tinnitus are not bothered by it or only require some rudimentary information about tinnitus. Because the impact of tinnitus varies widely for these patients, their management needs vary accordingly.
Unless there is a medical or psychiatric emergency, all patients who complain of tinnitus should be referred to an audiologist for a Level 2 Audiologic Evaluation. If left untreated, these mental health conditions can impede any rehabilitation efforts, including the clinical management of tinnitus. The model is designed to be maximally efficient to have the least impact on clinical resources, while still addressing the needs of all patients who complain about tinnitus. These providers may be unaware of tinnitus management resources that are available to help these patients. When indicated, the Level 2 evaluation can also include a brief structured tinnitus interview and brief written questionnaires to assess appropriateness of referral to a mental health clinic. During the first session, the principles of using sound to manage tinnitus are explained, and each participant uses a worksheet that is located in the self-management workbook provided at the Level 2 Audiologic Evaluation to develop an individualized "sound plan" to manage their most bothersome tinnitus situation—see Figure 5, PATM Sound Plan Worksheet [PDF]. Some patients with problematic tinnitus, however, require psychological intervention to alter negative reactions to tinnitus and to aid in coping with tinnitus.

Specifically, patients are taught that relaxation techniques such as deep breathing and imagery can reduce stress and tension caused by tinnitus, and changing how they think about their tinnitus can help them change how they feel about it.
A pilot study funded by VA RR&D using a national, centralized tinnitus management counseling program via telephone that is thus accessible to individuals from any geographic location is currently being formally evaluated. Also, PATM has been adapted to quickly identify and meet the unique tinnitus management needs of veterans and military members with TBI. His research focuses on developing standardized protocols for clinical assessment and management of tinnitus, and conducting randomized clinical trials to assess outcomes of different methods of tinnitus intervention.
The Canadian Tinnitus Association estimates that 360,000 Canadians have tinnitus, and approximately 150,000 find that it seriously impairs the quality of their life. It is a condition that can result from a wide range of underlying causes, such as neurological damage (like brain injury or multiple sclerosis), ear infections, oxidative stress, foreign objects in the ear, nasal allergies that prevent (or induce) fluid drain, wax build-up in the ear and exposure to intense percussive and loud sounds.
Treatments include identifying and healing an underlying cause, or reducing or masking the noise to make the tinnitus less noticeable.
It is estimated that 40% of individuals who suffer from tinnitus experience hyperacusis, but it can occur without tinnitus.
Clinical and epidemiological studies confirm that TBI is strongly associated with tinnitus [9]. These efforts led to the development of Progressive Tinnitus Management (PTM), a program involving patient educational counseling that assists patients in learning how to self-manage their reactions to tinnitus [13].
Level 4 services are required by relatively few patients and involve primarily in-depth interviews by an audiologist and psychologist, who attempt to determine why the tinnitus continues to be a problem. Some people distressed by their tinnitus report symptoms of depression and anxiety, such as sleep disturbance, difficulty concentrating, fatigue, irritability, and even suicidal ideation [25-27]. Because the telehealth intervention was designed to help only with tinnitus problems, and not with hearing problems, it was necessary to distinguish these two problems to determine candidacy for the study.
The baseline questionnaires included (1) Tinnitus Questionnaire, (2) Hospital Anxiety and Depression Scale (HADS), (3) THI, (4) Primary Care PTSD screening tool (PC-PTSD), and (5) Epworth Sleepiness Scale (ESS). It obtains demographic data as well as information about the participant’s tinnitus and its effects, prior clinical services received for tinnitus, hearing difficulties, and prior services received for hearing loss.
The THI has been validated for use with patients, and it is one of the most often used and cited tinnitus instruments. The intensified use of explosive devices and mines in warfare and noise from weapons have resulted in auditory dysfunction, tinnitus, TBI, mental health conditions, and pain complaints among members of the military. The invisibility of closed head injury, hearing loss, and tinnitus heighten the importance of screening for TBI, PTSD, depression, hearing impairment, and tinnitus in those service members exposed to blast injury.
Our subsequent tinnitus clinical research pointed to the need to provide tinnitus clinical services in a hierarchical manner, that is, to provide services only to the degree necessary to meet patients' individual needs. Therapeutic sound can be used in a variety of ways with PATM, which is necessary because patients encounter different situations that differentially affect how they react to their tinnitus. Epidemiological studies generally reveal that about 80% of people who experience tinnitus are not particularly bothered by it.
Whenever possible, mental health professionals should have expertise in the management of tinnitus, or at least be familiar with the nature of tinnitus within the context of coexistent psychological problems. Figure 4, the PATM flowchart [PDF], shows the five levels of progressive tinnitus management. The triaging guidelines that we developed (shown in Figure 4) are designed mainly for nonaudiologists who encounter patients complaining of tinnitus. Tinnitus patients who require amplification are fitted with hearing aids, which often can result in satisfactory tinnitus management with minimal education and support specific to tinnitus. This psychological component is particularly important for tinnitus patients who also experience PTSD, depression, anxiety, or other mental health problems.
Rather, psychologists can assist patients cope with tinnitus using CBT, which is a specific modality of psychotherapy shown to be effective in treating many health conditions. The Level 4-Tinnitus Evaluation includes an intake interview and a tinnitus psychoacoustic assessment. If individualized management is not effective after about 6 months, then different forms of tinnitus intervention such as neuromonics tinnitus treatment, tinnitus masking, tinnitus retraining therapy, and tinnitus focused CBT should be considered. Tinnitus can occur not only as a direct consequence of the injury causing TBI but also as a side effect of medications commonly used to treat cognitive, emotional, and pain problems associated with TBI.
This modified centralized approach to tinnitus management allows for frequent and brief intervention to accommodate the needs of people with impaired memory, limited concentration, and other cognitive difficulties often associated with TBI. Report to Congress on mild traumatic brain injury in the United States: Steps to prevent a serious public health problem. VHA Directive 2007-013: Screening and evaluation of possible traumatic brain injury in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans. Through her involvement in tinnitus clinical trials over the last 8 years at the NCRAR, she has developed considerable expertise in tinnitus assessment and management, and in the training of audiologists to perform tinnitus management. Her research interest focuses on the psychological interventions for tinnitus and the comorbidities of mental health disorders with tinnitus.
We developed Progressive Tinnitus Management (PTM), which uses education and counseling to help patients learn how to self-manage their reactions to tinnitus.
In the past decade, it has become evident that blast-related TBI may be more strongly associated with tinnitus than non-blast-related TBI. For the present study, we were interested in exploring the feasibility of adapting PTM to address the tinnitus management needs of Veterans and military personnel with TBI by providing the educational counseling via home-based telehealth (telephone counseling). CBT is an evidence-based psychotherapy commonly used for pain, depression, anxiety, and tinnitus that also can be effective in individuals with a history of TBI, particularly mild TBI [19-21].
The structured educational curriculum focused on teaching patients how to develop action plans for using sound in specific ways to address situations when the tinnitus was most bothersome. Psychological techniques had already been developed and used with patients who experience tinnitus. The primary purpose of the workbook was to impart useful, actionable information that helps patients make good decisions about their tinnitus healthcare. The CBT information led to development of a worksheet (Changing Thoughts and Feelings Worksheet in Appendix 2, available online only) to develop an action plan for implementing specific tasks relevant to managing reactions to tinnitus. Use of the THS (Appendix 3) enables rapid assessment of the effects of hearing loss separate from the effects of tinnitus [23,32].
If time permitted, the psychologist introduced the use of CBT for tinnitus, the rationale behind stress management for tinnitus, and the relaxation techniques. Symptoms of mild TBI or concussion frequently include tinnitus, which can occur not only as a direct consequence of the injury causing TBI but also as a side effect of medications commonly used to treat cognitive, emotional, and pain problems associated with TBI. The remaining 20% are bothered, but to different degrees-as depicted by people with "progressively more severe tinnitus problems" toward the top of the pyramid. Tinnitus patients with these problems should be referred for evaluation by a mental health professional. It is sometimes also appropriate to screen for the presence of mental health symptoms and to refer patients to a mental health clinic because these symptoms can interfere with successful self-management of tinnitus.
Any patient found to have problematic tinnitus receives "How to Manage Your Tinnitus: A Step-by-Step Workbook" and is invited to attend Level 3-Group Education. Recent evidence supports the use of group education as a basic form of tinnitus intervention. Psychological intervention can be an important component of an overall approach to tinnitus management for patients with mild TBI.

Administration of the intake interview is the primary means of determining whether one-on-one individualized tinnitus management is needed. Persistent post-concussive syndrome: Structure of subjective complaints after mild traumatic brain injury, Journal of Head Trauma Rehabilitation, 10 (3), 1–17. Her research focuses on the development of patient health education programs and materials, standardized protocols for clinical assessment and management of tinnitus, and blast injury and auditory dysfunction. For example, in a subset of blast-injured patients seen at Walter Reed Army Medical Center (2003-2005), 49 percent reported tinnitus [10]. The education was designed to be patient-centered and to lead to self-efficacy in managing reactions to tinnitus. Multiple trials support CBT as an effective psychological method for managing tinnitus [20]. They found significant improvement in quality of life (decrease of global tinnitus severity) for those receiving CBT compared with those who did not receive CBT.
These particular components were selected because they have been identified in studies to be beneficial for patients who have tinnitus [30-31]. The statements in section A address tinnitus-specific problems not related to hearing difficulties.
Each of these conditions can compromise efforts to manage tinnitus, so evaluating the participants for these potential comorbidities was essential.
For example, outcomes of moderate and severe TBI tend to follow a gradient of severity predicted by acute injury characteristics, while outcomes of mild TBI can be varied and unpredictable [3]. ATM therefore was completely revamped, resulting in a five-level hierarchical program of tinnitus management that we refer to as progressive audiologic tinnitus management (PATM).
Although this method has been developed and evaluated for veterans with tinnitus, PATM protocols can be applied to any adult with problematic tinnitus. The tip of the pyramid contains the relatively few patients who have the most severe tinnitus condition, that is, those who are debilitated by their tinnitus. A handout that audiologists can share with their health care provider referral sources is found in Tinnitus Triage Guidelines—intended to be provided to nonaudiologist clinicians with patients who complain of bothersome tinnitus.
Patients should also be referred immediately to a mental health professional if they report suicidal ideation, or if they have bizarre thoughts or perceptions such as "hearing voices." Patients with PTSD and severe tinnitus may require test protocol modifications and referrals to mental health that address the powerful limbic system responses. The workbook, written at the sixth-grade reading level, contains information on using sound to manage tinnitus, changing thoughts and feelings to manage tinnitus, relaxation techniques, hearing conservation, sleep hygiene tips, and general tinnitus information.
Group education has been shown to be effective as part of a hierarchical tinnitus management program at a major tinnitus clinic. Further information about managing tinnitus is then presented, and the participants revise their sound plan based on the discussion and new information. Protecting military convoys in Iraq: An examination of battle injuries sustained by a mechanized battalion during Operation Iraqi Freedom II. She has received funding from the VA Rehabilitation Research and Development Service to conduct research as a Co-Principal Investigator on studies related to tinnitus management and traumatic brain injury. Also, 38 percent of inpatients with blast injury at the Palo Alto Department of Veterans Affairs (VA) Polytrauma Rehabilitation Center complained of tinnitus [11]. The purpose was to determine whether telehealth intervention for tinnitus was feasible and efficacious for each of the three groups. Level 1 consists of guidelines for referring patients who complain of tinnitus to the appropriate clinical services. CBT is an evidence-based and appropriate addition to PTM to address the psychological components of tinnitus distress that are so common with Veterans. Specifically, instructions were provided for how to use sound to manage tinnitus in situations when tinnitus is bothersome.
The Tinnitus Pyramid highlights that patients who complain of tinnitus have very different needs, ranging from the provision of simple information to long-term individualized therapy. Videos of PATM Level 3 counseling and methods of relaxation and imagery based on cognitive-behavioral therapy (CBT), as well as a CD demonstrating the different ways that sound can be used to manage tinnitus, are currently under development and will be added to the workbook to provide the audiologist and patient with additional intervention tools in a multimodal format. The NCRAR completed a randomized clinical trial evaluating group education for tinnitus in almost 300 patients that showed significantly more reduction in tinnitus severity for those in the group education group as compared to control groups. By the end of the second session, the participants should have learned how to develop, implement, evaluate, and revise a sound plan to manage their most bothersome tinnitus situation. Special procedures are used to select devices for tinnitus management, including ear-level noise generators and combination instruments, and personal listening devices. Because the population with TBI can vary greatly in terms of tinnitus severity, peripheral and central function, speech perception abilities in quiet and degraded conditions, cognition, and emotional, behavioral, and physical health, there is no universal standardized approach to audiologic management or tinnitus management of persons with TBI. Participants with clinically significant tinnitus were recruited into three groups: probable symptomatic mild TBI (n = 15), moderate to severe TBI (n = 9), and no symptomatic TBI (n = 12).
Tinnitus can occur not only as a symptom of TBI and side effect of medications commonly used to treat cognitive, emotional, and pain problems associated with TBI, but can also be a direct consequence of the event causing TBI, as in the case of blasts.
Military and VA medical centers were contacted to recruit individuals with clinically significant tinnitus--both with and without a history of TBI.
Unless the patient has urgent medical or mental health concerns, the initial services should involve a hearing assessment and brief assessment of tinnitus impact.
All the problems in section A are problems that can be addressed with intervention specific to tinnitus that would be available through the telehealth program. They are encouraged to use the Sound Plan Worksheet on an ongoing basis to write additional sound plans for other bothersome tinnitus situations.
While symptoms of mild TBI will often resolve given time and no subsequent insults to the head [3,5], a minority of individuals (~15%) may experience long-term cognitive, emotional, and physical symptoms after the injury event [3].
Chandler and Edmond note that tinnitus is a common but often underreported auditory dysfunction with blast-related injury [12]. Principles and application of educational counseling used in progressive audiologic tinnitus management. Hearing impairment and traumatic brain injury among soldiers: Special considerations for the audiologist. The research assistant conducted initial screening for tinnitus and TBI and mailed materials to eligible candidates. During the level 2 evaluation, the brief assessment of tinnitus impact determines whether tinnitus-specific services are appropriate.
All groups showed trends reflecting improvement in self-perceived functional limitations due to tinnitus. Posttraumatic stress disorder and posttraumatic disorder-like symptoms and mild traumatic brain injury. The intervention consisted primarily of efforts to facilitate the therapeutic use of sound and CBT techniques to effectively manage reactions to tinnitus.
Outcomes assessment was conducted using the Tinnitus Handicap Inventory (THI) at baseline and at 12 and 24 wk following baseline.

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