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The impact of group singing on belonging for adults with chronic mental illness living in the community. The influence of music on the physical activity levels of older adults following cardiac rehabilitation. Can musical participation promote subjective dimensions of social inclusion in mainstream schools? Music therapy performances with pre-adolescent children and families living in crisis: An interpretative phenomenological analysis.
Parents and music therapists’ reflections on the experience of music and music therapy for paediatric palliative care patients and their families, who come from diverse cultural backgrounds. Exploring parent’s experiences of attachment with their baby through singing in a Neonatal Unit.
The Power of Sound- Effectiveness of Samonas Sound Therapy in Treating Pre-School Children with Autism. Shifts in parental responsiveness and self-efficacy in vulnerable families, following participation in Sing&Grow.
Auditory rehabilitation with music training: A study of learning-dependent plasticity in people with hearing loss.
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Suffering from tinnitus does not necessarily mean feeling diseased due to the phantom noise.
In case of acute tinnitus manifestation, existing treatment options may be considered unsatisfactory.
Any effective therapy for tinnitus requires a fundamental understanding of its physiological and neural background. Based on previous studies on structural plasticity, we expected a neural correlate of the therapy effect to be most prominent within auditory areas (Heschl's gyri), as tinnitus distress is highly related to structural GM loss in these regions. In this study, we included participants who were diagnosed with acute tinnitus persisting for a maximum of 3 months, without significant symptom change after an initial medical intervention according to AWMF guidelines (glucocorticoids or rheological drugs).
Fifty patients with experience of a recent tinnitus onset (between 6 and 12 weeks prior to the intervention) were invited to participate in the music therapy study subsequent to treatment according to the standard clinical protocol for acute tinnitus in the University Hospital for Ear, Nose, and Throat at the University of Heidelberg. After the period of the standard clinical treatment protocol, 7 patients were excluded from music therapy due to disappearance of tinnitus.
After recruitment of tinnitus patients, a group of 22 healthy participants were included into the music therapy condition serving as active controls (AC).
Therapy effects on tinnitus severity and individual tinnitus related distress were assessed by Tinnitus Questionnaire (TQ) developed by Goebel and Hiller (1998). Revealed clusters from GM contrasts between groups were anatomically assigned to brain structures using the cytoarchitectonic maps as published in Morosan et al.
The music therapy according to the Heidelberg Model of Music Therapy for tinnitus (Argstatter et al., 2008) is a manualized short term treatment approach lasting for nine consecutive 50-min sessions of individualized therapy. Tinnitus-related mental load in terms of distress or psychiatric disorders was measured by TQ at T0 (pre-participation evaluation), at T1 (therapy start) and therapy end (T2). Over the observation period of 1 week, Heidelberg Model of music therapy was applied to TG patients, whereas PTC patients were not treated during this time span. Mariko Takahashi is an ENT physician and an associate professor at Nagoya City University in Japan. Learn about an easy step-by-step process that will allow you to successfully manage patients with tinnitus. This course reviews a comprehensive process in working with patients who report severe cases of tinnitus.
This course will focus on all the elements required in offering tinnitus management in your facility. When working with tinnitus patients, it is imperative that your referring physicians are educated in tinnitus therapy and proper referrals.
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The neuroscientifically motivated Heidelberg Model of Music Therapy, previously developed by the German Center for Music Therapy Research, Heidelberg, Germany, was applied to explore its effects on individual distress and on brain structures. Quite the contrary, neither perceived loudness nor tinnitus frequency seem to correlate with mental strain, but it is the emotional correlate of tinnitus, that is, tinnitus distress, which may trigger such feelings of diminished well-being (De Ridder et al., 2011a).
On the one hand, several pharmacological approaches (Patterson and Balough, 2006) have been established considering tinnitus to be equivalent to sudden sensorineural hearing loss (Hesse and Laubert, 2010) or to any cochlear damage (Shim et al., 2011). Before including the participants in music therapy, a waiting period up to 4 weeks was warranted in order to prevent both delayed drug response and the influence of possible spontaneous remission. All patients had an age-appropriate hearing level and reported no otological or psychological co-morbidity.
The TQ refers to both tinnitus-related functional disabilities (such as concentration difficulties or hearing impairment) and emotional impairments (such as fear, anger or frustration due to tinnitus). Between these MRI sessions, TG and AC were treated with music therapy according to the Heidelberg Model.
Brain compartments of white and gray matter were segmented, DARTEL normalized by IXI-template to MNI space (Ashburner, 2007), and smoothed by Gaussian kernel of 10 mm radius.
The numerical procedure was carried out as a Two-Way ANOVA calculating the influence of the three participant groups and the two dependent time points, scanned before and after the study week, respectively. Integration of both active as well as receptive techniques, not passive suppression of the tinnitus sound, but rather self-effective influence on the sounds. Acoustic attention control by active participation, particularly in the form of vocal exercises both during and between music therapy sessions. Improvement of acoustic perception by means of detailed training on intonation and listening capacity in the range of the transposed tinnitus frequency.
Musically based training in relaxation and well-being in order to decouple tinnitus from psychophysiological reaction patterns. Tinnitus counseling using educational techniques focusing on individual tinnitus-related problems.
The resulting therapy effect was assessed by the difference of TQ scores between T1 and T2. Comparing structural alterations between T1 and T2, several brain regions revealed increased GM density in treated vs. General structural effects during the therapy week in comparable samples resulted in widely spread increased GM density in TG vs. Its main components are directive counseling to decrease tinnitus-related negative reactions and sound therapy to reduce the strength of the perceived tinnitus signal (Jastreboff, 2011).
The tools and counseling techniques will comfortably guide you through a process of meeting the needs of these patients and recommendations for appropriate referral considerations. This presentation will give you solutions on how to have this conversation with your referring physicians. This informal discussion will teach you about using Zen for this population and provide an opportunity for you to ask questions to an expert on your patients. This therapy is a compact and fast application of nine consecutive 50-min sessions of individualized therapy implemented over 1 week. Beyond that, the phantom noise often carries additional psychiatric, psychosocial, or psychosomatic comorbidities such as anxiety and depression, concentration and attention deficits, as well as sleep disorders (Jacques et al., 2013). In line with this assumption, GM alterations in auditory cortex were not correlated with tinnitus sound, but with severity of tinnitus-related distress (Schecklmann et al., 2013).
However, none of these treatment methods have proven to be effective after replication in controlled trials (Elgoyhen and Langguth, 2011).
This treatment approach strives for an integration of strategies to manage the psychological state and to possibly reverse the underlying neuronal reorganization. After completion of this pharmacological treatment during the first weeks after tinnitus onset, tinnitus patients underwent a pre-participation evaluation for participation in the music therapy.

At the time point of the pre-participation evaluation (T0) the patients were randomly divided into two groups, a treatment group (TG) and a waiting group for passive tinnitus controls (PTC).
TQ scores were obtained at three different times, during inclusion examinations, before start of treatment, and after the therapy week.
The therapy was carried out by a team of two expert therapists, usually one music therapist and one psychotherapist.
Treatment by the compact approach of the Heidelberg Model of Music Therapy over 1 week added up to 450 min of therapy sessions (9 × 50 min). Treatment by Heidelberg Model of Music Therapy led to decrease of 16 score points as compared to untreated patients on average (error bars: standard error of mean).
Broadband noise or conventional hearing aid amplification are commonly used in sound therapy in a TRT framework, since they are relatively neutral to listen to and thus unlikely to attract attention and induce strong emotional reactions in the patients. Clinical improvement and long-term effects over several years have previously been published. This epidemiological profile points to the value of investigating the origins of tinnitus more thoroughly in order to get better understanding of its nature and of the potential for remediation. Hence the existence of tinnitus per se (by phantom noise) does not require any therapeutic intervention.
For this purpose, complementary music- and psychotherapeutic interventions, comprising emotional regulation of tinnitus load and exercises of frequency discrimination in the spectral range of tinnitus noise, have been organized into several modules, resulting in a manualized short-term music therapeutic treatment concept whose separate treatment modules and long term effects are described in detail by Argstatter et al. In addition to standard audiological testing and otolaryngological examination, important demographic and tinnitus-related data were collected. This study protocol consisted in 9 consecutive 50-min sessions of individualized therapy over 5 days, comprising acoustic training for frequency discrimination, auditory attention control tasks, and guided exercises for mindfulness and distress regulation.
The preceding TQ assessment as part of the inclusion examination was integrated into the experimental setup to exclude novelty effects from further evaluation of therapy effect.
The highest effect was measured in the right Rolandic operculum resulting in GM increase of about 1.7% in treated patients.
Music, on the other hand, is generally not recommended, since it may induce strong emotions, and may attract attention as well (Jastreboff & Hazell, 2004). However, the underlying neural basis of the therapy's success has not yet been explored. Tinnitus is thought to be triggered in many cases by cochlear damage, resulting in abnormal or missing afferent input to the auditory cortex (Moller, 2007).
But since tinnitus often co-occurs with considerable emotional decline among affected patients, there is still demand for therapeutic assistance. These adjuvant psychotherapeutic interventions consist of one or more of the following elements: psycho-educative counseling, relaxation training, and general and tinnitus-related stress management.
Patients were excluded if the tinnitus was related to anatomic lesions of the ear, to retrocochlear lesions or to cochlear implantation.
For ethical reasons, PTC patients also received the therapeutic intervention, but following the study period.
Resulting structural findings from this contrast were further used as spatial mask for general effects of music therapy.
The resulting contrast was subsequently considered as a mask for general effects of the therapy situation, comprising training tasks, relaxation sessions, and specific auditory exercises.
However, we have seen a number of clinical cases in which neither of the two conventional TRT sound stimuli produced the desired effect. In the current study, the therapy was applied to acute tinnitus patients (TG) and healthy active controls (AC). However, many available therapies resulted in relatively small effects or lacked improvement in tinnitus load (Pichora-Fuller et al., 2013). The authors also reported the high clinical efficacy and long-term effects of this approach in chronic tinnitus patients. Whereas psychological strategies are intended to modulate attention and emotion toward tinnitus, noise maskers and hearing aids instead interact with acoustic sensation to suppress tinnitus perception. Corresponding clinical therapeutic effects in patients with acute tinnitus have been previously reported by Grapp et al.
The latter criterion was chosen to exclude interaction between music therapy and hearing aids for the present.
Fractal music is described as sequences of tones with no lyrics, which sound something like wind chimes.
As predicted, the therapeutic intervention led to a significant decrease of tinnitus-related distress in TG compared to PTC.
Tinnitus sound masking was developed in the early 1970s (Coles et al., 1984) and is still being used in mild cases, because a lasting improvement can be achieved as long as the external noise is applied. This step was implemented to separate tinnitus-related effects from general therapy-related effects. Predictable without being monotonous, the music sounds familiar, but is not associated directly with music that the listener holds in memory (Sweetow & Jeppesen, 2012).
The devices led to reduced tinnitus distress, especially when combined with hearing aids amplifying the impaired frequency range (Oz et al., 2013). The authors of this study measured a decrease of tinnitus-related mental load in treated compared to untreated patients after 1 week of therapy. All obtained clusters of each comparison were corrected post-hoc by extent threshold of 125 contiguous voxels and reported after family-wise error (FWE) correction on cluster-level of 5% alpha error. Assessment by repeated measures design for several groups (Two-Way ANOVA) revealed structural gray matter (GM) increase in TG compared to PTC, comprising clusters in precuneus, medial superior frontal areas, and in the auditory cortex.
Direct modulating of the tinnitus-related activity is intended in either Transcranial Direct Current Stimulation (tDCS) or rapid Transcranial Magnet Stimulation (rTMS), too (Langguth and De Ridder, 2013). This improvement on tinnitus distress by the aforementioned therapy concept formed the starting point of our research.
This pattern was further applied as mask for general GM changes as induced by the therapy week.
According to the authors, missing signals by sensory deafferentation cause high-frequency, gamma band, synchronized neuronal activity in the sensory cortex. In most of these studies the primary auditory cortex has been targeted for tinnitus treatment by cortical stimulation (Simon et al., 2012). We aimed to investigate the corresponding neural correlates of this distress-related improvement in tinnitus patients more thoroughly. The therapy-like procedure in AC also elicited similar GM increases in precuneus and frontal regions. This activity only reaches awareness when it co-activates brain networks that are related to self-perception and salience (amygdala, anterior cingulated, anterior insula, and precuneus). However, benefits from rTMS therapy have not been shown to persist over time (Theodoroff and Folmer, 2013). Thus, we sought to gain a deeper insight into the complex brain etiology and into the possibility of cortical reorganization in tinnitus. In such way getting conscious, the phantom percept also activates a non-specific distress network that in turn overlaps with salience coding, resulting in an emotional coupling of tinnitus to the experience of distress. The results were positive, so a larger trial with a total of 91 patients in TRT categories 1 and 2 was initiated. AC was calculated within the mask for general GM changes to obtain specific effects in tinnitus patients, yielding GM increase in right Heschl's gyrus, right Rolandic operculum, and medial superior frontal regions.
Structural brain analysis observing neuronal plasticity has been found to be suitable for understanding correlations between such mental sensations and neural mechanisms (Valkanova et al., 2014). In line with recent findings on the crucial role of the auditory cortex in maintaining tinnitus-related distress, a causative relation between the therapy-related GM alterations in auditory areas and the long-lasting therapy effects can be assumed. Noteworthy, even though they all consistently report structural differences, their results largely differ regarding both the localization and the direction of changes.
The Tinnitus Handicap Inventory (THI) is a 25-item questionnaire with three subscales: functional, emotional and catastrophic responses.
However, there is growing consensus on the involvement of gray matter (GM) alterations in auditory brain areas when suffering from tinnitus distress.
The responses are summed with a total score that ranges from 0 to 100 (higher scores indicating a greater self-perceived handicap).The minimum THI score considered clinically significant is 18. More precisely, tinnitus distress correlated negatively with GM volume in bilateral auditory areas, pointing to higher individual tinnitus distress with lower gray matter volume.

The average age, gender, hearing level, THI, and HHIA scores at the initiation of the study are shown in Table 1.
The authors argued that the latter tinnitus-related alterations in dmPFC might not be related to distress, but to individual loudness of tinnitus sensation. According to the manufacturer’s specifications, the fractal music produced in the Zen program consists of sequences of tones with no lyrics. The fractal music and broadband options can be used separately or in combination, with the hearing aid microphones switched on or off.
Patients were instructed to try all options (fractal music style, broadband noise, conventional amplification) included in their devices at home.
The data logging function was activated to record the patients’ daily hearing aid usage and use of different program options. The following trend was observed:Patients who chose to purchase the conventional simple sound generator (Group 2) were typically the ones with a relatively mild (or no) degree of hearing loss (self-perceived and objectively measured), while their THI score suggested a severe degree of tinnitus (Table 1). For these patients, the tinnitus is expected to have a greater impact on their daily lives than the hearing loss.The reverse client profile was observed in the group who preferred conventional hearing aid amplification as sound therapy (Group 3). These patients typically had a moderate-moderately severe degree of hearing loss (self-perceived and objectively measured), while their tinnitus was at the moderate end of the scale.
Thus, the assumption was that the hearing loss may be the greater problem for the patients who chose a conventional hearing aid.Client profiles for the patients who chose the combination device (Group 1) varied, but they typically had a severe degree of tinnitus combined with a moderate (or more severe) degree of hearing loss (self-perceived and objectively measured), and a severe degree of depression. 20% (6 patients) replied that they already owned a pair of hearing aids, while 17% (5 patients) were unable to perceive an effect from the sound therapy. The remainder of this paper will report the results for this specific group.Of the 33 patients who purchased a combination device with the Zen feature, 25 participated in the re-evaluation after three and six months of therapy. Notable improvements were observed already after the first three months in the THI (Tinnitus Handicap Inventory) scores of the majority of patients who used fractal music as sound therapy. Scatter plots of 25 patients’ THI scores at the initial visit and after six months of therapy.
Each data point represents a single patient’s THI at the initial visit (horizontal axis) and after six months of therapy (vertical axis). Data points located to the right of the stippled line indicate an improvement of 20 points or more in THI.The patients were also asked to indicate the intensity level and frequency of occurrence of their tinnitus at the initial visit and after 6 months of therapy. Notable improvements were observed both in the VAS scores assigned for intensity level and for frequency of occurrence after 6 months of therapy. Scatter plots of 22 patients’ VAS scores for perceived intensity level of their tinnitus at the initial visit and after six months of therapy.
Each data point represents a single patient’s VAS score at the initial visit (vertical axis) and after six months of therapy (horizontal axis). Scatter plots of 23 patients’ VAS scores for frequency of occurrence of their tinnitus at the initial visit and after six months of therapy. The results are summarized in Figures 4-8.Overall satisfaction scores are shown in Figure 4. 69% of the patients reported being either satisfied or very satisfied with the sound therapy. A small minority (8%) reported being dissatisfied, while 23% replied that they were neither satisfied nor dissatisfied with the therapy.Figure 4.
Overall satisfaction with sound therapy in patients who used Zen for 6 months.One of the basic rules for the use of sound generators in successful TRT treatment is that it must not evoke negative feelings in the form of discomfort or annoyance in the patient (Jastreboff, 2011). The patients were therefore asked to evaluate the fractal music in terms of how pleasant they perceived it to be, and whether they had become tired of it after six months’ use.
65% reported perceiving the fractal music as either comfortable or very comfortable, while 35% were neutral.
None of the patients reported perceiving the fractal music as uncomfortable to listen to (Figure 5). According to the manufacturer, under normal circumstances the music should not interfere with speech perception, unless the patient has a very narrow dynamic range resulting from a severe degree of hearing loss (Widex zen therapy, 2012). This was largely supported by the results in the present study, as 82% of the patients reported being able to hear speech well in the presence of fractal music (see Figure 7).Affordable price was reported to be the main motivation for choosing a simple broadband sound generator by many patients in Group 2.
Patients in Group 1 were therefore asked to evaluate the combination device in terms of price.
75% of the patients who had chosen the combination device responded that it was expensive, 8% that it was too expensive, while 13% found it reasonable.Figure 7. Both cases were part of the initial pilot study group of 24 patients.Case 1Case 1 was a 70-year-old female who had had severe hearing loss in her left ear since childhood. She was not concerned about her hearing loss, however, and had not considered hearing aids. Her motivation for seeking help was a strong perception of tinnitus in her right ear which had begun two months previously and had steadily grown worse. The tinnitus had a pervasive negative affect on her daily life, making it difficult for her to maintain her relationship with her family, and reducing both her performance at work and her ability to do simple housework at home. Her appetite was lost from anxiety and fear that the tinnitus would remain untreatable until her death. Prior to her visit at the Sekiya ENT clinic, she had sought treatment in several other clinics, and had tried a variety of therapies, but had experienced no improvement. Visual Analog Scale (VAS) measures of 100% were assigned by the patient for both loudness and frequency of occurrence of the tinnitus. Audiogram for Case 1.Due to her reluctance to trial hearing aids and the asymmetry between the hearing loss in the left and right ears, it was decided to let the patient wear a combination device (Widex mind440) on her right ear only during the trial period. At the first follow-up visit after a month, she described fractal music as a comfortable listening experience and said that her anxiety was reduced. After 3 months, she was coping well with her tinnitus even without the device, and her THI score had dramatically improved from 96 to 12. After six months, the amplification-only program was used more than the fractal music program, and her THI score remained low at 18. Usage pattern and self-perceived tinnitus and hearing loss for Case 1.Case 2Patient 2 was a 67-year-old female who had been suffering from severe tinnitus in her left ear for more than a year. She had sought treatment at eight different clinics, and had tried a variety of therapies, but had experienced no improvement.
The patient rejected the suggestion of wearing hearing aids, but her tinnitus was so distressing that she was willing to try a combination device (Widex mind) as a TRT sound therapy device for her left ear.Figure 10. However, the patient complained that she was annoyed with the broadband noise already after two weeks.
The broadband noise combinations were then replaced with a hearing aid + fractal music, and a fractal music-only option.
Her THI score had improved to 50 after the three months, and the patient reported that the tinnitus had not bothered her so severely. The broadband noise options were replaced with fractal music options after two weeks.ConclusionsAs the sound has to be listened to for prolonged periods of time, the TRT protocol prescribes the use of neutral stimuli that facilitate passive listening and do not evoke a strong emotional response in patients, such as broadband noise or conventional hearing aid amplification. Although not prohibited in TRT, music is not generally recommended, since it may invoke a strong emotional response and attract attention (Jastreboff & Hazell, 2004). However, a good effect was obtained when using the fractal music available in the Widex CLEAR, mind440, and mind220 combination devices within a TRT treatment framework.
Improvements in THI scores were observed after six months in 92% of the patients who used fractal music as sound therapy. Our results indicate that some patients will eventually tire of the music, which suggests that patients should be given several Zen tunes or advised to use their preferred Zen style in combination with other stimuli.The results obtained in the present study suggest that a combination device offering flexible program combinations with conventional amplification, broadband noise and fractal music is an optimal choice for hearing-impaired patients with high THI scores. The two cases also illustrate how a combination device is sometimes effective, not only in reducing the negative effects of tinnitus, but also as a way of introducing amplification to reluctant hearing aid candidates.ReferencesHenry, J. Tinnitus retraining therapy: An implementation of the neurophysiological model of tinnitus. Psychometric adequacy of the Tinnitus Handicap Inventory (THI) for evaluating treatment outcome.
The hearing handicap inventory for adults: Psychometric adequacy and audiometric correlates.

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