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02.01.2014

Tinnitus retraining the brain, stress induced pulsatile tinnitus - PDF Review

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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 processing of information results in continuous changes of the connections within the brain that are involved in transmitting signals from the ear to the cortex. This is the basis of TRT, training the brain to habituate tinnitus sounds and classifying them to represent a neutral, insignificant signal.
The conscious awareness of sound takes place near the surface of the brain, when a pattern of electrical activity traveling up the nerve of hearing from the ear reaches the auditory cortex. When a sound has special or critical meaning, like the baby waking at night, or the creaking of a floorboard, or the sound of our first name, we respond to it in an automatic manner, even if the volume is very soft. Most of our day-to-day activity consists of a series of conditioned or learned responses, executed to order, like reading, writing, playing an instrument or driving the car. 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. The presence of any continuous stimulus usually results in a process called habituation, whereby the individual responds less and less to the stimulus as long as it does not have any special negative meaning. It is important to distinguish between the role of the ear in the EMERGENCE of tinnitus (e.g. At the present moment TRT is available in relatively few centres, but the techniques are spreading and gradually being learned and used in an increasing number of ENT and audiology departments around the world. This article may be circulated to patients, their friends and families, freely, provided it is not altered in any way. Vagus nerve stimulation (VNS) involves a device, usually implanted in the body, that sends electric signals up into the brain from a nerve in the neck.
Pairing vagus nerve stimulation with particular tones, reorganizes the brain’s frequency map to extinguish tinnitus. If part of the cochlea is damaged, say by years of drumming for Metallica, that section ceases to send information about that pitch to the corresponding part of the brain. Engineer and his coinventor Michael Kilgard’s had an insight, which was to pair vagus nerve stimulation with tones that correspond to the frequencies just above and below the damaged area. A therapist pairs vagus nerve stimulation with a stroke patient’s motion to help him relearn movements. After years of careful animal studies and human clinical trials, these therapies are close to commercialization. IEEE Spectrum’s general technology blog, featuring news, analysis, and opinions about engineering, consumer electronics, and technology and society, from the editorial staff and freelance contributors. Sign up for the Tech Alert newsletter and receive ground-breaking technology and science news from IEEE Spectrum every Thursday. This issue will delve into a neurophysiological approach to reducing tinnitus symptoms called Tinnitus Retraining Therapy (TRT). Instead of the expected results, however, researchers found something completely unexpected and very surprising. They hear it similar to the way we hear the sound of the refrigerator in our kitchen, of which we are not normally aware and when we do hear the sound, it is not bothersome. The processing of information occurs on several levels for each sensory system, each level contributing to the final stage when a signal reaches the cortex.
The auditory system is closely connected with the part of the brain that controls emotions (limbic system) and the automatic response of the body to danger (autonomic nervous system). Connections within the nervous system are continuously modified, resulting in the enhancement of significant signals and a decrease of neuronal response to irrelevant signals. Sounds that are new, or associated with a negative experience, are treated as significant, evoke an emotional response that triggers the body to “fight or flight.” The repetition of these sounds results in enhancement of their perception and in a resistance of the perception to be suppressed by other signals. In the absence of noticeable sound levels there is still a high level of neuronal activity in the auditory nerve and pathway, but this activity is random.
Repeated activations by a sound not associated with anything of significance will result in decreased activation of the cortical and limbic areas.
Silence actually enhances tinnitus and patients undergoing TRT are advised to avoid silence.
Hearing in animals (who are constantly in fear of their lives because of attacks from predators) has to be very sensitive and specific.
This happens after a short learning period, but the responses can remain as strong as ever throughout life.
Between ear and brain there are 2M nerve cells forming a neuronal network, capable of sophisticated pattern recognition, enhancement and suppression of auditory signals.
Other examples of conditioned responses include the famous Pavlov dog experiment.So, each and every sound that we hear and learn the meaning of, has an ‘emotional label’ attached to it, which may change from time to time according to how we feel in ourselves and the context in which we hear it.
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. It may also emerge for the first time when something else unpleasant or frightening is happening to us.
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. Any new experience produces an ‘orienting response’ where we are forced to pay attention, until the signal is classified and understood. 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.


Retraining should be guided by professionals with experience in this field, forming part of a multi-disciplinary team. In the subconscious part of the brain concerned with hearing, beyond the inner ear, but before the act of conscious perception of sound takes place, subconscious filters, networks of nerve cells (neuronal networks) are programmed to pick up signals on a ‘need to hear’ basis.
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). Many of the organizations pursuing vagus-nerve-based treatments are targeting the brain’s centers that release neurotransmitters to treat conditions as various as epilepsy, migraine headache, and heart failure. In tinnitus, damage to the inner ear, or cochlea, results in a persistent perceived sound that can be annoying or even downright debilitating. Ischemic stroke, the kind caused by a blood clot, kills a portion of the brain by starving it of oxygen. Microtransponder hopes to be cleared by the European Union to start selling the tinnitus therapy there late this year and the stroke therapy in mid-2016. Animal studies show it might help the brain learn to ignore the sights or sounds that trigger the terrors of post-traumatic stress disorder, or help extinguish the repetitive behaviors of obsessive-compulsive disorder.
Food and Drug Administration recently approved two implantable devices that treat depression by transmitting electronic pulses to a nerve in the neck.
Jastreboff developed his model of tinnitus which postulates the involvement of the limbic (emotional) and autonomic nervous systems in the perception of tinnitus. On the other hand, sound associated with a significant event, particularly related to danger, will be enhanced and will strongly activate the cortical areas and emotional response.
The cochlea, or inner ear, which changes sound waves into these electrical patterns, is a surprisingly noisy place, where continuous mechanical and electrical activity in 17,000 hair cells can now be monitored with sensitive, computer enhanced, listening devices (otoacoustic emissions). The ability of animals to develop extremely acute hearing, by which they could detect the very small sounds of an attacker a long way off, contributes to the survival of that species. For example the sound of a neighbour’s television set may be acceptable, or unpleasant and intrusive, depending on whether it belongs to a well loved friend or relation, or somebody else who for various reasons we dislike or distrust. The subjects thought they might be undergoing a hearing test, but actually experienced 5 minutes of totalsilence. 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). This mechanism is best illustrated by the Jastreboff model in a graphical format (Figure 4).
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). However many people can be helped by understanding the Jastreboff model and applying the principles of retraining as described on our website. Think again of the way we invariably detect the sound of our own name, or a distant car horn, or a new baby stirring in sleep, whereas we may be unaware of the sound of rain pounding on the roof or surf beating on a seashore. The final stage in this process is when the signal is no longer detected, and cortical neurones are unresponsive.
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 vagus links to a deep-brain structures, such as the nucleus basalis and the locus coeruleus, which are stuffed full of neurotransmitters like acetylcholine and norepinephrine—key neurochemicals in the cellular mechanisms of learning and memory. The cochlea is a transducer that’s organized like a piano keyboard, with one end sending signals about low frequency tones to the brain and the other responding to high-pitched sounds. Looking for any input it can get, the disconnected part expands to absorb neighboring frequencies—think of one key on a piano expanding to take over the five or six nearest it. If it happens in the motor cortex, the part of the body once controlled by the dead tissue becomes paralyzed—but not always completely.
His research began with the ongoing effort at that time to describe the acoustics of tinnitus. When we are exposed to a measurable amount of sound the activity within the auditory system increases and becomes more regular and synchronized. Our brain sorts sounds according to their significance, giving important sounds high priority and filtering out, or habituating, insignificant sounds. The patient is taught the basic function of the auditory system and the brain relative to tinnitus. These warning signals produce acute anxiety, prompting appropriate action to avoid attack, the so- called survival reflex. However the mother still wakes to the baby stirring even though she has just slept through a thunderstorm.
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. In addition, the neurons of the expanded part have a heightened tendency to fire in synchrony—trigger one neuron and the rest will fire up along with it. The brain’s motor map is loose enough that a few, weak connections to that body part will exist in other, healthy parts of the brain. This activity undergoes extensive processing in several subcortical centers within the auditory pathways before reaching the cortex where perception of sound occurs. The rules controlling sorting priorities are in flux and change throughout an individual’s lifetime.
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.


We respond in the same way to the sound of a motorcar horn, by automatically putting our foot back on the pavement or sidewalk.
This simple experiment shows almost anyone can detect background electrical activity present in every living nerve cell in the hearing pathways as a sound.
It is part of the mechanism that all animals have developed for self preservation, although clearly in this situation it is not working to our advantage!
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. Imagine trying to habituate your response to spiders, which you hate, simply by avoiding them. Thus a small candle in the corner of a large darkened room seems dazzlingly bright until floodlights are switched on making it virtually invisible. In this therapy, movement of the partially paralyzed part is akin to providing the non-tinnitus tones, stimulating the remaining connections in the brain. TRT postulates that with the proper training one can enhance their perception of some sounds while training their brain to filter out other sounds. 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. Later on there is a continuous process of matching familiar memory patterns with those coming from the ear.
This shows that weak patterns of sound, if of great significance, can be detected by subconscious filters, (Figure 2) in the hearing pathways, between ear and brain.
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. Pairing vagus nerve stimulation and movement, strengthens those connections, remodeling the brain so that healthy parts can take over for the dead brain tissue.
Each time a pattern from the ears is matched with a pattern in the auditory memory we have the experience of hearing and recognizing a sound. We have this experience every day with sounds that alarm us, or sounds that soothe us such as music, or the sounds of nature. The conditioned response also triggers activity outside the auditory system where there are large numbers of connections with the limbic system (Figure 3) which is concerned with emotion and learning. These electrical signals are not evidence of damage, but compensatory activity that occurs all the time in the auditory system of each one of us. 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. This reaction controls the disposition of subconscious filters, which are constantly looking for threats. 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. WSGs contain many frequencies, and therefore gently stimulate all the nerve cells in the auditory pathways allowing them to be more easily programmed, (increasing plasticity).
Make sure there is always a pleasant, non-intrusive background sound (like a large slow fan, or an open window, and purchase a device for generating nature sounds). Also activated is the autonomic nervous system, which activates the body, to prepare for any eventuality. 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. Another part of the brain close to this initial hearing centre is involved in the meaning of what we hear, and in interpreting the language.
In our experience, tinnitus improves when the patient overcomes these feelings and stops dwelling on thoughts of injustice. Firstly the disappearance of the reaction means that sufferers no longer feel bad, or distracted, and normal life activities can be resumed – sleep, recreation and work, as before.
Sadly some people think because tinnitus can return after TRT that ‘the treatment has failed’. Nature sounds are always the best, as they are already habituated, and usually produce feeling of relaxation, calm and well-being. This involves high levels of autonomic function; tense muscles, raised heart and breathing rates, sweating, and are the complete opposite to the state of relaxation. 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. 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!). 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. In all cases, sound enrichment should be practiced, using unobtrusive sound sources, to break the silence.



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