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Key words: compensation, hearing disorders, loudness matching, loudness perception, malingering, pitch matching, pitch perception, rehabilitation, reliability of results, tinnitus, tinnitus diagnosis. Abbreviations: ANOVA = analysis of variance, HL = hearing level, LM = loudness match, PM = pitch match, PVAMC = Portland VA Medical Center, SD = standard deviation, SL = sensation level, SPL = sound pressure level, TES = Tinnitus Evaluation System, VA = Department of Veterans Affairs, VHA = Veterans Health Administration. Chronic tinnitus is the persistent sensation of hearing a sound that exists only inside the head. Special audiological tests are effective in detecting deliberate exaggeration of hearing loss [10-11], but no documented test exists that is capable of detecting the presence or absence of tinnitus. Any type of audiometric test for tinnitus diagnosis may rely at least partly upon the demonstration of response reliability.
We completed a pilot study to investigate the potential for LM functions to detect differences between 12 subjects with tinnitus versus 12 subjects without tinnitus [16]. Study inclusion criteria were intended to identify two groups of individuals: those who experienced chronic tinnitus (tinnitus subjects) and those who did not experience tinnitus (nontinnitus subjects). Candidates who passed telephone screening were invited to make an appointment to determine whether they met the audiometric criteria for study entry.
After signing informed consent, subjects had their hearing evaluated manually by an audiologist (conventional hearing threshold evaluation that obtained results in decibel hearing level [HL]). Following the conventional hearing threshold evalua-tion, subjects completed a baseline questionnaire that asked their age, sex, veteran status, and tinnitus status. To ensure that the tinnitus and nontinnitus groups exhibited approximately the same degree of hearing loss, we matched subjects by hearing loss with respect to both their low (0.5, 1, 2 kHz) and high (3, 4, 6 kHz) frequency average hearing thresholds (in decibel HL).
Audiometric testing was conducted in a double-walled sound-attenuated suite (Acoustic Systems Model RE-245S, ETS Lindgren; Cedar Park, Texas). The TES Module also serves as a control device (user interface), enabling patients to easily control stimulus parameters and respond to tests.
All-new programming was required to support the new platform and to create new testing capabilities. All testing data are stored via connectivity to a Microsoft Access database (Microsoft Corp; Redmond, Washington). The management interface is used to manage patient information, create and configure test session templates (preconfigured test scenarios), launch test sessions, and report on test results. As a single integrated device with earphones (ER-4B, Etymotic Research, Inc; Elk Grove Village, Illinois) permanently attached, the TES Module is calibrated independently in the laboratory and then sent out to a testing site.
Prior to conducting the tinnitus matching tests, we carefully instructed the nontinnitus subjects to ensure that they responded to all testing as if they were attempting to prove that they did in fact experience chronic tinnitus.
Tinnitus matching requires patients to make a clear distinction between the tinnitus perception and the matching tones. For the nontinnitus subjects, if one ear had better hearing sensitivity, then that ear was selected as the stimulus ear. Following the general instructions, we provided specific instructions for obtaining hearing thresholds (in decibel sound pressure level [SPL]) with the TES.
After a threshold was obtained at 1 kHz, we then obtained an LM (in decibel SPL) at the same frequency. This sequence of testing (average hearing threshold followed by average LM) was then repeated at the next higher test frequency (1,260 Hz) followed by the remainder of the test frequencies in ascending order.
When hearing thresholds and tinnitus LMs had been obtained at all 13 test frequencies, on-screen instructions were shown to explain the PM task. The previously described testing was conducted during two sessions that were at least 3 days apart. Within- and between-session correlations were computed for the dB SPL LMs and compared between the tinnitus and nontinnitus subjects.
Within-subject PM variability (five observations for each of the two tests within the two test sessions) was pooled within and across subjects and compared between the tinnitus and nontinnitus subjects on the premise that subjects with tinnitus would exhibit less variability in pitch matching. Demographic and audiometric characteristics of tinnitus subjects (n = 36) and nontinnitus subjects (n = 36).
Tables 2 and 3 show the LM means (and standard errors) in decibel SPL and decibel SL, respectively, for the sessions and runs in the tinnitus and nontinnitus subjects for 1 to 16 kHz. Across-subject mean loudness matches (dB sound pressure level) for tinnitus subjects (n = 36) and nontinnitus subjects (n = 36).
Across-subject mean loudness matches (decibel sensation level) for tinnitus subjects (n = 36) and nontinnitus subjects (n = 36). Table 4 shows the within-session LM correlations (between two test runs on the same day) for the tinnitus and nontinnitus subjects for 1,000 to 12,700 Hz. Within-session loudness-match correlations (decibel sound pressure level) for tinnitus subjects (n = 36) and nontinnitus subjects (n = 36).
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. The VA really should establish a presumption that female service members were raped or sexually assaulted in service.
The VA presumes that certain medical conditions are caused by Agent Orange exposure – the presumption is based on science showing that the rate of diagnosis of certain conditions is higher in Vietnam Veterans exposed to Agent Orange than in the regular population. Corroboration is one of those few words that means the same to real people as it does in the legal system: it means to confirm or give support to a particular theory, fact, assertion, etc. But if I call the police to tell them there is a power line down on top of a car on my neighborhood street, they are not going to need anyone to corroborate that. When it comes to Military Sexual Trauma cases, however, we have created an interesting little anomaly. Get statements from fellow soldiers that observed a decline in your performance – if you can get an officer or two to pitch in a statement, that always helps.
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Ascertaining the presence of tinnitus in individuals who claim tinnitus for compensation purposes is very difficult and increasingly becoming a problem. That is, the validity of any response depends upon its reproducibility; thus, response reliabili-ty is expected to be an important component of any test developed to assess the presence of tinnitus for claims purposes. Testing was done using a computer-automated program that had recently been modified to allow more patient control of test stimuli (through the use of a handheld control pad device). Essentially the same protocol was used, except this study used a computer-automated testing system that was completely redesigned for improved functionality.
Subjects were recruited by a local newspaper advertisement, by flyers posted around the Portland Department of Veterans Affairs (VA) Medical Center (PVAMC), and from other auditory investigations that were being conducted at the National Center for Rehabilitative Auditory Research.
As part of the informed consent process at the start of the appointment, all candidates were told that the study was being conducted to determine the effectiveness of a new technique for measuring various aspects of tinnitus.
Subjects with tinnitus completed a written tinnitus questionnaire in which they reported the length of time they had had tinnitus, whether their tinnitus was tonal or nontonal, and whether their tinnitus was binaural or unilateral. Collection of data from human subjects was approved by the PVAMC institutional review board committee. We used the latest version of our computer-automated testing system that has undergone several revisions over a period of 10 years [16-19]. This was accomplished by constructing the TES Module enclosure to also serve as a handheld control pad for patients to control the auditory stimuli. They were instructed to "Imagine a sound in your head or ears and try to match that sound consistently to the sounds that you will hear through earphones.
This is done most easily if the stimulus in one ear is compared to the tinnitus in the contralateral ear [21-22].
Before testing began, the program presented a series of screens describing the general testing procedures, followed by specific instructions for hearing threshold testing. Each test frequency was presented at the output level previously selected as a tinnitus LM during the threshold and LM testing.
Two test runs (thresholds, loudness matching, and pitch matching) were conducted within each session.
A repeated measures analysis of variance (ANOVA) was used to assess the difference in LMs (dB SPL and dB SL) between the tinnitus and nontinnitus subjects across the four tests.
This analysis was motivated by the expectation that the correlations between the two tests within a session and the correlations between sessions would be greater for the tinnitus subjects than for the nontinnitus subjects and would represent more consistent responses for the tinnitus subjects. With one exception (10,080 Hz), mean SPL LMs were consistently greater for nontinnitus than for tinnitus subjects. 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].
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The United States Department of Veterans Affairs the Veterans Health Administration, or VHA. This study examined the potential to observe differences in loudness and pitch matches between individuals who experience tinnitus versus those who do not. Epidemiology studies reveal that between 10 and 15 percent of all adults experience chronic tinnitus [2-7]. Because so many parameters of tinnitus are capable of being measured, any of those parameters could potentially be used for repeated testing to evaluate a tinnitus claim.
Candidates with tinnitus were told that they had been invited to participate in the study because they had tinnitus that was constant and therefore could be measured. The system enabled direct patient control of certain stimulus parameters during testing to make testing more efficient.
For most of the tests, the computer presents a starting sound and the patient turns a dial on a peripheral hardware device (TES Module) to control output level, frequency, or bandwidth of the sound. The peripheral hardware device (TES Module) was developed to enable specialized auditory tests.
The TES control pad includes a continuous rotating encoder dial that provides a single-point adjustment of a parameter of interest (programmable and determined according to the particular test or test phase).
Information about test parameters is stored in an Access database, which also determines which tests to run for each session and provides parameters to control the hardware behavior. The TES uses decibel SPL because normative hearing threshold levels have not been established for frequencies above 8 kHz and because the earphones used with the TES have not been documented for conventional audiometric testing of hearing sensitivity.) Testing started when a hearing threshold was obtained at 1 kHz. It is critical for them to clearly understand the difference between these two psychological attributes of sound for us to obtain well-informed, and therefore accurate, matching measurements [21,23]. These differences were significant at frequencies of 2 kHz and below and diminished in the higher frequencies. The nontinnitus group had a similar distribution of correlations, except that half the frequencies had correlations that were below 0.90.
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. I filed and unrestricted report and filed criminal charges against the 3fellow soldiers who gang raped and sodomized Me , took my virginity and knocked me up.
This study follows a previous pilot study we completed that included 12 subjects with and 12 subjects without tinnitus.
The basis for awarding a tinnitus disability is that the tinnitus is (1) at least recurrent (intermittent) and (2) related to military service [8-9]. Jacobson et al., however, reported results from an experiment that showed test-retest reliability of LMs to be similar between individuals with and those without tinnitus [13]. The key is to determine which test, or combination of tests, will be most effective in accomplishing this purpose. No other screening criteria were applied because the intent was to simulate real-life individuals who might be attempting to claim the presence of tinnitus. Candidates who did not have tinnitus were told that they could represent individuals who might want to claim tinnitus when they do not actually experience it. The present fifth-generation system is referred to as the Tinnitus Evaluation System (TES). The TES Module brings various capabilities together in one small device that connects to a personal computer.
In addition, four push buttons are included on the TES control pad to facilitate patient responses.
Patient responses made with the TES Module encoder dial and response buttons are recorded to the same database from which the test session parameters are read.
The management interface presents configuration options through the test session configuration dialogs, in which tests and their parameters can be preset into session templates to allow an operator to easily run many patients through the same battery of tests. A testing interface program checks the device's calibration time stamp and compares it with the one already stored in the database.
Subjects determined on their own how they would respond in a consistent manner in spite of their nonexistent tinnitus. They were queried to ensure that they understood that they would be matching tones in one ear to an imagined tinnitus in the contralateral ear. To ensure that the subjects understood pitch and loudness, we included a series of instruction screens that explained the concepts prior to performing tinnitus loudness matching. Tinnitus and nontinnitus subjects were similar in age, sex, veteran status, and mean hearing thresholds (Table 1).
SL LMs were essentially equal between the tinnitus and nontinnitus subjects across the frequencies. 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.
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The only difference was that individuals without tinnitus generally provided LMs at higher levels.
Tinnitus loudness matching has been shown to be very reliable with tinnitus patients, but the Jacobson et al. Reliability of the LMs was at least as good for the nontinnitus group as for the tinnitus group, both within and across sessions. Any screening criteria other than the presence or absence of tinnitus might have introduced bias to the samples.
These capabilities include signal genera-tion (pure tones and noise bands) and signal processing (mixing, switching, muting, attenuation, and headphone buffering). Testing sessions can then be launched by selecting a patient record and preconfigured template. If newer calibration data are available, they are downloaded from the TES Module, saved in the database, and used in testing to provide calibrated stimulus levels. If the tinnitus was perceived to be symmetrical, then the stimulus ear was determined randomly.
Subjects rotated the encoder dial to find the point of minimum audibility for the tone and then selected the threshold level by pressing the response button.
In session 2, the tinnitus subjects showed significantly greater correlations in 4 of the 12 frequencies.
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.
Hearing loss can be due a number of different reasons; it can Can I get a hearing aid from VA? Results of this study revealed no significant differences between groups with regard to decibel sensation level (SL) loudness matches and within-session loudness-match reliability. As of October 2008, 558,232 veterans had been awarded tinnitus service-connection disability.* Among veterans returning from the Iraq and Afghanistan wars, tinnitus is the most common service-connected disability (67,689 veterans in 2008). In addition, pitch matches (PMs) were obtained from each subject, which involved subject selection of the frequency that most closely matched the pitch of the tinnitus from the different test frequencies. The pure tone quality, output linearity, frequency accuracy, pulse characteristics, and signal cross talk of the TES Module conform to the American National Standards Institute specification for audiometers across the standard frequency range from 125 to 8,000 Hz [20].
The operator can override the template tests' default values of some parameters on a per-session basis. Following the instructions, we presented the tone at a randomized output level above the level of the hearing threshold that had just been established.
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. If you already have had a VA hearing aid, you will not receive a supply of batteries unless your new hearing aid uses different size batteries than your old hearing aid.
Director BioCommunication Laboratory University of Maryland My buddy got VA Hearing Aids also, he only uses em to watch TV???? Between-group differences revealed that the tinnitus subjects had (1) greater decibel sound pressure level loudness matches, (2) better between-session loudness-match reliability, (3) better pitch-match reliability, and (4) higher frequency pitch matches. These concerns have prompted our overall effort to develop tests that can help ensure that a tinnitus disability is accurately rated and that allow for reexamination whenever a need exists to verify the continued existence of tinnitus. These PMs were performed multiple times after loudness matching and the multiple PMs were averaged. A special test template was devised to enable the device to be calibration-checked on-site at regular intervals.
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.
These findings support the data from our pilot study with the exception that decibel SL loudness matches were greater for the tinnitus subjects in the pilot study. The result of pitch matching was that the mean PMs for the tinnitus group were significantly higher in frequency than for the nontinnitus group. The reporting module of the management interface uses preformatted reports for presenting test results from the response database. 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. Tinnitus loudness and pitch matching may have some value in an overall battery of tests for evaluating tinnitus claims. All calibration procedures are conducted in a double-walled sound-attenuated suite (Acoustic Systems Model RE-245S). 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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  • KiLLeR The two muscles attached to the middle ear nothing that worked for people liken the.
  • Ramin4ik Every day they tinnitus is much less clear, but decrease the state of wellbeing, the.
  • Raufxacmazli Lessens anxiety, and sat down broken.