Tinnitus Retraining Therapy

Question 1

What is the neurophysiological model?

Answer 1

A number of systems in the brain, other than the auditory system, are involved in the phenomenon of tinnitus
Limbic system and autonomic nervous system
Both systems are crucial for well-being, learning, and brain retraining, but problems can arise when they overreact to neutral stimuli like tinnitus

Question 2

Why do they think that the limbic system is involved in tinnitus?

Answer 2

The limbic system triggers strong emotional responses to stimuli and activates the “fight or flight” response in intense situations like immediate threats

Question 3

Why do they think that the autonomic system is involved in tinnitus?

Answer 3

The autonomic nervous system regulates automatic body functions such as heart rate and breathing, preparing the body for quick action without conscious control

Question 4

When tinnitus becomes associated with negative emotions, does it trigger strong reactions in the limbic and autonomic nervous system?

Answer 4

Yes
Once arousal of the limbic and autonomic nervous systems is sufficiently high, the stimulus linked to this activation will dominate all other brain functions

Question 5

What differs from patients who merely experience tinnitus and those who suffer?

Answer 5

Depends on the presence of the connections between the auditory system, the limbic system, and the autonomic nervous system

Question 6

How does the vicious cycle of tinnitus occur?

Answer 6

Once tinnitus acquires a negative connotation and starts to induce activation of the autonomic nervous system, it initiates a cascade of events
This leads to progressively stronger activation of the limbic and autonomic nervous systems through a conditioned reflex arc
Once we associate a stimulus with something negative, we are unable to remove this association easily because it is a part of a conditioned reflex

Question 7

Are conditioned reflexes an aspect of tinnitus perception?

Answer 7

Yes
If perception of a signal is associated with high levels of emotional distress, conditioned reflexes are created, causing the tinnitus-related neuronal activity (conditioned stimulus) to evoke high levels of activation of the limbic and autonomic nervous systems (conditioned reaction)
A constant state of alertness causes tinnitus patients to become exhausted and complain of lack of sleep
They are be unable to focus attention on anything else but tinnitus and experience overall loss of life quality

Question 8

Can all conditioned reflexes be reversed?

Answer 8

Yes
Natural habituation of various stimuli is continuously taking place
More than three-quarters of people who experience tinnitus naturally habituate to it
*Foundation of TRT - teaching the brain how to do this

Question 9

What is habituation?

Answer 9

Repetitive appearance of a particular sound, the subcortical pathways will block it, and the individual will be unaware that the sound is present
Prevents the signal from reaching higher cortical areas involved in awareness
Not a cure for tinnitus, it can still be perceived when attention is focused on it, but there is no reaction and awareness is reduced

Question 10

What are the two types of habituation?

Answer 10

Habituation of reaction
Habituation of perception

Question 11

When does tinnitus become bothersome?

Answer 11

When there is a failure of filtering mechanisms at a subcortical level and that the symptoms becomes distressing because of the involvement of the emotional and reaction systems
Model implies that these filtering mechanisms could potentially be modified or retrained to filter again

Question 12

What is tinnitus retraining therapy?

Answer 12

A treatment based on the neurophysiological model of tinnitus described by Dr. Pawel J Jastreboff
TRT is a habituation-based treatment that utilizes counseling to decrease the strength of tinnitus-evoked reactions and sound to decrease the strength of the tinnitus signal
Patients are taught the principles of brain function, the mechanisms of tinnitus and of tinnitus-induced annoyance, and the basis for achieving tinnitus habituation

Question 13

What are the goals for TRT?

Answer 13

Induce and facilitate the patient’s habituation to their tinnitus.
Eliminate reactions induced by tinnitus
Prevent spread of tinnitus signal to other brain systems

Question 14

Has TRT had successful outcomes?

Answer 14

Yes
Patient still perceives tinnitus but not bothered by it anymore (Habituation)
Enhanced quality of life through decreased tinnitus distress

Question 15

What are the two main components of TRT?

Answer 15

Retraining counseling (habituation of the reaction to tinnitus)
Sound therapy (habituation to the perception of tinnitus)

Question 16

What is the basic protocol for TRT?

Answer 16

Introductory contact
Initial visit: taking history of tinnitus, audiologic and medical assessment, assessing the category for treatment, and TRT counseling.
Instrument fitting (if needed)
Follow-up visits: evaluation of the patient’s status and further counseling
Closing the treatment

Question 17

Is a thorough audiological and medical evaluation required prior to treatment?

Answer 17

Yes
Including condition, need for treatment, motivation to comply with treatment requirements

Question 18

What is the TRT initial interview?

Answer 18

A structures set of questions that are designed specifically to determine proper placement of patients into TRT treatment categories, assess tinnitus impact and severity, identify sensitivity to sounds, and assess subjective hearing difficulties that could impact treatment
This can last up to 1 hour and psychoacoustic testing can require up to 2 hours

Question 19

Can you send the TRT interview form to a patient prior to the appointment for them to fill out?

Answer 19

No
Not a questionnaire, so do not email it to the patient to fill it out beforehand or have them do it in the office

Question 20

What should happen after the TRT initial interview?

Answer 20

Once the assessment is completed, the clinician and patient should review the results and collaborate to determine the most appropriate course of action
Patient must fully understand all aspects of the treatment prior to making the commitment (treatment objectives, schedule of treatment sessions, requirements for using ear-level devices, costs associated with treatment, any other pertinent details of the planned treatment)

Question 21

Do you categorize patients?

Answer 21

Yes
All patients are placed in one of five treatment categories (0-4), which may be changed during the treatment
Categories are based on severity and/or duration of tinnitus, presence and extent of hyperacusis, subjective significance of hearing loss, prolonged exacerbation of symptoms following sound exposure

Question 22

What is category 0?

Answer 22

Mild or recent symptoms
Low level of severity and has relatively little impact on life
Not received negative counseling

Question 23

What is the treatment for category 0 tinnitus?

Answer 23

One session of simplified counseling
Help them view tinnitus as neutral
Sound enrichment should be advised
Short follow-ups are mainly focused on patient’s status

Question 24

What is category 1?

Answer 24

Tinnitus alone (high impact)
High severity
Predominant complaint is tinnitus
Do not have hyperacusis, subjectively significant hearing loss, or prolonged exacerbation of tinnitus from sound exposure (loud noise doesn’t make tinnitus worse)

Question 25

What is the treatment for category 1 tinnitus?

Answer 25

Intensive counseling focused on tinnitus and sound therapy with ear-level devices set at a level close to the mixing point Follow-ups are initially more frequent and later spaced every 6 months Typically lasts 9 to 18 months

Question 26

What is category 2 tinnitus?

Answer 26

Tinnitus and subjectively significant hearing loss without hyperacusis Significant effect on their lives Do not have significant hyperacusis Sound exposure has no prolonged effect on tinnitus

Question 27

What is the treatment for category 2 tinnitus?

Answer 27

Counseling and sound therapy involving the fitting or refitting of appropriate hearing aids Counseling is focused on hearing loss and its role in triggering and enhancing tinnitus Patients are instructed to provide an enriched auditory background while using the hearing aid as an amplifier Hearing aids used during all waking hours, not just for communication Follow-up visits focus on sound enrichment strategies

Question 28

What is category 3 tinnitus?

Answer 28

Hyperacusis without prolonged enhancement from sound exposure Patients exhibit significant hyperacusis with or without significant tinnitus May have misophonia

Question 29

What is the treatment for category 3?

Answer 29

Initial treatment focuses on hyperacusis using sound therapy for desensitization and addressing other auditory issues Hyperacusis often resolved within six months, after which other issues are addressed

Question 30

What is category 4 tinnitus?

Answer 30

Prolonged worsening of symptoms by sound exposure Most difficult to treat Hyperacusis is the dominant complaint with tinnitus as secondary or absent Crucial feature is the exacerbation of symptoms for prolonged periods of time as a result of noise exposure

Question 31

What is the treatment for category 4?

Answer 31

Extensive counseling focused on hyperacusis and many adjustments in sound therapy to allow for gradual desensitization based on the patient's individual needs Patient education on physiological mechanisms in TRT is important Use of the wrong sound therapy can make category 4 patients much worse

Question 32

Is assigning a tinnitus patient to a category important to treatment?

Answer 32

Yes It is essential for successful therapy because inappropriate treatment could make symptoms worse During treatment, a patient often moves from one category to another as the situation changes (successful treatment results in patients reaching category 0 before complete habituation)

Question 33

What are patients instructed to practice during TRT?

Answer 33

Sound enrichment of the auditory background Avoid silence

Question 34

What does retraining therapy (counseling) include?

Answer 34

It involves teaching patients about the mechanisms of hearing, the basics of the brain function, and the specifics of the neurophysiological model of tinnitus This always occurs one on one Aims to demystify tinnitus and/or decrease sound tolerance

Question 35

What is the nondirective style of counseling?

Answer 35

Patient-centered therapy Counseling emphasis is on the patient more than the problem Goal is for patients to experience growth which enables them to be better equipped to deal with future problems Patients are encouraged to share their thoughts and beliefs with the counselor who affirms their worth by listening

Question 36

What is the directive style of counseling?

Answer 36

Focuses on the problem that is the reason for therapy Goal is to solve the problem through the provision of new information and attitudes to the patient Clinician determines the goal of treatment and assists the patient in attaining that goal

Question 37

What are some common elements across TRT sessions?

Answer 37

Explanation of the results of audiological testing Presentation of the basic functions of the auditory system Presentation of the basic rules of perception including the impact of contrast on signal strength Presentation of the basics of brain function and the interactions of various different systems of the brain Relating these basic concepts to the specific patient: explaining why tinnitus and decreased sound tolerance create such profound problems Explanation of the theoretical basis of habituation and how it can be achieved Discussion with the patient about proposed treatment(s), including discussion regarding the role and utilization of sound Answering any additional questions that the patient may have on the basis of the neurophysiological model

Question 38

What are the key concepts that are conveyed in retraining counseling?

Answer 38

Tinnitus and hyperacusis are side effects of compensatory actions within the auditory pathways, not medical problems Misophonia results from enhanced functional connections between the auditory and limbic systems. Problems caused by tinnitus or misophonia indicate activation of the autonomic nervous system, which prepares the body for unnecessary action. This unnecessary preparation triggers neuronal and hormonal changes, which we experience as anxiety, stress, and annoyance Auditory and the limbic and autonomic nervous systems typically are working normally The problem results from incorrect functional connections between these systems, resulting in a proper reaction to an improper stimulus These connections are created, and work, following the principles of conditioned reflexes It is possible to retrain these reflexes, once tinnitus is reclassified to a category of neutral/slightly negative stimuli, to achieve habituation of the reactions induced by tinnitus and to achieve habituation of its perception The process of habituation is facilitated by enrichment of the auditory background, which by increasing background neuronal activity weakens the tinnitus signal

Question 39

What is sound therapy?

Answer 39

Enrichment of the sound environment The aim is to reduce the perceptual contrast between the tinnitus and the external environmental noise and the reduce stress or to distract attention from the tinnitus

Question 40

What are the different approaches to sound therapy?

Answer 40

The introduction of additional sounds Increasing the volume of existing sounds Using hearing aids to amplify environmental sounds by hearing aids Using wearable sound generators *More than one approach is typically used

Question 41

What are the general principles of sound therapy?

Answer 41

The strength of the neuronal signal within the brain depends on the difference/contrast between the signal and the background neuronal activity We react not to the absolute but to the relative strength of the stimulus compared with the background All tinnitus patients should enrich their environment with sound to “Avoid Silence” since silence enhances the perception of tinnitus and perception of bothersome sounds

Question 42

What are some important considerations for selecting an optimal sound?

Answer 42

Sound used should minimize the strength of the tinnitus signal External sounds should not induce any negative reactions (e.g., annoyance) Sounds used in sound therapy should be stable, neutral, not attract undue attention, interfere with communication or affect everyday activities Natural sounds generated by specialized electronic devices are preferrable Original tinnitus signal should be preserved, if tinnitus is suppressed (“masked’), habituation will never occur

Question 43

What is the mixing point?

Answer 43

Sound level used in sound therapy that is close to but below the level of partial suppression

Question 44

Why do you use the mixing point for sound therapy?

Answer 44

The intensity of the sound in sound therapy affects the process of habituation When sound levels are close to hearing threshold, the low-level signal can enhance the tinnitus through stochastic resonance If the external sound is intense enough to make the tinnitus inaudible, habituation drops to zero

Question 45

What is the instrumentation for sound therapy?

Answer 45

Includes medical and non-medical devices An easy and inexpensive method to enrich background sound is through tabletop devices, smartphones, computers, iPads, internet downloads, specific apps, TV, radio, and playing music (external high-quality speakers or headphones are preferrable to avoid distortion) Ear-level devices include sound generators and hearing aids (for those with normal or near normal low frequency thresholds, a vent should be used)

Question 46

Do wearable sound generators have advantages?

Answer 46

Yes Commonly used due to their ability to provide controlled sound delivery Patients should have full control over the adjustment of sound level in each ear-level device Instrument fitting must be bilateral to avoid asymmetrical stimulation of the auditory system Open fittings are needed to minimize the occlusion effect and the reduction of normal access for environmental sounds Wearable sound generators, or combination instruments, are essential in hyperacusis Optimally, instruments should be worn throughout waking hours The instruments should be worn particularly whenever there is a low level of background noise Proper counseling is vital for the effectiveness of sound therapy

Question 47

What are some potential factors related to a failure of sound therapy?

Answer 47

Temporary worsening of symptoms Inadequate initial counseling or lack of sufficient follow-up visits Lack of follow up and not teaching the model properly are the commonest causes of failure The presence of litigation makes habituation difficult Severe psychological problems Effects of medications Category 4 patients Suppression of tinnitus evoked by hearing aids Focusing on a cure

Question 48

Are follow-up sessions crucial for TRT?

Answer 48

Yes Crucial for maximizing the therapeutic effects of TRT Involves continuous counseling and reinforcement of treatment goals Initially frequent and may include face-to-face or remote interactions Focuses on the patient's specific tinnitus and hyperacusis conditions to support habituation Used to assess changes in the patient's status using structured interviews and specific questionnaires

Question 49

Are LDLs assessed at each visit for patients with hyperacusis?

Answer 49

Yes Generally to guide treatment and assess improvement

Question 50

How do you identify the end-point of treatment or decide when a significant therapeutic effect has been achieved?

Answer 50

No precise way to do this Depends on meeting the patient's expectations and goals Should be a mutual decision between the clinician and the patient Keep communications open for potential follow-up if needed May be closed when patients achieve minimal symptom scores with awareness at 10% or less and annoyance near zero