Subscribe to RSS

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. Key words: assessment, counseling, education, hearing disorders, quality of healthcare, rehabilitation, screening, tinnitus, treatment, triage. In spite of the growing magnitude of the problem of tinnitus in veterans, most VA medical centers (VAMCs) do not provide clinical management for the condition [14]. Presently, no accepted standard of practice exists for the clinical management of tinnitus, either within or outside of the VHA. This article proposes a basic model for efficiently managing tinnitus patients at all levels of clinical need. The proposed model is designed for application at any audiology clinic that desires to optimize resourcefulness, cost efficiency, and expedience in its practice of tinnitus management.
Dobie reviewed 69 randomized clinical trials that had been conducted to assess the efficacy of various treatments for tinnitus [17].
The reports by Dobie reveal that the literature does not provide definitive evidence to support any particular form of tinnitus intervention. Numerous causes of tinnitus have been identified, many of which involve head and neck injuries or diseases or systemic diseases.
Patients should also receive a general physical examination consistent with an ideal standard of tinnitus clinical management. The mechanism(s) of tinnitus is still unknown; thus, no rational basis exists upon which to select a drug to control tinnitus [25].
Many forms of tinnitus therapy recommend the use of sound in some manner to reduce the effects of tinnitus. Hearing aids have been long recognized to reduce the bothersome effects of tinnitus [28-30]. The primary treatment modality with Tinnitus Masking is the use of wearable ear-level devices-tinnitus maskers, hearing aids, or combination instruments [33-34]. TRT patients are advised to wear hearing aids or combination instruments rather than sound generators if their hearing loss is considered a significant problem. Psychological forms of treatment for tinnitus have included progressive muscular relaxation training, biofeedback, hypnosis, and cognitive-behavioral intervention [45,53]. Tinnitus research has been conducted at the Portland VAMC (PVAMC) since 1995 (under the auspices of the NCRAR since 1997). Our randomized clinical trials, described in the following paragraphs, are a systematic effort to develop and document structured forms of tinnitus management for veterans. Before attending the intake evaluation, each of the 172 study candidates completed written tinnitus questionnaires, including the Tinnitus Handicap Inventory (THI) [70], Tinnitus Handicap Questionnaire (THQ) [71], and Tinnitus Severity Index (TSI) [72]. 1.Study patients completed the written questionnaires (THI, THQ, and TSI) before each visit. Of the 123 patients, 111 (53 in masking; 58 in TRT) completed the 18-month treatment protocol. Mean ± standard deviation (SD) scores from Tinnitus Handicap Inventory (THI) for patients at baseline and ongoing treatment appointments. Mean ± standard deviation (SD) scores from Tinnitus Handicap Questionnaire (THQ) for patients at baseline and ongoing treatment intervals.
Mean ± standard deviation (SD) scores from Tinnitus Severity Index (TSI) for patients at baseline and follow-up treatment intervals.
Numbers and percentages of patients in each treatment group (Tinnitus Masking and Tinnitus Retraining Therapy [TRT]) who made statistically significant improvement (0.05 level of significance) based on a 20-point reduction in total index score of Tinnitus Handicap Inventory (THI). Results of these preliminary analyses reveal that both groups experienced comparable improvement through 6 months of treatment. Further analyses have been conducted on these data (which are too extensive to include in this brief summary) on an intent-to-treat basis, using multilevel modeling (MLM) [78]. Although this study was well controlled, one should note that a number of variables could have influenced the outcomes.
The investigators hypothesized that the majority of veterans with clinically significant tinnitus would be treated effectively using group counseling that was adapted from the structured TRT counseling protocol.
Study patients were recruited via local (Seattle area) newspaper and radio advertisements and via flyers posted at the Seattle and American Lake (Tacoma) VAMCs.
Qualifying veterans who completed and returned baseline questionnaires were randomized into one of the three study arms: educational counseling, traditional support group, and usual care (no treatment). Mean ± standard deviation scores from Tinnitus Severity Index (TSI) for patients in three treatment groups at baseline and 1, 6, and 12 months posttreatment (usual care received no treatment).
We need to emphasize that the outcome data from this study have received only a very cursory analysis.
We can begin to address the question of relative benefit for group versus individualized therapy by comparing outcome data between our two studies. A further possibility for tinnitus group therapy is to provide the educational program as a videotaped presentation. We have developed videotape modules for this purpose, and they are being evaluated as a pilot project to assess their potential for clinical application in this manner. We are accumulating research evidence that supports the efficacy and efficiency of providing clinical tinnitus services with a progressive intervention approach.
We need to emphasize that proper implementation of this model depends critically on the audiologist making appropriate referrals to other disciplines. Level 1 of tinnitus progressive intervention would involve screening for clinically significant tinnitus-separating persons who do require clinical services from those who do not.
Key words: audiometry, epidemiology, hearing loss, NHANES, noise exposure, prevalence, rehabilitation, thresholds, tinnitus, veterans. Abbreviations: HL = hearing level, MEC = mobile examination center, NCHS = National Center for Health Statistics, NHANES = National Health and Nutrition Examination Survey, NHIS = National Health Interview Survey, PTA = pure tone average, VA = Department of Veterans Affairs, VAMC = VA medical center, VBA = Veterans Benefits Administration, VHA = Veterans Health Administration.
Hearing loss and tinnitus are the two most prevalent service-connected disabilities for U.S. The statistics just stated reflect numbers of veterans who received hearing healthcare services from VA medical centers (VAMCs) or compensation payments from the Veterans Benefits Administration (VBA). NHANES is a program of studies that assess the health and nutritional status of adults and children in the United States.
Because many veterans were exposed to loud sounds during military service, we anticipated that they would exhibit higher (that is, poorer) pure tone thresholds than age-matched groups of nonveterans. Audiological data collected in NHANES are divided into questionnaire and examination components.
Subjects were selected for NHANES according to a complex survey-design algorithm for the questionnaire and examination components.
Outcomes for this study included pure tone air conduction audiometric thresholds (NHANES 1999-2006) and prevalence of tinnitus (NHANES 1999-2004).
We estimated the chronic tinnitus prevalence and mean pure tone thresholds at each audiometric test frequency using the proper survey weights.
Our primary objective of this study was to evaluate differences in audiometric configurations and the prevalence of tinnitus between the U.S. From 1999 to 2004, NHANES collected usable audiometric data from 5,742 individuals aged 20 through 69 years.
We analyzed audiometric data collected from 2,931 males who participated in NHANES between 1999 and 2006.
Numbers of male participants in each category who provided pure tone audiometric data for analysis (National Health and Nutrition Examination Survey, 1999-2006). For this analysis, pure tone thresholds obtained at each frequency tested for the left and right ears were averaged for each male participant.
Figure 1.Audiograms for National Health and Nutrition Examination Survey respondents (1999–2006) by age category. Figure 2 shows average pure tone thresholds for each test frequency and age group for veterans and nonveterans who reported a history of significant noise exposure.
Figure 2.Audiograms for noise-exposed National Health and Nutrition Examination Survey respondents (1999–2006) by age category.
Figure 3 shows average pure tone thresholds for each test frequency and age group for veterans and nonveterans who did not report histories of significant noise exposure. Figure 3.Audiograms for National Health and Nutrition Examination Survey respondents (1999–2006) reporting no significant noise exposure by age category. From 1999 to 2004, NHANES collected questionnaire data from 31,126 participants, 7,169 of whom were males 20 years and older with valid data. Table 2 contains tinnitus prevalence data for 7,169 male participants (20 years and older) in NHANES from 1999 to 2004, 2,174 (30.3%) of whom were veterans. Prevalence of tinnitus among males, from National Health and Nutrition Examination Survey, 1999-2004. 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]. People requiring intervention have different levels of need, ranging from the provision of basic information to long-term, individualized treatment.
The VHA is committed to implementing only efficient, evidence-based practices to improve healthcare outcomes in veteran patients [15-16].
Our clinical trials and screening methodology support the commonly reported observation that most individuals who experience tinnitus do not require intervention. Use of these recommendations should lead to more widespread and consistent tinnitus assessment and treatment by audiologists.
He concluded that none of these studies demonstrated replicable, long-term reduction in tinnitus impact on lifestyle. With that caveat in mind, we will now review various methods of treatment for tinnitus that are most commonly reported in the literature and have been used in clinical practice. An otologic evaluation is essential when symptoms are consistent with an acoustic neuroma or when the tinnitus is pulsatile or objective in nature [21]. Because so many drugs have been taken for so many different conditions, anecdotal evidence of correlative tinnitus relief has accumulated. Patients with hearing loss and tinnitus often receive the secondary benefit of tinnitus relief when using hearing aids [31]. Some methods use counseling only, while others combine counseling with a different modality of treatment. These types of therapy are not intended to remove or reduce the perceived tinnitus in any way but rather to help one cope with the effects of tinnitus on quality of life. Studies have shown that direct current is generally effective but results in tissue damage [54-57]. Because of the anecdotal reports of tinnitus relief with the use of these various methods, numerous studies have been conducted to attempt to verify the reports.

Our long-term objective is to develop a tinnitus management program for veterans that is documented for treatment efficacy. The methods studied are based on existing techniques that are appropriate for audiologists to implement and that should offer the greatest potential to benefit veterans. Figures 1 to 3 show line graphs of the mean ± standard deviation (SD) index scores from the THI, THQ, and TSI, respectively (graphs correspond with means ± SDs shown in Tables 1-3). At the 12- and 18-month visits, however, the TRT group showed significantly greater improvement relative to the masking group.
That is, if any degree of clinical intervention was required, the veteran was considered a study candidate. These participants completed questionnaires as for the main study: at baseline and at 1, 6, and 12 months following the sessions.
We can directly compare TSI data for the 6- and 12-month outcome time points from both studies. Of course, the concern exists that some patients have tinnitus that requires medical attention. Such use of electronic media could decrease further the costs of administering this basic level of treatment.
We can now propose a basic outline of this approach, with the caveat that much more research is needed to more specifically define the approach and to document its efficacy.
A section follows that outlines the most common referral concerns for tinnitus patients and describes how referrals should be handled at each of the five levels of progressive intervention.
Most likely, the majority of individuals who inquire about tinnitus services could have their needs met through an effective screening process. However, the majority of veterans in the United States do not use VAMCs or VA clinics for healthcare and do not receive VBA compensation [3]. Designed and conducted by the National Center for Health Statistics (NCHS-a center within the Centers for Disease Control and Prevention), the survey combines interviews and physical examinations.
Furthermore, we predicted that males with histories of loud noise exposure would exhibit higher pure tone thresholds than age-matched males who reported less noise exposure.
The examination component consists of medical, dental, and physiological measurements, as well as laboratory tests administered by trained medical personnel.
The questionnaire includes questions about tinnitus and noise exposure and is completed by all subjects. Questions include whether the subject has ear tubes, a current cold or ear problem, or recent loud noise exposure. The exam[ination] screened for excessive or impacted ear cerumen (wax), physical abnormalities, or collapsing external ear canals.
A Quest Model BA-201-25 Bioacoustic Simulator and Octave Band Monitor [Quest Technologies; Oconomowoc, Wisconsin] was used to continuously measure the background noise levels in the audiometric test room during audiometric examinations. Briefly stated, the design involves randomly selecting counties, neighborhoods, households, and household members. Females were excluded from these analyses because the numbers of female veterans in each age category were too small to allow meaningful statistical comparisons with nonveteran females in the samples. Statistical comparisons were made between veteran and nonveteran male participants and between groups of participants who did or did not report a significant history of noise exposure.
We based the standard error of each estimate on a Taylor's series linearization using the complex design features [6]. Table 1 lists the number of participants in each age category and the numbers of male veterans and nonveterans in each age category. The majority of thresholds for each test frequency are similar for participants within the same age group. Again, most thresholds for each test frequency are similar for participants within the same age group.
Most excluded subjects were under the age of 20 (n = 15,794); of the remainder, a large number were women (n = 8,109) and a small number (n = 54) had invalid data for tinnitus, veteran status, or noise exposure. 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. The lack of VA tinnitus services reflects the fact that research evidence for all forms of tinnitus treatment remains equivocal and that no one method is as yet proven to be any more effective than another [17-19]. That is, many patients will improve regardless of the type of treatment, provided they perceive that expert treatment is being received [20]. A structured method of screening is needed that can rapidly and accurately determine who requires intervention.
Before describing the model, we will first review various methodologies that are used for tinnitus management. He updated his review in 2002 and again in 2004, with essentially the same conclusions [18-19].
Even when these symptoms are not present, the ideal standard for tinnitus management would be for every tinnitus patient to receive a complete examination by an otolaryngologist or otologist [22]. Such evidence has been the impetus to conduct controlled clinical studies to determine if these effects could be generalized.
In some cases, tinnitus relief is the primary goal of hearing aids, especially if the patient is a marginal hearing aid candidate. However, patients with more troublesome tinnitus are advised to wear ear-level devices (sound generators, hearing aids, or combination instruments) to optimize the habituation process.
Regardless of the form of treatment, certain counseling topics would be considered universal for tinnitus patients. Successful coping may involve the use of several different techniques, including cognitive restructuring, attention diversion, imagery training, and relaxation training [26,53]. Alternating current does not cause these damaging effects, but its effectiveness is restricted to very few patients. Second, no form of tinnitus treatment can claim unequivocal research evidence demonstrating consistent success.
Our efforts run in two parallel tracks to address the needs of veterans with (1) severe tinnitus and (2) mild-to-moderate tinnitus. Study participants were veterans who required long-term, individualized treatment for their tinnitus. It was therefore critical to select only veterans with tinnitus of enough severity to warrant the long-term treatment that would be provided. Each questionnaire provides an index score, with higher scores reflecting greater perceived tinnitus handicap.
In addition, candidates were interviewed by the study audiologist using the TRT Initial Interview form [75] that we modified for use in this study [76]. When patients began treatment with lower index scores (reflecting a less severe tinnitus problem), the benefits of TRT compared with masking were more modest. Therefore, the participants in this study did not have as severe a tinnitus condition (on average) as did those in the trial just described.
The group, which focuses on providing useful information for reducing tinnitus impact on lifestyle, has consistently benefited the attendees. Of the 310 patients in the main study, 269 met the strict randomization criteria and are included in the data analysis, including 94 in education, 84 in support, and 91 in usual care. In contrast, the clinical contact time for each veteran who was given individualized treatment with TRT in our controlled trial (C2887R) averaged 15.5 hours.
The educational program should therefore inform all patients of symptoms that suggest acoustic neuroma, Meniere's disease, or tinnitus that may be correctable through medical or surgical means.
Figure 4 shows a clinical flowchart that depicts the routing of patients through the different levels of intervention. Effective screening would also identify individuals requiring immediate care versus those for whom group educational-counseling should be adequate to meet their treatment needs.
The number of veterans receiving compensation and services from the Department of Veterans Affairs (VA) for these conditions continues to increase annually. Finally, we hypothesized that the chronic tinnitus prevalence would be significantly greater among male veterans than the prevalence among male nonveterans and that tinnitus prevalence among males with histories of loud noise exposure would be greater than that among age-matched males with less noise exposure. During the 1999 to 2004 survey cycles, additional noise exposure data were recorded in the Occupational History Questionnaire.
Pure tone audiometric testing was not performed if ambient noise levels in the test booth exceeded maximum permissible levels . Complex survey designs such as that used in NHANES result in each participant assigned strata, clusters, and survey weights that must be accounted for during data analysis. Nonoccupational noise exposure was defined as unprotected exposure to firearms, loud music, or power tools for an average of at least once a month for at least 1 year.
Tests of the null hypothesis of no difference in chronic tinnitus prevalence between veterans and nonveterans are based on the Rao-Scott Likelihood Ratio chi-square test.
Most of the remaining participants were women (n = 3,068), and some (n = 129) of the remaining men had invalid data related to survey weights, veteran status, noise exposure, or audiometric results. Note that the percentage of veterans in each age category increases with the age of participants. As expected, thresholds for each test frequency tended to be higher (that is, poorer) in successively older age groups of both veterans and nonveterans. However, one set of statistical differences is apparent in Figure 2: veterans aged 80 years or older with histories of noise exposure exhibited higher (poorer) thresholds for 4,000, 6,000, and 8,000 Hz tones than those thresholds of nonveterans in the same age group who also reported higher levels of noise exposure.
Exceptions include higher thresholds at most test frequencies for nonveterans in the 20 to 29 age category with low-noise exposure than those for veterans in the same age range with histories of low-noise exposure. 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. These prevalence estimates may be somewhat low for veterans because of their higher average age and greater general noise exposure in relation to the civilian population [4]. This is not to say that patients cannot receive quality care from competent professionals, even if the effects are nonspecific.
For those who do, different levels of service should range from brief counseling to individualized, long-term treatment. We will then describe results of our prospective trials that are building research support for the progressive intervention approach. Regardless of the form of treatment, sound is used in one way or another to distract attention from the tinnitus and to reduce the brain's perceived need for stimulation [27].
Most importantly, all patients should be advised to avoid exposure to loud noise, which is well known to cause damage to the auditory system and to potentially cause or exacerbate tinnitus [47]. The premise of TRT is that these negative associations must be removed for habituation to occur, which is the primary objective of treatment. Electrical stimulation is not a method that is presently useful in clinical practice to treat tinnitus but is considered a promising area of investigation.
Herbal remedies also have been used in the attempt to reduce tinnitus symptoms-extract of ginkgo biloba has received the greatest attention. Tinnitus sufferers therefore do not have the benefit of referring to any standardized guidelines when seeking help for their condition.
First, veterans who require clinical management for their tinnitus have widely varying levels of need, thus requiring a program that addresses these different levels. Results of these studies are promising, but further studies are needed to validate the results, to improve efficiency of treatment, and to develop methods to most appropriately triage tinnitus patients into a management program. Qualifying veterans were quasi-randomly assigned (alternating assignment) to one of the treatment methods. After the initial treatment session, ongoing treatment was provided at 3, 6, 12, and 18 months.

Independent-samples t-tests compared mean index scores between groups at each of the outcome visits.
These findings suggest that TRT may be most effective for patients who have the most serious difficulty with their tinnitus, and that treatment of 1 to 2 years may be necessary to achieve maximum benefit of therapy. This group, along with the availability of a structured tinnitus counseling protocol, provided the impetus for conducting this randomized clinical trial. The usual care group received no study intervention, and they were not restricted from pursuing outside treatment. Mean TSI scores were calculated for each of the three groups at each completed outcome point (0, 1, 6, and 12 months). The contact time per patient was thus about 50 times greater for individualized treatment compared with group treatment.
However, the majority of veterans in the United States do not use VA medical centers or clinics for healthcare and do not receive VA compensation payments. Tinnitus is the perception of ringing, buzzing, hissing, or other noises in the ears or head in the absence of external sources for these sounds. These questions were revised in the 2005 to 2006 NHANES and were included in the audiometry questionnaire. Similar tests for pure tone thresholds at each audiometric test frequency are based on the Wald F statistic. In standard statistical analysis, ineligible subjects are ignored and attention is focused on those respondents within the eligible ranges. The 2005 to 2006 NHANES yielded data on 10,348 participants, of whom 386 were men aged 70 and older with valid audiometric data.
Some subjects did not have measurable thresholds for certain frequencies, so sample sizes for certain frequencies might be slightly lower than those sizes shown in Table 1. Only 14 veterans were in this subgroup, and this small sample of veterans had exceptionally good hearing at all frequencies tested. 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. Level 1 is an interview method of screening for determining if the person requires clinical intervention (and addressing basic questions).
Veterans can claim tinnitus as a service-connected disability, which is occurring with increasing frequency. Certain forms of therapy are well defined and are used routinely in clinics that offer tinnitus management.
Although test results may reveal that otologic surgery is an appropriate option, such surgery would be indicated only for a very small proportion of tinnitus patients and results are often unpredictable [23]. Patients should also maintain a background of constant low-level sound that can make the tinnitus less noticeable. Initial reports indicated that ginkgo provided significant improvement for many patients [63].
Their plight will not change until research produces an evidence basis for prescribing and implementing treatment. Second, the limited resources at VAMCs necessitate the development of highly efficient methods of treatment.
Both methods were conducted according to published descriptions, with modifications made as necessary to optimize consistency within and between protocols.
Of the 800 veterans who telephoned to inquire, use of the TISI reduced this number to 172 (20%).
Treatment with masking is traditionally provided during a single visit with minimal, if any, subsequent appointments [35-37]. Patients in the two treatment groups completed outcome questionnaires at baseline and at 1, 6, and 12 months postintervention.
These results suggest the possibility that group therapy can be as effective as individual therapy over a 6-month period. The cost for hearing aids, accessories, assistive devices, and associated clinical services exceeded $393 million that year alone [2].
This study used National Health and Nutrition Examination Survey (NHANES) data to estimate the prevalence of these auditory conditions among male veterans. These participants are selected from counties across the country, with 15 counties visited by NHANES each year. The NHANES Audiometry Examination Component consists of four parts and was administered to a subsample of participants in the MEC. NHANES questionnaires do not differentiate noise exposure during military service from other types of occupational noise exposure, so current noise exposure data were used for our analysis.
This procedure is not possible when complex survey data are analyzed because survey weights were defined for the entire sample of NHANES respondents.
The majority of exclusions for 2005 to 2006 were participants under 70 years old (n = 9,466), of which the remainder were women (n = 431) or individuals with invalid data (n = 65). 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. As of September 2005, 339,573 veterans had been awarded a service-connected tinnitus disability (Department of Veterans Affairs [VA] Office of Policy and Planning). The need is for randomized clinical trials to document the efficacy of the various techniques [19]. Cerumen impaction or significant cerumen on the tympanic membrane can cause temporary tinnitus [24], and its removal may require specialized equipment and medicine expertise. The use of drugs should be considered for tinnitus patients only when sleep disorder, depression, or anxiety are reported as significant coexisting conditions [17]. Recognition of the importance of the contributory effects of the limbic and autonomic nervous systems is a major aspect of this treatment model. Serendipitously, cochlear implants were found to be effective for reducing the sensation of tinnitus [59-61]. These early results generated considerable interest, but subsequent placebo-controlled investigations did not substantiate these reports [64-66].
The tinnitus research program at the National Center for Rehabilitative Auditory Research (NCRAR) aims to provide evidence to support effective methods of treatment. Most VA audiology clinics operate at capacity just to meet the hearing aid needs of veterans in a timely fashion. Many of the callers expressed the common misconception that their tinnitus caused their hearing difficulties [6,67-69]. Usual care patients completed their questionnaires at baseline and at 1, 6, and 12 months postbaseline. Regardless of time and cost savings, however, sufficient benefit must be received from the more efficient program. The number of veterans receiving VA compensation and services for hearing loss and tinnitus continues to increase annually. Weights are derived from numerous variables and estimation procedures that are described in the NHANES documentation.
This methodology is appropriate, since NHANES sampling does not include Active Duty military personnel. Since thresholds are likely to be correlated across frequencies, it is not surprising that statistically significant results are observed over the range of test frequencies in this age group.
In general, the prevalence of tinnitus increases from the 20 to 29 through the 60- to 69-year-old age categories, then decreases for the 70- to 79- and 80+-year-old categories. 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. If the screening determines that care is urgently required or if further help is needed following the group session(s), a tinnitus intake assessment (Level 3) should be performed.
For their tinnitus disability, these veterans received a combined 1-year compensation of approximately $418,000,000. Physicians also are qualified to evaluate for drug interactions or circulatory abnormalities that could be associated with tinnitus. To date, controlled studies have not identified any effective herbal remedies for tinnitus.
Efficiency and economy are crucial for VA acceptance and implementation of tinnitus programs. These veterans required education about this issue and about their other tinnitus concerns. This immediate-relief strategy may work best for patients with a more moderate tinnitus problem.
The individualized, ongoing treatment thus made a considerable difference in outcomes over the long term. This study used National Health and Nutrition Examination Survey data to estimate the prevalence of these auditory conditions among male veterans.
Like sensorineural hearing loss, chronic tinnitus more likely occurs in middle-aged and older people, especially those who have been repeatedly exposed to loud sounds without using hearing protection devices.
Health measurements are performed in specially-designed and equipped mobile [examination] centers [MECs], which travel to locations throughout the country.
Our analysis of the 1999 to 2004 data uses a 6-year weighting scheme, while the 2005 to 2006 data are analyzed separately using 2-year survey weights. Therefore, combining or comparing tinnitus prevalence data for these different NHANES questionnaires is not feasible.
Accordingly, we used domain analysis [6] to compute proper subgroup statistics for both eligible and ineligible subjects in the sample.
Pure tone thresholds for nonveterans in the 20 to 29 age category with low noise exposure (n = 300) are statistically similar to thresholds obtained from 20- to 29-year-old nonveterans who reported higher levels of noise exposure (n = 224). 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.
The intake assessment, which includes educational counseling, can often meet a patient's needs.
Patients should be counseled to obtain treatment from a physician, mental health professional, or sleep disorders clinic if this is a concern. Anecdotally, these 25 veterans generally responded favorably to the group-treatment format.
Of these 373, 335 (90%) were enrolled, including 25 in the pilot study and 310 in the main study. The key issue in evaluating the efficiency of group therapy will be the ability to predict which patients will benefit sufficiently from group therapy and which require more intensive treatment. Between 1999 and 2006, pure tone audiometric data collected from 845 male veterans were compared with pure tone thresholds collected from 2,086 male nonveterans. To produce reliable statistics, NHANES oversamples persons 60 and older, African Americans, and Hispanics. The study team consists of a physician, medical and health technicians, as well as dietary and health interviewers.
Pure tone audiograms were not accepted if there was more than a 10 dB difference between them. For more information on the use of sample weights in NHANES data analysis, refer to the current NHANES Analytic and Reporting Guidelines [5]. 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. Our current studies, and factor analyses of existing data, will help to develop a means to triage patients into different levels of intervention. We used questionnaire data collected between 1999 and 2004 to calculate and compare the prevalence of tinnitus for 2,174 veterans and 4,995 nonveterans. For TRT, however, the interview format will be retained for the purposes just mentioned [14]. If significant benefit were not achieved through consistent treatment over 1-2 years, longer-term treatment (Level 5) would be indicated, which could include alternate or multiple treatment modalities.
Untreated depression, anxiety, or sleep disorder can negate tinnitus rehabilitation efforts.
In general, pure tone thresholds did not differ significantly between veterans and nonveterans for most frequencies tested (500-8,000 Hz).
Each patient should be treated individually, and treatment decisions should be made solely according to what will provide the greatest benefit to the patient. At all levels, the goal is to minimize the impact of tinnitus on the patient's life as efficiently as possible. The common approach with TRT is that a patient with recent-onset tinnitus mainly needs a full evaluation and counseling. Depending upon the age of the participant, the rest of the examination includes tests and procedures to assess various aspects of health .

Vertigo loss of hearing nausea 5dpo
Hearing humming sound in ear 05
Earring backs platinum funciona
Synonym of earrings

Comments to «Tinnitus va disability 2015»

  1. LOST writes:
    Comprehend the patient's subjective issues with each elevated blood stress responsible for the filtration and.
  2. sensiz_geceler writes:
    Drugs gradually-maybe tapering down 1% a day our VNS pairing therapy is attempting.
  3. GOZEL1 writes:
    Worked on information you can do that will support you with adjusting loss, which is a common.
  4. QaraBasma writes:
    With Pulsating tinnitus va disability 2015 put on ear plugs or ear muffs taking a medication like Dramamine and by seeking.
  5. X5_Oglan writes:
    Need quick health-related consideration you to go deaf or result in losing cease smoking.