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Hearing Journal:
doi: 10.1097/01.HJ.0000293152.09091.a9
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Tinnitus Retraining Therapy: A modified approach

Tyler, Richard S.; Bergan, Cynthia J.

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Richard S. Tyler, PhD, is Professor and Director of Audiology in the Department of Otolaryngology-Head and Neck Surgery and Professor in the Department of Speech Pathology at the University of Iowa. Cynthia J. Bergan, MA, is an audiologist in the Departments of Speech Pathology and Audiology and Otolaryngology-Head and Neck Surgery, University of Iowa. Correspondence to Dr. Tyler at rich-tyler@uiowa.edu.

Tinnitus Retraining Therapy (TRT), as proposed by Jastreboff1 and Jastreboff and Hazell,2 has provided the framework for a treatment of tinnitus. Although its efficacy has not been empirically studied in a controlled setting, the systematic strategy has attracted numerous therapists and patients. Many people have actively sought this treatment, some traveling long distances in their desperation to find someone with experience with this treatment protocol. Many of these patients report that they have been treated successfully.

The procedure is not without controversy. It has been widely criticized for its lack of supporting data, its apparent disregard of widely held psychological principles, and the manner in which it has been promoted. Many healthcare professionals are reluctant to use Tinnitus Retraining Therapy, in part because the claims appear to be extravagant and in part because there has been little published in the way of investigations with valid and reliable test metrics and adequate controls.3-5 Professionals will likely remain skeptical until an independent evaluation can be performed.

Wilson et al. conclude, “Methodological limitations in the research which has been published to date preclude any claims about the efficacy of …Tinnitus Retraining Therapy.”3 (page 273).

Kroener-Herwig et al. suggest that “the interaction between neuroacoustic and emotional processes emphasized by Jastreboff is, however, neither new nor sufficiently elaborated.”4

We believe that some aspects of Tinnitus Retraining Therapy have merit. However, we also believe certain modifications will enhance its efficacy. This article presents our preliminary modifications to TRT. It integrates the contributions of Jastreboff and colleagues with additional established psychological therapies as well as some strategies gained from our own tinnitus treatment experience.

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BACKGROUND OF TINNITUS RETRAINING THERAPY

Jastreboff1 and Jastreboff and Hazell2 developed a protocol based on neurophysiologic and psychological principles of habituation. If a sensory system is repeatedly exposed to a non-threatening stimulus, the system will eventually habituate to it. Jastreboff adapted this phenomenon into a tinnitus therapy. There are two components to TRT: (1) providing counseling so the patient is not afraid of his tinnitus, and (2) exposing the patient to low levels of background noise. The low levels of background noise facilitate the habituation process.

Jastreboff and Hazell describe the neurophysiologic rationale for Tinnitus Retraining Therapy: “White noise should interfere with the pattern-recognition process making it more difficult to separate the tinnitus signal from the background neuronal activity”2 (page 10). They note that “masking is actually counterproductive… perception of tinnitus has to be present during the process of retraining” (page 14). “Clinical improvement…[is]…measured in months, with the ultimate benefit being reached after about 1 year to 18 months. Contrary to other methods, once this stage is achieved, there is no need for further systematic intervention” (page 12).

Jastreboff, Gray, and Gold present some key elements of Tinnitus Retraining Therapy and some preliminary results.6 For example, they note that “directive counseling” is necessary but not sufficient, and the majority of patients require binaural maskers (page 239). Generally, most patients were required to use these at least 6 hours a day. The process typically required 12 months, but they “insist that patients continue for another 6 months to ensure that plastic changes within the brain are firmly established.” They report that, since 1991, they have seen more than 500 patients and have gathered data on more than 100 subjects. “From the group fitted with noise generators, 83% of the patients exhibited significant improvement.” (page 239) More recent work by Jastreboff is consistent with this observation.7-9

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Directive counseling

An excellent review of the directive-counseling component of Tinnitus Retraining Therapy is provided by Wilson et al.3 Directive counseling involves teaching the patient about various principles and theory of hearing, deafness, tinnitus, and learning. It refers to the therapist imparting “information to the client and controlling the process by which this occurs.” (page 274) The primary aim of the directive counseling is to ensure that patients are not afraid of their tinnitus. If they are afraid of their tinnitus, they cannot habituate to it.

Most professionals would agree that providing the patient with background knowledge about these matters is beneficial (e.g., Tyler, Stouffer, and Schum;10 Stouffer and Tyler;11 Wilson et al3). Many therapy protocols have included such information for decades. Wilson et al. suggest that the directive, tutorial style proposed in the original version of TRT could be improved by a more interactive model.3

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Background noise—habituation

The new concept introduced by Jastreboff is that the background noise must be at a very specific level. This “mixing point” is defined as the level where the noise just starts to mix with the tinnitus. The tinnitus must be audible. Masking the tinnitus will not result in habituation, and noise levels below the mixing point will be less effective at habituation.

The primary aim of the noise exposure is to facilitate habituation. If the brain is exposed to non-significant, low-level noise, it will habituate to it. By pairing the tinnitus with the background sound, the brain has more difficulty detecting the tinnitus signal and will associate the tinnitus with the insignificant sound, thus making it easier to habituate to the tinnitus. Jastreboff has claimed that treatment takes 18 months of continuous noise generator use, although positive results can be observed earlier (often within 3 months). Although TRT can be accomplished without wearable noise generators, the success rate has been reported to be considerably less.9 Jastreboff has noted that the use of two wearable noise generators is necessary in most patients.

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OVERVIEW OF OUR MODIFICATIONS TO TRT

Our initial attempt at modifying and perhaps improving Tinnitus Retraining Therapy focused on changing the counseling protocol from “directive” to an interactive version that provides for discussion and open exchanges with the patient. In addition, we routinely include some additional therapeutic strategies and incorporate them into our counseling sessions.

We have also produced a picture presentation that guides us in our interactions with patients. We believe this visual approach enables the patients to more easily understand the concepts. Although it remains to be seen if habituation is integral to tinnitus treatment, we do believe counseling is paramount and that our modifications may be helpful.

Many patients with tinnitus also have hyperacusis, and we have a separate series of picture presentations and counseling sessions that they go through.

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Counseling

Providing information

The audiologist provides in-formation to educate the patient about tinnitus in the following areas:

* Causes of tinnitus

* Prevalence of tinnitus

* Common symptoms

* The connection between hearing loss and tinnitus

* The link between tinnitus, the brain, and emotions

* The general principles of learning and unlearning

We have found there are advantages to having pictures for the patient during the counseling session. The pictures help the patient understand the concepts being conveyed. They also help the therapist present the information systematically and to remember the important points for each topic. Here we show three examples of the PowerPoint pictures used.

Figure 1 depicts a sche-matic representation of nerve fiber activity without acoustic stimulation. The patient is able to appreciate that nerve fibers carry information to the brain and that these nerve fibers are spontaneously active, even without external sound. The figure also depicts the difference between nerve fiber activity in normal and impaired auditory systems. This figure is used again later to illustrate a potential source of tinnitus.

Figure 1
Figure 1
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Figure 2 shows a flowchart of how the brainstem, cortex, autonomic nervous system, and limbic systems interact. In addition, there is a pictorial depiction of this interaction showing how a stimulus is interpreted as dangerous and thus activates the autonomic nervous system and triggers an emotion of fear.

Figure 2
Figure 2
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Figure 3 shows how one stimulus, a doorbell, can elicit three different reactions. We use this picture to discuss how the brain initially learns an automatic response to a stimulus. It is used again when we discuss how the brain can unlearn a response and learn a new response.

Figure 3
Figure 3
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The use of a diary

The patient keeps a diary for 2 weeks, listing his or her daily activities and the effect of these activities, if any, on the tinnitus. Patients use this diary to make a list of the things that reduce or intensify their tinnitus. They then use these lists to modify their lifestyle, doing more activities where the tinnitus is less noticeable or annoying and reducing those activities where the tinnitus is worse. Knowing the activities, situations, etc., that reduce or worsen the tinnitus gives patients some control over their tinnitus.

The use of background noise

The presence of background noise has been known for some time to be helpful to tinnitus patients. Background noise can mask the tinnitus,12 reduce the loudness of the tinnitus (partial masking), or serve as a distraction. Many clinicians have used music and environmental sounds as background sounds for tinnitus therapy.

The types of background sound used include:

* broad-band noise (heard as “sssshhhh”). Many patients report that it is easier to listen to this noise than to their tinnitus.

* music; usually soft, light, background music (e.g., classical baroque, simple piano music).

* sound produced particularly for relaxation or distraction (e.g., waves lapping against the shore, raindrops falling on leaves. Sometimes these are combined with light music.)

There are several different devices that produce these sounds:

* wearable devices that resemble hearing aids. These sound generators can be worn inside the ear canal or behind the ear.

* wearable devices with earphones or insert earphones (portable cassette or compact disc players).

* non-wearable devices, which include radios, tape players, compact disc players, or sound generators specifically produced for relaxation or tinnitus. Some are meant to be used at bedside with timers and different sound types.

We encourage our patients to try different sounds and to discover new sounds they find soothing or non-distracting. We also encourage them to record sounds in their environment that they have found helpful, but which might not be available on a cassette or compact discs.

Refocus therapy

The more people think about their tinnitus, the worse it gets. The worse it gets, the more they think about it.

Refocus therapy is used to teach patients to focus their thoughts away from the tinnitus and onto enjoyable activities. The patients make a list of activities they enjoy. This list of enjoyable activities and the list of activities that reduce the patient's tinnitus, mentioned above, are used to create a “plan of action” for when the tinnitus is annoying. The patients participate in this plan, and engage in one of these identified activities when their tinnitus is bothersome. This helps them to refocus, to take their mind off the tinnitus.

We also share with patients our belief that they should spend less time thinking and talking about tinnitus. We ask them to stop keeping the tinnitus diary after the initial 2-week period and to reduce their talking and reading about tinnitus. The less that patients think about their tinnitus, the easier it will be to reduce the negative emotional reaction.

Cognitive behavior modification

All patients can benefit from appreciating that the way they think and talk about their tinnitus can influence their reaction to it. Emotions experienced by a person are related to the thoughts the person has about an event, not the event itself. Henry and Wilson state, “Cognitive behavioral therapy…refers to the idea that by focusing on what you think (cognitive) and what you do (behavior), you can find solutions to problems.”13

Our use of cognitive behavior modification includes discussing with patients: (1) their negative thoughts about tinnitus, (2) how to identify and stop these negative thoughts,13 and (3) how to replace the negative thoughts with constructive counterthoughts.

Relaxation

Most of us experience times where we are more anxious or upset about things than usual. Knowing ways to calm ourselves and relax can be helpful. Many people with tinnitus report that their tinnitus becomes more bothersome during stressful periods. Others report their tinnitus causes more stress in their lives. By recognizing when they are upset, patients can change their reactions and relax more.

There are several types of relaxation techniques, including muscle relaxation and slow, deep breathing. Patients with high levels of anxiety may need to be referred to a psychologist for more formal relaxation training, including systematic relaxation exercises, mental imagery, meditation, yoga, or biofeedback.

Patient Expectation Nurturing

It has been well documented that a positive attitude, respect for the therapist, and a clear treatment plan can influence the outcome of treatment considerably (e.g., Brown14). While this is sometimes referred to negatively as a placebo effect, its properties can be used to improve prognosis in many areas of health care.14,15 We acknowledge its presence and refer to this as Patient Expectation Nurturing.

This approach sets a positive environment to facilitate success in any therapy.14-16 To nurture patient expectations, audiologists must:

* be perceived as a knowledgeable professional

* be sympathetic toward the individual

* demonstrate that they understand tinnitus

* provide a clear therapy plan

* show that they care about the patient

We also inform patients that we expect them to benefit from the treatment because others with similar tinnitus have benefited from this treatment in the past.

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Habituation

We have re-organized the habituation component of our modified Tinnitus Retraining Therapy into two components: habituation counseling and the use of the noise generators.

Our habituation counseling session includes:

* Defining habituation

* The use of the noise generator in habituation

* The importance of maintaining audibility of the tinnitus

We then introduce the noise generators. Instruction is provided on:

* Setting the volume level at the mixing point

* Wearing the devices a minimum of 8 hours per day

* The usage and care of the noise generators

When necessary, hearing aid plus masker combination units are used.

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Hyperacusis

Many tinnitus patients find moderately intense sounds very uncomfortable. When present, this “hyperacusis” should be treated along with the tinnitus. Treatment of hyperacusis involves using the noise generators for desensitization. When a patient has tinnitus and hyperacusis, we provide counseling for both. We believe these patients can start working on their thoughts and feelings about tinnitus while treating the hyperacusis. The noise generators are initially used to treat the hyperacusis. Once the hyperacusis is resolved, the noise generators are used for tinnitus habituation.

The hyperacusis counseling session includes:

* Defining hyperacusis

* The use of the noise generator in hyperacusis treatment

Noise generator instruction is provided on:

* Where to set the volume level

* Wearing the devices a minimum of 8 hours per day

* The usage and care of the noise generators.

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SUMMARY AND FUTURE DIRECTIONS

We believe that a systematic treatment plan for helping tinnitus patients is of great importance. Tinnitus Retraining Therapy is one such plan. We have developed some modifications to this plan, which we believe will be helpful.

Appropriate research using adequate controls and valid and reliable test measures is needed to determine which components are the most helpful and how we can improve our treatment of tinnitus patients.

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References

1. Jastreboff PJ: Phantom auditory perception (tinnitus): Mechanisms of generation and perception. Neurosci Res 1990;8:221–254.

2. Jastreboff PJ, Hazell JWP: A neurophysiological approach to tinnitus; clinical implications. Brit J Audiol 1993;27:7–17.

3. Wilson PH, Henry JL, Andersson G, et al.: A critical analysis of directive counseling as a component of tinnitus retraining therapy. Brit J Audiol 1998;32:273–286.

4. Reference are not Provided.

5. McKinney CJ, Hazell JWP, Graham RL: An evaluation of the TRT method. In Hazell JWP, ed. Proceedings Sixth International Tinnitus Seminar. London: The Tinnitus and Hyperacusis Center, 1999: 99–105.

6. Jastreboff PJ, Gray WC, Gold SL: Neurophysiological approach to tinnitus patients. Am J Otol 1996;17:36–240.

7. Jastreboff PJ: Tinnitus as a phantom perception: Theories and clinical implications. In Vernon J, Moller AR, eds., Mechanisms of Tinnitus. Boston and London: Allyn & Bacon, 1995: 73–94.

8. Jastreboff PJ: Controlling tinnitus. Hearing Health 1997;13(4):42–44.

9. Jastreboff PJ: Tinnitus Habituation Therapy (THT) and Tinnitus Retraining Therapy (TRT). In Tyler RS, ed., Handbook of Tinnitus. San Diego: Singular Publications, 2000: 357–376.

10. Tyler RS, Stouffer JL, Schum R: Audiological rehabilitation of the tinnitus patient. J Acad Rehab Audiol 1989;22:30–42.

11. Stouffer JL, Tyler RS: Characterization of tinnitus by tinnitus patients. J Sp Hear Dis 1990;55:439–453.

12. Vernon J, Meikle M: Tinnitus Masking. In Tyler RS, ed. Handbook of Tinnitus. San Diego: Singular Publications, 2000: 313–356.

13. Henry JL, Wilson PH: Tinnitus: A Self-Management Guide for the Ringing in Your Ears. Boston: Allyn & Bacon, 2002.

14. Brown J: The placebo effect in medicine. Sci Amer 1998;278(1):90–95.

15. De Saintonage DMC, Herxheimer A: Harnessing placebo effects in health care. Lancet 1994;344(8928):995–998.

16. Tyler RS, Haskell G, Preece J, Bergan C: Nurturing patient expectations to enhance the treatment of tinnitus. Sem Hear 2001;22 (1):15–21.

© 2001 Lippincott Williams & Wilkins, Inc.

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