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Tinnitus Retraining Therapy (TRT) is a well-defined method for treatment of individuals who suffer from tinnitus [1-4].
Habituation is a concept that has been a part of the learning and conditioning literature for many years and refers to a decrease in responsiveness because of repeated stimulation with an inconsequential stimulus [7]. Treatment with TRT has two components, and each component addresses a different aspect of habituation. Prospective controlled studies have not been reported to document outcomes of treatment with TRT [10,11]. TRT was first offered to patients at the University of Maryland Tinnitus and Hyperacusis Center in 1990. Clinical implementation of TRT requires patients to receive a thorough audiological and medical evaluation before entering treatment [6].
The examiner recommends treatment for TRT based primarily upon patients' audiological test results and their verbal responses from the TRT initial interview [14]. The TRT initial interview is designed to delineate a patient's relative problems with tinnitus, hearing loss, and loudness intolerance.
The original version of the TRT Initial and Follow-up Interview forms appears in a condensed format that is intended to simplify administration of the interviews as well as record keeping [14]. Because TRT is often used for treating tinnitus, practitioners must have access to standardized TRT assessment tools. Category 1 patients require extended treatment for their tinnitus condition but do not require the use of hearing aids. Proper patient categorization requires the clinician to clearly understand the patient's subjective difficulties with each of the conditions of tinnitus, reduced sound tolerance, and hearing loss.
Tinnitus of recent onset (up to about 6 months duration) may be more labile than longer-duration tinnitus and thus may resolve spontaneously [27]. From a population of over 1,800 tinnitus patients, 43 percent were reported to have described their tinnitus as consisting of multiple sounds [28].
Most patients responding to the TRT initial interview will have negative emotions associated with their tinnitus, with consequent effects on certain life activities.
This item comprises a series of questions related to the patient's use of hearing protection. Question 10 is straightforward in asking if the patient is receiving any other tinnitus treatment. Question 12 identifies bothersome aspects of tinnitus from a closed set of different activities that can be adversely affected by tinnitus. These two questions will obtain an estimate of the percentage of waking hours that patients are consciously aware of, and annoyed by, their tinnitus. Patients are given an opportunity to provide any additional information concerning their tinnitus.
Decreased sound tolerance can involve different components, including hyperacusis, misophonia, and phonophobia [4]. These questions are the same as questions 7 through 18 for tinnitus, but focus on effects of reduced sound tolerance. The TRT Follow-up Interview form (Figure 2) duplicates those questions from the TRT initial interview that would be considered necessary to monitor treatment progress and to determine treatment outcomes [14]. In the scripted instructions to the follow-up interview, patients are told to consider their tinnitus and its effects over the previous month when answering the questions.
Question 1 contains a series of questions about whether patients experience some days that are more affected by their tinnitus than others.
Question 5 determines the impact of tinnitus on various activities, as does Question 12 from the initial interview.
Questions 6 and 7 are the key questions that assist in determining if patients are habituating to, respectively, tinnitus perception and tinnitus reaction. Questions 8, 9, and 10 ask patients to estimate, respectively, their tinnitus loudness, annoyance, and life impact. Questions 23, 24, and 25 are particularly important for a clinician to determine the relative effects of tinnitus, reduced sound tolerance, and hearing loss on the patient's life.
Question 26 determines if patients feel that their auditory condition has benefited overall, considering tinnitus, sound tolerance, and hearing loss. This article provides tools to evaluate patients for treatment with TRT and to monitor the efficacy of treatment with TRT. The TRT Initial and Follow-up Interview forms were revised primarily to help determine outcomes of treatment in a standardized manner for a randomized clinical study currently being conducted at the Portland Department of Veterans Affairs (VA) Medical Center (VAMC) in which subjects receive treatment with either Tinnitus Masking or TRT. There are accepted methods for developing and testing scales that measure health or functional status. Substantial literature exists concerning tinnitus outcomes instruments-some of which have undergone the more traditional method of development and testing. With regard to the preceding comments, a need exists to provide further development and testing for the TRT interview forms to be documented as valid and reliable.
Finally, it should be noted that the developers of the original TRT interview forms administer the Tinnitus Handicap Inventory to all of their patients in addition to performing the interviews [41,42]. We wish to acknowledge the significant contributions from Tara Zaugg, MS; and Barbara Tombleson, BS. Dossier Cuisine Si vous trouvez le pamplemousse trop acide, vous l'aimerez sans doute davantage en patisserie. Dossier Lifestyle La France est reputee dans le monde entier pour ses delicieuses patisseries. Quand on blogue depuis quelques temps, il n'est pas rare d'etre contacte par des marques, ou des agences, pour d'eventuelles propositions de partenariats ou de monetisation. Dans la Ville Rose au joli nom romantique on ne se nourrit pourtant pas que d'amour et d'eau fraiche !
Il n'y a pas que le cinema pour rendre hommage a la ville de Paris, les blogs aussi font la part belle a la fameuse ville lumiere. Wanneer u een afspraak aanvraagt, krijgt u per mail een link toegestuurd waarmee u zelf een sessie kan inplannen. Hyperacusis betekent dat je overgevoelig bent voor normale, alledaagse geluiden die voor andere mensen niet te luid zijn (bijvoorbeeld het rinkelen van bestek). Misofonie betekent dat je bepaalde, specifieke geluiden onaangemaan, irritant of ondraaglijk ervaart (bijv. De tinnitus zakgids app, beschikbaar voor smartphone en tablet, biedt een ondersteuning voor mensen met oorsuizen.
How to cite this article Korres S, Mountricha A, Balatsouras D, Maroudias N, Riga M, Xenelis I. The aim of the study is to present our results regarding the efficacy of TRT for tinnitus relief in patients with clinically significant tinnitus compared to a group treated with vasoactive agents. According to the neurophysiological model of tinnitus, the perception of tinnitus is not necessarily the key element causing tinnitus to be problematic. The second element of TRT therapy, sound therapy, aims to decrease the sound contrast between tinnitus and silent environment leading to a reduced detection of tinnitus. Several independent centers have presented clinical results of TRT with success rates of about 80% and higher.2, 11-17 The objective of our study is the evaluation of TRT for clinically significant tinnitus after 1 year of treatment.
Then, an audiological assessment including pure-tone audiogram (PTA) and tympanogram were conducted in all cases. Subjects were classified into two groups: (1) Group 1 consisted of TRT patients who received a complete TRT (study group, n= 33). All TRT patients received directive counseling; each participant was reassured for the absence of brain tumor accounted for tinnitus emergence, while the neurophysiological model of tinnitus was explained in a concise way. Furthermore, the patients were particularly examined if treatment had an effect on the annoyance caused by tinnitus when conducting certain activities of daily living (sleep, concentration, relaxation, work).
Data were imported into a statistical computer program (SPSS 15.0) for further evaluation and analysis. Baseline comparison of THI and VAS scores for work, sleep, relaxation and concentration did not reveal any significant differences between the study group and the control group. The majority of patients in both groups suffered from presbycusis (42.4% of TRT patients, 50% of patients treated with vasodilators). In our study, we documented a satisfactory response obtained at 12 months after the beginning of TRT. TRT achieved by directive counseling and exposure to low-level broad band noise is an effective approach to tinnitus management. Chronic tinnitus can be caused by a variety of things, from impacted ear wax to medications that damage nerves in the ear, middle ear infection, and even aging. When chronic tinnitus is caused by a definable problem, like ear wax or grinding your teeth at night or taking aspirin, addressing that problem will often turn down the volume.
Not all insurance companies cover tinnitus treatments in the same way, so be sure to check your coverage. Hair cells in the cochlea transform sound waves into electrical signals that travel to the brain’s auditory cortex. I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. The TRT Initial Interview form was developed to guide clinicians in obtaining essential information from patients that would specify treatment needs.
It is estimated that about 80 percent of individuals who experience constant tinnitus naturally habituate to their tinnitus to such a degree that their tinnitus does not constitute a problem requiring clinical intervention [1,8]. The individual with problematic tinnitus first must habituate to any emotional responses to the tinnitus. Outcomes data have been reported from a number of clinics, however, indicating that treatment with TRT significantly benefited 70 to 85 percent of their patients (reviewed by Henry et al. In addition, patients must demonstrate that their tinnitus condition is sufficiently problematic to warrant implementation of long-term treatment with TRT. The TRT initial interview is a structured set of questions that are designed specifically to determine proper placement of patients into TRT treatment categories (described in TRT Patient Categories section). Using the TRT Initial Interview form, each of these three potential problems is discussed individually, enabling the clinician to differentially assess the subjective impact of each. These categories have been fully described elsewhere [4-6,21] and thus are only briefly described here (see the Table). They are fitted with wearable ear-level sound generators and counseled repeatedly, usually over a period of 1 to 2 years. Understanding the patient's natural tinnitus history is considered important for counseling [8]. The potential for spontaneous improvement is important to consider in the assessment of patients for treatment.
This question seeks to determine if there are days when these tinnitus effects are noticeably worse than on other days. Patients commonly report that their tinnitus becomes louder as a result of exposure to certain sounds. The questions will stimulate discussion about the need to provide hearing protection in dangerously noisy situations, but the main purpose is to determine if the patient is overprotecting his or her hearing. Often, patients have not analyzed specifically why tinnitus is a problem for them and this list prompts them with the most likely concerns. Patients are asked to rank their tinnitus with respect to loudness, annoyance, and life impact. In most cases, the TRT initial interview will have covered all the issues and patients will have nothing further to add. Patients must clearly understand the intent of Question 19 because their response to it will determine whether or not they are identified as having a problem with sound tolerance. Patients will often confuse functional effects of reduced sound tolerance with tinnitus effects. There can also be Category 4 placement specific to hyperacusis as shown in the Table, page 159.
No clear relationship exists between patients' audiograms and how they feel about their hearing [39]. During the preceding questioning, patients will have learned to distinguish between the conditions of tinnitus, reduced sound tolerance, and hearing loss.
Some of these questions have been modified relative to the initial interview as appropriate for follow-up evaluation. Thus, they are not asked to respond in relation to any particular day or circumstance, but to think of how the tinnitus has affected them generally during the previous 30 days. The clinician should have the patient's responses to the initial interview in hand during administration of the follow-up interview. Similar to Question 1, patients are asked to report if they feel that the amount of time they have been aware of their tinnitus, or annoyed by their tinnitus, has changed during the previous month. For these questions, as well as Questions 23, 24, and 25, clinicians are again advised to have the patient's previous answers available to indicate to the patient whether improvement has been noted. If improvement is not noted after 1 to 2 years of treatment, the clinician must assess honestly as to whether continued treatment with TRT is in the patient's best interest. If reduced sound tolerance was not noted as a problem during the initial interview, these questions are bypassed during the follow-up interview. The question requires only a yes or no response, but its intent is to raise the issue as a discussion point to evaluate whether the patient considers hearing loss a problem [39]. In some cases, only one of these is a problem at the beginning of treatment and treatment will be specific to that condition throughout the program. Question 27 is somewhat unusual because it asks patients how they would feel about giving back their ear-level devices. The original one-page interview forms, both initial and follow-up [14], can work effectively for the experienced TRT clinician.

Since all subjects in both groups were to receive the TRT initial and follow-up interviews, administering the interviews in a consistent fashion was essential. None of these instruments, however, has achieved discipline-wide consensus as a standardized method of evaluating the negative effects of tinnitus. Jastreboff and Jastreboff state that the choice of supplemental questionnaires is a matter of personal preference of the provider [14]. Tout comme une blogueuse peut decider de contacter d'elle-meme une marque qu'elle apprecie et avec laquelle elle souhaiterait collaborer. On a finalise le menu, reflechi a la decoration de la table, on a achete (presque ?) tous les cadeaux, et on les a meme emballes !
Ons team bestaat uit psychologen, een audiologe en een ervaringsdeskundige, die allemaal een gespecialiseerde opleiding hebben gevolgd.
Naast de psychologische en audiologische insteek, speelt de bezieling van een ervaringsdeskundige een belangrijke rol.
Vervolgens gaan we kijken waar deze problemen hun oorsprong vinden en wat we er aan kunnen doen. Meer informatie over de therapie, onze aanpak en de kostprijs vindt u in onze informatiebundel. It is based on the neurophysiological model of tinnitus described by Jastreboff in 1990 postulating that tinnitus results from the interaction of several subsystems in the nervous system1.
It is even possible for the patient to have reactions to stimuli which are not consciously perceived6-7. The first component of TRT, directive counseling, may change the way tinnitus is perceived. According to Weber-Fechner's law, a sound is perceived as less intense whenever it is presented to the nervous system together with a noise background.
We compare TRT patients with a group of patients who refused TRT when recommended and were administered vasoactive agents instead. Sixty-three patients with disabling tinnitus referred to the ENT Departments of the Ippokratio Hospital of Athens and Tzanio Hospital of Piraeus between January 2005 and July 2009 were examined.
In addition, a physical examination of ear, nose and throat was performed by an otolaryngologist.
Auditory evoked potentials and magnetic resonance imaging with gadolinium were performed in order to rule out retrocochlear disease if required. The total THI score varied from 0 to 100, with 0 being asymptomatic and 100 being the strongest complaint.
The participants were further classified as either Category 1 (n= 4) or Category 2 (n= 29) patients according to Jastreboff's classification. On the basis of the audiometric threshold, category 1 patients (n= 4) were fitted with wearable earlevel sound generators, while category 2 patients (n= 29) were fitted with combination devices that incorporated both hearing aids and sound generators. A Greek translation of the THI was administered in order to assess treatment a year after therapy initiation. All patients reported the level of problems in the 0-10 scale of the structured interview form20 that was used to assess the annoyance.
A paired t-test was performed to evaluate the statistical significance of a difference between the mean THI and VAS scores before and after treatment. No statistical significant differences in pre- and post-treatment THI scores were detected between genders. Mean pretreatment and post-12-month treatment THI scores for TRT patients and patients treated with vasoactive medications. Mean pretreatment and post-12-month treatment VAS scores for work, sleep, relaxation and concentration for patients treated with TRT (upper panel) and patients treated with vasoactive medications (lower panel). Other diagnoses included sudden deafness, noise-induced hearing loss, Meniere's disease and idiopathic. Sound therapy decreases the sound contrast between tinnitus and silent environment leading to a reduced detection of tinnitus. It’s common after sitting through a loud concert or an exuberant football game, or after taking aspirin or an antibiotic for a while. Damage to hair cells in the ear’s cochlea (see the illustration below) are suspected as a common pathway for these causes. You can do this by listening to music or having a radio, fan, or white-noise machine going in the background. If you’re willing to enroll in a research study, you may be able to receive a cutting-edge treatment free. When these cells are damaged by loud noise, medications, or other problematic inputs, brain circuits don’t receive the signals they are expecting to get. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. The TRT Follow-up Interview form is similar to the initial interview form and is designed to evaluate outcomes of treatment. The model identifies different areas of the brain that can be involved in tinnitus and theorizes as to how those areas interact to create a clinical condition of tinnitus [5,6].
Such natural habituation apparently does not occur for about 20 percent of these individuals.
In 1999, Jastreboff created another center to treat tinnitus and hyperacusis patients at the Emory University School of Medicine in Atlanta, Georgia. In addition to questions about tinnitus, the TRT interview includes questions about decreased sound tolerance (hyperacusis) and about subjective hearing difficulties [6,15].
In addition, use of the interview educates the patient to understand these problems and how they differ. The abbreviated nature of the questionnaire items requires the clinician to fully understand the intent of each item in order to phrase the questions appropriately and is a reminder to assure that all questions are asked. This paper provides the expanded forms of the initial and follow-up interviews to clinicians who are practicing, or who intend to practice, TRT with their tinnitus patients.
Category 0 identifies patients whose tinnitus condition requires only basic counseling and sound therapy without the need for wearable sound generators or hearing aids.
Category 2 patients also require extended treatment for their tinnitus condition, but in addition, they report significant hearing difficulties. The treatment approach will vary according to category; thus, accurate placement of patients into these categories is critical to provide proper treatment. The tinnitus description defines the symptom for both patient and clinician, providing a common reference for the remainder of the tinnitus-related questions. With an increase in tinnitus duration, the likelihood of tinnitus being a permanent condition also increases. Based on these data, tinnitus is likely to consist of multiple sounds for about half of all patients attending tinnitus clinics. Many patients with tinnitus use earplugs or earmuffs to prevent their tinnitus from becoming worse.
This information is important for the clinician to help the patient determine the best overall course of treatment.
Since habituation is the primary goal of TRT, these questions are particularly helpful in assessing this outcome of treatment.
Only the end points of each scale have labels; thus, patients must select a number on the continuum in relation to the two extremes.
Hyperacusis is a physiological response to certain sounds; thus, some level of physical discomfort is involved. It is thus important to guide the patient to respond appropriately, keeping in mind the different components of reduced sound tolerance as described for Question 20. In the latter case, certain sounds will exacerbate the hyperacusis for an extended period of time (at least until the next day). Some patients will reveal a significant reduction in hearing sensitivity and yet will not be bothered particularly by their hearing loss.
These three questions now allow them to consider how much each condition is a problem in relation to the other. It is thus important to know if patients feel that they are having fewer bad days than before.
Indicating the previous responses on the follow-up interview form is helpful when asking about these activities. An awareness that improvement has occurred can be very encouraging to the patient and is an important incentive to maximize compliance with the treatment protocol. If reduced sound tolerance was initially reported, completing these questions will enable an evaluation of treatment efficacy. This perception often changes from appointment to appointment, which can potentially result in making changes in ear-level devices.
In other cases, more than one of these conditions will be a problem at the outset of treatment and their relative effects can change during treatment. Many clinicians, however, especially those who are relatively new to TRT, have expressed the need for scripting of questions and for explaining the various questions in the forms. The interview forms therefore were revised so that exact wording of each question would be provided on each form. Such an approach has not yet been taken with the TRT interview forms, which were originally developed by the second and third authors of this paper because of their perception that take-home questionnaires were inadequate for assessing tinnitus patients [14]. Meikle and Griest have reviewed the various outcome measures that have been developed and have noted the many discrepancies between them [40].
A working group has been formed that is presently evaluating four tinnitus outcomes instruments, including the TRT interview forms, the Tinnitus Handicap Inventory [41,42], the Tinnitus Handicap Questionnaire [19], and the Tinnitus Severity Index [43].
Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. Celebrating a decade of evaluation and treatment: The University of Maryland Tinnitus and Hyperacusis Center. An experimental study to test the concept of adaptive recalibration of chronic auditory gain: interim findings.
Modification of loudness discomfort level: evidence for adaptive chronic auditory gain and its clinical relevance. Shifts in dynamic range for hyperacusis patients receiving Tinnitus Retraining Therapy (TRT).
Changes in loudness discomfort level and sensitivity to environmental sound with habituation based therapy. Psychometric adequacy of the Tinnitus Handicap Inventory (THI) for evaluating treatment outcome.
Most of the time this is something that at some level you have to get used to and come to terms with, Glazer says. Greek translation of the Tinnitus Handicap Inventory (THI) and visual analogue scale (VAS) for annoyance caused by tinnitus when conducting four major activities of everyday life (work, sleep, relaxation and concentration) were examined in a 12-month period. According to the model, tinnitus, a phantom auditory perception, is usually generated in the cochlea, while the limbic and sympathetic part of the autonomic nervous systems are responsible for the development of tinnitus annoyance.
Habituation is the cornerstone of TRT which aims to alter the mechanisms that transfer the signal from the auditory to the limbic and autonomic nervous systems and thereby remove tinnitus-induced reactions8. The patient is taught the basic knowledge about the auditory system and its function, the mechanism of tinnitus generation and the annoyance associated with tinnitus.
9 The therapy employs long-term use of sound, the level of which is adjusted at or just below the mixing point (the point at which the tinnitus and the noise begin to mix together). A score >58 indicates severe tinnitus, almost always heard, which leads to disturbed sleep patterns and can interfere with daily activities.18 On the contrary, a score 36 correlates with mild tinnitus, easily masked by environmental sounds and easily forgotten with activities18. 21 Category 1 patients experienced tinnitus as a significant subjective problem but did not have hearing difficulties. Two-tailed t-test for independent groups was used to compare baseline THI and VAS scores between groups, and mean differences after treatment.
Activation of the amygdala and anterior cingulate during nonconscious processing of sad versus happy faces. Nonconscious influence of masked stimuli on response selection is limited to concrete stimulus- response associations.
Guidelines for the grading of tinnitus severity: the results of a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons, 1999. Long-term improvement in tinnitus after modified tinnitus retraining therapy enhanced by a variety of psychological approaches. But as many as 50 million Americans have chronic tinnitus (pronounced tih-NITE-us or TIN-ih-tus)—a constant ringing, whistling, buzzing, chirping, hissing, humming, roaring, or even shrieking.
As I write in the September issue of the Harvard Women’s Health Watch, chronic tinnitus can also be a symptom of Meniere’s disease, a disorder of the balance mechanism in the inner ear.
If money is no issue, you can buy devices worn like hearing aids that generate low-level white noise. They respond by generating abnormal activity, which results in the illusion of sound, which is tinnitus. Most feel helpless about improving their work conditions or solving technical problems in patient care.
The treatment approach is aimed to induce and facilitate habituation by the patient to his or her tinnitus. Habituation to tinnitus perception can only occur if there has been habituation to the associated emotional responses. In the past 7 years, he has conducted 13 three-day instructional courses in the United States that have been offered to physicians and audiologists to learn the TRT protocol. It is thus critical to accurately assess the patient's condition, need for treatment, and motivation to comply with all treatment requirements. Hyperacusis is a condition that is observed to occur to some degree for approximately 30 to 40 percent of patients who are evaluated for TRT [4,16,17].

The process helps the examiner and patient to mutually determine the optimal course of treatment.
To help conduct the interview in a standard manner, the main questions are presented verbatim at the bottom of the forms. Further, to ensure that the TRT practitioner fully understands the intent of each question, detailed explanations are provided.
Typically, these patients achieve enrichment of their sound background using tabletop sound generators and other sound-generating devices [22]. They receive the same treatment as for Category 1 patients except that they are fitted with either hearing aids or ear-level combination devices that incorporate both hearing aids and sound generators. This baseline description might also be useful for the clinician to compare during and following treatment to determine if the patient's tinnitus characteristics have changed as a result of treatment. For the TRT evaluation, it is important for patients to identify which of the tinnitus sounds is most bothersome.
Such action in fact will result in the tinnitus sounding louder, because of the occlusion effect, and is reported to cause reduced loudness tolerance [29-35]. Many of these other types of treatment have no scientific basis and the patient should be educated regarding realistic expectations. Question 13 determines the amount of time patients spend thinking about their tinnitus; thus, it is specific to habituation of tinnitus perception. The main consideration is to determine whether patients have trouble tolerating everyday sounds that are otherwise tolerated comfortably by most other persons.
It is an educational process for some patients who will gradually begin to understand how these different factors have affected their lives differentially.
Other patients complain about considerable hearing difficulties that would seem incongruous with their mild hearing loss. The clinician should be aware if the patient is concurrently receiving treatment with anxiolytics or other psychotropic medications and should consider potential effects of such treatment. Patients can be told if they have shown improvement or not, but it is not advised to inform them of their previous responses.
Such changes will usually involve the addition of amplification as the patient recognizes the degree to which hearing loss is a problem.
For example, if hyperacusis is the primary problem at the beginning of treatment, the treatment protocol will be specific to the hyperacusis. In most instances, patients will indicate adamantly that they would not be comfortable giving up their devices. These revised forms now are being used in the TRT training seminars, and their clinical application will minimize variability in administration of the questionnaires.
These authors therefore designed structured interviews to be a guide for acquiring information from patients and to evaluate potential changes during treatment. Meikle and Griest emphasized the need for a single standardized instrument to assess tinnitus-related distress and resulting functional impairment. In onderling overleg kunnen er nog follow-up sessies worden ingepland om de evolutie verder op te volgen.
The THI score was significantly improved in the TRT group, as well as mean VAS scores, in all measures.
Tinnitus is responsible for anxiety, problems with concentration, panic attacks and suppression of the ability to enjoy activities in life in 20% of patients who experience the symptom1-3.
It is apparent that TRT neither attempts to eliminate the source of tinnitus signal, nor to directly affect the neuronal symptoms responsible for reactions; therefore, TRT is effective regardless of the etiology of tinnitus8. Additionally, based on the TRT Initial Interview 19, the patients were particularly asked if tinnitus prevented four major activities of everyday life: work, sleep, relaxation and concentration.
On the contrary, category 2 patients reported both tinnitus and hearing problems.2 Group 2 consisted of patients who refused TRT despite our recommendation and were treated with vasoactive medications (control group, n= 30). Hearing impairment (>25 dB in at least 1 frequency) was present in 29 out of 33 patients (87.9%). 30 We believe that patients should be encouraged to attend TRT for at least a period of a year in order for optimal and stable improvement to be achieved. The objective of this study was to present the results regarding the efficacy of TRT for tinnitus relief in patients with clinically significant tinnitus.
The forms have been used in a highly abbreviated format with the potential for inconsistent interview administration between examiners. The inherent variability in administering the TRT interviews can be reduced further by scripting each question. Further details regarding administration of the Initial Interview form have been provided elsewhere [6]. These patients require fewer follow-up visits than do patients in the other TRT categories. Category 3 patients have the primary problem of hyperacusis and are treated for this condition with a specific TRT protocol that involves use of wearable sound generators or combination instruments. The first is that the patient who has recent-onset tinnitus should be started on full treatment as soon as possible. Constraining the psychoacoustic evaluation to the most bothersome tinnitus sound can save a substantial amount of time and, therefore, is subsequently used as a reference during the tinnitus matching procedures. It is important for the clinician to be sensitive to the patient's potential need for psychological or psychiatric evaluation and treatment and to refer the patient as necessary [6]. Patients in Category 4 are the most difficult to treat effectively, and a specific variation of TRT is implemented for these patients [21,23]. It is thus an important issue, but the examiner must use caution during the questioning so as not to give patients the new concern that sound might make their tinnitus worse. Question 14 evaluates how much of their time they are annoyed by their tinnitus, which helps to determine if they are habituating to their tinnitus reaction. If this occurs, patients can generally recall the types of everyday sounds that cause loudness discomfort. The objective of these questions is to determine the patients' subjective feelings about their hearing, regardless of their hearing thresholds.
Thus, for some patients, it is simply a matter of continuing to encourage them in spite of their lack of progress.
At a follow-up visit, the hyperacusis may become less of a problem and the tinnitus might become the primary concern. Question 28 is quite general in asking if patients are glad or not that they started the program. Our hope is that this information will be useful for promoting a higher level of standardization in conducting TRT. The interview forms are a clinical tool to conduct TRT and, while not claimed as a universal tinnitus assessment technique, can potentially be used with other types of tinnitus treatment methods. Most importantly, the four questionnaires are being evaluated with respect to how the patients themselves respond to the questionnaire items. Thus, for the clinician or researcher who is actively involved in conducting TRT, we suggest that the interview forms be used along with one of the self-administered questionnaires that has undergone documentation for validity and reliability. Comparison of the mean improvement of THI and VAS scores after treatment showed significant differences between the two groups, favoring TRT treatment. The 30 subjects from the control group treated with vasoactive agents included 15 males and 15 females. We conclude that although TRT is not a cure, since it does not remove tinnitus, it reduces the level of annoyance induced by tinnitus and improves the ability of patients to work, sleep, relax or be concentrated.
Sound therapy is thought to be effective only when the emotional responses have been neutralized. Misophonia reflects dislike of sound [6,18] and is present in the majority of patients [17].
Furthermore, for outcomes research, standardization of wording is vital to ensure consistent administration of the interviews within and across patients and within and across examiners.
The TRT Follow-up Interview form is a shortened version of the Initial Interview form because some items in the initial interview would not be relevant to evaluate treatment outcomes at follow-up visits.
Category 4 patients are relatively uncommon and suffer from a condition in which their tinnitus or their hyperacusis is significantly worsened because of exposure to certain types of sounds. From a group of 784 nonveteran tinnitus patients, however, 47 percent was reported as not being able to identify any precipitating event that could be associated with their tinnitus onset [26]. When treatment is provided with TRT, the psychoacoustic characterization of tinnitus is irrelevant and is mentioned only briefly during counseling.
Patients need to know that the use of hearing protection for any reason other than protection from damaging levels of sound constitutes overprotection. Many patients will report that the main problem with tinnitus is that it interferes with their hearing ability.
Habituation to both the perception of and the reaction to tinnitus would indicate that the program has been successful [1,36,37]. The responses will determine whether placement in Category 2 is appropriate, which would indicate the use of amplification. At some point, however, the clinician and patient should mutually decide if another form of treatment is the best option. Otherwise, there is the potential that the patient would be constantly frustrated by hearing difficulties. In such a case, the treatment effort would shift to address primarily the tinnitus condition. Such an analysis is possible because each of the questionnaires has been used in the tinnitus treatment study that is presently being conducted at the Portland VAMC.
Symptoms of anxiety and depression in cases of clinically significant tinnitus are attributed to the inappropriate activation of the conscious cortex and subcortical level by tinnitus signal through existing connections between the auditory pathways and the cortical and subcortical areas.
The expanded forms are presented in this article, and the intent of each question is explained. Subjective hearing difficulty is a problem that patients often assume to be the result of their tinnitus [6,19]. The Follow-up Interview form also contains specific instructions for obtaining outcomes information. This study was an analysis of clinical data from 149 patients, of which 28 of the patients reported a total absence of their tinnitus even when attempting to focus their attention on it. The sooner treatment is started, the sooner this vicious cycle can be broken and the patient's normal life can be restored. These examples represent very different kinds of problems that would indicate different strategies of treatment.
If treatment is fully successful, these percentages of time will drop to zero or close to zero.
For patients who were initially fitted with hearing aids, it will be important, of course, to provide appropriate follow-up care to ensure that the amplification is performing adequately.
It is thus important at each of the follow-up visits to redefine the extent of each of these auditory problems. An important outcome of this effort will be an assessment of the performance of the expanded TRT interview forms in relation to the three self-administered tinnitus instruments that have been documented for validity and reliability. It reduces the level of annoyance induced by tinnitus and improves the ability of patients to work, sleep, relax or be concentrated. The connections between the auditory, limbic and autonomic nervous systems are governed by the principles of conditioned reflexes2-3 which can explain why significant tinnitus may be the result of nonacoustic factors, e. Hearing impairment (>25 dB in at least 1 frequency) was present in 25 out of 30 subjects of the control group (83.3%). Standardized administration of these interview forms will facilitate greater uniformity in the initial evaluation and outcomes analyses of patients treated with TRT.
Proper training to perform TRT requires attendance at one of these courses, which have been completed by over 300 health professionals in the United States and over 600 in other countries. In most of these cases, the hearing assessment reveals reduced hearing sensitivity of the sensorineural type. With these forms and the instructions provided herein, TRT clinicians have the tools necessary to administer the TRT interviews in a standardized fashion.
If generalizable, these data would indicate that approximately half of the nonveteran tinnitus patient population do not know the cause of their tinnitus, and this may be a major reason why they seek professional help. The second school of thought is that patients should be informed of the potentially labile nature of tinnitus during its first few months.
Patients using amplification therefore should be asked any questions that would be important for assessing any problems.
Following this effort, a further revised TRT interview form may be proposed that will require testing for validity and reliability.
Thus, most likely, the tinnitus is not causing their hearing difficulties but rather the decline in sensory cell population in the cochlea is causing their hearing loss [6,20].
This finding leads to the question, Does tinnitus of unknown onset result in greater tinnitus distress than when the cause is clearly identified? Whether or not the tinnitus resolves completely, the patient's fears may be sufficiently allayed by the hopeful information. Most likely, a generalized version of a self-administered tinnitus outcomes instrument will be developed and promoted for standardized clinical and research application. For TRT, however, the interview format will be retained for the purposes just mentioned [14].
Each patient should be treated individually, and treatment decisions should be made solely according to what will provide the greatest benefit to the patient. The common approach with TRT is that a patient with recent-onset tinnitus mainly needs a full evaluation and counseling.

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