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A sequential program emerges as one of the most promising, research-based methods to help veterans manage their tinnitus. In order to help patients, it is necessary to mitigate the functional effects of tinnitus, such as difficulties with sleep, concentration, and relaxation.
People who experience tinnitus have most typically been exposed to loud noise that caused peripheral auditory damage, resulting in both tinnitus and hearing loss. Military personnel are exposed to numerous hazards associated with tinnitus and hearing loss, including but not limited to high levels of noise. These auditory problems can become significantly greater following military discharge due to aging and further insults to the auditory system.
Although many therapies for tinnitus are available, most are not supported by rigorous scientific research.
Our research efforts in Portland have led to the development of Progressive Tinnitus Management (PTM), a detailed, comprehensive program endorsed by the VA central office for use at VA medical centers. An initial referral is followed by a hearing evaluation and brief assessment of tinnitus impact. If needed, the patient is advised to attend education workshops designed to provide patients with skills to self-manage their tinnitus. If the patient still experiences problematic tinnitus following the workshops, an interdisciplinary (audiology and psychology) evaluation is completed.
PTM was developed specifically for efficient implementation at VA medical centers, but there are still some barriers to providing comprehensive tinnitus services at all VA medical centers.
To address these issues and as part of an overall effort to make tinnitus services available to all veterans, we conducted a pilot program to provide national in-home tinnitus education. Since telemedicine technology is advancing rapidly, it is now possible to develop PTM as a full telemedicine program using different delivery models. In addition, the infrastructure for conducting telemedicine is already in place at most VA medical centers. Tinnitus is a problem that is recognized at all levels of the Veterans Health Administration. Tinnitus CoachingIm Rahmen des Tinnitus Coachings erhalten Sie einerseits Informationen zur Entstehung, Aufrechterhaltung und Behandlung des Tinnitus.
Meniere’s Disease is a condition of the inner ear that causes episodes of vertigo, tinnitus (ringing or buzzing in the ear), and hearing loss.
Meniere’s disease is thought to be due to endolymphatic hydrops, which is an excess of fluid in the inner ear that can cause damage to the vestibular apparatus. An accurate diagnosis is determined by a detailed subjective history from the individual, as well as ruling out other causes. At this time, there is no cure for Meniere’s Disease; therefore treatment consists of symptom management. Cornerstone Physiotherapy has been voted as one of the top Physiotherapy clinics in Toronto. 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.
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Dementia is a progressive disease and it the loss of mental ability and acuity, which tends to interfere with the daily life of the person. Progressive dementia can take a toll on the caretaker and the rest of family and this is terrible since the prognosis for the disease is varies from one person to another.
However, dementia is not a disease that anyone would want to experience as you slowly lose all your abilities like remembering, walking and talking. If you are wondering about progressive dementia and prognosis regarding a family member, it is best to consult the doctor who would be best suited to give you an indication based on your loved ones condition. Anything that can cause hearing loss can also cause tinnitus, including noise exposure, and the odds of having tinnitus increase as hearing loss increases.
In spite of awareness about these potential exposures and increased efforts to use hearing protection in the field, a substantial number of military personnel still experience auditory damage. The Veterans Benefits Administration reports that in fiscal year 2011, tinnitus was the most prevalent service-connected disability, with 840,865 affected.
A cure for tinnitus does not yet exist, and despite claims to the contrary, no method has been proven to provide long-term suppression of tinnitus loudness and intensity.
Two years later, the VA National Center for Rehabilitative Auditory Research was established at the same location, which included tinnitus research.
After possibly receiving a hearing aid at this time, the patient is assessed to determine if tinnitus-specific intervention is needed. This in-depth assessment of the patient’s tinnitus needs determines whether the patient requires individualized support.
As reported in the Journal of Rehabilitation Research and Development in 2012, it demonstrated the feasibility and efficacy of performing PTM intervention over the telephone, with educational materials provided by mail.
The VA Rehabilitation, Research, and Development Service has supported most of the tinnitus research that we have conducted, as well as studies conducted by other investigators. Andererseits werden mit Ihnen gemeinsam Strategien und Fertigkeiten erarbeitet, um das Ohrgeräusch dauerhaft auszublenden, sodass es Ihr Leben nicht mehr negativ beeinflussen kann.
Overtime, the disease can progress resulting in more frequent episodes of vertigo and progressive hearing loss.


However, the presence of endolymphatic hydrops does not always lead to the development of the disease. A hearing test is also an important piece of information to determine if hearing loss has occurred. Diet Modifications – A low-sodium diet and the avoidance of CATS (coffee, alcohol, tobacco, and stress) have been demonstrated to help reduce the severity of symptoms. Physiotherapy – Between episodes of vertigo, individuals may notice feelings of imbalance or dizziness.
Vestibular Rehabilitation Therapy (VRT) can assist in managing dizziness and imbalance between episodes. 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. Dementia is characterized by short term memory loss and is very different from age-related memory loss.
But one thing is certain that the lifespan of a person suffering from dementia is less compared to a healthy person of the same age.
In addition, as the disease progresses, you will need more and more help just to perform daily living activities like bathing, dressing and using the toilet.
In addition, as the disease progresses, you will notice a change in the person's personality, behavior and moods. Tinnitus was also the most prevalent service-connected condition for veterans who first began receiving benefits (87,261 veterans). As a result, in order to help patients, it is necessary to mitigate the functional effects of tinnitus, such as difficulties with sleep, concentration, and relaxation. Many methods of sound therapy have been developed, and numerous companies are promoting sound therapy products. Our tinnitus research has remained focused on developing effective, evidence-based methods of tinnitus management for veterans. Additionally, for PTM intervention to be effective, veterans must travel multiple times to a VA medical center, which some veterans are simply not able to do. The workshops, evaluations, and individualized support efforts in PTM are ideally suited to telemedicine implementation. We will continue to develop and evaluate these methods to improve tinnitus services and to make them available to all veterans who need them.
James Henry [author of the accompanying story] that was available to veterans and involved several types of treatments. The cause for this excess fluid is generally unknown, but some research suggests it may be due to compression of blood vessels, autoimmune disorders, genetics, or a virus.
As the disease progresses, objective tests using infrared goggles can also detect deficits of the vestibular system. Many people with Meniere’s also find that limiting intake of monosodium glutamate (MSG) and sugar can reduce symptoms. By working with a vestibular physiotherapist, impairments that are present between vertiginous episodes can be identified and vestibular exercises can be prescribed to improve symptoms.
Our vestibular physiotherapists can also assist with lifestyle changes that may assist your management of the condition. 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. This can be very frustrating for the person suffering from dementia and it would explain why so many patients resort to verbal or physical aggression. Clearly, tinnitus is a high-priority healthcare issue for the military and the Department of Veterans Affairs (VA).
It remains unknown, however, if there is any difference among the various sound therapy methods. Eighteen tinnitus projects have been funded, including four that are currently in progress.


The infrastructure for providing in-home tinnitus self-help education is fully developed, and participants are being recruited into the study. In later stages of the condition, individuals can also experience balance difficulties between episodes. Individuals can keep a dietary journal to assist in determining what foods may influence their symptoms.
Although vestibular rehabilitation will not prevent an episode of vertigo, it greatly helps manage the symptoms that may be present between attacks. To have medications prescribed, you should discuss this condition with your family physician or ENT that is monitoring your care. 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.
If dementia affects vital organs, as is the case in advanced dementia, the prognosis is not very good. I was thoroughly evaluated for hearing loss and was given a masker and a hearing aid, which have been a big help to me in coping with the tinnitus. Anti-depressants and anti-anxiety medications may be used as well, if stress and anxiety are present.
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.
However, people in early stages of dementia can lead a full and quality life just by taking a few precautions.
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.
Tinnitus kann in jedem Alter auftreten, die HA¤ufigkeit steigt jedoch mit zunehmendem Alter. 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.
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. Our current studies, and factor analyses of existing data, will help to develop a means to triage patients into different levels of intervention. 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. At all levels, the goal is to minimize the impact of tinnitus on the patient's life as efficiently as possible. A?ber autogenes Training, progressive Muskelrelaxation, Yoga oder HA¶ren von Entspannungsmusik).a€? Liegt begleitend eine HA¶rminderung vor, ist eine HA¶rgerA¤teversorgung ein notwendigerBestandteil der Behandlung von Tinnitus.



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