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Die Tinnitus Retraining Therapie, die in den USA und England entwickelt wurde, setzt darauf, storenden Tinnitus durch Habituationsprozesse aus der Wahrnehmung verschwinden zu lassen, oder das Tinnitusgerausch in ein unbedeutendes Hintergrundgerausch zu verwandeln.
Die Tinnitus Retraining Therapie wird in speziellen Tinnituspraxen zusammen mit Horakustikern ambulant durchgefuhrt, den Patienten bleibt ein Klinikaufenthalt erspart. Sie durfen nicht mit den Maskern verwechselt werden, die in fruheren Tinnitus Therapien eingesetzt wurden. Eine Doppelblindstudie oder eine Studie mit Kontrollgruppe ist bei der TRT aufgrund der besonderen Natur des Krankheitsbildes und der Therapieform nur sehr schwer oder uberhaupt nicht durchfuhrbar.
Die Tinnitus-Retraining-Therapie basiert auf der Zusammenarbeit von Fachleuten aus der Medizin, Horakustik und der Psychologie, die gemeinsam das Ziel verfolgen, das Gehirn gegenuber dem Ohrgerausch unempfindlich zu machen und die Wahrnehmung des Betroffenen umzulenken. Gabriele Lux-Wellenhof ist Horakustik-Meisterin und mit dem Thema Tinnitus und Hyperakusis schon sehr lange vertraut. Petra Buhler ist Diplom-Psychologin und konzentrierte sich bereits wahrend ihres Studiums auf das Gebiet der Phantom-Wahrnehmung.
Second, in the absence of widespread training in treatment approaches for severe debilitating tinnitus in the 1990s, TRT filled a void in the clinical armamentarium of the audiology community. Individuals meeting the eligibility criteria have an equal probability of being randomized to one of the three treatment groups in the TRTT. The standard-of-care treatment is similar to that typically provided to patients with severe tinnitus at the participating military medical centers. Additional secondary outcomes include change in the Digit Symbol Substitution Task [77] and the EuroQol. 56.Schmitt C, Kroner-Herwig B, Comparison of tinnitus coping training and TRT: Are they superior to education? This item will be sent through the Global Shipping Programme and includes international tracking.
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How to cite this article Korres S, Mountricha A, Balatsouras D, Maroudias N, Riga M, Xenelis I.
The aim of the study is to present our results regarding the efficacy of TRT for tinnitus relief in patients with clinically significant tinnitus compared to a group treated with vasoactive agents. According to the neurophysiological model of tinnitus, the perception of tinnitus is not necessarily the key element causing tinnitus to be problematic. The second element of TRT therapy, sound therapy, aims to decrease the sound contrast between tinnitus and silent environment leading to a reduced detection of tinnitus.
Several independent centers have presented clinical results of TRT with success rates of about 80% and higher.2, 11-17 The objective of our study is the evaluation of TRT for clinically significant tinnitus after 1 year of treatment. Then, an audiological assessment including pure-tone audiogram (PTA) and tympanogram were conducted in all cases. Subjects were classified into two groups: (1) Group 1 consisted of TRT patients who received a complete TRT (study group, n= 33).
All TRT patients received directive counseling; each participant was reassured for the absence of brain tumor accounted for tinnitus emergence, while the neurophysiological model of tinnitus was explained in a concise way.
Furthermore, the patients were particularly examined if treatment had an effect on the annoyance caused by tinnitus when conducting certain activities of daily living (sleep, concentration, relaxation, work). Data were imported into a statistical computer program (SPSS 15.0) for further evaluation and analysis.
Baseline comparison of THI and VAS scores for work, sleep, relaxation and concentration did not reveal any significant differences between the study group and the control group. The majority of patients in both groups suffered from presbycusis (42.4% of TRT patients, 50% of patients treated with vasodilators). In our study, we documented a satisfactory response obtained at 12 months after the beginning of TRT. TRT achieved by directive counseling and exposure to low-level broad band noise is an effective approach to tinnitus management. Sie bleiben in ihrer gewohnten Umgebung und konnen ihrem normalen Familien- und Berufsleben nachgehen. Er geht ein auf die Fragen, Angste und die personlichen Umstande der Patienten, die durch das Counseling auf die Habituation eingestellt werden. Diese Desensibilisierung fuhrt zu einer verminderten emotionalen Reaktion, zu einem Verlust der Angste. Die Auswertung der Ergebnisse bei den behandelten Patienten im Tinnitus Zentrum Frankfurt erfolgte daher retrospektiv auf der Grundlage der Angaben der Patienten auf dem Erfassungsbogen von Professor Pawel Jastreboff. Die Neuausgabe wurde einschlie?lich des umfangreichen Adressen-Teils nochmals uberarbeitet und auf den aktuellsten Stand gebracht. Studien an den fuhrenden Kliniken in Baltimore und Nottingham brachten sie mit der Tinnitus-Retraining-Therapie in Beruhrung. The tinnitus management is based on the patient's complaints, history, audiologic evaluation, and self-assessment. Acceptance and commitment therapy versus tinnitus retraining therapy in the treatment of tinnitus: A randomised controlled trial. Celebrating a decade of evaluation and treatment: The University of Maryland Tinnitus and Hyperacusis Center. Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. The functional neuroanatomy of tinnitus: Evidence for limbic system links and neural plasticity. Adaptive plasticity of loudness induced by chronic attenuation and enhancement of the acoustic background. Hyperacusis and related sound tolerance complaints: Differential diagnosis, treatment effects, and models. Shifts in dynamic range for hyperacusis patients receiving Tinnitus Retraining Therapy (TRT).
Incremental shifts in loudness discomfort level among tinnitus patients with and without hyperacusis. Changes in loudness discomfort level and sensitivity to environmental sound with habituation based therapy.
Modification of loudness discomfort level: Evidence for adaptive chronic auditory gain and its clinical relevance. Evaluation of tinnitus retraining therapy in comparison to cognitive therapy and broad-band noise generator therapy. Outcomes of long-term outpatient tinnitus-coping therapy: Psychometric changes and value of tinnitus-control instruments. A critical analysis of directive counselling as a component of tinnitus retraining therapy.
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You've read and agree to the Global Shipping Programme terms and conditions - opens in a new window or tab. Import charges previously quoted are subject to change if you increase your maximum bid amount. It is based on the neurophysiological model of tinnitus described by Jastreboff in 1990 postulating that tinnitus results from the interaction of several subsystems in the nervous system1.
It is even possible for the patient to have reactions to stimuli which are not consciously perceived6-7. The first component of TRT, directive counseling, may change the way tinnitus is perceived. According to Weber-Fechner's law, a sound is perceived as less intense whenever it is presented to the nervous system together with a noise background.
We compare TRT patients with a group of patients who refused TRT when recommended and were administered vasoactive agents instead. Sixty-three patients with disabling tinnitus referred to the ENT Departments of the Ippokratio Hospital of Athens and Tzanio Hospital of Piraeus between January 2005 and July 2009 were examined. In addition, a physical examination of ear, nose and throat was performed by an otolaryngologist.
Auditory evoked potentials and magnetic resonance imaging with gadolinium were performed in order to rule out retrocochlear disease if required. The total THI score varied from 0 to 100, with 0 being asymptomatic and 100 being the strongest complaint. The participants were further classified as either Category 1 (n= 4) or Category 2 (n= 29) patients according to Jastreboff's classification. On the basis of the audiometric threshold, category 1 patients (n= 4) were fitted with wearable earlevel sound generators, while category 2 patients (n= 29) were fitted with combination devices that incorporated both hearing aids and sound generators. A Greek translation of the THI was administered in order to assess treatment a year after therapy initiation. All patients reported the level of problems in the 0-10 scale of the structured interview form20 that was used to assess the annoyance. A paired t-test was performed to evaluate the statistical significance of a difference between the mean THI and VAS scores before and after treatment.
No statistical significant differences in pre- and post-treatment THI scores were detected between genders. Mean pretreatment and post-12-month treatment THI scores for TRT patients and patients treated with vasoactive medications.
Mean pretreatment and post-12-month treatment VAS scores for work, sleep, relaxation and concentration for patients treated with TRT (upper panel) and patients treated with vasoactive medications (lower panel). Other diagnoses included sudden deafness, noise-induced hearing loss, Meniere's disease and idiopathic. Sound therapy decreases the sound contrast between tinnitus and silent environment leading to a reduced detection of tinnitus.
Als wei?es Rauschen bezeichnet man Gerausche, die alle horbaren Frequenzen in gleicher Lautstarke erfassen. Uber siebenhundert Patienten wurden ausgewertet, der Belastungsgrad des Tinnitus vor und nach der Behandlung erfasst. The goal of the treatment is to reduce negative cognitive, affective, physical, and behavioral reactions to tinnitus and to improve the patient's well being and quality of life. Additionally, we are evaluating the impact of change in tinnitus severity on outcomes related to the participant's health by assessing change from baseline in the Hearing Handicap Inventory, [79] Beck Depression Inventory Fast Screen, [80] Positive And Negative Affect Schedule, [81] and state sub-scale of the State-Trait Anxiety Inventory. If you reside in an EU member state besides UK, import VAT on this purchase is not recoverable. Import charges previously quoted are subject to change if you increase you maximum bid amount.
Greek translation of the Tinnitus Handicap Inventory (THI) and visual analogue scale (VAS) for annoyance caused by tinnitus when conducting four major activities of everyday life (work, sleep, relaxation and concentration) were examined in a 12-month period.
According to the model, tinnitus, a phantom auditory perception, is usually generated in the cochlea, while the limbic and sympathetic part of the autonomic nervous systems are responsible for the development of tinnitus annoyance. Habituation is the cornerstone of TRT which aims to alter the mechanisms that transfer the signal from the auditory to the limbic and autonomic nervous systems and thereby remove tinnitus-induced reactions8.
The patient is taught the basic knowledge about the auditory system and its function, the mechanism of tinnitus generation and the annoyance associated with tinnitus. 9 The therapy employs long-term use of sound, the level of which is adjusted at or just below the mixing point (the point at which the tinnitus and the noise begin to mix together). A score >58 indicates severe tinnitus, almost always heard, which leads to disturbed sleep patterns and can interfere with daily activities.18 On the contrary, a score 36 correlates with mild tinnitus, easily masked by environmental sounds and easily forgotten with activities18. 21 Category 1 patients experienced tinnitus as a significant subjective problem but did not have hearing difficulties. Two-tailed t-test for independent groups was used to compare baseline THI and VAS scores between groups, and mean differences after treatment. Activation of the amygdala and anterior cingulate during nonconscious processing of sad versus happy faces. Nonconscious influence of masked stimuli on response selection is limited to concrete stimulus- response associations. Guidelines for the grading of tinnitus severity: the results of a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons, 1999.
Long-term improvement in tinnitus after modified tinnitus retraining therapy enhanced by a variety of psychological approaches.
Dieses Rauschen wirkt vollig neutral, wahrend der Tinnitus Spitzen in bestimmten Frequenzbereichen hat und somit wie ein Alarmgerausch wirkt. In einer Nachuntersuchung nach funf Jahren konnte ein Verbesserung des Belastungsgrades von Tinnitus um mindestens 30 Prozent bei etwa 80 Prozent der Patienten festgestellt werden. Er hat sich auf die Untersuchung und Behandlung von Erkrankungen des Innenohres einschlie?lich des Gleichgewichtsorgans spezialisiert. Tinnitus may be heard continuously or intermittently within one or both ears or within the head. Specific treatment recommendations are individualized to reflect the participant's concerns and coping abilities as well as his or her engagement in the decision-making process regarding treatment options.The double-blind sound therapy, implemented with a placebo-controlled sound-generator device, is an innovative feature of the TRTT. Controlled prospective study of tinnitus retraining therapy compared to tinnitus coping therapy and broad-band noise generator therapy.
The THI score was significantly improved in the TRT group, as well as mean VAS scores, in all measures. Tinnitus is responsible for anxiety, problems with concentration, panic attacks and suppression of the ability to enjoy activities in life in 20% of patients who experience the symptom1-3. It is apparent that TRT neither attempts to eliminate the source of tinnitus signal, nor to directly affect the neuronal symptoms responsible for reactions; therefore, TRT is effective regardless of the etiology of tinnitus8. Additionally, based on the TRT Initial Interview 19, the patients were particularly asked if tinnitus prevented four major activities of everyday life: work, sleep, relaxation and concentration. On the contrary, category 2 patients reported both tinnitus and hearing problems.2 Group 2 consisted of patients who refused TRT despite our recommendation and were treated with vasoactive medications (control group, n= 30). Hearing impairment (>25 dB in at least 1 frequency) was present in 29 out of 33 patients (87.9%). 30 We believe that patients should be encouraged to attend TRT for at least a period of a year in order for optimal and stable improvement to be achieved. The objective of this study was to present the results regarding the efficacy of TRT for tinnitus relief in patients with clinically significant tinnitus.
Neither the study participant nor the treating audiologist will know the type of sound generator that the study participant receives. Comparison of the mean improvement of THI and VAS scores after treatment showed significant differences between the two groups, favoring TRT treatment.
The 30 subjects from the control group treated with vasoactive agents included 15 males and 15 females. We conclude that although TRT is not a cure, since it does not remove tinnitus, it reduces the level of annoyance induced by tinnitus and improves the ability of patients to work, sleep, relax or be concentrated. Denn der Tinnitus als Objekt der Habituation muss fur das Ohr horbar bleiben, damit sich das Gehirn darauf einstellen kann. Auch die 20 Prozent von Patienten, bei denen keine signifikante Besserung der Tinnitusbelastung zu erzielen war, gaben an, durch die TRT profitiert zu haben und mit der durchgefuhrten Behandlung zufrieden zu sein. Tinnitus may or may not be associated with a known causal event or suspected pathology.Estimates broadly place the prevalence of tinnitus between 10% and 20%, corresponding to ~30-60 million affected persons in the US population.


This neuroimaging evidence, in turn, has provided support for the concept of directive counseling and its importance in the TRT protocol in initiating habituation of the inordinate emotional and negative responses to the tinnitus. Because it is not possible to blind study participants, nor the treating audiologist, to directive counseling versus the standard of care, all audiological outcomes will be measured by a second audiologist who is blinded to the treatment assignment. Immediately before treatment assignment, each study participant completes the tinnitus health-related quality-of-life instruments and other psychological profile tests. Symptoms of anxiety and depression in cases of clinically significant tinnitus are attributed to the inappropriate activation of the conscious cortex and subcortical level by tinnitus signal through existing connections between the auditory pathways and the cortical and subcortical areas.
Sie konnten danach besser verstehen, wie und warum das Tinnitusproblem ihnen zu schaffen machte. Roughly 5% of the affected population seek healthcare for their tinnitus (~15 million persons).
There is an inherent risk of information bias in the TRTT in that the tinnitus health-related quality-of-life outcomes are being completed by the study participant.The TRTT is being conducted at US military medical centers with active-duty and retired military personnel and their dependents, all of whom qualify because of their severely distressing tinnitus. The initial treatment visit takes place following the randomization visit, and is followed by a second treatment visit 1 month later. It reduces the level of annoyance induced by tinnitus and improves the ability of patients to work, sleep, relax or be concentrated.
The connections between the auditory, limbic and autonomic nervous systems are governed by the principles of conditioned reflexes2-3 which can explain why significant tinnitus may be the result of nonacoustic factors, e.
Hearing impairment (>25 dB in at least 1 frequency) was present in 25 out of 30 subjects of the control group (83.3%).
For example, one of the ideas motivating sound therapy is that exposure to an enriched sound environment is critical in regulating a compensatory process, operating within the central auditory pathways, to amplify otherwise undetectable tinnitus activity.
Although the incidence and prevalence of tinnitus among US military personnel is unknown, it is probably much higher than that among the overall population because of increased exposure to loud noise. Follow-up visits at clinical centers take place at 3, 6, 12, and 18 months, and include completion of tinnitus outcome questionnaires at all visits. In the interim, a more detailed description of the TRTT study design and its development will be forthcoming in a separate report. The six military clinical centers now participating in the TRTT include three Navy and two Air Force sites and the newly integrated-service site at the Walter Reed National Military Medical Center.
Participation in and completion of a TRT training course has effectively served the tinnitus clinical and patient community as qualification to conduct TRT. The participating Navy sites are the Naval Medical Center Portsmouth, the Naval Hospital Camp Pendleton, and the Naval Medical Center San Diego.
These ongoing training efforts, together with numerous presentations at professional and scientific meetings by Jastreboff, Hazell, and independent clinicians using TRT, propelled TRT to the forefront of treatment for debilitating tinnitus at the turn of this century. The participating Air Force sites are the David Grant Medical Center at Travis Air Force Base and the Wilford Hall Ambulatory Surgical Center at Lackland Air Force Base. US Army clinical centers are also expected to join the TRTT as new treatment sites over the next year to enhance and expedite study recruitment. The authors thank the US Navy and Air Force for their continued support of this project, acknowledge the significant contributions of General Hearing Instruments, Inc.
For the vast majority of tinnitus patients, the tinnitus signal is believed to arise in the cochlea or auditory periphery (source), and is filtered out at a subcortical level as shown in [Figure 1].
In the foreword for a special issue of the Journal of the American Academy of Audiology devoted to tinnitus, Jacobson stated that "TRT has become the non-medical management of this decade" for treating severe tinnitus.
The main feature of the TRTT study population is that patients have severely debilitating subjective tinnitus with onset of symptoms at least 1 year prior to treatment.
Although tinnitus may be detectable, it is not bothersome in this conceptual representation of the model.
This manuscript is based on a presentation at the 5 th International Tinnitus Research Initiative Conference held in Grand Island, NY in August 2011.
Accordingly, the majority of Americans who experience tinnitus at one time or another are neither routinely aware nor annoyed by their tinnitus.
This research has been approved by the Institutional Review Boards at all participating military clinical sites, the University of Alabama, and Johns Hopkins University. However, in severely debilitated patients, estimated at 1-2% of the US population, conscious and subconscious neuronal circuitry is activated by the distress accompanying the tinnitus. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Departments of the Navy and Air Force, Department of Defense, or the United States Government.This work was prepared as part of official duties performed by the military service members and civilian employees participating in the TRTT project. Many of these reports appeared at the Sixth and Seventh International Tinnitus Seminars in 1999 and 2002, respectively. This engagement includes activation of the subcortical, associated cortical areas, and auditory cortex, as well as the limbic and autonomic nervous system structures depicted in the model. A review of some of these early reports and other relevant studies [Table 2] revealed clinical success rates approaching or exceeding 80% (as judged by a minimum of 20% change on two or more tinnitus-specific, health-related, quality-of-life scales) across various study populations. If at the conclusion of treatment TRT is ultimately successful in habituating the negative reactions (H R ), emotional associations (H E ), and tinnitus perception (H P ), as shown in [Figure 3], then the model for the successfully treated, previously distressed tinnitus patient will be the same as that shown in [Figure 1]. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person's official duties. They also argued that "a randomized trial with some agreeable controls" is unnecessary because "the validity of this study, time frame, and sample of patients will be questionable and will face many ethical issues" (p. Other components of the model are not activated and, therefore, there is neither awareness nor annoyance in response to the tinnitus. This depiction of the model is representative of the vast majority of persons with tinnitus, who are neither bothered nor distressed by their tinnitus (After Jastreboff[21])Click here to viewFigure 2: Neurophysiological model of tinnitus depicting full activation, including activation of non-auditory limbic and autonomic nervous system structures that are responsible for the emotional and negative reactions to the tinnitus. This engagement of both conscious and subconscious neuronal circuitry gives rise to the awareness and annoyance associated with distressing tinnitus (After Jastreboff[21])Click here to viewFigure 3: Neurophysiological model of tinnitus depicting complete tinnitus retraining therapy - induced habituation of the emotional (HE) and negative (HR) reactions to the tinnitus and it perception (HP). The most valid objection to TRT continues to be the lack of scientific evidence from rigorously controlled randomized trials to support the efficacy of TRT, its component parts (directive counseling and sound therapy), or the underlying mechanisms. A Wessex Institute report pointed out multiple methodological shortcomings in the early observational studies of TRT.
Sound therapy reinforces the habituation process and facilitates the habituation of the perception (awareness) of the tinnitus through enrichment of the tinnitus patient's sound environment. Exposure to low-level background noise from sound therapy makes tinnitus more difficult to resolve, while also resetting central auditory gain processes that are thought to play a critical role in tinnitus. Habituation of the tinnitus perception, which follows after habituation of the negative reaction, ostensibly occurs automatically. Sound therapy may be achieved by any reasonable means that enriches the patient's sound environment, including the use of personalized bilateral ear-worn sound generators and hearing aids. TRT, however, yielded a superior outcome for patients with greater tinnitus severity at the start of treatment. Bauer and Brozoski [65] reported that both TRT and general counseling, without additional sound therapy, are efficacious in reducing the annoyance and impact of tinnitus. The TRT-related improvements accrued over an 18-month period and were reported to be robust and clinically significant. Westin et al.[1] compared the treatment effects of acceptance and commitment therapy (ACT) with TRT for reducing the impact of tinnitus. They reported that ACT yielded significantly greater reductions in tinnitus impact than did TRT at 10 weeks, 6 months, and 18 months after onset of the assigned treatment. The results from a third trial, led by Richard Tyler at the University of Iowa, are yet to be published. Specifically, it was noted in the Cochrane review of TRT to be a primary factor, eliminating many TRT-related studies from review consideration. In some cases, the counseling has been expanded to include aspects or features of cognitive behavioral therapy, which may have influenced or confounded previous reports of TRT efficacy. Moreover, no published randomized study to date has controlled for the treatment effects of directive counseling or sound therapy apart from their combined effects in TRT, nor have investigators examined the relative contributions of these components to TRT success in a rigorous trial.
Thus, in the persistent absence of a rigorous and definitive randomized controlled trial, we proposed and were funded by the National Institute of Deafness and Other Communication Disorders (NIDCD), National Institutes of Health, to conduct the first large-scale, randomized, placebo-controlled, multi-site clinical trial of TRT, the Tinnitus Retraining Therapy Trial (TRTT), which is described in the remainder of this report. The primary objective of the TRTT is to assess the efficacy of TRT as a treatment for severe debilitating tinnitus. The TRTT includes persons with functionally adequate hearing sensitivity who do not need to use hearing aids.



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