Dr. Tyler is a professor of otolaryngology-head and neck surgery and of communication sciences and disorders at the University of Iowa. He has hosted an annual Tinnitus Treatment Workshop for 20 years and is the editor of Tinnitus Handbook (2000), Tinnitus Treatment: Clinical Protocols (2006), and The Consumer Handbook on Tinnitus (2008).
Tinnitus can have devastating consequences for many people, and it currently has no cure. While patients react differently to this ringing in their ears, the effects of tinnitus can disturb their work and social lives. Unfortunately, many clinicians worldwide have been slow to familiarize themselves with the rehabilitation therapies that have been developed.
A range of psychotherapeutic approaches are already available to tinnitus patients, with more to come. Many of the therapies share similar properties, using behavior modification techniques to teach patients new ways of reacting, and helping them to think differently about their condition. (See a review in Tyler RS, ed. Tinnitus Treatment: Clinical Protocols. New York: Thieme, 2006.)
We have successfully used a picture-based approach that focuses on individual needs and the four primary areas affected by tinnitus: thoughts and emotions, hearing, sleep, and concentration (Prog Brain Res 2007;166:425). Various cognitive behavior therapies have been applied in the treatment of the condition (see FastLinks), and a very elegantly structured guide was published to aid clinicians of different professional backgrounds (Henry JL, Wilson PH. The Psychological Management of Chronic Tinnitus: A Cognitive-Behavioral Approach. Boston: Allyn & Bacon, 2000).
Another integral component of tinnitus rehabilitation is sound therapy. While this approach of playing a low-level background noise has been advocated for decades, the effectiveness of sound therapy has only recently been established because individuals have distinct preferences for background sound.
Since numerous studies show that these rehabilitation approaches are effective in treating tinnitus, one wonders why government agencies and insurance companies have not supported and reimbursed these treatments. I believe our national organizations should take a leading role in promoting our services (see FastLinks).
Specialized Treatment Based on Cognitive Behavior Therapy versus Usual Care for Tinnitus: A Randomized Controlled Trial
Cima RF, Maes IH, et al Lancet 2012;379(9830):1951
This recent well-designed trial clearly demonstrated that clinicians trained to treat tinnitus can be effective. The researchers compared a comprehensive specialized counseling approach with the usual care that patients receive in the Netherlands. A total of 492 patients were included in the study.
An understanding of the components of the two approaches is critical for interpreting the study. Both likely differ substantially from what is offered in the United States and in other countries. Hearing aids, if present, were optimized by an audiology assistant in the two groups. Tinnitus maskers were only provided when specifically requested by the patient. In my experience, many patients must be encouraged to try maskers, and many do end up benefiting. When maskers were prescribed, a narrow band-noise centered on the pitch-match frequency was used, but this approach has been discouraged (ASHA 1987;29:27).
Usual care included a consult with a clinical physicist in audiology and counseling by a social worker on the use of hearing aids and maskers. In the United States, these services would have been provided by an audiologist.
Specialized care included a consult with a clinical physicist in audiology trained in tinnitus retraining therapy counseling, and a psychology assistant provided tinnitus retraining therapy counseling elements. These steps were followed by group sessions or individual ones if group sessions were contraindicated. The group session involved a clinical psychologist, physical therapist, clinical physicist in audiology, social worker, movement therapist, and speech therapist. Our group sessions, and I suspect most in the United States, do not include a movement therapist, physical therapist, social worker, or speech therapist. Both the group and individual care protocols used psychoeducation, cognitive restructuring, exposure techniques, cognitive behavior therapy, mindfulness-based elements, stress relief, attention redirecting, and applied relaxation.
Tinnitus retraining therapy involves directive, not collaborative, counseling, which has been criticized in the literature (Scand Audiol 2000;29:67; Ear Hear 2012;33:588).
This important study clearly shows that patients who receive specialized tinnitus treatment can benefit much more than those who receive minimal care. We should all take this as encouragement to learn more about tinnitus treatment options and offer comprehensive care to our patients. Conferences on tinnitus treatments and directions for establishing a clinic in your practice are available (Am J Audiol 2008;17:25). There is something you can do to help these patients.
* Read more about cognitive behavior therapies for tinnitus in Tinnitus: A Multidisciplinary Approach by Gerhard Andersson et al (http://bit.ly/MDApproach), Tinnitus Handbook by Richard Tyler (http://bit.ly/TNHandbook), and Living with Tinnitus and Hyperacusis by Laurence McKenna et al (http://bit.ly/LivingTN).
* Dr. Tyler's article, “The End of Audiology—Maybe,” is available at http://bit.ly/EndofAud.
* Read past Journal Club columns in a special collection at http://bit.ly/JClubCollection.
* Click and Connect! Access the links in The Hearing Journal by reading this issue on our website or in our new iPad app, both available at thehearingjournal.com.
* Comments about this article? Write to HJ at HJ@wolterskluwer.com.
© 2013 Lippincott Williams & Wilkins, Inc.