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05.07.2014

Tinnitus retraining therapy (trt) outcomes after one-year treatment, ginkgo biloba tinnitus erfahrung - Review

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Towards the end of the 1980s, a neurophysiological model of tinnitus was proposed, which eventually led to the development of Tinnitus Retraining Therapy (TRT). TRT uses a combination of low-level broad-band noise and counseling designed to help the patient learn how to deal with their tinnitus better.
2) Habituation of sound perception allowing the patient to ignore the presence of tinnitus. To make habituation easier, retraining counseling and sound enrichment are administered. Conclusions The aim of this study was to assess the efficacy of sound stimulation delivered by open-ear hearing instruments (OHIs) for tinnitus treatment using Tinnitus Retraining Therapy (TRT).
There is considerable evidence that many forms of tinnitus are caused by central changes that may occur after peripheral lesions. Auditory stimulation is one of the most employed therapeutic methods for tinnitus, and one of the most beneficial. Hearing aids designed for people with tinnitus and hearing loss provide amplification that facilitates auditory stimulation to ameliorate tinnitus. Implantable hearing aids are now used by many people, which made it possible to assess their efficacy in tinnitus treatment. Other devices can be used for tinnitus management for immediate relief before a more complete sound therapy can be initiated. Sound stimulation has its beneficial effect on most forms of tinnitus by activating neural plasticity, which requires time to develop. The specific guidelines on hearing aid device adaptation are crucial for an effective auditory stimulation of tinnitus-affected patients. The most frequent causes of tinnitus seem to be cochlear damage, as almost all individuals with tinnitus have hearing loss. Auditory stimulation is one of the most employed therapeutic methods and one of the most beneficial for patients suffering from tinnitus [32].
The most suitable hearing aids for sound therapy are the open-ear hearing aids [38, 39], which have a mini speaker placed at the entrance of the ear canal. Besides sound generators and acoustic prostheses, other devices that are not specifically designed for treatment of tinnitus can be used for tinnitus management.
Clinical studies [29, 34, 35] have shown that not only do hearing aids improve hearing ability, but they can also reduce or suppress tinnitus.
For instance, in a study carried out in 1999 [44], 50% of hearing aid wearers experienced relief from tinnitus, with a median improvement of 10% after only 6 weeks from the first application. Favoring the ability to listen to tinnitus according to Jastreboff’s neurophysiologic hypothesis. Improving communication and reducing the discomfort often reported by patients as sounds and voices covered by tinnitus.
Stimulating the auditory nervous system in a normal way and not only with tinnitus (phantom sounds). The role of the therapist should not be limited to the technical aspects of hearing aids and their application, but should aim at developing an empathic and confident relationship with the individual patient. The introduction of the so-called open-ear hearing aids helped overcome some of these problems, allowing application of hearing aids to individuals with mild hearing loss, such as many individuals with tinnitus have.
Optimal results in management of tinnitus are not only obtained with the application of technologically advanced hearing aid devices but, most of all, with their adjustment to the individual person’s needs and through patient counselling.
Here’s the first thing you need to know about the state of tinnitus treatment: there is no scientifically accepted cure. One very important thing to take into consideration when evaluating medical claims is the hierarchy of evidence: where findings from stronger studies are accorded more weight than findings from weaker studies (for example, a grouped analysis of many experiments on a particular treatment is held in higher regard than any single one of those experiments). The tinnitus treatment space is flooded with scams or treatments that are based on little to no evidence. The following treatments are treatments for sensorineural tinnitus (tinnitus caused by hearing loss, or a deprivation of sensory input from damaged hearing cells). The purpose of tinnitus retraining therapy, or TRT, as it is widely known, is to enhance the brain’s habituation response to the tinnitus tone.
Effectiveness: It does not lower the volume of your tinnitus, and has generally been found to be moderately effective in decreasing the psychological harm of tinnitus.
Tinnitus masking is similar to TRT, however relies exclusively on the usage of background noise to “mask” or “hide” the tinnitus tone. Meditation has been an under-publicized treatment option for tinnitus since the research on it is relatively new. Currently, there is not enough evidence to recommend any specific drug as a medication to lower the volume of tinnitus. Sound therapies are forms of treatment that claim to reduce the volume of your tinnitus tone with specialized sounds, usually customized for the individual patient. For example, all the evidence in favor of the efficacy of Neuromonics, a sound therapy proprietor, appears to have been funded by the company itself. The common thread behind the aforementioned treatments is that they generally have a high cost (neuromonics costs thousands of dollars) and require a proprietary device (which appears to be nothing more than a proprietary audio player, a way of inflating the cost of treatment). Some studies have shown that Notched Music and Notched White Noise may have some efficacy in lowering the volume of one’s tinnitus tones.
TRT is based on habituation of the perception of tinnitus.1-5 This model postulates that there is an interaction between specific structures of the central nervous system, which, together with the cochlea and the auditory pathways, play a fundamental role for the appearance of tinnitus. When tinnitus signals are presented to the nervous system together with a background noise signal (sound enrichment), the perception is less intense and more difficult to detect. Follow up visits, counseling, and check of hearing instrument fitting after 1 month and subsequently after 3 months. In unilateral fittings, the hearing aid was applied to the side with tinnitus and hearing loss. This reduction translates into a shift from a moderately severe to severe condition to a mild condition, according to the Tinnitus Handicap Inventory (THI) questionnaire scale (Figure 5).
Tinnitus patients falling within Jastreboff’s tinnitus categories 1 and 21 and with mild moderate hearing loss in the 2-6 kHz frequency range were included in the study. The time it takes for sound stimulation to reduce an individual’s tinnitus varies and may require a 6- to 8-month time frame.
Especially regarding treatment with sound, it is important to know if tinnitus is caused by pathology of the ear or the auditory nervous system. Such nonspecific effects could account for the increase in SA in the cochlear nerve after the administration of high doses of salicylate (see above). Importantly, cochlear damages – induced after noise trauma, for instance – cause a dramatic decrease of SA in the cochlear nerve [18, 19].


This decrease in central inhibition is supposed to account for the changes in the evoked and SA after cochlear damage. These central changes could ultimately result in the emergence of an aberrant neural activity that could induce tinnitus.
Such therapy has no noticeable side effects and may be administered through simple devices [33]. Unfortunately, hearing aids currently available are not able to amplify sounds with a frequency above 6–7 kHz, a range of hearing that is often impaired in individuals with tinnitus; for this reason, ordinary hearing aids may be less efficient in compensating for lost auditory stimulation. These results were confirmed by subsequent studies, which extended the investigation to individuals who had tinnitus and mild hearing loss [34, 45].
Only a comprehensive evaluation may allow the therapist to have an accurate picture, in order to tailor the most appropriate and effective therapeutic plan.
For example, sound environment generators are mostly indicated during night rest in patients affected by mild tinnitus. The parameters are crucial for auditory stimulation achieving maximal benefits on tinnitus. In fact, even partial occlusion of the auditory canal may cause unease of use and may even increase tinnitus perception. Open-ear hearing aids also provide a stimulation mainly in the frequency region of the tinnitus pitch. In fact, many tinnitus patients are sensitive to amplification, which sometimes requires less gain and maximum output than in patients who do not have tinnitus. Patients are generally able to fully understand the volume regulation procedure and to safely carry it out, but often more than one round of counselling is necessary and analog scales should be used to track the intensity of both tinnitus and therapeutic sound. Each single patient must be listened to, counselled, and informed throughout therapy planning and during follow-up.
Tonndorf J (1987) The analogy between tinnitus and pain: a suggestion for a physiological basis of chronic tinnitus. Norena AJ and JJ Eggermont (2003) Changes in spontaneous neural activity immediately after an acoustic trauma: implications for neural correlates of tinnitus. Norena A, C Micheyl, S Chery-Croze et al (2002) Psychoacoustic characterization of the tinnitus spectrum: implications for the underlying mechanisms of tinnitus. Puel JL, J Ruel, M Guitton et al (2002) The inner hair cell synaptic complex: physiology, pharmacology and new therapeutic strategies. Argence M, I Saez, R Sassu et al (2006) Modulation of inhibitory and excitatory synaptic transmission in rat inferior colliculus after unilateral cochleectomy: an in situ and immunofluorescence study. Dong S, WH Mulders, J Rodger et al (2009) Changes in neuronal activity and gene expression in guinea-pig auditory brainstem after unilateral partial hearing loss.
Norena AJ and JJ Eggermont (2005) Enriched acoustic environment after noise trauma reduces hearing loss and prevents cortical map reorganization.
Norena AJ, M Tomita and JJ Eggermont (2003) Neural changes in cat auditory cortex after a transient pure-tone trauma.
Mulders WH and D Robertson (2009) Hyperactivity in the auditory midbrain after acoustic trauma: dependence on cochlear activity.
Moffat G, K Adjout, S Gallego et al (2009) Effects of hearing aid fitting on the perceptual characteristics of tinnitus.
Norena AJ and JJ Eggermont (2006) Enriched acoustic environment after noise trauma abolishes neural signs of tinnitus.
Han BI, HW Lee, TY Kim et al (2009) Tinnitus: characteristics, causes, mechanisms, and treatments. Jastreboff PJ and JWP Hazell (2004) Tinnitus retraining therapy: implementing the neurophysicological model. Del Bo L, U Ambrosetti, M Bettinelli et al (2006) Using open-ear hearing aids in tinnitus therapy. Van de Heyning P, K Vermeire, M Diebl et al (2008) Incapacitating unilateral tinnitus in single-sided deafness treated by cochlear implantation. Holgers KM and BE Hakansson (2002) Sound stimulation via bone conduction for tinnitus relief: a pilot study. Surr RK, JA Kolb, MT Cord et al (1999) Tinnitus Handicap Inventory (THI) as a hearing aid outcome measure. Henry JA, TL Zaugg and MA Schechter (2005) Clinical guide for audiologic tinnitus management II: treatment.
Molini E, M Faralli, C Calenti et al (2009) Personal experience with tinnitus retraining therapy. Baracca GN, S Forti, A Crocetti et al (2007) Results of TRT after eighteen months: Our experience. Sheldrake JB, JWP Hazell and RL Graham, (1999) Results of tinnitus retraining therapy, in Proceedings of the sixth International Tinnitus Seminar, Cambridge UK September 5th-9th 1999, J Hazell, Editor.
Ito M, K Soma and R Ando (2009) Association between tinnitus retraining therapy and a tinnitus control instrument. Tinnitus masking, like TRT, has been shown to have efficacy in reducing the psychological harm from tinnitus, but similarly, does not reduce the volume of the tinnitus tone.
A variant of meditation known as Mindfulness Based Stress Reduction has shown good efficacy in one experiment in reducing the distress associated with tinnitus. There is some promising evidence that a benzodiazepene class drug, Clonazepam, may have some efficacy in lowering the volume of your tinnitus, but more research needs to be done. Some studies have shown promise, including a sound therapy called Acoustic Modulated Reset Therapy, and another sound therapy referred to as S-Tones.
The Notched Music studies appear to have no commercial affiliation at this time – but the authors behind the Notched White Noise studies could attempt to commercialize their treatment in the future.
Maskers emit sounds that either partially or completely cover the sounds of tinnitus, while TRT sound generators emit a quieter sound that allows the tinnitus to still be heard. In bilateral fittings, tinnitus was perceived centrally and there was a bilateral hearing loss.
Assessing audiological, pathophysiological, and psychological variables in chronic tinnitus: a study of reliability and search for prognostic factors. There is now considerable evidence that most forms of tinnitus are caused by changes in the central nervous system after peripheral lesions [3, 4]. The increase in use of implantable hearing aids during recent years has made it possible to assess their efficacy for treatment of tinnitus.
Conversely, these devices may be useful for immediate relief before a more complete sound therapy is started. However, patients with disturbing tinnitus and without subjective hearing impairments benefit from custom sound generators, which should be worn at least 8 h during the daytime, in combination with an environment generator during night rest.


The open-ear hearing aids, thus, provide important advantages, such as sound enrichment, that reduce tinnitus by activating the neural plasticity. During TRT therapy, the correct balance between sound stimulation and amplification can be determined with in situ instruments after some weeks of use [52]. This enables therapists to fully understand their patient’s problems and to solve them to the greatest extent through a proper selection of prosthetic devices and finding the optimal settings. Basically, the medical community has evaluated the literature on scientific experiments on tinnitus treatment, and has ruled that there is insufficient evidence to definitively point to any particular treatment as being effective in completely eliminating tinnitus. The remainder of tinnitus treatments are based on a varying amount of scientific evidence, with varying degrees of strength.
TRT is intended to help this process along, and reduce the psychological consequences of tinnitus.
Tinnitus masking can actually be done relatively safely by yourself, in that you can simply listen to free masking sounds downloaded from the internet through any MP3 playing capable device. The primary advantage of Notched Sound Therapy is that it is significantly more affordable than competing sound therapies (as it does not require a special device). In my discussions with a leading academic researcher on tinnitus, in cases where people have tinnitus from hearing loss, a restoration of the peripheral input from the ear by replacing dead or damaged hearing cells, would, in theory, eliminate the tinnitus tone.
For treatment of tinnitus, it is important to distinguish between these two models, as they imply different therapeutic strategies.
This strongly argues against a peripheral origin of tinnitus encountered in human subjects (related to peripheral damages). In addition, a strong neural hyperactivity has been observed in the auditory cortex after a noise trauma [26]. In case sound enrichment should be required all day long (and tinnitus is not associated to hearing loss), “custom” ear level sound generators may be suitable. Custom sound generators are both useful for total masking therapy [36] and for partial masking therapy, according to tinnitus retraining therapy (TRT) [37] (Picture 2). The Combi devices represent the most innovative and efficient therapeutic tools for tinnitus and hearing loss, because they can combine auditory stimulation in impaired hearing areas with either partial or total tinnitus masking [40, 41]. Implantable middle-ear prostheses provide better sound therapy for some patients with tinnitus than traditional hearing aids [42], probably because they provide amplification in a wider frequency range and because of the “naturalness of the amplification”. The results of long-term treatment may be assessed through visual analog questionnaires and the use of different kinds of scales [37] to allow tracking treatment progress.
Sound generators should be adjusted to the frequency of the tinnitus in order to activate the auditory nerve close to tinnitus frequency. The large variability of the requirements for tinnitus patients regarding amplification has prevented adaptation of an uniform formula that is suitable for all tinnitus patients.
Tinnitus has been associated with anxiety, depression, and a reduction in short-term memory – thus many patients are keen on seeking treatments for it. What there are, however, are some promising therapies that could work, but more research needs to be done to make a definitive conclusion. The other medications used to treat tinnitus are primarily meant to alleviate the effects of tinnitus without lowering the tinnitus tone’s volume. In fact, the peripheral model suggests that the aberrant neural activity is responsible for tinnitus perception.
Audiometric test results do not usually reflect variations in tinnitus and thus, are not valid measures of relief [48]; tests, therefore, do not need to be periodically repeated. It is also important not to underestimate the hearing of one’s own voice which often causes difficulties in the understanding of speech, as well as being unpleasant for the individual and may cause a sensation of “closure” that can worsen tinnitus.
Individuals with tinnitus often benefit from having the option of noise reduction switched off or turned down. A famous anecdote claims Van Gogh attempted to cut his ear off due to tinnitus, and if you have it, you probably know why.
This therapy typically requires that one goes through an audiology clinic, and can cost several thousands of dollars. An older class of antidepressants referred to as tricylics has not shown significant benefit in treating tinnitus associated distress. The key message, though is one of hope: our scientific understanding of tinnitus continues to progress, and although a total cure is not yet here, it is on the horizon. Finally, changes in the pattern of spontaneous discharge (increase in firing rate and synchrony), consistent with the psychoacoustic properties of tinnitus [4], have been observed after acoustic trauma [3, 27].
Central inhibition could control a kind of central gain [28, 30], increasing central inhibition, by providing the auditory system with augmented input that is supposed to decrease neural hyperactivity induced after hearing loss. For individuals with hearing loss, open-ear hearing aids are suitable [34, 35], as well as tinnitus control combination instruments (Combi), which combine a prosthesis and a sound generator. Cochlear implants can provide input to the auditory nervous system that can reduce tinnitus in many individuals, both in those with severe hearing loss and in individuals with good hearing on one ear who have severe tinnitus referred to that side [43]. Cerebral plasticity requires some time to develop, and the needed duration of therapy may, therefore, vary from patient to patient [49].
In the selection of hearing aids, all elements that can cause a patient’s discomfort and increase the perception of tinnitus must be taken into account, including cosmetic aspects.
There are many variations of tinnitus tones and the volume of one’s tinnitus tone can vary dramatically. A recent study [6] has shown that salicylate-induced tinnitus may be caused by activation of NMDA receptors expressed in the synapses of cochlear hair cells and dendrites of spiral ganglion neurons.
In animals, we have shown that an acoustic environment enriched in high frequencies could prevent the central changes normally induced after a noise induced hearing loss [24, 31].
Optimal relief from tinnitus may require a 6- to 8-month therapy using hearing aids and sound generators [50, 51].
Hearing aids and sound generators should ideally be forgotten after they have been applied. If tinnitus was normally caused by increased activation of NMDA receptors, a possible therapeutic approach that could suppress such “peripheral tinnitus” would be inactivating NMDA receptors [6, 7]. Moreover, we could induce a dramatic decrease of hypersensitivity in human subjects reporting hyperacusis, after these subjects were stimulated a few hours a day for several weeks with a customized stimulus (the long-term spectrum of the stimulus corresponded to the hearing loss of each subject [28]).



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Comments to “Tinnitus retraining therapy (trt) outcomes after one-year treatment”

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  3. ELIK_WEB:
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