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Author: admin | 29.11.2013 | Category: Tinnitus Hearing Loss

INTRODUCTION: Musical training positively influences the cortical plasticity of the brain and has proven to be effective in treating chronic tinnitus. OBJECTIVES: A neuro-music therapy concept, the "Heidelberg Neuro-Music Therapy" treatment was developed and evaluated. MATERIALS AND METHODS: N = 135 patients (mean age 47 years) with chronic, tonal tinnitus attended a standardized protocol for Neuro-Music Therapy (either "standard therapy" ST or "compact therapy" CT). CONCLUSIONS: The "Heidelberg Neuro-Music Therapy" is a method with fast onset and long lasting effect for patients with "tonal" tinnitus. Apart from emotional disturbances such as anxiety, depression, sleep impairments or irritation1, the main complaints of the persons concerned with ringing in the ear are difficulties in concentrating their attention2 and in auditory perception3.
Data from human neuroimaging support the hypothesis of a final common pathway for tinnitus6 and propose a compromised "noise cancellation mechanism"7 to be liable for the enduring tinnitus percept. It is known that pleasant music verifiably reduces activities in the amygdala and enhances activity in nucleus accumbens and thalamus8,9.
Disadvantages are the rather lengthy application and the passive "sounding" of the tinnitus instead of an active exposition to the tinnitus sound. Therefore a short-term Neuro-Music Therapy based on active treatment modules seems to be fruitful in treating chronic tinnitus.
The novel treatment according to the "Heidelberg Model of Neuro-Music Therapy" is based on the notion that tinnitus is experienced as an auditory percept - just as musical stimuli are experienced as auditory percepts.
Two standardized protocols for tinnitus music therapy were defined: a "standard therapy" (ST) and a "compact therapy" (CT) (see patient flow-chart).
All patients receive a comprehensive psycho-educative counseling in order to establish a cognitive model of tinnitus20. As the specific modules used in therapy are based on the individual tinnitus sound, a tinnitus-equivalent has to be set up by means of a commercially available sinus generator.
In the Resonance Training the patient learns a vocal exercise stimulating the cranio-cervical resonating cavities.
The Neuroauditive Cortex Training uses tone sequences performed live by the therapist on a piano which have to be vocally imitated by the patient. The Tinnitus Reconditioning offers coping mechanisms related to stress control along with a sound based habituation procedure. During the relaxation exercise, the tinnitus sound will be integrated intermittently into the background music. Patients were eligible if they suffered from chronic tinnitus (duration > six months) which could be musically compiled (distinct frequency) and had no psychiatric co-morbidity.
Since patients were recruited nationwide it was not possible to randomize the patients to the groups in the true sense of the word. Based on data from a pilot study23 we calculated the a priori power and thus estimated the minimum control group size with the power analysis program "GPOWER"24 to n = 15. As part of the medical history, psychosomatic and audiologic co-morbidities as well as socio-demographic data and tinnitus characteristics were assessed.
On the whole 69% of the patients presented with high frequency hearing loss (> 20 dB hearing impairment present in at least three test frequencies > 3000 Hz) and about 42% presented with low frequency hearing loss (> 30 dB hearing impairment present in at least one test frequency 0-2000 Hz).
Due to the stratified group allocation, no group differences in socio-demographic data were obtained. Patients in the music therapy groups ST and CT received a treatment according to the "Heidelberg Model of Neuro-Music Therapy" as described above.
Patients in the control group PT received a psychosocial intervention based on psychological tinnitus treatment strategies25 combined with placebo music therapy elements. Assessment of tinnitus symptoms was performed three times, at admission ("pre"), at discharge ("post") and six months after therapy ("follow-up FU").
Apart from statistical significance, individual changes were assessed according to the concept of clinical significance27. At discharge all patients of the music therapy groups had the opportunity to rate their subjective therapy satisfaction. Statistical analysis of the data was performed using parametrical and non-parametrical tests in SPSS 16 (SPSS Inc.
In order to predict parameters possibly influencing therapy outcome, a logistic regression model (CATREG, SPSS 16.0) was calculated using TQ-score immediately after therapy as an indicator for therapy success as a dependent variable. Analysis of TQ scores revealed a highly statistically significant reduction pre-post (p p =.913). The overall reduction in the music therapy groups can be explained by significant changes in distinct sub-scales of the TQ, especially of "E = emotional problems" (p p p p p >.05).
According to the concept of "clinical significance", more than 80% of the patients the music therapy groups (ST and CT) achieved a reliable reduction in their tinnitus scores from admission to discharge and could thus be categorized as "responder". On a subjective level, 67% of the patients treated with music therapy regarded their symptoms as "better", 22% observed no change and 11% stated to be worse off.
Apart from immediate therapy-related effects, there could be other factors influencing therapy outcome ("moderator variables"). In order to set the results in the context of existing therapies, a psychologically based treatment group was used as control group. Animal models 29 as well as results from research on tinnitus treatments30 suggest the use of very specific stimuli, i.e.
The "Heidelberg Model of Neuro-Music Therapy" on the other hand integrates some well known psychological techniques and strategies in order to reduce the tinnitus sensitivity by means of an immediate exploration of the tinnitus sounds by the patient.
The rather low positive feedback rate of the Neuroauditive Cortex Training (only about a quarter of the patients rated this module as helpful) might have been due to the wording during the therapy.
The Resonance Training is a purely vocal exercise that stimulates the auditory pathway by means of somatosensory innervations and enables the patients to control their tinnitus perception.
It is known that there are manifold cross-modalities in processing somatosensory and auditory stimuli 35. The Neuroauditive Cortex Training contains a detailed "intonation-training" with purpose-built musical stimuli, based on the individual tinnitus frequency in order to increase the patients" discriminative abilities and enhance their attentive skills. In chronic tinnitus characteristic auditory cortical reorganizations are traceable, which seem to be frequency specific 40,41. Tinnitus Reconditioninghas distinct features in that it combines musical distractors with psychophysiological relaxation and imagination of mental well-being. Since the application of the "well-being image" is linked to acoustic stimuli (relaxation music, tinnitus equivalent sound), the connection "well-being image - relaxation - tinnitus reduction" can be explained in terms of classical conditioning 46. The neurological basis seems to be in an endogenous system located in the medial temporal lobe system (MTLS) 6 and the reticular formation (RF) 47.
On the whole, music therapy is a method with short duration, fast onset and long lasting effect for patients with "tonal" tinnitus and light to moderate tinnitus severity (Figure 1 and 2). Paper submitted to the RBCMS-SGP (Publishing Management System) on April 1, 2012; and accepted on August,16, 2012.
This study examines the outcomes of patients undergoing the Neuromonics tinnitus treatment protocol at a single, tertiary referral center over a 2-year period. Tinnitus, defined as head noise in the absence of an acoustic stimulus, is a complex symptom affecting 40-60 million people in the United States [1]. Various questionnaires, such as the Tinnitus Handicap Questionnaire, Tinnitus Effects Questionnaire, Tinnitus Handicap Inventory, and Tinnitus Reaction Questionnaire (TRQ), have been developed as a means of quantitatively assessing the effect tinnitus has on an individual's quality of life [11-13]. This study evaluated our experience with the Neuromonics device in suitable patients from August 2007 to July 2009. All patients who initiated treatment with the Neuromonics device at our clinic between August 2007 and July 2009 were included in this study.
Treatment with the Neuromonics device involves two components: soft, relaxing music of varying amplitude and a separate wideband noise similar to white noise. At 2 months after initiation, patients repeated audiological testing, completed a new TRQ, and were subsequently transitioned to the next phase of treatment (phase 2). There was no appreciable change in hearing levels during the course of the treatment for any of the patients (data not provided). Thirteen of the 15 patients in the incomplete group returned their device within 3 months of initiation.
The average percent change in TRQ score from initial to last test was also examined as a function of the initial TRQ score. Tinnitus is not a disease but rather a complex symptom believed to result from abnormalities in central and peripheral auditory pathways. In this study, 47 patients were enrolled in a treatment protocol with the Neuromonics device over a 2-year period.
Though these results provide evidence of potentially successful treatment with the Neuromonics device, there was also a large group of nonresponders. Candidacy criteria for the Neuromonics tinnitus treatment protocol have not been firmly established, though some basic guidelines have been proposed by the manufacturing company (Neuromonics Clinician's Guidelines, Client Candidacy Guide, Neuromonics Pty Ltd., Sydney, Australia). The extent of a patient's reaction to his or her tinnitus, as measured by the initial TRQ score, might be an important variable to consider when determining treatment efficacy. Though hearing considerations are certainly important in deciding on treatment strategies for patients with tinnitus, the current study did not demonstrate any differences in hearing threshold levels among those who were successful in completing the Neuromonics protocol and those who were not, nor was there a correlation of PTA to percentage change in final TRQ score.
We thank Lonneke Heuvelmans, AuD, and Nicole Greene, AuD, for their assistance with this project. OBJECTIVE: To correlate the annoyance of tinnitus assessed by the Tinnitus Handicap Inventory and on a visual analogue scale with the evoked otoacoustic emission test result in tinnitus patients with normal hearing.
CONCLUSION: It was not possible to associate the annoyance caused by tinnitus with the TEOAE suppression test results, although suppression effects were found to decrease with increasing annoyance. Tinnitus is a sound perceived in one or both ears even in the absence of a sound stimulus, which directly affects the quality of life of individuals1-3.
The human cochlea receives afferent innervation (eighth pair) and innervation of ipsi- and contralateral efferent fibers of the superior olivary complex (olivocochlear bundle).
The otoacoustic emission (OAE) suppression test is an audiological test that assesses the efferent auditory system by investigating response amplitude suppression or changes in the latency and in the phase of EOAEs when a contralateral acoustic stimulus is introduced simultaneously to test recordings14. There are no studies in the literature establishing a correlation between the level of annoyance reported by tinnitus patients and the OAE suppression test. A case-control study was conducted at the Otolaryngology Department of Hospital de Base do Distrito Federal, city of Brasilia, Brazil. The study sample was initially based on a population of 80 subjects with tinnitus and normal hearing determined by a hearing test. Subjects of both genders ranging in age from 20 to 60 years, who suffered from tinnitus, had normal hearing thresholds (up to 25 dB) in all frequency bands tested, type A tympanometric curves and DPOAEs and TEOAEs, and signed the written consent form were included in the study. The participants were submitted to the following assessments: anamnesis and evaluation of tinnitus annoyance by the Tinnitus Handicap Inventory (THI) and on a visual analog scale (VAS). No significant differences in the overall suppression effect or in the values according to frequency band were observed between the two groups. The correlation between the discomfort caused by tinnitus and the level of TEOAE suppression was also analyzed. Although no significant correlation was found between the discomfort caused by tinnitus and OAE suppression effects, the results were analyzed using tests for homogeneity of variances and trends. Tinnitus is a symptom that has major effects on many aspects of the life of affected individuals.
With respect to tinnitus periodicity, 80% of the subjects studied reported continuous tinnitus and 20% intermittent tinnitus. Cortina et al.23 investigated factors that improve and worsen the perception of tinnitus in 300 subjects with chronic tinnitus. Otoacoustic emissions are present in individuals with normal hearing thresholds and are no longer produced when the hearing loss is greater than 30 dB.
Alterations in OAEs are more common in individuals with tinnitus compared to those without the symptom.
The participants in the present study exhibited no changes in the DPOAE and TEOAE tests according to the protocol established in the methods section. Although the presence of normal OAEs was used as an inclusion criterion in the present study, the OAE response amplitudes were lower in tinnitus patients than in the control group; however, this difference was not statistically significant in the DPOAE or TEOAE test, in agreement with the findings reported above. Sato et al.29 and Miller30 reported greater OAE response amplitudes in females, a fact that might be due to differences in anatomical configurations between genders. The suppression of evoked OAEs is a test that can add value to the diagnosis of different diseases since it is a noninvasive and relatively rapid procedure to evaluate the efferent auditory pathway. In the case of individuals with tinnitus, several studies have investigated the correlation between the presence of tinnitus and the absence of suppression of evoked OAEs, but there is still no consensus about this association6,16,27,31-33. The difficulty in verifying an association can be explained by the fact that tinnitus is a symptom of variable etiology which, in many cases, is multifactorial.
Another factor that may have influenced data collection and analysis in studies investigating suppression effects is the lack of a well-established test protocol in terms of the type and intensity of the click and suppressor noise. The protocol adopted in this study was chosen based on its possible reproducibility in future studies and its application with the equipment used for data collection. Mor & Azevedo16, studying OAEs and the olivocochlear system in subjects with tinnitus and normal hearing, observed no significant difference in the OAE response amplitudes between the tinnitus and control groups in terms of general responses or according to frequency band.
Riga et al.6 investigated the suppression of OAEs in 18 subjects with tinnitus and normal hearing. Studying 30 subjects with tinnitus and a control group, Geven et al.32 observed no significant differences in the overall analysis of OAE suppression. In the present study, no significant differences in the overall suppression effect were observed between groups, but there was a significant difference at the 1-kHz frequency. The prevalence of tinnitus is high and this condition is the third worst symptom after severe and intractable pain and dizziness.
The annoyance caused by tinnitus does not seem to be related to factors such as gender, location of the symptom, age or hearing loss, and affects each individual in a different manner. The objective of the present study was to verify the existence of a possible relationship between annoyance reported by patients with tinnitus and normal hearing and the TEOAE suppression test. Since tinnitus is a symptom of multifactorial origin and is often associated with other conditions, psychiatric aspects should also be taken into consideration. In another study, Granjeiro et al.25 demonstrated that tinnitus annoyance was not correlated with outer hair cell function when normal and altered TEOAEs and DPOAEs were evaluated. The objective of the present study was to evaluate the relationship between tinnitus annoyance and suppression of OAEs, but not related psychiatric aspects. Kehrle39 evaluated the level of annoyance in tinnitus patients with normal hearing thresholds and compared it to the results of the brainstem auditory evoked response test and to anxiety and depression scores.
In summary, suppression effects were absent in a considerable proportion of the tinnitus patients studied. It should be noted that there was a statistical trend indicating a decrease in the value of OAE suppression as the level of tinnitus annoyance increased. It is possible that the protocol used in this study or even the OAE suppression test does not present adequate sensitivity and specificity to differentiate patients with tinnitus and controls. The present results showed the lack of a significant correlation between the annoyance reported by tinnitus patients with normal hearing thresholds and the TEOAE suppression test result.
The TEOAE suppression test results were more frequently altered in tinnitus patients compared to control subjects, but the difference was not significant.
Paper submitted to the RBCMS-SGP (Publishing Management System) on November 15, 2015; and accepted on December 24, 2015. Tinnitus must always be thought of as a symptom and not a disease, just as pain in the arm or leg is a symptom and not a disease. Objective tinnitus may be due to muscle spasms in the middle ear or Eustachian tube; alternatively it may be due to abnormalities in the blood vessels surrounding the ear.
There are two muscles in the middle ear, on occasion one or both of these muscles may begin to contract rhythmically for brief periods of time, for no apparent reason.
Should the muscle spasm continue, medical treatment (muscle relaxants) or surgery (cutting the spastic muscle) may be necessary. Muscular tinnitus resulting from spasm of one of the various muscles of the throat attached to the Eustachian tube is uncommon, but can also result in episodes of rhythmic clicking in the ear. There are two large blood vessels intimately associated with the middle and inner ear : the jugular vein and the carotid artery. It is not uncommon to hear one’s heartbeat or to hear the blood circulating through these large vessels. Obstruction of the external ear canal by wax, foreign bodies or swelling may produce a hearing impairment or pressure on the eardrum. Disturbances of function of the middle ear may result from allergy, infection, injury, scar tissue or impaired motion of the three middle ear bones. Any condition which disturbs the fluid pressure in the inner ear chamber may produce head noises.
Knowing this, we may recommend that a patient with severe tinnitus be treated with antidepressants or anti-anxiety medications. If the examination reveals a local or general cause of the head noise, correction of the problem may alleviate the tinnitus.
6.Tinnitus will not cause you to go deaf and will not result in you losing your mind, so forget such distracting and terrifying thoughts.
When tinnitus is associated with a hearing impairment, even a mild one, the use of a hearing aid in the involved ear is frequently very effective in reducing the awareness of the head noise by “masking out” the tinnitus.
Should you be interested in treatment, we are able to refer you to the Concord Hospital Tinnitus Clinic. The Neuromonics device was invented in Australia and is a form of tinnitus therapy, designed to retrain the brain to not hear the tinnitus. Adapted from the Patient Discussion Booklet American Academy of Otolaryngology Head & Neck Surgery Reprinted by Permission.
INTRODUCTION: Tinnitus habituation and tinnitus acceptance both describe an apparent lack of responding to tinnitus noise. MATERIALS AND METHODS: A large sample of chronic tinnitus sufferers (n = 273) were recruited via advertisements placed at tinnitus clinics and websites and in the media.
RESULTS: Exploratory factor analysis showed that a single factor solution explained 40% of the variance in the scale items. Tinnitus is the perception of noise in the ears or head in the absence of an external acoustic source1-3.
Historically, classical conditioning has primarily informed our understanding of the manner in which people adaptively respond to tinnitus. Consistent with this viewpoint, tinnitus tolerance has previously been shown to be correlated with longer tinnitus duration, whereas problem tinnitus was correlated with younger age and recent tinnitus onset9. Similarly, acceptance is described as a process of allowing or letting be rather than rushing in to try to fix or change one's experiences.
In summary, tinnitus habituation and tinnitus acceptance both describe an apparent lack of responding to tinnitus noise that is assumed to weaken the contingency between tinnitus noise and habitual distress.
To evaluate this premise, we examined the factor structure of the seven acceptance items from the 24-item Tinnitus Response Scales15 and 19 additional items that tapped the perceptual and behavioural aspects of tinnitus habituation.
Seven-hundred-one people visited the study URL between February and July 2006, 273 of whom participated (39% response rate). A panel of international tinnitus researchers was asked to judge a large pool of items in an early version of the Tinnitus Response Scales (TRS). The Tinnitus Reaction Questionnaire (TRQ)23 is a 26-item self-report measure of tinnitus responding that quantifies psychological distress, using 5-point Likert type scales, ranging from 0 to 4, with high scores indicating worse tinnitus distress. A Principal Component Analysis (run in SPSS version 22) was employed to examine the factor structure of the 26 habituation and acceptance items. Habituation is central to our current understanding of tinnitus adaptation14,24 and it is the basis of most of the evidence-based treatments for chronic tinnitus25,26. In this study, we evaluated the premise that tinnitus habituation and tinnitus acceptance are overlapping processes that represent different aspects of the larger tinnitus adaptation process.
To evaluate this premise, we conducted an EFA on the seven acceptance items from the 24-item TRS15 and 19 habituation items from an early 87-item version of the TRS.
Taken together, the results suggest that tinnitus habituation and acceptance items tapped different but related aspects of the tinnitus adaptation process.
This interpretation is also consistent with the current understanding of tinnitus habituation as an automatic, effortless, subconscious, and unintentional shift of attention away from tinnitus noise with each new episode of tinnitus awareness14,17, whereas tinnitus acceptance involves the recognition of the noise, non-reactivity to it, and the effortless ability to shift attention towards a valued activity or focal point15. Finally, with regards to clinical implications, the study results may indicate that there is some merit in examining for potential synergy between the tinnitus habituation and tinnitus acceptance treatments. An exploratory factor analysis indicated that seven tinnitus acceptance items from the Tinnitus Response Scales15 and 19 additional tinnitus habituation items all loaded onto a single tinnitus adaptation factor.
Paper submitted to the RBCMS-SGP (Publishing Management System) on September 19, 2014; and accepted on September 27, 2014.
A new strategy for idiopathic subjective tinnitus treatment - sound stimulation during sleep - has been applied. Mechanisms that underlie tinnitus perception are still not well understood; nevertheless, nowadays it is accepted that interactions between altered cochlear inputs and distorted central auditory processing provoke tinnitus.
This study was approached on a multidisciplinary basis: otolaryngology, psychology and sleep medicine.
Eleven patients with idiopathic subjective tinnitus (10 males and one female, from 31 to 71 years old) were studied during 24 weeks. Sound stimulation during sleep improved the tinnitus intensity in all patients; most of them (8 out of 11) exhibited the greatest decrement in the first week of treatment, while in the remaining 3 patients the tinnitus intensity took 2 or 3 weeks to decrease. In this pilot study we show the positive result -significant decrement in the tinnitus intensity - of the sound stimulation applied during sleep. On the other hand, it is well accepted that mechanisms of learning and memory occur during sleep, organizing sensory inputs and consolidating memories, in a different way than during wakefulness, and even better since less sensory inputs disturb processing, consequently, our protocol is based on stimulation during sleep. Centro de Medicina del Sueňo, Facultad de Medicina, Instituto Universitario CLAEH, Punta del Este, Uruguay. Brief summaries were presented in the following meetings: 2nd Tinnitus Research Initiative Meeting, Principality of Monaco, 2007. III XXX Congress of Association for Research in Otolaryngology, Phoenix, Arizona, USA, 2008 World Association of Sleep Medicine Congress, Sao Paulo, Brazil, 2009. An illegal party drug could hold the answer tinnitus sufferers have long been waiting to hear.
This week, an international conference devotes three days of expert discussion to tinnitus research, a condition which causes a constant and long-term ringing within the ear drum.
Researchers from Auckland hope the conference could be the springboard to the first approved trials of tinnitus treatment using the drug MDMA, one component used to make the illegal street drug ecstasy. He said if medicinal MDMA was to be imported, it would have to be done under very strict controls. Heidelberg Neuro-Music Therapy for chronic-tonal tinnitus - treatment outline and psychometric evaluation. But more than 80% of the music therapy patients (both ST and CT) revealed a reliable improvement ("responder") compared to 44% in the PT group. A number of potential working factors accounting for the treatment success are highlighted. The main reason seems to be the permanent awareness of the tinnitus and the diminished ability to habituate to the sounds4. According to these assumptions, the tinnitus sounds originate from lesions in the auditory pathways. Therefore the patients shall be enabled to actively control the sounds in order to reorganize the underlying neuronal mechanisms maintaining the tinnitus17. The overall therapeutic dose rate (500 minutes of therapy) was equal just as were the intervention modules (including the counseling). The aim is not to reproduce a psychometrical pitch-matched tone but rather a sound that is subjectively equivalent to the patients" "ear sounds". A systematic and targeted training of inaccurately intonated musical sounds enables the patients to exert influence on their auditory processes since they learn to actively filter out irrelevant information and to concentrate on relevant acoustic stimuli.
By means of music as calming background stimulus, the balance between the activity of the sympathetic and the parasympathetic branches of the autonomic nervous system shall be restored. The volume is adapted to the individual hearing level compensating for a potential hearing deficit. The therapy concept was announced by press releases (newspapers and magazines, radio and TV) and offered to patients at the outpatient department of the local ENT-clinic of the university hospital. The therapy was designed as group intervention with five weekly sessions a 90 minutes and an additional individual counselling (50 minutes) leading to therapy duration of 500 minutes equal to the music therapy intervention.
The main outcome criteria were the absolute scores of the German version of the tinnitus questionnaire ("Tinnitus-Fragebogen", abbreviated "TQ") by Goebel and Hiller26 as well as the relative decrease in TQ scores. They had to answer three specific questions a) "Was your tinnitus percept changed by the music therapy?" (Answers: worsened - unaffected - improved) and b) "Which elements from therapy did you consider helpful?" (open question). In the logistic regression demographic, therapy and tinnitus related factors were entered in the model to define those factors that are associated with tinnitus and may therefore contribute to therapy success.
Therefore there is an urge for a short term therapy with preferably minimal effort but long lasting effect. In terms of treatment outcome this group was target underperforming since just less than half of the patients achieved the desired symptom reduction. At the core of the "Heidelberg Model of Neuro-Music Therapy", the patients are actively "confronted" with their individual tinnitus sounds and are told to deal with their tinnitus explicitly instead of trying to take no notice of the tinnitus. These modules enhance the self-determination and the control beliefs of the patients since they learn techniques in order to actively influence their tinnitus. The patients possibly did not know the scientific label of the intervention thus the answers in the feedback-sheet were blurred because the patients could not label this intervention. One specific of the "Heidelberg Model of Neuro-Music Therapy" is the establishment of a tinnitus-equivalent sound. Many patients can voluntarily change the percept of their tinnitus by for example teeth clenching, pressure on the occiput, forehead, vertex and temples, head turning and shoulder abductions 36. Frequency discrimination training may interrupt the cortical representations that are generating tinnitus 42,43. This module increases the auditory filtering and supports a modified emotional processing of the tinnitus sound. The MTLS is suspected to be responsible for the establishment of a "tinnitus memory" similar to the pain memory. Further studies are needed in order to evaluate which elements of the music therapy contribute most to the overall effect and to scrutinize the proposed working factors of the modules. The treatment of tinnitus related psychological distress is part of the music therapy concept, though the duration is very short and music therapy presents a focal therapy and no in-depth psychotherapy will be possible. University Hospital for Ear, Nose, and Throat - University of Heidelberg - Heidelberg - Germany.
Tinnitus outpatient department - German Center for Music Therapy Research - Heidelberg - Germany. A retrospective review of patient records was performed with the objective of collecting demographic and audiological information and identifying changes in score on an established tinnitus questionnaire (Tinnitus Reaction Questionnaire [TRQ]) after treatment. Though the precise etiology in most cases is unknown, an abnormal interaction between peripheral and central auditory pathways is believed to play a role in tinnitus development [2]. The TRQ has been used extensively in research protocols and is useful as a means of measuring a change in a subject's tolerance of tinnitus [2,11].
Historical, demographic, and audiological information was reviewed, and the percent change in TRQ score was calculated for those patients completing the treatment course.
A total of 47 patients underwent the initial assessment and went on to receive the Neuromonics device. At different stages in the treatment protocol, the white noise is added or taken away to help mask the tinnitus or aid in desensitization, respectively. Each patient completed the TRQ, a 26-question survey designed to measure patient attitudes and thoughts about their tinnitus over the previous week (Table 2).
The audiologist set the minimum volume of the device, determined the levels for use at different stages in the protocol, and discussed device usage and management with the patient.
Again, they were asked questions regarding the level of interaction with their tinnitus and any relief experienced up to this point. The broadband masking threshold, loudness discomfort levels, and residual inhibition levels were retested. Chi-square was used to compare categorical variables between groups, and analysis of variance was used to test differences between group means.
Table 3 shows the mean TRQ scores for each of the three groups and all patients at each test interval.


Significant research efforts have been undertaken over the last two decades to better understand the causes of tinnitus and to examine the effects of various proposed treatments [3,4,14-17]. Fifteen of the 47 patients (32%) enrolled in the treatment protocol eventually returned their device and did not complete treatment. Unlike those with a specific disease process, patients with tinnitus need not necessarily go through a series of progressively more involved treatments. In the current study, we found no significant correlation between final percent change in TRQ score and initial TRQ score, although patients with initial TRQ scores higher than 26 had a larger percentage reduction in TRQ score (see Table 4). Hearing aids must still be considered a valuable and successful therapy for patients suffering from hearing loss and tinnitus and should be discussed as a treatment option for appropriately selected patients. Though research efforts continue to try to understand the mechanisms and causes of subjective tinnitus, new treatments are being developed to aid those suffering from this difficult problem. Association between suppression of otoacoustic emissions and annoyance levels in tinnitus patients with normal hearing.
For the purpose of comparison, a control group was formed, which consisted of 17 subjects with no hearing complaints and normal hearing. The annoyance caused by tinnitus has negative impacts on the life of affected individuals, reducing concentration and sleep and compromising emotional balance and social life. However, about 10 to 20% of individuals with normal hearing thresholds have tinnitus in any time of life8-13.
The efferent olivocochlear bundle is composed of two systems: the medial system, which innervates outer hair cells, and the lateral system, which innervates inner hair cells.
Suppression may be absent in cases of tinnitus, but its association with possible dysfunction in the medial efferent tract has not been confirmed. Thus, two patients may not perceive tinnitus in the same way, but all of them agree that the discomfort caused by it leads to anguish and despair17-19. Therefore, the aim of the present study was to investigate the occurrence of this association. Next, OAE testing was performed and 20 subjects with normal results for distortion product otoacoustic emissions (DPOAEs) and transient evoked otoacoustic emissions (TEOAEs) were included in the study (tinnitus group). Exclusion criteria were audiometry tests showed hearing thresholds above 25 dB or abnormal OAEs, the presence of neurological disorders, drug treatment for tinnitus and ototoxic drug use. A value higher than 0.5 dB was defined as a suppression effect as described by Velenovsky & Glattke20.
The results were tabulated and analyzed statistically using descriptive statistics and parametric (Student t-test) and nonparametric tests (Pearson's chi-square test). No significant differences were observed; however, the mean response amplitude was higher in females both in the control and tinnitus groups at all frequencies tested. As can be seen in Figure 1, the absolute values of the suppression effect decreased with increasing discomfort caused by tinnitus. Trends of suppression effects according to tinnitus intensity assessed by the Tinnitus Handicap Inventory in subjects of the tinnitus group (ANOVA for trend analysis).
Sanchez et al.21 observed continuous tinnitus in 69% of cases and data from the Oregon Hearing Research Center22 revealed the presence of continuous tinnitus in 85 to 90% of the subjects studied.
Silence was reported to worsen tinnitus by 66% of the subjects, followed by nighttime (61%) and anxiety (54%). Changes in cochlear function are likely to be detected by the OAE test before the audiogram shows hearing loss24-26. However, the annoyance caused by the symptom is not associated with the degree of hearing loss11.
In the present study, although not statistically significant, the amplitudes of the DPOAE and TEOAE responses were also greater in women both in the tinnitus and control groups. We found no studies in the literature providing reference statistics regarding the occurrence of normal OAE suppression in normal-hearing adults, but some studies involving a control group reported data about the presence of a suppression effect. It is therefore difficult for researchers to select a homogenous group of subjects with tinnitus for the development of studies. Hood et al.34 investigated the suppression of OAEs by testing different intensities of the contralateral noise (50, 55, 60, 65 and 70 dB) and concluded that an association exists between the suppressor noise and active cochlear mechanisms and efferent function.
There was also no significant difference in the occurrence of suppression effects between the two groups, although the suppression values were lower in tinnitus patients. In contrast to the present study in which ears were analyzed independently, these authors performed an analysis according to subject and observed that in subjects with unilateral tinnitus the efferent system seemed less efficient on the side of the symptom since OAE suppression was lower in ears with tinnitus35.
The annoyance caused by tinnitus severely impairs the quality of life of about 2% of the population. Studies have reported that the annoyance of tinnitus decreases over time, suggesting that the patient becomes accustomed to the symptom37,38. Tinnitus patients exhibited a lower overall suppression effect and suppression according to frequency than control subjects. A large proportion of patients with tinnitus have anxiety and depression disorders associated with the symptom. The authors suggested that, although cochlear dysfunction is a possible cause of tinnitus, it is not associated with the annoyance caused by the symptom. Studies in the literature have reported an association between tinnitus annoyance, anxiety, and depression. The authors concluded that tinnitus annoyance is not associated with normal or abnormal brainstem auditory evoked potentials (BAEPs), suggesting that dysfunction at the brainstem level is not related to annoyance. However, this finding was also common in control subjects, with no significant difference between groups. Further studies involving a larger sample of tinnitus patients with normal hearing in each annoyance category are needed, despite the difficulty in obtaining a homogeneous group of subjects with tinnitus and normal hearing thresholds and OAE tests. Figueredo RBS, Corona AP Influencia do zumbido nos limiares auditivos de altas frequencias.
It may be intermittent or constant, mild or severe, and vary from a low roar to a high-pitched type of sound. Because the function of the auditory (hearing) nerve is to carry sound, when it is irritated from any cause the brain interprets this impulse as noise. The most common form of tinnitus is audible only to the patient; this is called subjective tinnitus. Because the muscles are attached to one of the middle ear (hearing) bones these contractions may result in a repetitious sound in the ear. This may be noticeable when an individual has a fever, a middle ear infection, or after engaging in strenuous exercise. This can be due to thickening of the blood vessel wall (a normal occurrence as one grows older), a kink in the vessel or an abnormal growth on the vessel wall. This may be due to infection, allergy or circulatory disturbances which produce changes not only in the fluid, but also in the encasing membranes of the inner ear.
The slightest swelling or interference with these delicate cells from any cause readily produces impairment of function and irritation.
After reviewing the many causes of this symptom it is easy to understand why the hearing may at times be affected when tinnitus is present. Patients of this type are also the ones who are most likely to benefit from biofeedback treatment. In most cases however, there is no medical or surgical treatment which will eliminate tinnitus. Make every effort to avoid nervous anxiety, as this only stimulates an already tense auditory system. Learn as quickly as possible to accept the existence of the head noise as an annoying reality and then try to completely ignore it as much as possible. Any white noise in the room, will serve to mask the irritating head noises and make them much less noticeable.
If one sleeps in an elevated position with one or two pillows, less congestion to the head will result and the tinnitus may be less noticeable.
Treatment consists of biofeedback exercises in hourly sessions, in which the patient learns to control circulation to various parts of the body and relax muscles attached to the head. The device resembles an MP3 player with head phones and is worn for 1 to 2 hours a day over a period of weeks to months. The information should not be used for diagnosing or treating a health problem or a disease and should not be substituted for professional medical care. However, no prior studies have evaluated the possible overlap between tinnitus habituation and acceptance processes in chronic tinnitus sufferers.
They were asked to complete an online survey asking about their tinnitus history and recent experiences of tinnitus habituation, sensitization to tinnitus noise, and tinnitus acceptance, and distress.
That is in this study, tinnitus-habituation items tapped perceptual awareness and behavioral responses to tinnitus, whereas tinnitus acceptance items tapped cognitive responses to the noise (i.e.
Most people with chronic tinnitus are not too bothered by the noise and eventually learn to adapt to it4. Taken together, the results suggest that tinnitus is less likely to distress an individual over time. Hallam's Habituation Model of Tinnitus Suffering12 posits that tinnitus distress may be symptomatic of a sufferer's failure to habituate to the noise.
Thus, acceptance permits a person to view a situation non-judgmentally and in the present moment as suggested by Kabat-Zinn as cited in the study of Segal et al.20.
However, tinnitus habituation involves an automatic, subconscious, and unintentional shift of attention away from the noise (i.e. Respondents were required to be 18 years or older and to have experienced tinnitus for one-month or more. If consensus was reached, TRS items were retained in the scale, resulting in an initial 87-item scale. The scale items asked the participants to rate the extent to which a series of statements applied to them or their tinnitus, using scales ranging from 0 (not at all true) to 10 (perfectly true).
The scale has four subscales: general distress, interference, severity and avoidance, but only total scores are usually computed, as was the case in this study. In an Exploratory Factor Analysis (EFA) we examined the factor structure of the seven TRS-acceptance items15 and 19 habituation items (26 items in total) obtained from an early version of the TRS (87-items).
Nonetheless, mindfulness-or acceptance-based tinnitus treatments have recently been shown to be effective21,22, and possibly more effective than habituation-based treatments (e.g. First, both processes describe a state of non-reactivity to tinnitus noise that may lead to a lessening of the contingency between tinnitus noise and habitual distress15,19,20. This analysis showed that all but one of the scale items loaded strongly onto a single factor (i.e.
With regards to timing, tinnitus acceptance cognitions might be expected to enable a person with chronic tinnitus to adopt a non-judgmental and neutral regard for the noise, which can then facilitate their habituation to the noise.
That is, tinnitus habituation and acceptance appear to be similar and potentially complementary processes of tinnitus adaptation. First, audiological characteristics of the sample were not obtained just self-reports of their clinical condition. School of Cognitive, Behavioural & Social Sciences - University of New England - ARMIDALE - Australia. It was based on the knowledgement that the auditory system also works during sleep, processing the incoming information. The physiological abnormalities that cause subjective tinnitus perception arise in the central nervous system (CNS). Twenty two patients were evaluated; thirteen of them complied with inclusion criteria and were studied, two abandoned the treatment, remaining eleven within the protocol. Patients were evaluated by a psychologist at the beginning of the treatment and also in the middle and at the end of it. Patients' sleep conditions were clinically evaluated, exploring possible insomnia related to tinnitus or other sleep disturbances (i.e.
Sound generation and stimulation were programmed to reproduce a sound with the same characteristics as that of each patient's tinnitus. Uma, a amplitude da resposta em frequencias diferentes das iPod (cinza traco) eo notebook (preto traco) resposta mostrando apartamento ao longo da largura de banda de trabalho. After concluding the otolaryngology evaluation, eleven patients began the treatment and they were followed up and evaluated during 24 weeks. Each patient was seen by a psychologist three times, at the beginning, the middle and the end of the treatment. Five out of eleven patients had sleep disorders at the beginning of the treatment, four of them suffered insomnia characterized by difficulty to fall asleep with the corresponding daytime consequences such as tiredness, lack of energy, concentration difficulty, irritability. The present protocol was based on the tenet that most forms of tinnitus are caused by functional changes; thus, it should be possible to reverse them by proper sound treatment taking advantages of the neural plasticity properties of the CNS. University of Auckland senior lecturer Grant Searchfield said there were enough reports from those with tinnitus who had taken ecstasy for him to be interested in what the effects could be. Tinnitus distress was assessed using the German version of the Tinnitus-Questionnaire (TQ) at admission, at discharge and six months after therapy. Therapy impact seems to be lasting since TQ scores remained stable until follow-up at six months.
For that reason the predominant wish of the patients is to get rid of the "annoying" and "intrusive" sounds5 and to regain confidence in their sense of hearing.
Usually these sounds should be blocked off by feedback connections from limbic regions before reaching the auditory cortex. Musically based interventions11,12,13 also have proven to be highly effective in treating chronic tinnitus - possibly by correcting tinnitus evoking neuronal mechanisms14. If they could actively influence their tinnitus, their control beliefs will rise and thus let down the strains15. Purpose-built music therapeutic interventions were merged to modules and integrated into a standardized manual. During the interval between the sessions, the patients have to exercise themselves in Resonance Training for three minutes every hour. For this purpose, before the training session starts, the patients have to set the background music to a convenient level such that they can easily listen to the music while still being able to follow verbal instructions from the therapist.
Only patients coming from the proximity of Heidelberg were allocated in a randomized way (computer generated) either to the ST group or the PT group.
The regression analysis reveals a highly significant relationship between the tinnitus score and the independent variables (p 2= 0.43). The proposed therapy concept "Heidelberg Model of Neuro-Music Therapy" seems to be a potential completion of the therapy spectrum. Given that this group received also placebo music therapeutic elements (active listening to preselected musical pieces) and an individual counseling, it seems reasonable to argue that the positive and long lasting effect of the music therapy according to the "Heidelberg Model of Neuro-Music Therapy" is due to the far more specific and active musical training aiming directly at the individual tinnitus sound. There exists a variety of procedures using a combination of counseling and acoustic stimulation. In doing so, the duration of the therapy does not exceed ten weeks (standard therapy) and can even be compacted to five days (compact therapy). Many patients stated though that they would enjoy singing or listening to music subsequent to the therapy. Levine 37 proposed interactions between auditory perception and somatosensory input at the dorsal cochlear nucleus. Experimental data indicate that it is more efficient to train at normal hearing frequencies rather than in the region of hearing loss or tinnitus frequency 44,45. Biocybernetics of attention in the tinnitus decompensation: An integrative multiscale modeling approach.
Development and psychometric adequacy of the screening version of the tinnitus handicap inventory.
Final common pathway for tinnitus: theoretical and clinical implications of neuroanatomical substrates. Intensely pleasurable responses to music correlate with activity in brain regions implicated in reward and emotion. The rewards of music listening: response and physiological connectivity of the mesolimbic system.
Auditive stimulation therapy as an intervention in subacute and chronic tinnitus: a prospective observational study. A multi-centre study on the long-term benefits of tinnitus management using Neuromonics Tinnitus Treatment.
Listening to tailor-made notched music reduces tinnitus loudness and tinnitus-related auditory cortex activity. A cognitive model of tinnitus and hyperacusis; a clinical tool for patient information, appeasement and assessment.
Musiktherapie bei Tinnitus: Interdisziplinare Pilotstudie zur Uberprufung des Heidelberger Modells. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research.
Enriched acoustic environment after noise trauma reduces hearing loss and prevents cortical map reorganization. Treatment of tinnitus with a customized, dynamic acoustic neural stimulus: underlying principles and clinical efficacy. Cross-modal interactions of auditory and somatic inputs in the brainstem and midbrain and their imbalance in tinnitus and deafness.
The effect of a new treatment based on somatosensory stimulation in a group of patients with somatically related tinnitus.
Auditory discrimination training for tinnitus treatment: the effect of different paradigms. Auditory perceptual learning at normal hearing frequencies affects changes in tinnitus intrusiveness and percept. Tinnitus suppression by low-rate electric stimulation and its electrophysiological mechanisms.
Classical conditioning as the basis for the effective treatment of tinnitus-related distress.
The dorsal cochlear nucleus as a participant in the auditory, attentional and emotional components of tinnitus. Forty-seven patients initiated treatment with the Neuromonics device during the study period. Various therapies have been proposed for the treatment of tinnitus, including the use of masking devices, hearing aids, cognitive behavioral therapy, habituation programs, acupuncture, transcranial magnetic stimulation, and various herbal and vitaminbased supplements [3-10].
We hypothesize that the Neuromonics device can aid in tinnitus desensitization and lessen patient symptomatology and, thus, is a unique therapeutic option. All patients were referred by physicians in our clinic to audiologists within the clinic specializing in tinnitus treatment. There was a wide range of duration of tinnitus prior to using the Neuromonics device, with the majority of patients having had tinnitus for 5 years or less. Treatment with the Neuromonics device is designed to be received through the use of individual earphones.
For each question on the TRQ, a score from 0 to 4 is possible, with a total TRQ score that may range from 0 (no bothersome tinnitus) to 104 (maximally bothersome tinnitus).
At 2 weeks after the initial assessment, patient use time was uploaded from the device to a computer. At this point, patients were counseled to turn the volume of the device down so that they could hear their tinnitus 60% of the time and the music the remaining 40% of the time (with the device on) for desensitization purposes. Paired samples t-tests were used to evaluate the difference in initial, final and initial, and second TRQ scores, whereas independent samples t-tests were used to examine differences between patients with and without prior treatment.
Nine patients felt that the device was of no help, whereas four patients felt it made their tinnitus worse. Table 4 shows the breakdown of mean change to last test by group and initial score category.
Recently, a customized acoustic stimulus delivery system, the Neuromonics device, was introduced as a means of promoting neural plasticity within the auditory system in hopes of minimizing or abolishing tinnitus-related symptomatology [2,14]. The average reduction in TRQ score for this group was 62%, similar to that found in earlier studies [2].
Most reported that the device was of "no help" and felt that the device may have made their tinnitus subjectively worse. Consequently, the Neuromonics protocol may prove equally effective in patients who have and have not tried other treatments. This is not unexpected, as individuals with TRQ scores of less than 26 likely represent patients who are less affected by their tinnitus and consequently are less likely to have a substantial change in their symptoms with any treatment modality.
Further studies will be necessary to determine whether there is a minimum threshold level that is required for patients undergoing treatment with the Neuromonics device, because issues related to maximum device amplitude may arise with more profound hearing losses. The Neuromonics tinnitus treatment protocol was designed to target both the auditory and behavioral components involved in an individual's perception of tinnitus. Treatment of tinnitus with a customized, dynamic acoustic neural stimulus: Underlying principles and clinical efficacy. Biofeedback-based behavioral treatment for chronic tinnitus: Results of a randomized controlled trial. Transcranial magnetic stimulation for the treatment of tinnitus: A new coil positioning method and first results. Effects of repetitive transcranial magnetic stimulation on chronic tinnitus: A randomized, cross-over, double blind, placebo-controlled study.
Tinnitus Reaction Questionnaire: Psychometric properties of a measure of distress associated with tinnitus.
Psychometric adequacy of the Tinnitus Handicap Inventory (THI) for evaluating treatment outcome. Treatment of tinnitus with a customized, dynamic acoustic neural stimulus: Clinical outcomes in general private practice. Treatment of tinnitus with a customized acoustic neural stimulus: A controlled clinical study.
The participants were submitted to hearing tests, immittance testing and tests for the evaluation of acoustic reflexes, distortion product otoacoustic emissions, transient evoked otoacoustic emissions (TEOAEs), and suppression of TEOAEs. Patients with complaints of tinnitus indicate the annoyance of the symptom to be distressing. Several lines of research have been proposed to better understand the auditory pathway in tinnitus patients with normal hearing. These two systems influence the modulation of cochlear activity both by exciting and inhibiting it. For the purpose of comparison, a control group was formed, which consisted of 17 subjects of both genders with confirmed presence of OAEs and no tinnitus complaints.
A recent study published in The Lancet reported that tinnitus is more common in the left ear and usually progresses gradually, but a sudden onset may occur. In the present study, silence was reported to worsen tinnitus by 70% of the patients and anxiety by 40%. In a similar study, Paglialonga et al.27 found altered DPOAE tests in 78% of subjects with tinnitus. However, it was not the objective of that study to establish protocols for clinical practice.
The authors found lower OAE response amplitudes in the tinnitus group compared to the group without the symptom, but the difference was not significant as observed in the present study. The protocol consisted of TEOAE analysis using a stimulus of 65 dB and a contralateral noise of 70 dB. The clinical evaluation of patients reporting annoyance of tinnitus should also include the assessment of mental state. In that study, a significant association was found between the discomfort reported by tinnitus patients and anxiety and depression scores25. However, the authors found statistically significant results when anxiety and depression were analyzed. Jader Reis Reboucas Filho, Head of the Otorhinolaryngology Service, HBDF, for permitting this study on the premises of the Hospital.
A clinical study of the efferent auditory system in patients with normal hearing who have acute tinnitus. Characteristics of tinnitus with or without hearing loss: clinical observations in Sicilian tinnitus patients. Transient and distortion product evoked oto-acoustic emissions in normal hearing patients with and without tinnitus. Comparison of auditory brainstem response results in normal-hearing patients with and without tinnitus. Emissoes otoacusticas e sistema olivococlear medial: paciente com zumbido e sem perda auditiva. Suppression of otoacoustic emissions in populations with normal hearing sensitivity In: Robinette MS, Glattke TJ, eds. Prevalencia de fatores de melhora e piora na percepcao do zumbido em pacientes com zumbido cronico. Relacao do incomodo do zumbido com a funcao das celulas ciliadas externas e os transtornos de ansiedade e depressao em individuos com limiar auditivo normal. Quantitative analysis of cochlear active mechanisms in tinnitus subjects with normal hearing sensitivity: multiparametric recording of evoked otoacoustic emissions and contralateral suppression. Is the degree of discomfort caused by tinnitus in normal-hearing individuals correlated with psychiatric disorders?
Occurrence and suppression effect of otoacoustic emissions in normal hearing adults with tinnitus and hyperacusis.
Contralateral suppression of transient-evoked otoacoustic emissions in humans: intensity effects. Relacao do incomodo do zumbido com os potenciais evocados auditivos do tronco encefalico e com os transtornos de ansiedade e depressao em individuos com limiar auditivo normal.
This circulation increase is temporary and usually subsides when the exertion or fever are reduced.
Further testing may be necessary to determine the cause and treatment indicated in these uncommon cases.
If a hearing loss coexists with tinnitus, the severity of the head noise is not an index as to the future course of the hearing impairment.
At times a symptom such as tinnitus may in itself lead to depression and this can then make the tinnitus more bothersome; a vicious cycle develops. Try tuning the radio in between radio stations and increase the sound level to the same as that of your tinnitus. Please consult your health care provider if you have, or suspect you have, a health problem. In contrast, people with problem tinnitus may be severely affected by the noise in potentially engrossing (e.g.
In addition, several recent EEG studies have reported that tinnitus complainers and treatment-seekers experience deficits in tinnitus habituation such as larger middle-latency potentials and less distinct habituation of the vertex potential to auditory stimuli5,10.
However, tinnitus habituation was narrowly defined in the model as referring to short-interval aversive stimuli, whereas tinnitus is typically chronic in nature. As detailed below, tinnitus habituation and tinnitus acceptance are conceptually similar constructs that share several features in common. In particular, tinnitus acceptance is posited to involve shifting attention away from the noise (which cannot be controlled) toward that which can be controlled (e.g. They were recruited via newspaper advertisements, radio and television interviews, and notices placed in tinnitus newsletters, websites, and noticeboards (British Tinnitus Association), and tinnitus and Meniere's disease internet chat-rooms. The sample was comprised 150 males and 123 females, ranging in age from 18 years to 99 years (M = 51 years; SD = 14). The published version of the scale is reported to have three distinct subscales: tinnitus acceptance, control and defeat.
The scale is reported to have good convergent and divergent validity, and is highly correlated with measures of anxiety, depression and tinnitus. A correlational matrix indicated that most of the correlations exceeded .3, thus, the items appeared to be suitable for factoring. Thus, any overlap between the two processes might be exploited to enhance the efficacy of the two tinnitus treatments. Second, as previously described15, clinical, demographic and psychological data from this sample indicates that the participants were less distressed than tinnitus sufferers in other studies23,28,29, although they did have similar tinnitus characteristics7,30,31.


Consequences of suppressing thoughts about tinnitus and the effects of cognitive distraction on brain activity in tinnitus patients. Development of the Tinnitus Response Scales: Factor analyses, subscale reliability and validity analyses. Mindfulness-based cognitive behaviour therapy for depression: a new approach to preventing relapse. Clients' in-session acceptance and cognitive defusion behaviors in acceptance-based treatment of tinnitus distress.
A randomized controlled trial of mindfulness-based cognitive therapy for treating tinnitus. Tinnitus reaction questionnaire: psychometric properties of a measure of distress associated with tinnitus.
A comparison of benefit and economic value between two sound therapy tinnitus management options. Acceptance and commitment therapy versus tinnitus retraining therapy in the treatment of tinnitus: a randomised controlled trial. Psychological profile and somatic complaints between help-seeking and non-help-seeking tinnitus subjects. It is now evident that most forms of subjective tinnitus are caused by changes in the function of the central auditory nervous system while these changes are not associated with any detectable anatomical lesion. Since the sensory information in general is continuously reaching the CNS, its processing will be differentiated according to the current physiological state of the brain: wakefulness, with different levels of motor activity and attention, and sleep5. Tinnitus Retraining Therapy (TRT) is a behavioral treatment that has roots in the hypothesis that tinnitus is caused by expression of the neural plasticity41,42.
Every patient was evaluated by an otolaryngologist with a clinical interview and specific tests: impedanciometry, tonal liminal audiometry, high frequency audiometry, logoaudiometry, otoacustic emissions (spontaneous, transients and distortion product) and magnetic resonance imaging (MRI). Personal interview to evaluate anxiety and depression, and a specific test for tinnitus repercussion (Tinnitus Handicap Inventory, THI) were done. Audio stimulation was performed using commercial iPod Shuffles (Apple, USA) with their own ear buds.
Sound stimulation was applied through an ipod, to the same side that patients perceived the tinnitus (unilateral or binaural). Everyone improved their insomnia with the tinnitus treatment, two of them - treated chronically with benzodiazepines- abandoned successfully their chronic treatment.
Since we found changes in the auditory tests (TLA, HFA, logo and OAE) in tinnitus patients, we proposed the sound stimulation with the same characteristics in frequencies and intensity as the tinnitus as a way of reinstalling the normal balance in the central level processing of information, hypothesizing that tinnitus emerges to replace an input deficit. Regional cerebral blood flow during tinnitus: a PET case studied with lidocaine and auditory stimulation.
Lateralized tinnitus studied with functional magnetic resonance imaging: abnormal inferior colliculus activation. In vivo approach to the cellular mechanisms for sensory processing in sleep and wakefulness. Firing of inferior colliculus auditory neurons is phase-locked to the hippocampus theta rhythm during paradoxical sleep and waking. Auditory processing during sleep: correlation of cortical unitary activity with hippocampus theta Rhythm. Sleep and wakefulness modulation of the neuronal firing in the auditory cortex of the guinea-pig.
The effects of sleep on the auditory brainstem response (ABR) and the middle latency response (MLR). Late component variants of single auditory evoked responses during NREM sleep stage 2 in man.
Auditory stimulation therapy as an intervention in subacute and chronic tinnitus: a prospective observational study. Treatment of tinnitus with a customized dynamic acoustic neural stimulus: underlying principles and clinical efficacy.
Electrical stimulation of auditory and somatosensory cortices for treatment of tinnitus and pain. Transcranial magnetic stimulation(TSM) for treatment of chronic tinnitus: clinical effects. The western heptatonic musical tonality forms the basis of the active music therapy procedures. The most common side effects are headache and laryngitis if the exercise is not executed properly, either too often, too long or with too much pressure. Group differences of sociodemographic data and audiometric tinnitus characteristics were analyzed with the c2-test or univariate analysis of variance (ANOVA). About 80% of the patients accomplished a reliable decrease of tinnitus pathology in the course of music therapy and about two thirds of the patients describe their tinnitus symptoms as "improved" after therapy.
Often the musical stimuli are spectrally modulated in order to account for hearing impairments31,32 and are incorporated as a passive means patients have to listen to for rather lengthy intervals (months up to years). The main parts of the therapy consist of active music therapy modules; hence there is no need and no purpose for spectrally changing the music used.
We therefore propose that it is possible to alter the internal tinnitus spectrum by means of the Neuroauditive Cortex Training, which represents a specific perceptual training within the normal hearing frequencies. RF neurons coordinate sensory and motor functions and influence cortical activity via the thalamus. Fourteen patients completed treatment, and another 18 were actively undergoing treatment at the end of the study period. Though some of these treatments have proven beneficial for select patients, a definitive treatment for tinnitus remains to be discovered.
Patients subsequently completed a tinnitus history questionnaire that included demographic information and information about prior ear surgeries, duration of tinnitus, affected ear(s), any prior treatments aimed at tinnitus relief, and any history of medical problems or comorbid conditions. Discussion about device use ensued, and questions regarding interaction with the treatment and relief obtained were asked and recorded. During phase 2, the wideband noise was dropped completely, and the patient listened only to the relaxing music during Neuromonics use. They were also instructed to decrease use of the device to 2-4 hours per week and, eventually, to use it only when needed (maintenance phase). Pearson correlation coefficients were computed to examine the relationships between PTA, initial TRQ, and percent change in TRQ. The few patients in the lowest initial TRQ score category had the smallest average change, but score categories beyond that showed little difference. Preliminary data reported on the use of the Neuromonics device have shown that more than 80% of patients achieve clinically significant reduction in their tinnitus, defined as a greater than 40% reduction in tinnitus disturbance as measured by the TRQ [18]. Moreover, 11 of 14 (78.6%) had a greater than 40% reduction in TRQ score over the course of the treatment, a definition for success that has been used in prior studies [2]. The average initial TRQ score for this group was 53.9, a value that fell between the average initial scores for the completed and active groups.
Most patients in this study received some form of prior treatment, but the mean percent reduction in TRQ score for patients in the completed group without any prior treatments (n = 4) was not significantly different from that of those with prior treatments (n = 10). We also found no significant correlation between initial TRQ score and duration of use of the device.
Its specialized acoustic stimulus targets the effects of auditory deprivation while its relaxing music is intended to reduce involvement of the limbic and autonomic nervous systems in the perception of tinnitus. The tests were performed in a sound-treated booth using a linear contralateral noise of 60 dB.
There are reports of attempted suicide as a result of the despair and disability caused by tinnitus. One of these lines advocates that changes at central levels of the auditory system and in the efferent pathway, more specifically in the superior olivary complex, are one of the causes of tinnitus in normal-hearing individuals, although the role of the efferent system in the etiology of tinnitus remains unclear14-16. The function of these systems can be measured through the suppression of evoked otoacoustic emissions17.
For analysis of the suppression effect, an ipsilateral linear click presented at an intensity of 65 dB NPS was used as the evoking stimulus.
However, the difference between these two groups was not statistically significant (Table 3).
In the present study, there was a predominance of bilateral tinnitus, and in cases of unilateral tinnitus the left ear was more frequently affected. The authors emphasized that DPOAEs were more sensitive in detecting outer hair cell dysfunction in individuals with tinnitus than TEOAEs. Patients who require sick leave due to tinnitus are up to three times more likely to receive disability retirement than patients with other diseases36.
The value of OAE suppression of tended to decrease as the level of annoyance caused by tinnitus increased. Patients with tinnitus are more likely to develop symptoms of depression than those without tinnitus28. The results of that study demonstrated that the severity of tinnitus annoyance is associated with the severity of anxiety and depression disorders and not the auditory causes themselves39. The present study suggests that, although dysfunction of the medial efferent system is one of the theories accepted as an etiology of tinnitus, the changes found in this system do not seem to be related to the annoyance reported by the patients of this study. If you are exposed to certain sounds which increase our head noise, make it a point not to repeat that experience. However, after ongoing exposure to the noise a gradual lessening of awareness is experienced that can bring about a lessened contingency between tinnitus noise and its' habitual meaning or consequences (e.g.
Thus, different tinnitus subgroups seem to exist in terms of the cortical processing of tinnitus-like, externally-presented stimuli: (a) people who readily habituate to external noise, and (b) those who find it difficult to habituate to it.
First, habituation is described as an automatic, effortless, subconscious, and unintentional shift of attention away from tinnitus noise with each new episode of tinnitus awareness14,17.
They were asked to click on the imbedded study URL in the advertisement which took them to the online survey.
The TRS has high reported internal consistencies with all the subscale Cronbach's alphas reported to be above .8015. However, as detailed below, tinnitus habituation and acceptance are likely to be related and overlapping processes.
However, mindfulness-based tinnitus treatments may already include an implicit focus on tinnitus habituation processes, albeit involving the cognitive aspects of this adaptation process.
Third, survey-based approaches have not previously been used to evaluate tinnitus habituation. The stimulus was a sound that mimetized the tinnitus and was fixed at the same tinnitus intensity, applied through an iPod.
The subjective tinnitus may be the result of the expression of neural plasticity and anomalies may develop because of decreased input from the ear, deprivation of sound stimulation, overstimulation or yet unknown factors1. Early in the twentieth century, the concept of sleep as the result of a blockage of the auditory inflow was introduced6 while, later on, Bremer7 proposed that it was the extensive deafferentation of ascending sensory impulses to the isolated brain that resulted in sleep. The aim of TRT is to psychologically disconnect the patient from dependence on the tinnitus while subjecting the patient to moderate levels of sounds to reverse the effect of sound deprivation on the function of the CNS43. Also general evaluation was done through routine tests (blood lipids, serum thyroid hormones, glucose test, urea and electrolytes, creatinine, complete blood test, urine test). Conventional Polysomnography was recorded in two patients, during two nights each one (first night without sound stimulation and the second one during the stimulation with their specific sound) in order to analyze potential hypnograms changes due to the sound.
All sounds were created with custom software developed in Matlab, creating complex sounds by combining pure tones, white and pink noise and filtered white noise (peak filter, Q) at 44100 samples per second. Aplicando a linearidade dos sons criados, vamos supor que todos os sons mostram a mesma resposta e poder tanto no caderno e saida iPods (tensao).
Each night, patients fixed the sound stimulation intensity at the tinnitus masking level, selecting among the 25 ipods steps. Between 1 and 6 years of tinnitus evolution were considered, with no differences in the results presented. Everyone has a particular lifestyle, with demanding jobs and no vacation time by own initiative.
Mutual stimulation via both the thalamic and paralimbic pathways ultimately lead to tonotopic changes in the auditory cortex7 while reciprocal innervations of the medial temporal lobe system give rise to memory consolidation leading to a paradoxical "tinnitus memory"6. Therefore the Neuro-Music Therapy is indicated only if the patients indentify their tinnitus as "tonal" (sinus tones).
Any psychiatric disorder or ongoing medication with antidepressants or antipsychotic drugs yields to exclusion of the patients. Selection of the musical pieces was based on the individual musical taste and preferences as well as on the emotion evoking impact of the musical pieces.
Therapy outcome as assessed by the TQ and the CPT were evaluated using univariate analysis of variance (ANOVA) for repeated measure procedures. This effect was independent of the patient"s treatment allocation to standard therapy or compact therapy.
Additionally, a tinnitus-equivalent sound provides the possibility to deal with the symptoms in an immediate and direct way. Therefore an activation of cranio-cervical and cranio-facial muscles and nerves by means of the Resonance Training might correct the auditory pathway by means of indirect stimulation of the joint "relay-station" cochlear nucleus 36.
Furthermore it is very important to ensure the training regime is intrinsically motivating.
Stress is considered to potentiate the severity of tinnitus due to the proposed accompanying reduction and alteration in auditory masking 6. The Neuromonics tinnitus treatment protocol (Neuromonics Pty Ltd., Sydney, Australia) is a relatively recent therapeutic option that was developed to target both the auditory and behavioral components involved in an individual's perception of tinnitus [2]. The completed group consisted of 14 patients who completed the 6- to 8-month course of treatment with the Neuromonics device.
Although the incomplete group appeared to have a larger percent of patients in this long-duration category, there were only a very small number of such patients (n = 3), and the difference from the other two groups (each n = 1) was not statistically significant. Pure-tone audiometry with supraaural headphones was performed at inter-octave frequencies from 250 to 8,000 Hz, with additional highfrequency testing from 10 to 12.5 kHz. During this phase, the background wideband noise was consistently present while the intensity of the relaxing music was periodically altered.
We also examined initial TRQ score and percent change in TRQ score at last test as a function of reported duration of tinnitus symptoms (Table 5). However, owing to its recent introduction, there are a limited number of studies evaluating the therapeutic effectiveness of the Neuromonics device in clinical practice. The two additional groups in our patient population were those patients who were still actively undergoing treatment at the end of the study period (active group) and those who returned their device (incomplete group). There is a need for continued research to examine whether a single treatment modality or multiple treatment methods, either simultaneously or in succession, is necessary for optimal relief of tinnitus.
That is, initial score was not predictive of who found the device of no help and gave up its use early.
Based on the results of our study, the Neuromonics device appears to be useful as a means of significantly reducing the effects of tinnitus on an individual's daily life. The presence of suppression effects was defined when the response amplitude was 0.5 dB or higher. The suppressor noise consisted of contralateral white noise stimulation at intensity of 60 dB NPS. Regarding factors that improve the symptom, in the study of Cortina et al.23, noise was mentioned by 38% of the participants and periods of rest by 26%.
This finding provides further evidence of involvement of the efferent system in the generation of tinnitus. However, it is less clear whether the same processes underpin the habituation to internally-induced, tinnitus noise.
Thus, in reality, a person must repeatedly habituate to the tinnitus each time the noise enters their awareness, and this awareness can be amplified by external noise, quiet, or even stress13.
That is, tinnitus adaptation is posited to occur at both the perceptual and psychological response levels.
That is, if the noise is regarded by a person as being meaningless and harmless then an orienting response to the noise may not occur, although habituation may occur.
That is, similar to tinnitus habituation, tinnitus acceptance has the potential to lessen the contingency between tinnitus noise and habitual distress by providing sufferers with the opportunity to view their situation dispassionately and reflect on the validity of these judgements, thoughts, feelings, and behaviour, thereby, dampening the effects of any negative thoughts on psychological wellbeing15.
Consistent with this overlap, we evaluated the premise that the two tinnitus processes are overlapping and related aspects of tinnitus adaptation.
Participants had had their tinnitus for different lengths of time with 59% having had tinnitus for more than 5-years (n = 160), 27% had tinnitus for 2 to 5 years (n = 73), and 14% had tinnitus for less than 2-years (n = 39); one participants did not indicate the duration of their tinnitus. In this study, only the seven acceptance items from the TRS were evaluated along with 19 additional items that tapped the perceptual and behavioural aspects of tinnitus habituation. Most of the TRS-acceptance items (except the item "I leave situations because I cannot tolerate my tinnitus noise") and all of the habituation items loaded onto a single factor, tinnitus adaptation, which explained 40.2% of the item variance, see Table 1 for factor loadings of the different items. Thus, there may be some synergy or complementarity between the two treatments, although such a premise has yet to be evaluated. Thus, it is possible that this approach failed to capture the automatic behavioural experiences of tinnitus habituation that were beyond conscious recall or the understanding of the tinnitus sufferer. All patients decreased their tinnitus intensity in the first month of treatment (statistically significant), most of them in the first week. Furthermore, patients whose sleep was most disturbed rated significantly greater tinnitus annoyance in the evening underscoring the influence of tinnitus on sleep disorders38. Other tinnitus therapies based on sound are being applied as an special program of music therapy that strives to integrate the tinnitus sound into a musically controllable acoustic process44, sequential sound therapy45 and customized sounds46,47.
The inclusion criteria were adult patients with idiopathic subjective tinnitus, with normal imagenology and without any organic causes. Conventional Polysomnography consisted in six electroencephalographic recordings, eye movements, electromyogram, respiration, oximetry and electrocardiogram.
These sounds could be created selecting their frequency, power (relative to full scale), Q and duration. Patients wrote down each night the stimulation intensity and the hours stimulated, together with other observations that they considered important (illnesses, relevant stress situations, etc.). Tinnitus intensities were normalized as steps in the ipod, being 25 the highest for each patient before beginning the treatment (week 0).
Three of them have obsessive personality and one was depressive and rejected psychotherapy. According to the results from the regression analysis, there was - apart from tinnitus masking level - no influence of tinnitus characteristics or otological co-symptoms on therapy success. A deliberate regulation of emotional responses towards the tinnitus sounds might enhance gate control mechanisms and restore misdirected "filter functions" of thalamic and limbic areas. Of those who completed the treatment, the mean posttreatment TRQ score was significantly lower than the pretreatment score ( p ~ .001).
This therapy involves the use of a specialized acoustic stimulus aimed at targeting the effects of auditory deprivation and relaxing music to reduce involvement of the limbic and autonomic nervous systems in the perception of tinnitus. The active group consisted of 18 patients who were actively undergoing treatment but had not yet completed the planned course at the end of the study period. Most of the patients (72%) had reported trying prior treatments, including hearing aids (n = 8), maskers (n = 10), music (n = 9), vitamins (n = 11), biofeedback (n = 2), tinnitus retraining therapy (n = 1), and other therapeutic options (n = 7). The number of patients in any one group and duration category are too small for statistical analysis, but there appears to be a tendency for those with a very short duration of symptoms to show the most improvement.
Of all patients with at least one follow-up TRQ, 75% had a greater than 40% reduction in TRQ score.
Nevertheless, it will be important to delineate which candidates are more likely to benefit from treatment with the Neuromonics device, and initial severity of symptoms is a factor warranting further study.
Future clinical studies are needed regarding the precise candidacy criteria and longer-term efficacy of this novel treatment device.
About 20% of patients with tinnitus report significant annoyance associated with major impairment of quality of life4-7.
In the present study, 30% of the patients reported background sounds (radio or TV) and music to improve tinnitus. Thus, some people appear to become sensitized to and do not adapt to the noise, increasing their chances of experiencing tinnitus distress3,6 and related problems such as concentration difficulties, frustration, annoyance, irritability, fear, worry, sleep problems and mood disturbance4,6,7.
However, if the person happens to experience fear, annoyance or distress in response to the noise they may become sensitized to it and fail to habituate to the noise8. Such an interpretation is consistent with Jastreboff's Habituation Model of Tinnitus14 which posits that tinnitus perception (e.g. About 29% (n = 80) had not received a formal tinnitus diagnosis or could not recall having received the diagnosis. That is, all but one of the items loaded strongly onto factor 1, with many cross-loadings around .3 or below on factors 2-4. Further, the seven-item TRS-24 acceptance subscale and the 19 habituation items were very highly correlated with each other. Finally, the results were only cross-sectional in nature therefore precluding any causal inferences being drawn. Taken together, the results suggest that tinnitus adaptation is comprised of a cognitive component (i.e.
Tinnitus intensity continued decreasing in the following weeks; three patients presented periods of total silence. In a number of patients subjective tinnitus may be initiated by a discontinuity in the spontaneous or low-level stimulus inducing neural activity across auditory nerve fibers with different characteristic frequencies (CFs). Electrophysiological approaches as unitary recordings, immunoreactive staining techniques as well as functional magnetic resonance imaging in humans are some contributions to such concept8-10.
On the other hand, daytime sleepiness is more common in subjects with tinnitus and it is even more frequent in patients with both tinnitus and poor sleep39.
Many of these therapies are still under investigation and only some of them have been objectively evaluated in clinical trials48. This research has been approved by the Ethical Committee of the Faculty of Medicine CLAEH University, according to the International Ethic Guidelines for human research.
Table 2 shows audiological evaluation; while all patients showed alteration in at least one of the parameters explored, no one needed to be equipped with audiphones.
Personal interviews with the psychologist showed the patients' evolution much better than the THI scale, which did not appear as a precise technique to evaluate evolution, at least when the degree of tinnitus repercussions were not severe. Patients were continuously clinically evaluated and two of them were also studied by polysomnography.
Systematic desensitization is also used to combat the attentionrelated component of an individual's perceptive response to tinnitus.
The incomplete group was made up of 15 patients who returned their device or chose not to complete the course of treatment during the study period. All patients were counseled regarding the nature and course of tinnitus as a complex symptom and their candidacy for the Neuromonics device.
Across all patients, the mean percent improvement declines slightly with each increment in duration, although this did not achieve statistical significance. Our data were somewhat limited, as the number of patients who successfully completed the protocol with initial TRQ scores at either extreme was small. The equipment possesses a semi-automated method in which samplings are presented alternately in the presence or absence of the suppressor noise at an interval of 3 seconds.
A similar proportion were diagnosed by a general practitioner (n = 80) or ear-nose-throat specialist (n = 76) and the rest (n = 26) received the diagnosis from an audiologist. The correlation between the TRS-acceptance items and a subscale comprised of the 19 habituation items was shown to be high (r = .81). This discontinuity may be caused by functional loss of outer hair cells in those regions where inner hair cells are preserved.
Velluti and co-workers postulated the sensory systems as a main factor in active participation in sleep processes11-14. After the sound mimicked the perceived tinnitus, it was saved as a .wav file (16 bit, PCM) and consequently loaded to the iPod Shuffle. Changes neither in the sleep stages percentages nor in the sleep architecture (hypnogram) were exhibited when comparing two completed nights (with and without sound stimulation) in each patient.
Across all 47 patients, 48.9% achieved a successful reduction of 40% or greater in TRQ score.
Although only the completed group had final TRQ scores, some patients in the other groups had one or more follow-up tests. Further clinical information will be needed to determine whether patients with extremely high initial TRQ scores, and thus more bothersome tinnitus, are perhaps more likely to benefit from treatment. The reduced spontaneous activity for nerve fibers with CFs in the hearing loss range may result in a reduction of inhibition, mediated by the auditory efferent system, at more central levels4. The processing of sensory information is definitely present during sleep, since profound modifications occur. These facts underscore the importance of identification and successful treatment of sleep disorders in patients with tinnitus.
Drugs have not demonstrated to provide replicable long-term reduction of tinnitus49; many of them are still at a research level, such as transcranial magnetic or cortical electric stimulation of the auditory cortex50,51. Nevertheless, the relative reduction and the individual improvement (reliable change index) were independent from the basic TQ-value - therefore also patients with comparatively lower strains still benefit from the therapy in equal measure. There was no correlation among pure-tone average, initial TRQ score or duration of use, and percentage change in TRQ score for those with at least one follow-up test. In brief, most (85%, n = 232) of the participants reported that their tinnitus loudness was variable over time, and about two-thirds described their tinnitus awareness as constant (65%, n = 177).
This reduced inhibition of neurons with CFs induces hypersensitivity and hyperactivity in these neurons, generating a "phantom sensation", that is a sensation referred in a different location on the body (in this case usually the ear) than the anatomical location of the abnormality that causes the symptoms1.
All sensory systems reviewed, visual, auditory, somesthetic and olfactory, as well as temperature receptors, etc., demonstrate some influence on sleep and, at the same time, the sensory systems undergo changes that depend on the CNS sleep or waking condition. The custom software was programmed to adjust the power of the sound signal in order to have equal full scale voltage output.
Based on these preliminary findings, treatment with the Neuromonics device is successful in reducing TRQ scores in appropriately selected patients with tinnitus.
Since most forms of severe tinnitus are caused by functional changes, it should be possible to reverse it with proper sound treatment, taking advantages of the neural plasticity properties of the CNS. From several viewpoints, the auditory is a special system related to sleep neurophysiology, exhibiting a series of unique associated changes12,15,16. The same ear buds were used to mimic and deliver the stimulus, thus ensuring that equal voltage would be transduced into equal sound pressure. Otoacoustic Emissions (OAE) -spontaneous, transient and distortion product- were recorded in each patient. Given the conceptual overlap between the two processes, these results may indicate that there is some merit in testing for possible synergy between habitation- and acceptance-based therapies for the treatment of problem tinnitus. The auditory incoming signals to the CNS may change the sleep characteristics, while, conversely, the CNS can control by feedback mechanisms the auditory input in close correlation with the sleep-wakefulness cycle11. Receptor and auditory nerve action potentials exhibited amplitude changes when analyzed during quiet wakefulness, Slow Wave Sleep (SWS) and Paradoxical Sleep (PS) in guinea-pigs16,17. Auditory evoked potentials recorded from the primary cortical area in rats also exhibited amplitude shifts when the animal passed from wakefulness (W) to sleep. All evoked potentials components of the averaged waveform were larger during SWS than in W or PS18. Most relevant, reciprocally, auditory deprivation (experimental deaf guinea pigs and hamsters) produces changes in the sleep stages percentages26,27. Reports in humans showed marked changes on the evoked potentials later components during sleep28-31.
A high amplitude complex waveform dominates in SWS stages 2, 3 and 4, which is the result of summed K-complexes evoked by sensory stimuli32.
Semantic information is possible in SWS stage 2 and PS33, whereas the presence of P3 seems to be essential for stimulus encoding, despite the question if W and sleep P3 could be considered equivalent remains to be answered32. Moreover, this negativity has been reported also in newborns "quiet sleep" and linked to learning35. Intracochlear implanted humans changed their sleep characteristics when implant remained "on" during the night36.



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