TINNITUSTODAY Vol. 44, No. 1, Spring 2019
To Promote Relief, Help Prevent, and Find Cures for Tinnitus
Sound Choices for
Managing Tinnitus Things to Consider When Selecting Sound Therapy Products Are Hearing Aids an Answer? How Tinnitus Can Affect You and Your Partner Tinnitus Tools • Best Apps for Meditation • A Key Test for Understanding Tinnitus
A publication of the
Visit & Learn More About Tinnitus at ATA.org
ATA thrives through the dedication of a vast number of people, all of whom make a difference. Join the Jack Vernon Legacy Society Jack Vernon co-founded ATA in 1971 to lead the way in researching a cure, developing effective treatments, and creating broad-based support and awareness of tinnitus. ATA invites individuals and organizations to join our journey. How can you contribute? M onthly or annual financial contributions
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C onvert stock and/or real estate into a unitrust We hope you’ll be a part of the legacy of securing silence for those with tinnitus through a variety of treatments, as well as finding a cure for the millions who endure incessant noise and anxiety.
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Table of Contents
Vol. 44, No. 1, Spring 2019
PERSONAL STORIES
SPECIAL FEATURES
4|
Breaking a Quarter | 10 Century of
Commercial Devices for Sound-Based Management of Tinnitus: Where’s the Evidence?
Silence Helped Strengthen My Mind and Spirit
as 23 | Audiogram Tinnitus Roared Sitting for an
17 |
Are Hearing Aids the Answer? Hearing Loss, Reducing Tinnitus Perception, and Slowing Cognitive Decline
The Importance of | 35 Talking About Tinnitus and Listening
hen Treatment for Triggers 30 | WDepression Tinnitus wo Days of Learning Me ‘Own’ My 42 | THelped Tinnitus of 20 Years
YOUR HEALTH
Mindfulness| 45 Based Tinnitus
Stress Reduction
SCIENCE & RESEARCH NEWS
Relationship of | Tinnitus to 13 Vestibular Disorders: The Awareness of Movement
15 | Researcher Answer The Use of Hearing for Sound 21 | Aids Therapy Reader Question &
Research Paves the | 28 Way to Advances in
ATA NEWS
33 |
27th Annual | 44 Hyperacusis and
Treatments
Improving Reliability of Tinnitus Pitch and Loudness Matching: The Tinnitus Likeness Rating (TLR) Method
Tinnitus Conference at the University of Iowa
TINNITUS TOOLS & RESOURCES
If You Have Tinnitus but | 22 Hear Well, Do You Need a Hearing Test?
38 | Affect Your Partner? An Assessment 48 | of Tinnitus Apps How Can Tinnitus
Spotlight on Patient | 25 Providers Support Group | 40 Locations Meditation Apps for 47 | Relaxation and Sleep
FROM THE BOARD CHAIR
Striking the Right Balance in Sound Management
LaGuinn P. Sherlock, AuD Chair, Board of Directors
I have tinnitus, not trouble hearing. Why would hearing aids help?” That’s a good question. Tinnitus is the perception of phantom sound inside the head. The most common cause is age-related or noiseinduced hearing loss, and most people with tinnitus have some hearing loss. Hearing aids might provide relief by balancing the volume of external sounds with the internal sound of tinnitus, just as the balance knob on a stereo adjusts the output of each speaker. The brain is constantly filled with electrical activity from multiple sources, which can sometimes be perceived as sound in very quiet places. External sounds, such as people talking, birds chirping, and fans blowing, produce sound waves that mechanically vibrate the eardrum. The inner ear converts the vibrations into electrical signals and delivers them to the brain, where they are perceived as sound. Tinnitus is a phantom sound because it is not produced by external sound waves. Hearing loss, however mild, decreases input of external sounds, shifting the balance to the interior “speaker,” making tinnitus seem “louder” and more noticeable. Hearing aids and sound therapy can restore balance by increasing the volume of external sounds, thus diminishing perception of tinnitus. Hearing aids do not make the tinnitus disappear, but over time, the tinnitus can become less noticeable. Hearing aids can also provide relief by reducing the strain to hear and providing distraction from the tinnitus. Combining hearing aids or sound therapy with stressreduction strategies, education, counseling, and support offers the best possibility of relief from tinnitus today.
Support the American Tinnitus Association by Shopping at When you’re shopping for yourself, friends and family on Amazon, the American Tinnitus Association hopes you’ll link your shopping account to , the online retailing company’s generous program that enables you to shop and contribute to your favorite nonprofit organization at the same time. Amazon pays all program expenses and donates half of a percent of the cost of your eligible purchases to your favorite earmarked charity. Won’t you choose the American Tinnitus Association to help us advance tinnitus research and treatments? https://smile.amazon.com/ch/93-0749558
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MANAGING EDITOR Joy Onozuka American Tinnitus Association PUBLISHER Torryn P. Brazell, CAE American Tinnitus Association PODCAST PRODUCER AND WRITER John A. Coverstone, AuD Sentient Healthcare, Inc. EDITOR-AT-LARGE Robert Sweetow, PhD EDITORIAL ADVISORY PANEL James A. Henry, PhD National Center for Rehabilitative Auditory Research (NCRAR) U.S. Department of Veterans Affairs Gail M. Whitelaw, PhD Department of Speech and Hearing Science The Ohio State University DIGITAL DESIGN & PRODUCTION TEAM JML Design, LLC ADVERTISING Tinnitus Today is the official publication of the American Tinnitus Association. It is published three times per year in April, August, and December and mailed to members and donors. The digital version is available online at www.ata.org. To grow your company’s brand reach, contact tinnitus@ata.org. ATA HEADQUARTERS American Tinnitus Association 8300 Boone Blvd, Suite 500 Vienna, VA 22182 USA T: 800.634.8978 (Toll Free) T: 202.800.6590 www.ata.org TO GIVE TO THE ATA American Tinnitus Association PO Box 424209 Washington, DC 20042-4049 The American Tinnitus Association is a nonprofit corporation, tax-exempt under 501(c) (3) of the Internal Revenue Code, engaged in educational, charitable, and scientific activities. Tinnitus Today magazine is © copyrighted by the American Tinnitus Association. ADVERTISEMENT Publication of any advertisement does not in any way or manner constitute or imply ATA’s approval or endorsement of any advertised product or service.
FROM THE PUBLISHER
ATA BOARD OF DIRECTORS LaGuinn P. Sherlock, AuD, Bethesda, MD—Chair
Alone With Tinnitus
Ted Turesky, PhD, Boston, MA—Vice Chair Scott C. Mitchell, JD, Houston, TX—Secretary Gary P. Reul, EdD, Issaquah, WA—Treasurer David Hadley, MBA, San Francisco, CA— Assistant Treasurer Michael E. Hoffer, MD, Miami, FL David Hopkins, DO, Edmond, OK Jeannie Karlovitz, AuD, Downington, PA Thomas Lobl, PhD, Valencia, CA Jill Meltzer, AuD, Chicago, IL John Minnebo, MBA, Philadelphia, PA Joseph Trevisani, New York, NY Melissa Wikoff, AuD, Atlanta, GA Ron Zagel, Grand Rapids, MI Jinsheng Zhang, PhD, Detroit, MI Torryn P. Brazell, Vienna, VA—Ex-officio HONORARY DIRECTOR William Shatner, Los Angeles, CA ATA SCIENTIFIC ADVISORY COMMITTEE Michael E. Hoffer, MD, FACS—Chair University of Miami Health System Miami, FL USA Shaowen Bao, PhD Helen Wills Neuroscience Institute Berkeley, CA USA Susan M. Bowyer, PhD Henry Ford Health Systems, Detroit, MI USA Marc Fagelson, PhD East Tennessee State University Johnson City, TN USA Fatima T. Husain, PhD University of Illinois, Urbana-Champaign Champaign, IL USA Mark S. Mennemeier, PhD University of Arkansas, Little Rock, AR USA
Millions of people are bothered by tinnitus, so why do so many people feel alone? The isolation and the frustration compound the burden of living with tinnitus. What can we do to offer relief? Listen. Tinnitus varies radically between individuals, so never assume you know what a person is hearing and going through. Listen to what is being said, without offering advice or making judgments. Be empathetic. You may not be able to imagine what it is like to have incessant noise, 24/7, in your head, but you can imagine what it’s like to go without sleep or to be afraid of what the future might hold. By acknowledging the stress and anxiety that someone with tinnitus might feel, you provide comfort and a safe space for that person. Stay informed. Friends and family of people bothered by tinnitus are often at a loss as to how they can help. Yes, you listen and are empathetic, but you want to do more. The American Tinnitus Association provides exceptional educational resources and information on so many aspects of tinnitus. Stay informed by subscribing to Tinnitus Today, visiting our webpage, and liking us on Facebook. Contribute to the ATA. We exist through the generosity of individual donors, without which our doors would close, ending funding for research toward cures, access to up-to-date information on tinnitus treatment and research, and compassionate guidance to people in distress who contact us directly. We make a difference by being here for one another, so I hope you’ll find a way to contribute to building a strong tinnitus community, where no one feels alone.
Torryn P. Brazell, CAE Publisher
The opinions expressed by contributors to Tinnitus Today are not necessarily those of the publisher or the American Tinnitus Association. This publication provides a variety of topics related to tinnitus for informational purposes only. ATA’s publication of any advertisement in any kind of media does not, in any way or manner, constitute or imply ATA’s approval or endorsement of any advertised product or service. ATA does not favor or endorse any commercial product or service.
Larry E. Roberts, PhD McMaster University, Hamilton, ON, Canada Maria Rubio, PhD, MD University of Pittsburgh, Pittsburgh, PA USA Jeremy G. Turner, PhD Illinois College, Jacksonville, IL USA Roland Schaette, PhD UCL Ear Institute, London, England Grant D. Searchfield, PhD University of Auckland, Auckland, NZ Athanasios Tzounopoulos, PhD University of Pittsburgh, Pittsburgh, PA USA
Letters to the ATA
The ATA encourages readers to send comments and questions about tinnitus and/or articles to editor@ata.org. Emails selected for publication may be edited for brevity, clarity, and grammar.
Pim Van Dijk, PhD University Medical Center Groningen Groningen, Netherlands Fan-Gang Zeng, PhD University of California, Irvine, Irvine, CA USA
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SPECIAL FEATURE
Consumer Devices for SoundBased Management of Tinnitus: Where’s the Evidence? By Devon Kulinski, BA, and Candice Manning, AuD, PhD
Sound therapy for tinnitus management refers to any use of sound with the intention of reducing a person’s perception of or reactions to tinnitus in a clinically meaningful way.1 This article outlines sound therapy as a treatment option for tinnitus and discusses products that are commercially available. We carefully consider consumers’ needs and compare them to the research evidence to help facilitate successful sound therapy intervention.
Sound Therapy: Then and Now The first publication on the use of sound therapy for the treatment of tinnitus dates back to 1821 when French physician Jean-Marc Itard described the use of a roaring fire, among other environmental sounds, to effectively mask the perception of the phantom ear noise.2 In lieu of a cure, Itard’s opinion on the role of the physician was to “make tinnitus less unbearable, especially from the point of view of sleep disturbance and ongoing worry.” Fast-forward almost two hundred years and this approach 4
TINNITUS TODAY SPRING 2019
is still widely accepted in current clinical practice. Unlike Itard, modern technology allows for the advent of innovative commercial products to deliver therapy for tinnitus sufferers. Instead of a roaring fire, sound generators can simulate soothing environmental sounds. Similarly, with the tap of a button smartphones easily enable users to listen to music, audiobooks, or apps with customizable sounds. Other approaches attempt to more accurately target the auditory system and the brain with the use of individually tailored sounds intended to create lasting effects even after the stimulus is turned off. These techniques advocate more than just transient management of the symptom. Some products report a sustained long-term reduction of psychoacoustic properties of tinnitus.3, 4 More products will make their way into the hands, and ears, of the general public. With most consumers paying out of pocket for these treatments, it is crucial to compare them against current standards of care. Customers and clinicians alike need quality research evidence to evaluate product efficacy. When it comes to commercial devices for sound-based tinnitus management…where is the evidence?
Clinical Practice Guidelines Before discussing commercial devices, we provide a brief overview of best practices for the clinical management of tinnitus. For a more in-depth look at clinical practice guidelines, please read Dr. James Henry’s featured piece in the Winter 2017 issue of Tinnitus Today entitled ”Tinnitus Management Based on Research Evidence.”5 It provides basic guidance for any person dealing with bothersome tinnitus. In the United States, the closest thing we have to a gold standard for the management of persistent, bothersome tinnitus is the American Academy of Otolaryngology—Head & Neck Surgery Foundation’s (AAOHNSF) “Clinical Practice Guideline: Tinnitus.”6 Part of the AAO-HNSF guideline assesses intervention techniques by giving a rating ranging from “strong recommendation for” to “strong recommendation against.” These ratings were determined on the basis of a systematic review of high-quality research evidence, which constitutes the highest form of validity in the scientific community.7 In the AAO-HNSF guideline, only education and counseling, hearing aid www.ATA.org
SPECIAL FEATURE
evaluation, and cognitive behavioral therapy achieved the status of “recommendation” supported by strong research evidence. Other options, such as medical therapy, dietary supplements, acupuncture, and transcranial magnetic stimulation, were also considered but were given a “recommendation against” or “no recommendation” based on insufficient or poor research evidence at the time the guideline was developed. The evidence for sound therapy lies somewhere in the middle; the AAOHNSF lists it as an “option.” This rating highlights less certainty in the positive outcomes of sound therapy, or, in other words, the well-done studies that have been published show little advantage of one approach (or product) over another. There is no inherent harm in soundbased therapies for the treatment of tinnitus, provided the sound is delivered at a safe level. In fact, many individuals report positive outcomes with the use of different types of sound, including use of various commercial devices. But what device will give the most benefit for a specific patient? And how do we separate fact from fiction when reading product endorsements?
Internet Search for Sound Therapy Products Ambivalence within the scientific community on using sound therapy for tinnitus management was the inspiration for this investigation. Because there is no widely accepted standard of practice for sound therapy, those seeking intervention often rely on their own independent research. We put ourselves in the shoes of a consumer and focused on sound-
based treatment options that are readily available to the public. Using the Google search engine, we typed in “tinnitus sound therapy” and began to browse. The results from the first five pages of our search are represented in Figure 1. Of the 46 unique links, 15 connected to pages for commercial products. One was free to download or use on the internet, three offered a “lite” (or free) version, and the remaining 11 were paid products. The range in pricing was significant, from a $2 cell phone app to several thousand dollars for an intervention with strict treatment guidelines. The remaining links yielded results for published research, news articles, blogs, webpages of tinnitus organizations, general medical information on tinnitus, and advertisements for tinnitus clinics in our area.
internet search is provided in Table 1. Note that inclusion of these products does not in any way constitute an endorsement by us, the entities we work for, or the American Tinnitus Association. Our goal is simple: to use the products found in a Google search as a basis for investigation, then review current research evidence to support or refute the claims that are made.
Products Primarily Intended to Reduce Reactions to Tinnitus The term “masking” is often misrepresented in tinnitus literature. Dr. Jack Vernon pioneered the masking method with the original intent of replacing tinnitus with a more acceptable sound consisting of broadband noise to provide a sense of immediate relief from any negative reactions to tinnitus.8 He soon discovered that covering tinnitus with another sound was often not
Commercial Products A listing of commercial sound therapy products appearing in our
Figure 1. First 5 Pages of “Tinnitus Sound Therapy” Google Search Research Information
2
Advertisements
Paid Product
9
4 15
Products
4
13 News Article/Blog
11
3
Free Products Organizations
Results from the first five pages of a Google search using the search phrase “tinnitus sound therapy,” sorted by category. Source: Google
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SPECIAL FEATURE
necessary because patients reported benefit from low-level noise that still allowed tinnitus to be heard. This discovery was in keeping with the sound enrichment principle, which has been popular since Itard’s time. Sound enrichment is the basis of many products available for purchase. The general principle is to provide
consistent stimulation to the auditory system with low-level external sound, thus reducing the contrast between the tinnitus sound and a quiet environment. Sound enrichment uses broadband noise, tones, music, nature sounds, and so on to achieve a therapeutic effect. It does not change the tinnitus itself, but it can be
used to effectively manage negative reactions, distract attention away from the tinnitus sound, or possibly lead to habituation (i.e., the brain’s ability to stop paying attention to meaningless stimuli, such as the low hum of the refrigerator in your kitchen). However, a sound that is effective for one person may not have a
Table 1. 15 Commercial Products for Sound Therapy Product
Primary Intended Effect: Reduction in Tinnitus
Price Range*
Method of Delivery
Type of Sound
ReSound Tinnitus Relief (and Lite)
Reaction
$69.99 (12-mo. subscription)/ Lite version free
App
Sounds** from ReSound library
Restored Hearing – Sound Relief
Reaction
$79 (3-mo. subscription)
App
Combination of low-frequency noise bands
Sound Oasis – Sound Therapy System
Reaction
$79.99
Tabletop device
Sounds** from Sound Oasis library or userdownloaded sounds
Sound Pillow® Sleep System
Reaction
$159.88
Pillow with embedded speakers
Sounds** from Sound Pillow® library or userdownloaded sounds
Tinnitus Therapy Pro (and Lite)
Reaction
$5.99/Lite version free
App
Sounds** from Tinnitus Therapy Pro library
Tinnitus Tunes
Reaction
$97 (12-mo. subscription)
Web-based
Sounds** from Tinnitus Tunes library
Whist – Tinnitus Relief (and Lite)
Reaction
$1.99/Lite version free
App
User-designed pure tones and narrowband noise
AudioNotch
Perception
$99.95 (12-mo. subscription)
App
Noise or music notched around tinnitus pitch
Desyncra™ for Tinnitus
Perception
Consult with a qualified provider
Wearable therapy system
Patterned sinusoidal tones matched to tinnitus
Levo Therapy System
Perception
Consult with a qualified provider
Wearable therapy system
“Sound print” matched to tinnitus using company software
Neuromonics® – Tinnitus Alleviator
Perception
$99.99
App
Spectrally modified music
Tinnitus Notch
Perception
Free
Web-based
Noise notched around tinnitus pitch
®
Note: Products are listed in the order they appeared in the first five pages of a Google search using the search phrase “tinnitus sound therapy.” * Pricing was determined via product pages on 1/15/2019, where applicable. Subscription service pricing varied and is represented here using the most cost-effective membership available. ** Sounds include but are not limited to broadband noise, nature and environmental sounds, music, and speech sounds.
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SPECIAL FEATURE
therapeutic effect on another. Thus, the use of sound requires an individualized approach that may take trial and error to determine which sound (or sounds) work for a given tinnitus problem situation. For example, music may be beneficial when focusing at work, but not helpful when trying to fall asleep at night. Sound therapy products intended to reduce reactions to tinnitus tout “customizable,” “affordable,” and “convenient” options for treatment. As shown in Table 1, most of these products come in the form of a cell phone app. An app is advantageous because it provides direct access to therapy without requiring an additional device. Stand-alone products targeting specific settings where tinnitus is particularly bothersome are also available. For example, many people struggle with tinnitus when trying to fall asleep. The Sound Oasis tabletop sound generator and the Sound Pillow® provide unique remedies for specific tinnitus situations though they do not provide the same flexibility as a product downloaded directly to a mobile device. If used properly, these products offer a practical and inexpensive therapy that can be readily selfimplemented in daily life.
Products Intended to Primarily Reduce the Perception of Tinnitus Certain methods of sound therapy propose loftier aspirations than reducing reactions to tinnitus. These methods are intended to produce changes in how the brain processes sound (via neural plasticity) to reduce www.ATA.org
"…methods are intended to produce changes in how the brain processes sound … to reduce the perception of tinnitus." the perception of tinnitus. They also typically require more stringent therapy regimens involving several hours of use per day over some period of treatment. Claims of a “proven method of therapy backed by scientific research” often garnish these product pages. Some offer evidence through published articles. For example, AudioNotch uses headphones to play music or tones filtered around the dominant tinnitus pitch to promote “lateral inhibition.” One study cites an average reduction in tinnitus volume of approximately 12 decibels (dB) with this method.3 This process aims to selectively stimulate auditory neurons that do not produce the tinnitus and eventually rewire the connections, or laterally inhibit, adjacent populations that are hyperactive, thus leading to decreased tinnitus loudness. Desyncra for tinnitus “rewires the brain” through a desynchronization of cortical neural populations associated with tinnitus through a process called acoustic coordinated reset neuromodulation.9 This product is a wearable device that presents a repeated randomized sequence of sinusoidal tones at frequencies grouped around the tinnitus pitch along with silent cycles to optimize the desynchronizing coordinated reset effect. One randomized controlled trial (RCT) using this product reported
a reduction of tinnitus loudness and annoyance in both acute and sustained conditions as compared to only acute benefits with traditional noise-like stimulation.4 The Levo System is another sound-emitting device that has gained considerable traction in the national media for its success in treating patients with tinnitus. This device uses an acoustic stimulus called a “sound print,” which employs software to mimic tinnitus perception. Unlike a majority of sound devices, this product is meant to be worn while sleeping to facilitate habituation over time. Results from one RCT indicated more improvement on selfrated loudness while using the Levo System when compared to control groups, but on average, all groups, which received audiologic and tinnitus counseling, benefited from reduced tinnitus-related distress.10 By and large, these products are more expensive. Some offer subscription services that need to be renewed yearly. Others combine aspects of clinical care such as counseling and hearing tests with fitting of devices that deliver the sound therapy. To some potential consumers, the price may be prohibitive. For others, the severity of distress caused by tinnitus along with lack of success with other methods may give the impetus to invest. These TINNITUS TODAY SPRING 2019
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methods may be most beneficial for individuals who want to follow a structured treatment schedule or who prefer counseling from a professional.
Summary of Evidence: Sound Therapy Scientific evidence follows a hierarchical structure, with the strongest evidence found in systematic reviews.7 These publications are conducted by multiple experts in the field, involve an exhaustive literature review using strict inclusion criteria, and focus on RCTs to validate claims. Studies included should be replicable, relevant, and independent from the company marketing the product. When making an argument in support of a specific method of sound therapy, it is essential to conduct systematic reviews because they are the basis for establishing clinical guidelines. Contrary to the evidence-based methods of tinnitus intervention recommended in the AAO-HNSF guidelines, the research literature accounting for success with sound therapy remains muddled.11 Many shortcomings emerge from flawed study designs and an inability to separate the use of sound from other aspects of therapy, such as counseling. Further, there is little uniformity in outcome assessment across protocols, making metaanalysis of all relevant studies difficult. A recent publication citing evidence in animal models even warns of possible unintended longterm consequences within the central auditory system by using white noise for sound therapy.12 Published studies like these are concerning given 8
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that white noise has been a central component of sound therapy for decades and remains one of the most common sounds used for tinnitus management. However, readers should not be alarmed because there is no evidence that low-level broadband noise has harmful effects on human hearing, as argued by several responses to the editor.13–15 This serves as an example of how published articles may ultimately do a disservice to the millions of people who depend on sound therapy for relief. Although letters to the editor are constructive in the scientific community, a recommendation from a systematic review would unequivocally validate sound therapy’s place in tinnitus management. To that end, several systematic reviews on sound therapy techniques have been published over the last decade.16–19 According to these rigorous reviews, a common theme across the literature is insufficient available evidence or a failure to show strong evidence for the efficacy of a single method of sound therapy in the management of tinnitus. However, as stated by Hobson, Chisholm, and El Refaie: “The absence of conclusive evidence should not be interpreted as evidence of lack of effectiveness” because optimal management may involve multiple strategies.17 Similar to the heterogeneity in tinnitus as a symptom, Searchfield, Durai, and Linford explain that the term “sound therapy” applies to a wide collection of sound-based approaches that may not be compatible for each individual.19 Suffice it to say, no review identified an optimal sound therapy
strategy. In general, if a method of sound therapy can be easily implemented in a person’s daily life and is beneficial at a low level, then there are no contraindications for its use. Further, many reviews concur with the AAO-HNSF guideline and recommend various clinical assessments, including thorough case history and hearing assessment, to determine the best intervention. Although the evidence gathered questions the optimistic claims for sound therapy as advertised, some reported systematic reviews are outdated and do not include the current products listed in Table 1. Also, additional RCTs involving different products are emerging and must be accounted for in future systematic reviews.10, 20
Concluding Remarks By taking an evidenced-based approach in evaluating commercial sound therapy devices, we cannot show that any one method is more effective than any other. In other words, it may be that a free app available on a cell phone or webpage is just as effective as a paid product in delivering the benefit that is needed for a particular person. Research comparing free apps to costly devices has not been conducted, and it seems unlikely that the makers of these devices would be motivated to fund such research. This is not to discount or refute the promise of the novel approaches to sound therapy that aim to permanently suppress the perception of tinnitus. Instead, it serves as a call to arms for increased support for large-scale RCTs on these modes of intervention. www.ATA.org
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It may be that a universal treatment for tinnitus does not exist. Rather, successful sound therapy may require an individualized, multidisciplinary approach that seeks to understand and mitigate how bothersome tinnitus manifests for each person. Success may also be determined by a patient’s willingness to accept an intervention protocol, agree to different sounds, and pay for treatment.1 Although current methods of sound therapy for the management of tinnitus demonstrate varying degrees of success, we are optimistic that the search for an optimal treatment strategy will be successful. We believe that substantial progress will be made in the realm of sound-based treatment options for tinnitus. Devon Kulinski is a fourth-year Doctor of Audiology extern from Northeastern University under the mentorship of Drs. James Henry, Candice Manning, and Sarah Theodoroff at the National Center for Rehabilitative Auditory Research (NCRAR) at the VA Portland Health Care System (VAPORHCS). His position is funded by the Office of Academic Affairs, and he divides his time equally between research support and direct patient care. His research interests include hearing conservation, clinical management and treatment of tinnitus, and military audiology. After completion of his AuD in May, he hopes to continue to work with a research focus and eventually pursue a PhD in the field.
Candice Manning received her Doctor of Audiology and Philosophy from East Carolina University in 2014. She completed her dissertation on notched noise therapy for tinnitus treatment through a self-designed smart device application. She then completed a www.ATA.org
postdoctoral fellowship with the United States Army Research Laboratory to study the effect of tinnitus on speech intelligibility in noise over military communications headsets. Currently, she is a research audiologist at the National Center for Rehabilitative Auditory Research (NCRAR) and an assistant professor at Oregon Health & Science University. Her research focuses on tinnitus perception by working to establish clinical normative standards, designing and studying the use of web-based technology for patient-centered tinnitus assessment and management, and evaluating tinnitus sound therapy management options through the use of hearing aids and combination units. 1 Hoare, D. J., Searchfield, G. D., El Refaie, A., & Henry, J. A. (2014). Sound therapy for tinnitus management: Practicable options. Journal of American Academy of Audiology, 25, 62–75. 2 Stephens, S. D. G. (1984). The treatment of tinnitus – a historical perspective. Journal of Laryngology and Otology, 98, 963–972. 3 Lugli, M., Romani, R., Ponzi, S., Bacciu, S., & Parmigiani, S. (2009). The windowed sound therapy: A new empirical approach for an effective personalized treatment of tinnitus. International Tinnitus Journal, 15(1), 51–61. 4 Tass, P. A., Adamchic, I., Freund, H. J., Stackelberg, T., & Hauptmann, C. (2012). Counteracting tinnitus by acoustic coordinated reset neuromodulation. Restorative Neurology and Neuroscience, 30, 137–159. 5 Henry, J. (2017). Tinnitus management based on research evidence. Tinnitus Today, Winter, 5–9. 6 Tunkel, D., Bauer, C., Sun, G., Rosenfeld, R., Chandrasekhar, S., Hussey, H.,…Whamond, E. (2014). Clinical practice guideline: Tinnitus. Otolaryngology – Head and Neck Surgery, 151(2S), S1–S40. 7 Higgins, J. P. T., & Green, S. (Eds.). (2011). Cochrane handbook for systematic reviews of interventions (version 5.1.0) [updated March 2011]. Cochrane Collaboration. Retrieved from http://handbook.cochrane.org 8 Vernon, J. (1976). The use of masking for relief of tinnitus. In: H. Silverstein and H. Norell (Eds.), Neurological surgery of the ear (Vol. II) (pp. 104–118). Birmingham, AL: Aesculapius Publishing.
9 Tass, P. A. (2003). A model of desynchronizing deep brain stimulation with a demand-controlled coordinated reset of neural subpopulations. Biological Cybernetics, 89, 81–88. 10 Theodoroff, S., McMillan, G. P., Zaugg, T. L., Cheslock, M., Roberts, C., & Henry, J. A. (2017). Randomized controlled trial of a novel device for acoustic treatment of tinnitus during sleep. American Journal of Audiology, 26, 543–554. 11 Hoare, D. J., Kowalkowski, V. L., Kang, S., & Hall, D. A. (2011). Systematic review and meta-analyses of randomized controlled trials examining tinnitus management. The Laryngoscope, 121(7), 1555–1564. 12 Attarha, M., Bigelow, J., & Merzenich, M. (2018). Unintended consequences of white noise therapy for tinnitus – otolaryngology’s cobra effect: A review. JAMA Otolaryngology – Head & Neck Surgery, 144(10), 938–943. 13 Folmer RL. No evidence of broadband noise having any harmful effect on hearing. JAMA Otolaryngology--Head, Neck & Surgery. Published online Jan. 24, 2019. doi:10.1001/ jamaoto.2018.3985 14 Henry JA, Manning C, Griest S. No evidence of broadband noise having any harmful effect on hearing. JAMA Otolaryngology – Head, Neck & Surgery. Published online Jan. 24, 2019. doi:10.1001/jamaoto.2018.3995 15 Coverstone, J. A. (2018). Are there negative effects from white noise sound therapy? Tinnitus Today, Winter, 43(3), 53. 16 Phillips, J. S., & McFerran, D. (2010). Tinnitus Retraining Therapy (TRT) for tinnitus. Cochrane Database of Systematic Reviews, 3, CD007330. 17 Hobson, J., Chisholm, E., & El Refaie, A. (2012). Sound therapy (masking) in the management of tinnitus in adults (review). Cochrane Database of Systematic Reviews, 11, CD006371. 18 Wegger, M., Ovesen, T., & Larsen, D. G. (2017). Acoustic coordinated reset neuromodulation: A systematic review of a novel therapy for tinnitus. Frontiers in Neurology, 8, 36. 19 Searchfield, G. D., Durai, M., & Linford, T. (2017). A state-of-the-art review: Personalization of tinnitus sound therapy. Frontiers in Psychology, 8, 1599. 20 Henry, J. A., McMillan, G., Dann, S., Bennett, K., Griest, S., Theodoroff, S.,…Saunders, G. (2017). Tinnitus management: Randomized controlled trial comparing extended-wear hearing aids, conventional hearing aids, and combination instruments. Journal of the American Academy of Audiology, 28(6), 546–561.
Disclaimer of Medical Advice: The content provided in Tinnitus Today magazine, including treatments, outcomes, charts, profiles, images, and advice, is for informational purposes only and does not constitute medical advice and is not intended to be a substitute for independent professional medical judgment, advice, diagnosis, or treatment. Articles are not intended to establish a standard of care to be followed by a reader of the magazine. The American Tinnitus Association advocates that you should always seek the advice of your physician or other qualified healthcare provider with any questions or concerns you may have regarding your tinnitus and/or health. Research and medical information changes constantly. Therefore, the information in the magazine should not be considered current, complete or exhaustive. The ATA does not recommend or endorse any specific tests, products, procedures, opinions, or other information that may be provided in magazine articles.
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ď„° PERSONAL STORY
Breaking a Quarter Century of Silence Helped Strengthen My Mind and Spirit By Desiree Kranendijk
In 1992, at the age of 21, I contracted acute bacterial meningitis. This left me deaf in my left ear, with vestibular issues that made walking difficult, prone to minor epileptic seizures, and with overwhelmingly intrusive tinnitus. I clung to the thought that I was lucky to be alive, never imagining that there would be a mental health toll from not acknowledging the many obstacles I faced and from the burden of my self-imposed silence about living with tinnitus. Initially, I had double vision and could barely see, which made learning how to walk even more difficult. The optic nerve was eventually restored, so I could see. However, such milestones felt bittersweet because of my hearing loss and the relentless tinnitus. I had learned early in childhood to suppress difficulties, because my mother was diagnosed with a terminal illness when I was 13. Watching her and wanting to provide comfort, I kept my troubles and 10
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worries to myself. When I contracted bacterial meningitis, I again concealed my problems from her, because her quality of life was so limited. As soon as I was able, I returned to university, dove into my studies as best as I could, and rarely mentioned my health struggles to anyone. In 1994, my university research in international development took me to Guatemala, where I met my future husband, who is Canadian. However, my tinnitus was negatively affecting my professional and private life. Within months of my return home to the Netherlands in 1995, my ENT specialist suggested
labyrinthectomy, a procedure sometimes used to decrease vertigo. The theory behind performing the labyrinthectomy was that hair cells were still trying to “broadcast,� and, by killing the remaining cells, the tinnitus signal would cease. Although I knew the chances for improvement were limited, I still had hope. Therefore, I was very disheartened when the surgery failed to alleviate my tinnitus. At that point, I resigned myself to the fact that this condition would be lifelong. At 25, I moved to Vancouver to be closer to my future husband. Living in a new country as an immigrant had its own challenges. I worked hard
"Through meditation and mindfulness, I now am able to separate myself mentally from the constant static noise in my brain instead of being enveloped in it." www.ATA.org
PERSONAL STORY
and landed a job at an international think tank. The work was exciting, but very challenging from an auditory perspective. My area was Latin America, and I was responsible for project implementation. This meant I worked with large groups translating between English and Spanish. My brain worked overtime, functioning in two languages, neither of which were my native tongue. Every day, I gave 100 percent of myself, so no one knew I had a problem. I exited that high-pressure job several years later, when my husband’s work took us to Ottawa, Canada. A few years after that, we moved overseas to Belgium for a number of years. When we returned to Vancouver, I co-founded a business with the objective of having a healthy balance between work and family. As usual, I kept silent about my hearing loss and tinnitus. My only confidants were a few close family members. Unwittingly, I had become adept at compensating for my hearing loss and tinnitus. I wasn’t shy or ashamed; it was just easier to adapt to and suppress the additional stress they created. In May 2009, my third child was born. As for all parents with a newborn, life became more hectic and less predictable. My children were the source of so much joy and so much activity that I failed to grasp that tinnitus was gradually destabilizing my mental well-being. The proverbial straw that broke the camel’s back was a freak accident that severely injured one of my children. That day, my mind began to unravel, despite the fact that my child would fully recover. www.ATA.org
"Learning to become comfortable talking about and acknowledging hearing loss, tinnitus, and mental health issues has allowed me to proactively adapt and evolve." My mental strength and physical energy were so sapped that it took tremendous willpower to get through each day. The sound of tinnitus was overwhelming; and each day, feelings of self-doubt, fear of losing control, guilt, irritation, low self-esteem, and anger penetrated everything. I could feel myself pulling away from people and entering a world of mental exile, where I was defined and controlled by tinnitus. In late 2017, I was determined to make a fresh start and get my life back on track. I stepped away from my business. However, divesting myself from the company was more difficult than anticipated. It proved to be the tipping point. I had a nervous breakdown by the end of the year. It felt like the walls of my mind crumbled, leaving me trapped with the noise of tinnitus. I sought help and was told that if I wanted to get better, I needed to stop suppressing my problems and emotions in order to identify underlying patterns of behavior. Once I understood the coping mechanisms that were adding to my stress, I could recover the life and joy I craved. Living for decades under selfimposed silence about my hearing loss and tinnitus was a significant
part of the problem and a major piece of the puzzle to solve. The recovery process enabled me to understand the counterproductive coping and masking mechanisms I had developed unconsciously from a young age because of my mother’s illness, her death, the death of my father, and the constant moves that kept me from establishing roots that might have provided better support. Self-care, let alone verbally expressing my daily challenges, was not a concept in my repertoire. My silence had finally exacted a heavy toll on my ability to simply get through a day. Since my breakdown, I have come a long way on the road to recovery. I know I will emerge as a stronger, more complete version of myself. After more than a quarter of a century, I am finally acknowledging and dealing with the challenges unleashed by that devastating infection, including how to live with tinnitus. I now wear contralateral routing of signals (CROS) hearing aids, which are designed for people with singlesided hearing loss. The hearing aid on my deaf ear transmits sounds to the ear with better hearing, making it easier to hear. It also decreases my perception of tinnitus. TINNITUS TODAY SPRING 2019
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PERSONAL STORY
I meditate daily and am trying direct neurofeedback, a therapy that uses electroencephalography (EEG) to help me gain control over my brain activity. Using imperceptible lowvoltage signals, the therapy attempts to disrupt repetitive negative neural patterns and establish healthy ones, resulting in an improved mental state. It’s like rebooting a frozen computer. I also committed myself to eye movement desensitization and reprocessing (EMDR) therapy, which is an interactive psychotherapy technique used for the treatment of trauma. (See box.) During EMDR therapy sessions, you briefly revisit traumatic or triggering experiences while the therapist directs your eye movements. For me, the meningitis and the sudden onset of tinnitus were very traumatic. Through EMDR, recalling these traumas became less emotionally upsetting. It allowed me to explore the memories and thoughts without having a strong psychological response. Over time, it helped reduce the tinnitus distress. EMDR, meditation, and neurofeedback have helped me tremendously in my ability to move my attention away from the sound of tinnitus. It’s like having a mute button that allows me to shut down feelings of anxiety and the fight-or-flight response that accompanies it. Through meditation and mindfulness, I now am able to separate myself mentally from the constant static noise in my brain instead of being enveloped in it. This simple act of observation is so powerful that I feel free and in control. 12
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Tinnitus has done nothing to improve my life. But, like many life challenges, it inadvertently gave me strengths, such as compassion and empathy. It has taught me profound lessons about the invisible and often unspoken world of mental health, which affects millions of us directly and indirectly. The heavy weight of silence eventually broke my spirit, whereas communication and support reopened the world of hope and broad horizons. Learning to become comfortable talking about and acknowledging hearing loss, tinnitus, and mental health issues has allowed me to proactively adapt and evolve. Trying to endure alone meant that I delayed getting better. Think about the concern we express and feel when a friend breaks a leg or has a serious illness. “How is your leg?” “How is your recovery going?” We’re eager to hear about their situation. But what about friends struggling with depression or tinnitus? For some reason, we would never ask, “How is your mind healing?” “Is your tinnitus making you crazy?” Through communication and dialogue, mental isolation and
loneliness disappear. You suddenly discover a whole community of people you didn’t even know existed; people who appear well and whole reveal things about themselves that you had no inkling of. They, too, were suffering in silence, perhaps out of fear or shame. I learned, much to my astonishment, that when I talked about my pain, my loss, my struggles, I was greeted immediately with empathy. More often than not, someone else has a similar story. We are not alone, but if we don’t talk openly about tinnitus and the many issues that it can trigger, we feel alone. So, please, speak up and seek help for yourself, a friend, or a family member, so they never hit that awful tipping point like I did. Desiree Kranendijk was born and raised in the Netherlands. As a young adult, she embarked on an international career in project design and management. She currently resides in Vancouver, Canada, with her husband, three children, and loyal dog. She enjoys the great outdoors, making road trips to U.S. national parks, and sharing food and wine with friends and family.
What is eye movement desensitization and reprocessing (EMDR) therapy? According to Psychology Today, EMDR is a nontraditional form of psychotherapy that includes a hand-motion technique to guide the patient’s eye movement from side to side. The intervention is intended to diminish negative thoughts and emotions associated with memories of a traumatic event. It remains a controversial therapy because it lacks research evidence for its effectiveness.
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SCIENCE & RESEARCH NEWS
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Relationship of Tinnitus to Vestibular Disorders: The Awareness of Movement Summary by John A. Coverstone, AuD
The ear is not only the home for hearing. Within the labyrinth that houses the sensory organ for hearing is also the organ for sensing movement, balance, and spatial orientation. This sensory function, part of the vestibular system, is responsible for our awareness of movement. The information gathered by the vestibular sensory organ is transmitted to many areas of the brain. It contributes to conscious awareness of movement, coordination with other systems,
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and compensatory movements of the eyes and lower body to help maintain balance and orientation. For example, to maintain your gaze on something or someone when you turn your head, your inner ear senses the movement and directs your eyes to move in the opposite direction. If you become unsteady, your legs, feet, and trunk automatically move to stabilize you – usually. A group of researchers from Karabuk University Faculty of Medicine in Turkey and the University of Miami Miller School of Medicine sought to determine whether vestibular problems are present in people with tinnitus.1 For this study, they sought only individuals with normal hearing – that is, with no known damage to the inner ear. They re-
cruited 32 patients with tinnitus for this study. Each complained only of tinnitus, with no hearing loss. They also recruited 30 control subjects who had no tinnitus or hearing loss. Each patient underwent a series of vestibular tests. Assessments of eye movements, called oculomotor tests, were performed. During one of these tests, subjects followed with their eyes a target moving continuously through their field of gaze, called smooth pursuit. During another test, subjects followed a rapidly moving target, which instantly moved from one location within the visual field to another. This is called saccadic eye movements. Subjects also performed gaze testing, in which they stared at a nonmoving target, and optokinetic tests, in which they tried to maintain a center gaze while a series of stripes moved across their visual field. Patients also were given caloric testing. This involves using air (in this case) or water to raise or lower the temperature of one ear. The result was that the vestibular organ in that ear was stimulated (in the case of warm irrigation) or inhibited (with cool irrigation). This causes a discrepancy in sensory input
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SCIENCE & RESEARCH NEWS
in each ear and an artificial sensation of movement. As a result, the eyes move to compensate, and that eye movement was measured. Eye movement velocities for warm versus cool irrigations of each ear were compared, and any weakness for the left or right ear was noted. Subjects were also given the Tinnitus Handicap Inventory, and the duration and side of tinnitus (left, right, or both) were documented. Analysis was then performed to determine any vestibular dysfunction and its relationship to tinnitus. No statistical differences in oculomotor function were found between the tinnitus group and the control group. An abnormal caloric response was found in 13 of the 32 patients in the tinnitus group, however. No abnormal responses were found in the control group. When caloric test results were compared to tinnitus characteristics, it was found that patients with severe tinnitus were likely to have abnormal caloric responses. No differences were found on other vestibular tests in those identified on the THI as having mild or moderate tinnitus distress. There were also no differences in caloric responses based on the length of time the subject had experienced tinnitus and no clear effect of which ear experienced tinnitus. Although the mechanisms involved are not well understood, this study demonstrates a significant incidence of vestibular disorder in patients with tinnitus. A caloric weakness may result from impairment of the vestibular nerve, which is within the same 14
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nerve bundle as the auditory nerve and may explain this comorbidity. The authors acknowledged that a larger study should be performed before clinical practices are updated. However, the authors propose that tinnitus may sometimes be an early symptom of vestibular problems. As a result, clinicians may need to consider assessment of vestibular function for patients with tinnitus and no hearing loss. 1 Ila, K., Soylemez, E., Yilmaz, N., Kayis, S. A., & Eshraghi, A. A. (2019). Vestibular functions in patients with tinnitus only. Acta OtoLaryngologica. Advance online publication. doi:10. 1080/00016489.2018.1548778
Š National Institutes of Health/National Institute on Deafness and Other Communication Disorders
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SCIENCE & RESEARCH NEWS
Reader Question & Researcher Answer What progress has been made toward a cure for tinnitus in the last decade? Answered by LaGuinn Sherlock, AuD, and Marc Fagelson, PhD
Tinnitus research has grown exponentially over the past 10 years. Although many clinical options are available now to help people achieve relief from tinnitus, such as sound therapy and cognitive behavioral therapy, an option to completely, reliably, and consistently eliminate tinnitus does not yet exist. However, to facilitate the search for a cure, an understanding of the underlying mechanisms and methods of measuring tinnitus and its effects is necessary. Much progress has been made in this regard. Today we know that there are multiple subtypes and causes of tinnitus, many of which will likely require different intervention approaches. The search for a method to completely eliminate tinnitus, and thus “cure” it, continues, and is happening all over the world. Methods to completely or partially eliminate tinnitus employ a wide range of strategies, from sound therapy to bimodal stimulation, and electrical stimulation to pharmacological intervention. Bimodal stimulation involves stimulating two sensory systems at the same time to change the way the
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brain processes sensory events. In the case of tinnitus, the two senses accessed are auditory (hearing) and somatosensory (touch) systems. For example, recent work done at the University of Michigan has shown that tinnitus can be at least partially suppressed using bimodal stimulation in people who can change their tinnitus by clenching their jaw or sticking out their tongue. Various forms of sound stimulation, such as hearing aids and masking devices, as well as electrical stimulation, including cochlear implants, are being studied. Many investigators are developing and analyzing medications to eliminate or suppress tinnitus. However, there are several challenges in developing medication, one of which is the identification of what to change (e.g., the sound itself, attention to the sound, effect of the sound on emotional state). Investigators must also agree on measurements of what is being changed by a drug or other intervention (e.g., loudness versus intrusiveness), and research is taking place to help answer these questions. So, although we do not have a cure today, steady progress is being made.
LaGuinn Sherlock is chair of the board of directors of the American Tinnitus Association. Dr. Sherlock has been practicing audiology since 1991 and has worked with thousands of patients who have tinnitus, both clinically and in research. She has worked at Johns Hopkins Medical Center, University of Maryland Medical Center, and for the Army Public Health Center at Walter Reed National Military Medical Center. Dr. Sherlock is currently studying the effect of tinnitus on concentration using reaction time and short-term memory tests. She serves as adjunct faculty in the Department of Hearing and Speech Sciences at the University of Maryland, College Park. Marc Fagelson, PhD, is a professor of audiology in the Department of Audiology and SpeechLanguage Pathology at East Tennessee State University. His clinical and academic teaching includes hearing science, audiological evaluation, pathologies of the auditory system, and tinnitus management. He co-edited Tinnitus: Clinical and Research Perspectives and a companion text, Disorders of Sound Tolerance, with Dr. David Baguley. He opened the James H. Quillen Mountain Home VA Medical Center Tinnitus Clinic in 2001; the clinic now enrolls more than 1,000 patients. Dr. Fagelson provides extensive and collaborative counseling for patients, as well as a variety of sound therapy strategies, to support their ability to manage tinnitus. He is also a member of the ATA’s Scientific Advisory Committee.
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Stimulating tinnitus research
Neuromod Devices is dedicated to validating its breakthrough tinnitus treatment approach in large randomized clinical trials in tinnitus patients. Neuromod Devices is an innovative company formed in late 2010 to clinically investigate ground-breaking tinnitus treatment technology that originated in the National University of Ireland, Maynooth.
To test and confirm the scientific hypothesis underlying this ground-breaking approach, Neuromod has embarked on a unprecedentedly robust clinical programme:
Tinnitus is a complex neurological condition that involves hearing, attention and emotion centers in the brain. Unlike sound therapies and noise maskers that only deliver one type of stimulus to the brain (sound), Neuromod’s approach combines auditory stimulation (sound) with trigeminal nerve stimulation, which is achieved noninvasively as gentle energy pulses delivered to the surface of the tongue by a proprietary tonguetip® device. By combining these neuromodulatory stimuli, Neuromod believes that greater and more sustained efficacy may be achieved.
2012: TAVSS single arm trial in 60 patients²
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2010: Proof of principle in 20 patients¹ 2016: Randomized double-blind multi-arm trial in 326 patients with 12 month long-term post-treatment follow up (TENT-A1)³ 2018: Randomized double-blind multi-arm confirmatory trial in 191 patients with 12 month long-term post-treatment follow up (TENT-A2)⁴ Neuromod will share the results of the TENT trials once complete and will work with regulatory authorities to make the product available to patients as soon as possible.
For further reference: 1.
WO2012069429A1; Method and apparatus for sensory substitution; Paul O’grady. Ross O’Neill, Barak A. Pearlmutter
2.
Hamilton, Caroline, et al. “An Investigation of Feasibility and Safety of Bi-Modal Stimulation for the Treatment of Tinnitus: An Open-Label Pilot Study.” Neuromodulation: Technology at the Neural Interface 19.8 (2016): 832-837.; ClinicalTrials.gov Identifier: NCT02570048
3.
D’Arcy, Shona, et al. “Bi-modal stimulation in the treatment of tinnitus: a study protocol for an exploratory trial to optimise stimulation parameters and patient subtyping.” BMJ open 7.10 (2017): e018465.; ClinicalTrials.gov Identifier: NCT02669069
4.
ClinicalTrials.gov Identifier: NCT03530306Treatment Evaluation of Neuromodulation for Tinnitus - Stage A2 (TENT-A2)
SPECIAL FEATURE
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Are Hearing Aids the Answer? Hearing Loss, Reducing Tinnitus Perception, and Slowing Cognitive Decline
By Grant D. Searchfield, PhD, Christine Fok, MSc, and Philip J. Sanders, PhD Candidate
Most populations in the developed world are aging populations, and the number of people with dementia worldwide is projected to double in the next three decades. These circumstances will have a huge impact on healthcare budgets worldwide, so urgent efforts are underway to investigate ways to reduce this burden. We are researching whether hearing aids can slow cognitive decline and reduce the rate of dementia in our population. The human ability to manage complex thinking tasks and memory (collectively called cognition) tends, with some exceptions, to become poorer with age. Some people do slightly worse on cognitive tasks and experience greater difficulties in daily life than would be expected for their age; this is described as mild cognitive impairment (MCI). Dementia is more severe than MCI and is associated with impaired memory and judgment or trouble with reasoning. www.ATA.org
As people age, the chances of developing hearing loss and tinnitus also increase. Persons with tinnitus are more likely to have hearing loss than not. Persons with tinnitus compared with those without tinnitus also tend to perform more poorly on complex thinking tasks. Untreated hearing loss has been identified as a risk for more rapid cognitive decline with aging. Thus, tinnitus, hearing loss, and poorer cognition with age are interrelated. Is it possible that hearing aids could improve hearing and tinnitus and reduce the chance of MCI and dementia? There is some indirect evidence that this may be the case. But people with MCI may struggle to get the best out of hearing aids. Our research investigates
whether hearing aids set to reduce the complexity of listening can improve hearing for this group, and at the same time improve cognition. To address the question of whether hearing aids may help, we discuss the effects of hearing loss and tinnitus on cognition, brain changes explaining hearing’s effect on cognition, how hearing aids may help, and our current research.
The Effects of Hearing Loss and Tinnitus on Cognition Evidence for the effects of hearing loss and the corresponding relationship with cognitive ability in aging is beginning to be reported from several studies. A
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SPECIAL FEATURE
review in The Lancet indicated that 9 percent of dementia cases could be attributed to hearing loss at midlife. This percentage may not sound high, but the next highest modifiable factor (excluding genetically inherited risks for dementia) at mid-late life was smoking, at 5 percent. Hearing loss and tinnitus, both symptoms of change in the hearing system, often occur together. However, although tinnitus is not always accompanied by a hearing loss sufficient to create a hearing handicap, tinnitus and hearing loss are strongly related, and it is possible that they
have independent but likely cumulative effects on cognition. Gerhard Andersson from Sweden is a leading researcher in this area. His group developed a model of tinnitus annoyance that includes the effect of tinnitus on attention and memory based on tests of cognitive performance.1 This model has shown hearing aids improve cognition in tinnitus sufferers.2 The effect of hearing loss can be integrated in this model (Figure 1).
Brain Changes Explaining Hearing’s Effect on Cognition Four main hypotheses have been proposed to explain the relationship
Figure 1. Progression from the Appearance of a Tinnitus Signal to its Annoyance Tinnitus Signal Cognitive Effects
Emotion
Negative Thoughts Hearing Loss
Annoyance Model illustrating the progression from the appearance of a tinnitus signal (the sound of tinnitus) to its annoyance. The relationship of hearing loss, tinnitus, and cognitive function is indicated in red. (Figure modified from Andersson and McKenna, 2006.)
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between hearing loss and cognitive decline.3, 4
1
Sensory deprivation: Cognition slowly declines over time because of decreased brain activity and brain stimulation that result from hearing loss.
2
Information degradation: This hypothesis is similar to that of sensory deprivation except that degraded sensory input resulting from hearing loss has an immediate negative (but potentially reversible) effect on cognitive task processing because insufficient sensory information is available. Hence, cognitive resources are expended on processing degraded sensory information, leaving insufficient resources available for other cognitive tasks. This is also how tinnitus is likely to mediate its effect on cognition.
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Cognitive load: Cognitive decline results in poor performance on perceptual tasks because fewer cognitive resources are available to process sensory information, even though sensory processing may be intact.
4
Common cause: A common factor, such as changes in brain structure or function, underlies both sensory and cognitive decline. It is possible that a combination of any or all of the above processes may occur and interact simultaneously. Our understanding of the relationship between sensory and cognitive decline remains limited. The direction of the relationship and the extent to which the sensory and cognitive systems influence each other remain unclear but are the subject www.ATA.org
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of increasing interest in the field of hearing research.
How Hearing Aids May Help Because tinnitus is associated with cognitive difficulties, such as reduced concentration and poorer memory, its treatment should improve cognition. When a hearing loss accompanies tinnitus, hearing aids are often recommended. A study compared the benefits of hearing aid use in 50 people with hearing loss and 50 people with tinnitus and hearing loss.2 Results from a cognitive test of reading span found improvements in both groups. The group with tinnitus and hearing loss showed the greatest improvement, suggesting that the hearing aids improved cognition by reducing both the hearing loss and tinnitus together. Evidence suggests that hearing aids may provide benefits in cognition for both conditions of hearing loss and tinnitus, but most research has focused on hearing loss, not tinnitus. Some studies have shown no cognitive decline in people using hearing aids compared to those not using hearing aids.5 Significant improvements in cognitive function have been seen after four months of hearing aid trial in a group of 95 patients compared to cognitive function in 99 people on a waiting list.6 In the UK Biobank cross-sectional data set (representing 164,770 participants who took a hearing test), hearing aid use was associated with better cognition independent of social isolation.7 Additionally, recent research in a sample of 2,040 Americans older than 50 years reported that the rate of www.ATA.org
cognitive decline based on memory scores measured over an 18-year period was successfully slowed with the fitting of hearing aids.8
Our Current Research Compelling evidence that hearing aids may be useful tools for reducing, preventing, or treating cognitive decline is emerging, but there remains a need for further research. Our research group has had a longstanding interest in the use of hearing aids for the management of tinnitus. Recently, we have turned our attention to whether hearing aids can slow cognitive decline. When audiologists fit hearing aids, the devices are programmed so they meet a set of standardized targets based on hearing test results. These targets account for hearing loss with adjustments for comfortable audibility of speech but do not usually consider the cognitive abilities of the listener. Modern hearing aids use fast processing to make sure soft sounds are heard and that background noise does not interfere too much with listening. However, people with cognitive difficulties cannot process rapid changes in sound easily, meaning the sound heard through the hearing aids can be confusing. We have developed an experimental hearing aid fitting approach that we have named “CogniAid” (hearing aid to assist cognition). Normal hearing aid settings try to make most sounds audible, and most people are able to use all this information. But people with poorer cognitive abilities may struggle to process the large amount of information, and it all becomes an overwhelming “blur.” The CogniAid
setting attempts to simplify listening by focusing on the amplification of conversational-level speech and deliberately sacrificing audibility of soft sounds. In other words, the users of the CogniAid would be expected to hear fewer sounds, but the quality of sounds that are heard should be better. With this strategy, persons with poorer cognitive abilities should be able to hear and make sense of conversations, even though they may miss some quiet sounds. We believe this “less in more” approach should improve hearing aid outcomes, and our hypothesis is that it will also improve cognition. A collaborative team from the Universities of Auckland and Canterbury is now investigating this approach in New Zealand. The study will follow 200 individuals over the age of 65 during their first year of hearing aid use. The project aims to answer the question: “Does the CogniAid fitting provide superior hearing and cognitive outcomes compared to standard hearing aid fittings?” We will accomplish this by comparing cognition and hearing loss before and after hearing aid use in 100 people using the CogniAid fitting and 100 people using the standard fitting. The preliminary data from our first trial group of 26 participants will be collected in the coming months. The research from this project is expected to be completed by 2021. Findings from this research will add to the growing evidence base for hearing loss and aging and is expected to improve hearing aid fitting services. TINNITUS TODAY SPRING 2019
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SPECIAL FEATURE
Summary Hearing aids help reduce the effects of hearing loss and tinnitus. Evidence is emerging that they slow cognitive decline and may reduce the risk of dementia. The relationships among tinnitus, hearing loss, and dementia are complex. The presence of one of these problems does not mean the others will occur; they are health risks, just as diabetes and smoking are risks that affect overall health in aging. We cannot guarantee that hearing aids will have the positive effects on cognition that we propose. More research is required to determine the effects of different hearing aid fitting approaches and how to extract the most benefit from hearing aids for individuals. It is possible that new medical treatments or means to prevent hearing loss will also be developed, and with that comes the promise of less tinnitus and improved cognition in aging. Although some of these ideas are still speculative, we believe that early use of hearing aids provides many benefits, including reduced tinnitus and the possibility of slowing cognitive decline. This research is funded by the Health Research Council of New Zealand. The researchers also acknowledge the support of the ATA toward our tinnitus research program.
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Associate Professor Grant D. Searchfield has been an audiologist since 1994 and obtained his Doctorate in Audiology in 2004. He is the clinical director of the University of Auckland’s Hearing and Tinnitus Clinic, scientific director of the tinnitus treatment website Tinnitus Tunes, and deputy director of the Eisdell Moore Centre for hearing and balance research. Dr. Searchfield is a primary investigator in Auckland University’s Centre for Brain Research and Brain Research New Zealand, a national center of research excellence. He is an associate editor for the International Journal of Audiology, Scientific Reports, and Frontiers in Neuroscience and Psychology. He is well known internationally for his research investigating the use of sound and hearing aids for tinnitus management. In addition to his tinnitus research, he is the lead investigator in a major multisite trial of hearing aids as a potential method to slow cognitive decline, which is funded by the Health Research Council of New Zealand. He is also a member of the ATA’s Scientific Advisory Committee. Christine Fok is a research assistant within the Section of Audiology, at the University of Auckland. She completed a BSc in biomedical science at the University of Auckland, where she discovered a strong interest in sensory neuroscience. For her master’s degree, she investigated novel drug therapies against noise-induced hearing loss. She is currently a research assistant for the CogniAid Study, managing participant recruitment and data collection.
Philip J. Sanders is a doctoral candidate at the University of Auckland studying under the supervision of Associate Professor Grant D. Searchfield. Sanders’s research interests include perception, multisensory processing, tinnitus, and brain plasticity. Upon completion of his thesis this year, he plans to continue working in the field of perceptual research. 1 Andersson, G., & McKenna, L. (2006). The role of cognition in tinnitus. Acta Oto-Laryngologica, 126(S556), 39–43. 2 Zarenoe, R., Hallgren, M., Andersson, G., & Ledin, T. (2017). Working memory, sleep, and hearing problems in patients with tinnitus and hearing loss fitted with hearing aids. Journal of the American Academy of Audiology, 28(2), 141–151. doi:10.3766/ jaaa.16023 3 Lindenberger, U., & Baltes, P. B. (1994). Sensory functioning and intelligence in old age: A strong connection. Psychology and Aging, 9(3), 339. 4 Schneider, B. A., & Pichora-Fuller, M. K. (2000). Implications of perceptual deterioration for cognitive aging research. In F. I. M. Craik & T. A. Salthouse (Eds.), The handbook of aging and cognition (pp. 155–219). Mahwah, NJ: Lawrence Erlbaum. 5 Amieva, H., Ouvrard, C., Giulioli, C., Meillon, C., Rullier, L., & Dartigues, J. F. (2015). Self-reported hearing loss, hearing aids, and cognitive decline in elderly adults: A 25-year study. Journal of the American Geriatric Society, 63(10), 2099–2104. doi:10.1111/jgs.13649 6 Mulrow, C. D., Aguilar, C., Endicott, J. E., Tuley, M. R., Velez, R., Charlip, W. S., . . . DeNino, L. A. (1990). Quality-of-life changes and hearing impairment. A randomized trial. Annals of Internal Medicine, 113(3), 188–194. 7 Dawes, P., Emsley, R., Cruickshanks, K. J., Moore, D. R., Fortnum, H., Edmondson-Jones, M., . . . Munro, K. J. (2015). Hearing loss and cognition: The role of hearing AIDS, social isolation and depression. PloS One, 10(3), e0119616. 8 Maharani, A., Dawes, P., Nazroo, J., Tampubolon, G., & Pendleton, N. (2018). Longitudinal relationship between hearing aid use and cognitive function in older Americans. Journal of the American Geriatric Society, 66(6), 1130–1136.
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SCIENCE & RESEARCH NEWS
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The Use of Hearing Aids for Sound Therapy Summary by John A. Coverstone, AuD
One of the most common treatments for tinnitus is sound therapy. The purpose of sound therapy is to lessen the perception of tinnitus and help give the individual relief from the tinnitus sound. When sound therapy is successful, clinicians can then focus on other aspects of treatment that may not be possible when tinnitus is still a prominent sound in a person’s daily life. Sound therapy may be accomplished with a number of devices. Many free apps, downloadable sound files, and websites offer masking sounds for tinnitus. A number of paid subscription or single-fee products are also available. One of the devices that has been used for many years is a hearing aid. Some of the first masking devices, called tinnitus maskers, were constructed within a hearing aid case, but only played noise. After hearing aids became digital, labs began to offer sounds for masking tinnitus in addition to standard amplification for hearing loss, with noises ranging from white noise to pseudo-random repeating notes in musical fashion. One of the reasons to use hearing aids as tinnitus maskers is to provide amplification for hearing loss, as well as www.ATA.org
provide tinnitus masking noise. However, many people with mild hearing loss may not realize that they have abnormal hearing and may not choose to use such a device, even though it would likely improve communication along with improving the perception of tinnitus. Researchers from the University of Oklahoma performed a retrospective study in which they reviewed patient files over a 2.5-year period.1 They looked for patients with mild hearing loss and tinnitus in order to study the adoption rate of hearing aids within that population. They also wanted to determine whether any characteristics of the patient group are associated with hearing aid adoption. Over the 2.5-year period, 89 of their 133 patients were identified as having mild hearing loss (called sensorineural hearing loss, which is caused by damage to the sensory organ and is permanent). They reported the majority as having tinnitus of moderate or greater severity, which is consistent with people in general who seek help for tinnitus. The researchers looked at age, hearing loss, score on the Tinnitus Functional Index, and score on the Tinnitus Handicap Inventory as predictive factors. Data indicated that adoption of hearing aids versus use of smartphone
apps was split evenly among the overall patient population. However, the authors found that greater age was more closely associated with choice of hearing aids for tinnitus masking. The authors proposed that this may be due to greater severity of hearing loss with aging. They noted that none of the patients under the age of 40 chose to use hearing aids for tinnitus masking. More remarkable was that increased severity of tinnitus was negatively associated with hearing aid use. In other words, more severe tinnitus generally resulted in people being less likely to choose a hearing aid for a tinnitus masker. No reason for this trend was proposed. The key points from this study are that mild hearing loss is present in a significant portion of patients with tinnitus and should be assessed for all patients seeking treatment for tinnitus. In addition, audiologists discussing options for sound therapy may find that smartphone apps are preferred by younger patients. This may be particularly true if the person does not perceive hearing loss. 1 Kimball, S. H., Johnson, C. E., Baldwin, J., Barton, K., Mathews, C., & Danhauer, J. L. (2018). Hearing aids as a treatment for tinnitus patients with slight to mild sensorineural hearing loss. Seminars in Hearing, 39, 123–134. TINNITUS TODAY SPRING 2019
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If You Have Tinnitus but Hear Well, Do You Need a Hearing Test? By Robert Sweetow, PhD
Many people with tinnitus question the necessity of a hearing test if their hearing seems normal. Here are four reasons why it is still important to receive an audiologic evaluation, even in the apparent absence of hearing loss.
1
To determine the appropriate treatment, professionals need to know whether the origin of an individual’s tinnitus is related to damage to the auditory system (it usually is) or to another health-related matter. Hearing loss is an insidious symptom. A person may have damage to literally thousands of hair cells (humans have about 20,000 in each ear) before he or she would even perceive any hearing loss. This is particularly relevant when the hearing
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loss is limited to the high frequencies, as is frequently the case. This damage to the cochlea is sufficient to cause tinnitus without simultaneously creating a perceived loss in hearing.
2
Tinnitus often precedes perceptible hearing loss, so it is important to establish baseline data for future comparison.
3
Many treatment procedures utilize sound-producing devices designed to distract, relax, partially mask, and/or facilitate habituation. These devices include, but are not limited to, noise or tonal generators and hearing aids. Most of these require tinnitus matching procedures (in addition to a basic audiogram) to determine the best parameters in which to program the instruments.
4
An appointment with an audiologist can provide helpful suggestions regarding how to best manage and cope with tinnitus. Why go? The audiogram (as part of an audiological evaluation) doesn’t simply determine the presence, absence, or degree of hearing loss. It also provides critical information used in ascertaining the overall condition of your auditory system as well as establishing parameters for tinnitus management procedures. Robert Sweetow, PhD, is a professor emeritus and former director of audiology at the University of California, San Francisco. He earned his undergraduate degree in communicative disorders from the University of Iowa, a master’s from the University of Southern California, and a PhD in audiology from Northwestern University. He is the co-developer of the LACE (Listening and Communication Enhancement) auditory training program. His research interests include amplification, counseling, rehabilitation, neuroscience, and tinnitus. Dr. Sweetow has written 25 textbook chapters and over 130 scientific articles and has been invited to speak at more than 300 scientific meetings worldwide. He is Editor-atLarge of Tinnitus Today magazine, a reviewer for several journals, author of Counseling for Hearing Aid Fittings, and a former member of the board of directors of the American Academy of Audiology (AAA). In 2008, Dr. Sweetow was awarded the Distinguished Achievement Award by the AAA. www.ATA.org
PERSONAL STORY
Sitting for an Audiogram as Tinnitus Roared By Joy Onozuka
As I sat in a sound booth undergoing audiometric tests, my stress levels soared because all I could hear clearly was my tinnitus. Maybe there was a beep, maybe there wasn’t. As I strained to listen, I felt a drop of sweat roll down my neck. I was annoyed because I had never considered that tinnitus was interfering with my hearing. In a soundproof environment, my tinnitus was disturbingly loud. I was relieved with the next segment of testing, responding to questions about words in conversations that played through the headphones. Actual words, instead of pure-tone pitch testing, provided a clear contrast to the sound of my tinnitus. Surely, I got this part right. I gazed at my audiologist through the window of the booth as she plotted the results, and I wondered if I could ask for a retake. Would that sound silly? In that moment, I understood why people blame other people or the surrounding environment for their hearing problems: If only my tinnitus weren’t so loud; if only the pitch had been louder or longer; if only I were being tested in a normal sound environment; if only I didn’t have hearing loss… For the first time since grade school, I was having an audiogram, www.ATA.org
partly because I knew I should because of my tinnitus—remember, more than 80 percent of people with tinnitus have some measure of hearing loss—but mainly because I was irritating my oldest son by asking him to repeat himself. I had no trouble hearing him when we were faceto-face, but I missed words when he spoke to me from behind while I was walking, cooking, or driving. His annoyance prompted me to make the appointment because I didn’t want to be “that person” living with hearing loss who waits an average of seven years before seeking help. What
else was I missing that I wasn’t even aware of? As Dr. Ana Anzola explained my results, I was relieved to see most of the marks on the audiogram fell within the normal range. Did it matter that I was missing things at frequencies above 4,000 hertz? “Yes,” said Dr. Anzola, in a cheerful tone. “You’re missing words and parts of conversations, especially in a noisy environment.” But doesn’t everyone have that problem? I thought to myself, hoping she wouldn’t suggest hearing aids. TINNITUS TODAY SPRING 2019
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PERSONAL STORY
She continued explaining that highfrequency hearing loss is typically the result of damaged hair cells in the lower part of the cochlea. “But if I hear well in most cases, what does it matter?” I asked. It matters, she said, because it makes it difficult to discriminate between many sounds, including k, d, t, f, th, s, and to understand speakers with higher-pitched voices, such as children and women. My misplaced confidence in correctly identifying words in the speech section of my hearing test typifies the predicament of hearing loss: You don’t get what you don’t get. I struggled to keep an open mind as Dr. Anzola began talking about how hearing aids would help with my hearing loss and possibly my tinnitus. Prior to making the appointment, I had done my homework, knowing that I’d be uncomfortable if talk turned to hearing aids. I had confirmed that Dr. Anzola dispenses hearing aids from the top hearing aid manufacturers – not just one or two, as is the case with some clinics – because I wanted to know that every
option was indeed an option. But, to be honest, not knowing the specifics of how hearing aids differ between companies and how my particular hearing needs would be best met, I had to trust her recommendations. In this sense, it’s important to ask your doctor and friends for recommendations on audiologists. And since an audiologist is someone you’re going to work with over time, like you would with an ophthalmologist or a dermatologist, you should select someone with good bedside manners. Do they listen to you? Do they explain your options? Do they provide meaningful advice for managing your tinnitus and/or hyperacusis? On a more practical level, do they unbundle services, meaning can you can pay for specific services as opposed to paying for a hearing aid package, which includes hearing aids and follow-up visits. For instance, if you have hearing aids, you can see the audiologist to have them reprogrammed. If you don’t have hearing loss, can you get baseline hearing aids to be used only as
maskers, which can play a variety of sounds to decrease the perception of tinnitus. Maskers are much less expensive than hearing aids. “Hearing aids aren’t a sexy purchase. If you aren’t ready to wear them, then it’s better to wait until you are.” That was a sales pitch I could live with. So, did I get hearing aids? Not at that moment; I wanted to think about it. Several weeks later, sitting at my own desk – glancing at my audiogram – I decided I had to at least try hearing aids. I know hearing aids don’t help everyone with their tinnitus, but I also know that hearing loss is something that silently creeps up on you, gradually depriving your mind of a spectrum of sound. Research says that’s a bad thing, because it can affect your cognition, balance, and your communication skills. Does it matter if hearing loss is only high frequency? Yes. I know this because I haven’t had to ask my son to repeat himself since I started wearing my hearing aids. That’s the sound check that mattered to me.
© ASHA - American Speech-Langage-Hearing Association
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HEALTHCARE PROVIDERS
Spotlight on Patient Providers GOLD LEVEL
Professional Members Listing current as of March 8, 2019
When making an appointment, please mention that you learned of the provider from the ATA, thereby ensuring that providers understand the importance of being a part of the ATA’s tinnitus patient-provider network. Melissa Alexander, AuD Alexander Audiology, Inc. Santa Monica, CA Eugene Antonell, BC-HIS Hear Better Now, LLC N. Dartmouth, MA Theodore Benke, MD Benke Ear Nose & Throat Clinic Cleburne, TX Judith Bergeron, BC-HIS, CDP Beauport Hearing Care Gloucester, MA Granville Brady, Jr., AuD Dr. Granville Brady, Jr. East Brunswick, NJ Diana Callesano, AuD Hearing and Tinnitus Center Woodbury, NY Collin Campbell, LAc Campbell Acupuncture & Herbal Medicine Clinic New York, NY Phoebe Clouser, AuD Hearing Partners of South Florida Delray Beach, FL Lois N. Cohen, LCSW, ACSW, BCD Tinnitus Counseling Northport, NY Shahrzad Cohen, AuD Auditory Processing Centers: Hearing Solutions Sherman Oaks, CA Lindsay Collins, AuD Sound Relief Hearing Center Centennial, CO Jean Couchman, MA Hearing Solutions, PLLC Midlothian, VA Theresa Cullen, AuD Cape Cod Hearing Center Hyannis, MA Ali Danesh, PhD Labyrinth Audiology Florida Atlantic University Boca Raton, FL Nikki DeGeorge, AuD Fayette Hearing Clinic Newnan, GA www.ATA.org
Kristen DesErmia, AuD Ascent Audiology & Hearing Bradenton, FL
Mario Hearing & Tinnitus Clinics 1208 VFW Parkway, #103 West Roxbury-Boston, MA
Patrick DeWarle, AuD Winnipeg Hearing Centres Winnipeg, MB, CANADA
Stephanie McGuire, AuD McGuire Hearing & Tinnitus Center Dayton, OH
Stelios Dokianakis, AuD Holland Doctors of Audiology Holland, MI
Jill Meltzer, AuD North Shore Audio-Vestibular Lab Highland Park, IL
Sara Downs, AuD Hearing Wellness Center Duluth, MN
Leah Mitchell, AuD Sound Relief Hearing Center Westminster, CO
Kaela Fasman, AuD Sound Relief Hearing Center Golden, CO
Christine Peacock, AuD Naples Audiology & Hearing Center Naples, FL
Lisa Fox-Thomas, PhD UNCG Speech & Hearing Center Greensboro, NC
Jeanne Perkins, AuD Audiologic Services Glen Ellyn, IL
Noreen Gibbens, AuD Middle Tennessee Audiology Hendersonville, TN
Julie Prutsman, AuD Sound Relief Hearing Center Highlands Ranch, CO
MaryRose Hecksel, AuD Audiology & Hearing Aid Center Lansing, MI
Richard Reikowski, AuD Family Hearing and Balance Center Akron, OH
Veronica Heide, AuD Audible Difference, LLC Madison, WI
Jennifer Reynolds, AuD Reynolds Audiology & Tinnitus Center Woodbury, MN
James Henry, PhD VA Portland Health Care System Portland, OR
Ann Rhoten, AuD Kentucky Audiology & Tinnitus Services Lexington, KY
Bruce Hubbard, PhD CBT for Tinnitus, LLC New York, NY
Sharon Rophie, AuD Harbor Hearing, P.A. Palm Harbor, FL
Jeannie Karlovitz, AuD Advanced Hearing Solutions Exton, PA
Christine Russell, AuD Sound Relief Hearing Center Fort Collins, CO
Deborah Lain, MSc Hope for Tinnitus Calgary, AB, CANADA
Mimi Salamat, AuD Dr. Mimi’s Audiology Clinic Walnut Creek, CA
Kate Landowski, AuD Sound Relief Hearing Center Denver, CO
Allison Sayer, AuD Sound Relief Hearing Center Scottsdale, AZ
Malvina Levy, AuD Hearing and Speech Center San Francisco, CA
Susan Schmidt, AuD Arizona Balance & Hearing Aids, LLC Phoenix, AZ
Larena Lewchuk, MCISc Audiology Clinic of Northern Alberta Edmonton, AB, CANADA
Cindy Ann Simon, AuD South Miami Audiology Consultants South Miami, FL
Ha-Sheng Li-Korotky, AuD, PhD Pacific Northwest Audiology Bend, OR
Jacqueline Smith, AuD Sound Relief Hearing Center Highlands Ranch, CO
Terence Limb, AuD Evergreen Speech & Hearing Clinic Kirkland, WA
Susan Smittkamp, AuD, PhD Associated Audiologists Shawnee Mission, KS
Robert Mario, BC-HIS, PhD Mario Hearing & Tinnitus Clinics Canton, MA
Randall Solomon, MD Island Psychiatry Port Jefferson Station, NY TINNITUS TODAY SPRING 2019
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HEALTHCARE PROVIDERS
William Stubbeman, MD TMS Psychiatry Los Angeles, CA
Nashlea Brogan, AuD Bluewater Hearing Sarnia, ON, CANADA
Kristen Furseth, AuD Willamette ENT Salem, OR
Christopher Sumer, NBC-HIS Coastal Hearing Aid Center Encinitas, CA
Mindy Brudereck, AuD Berks Hearing Professionals Reading, PA
Amy Greer, AuD ENT Associates of Johnstown Johnstown, PA
Gail Whitelaw, PhD OSU Speech-Language-Hearing Clinic Columbus, OH
Lisa Caldwell, MA The Hearing Coach Glossop, UK, ENGLAND
Kathleen Hadsell, AuD North Shore Audio-Vestibular Lab Highland Park, IL
Thea Wickey, AuD Sound Relief Hearing Center Scottsdale, AZ
Anne Carter, MA, PhD Pasadena Hearing Care St. Petersburg, FL
Sean Hagberg PhD Cranston, RI
Benjamin Whightman, AuD Sound Advice Audiology Livonia, MI
Troy Cascia, AuD University of California, San Francisco Audiology San Francisco, CA
Melissa Wikoff, AuD Peachtree Hearing Marietta, GA
Linda Centore, PhD, NP University of California School of Dentistry San Francisco, CA
Carolyn Yates, AuD Hearing Evaluation Services of Buffalo, Inc. Amherst, NY
Maura Chippendale, AuD Chippendale Audiology Cape Coral, FL
SILVER LEVEL
Professional Members Listing current as of March 8, 2019
When making an appointment, please mention that you learned of the provider from the ATA, thereby ensuring that providers understand the importance of being a part of the ATA’s tinnitus patient-provider network.
Patrick Coughlin, AuD Hearing Care Professionals Aberdeen, SD Terry Cummings, AuD Columbine Audiology and Hearing Aid Center Sterling, CO Ann DePaolo, AuD The Audiology Offices, LLC Kilmarnock, VA
Catherine Ahrens-Berke, BC-HIS Ahrens Hearing Center Fair Lawn, NJ
Ericka DeVore, AuD All About Hearing Longwood, FL
Jason Aird, AuD Iowa Audiology Coralville, IA
Susana Dominguez, AuD Hospital Italiano de Bs, AS, Argentina Capital Federal, BA, ARGENTINA
Nicole Ball, AuD Hearing Evaluation Services of Buffalo, Inc. Tonawanda, NY
Phillip Elbaum, LCSW Stritch School of Medicine, Loyola University, Chicago Deerfield, IL
Saranne Barker, AuD Raleigh Hearing and Tinnitus Center Raleigh, NC Randall Bartlett, MA Tinnitus & Audiology Center of Southern CA Los Angeles, CA Carol Bass, AuD All Ears Audiology Ithaca, NY Samantha Bayless, AuD The Hill Hear Better Clinic Cincinnati, OH Linda Beach Voorhees, NJ Alyssa Beaton, AuD Hearing Evaluation Services of Buffalo, Inc. Orchard Park, NY Lisa Blackman A Hearing Healthcare Center Philadelphia, PA
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Kimberly Eskritt, AuD Lambton Audiology Associates Sarnia, ON, CANADA Julie Farrar-Hersch, PhD Augusta Audiology Associates Fisherville, VA Brittany Fauble, AuD The American Institute of Balance Largo, FL Leon Flores, MD Monterey, MEXICO Michael Flores, AuD University of New Mexico Speech and Hearing Sciences Albuquerque, NM Anna Forsline, AuD National Center for Rehabilitative Auditory Research Portland, OR
Peter Harakas, PhD Cognitive Behavioral Therapy Associates, LLC Lexington, MA Jamie Hawkins, AuD Clarity Hearing Conroe, TX Dana Heath, MS Advanced Hearing LLC Alpharetta, GA Hannah Heet, AuD Duke Otolaryngology of Raleigh Raleigh, NC Sherry Hodge, AuD Advanced Hearing Care Anderson, IN Alan Hopkirk Invisible Hearing Clinic Glasgow, UK Wan Syafira Ishak, PhD Universiti Kebangsaan Malaysia Kuala Lumpur, KL, MALAYSIA Keun Kang Happy Sound Corporation Bayside, NY Edward Keels, MA Hear Now Hearing Aid Center Philadelphia, PA Kristen Keener, AuD IlluminEar Audiology Austin, TX Suzanne Kimball, AuD Univ. of Oklahoma Sciences Center Oklahoma City, OK Vanessa Lee, MA Auglaize Audiology Wapakoneta, OH Jason Leyendecker, AuD Tinnitus and Hyperacusis Clinic of Minnesota Edina, MN Brandon Lichtman, AuD Wheeling Hospital Wheeling, WV Virginia Lindahl, PhD Psychologist Alexandria, VA Robyn Lofton, BC-HIS Hearing Associates of Las Vegas Las Vegas, NV
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HEALTHCARE PROVIDERS
Dan R. Malcore Hyperacusis Network Green Bay, WI
Ashley Penrod, PA-C Alta View Specialty Clinic Sandy, UT
Christina Seaborg, AuD Hearing and Balance Center Charlotte, NC
Nancy McKenna, AuD, PhD Univ. of North Carolina Chapel Hill Chapel Hill, NC
Ann Perreau, PhD Augustana College Rock Island, IL
Alyssa Seeman, AuD Illinois State University Normal, IL
Abigail McMahon, AuD Sound Relief Hearing Center Fort Collins, CO
Jay Piccirillo, MD, FACS Washington University School of Medicine Saint Louis, MO
Brooke Means, AuD North Georgia Audiology Gainesville, GA
Bruce Piner, AuD Hearing and Balance Center Encino, CA
Brian Melzian, PhD US Environmental Protection Agency Jamestown, RI
Andrea Plotkowski, AuD ENT Consultants of East Tennessee Knoxville, TN
Mary Miller, PhD Premier Hearing and Balance Hammond, LA
Susan Rawls, AuD Cary Audiology Associates Cary, NC
Deanna Nickerson, AuD CarolinaEast ENT New Bern, NC
Jennifer Reekers, AuD Heartland Hearing Center Cedar Rapids, IA
Marni Novick, AuD Silicon Valley Hearing Clinic, Inc. Los Gatos, CA
Deanna Ross, AuD Albany ENT & Allergy Services, PC Albany, NY
James Orban, BC-HIS Miracle-Ear Hearing Aid Center Columbia, MD
Kelly Rostorfer, AuD Luebbe Hearing Services Columbus, OH
Melissa Palmer, AuD High Point Audiological Clayton, NC
Sandra Royle-Tabak, AuD Carolina East Ear, Nose, & Throat Morehead City, NC
Brian Worden, MD Kaiser Permanente Woodland Hills, CA
Tracy Peck, AuD Hearing and Speech Center San Francisco, CA
Mandy Rutta, AuD Gundersen Health System La Crosse, WI
Angela Zuendt, AuD Greenville Health System Greenville, SC
Paul Shea, MD Shea Ear Clinic Memphis, TN Susan Sheehy, AuD Alabama Hearing Associates Madison, AL LaGuinn Sherlock, AuD Walter Reed National Military Medical Center Bethesda, MD Martin Smith, PsyD Associates in Managed Care Denver, CO Rivka Strom, AuD Advanced Hearing NY, Inc. Brooklyn, NY Jennifer Sutton, AuD Hearing Evaluation Services of Buffalo, Inc. Williamsville, NY Robert Traynor, EdD, MBA Audiology Associates of Greeley, Inc Greeley, CO Peter Van Ostaeyen Antwerp, BELGIUM
Keep doing what you're doing in producing these magazines. The magazines give us hope! — J. Wolf
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TINNITUS TODAY SPRING 2019
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SCIENCE & RESEARCH NEWS
Research Paves the Way to Advances in Treatments A Researcher’s Perspective on Why Transcranial Magnetic Stimulation Is Not Yet Recommended as a Treatment for Tinnitus
By Robert L. Folmer, PhD
At the time the American Academy of Otolaryngology—Head and Neck Surgery Foundation’s Clinical Practice Guideline: Tinnitus was published in 2014, some promising studies of repetitive transcranial magnetic stimulation (rTMS) for tinnitus had been conducted, and some less promising ones had also been published. Results of our clinical trial were published in 2015, and we reported more positive results than many previous studies.1 One reason for this might be the higher rTMS stimulation intensities we used for our study. Unfortunately, we have not been able to secure funding for any follow-up studies, either single-site or multisite clinical trials. Perhaps the negative recommendations/guidelines published about rTMS treatment for tinnitus discouraged grant reviewers and funding agencies from funding future studies of the method. This is speculation. However, I am puzzled about why our promising clinical trial has not generated more enthusiasm among funding agencies. rTMS is an FDA-approved treatment for chronic depression that does not
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respond to other treatments, such as medications. Of course, rTMS treatment for depression is provided by psychiatrists. Otolaryngologists do not use rTMS, and most are not familiar with the technology. That might be another reason why the American Academy of Otolaryngology is not eager to endorse rTMS treatment for tinnitus – it is not an option available to most ENT physicians. After our clinical trial results were published in 2015, I was contacted by hundreds of patients from across the United States and around the world who were interested in rTMS treatment for tinnitus. Quite a few psychiatrists who use rTMS for depression also contacted me wanting to know how to use rTMS to treat tinnitus. I informed the psychiatrists about the protocols we used, but I also told them that additional research was needed to develop the most effective treatment methods for tinnitus. Among the problems with rTMS for tinnitus now:
1
rTMS is not ready to be implemented clinically as a treatment for tinnitus because additional research is needed to
develop and evaluate the most effective treatment protocols.
2
Some psychiatrists have tried to use rTMS to treat tinnitus patients. The problems with this are: • Most psychiatrists know little or nothing about tinnitus, including other treatment options, such as hearing aids and other types of sound therapy. • rTMS treatment for depression uses a different protocol, including a different scalp target location for stimulation and different stimulation frequencies, than what we used for tinnitus. If patients experience major depression plus tinnitus, rTMS treatment for depression might help them overall. Studies by our group and others have shown that improvements in depression are associated with reductions in tinnitus severity.2 Some patients who receive rTMS also report improvements in their sleep patterns, and improvements in sleep have been associated with reductions in tinnitus severity.2 If patients receive rTMS, they should wear earplugs during stimulation sessions.3 In an article published in 2017, I describe some of the factors that need
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SCIENCE & RESEARCH NEWS
to be assessed and addressed before rTMS should be implemented clinically as a treatment for tinnitus.4 Only by conducting larger-scale clinical trials will we begin to know which tinnitus patients are most likely to benefit from rTMS treatment.
Tinnitus Practice Guidelines on rTMS In 2014, the American Academy of Otolaryngology—Head and Neck Surgery Foundation published Clinical Practice Guideline: Tinnitus,* which includes the following assessment of repetitive transcranial magnetic stimulation (rTMS): STATEMENT 13. TRANSCRANIAL MAGNETIC STIMULATION: Clinicians should not recommend TMS for the treatment of patients with persistent, bothersome tinnitus. Recommendation (against) based on inconclusive RCTs (Randomized Controlled Trials).
Robert L. Folmer, PhD, served as Chief of Clinical Services for the Oregon Health & Science University (OHSU) Tinnitus Clinic from 1998-2007. In 2007, he joined the VA National Center for Rehabilitative Auditory Research (NCRAR) in Portland as a Research Investigator. Dr. Folmer’s research interests include transcranial magnetic stimulation (TMS) and other treatments for tinnitus; electrophysiological assessments of auditory and cognitive functions in patients who have multiple sclerosis (MS), Parkinson Disease, traumatic brain injury (TBI), or other neurological disorders. 1 Folmer, R. L., Theodoroff, S. M., Casiana, L., Shi, Y., Griest, S., & Vachhani, J. (2015). Repetitive transcranial magnetic stimulation treatment for chronic tinnitus: A randomized clinical trial. JAMA Otolaryngology – Head & Neck Surgery, 141(8), 716–722. Retrieved from http://archotol. jamanetwork.com/article.aspx?articleid=2388777 2 Folmer, R. L. (2002). Long-term reductions in tinnitus severity. BMC Ear, Nose and Throat Disorders, 2(3). Retrieved from https://bmcearnosethroatdisord. biomedcentral.com/track/pdf/10.1186/1472-6815-2-3 3 Folmer, R. L., & Theodoroff, S. M. (2017). Hearing protective devices should be used by recipients of repetitive transcranial magnetic stimulation. Journal of Clinical Neurophysiology, 34(6), 552. Retrieved from https://journals.lww.com/clinicalneurophys/ fulltext/2017/11000/Hearing_Protective_Devices_ Should_Be_Used_by.14.aspx 4 Folmer, R. L. (2017). Factors that contribute to the efficacy of repetitive transcranial magnetic stimulation (rTMS) for tinnitus treatment. Brain Stimulation, 10(6), 1121–1122.
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The following are select paragraphs from the clinical guideline’s supporting text: The purpose of this statement is to avoid the routine use of transcranial magnetic stimulation (TMS) for treatment of tinnitus. Although some studies have shown improvements in tinnitus severity and longer durations of tinnitus suppression after repetitive TMS (rTMS), methodological issues with these studies included small sample size, inadequate placebo conditions, variations in patient entry criteria, and differences in outcome measures. Randomized controlled trials (RCTs) and systematic reviews of available evidence have not demonstrated lasting reduction of tinnitus or improvements in patient QOL (quality of life) with rTMS. Piccirillo et al. performed two trials of rTMS and found no differences in improvement in tinnitus severity between active rTMS and sham stimulation over 2 weeks or 4 weeks, as measured by changes in the Tinnitus Handicap Inventory (THI). Anders et al. conducted an RCT with 42 tinnitus patients and found a very small improvement in tinnitus severity as measured by the THI or the Tinnitus Questionnaire after active rTMS as compared to a placebo condition, but no improvement was seen when tinnitus severity or perceived disruption of daily activities was assessed with visual analogue scales. Plewnia et al. performed an RCT of a type of rTMS called theta burst stimulation in 48 patients with chronic tinnitus, randomized to temporal cortex stimulation, temporoparietal cortex stimulation, and sham stimulation over the mastoid. Although tinnitus severity was slightly reduced in all three groups, there were no significant differences between the sham group and the temporal or temporoparietal stimulation groups. * Clinical Practice Guideline: Tinnitus can be accessed online at www.ATA.org or at https://journals.sagepub.com/doi/ pdf/10.1177/0194599814545325
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PERSONAL STORY
When Treatment for Depression Triggers Tinnitus By J. Nagel*
After suffering from both depression and anxiety for most of my life, and after trying numerous medications and seeing many different therapists in search of help with these conditions, I got up the courage to try transcranial magnetic stimulation (TMS). I had learned of it from a close family member who, like me, found little relief from medications but enjoyed excellent results from TMS. TMS is a machine treatment that utilizes a large magnetic device to target specific areas of a patient’s brain in treatment sessions that are done five times a week for four to six weeks. In theory, TMS treats depression and anxiety by “rewiring” the parts of the brain associated with these conditions. For some people with depression and tinnitus, TMS also seems to provide some relief from tinnitus. Unfortunately, that was not the case for me. To the contrary, the tinnitus that I have been coping with for more than a year actually was the product of my TMS sessions because I wasn’t given hearing protection to wear during the sessions! Committed as I was (and still am) to exploring different treatment modalities for improving my mental health, I first considered 30
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electroconvulsive therapy (ECT), a more invasive, albeit more readily available, treatment for anxiety and depression. But when I found out that a clinic was opening that would offer TMS in the West Coast city where I lived, I concentrated my efforts there, arranging an interview and assessment to discuss treatment and payment options. Because TMS is a relatively new and experimental treatment, it is not always covered by insurance. After several phone conversations, my insurance company agreed to cover the treatments, although my contribution was still substantial, including a $1,000 deposit to cover the copayments of $30 per treatment. Thinking the financial details had been settled, I began the treatments—only to find out that, once the clinic began billing my insurance, the claims were denied. It took nearly a year for the account to be paid. Beyond the anxiety aggravated by the payment issue itself, I struggled with the treatments. Hearing the thumping noise on a daily basis caused me pain and occasional nausea. Apparently, this was not a normal reaction. However, I always have been particularly sensitive to loud noises, so I continued. The technician eventually had to reduce the voltage of the treatment because of my
discomfort, before gradually increasing it again to the suggested daily dosage. Later on, I was offered headphones and the option to listen to music, but by then I had established a routine of taking my mind off the noise and pain by talking with the technician during the sessions. I was never given any written information about wearing hearing protection, nor did anyone suggest that not wearing protection could be harmful. About halfway through the course of 35 sessions, I remarked that I had a strange new ringing sound in my ears. The technician told me the noise would probably go away when the sessions ended, but it didn’t. And it still hasn’t. Indeed, it’s gotten worse. At first, the depression lifted a bit, but never the anxiety. And the tinnitus has continued to worsen, especially when I’m in a quiet room or trying to sleep. This, itself, has worsened my depression. I never had experienced “ringing in my ears,” as they say. As days, weeks, and months passed, I wondered whether I was going crazy. I was plagued with dark thoughts of giving up and surrendering to the situation. My depression and anxiety worsened. I desperately researched the matter and talked to others who suffered from tinnitus and found many had resigned themselves to the conclusion that there is no cure for the condition. www.ATA.org
PERSONAL STORY
What Is Transcranial Magnetic Stimulation? Transcranial magnetic stimulation (TMS) is a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain. The FDA approved TMS as a treatment for major depression in 2008, for treating pain associated with certain migraine headaches in 2013, and for obsessive-compulsive disorder (OCD) in 2018. Although TMS has not been approved for treatment of tinnitus, some people with tinnitus who have had TMS treatment for intractable depression and/or migraines have found that it also provides relief for tinnitus. Research into its usage for tinnitus treatment is ongoing. To learn more about such research, see www. clinicaltrials.gov • TMS is sometimes called rTMS because the treatment uses repetitive magnetic pulses delivered via an electromagnetic coil placed against your scalp. • There are different ways to perform TMS. In general, treatments are scheduled five days a week for four to six weeks, and last between 40 and 60 minutes for each session.
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• The neuroscience behind why TMS can alleviate depression, certain types of migraines, and OCD in some people is not clearly understood. As research continues into its usage, techniques are expected to change as scientists discover what works most effectively for each modality, particularly in regard to the targeted areas of the brain. • TMS is considered safe for most people. Side effects can include
headaches, lightheadedness, and discomfort at the points of stimulation. If you are interested in TMS, you should consult with your physician/psychiatrist to determine whether you’re a good candidate for the treatment. • Hearing protection is required during treatment because hearing loss and tinnitus can occur as a side effect of the noise. Earplugs should be provided prior to treatment.
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Having already endured a 30-plusyear struggle with fibromyalgia after a bad car accident and numerous back surgeries that followed, I seemed to be facing yet another incurable medical problem. My outlook seemed bleak. After a brief respite in the Florida sun for the winter, I resumed my quest for answers—for some kind of solution. I visited the audiologist I had seen before I left for the winter and was fitted with hearing aids (costing $5,000). They were highly recommended and were supposed to relieve tinnitus by masking it with white noise. That didn’t work for me, so I returned the set after a 30day trial, only to be shamed by the audiologist for not trying hard enough to make them work. Next, I heard about a technician who offered in-home audiology service. This individual provided me with a different brand of masking hearing aid, which I thought might be right for me. But, after numerous readjustment sessions, I had to return this pair as well. I felt increasingly hopeless. Even worse, in the course of these audiology tests, I learned that I had highfrequency hearing loss. This surprised me, because I still could hear what every couple seated around me was discussing in a noisy restaurant.
Since returning the hearing aids, I have tried meditation, headphones with calming tapes, white noise machines, and everything else I have read about in tinnitus-related literature. At this point, I have accepted that my best hope is to habituate. To this end, Tinnitus Today has been very helpful. I’ve learned of the struggles of others as well as their coping mechanisms. Knowing there are people out there bearing the same weight offers me guidance and hope. So, too, has it been helpful for me to participate in a new pilot program for tinnitus sufferers, offered at a local hospital and following a model developed by the Department of Veterans Affairs. After an extensive interview process and many delays, I was accepted into the program. With two other individuals, I recently completed a five-week course, acquiring both practical knowledge and coping skills from the stories of other affected individuals. Classes have focused on cognitive behavioral skills, while also encouraging use of a variety of headphone devices, meditation, calming sounds, and more. These techniques have been helpful, and I am committed to continuing with them and avoiding setbacks. Because I struggle daily with tinnitus, I look at every social situation
differently. I evaluate every coffee shop, grocery store, restaurant, airplane ride, car ride, and social gathering with a new set of eyes (or ears), and I never go anywhere without my earplugs. Sometimes I have to step outside and away from loud social gatherings because of my tinnitus and my hyperacusis. With the constant support of my husband and family, who do their best to understand my challenges, I now see how my depression, anxiety, hopelessness, and tinnitus are intertwined. I didn’t arrive at this condition by conventional means, in the way readers of this article might have found themselves dealing with tinnitus, but I’ve suffered just the same. I hope my story can help us continue to learn more about this condition, including its causes, its correlations, and its complicated relationship with other conditions. *Having struggled with anxiety and depression for most of my life, telling my TMS story was a big leap for me and one that I hope is helpful for others. I wrote my story anonymously because progress in the public’s understanding of and empathy toward people with mental-health challenges remains limited and inconsistent, in my view. Right now, my progress requires that I keep my story a private one, to a certain extent, so I don’t feel the burden of explaining my struggles to others. Managing depression is challenging, as is living with tinnitus!
Share Your Story What’s your story? The American Tinnitus Association invites readers to submit stories about living with tinnitus for possible publication in the magazine. Complete or partial stories, with a word length of 300 to 800 words, should be sent by email to editor@ata.org, or by mail to The ATA, 8300 Boone Blvd, Ste. 500, Vienna, VA 22182. Please include email and telephone contact information so Tinnitus Today staff can work with you on story development. The ATA reserves the right to edit for clarity, brevity, and grammar. 32
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SCIENCE & RESEARCH NEWS
Improving Reliability of Tinnitus Pitch and Loudness Matching: The Tinnitus Likeness Rating (TLR) Method Summary by John A. Coverstone, AuD
Historically, matching the pitch and loudness of a person’s tinnitus was considered by many to be an essential part of diagnostic examination. The goal was to identify the sound people were hearing, even though clinicians did not generally choose treatment options based on tinnitus pitch or loudness. In more recent years, many clinicians have stopped performing this procedure because tinnitus pitch was found to vary significantly from one measurement to the next. Sometimes pitch and loudness would be measured to reinforce to patients that tinnitus was real, but it has increasingly become a measurement viewed as having little practical application. Some devices and therapies currently used for tinnitus treatment rely on tinnitus pitch, however. Strategies such as notch therapy, spectrally altered music, and frequency discrimination training all depend on the patient’s tinnitus pitch. Therefore, the clinical need to consistently match a person’s tinnitus is growing. Tinnitus pitch is most often measured by forced choice. With this method, a subject must choose between options. When matching www.ATA.org
tinnitus pitch, for instance, the audiologist presents two sounds at different pitches. The patient chooses which sound is closest to the pitch of his or her tinnitus. A researcher at the University of Montreal, School of Speech Pathology and Audiology, has recently studied a method called the tinnitus likeness rating (TLR).1 In this study she compared the ability of TLR to consistently match tinnitus pitch and loudness with the traditional technique of forced choice. With TLR, subjects are presented with pure tones from 250 Hz to 16 kHz, with step sizes similar to those used for hearing testing. The subject rates each tone on a scale of 0 (not at all like my tinnitus) to 10 (exactly like my tinnitus) and uses a dial to set the loudness of the tone to be equal to that of their tinnitus. All tones are presented three times, and likeness ratings and intensity (loudness) levels are calculated for all presentations of each tone. Thirty-one participants were recruited for this study. The author randomized the order of TLR versus forced choice presentation as well as the clinician assigned to each subject during visit 1 and visit 2, four weeks later. For data analysis of TLR, the three frequencies (pitches) with the highest ratings were selected and compared with the
subject’s choice of pitch and loudness when using the forced-choice method. Statistical analysis was performed to determine concordance of each type of measurement. Concordance is a measure of reproducibility. In the case of the forced-choice paradigm, the author measured reproducibility of pitch selection regardless of ear and reproducibility of pitch selection for the same ear. Loudness level of tinnitus was considered only if the subject’s pitch selection from visit 1 was reproducible in visit 2. For TLR measurements, reproducibility of pitch was calculated when matching any of the three highest rated pitch selections, when matching two of the three selected pitches, and when matching all three of the selected pitches from visit 1 and visit 2. Calculations for loudness were made for instances when loudness selections were within 10 dB of each other and when they were within 5 dB of each other. When allowing the most inclusive criteria (any pitch matches between visits), 26 of the 31 subjects matched their tinnitus using TLR. Nineteen of those subjects also matched loudness with a consistency of 10 dB, and 12 matched within 5 dB. When requiring that two of three pitches match, 15 of TINNITUS TODAY SPRING 2019
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the 31 subjects matched their tinnitus using TLR (9 and 7 matched loudness within 10 dB and 5 dB, respectively). For the most stringent criteria of matching all three pitches rated highest, 4 subjects met this criterion (2 and 1 matched loudness within 10 dB and 5 dB, respectively). Using the more traditional forcedchoice method, 7 of the 31 subjects matched the pitch of their tinnitus between visit 1 and visit 2 when either ear was considered and 4 subjects matched the pitch in the same ear. Two subjects matched loudness within 10 dB, and 1
matched loudness within 5 dB, regardless of whether comparing either ear or the same ear only. This study shows promise for the tinnitus likeness rating to allow more-reproducible measurement of tinnitus in the clinic. At this time, specialized equipment is required to perform this method because of the automated presentation of tones, patient-entered likeness ratings, and patient-controlled volume of stimuli. For this study, the researchers needed to build a custom system to perform this task. This will be a limitation until this method is included
in standard audiology testing equipment or as a stand-alone device available for general purchase. At that time, audiologists may have a more reliable way to measure tinnitus pitch and loudness and possibly improve treatment outcomes when using methods that rely on these measurements. 1 Hébert, S. (2018). Individual reliability of the standard clinical method vs patient-centered tinnitus likeness rating for assessment of tinnitus pitch and loudness matching. JAMA Otolaryngology – Head & Neck Surgery, 144(12), 1136–1144. doi:10.1001/jamaoto.2018.2416
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SPECIAL FEATURE
The Importance of Talking About Tinnitus and Listening Considering the Impact of Tinnitus on the Person and the Partner
By Anne-Mette Mohr, Licensed Psychologist
Why Is It Worrisome When People Don’t Talk About Tinnitus? The onset of tinnitus can be a very stressful experience. A person might be afraid and overwhelmed by a sense of looming obstacles, such as living with the hearing loss that often accompanies tinnitus. Fears can be compounded by feelings of helplessness and being alone because others might not understand what it’s like to have tinnitus and hearing loss. As human beings, one of our most fundamental needs is to belong, to be a part of a relationship. The need to belong is embedded in our existence. We feel connected when those around us understand what we’re experiencing and how it affects www.ATA.org
us. Feeling understood means we are not alone in our experience. Being understood nurtures a sense of belonging that allows us to thrive. However, when a person with tinnitus is part of a couple and, yet, for whatever reason, is reluctant to talk about tinnitus and hearing loss with their partner, that sense of being understood and connected risks being lost. The result is a mutual lack of understanding that undermines their intimacy, their partnership, and threatens the feeling of “being a part of” the relationship. In this situation, not only the person with tinnitus but also the partner risks feeling alone. When a couple doesn’t talk about it, tinnitus and hearing loss result in stress for both people, and both can end up feeling very much alone. Aloneness goes against human nature and is worrisome because it negatively affects health and well-
being. It can give rise to feelings of helplessness, hopelessness, and grief (as a result of the feeling of lost connection in the relationship). What begins as a complex situation with tinnitus and possible hearing loss becomes an even more complicated situation imbued with feelings of isolation accompanied by stress and the possible emergence of anxiety or depression.
How to Help People Talk About Tinnitus In clinical practice, I find that clients with tinnitus are usually open to talking with their partner about the condition but assumptions about how their partner might react feed a reluctance to start the conversation. “How can I explain to my wife how I am doing without worrying her, without being viewed as troublesome, TINNITUS TODAY SPRING 2019
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SPECIAL FEATURE
“If therapy doesn’t address issues that might coexist with tinnitus, there’s the risk that bothersome tinnitus will continue to undermine the couple’s relationship, as well as the client’s ability to come to terms with tinnitus.”
demanding, or a victim, and so on? Will she reject me?”* If a client has tinnitus and hearing loss, common concerns are: “Will she be able to understand my limitations with hearing loss, such as remembering to get my attention before talking, or will she misunderstand, thinking: ‘Well, he hears what he wants to hear’?” Along with these concerns, clients often fear a loss of identity: “If I ‘reveal’ my ‘weakness,’ will I be looked at differently, or will something change, and where will that lead? Can I maintain a sense of dignity and my role within the family, since I might appear hopeless and weak?” Some of my clients talked with their partner about the condition but felt the partner didn’t really grasp the significance. Here, the clients’ assumptions proved to be a disappointing reality. 36
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Others with tinnitus decide not to discuss the condition with their partner because they feel they’re managing well on their own (even though they haven’t asked whether their partner agrees with that conclusion). Still other clients come to an understanding with their partner on how best to deal with tinnitus, such as spending time alone, getting more rest, or practicing other self-care strategies. Rather than working off assumptions of how the partner might cope, or ought to cope, I encourage each individual client to examine or consider how the condition affects his partnership and how he can ask for the support he needs from his partner so both can cope in a healthy manner. I ask all sorts of questions with the aim of casting as much light as possible on the entire situation. When we know what we are dealing with in a specific situation, it is much easier to decide what to do next. So, if clients are willing, I encourage them to express and
examine their assumptions about how their partner might react if they were to include that person in what they’re going through. Together, we challenge those assumptions to find out if they’re based in reality or are just assumptions. We try to clarify what clients need from their partner and whether those needs can realistically be met. We also explore what clients believe about their partner’s needs. Some clients are so consumed by their tinnitus that they forget about the needs of their partner. Some clients want to know what their partner thinks about the situation but, for some reason, can’t broach the topic. During sessions, we explore the best way for clients to express needs and what kind of support they want. Support can take many different forms. For some, support means their partner’s tacit acceptance of certain things, such as “needing a moment.” For others, support means being asked about how they’re doing. To others, support means the partner understands how the partner is doing managing tinnitus. Then there are those to whom support means being given the chance to talk without being offered advice. However, “just listening” can be hard on the partner. The act of “only” listening can make a partner feel helpless and overwhelmed because she or he must contain their own emotional pain and carry the emotional pain of the person with tinnitus. To be able to provide this type of support, partners may need their own support to cope with tinnitus in the relationship. www.ATA.org
SPECIAL FEATURE
Before a client can ask for support from a partner, it is important to consider what the partnership was like before the client developed tinnitus. Were they living parallel lives? If so, is it realistic to expect a partner’s support and engagement in the new situation involving tinnitus, or should the client seek support from a friend or a relative instead? Sometimes tinnitus is the last straw that pushes the person or the relationship to the brink of collapse. Up until the onset of tinnitus, the client might have led a very stressful life or experienced traumas, bereavement, or had an unhappy relationship with their partner. The client might also be struggling with comorbid conditions such as depression and anxiety. If it emerges that there are preexisting marital problems, then we talk about how to proceed. Sometimes the best solution is to refer the partner or the couple to a marriage therapist to work on their relationship, while I continue with the client to work through the tinnitus experience and other issues. If therapy doesn’t address issues that might co-exist with tinnitus, there’s the risk that bothersome tinnitus will continue to undermine the couple’s relationship, as well as the client’s ability to come to terms with tinnitus. If partners have been very supportive of one another during good times and bad, it’s beneficial to explore what helped them get through the bad times. Such knowledge can be useful in figuring out how to help them cope with tinnitus in the relationship. Sometimes tinnitus even can bring couples closer together. You never know. www.ATA.org
Through therapy, clients typically figure out if and how they want to involve their partner in their tinnitus experience. Some decide it’s more helpful to meet others with tinnitus, and sometimes they include their partner in those meetings. Some invite their partner to join a session with me. Others begin the process of opening up to their partners. By talking about tinnitus with their partner and others with tinnitus, clients can restore that nurturing feeling of “being a part of” their relationships –– thus reducing the stressful feeling of being all alone. Through this process, the partner without tinnitus will also regain that sense of connectedness. In finding a healthy way for couples to cope with tinnitus, it is essential to consider the specific couple, how willing they are to support each other’s experience, and how accompanying factors interplay with their partnership. Everything depends on the individual situation and on the needs of the person with tinnitus. Professionals
need to be respectful of this. However, generally speaking, if tinnitus is talked about, brought out into the light, then this helps to illuminate a healthy pathway forward. *For practical purposes, I’m designating the partner with tinnitus as male and the partner without tinnitus as female. Also, note the use of client or person, not patient, as is customary among psychologists in Denmark.
Anne-Mette Mohr is a licensed clinical psychologist specialized in existential psychotherapy in Denmark. Since 1992, Mohr has worked in the field of hearing loss, tinnitus, and inner ear diseases, such as Meniere’s disease, in private practice and as head of the House of Hearing counseling service in Denmark. She has had more than 10,100 individual therapy sessions with persons bothered by tinnitus and other hearing disorders. She is a frequent lecturer on the subject of tinnitus in Denmark and abroad. In 2018, Mohr was the keynote speaker at the 26th Annual International Conference on Management of the Tinnitus and Hyperacusis Patient at the University of Iowa.
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How Can Tinnitus Affect Your Partner? Summary by John A. Coverstone, AuD
A growing body of evidence exists to tell us the many and profound ways in which tinnitus can affect an individual. However, not many researchers have tried to study how tinnitus affects a patient’s partner. It is certainly reasonable to think that tinnitus may affect an individual’s partner in many ways, including social activities, relationships, sleep, stress, and intimacy. A group of researchers from the United States, Brazil, and Denmark attempted to determine how tinnitus may be perceived by partners of individuals with the condition.1 The authors created two websites to gather data. One website contained a survey for people with tinnitus. The other contained a survey for partners of
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those with tinnitus. Each questionnaire instructed participants to indicate their level of agreement with a series of questions. Agreement was indicated on a 10-point scale ranging from 0 (completely disagree) to 100 (completely agree), and open-ended questions were also provided so that participants could include their own thoughts. Questions for partners were directed toward assessing their understanding of tinnitus and how it affects the individual with tinnitus. Both surveys included questions about the tinnitus patient’s difficulty with concentration, thoughts and emotions, sleep, and hearing. People with tinnitus were also asked to complete the Tinnitus Primary Function Questionnaire, a 12-item questionnaire assessing concentration, thoughts and emotions, hearing, and sleep.
An invitation was emailed to nearly 53,000 students and staff at the University of Iowa, inviting those with tinnitus and their significant others to complete an online survey. A total of 333 people with tinnitus and 44 partners followed the link. Ultimately, 197 people with tinnitus and 25 partners completed the survey. In the area of concentration, partners rated the tinnitus patient’s difficulty with concentration to a similar degree as tinnitus patients did across most areas of the scale, although in the area of highest rating (90–100: absolutely agree), partners rated difficulty concentrating much more highly than did those with tinnitus. Partners also rated agreement with statements of depression more strongly than did those with tinnitus. For example, 74
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percent of those with tinnitus indicated that they strongly disagreed with the statement “I am depressed because of my tinnitus,” whereas only 28 percent of partners strongly disagreed with that statement for their loved one. Of partners, 20 percent (compared to 2% of those with tinnitus) strongly agreed with that statement, that their loved one experienced depression resulting from the tinnitus. A disproportionally high number of partners rated the statement as 81–90 on the scale as well. Data showed that people with tinnitus and their partners had similar views on how tinnitus interferes with the patient’s hearing, although it should be noted that there was no way to determine to what extent people with tinnitus did indeed have hearing loss.
Ratings regarding the effect of tinnitus on sleep were similar throughout much of the rating scale, although partners were noted to absolutely agree that tinnitus interferes with their loved one’s sleep significantly more than did people with tinnitus. Taken together, results indicate that those with tinnitus and partners of those with tinnitus did not completely agree about the effects of tinnitus. The authors interpret these results to indicate that people with tinnitus underestimate the effects that tinnitus has on their concentration, thoughts and emotions, hearing, and sleep, while partners noticed these difficulties. In the survey, those with tinnitus were provided with follow-up questions asking them to rate their partner’s
understanding of how tinnitus affects the same functions. People with tinnitus generally indicated that their partners do not fully understand how tinnitus affects concentration, thoughts and emotions, hearing, and sleep. As a result, the authors recommend that more counseling and education be performed regarding tinnitus, hearing, and hearing loss for both patients with tinnitus and their partners. Clinicians may consider including partners in tinnitus counseling so that the patient’s partner hears the same information. Partners may therefore be counseled and educated as well so they may better understand and support their loved ones who experience tinnitus. 1 Mancini, P. C., Tyler, R. S., Smith, S., Ji, J., Perreau, A., & Mohr, A.-M. (2018). Tinnitus: How partners can help? American Journal of Audiology, 46, 1–10.
ATA Scientific Advisor Committee Researcher Receives Prestigious Award Fatima Husain, PhD, was selected to participate in the University of Illinois at Urbana-Champaign’s Center for Advanced Studies (CAS), which will enable her to focus exclusively on research for spring semester in 2020. Husain, who is also a member of the ATA’s Scientific Advisory Committee, is a cognitive and computational neuroscientist at the university, investigating tinnitus through the use of functional MRI (fMRI). “The CAS award allows me a break from teaching to devote my time to exploring new analyses of the data being collected by my lab,” Husain said, when discussing the award with the ATA. “These new analyses will lead to better computational and theoretical models of tinnitus, whose predictions will lead to more focused experiments on neural mechanisms of tinnitus. In short, more time to study tinnitus and help patients!”
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TINNITUS RESOURCES
Support Group Locations People with tinnitus at every stage in their journey, from the first few days after onset to years later, can benefit from membership in a support group. Each tinnitus support group operates differently, but they all share a passion to provide meaningful discussion and a caring environment where one can be understood through shared experience. To confirm meeting times* for the groups listed below, email the point-of-contact person listed. California
Colorado
Los Altos Hills Tinnitus Support Group Congregation Beth AM 2670 Arastradero Road, Room 15 Los Altos Hills, CA 94022 Contact: Ken Adler, Amy Nelson, AuD, Brandon Cyrus, AuD E: karmtac@aol.com E: Amy.Nelson@kp.org E: brandon@landmarkhearing.com Los Angeles/Orange County Tinnitus Support Group Mariposa Women and Family Center 812 Town and Country Rd., Bldg. C Orange, CA 92868 Contact: Barry Goldberg E: bargold06@yahoo.com San Diego Tinnitus and Hyperacusis Support Group San Diego City Library North University City Branch 8820 Judicial Dr. San Diego, CA 92122 Contact: Michael J. Fischer, Dave Phaneuf E: michaeljohnfischer@hotmail.com E: djphaneuf@yahoo.com San Francisco Tinnitus Support/ Education Group Hearing and Speech Center of Northern CA Conference Room 1234 Divisadero St. San Francisco, CA 94115 Contact: Malvina Levy, AuD, Tracy Peck, AuD T: 415-921-7658 E: mlevy@hearingspeech.org E: tpeck@hearingspeech.org
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Denver Tinnitus Support Group Lutheran Medical Center 2nd Floor Learning Center 8300 West 38th Arvada, CO 80033 Contact: Rich Marr T: 303-875-5762 E: r.marr@comcast.net Mesa County Tinnitus Support Group Community Hospital 2351 G Road, Legacy Room 1 Grand Junction, CO 81505 Contact: Elaine Conlon T: 970-589-0305 E: conlonelaine@aol.com Florida Clermont Tinnitus Support Group Citrus Hearing Clinic 835 7th St. Suite 2 Clermont, FL 34711 Contact: Laura Pratesi, AuD T: 352-989-5123 E: drlaura@citrushearing.com Sarasota Tinnitus Support Group Silverstein Institute 1901 Floyd St. Sarasota, FL 34239 Contact: Carmen Trotta, Tom Terrenzi T: 941-993-7616, 941-462-1311 E: sarasota.ata@gmail.com Tinnitus Self-Help Group of Palm Beach County South County Civic Center 16700 Jog Road Delray Beach, FL 33446 Contact: Ellen Gartner T: 800-732-9217
The Villages Tinnitus Support Group Churchill Recreation Center 2375 Churchill Downs Lady Lake, FL 32162 Contact: Sal Gentile E: tvtinnitus@gmail.com Georgia Atlanta Tinnitus Support Group Dekalb County Public Library Dunwoody Branch, Meeting Room 5339 Chamblee Dunwoody Rd. Dunwoody, GA 30338 Contact: Erica Caplan E: elcatl@aol.com Illinois Chicago Suburban Tinnitus Support Group Glenview Public Library 1930 Glenview Rd. Glenview, IL 60025 Contact: Margie B E: maggie138@yahoo.com Maryland Washington D.C. Tinnitus Support Group Potomac Audiology 11300 Rockville Pike, Ste. 105 Rockville, MD 20852 Contact: David Treworgy, Gerry Baill E: david_treworgy@yahoo.com E: gsbaill@yahoo.com E: TinnitusDC@gmail.com Massachusetts Boston Tinnitus Support Group Athan’s Bakery 407 Washington St. Brighton, MA 02135 Contact: Kevin Plovanich E: KPMA@aol.com
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TINNITUS RESOURCES
Michigan Holland Tinnitus Support Group Holland Doctors of Audiology 399 E 32nd St. Holland, MI 49423 Contact: Stelios Dokianakis, AuD T: 616-392-2222 E: info@holaud.com Missouri St. Louis Tinnitus Support Group St. Louis County Library Headquarters East Room 1640 S. Lindbergh Blvd. St. Louis, MO 63131-3598 Contact: Tim Busche T: 636-734-4936 E: tennisfancincy@gmail.com Nevada Reno/Sparks Nevada Tinnitus Support Group Modern Audiology of Sparks 634 Pyramid Way Sparks, NV 89431 Contact: Scott Sumrall E: scottsumrall@sparkshearing.com T: 775-336-0211 New Jersey Tinnitus Self-Help Group, Ewing First Presbyterian Church 100 Scotch Road, Ewing, NJ 08628 Contact: Dhyan Cassie, AuD T: 215-984-8380 E: Dhyan1@verizon.net South Jersey Tinnitus Support Group 1020 North Kings Highway, Ste. 201 Cherry Hill NJ 08034 Contact: Linda Beach, MaryAnn Halladay, Barbara Kennedy E: linda.beach@gmail.com E: mhalladay@verizon.net E: harleyonholly@comcast.net New York Bronx Tinnitus Support Group 260 W. 231st St. Bronx, NY 10463 Contact: Dr. S. Karie Nabinet T: 917-797-9065 or 718-410-2301 E: kkwn12u@aol.com
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The Long Island Tinnitus Group Long Island Jewish Hospital 2nd Floor Conference Room 900 Franklin Ave. Valley Stream, NY 11580 Contact: Lisa Kennedy, Anthony Mennella T: 516-313-8061, 516-379-2534 E: aem830@verizon.net NYC Tinnitus Support Group Campbell Acupuncture PLCC 141 East 55th St. Suite 6d New York, NY 10022 Contact: Sara Higgins E: cliniccampbell@hotmail.com North Carolina Raleigh Tinnitus Support Group Raleigh Hearing and Tinnitus Center 10010 Falls of Neuse Rd., Ste. 12 Raleigh, NC 27614 Contact: Saranne Barker, AuD, Sheri Mello, AuD T: 919-790-8889 E: info@rhatc.com Oregon VA Portland Health Care System Tinnitus Education Group National Center for Rehabilitative Auditory Research 3710 SW US Veterans Hosp. Rd. Portland, OR 97239 Contact: Bryan Shaw E: Bryan.Shaw2@va.gov Texas Dallas/Ft. Worth Tinnitus Support Group Texas Health Presbyterian Hospital Plano 6200 W Parker Rd. Plano, TX 75093 or Callier Center for Communication Disorders 1966 Inwood Road Dallas, TX 75235 Contact: John Ogrizovich E: dfwtsg@yahoo.com
Virginia Northern Virginia Tinnitus Support Group Northern Virginia Resource Center for Deaf & Hard of Hearing Persons (NVRC) 3951 Pender Drive, Ste. 130 Fairfax, VA 22030 Contact: Elaine Wolfson, Marian Patey E: erwolfson@comcast.net E: mjpatey@fcps.edu Washington Seattle Tinnitus Support Group Broadview Public Library 12755 Greenwood Ave N. Seattle, WA 98133 or Greenwood Public Library 8016 Greenwood Ave. N Seattle, WA 98103 Contact: Keith Field T: 206-783-7105 E: keith_r_field@outlook.com Wisconsin Madison Tinnitus Support Group Doric Masonic Center 85 S Stoughton Rd. Madison, WI 53714 Contact: Deb Holmen T: 608 219 9277 E: dholmenihearu@gmail.com Each support group referenced here is independently operated and led by volunteers who wish to provide education and support to the tinnitus community. The American Tinnitus Association (ATA) does not sponsor or endorse these activities and expressly disclaims any responsibility for the conduct of any independent support group or the information they may provide. The ATA is not a healthcare provider and strongly recommends that you consult a qualified physician or hearing healthcare professional for medical advice on tinnitus and related hearing disorders.
*Support group information is updated on our online events calendar at ATA.org when new information is received. New groups continue to be organized so check the website periodically for updates: https://www. ata.org/managing-your-tinnitus/support-network/support-group-listing. If you’re interested in forming a group, please email tinnitus@ata.org or call 800-634-8978. If there isn’t a group in your area, the ATA has a volunteer network that provides email and telephone support. To connect with a volunteer in your time zone, see: https://www.ata.org/managing-your-tinnitus/ support-network/telephoneemail-support-listing
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PERSONAL STORY
Two Days of Learning Helped Me ‘Own’ My Tinnitus of 20 Years By David Strom
I have been living with tinnitus for 20 years, but, until last year, I didn’t “own” it. What does “owning” mean? It means that you control it, rather than allowing it to control you. Before I tell you how I came to own my tinnitus, a little background. In 1998, I was experiencing intense dizzy spells and was diagnosed with Meniere’s disease. Many of you have heard of or lived through what follows: dietary changes, a series of unsatisfying visits to various medical doctors, and a great deal of frustration – back then, it wasn’t easy to do internet research. Eventually, my attacks stopped. What I got out of that experience was a case of tinnitus. My situation is a bit unique: I have been deaf in my left ear since birth. My right ear hears just fine – except for this continuous tone that sometimes is louder, sometimes is softer, but always is there. Over the years, I have learned to deal with it, but owning it? Nope. Sometimes it was more than annoying, especially when I was in crowded, noisy rooms or restaurants. Sometimes I would hold a pity party for myself. Once, I attended a professional conference with about 300 people. We were seated at very long tables for dinner, 42
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and the noise was deafening. I quickly ate my meal and ran back to my room, in pain from the noise. I know it looked odd to my dinner companions. I have been a member of the American Tinnitus Association for most of the past two decades and appreciate the amount of knowledge the association provides to its members to help us understand and cope with this chronic condition. But even then I didn’t own my tinnitus. That is, until I went to the University of Iowa’s International Conference on the Management of the Tinnitus and Hyperacusis Patient1 last year. Known as the Iowa Conference, it is a small gathering of fewer than 100 people, including the speakers. Despite its size, it is a very full two days. Professionals, including nurses, medical doctors, researchers, and audiologists, make up 90 percent of the audience with a few of us patients scattered in and allowed to participate. It was very worthwhile, and I want to describe some of the things that I learned during the event. I was surprised at how much I didn’t know. And, it wasn’t just learning medical jargon, but actual, actionable, useful stuff that helped me begin to own my condition. First I learned that “owning” my tinnitus means I control it, rather than allowing it to control me. You aren’t defined by your tinnitus, you aren’t at
its mercy, and you manage your own treatment and your own response to it. The noise you and I hear may be all in our heads, but we have to use our brains to figure out a way to cope and live our lives. Many of the stories in Tinnitus Today carry this theme, but for some reason I didn’t really understand what they were getting at until I was sitting in the conference, listening to various presentations. Then it all clicked, so to speak. (Sorry for that pun.) Here are a few things I heard and took away from the event: Although I knew that tinnitus is different for everyone, I didn’t realize how different it is. Meeting others who have it and hearing their stories helped me to understand its individuality and the different paths that patients have taken to understand and cope with tinnitus. When you see the breadth and depth of research being done around the world, you begin to understand this is a huge problem – or many problems – to solve. You can get some of this insight and understanding by attending tinnitus support groups, too. Another thing I liked about the Iowa Conference was that you get to put yourself in your doctor’s shoes and see tinnitus from his or her perspective. This is helpful in understanding how they will treat you and respond to your needs and concerns. Several www.ATA.org
PERSONAL STORY
audiologists, therapists, and other professionals made presentations. As a patient, I could appreciate their different points of view. Meeting some of the ATA staff and board members who attended the conference (ATA is one of the sponsors) also was a treat. It helped to put a face on the organization and gave me an opportunity to thank these people in person for all their hard work in helping us. The conference is also a good place to get first-hand knowledge about cutting-edge research, particularly by the University of Iowa team, which has been involved in tinnitus work for decades. By the end of the two days, you feel like you know these folks quite well. At the conference, vendors presented their devices and explained how they are used and for whom they are intended. During
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one of these sessions, I learned that hearing aids are used as a way to manage tinnitus, even if you don’t have much in the way of hearing loss. They can be programmed to block out the frequencies that you think you are hearing with your tinnitus. Now, I know I am a bit of an unusual situation – no hearing in one ear, and the opposite in the other. Not to worry: there are specific kinds of hearing aids for this problem. Years ago, I investigated using a boneanchored hearing aid (BAHA), which involves implanting a microphone in the side of your skull (in my case, the left side) and transmitting the sound through your bones to your hearing ear.2 When I tried on the sample hearing aid back then, I could actually hear stereo and locate the source of the sound coming from behind me – both of these for the first time. I opted not to use the aid
then. But the advances in technology, especially in digital signal processing, are significant. Now there are wireless contralateral routing of signals (CROS) aids that can work with your cellphone via Bluetooth connections.3 At the conference, I talked to audiologists who worked with both BAHA and CROS aids and heard their first-hand experience. Access to that kind of insight is nearly impossible as an ordinary patient. As patients, we tend to interact with the medical-industrial complex when we have a problem: we break a bone, we want it fixed. We have an infection, we want to get rid of it. But the single-point-of-contact-with-ourdoctors method doesn’t work with a chronic condition, such as tinnitus (or Meniere’s or whatever). Research is ongoing: new drugs, new procedures, new devices, and so forth change and evolve the approaches available.
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PERSONAL STORY
Patients aren’t watching the medical literature like our doctors, because we are busy living our lives. And even if we are willing to put the time into doing internet research, we aren’t going to medical conferences and learning about many of the latest technologies and techniques. Until I attended the Iowa Conference, my knowledge of tinnitus was limited to what I read in this magazine. That is great, but it can’t provide me with everything that is going on in the tinnitus world. The Iowa Conference can quickly bring you up to speed in a way that doing your own net-based research or reading a medical journal article – even one intended for patients – can’t do easily.
Now, most medical conferences are way beyond my skills and knowledge (or so I imagine), and probably yours as well. Understanding the jargon of the different parts of the human body alone is daunting enough. The Iowa Conference certainly had its moments when I was totally lost. But it had plenty of other moments when I got useful information that was clearly explained and in terms that any layperson could understand. If you can, put Iowa City on your calendar and plan on attending the conference. You will be welcomed, and you might have the opportunity to understand more about our common affliction. The cost is minimal for the benefits I received.
David Strom is a freelance writer and professional speaker who lives in Saint Louis and writes for various technology business publications and blogs. He can be reached at david@strom.com.
1 For more information on this year’s conference, visit https://medicine.uiowa.edu/oto/education/ conferences-and-events/international-conferencemanagement-tinnitus-and-hyperacusis. 2 Johns Hopkins Medicine. (n.d.). Baha – the implantable hearing device. Retrieved from https:// www.hopkinsmedicine.org/otolaryngology/ specialty_areas/hearing/hearing-aids/baha.html 3 American Academy of Audiology. (2015, June 29). CROS and BiCROS hearing aids. Retrieved from https://www.audiology.org/news/cros-and-bicroshearing-aids
27th Annual International Conference at the University of Iowa
Management of the Tinnitus & Hyperacusis Patient ATA The 27th Annual International Conference, Management of the Tinnitus & Hyperacusis Patient, will be held June 13–14, 2019, at the University of Iowa. The educational event is intended for otologists, audiologists, hearing aid specialists, and other healthcare professionals providing clinical services for tinnitus patients. Topics include an overview of current evaluation practices, management
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strategies, and research. Presentations are given by leading researchers, practitioners, and leaders in advocacy and include the latest developments in the areas of medical treatments, neuroscience, sleep therapy, noise-induced hearing loss, and hyperacusis. The conference is intended to increase the knowledge and skills of clinicians; however, it is open to patients and their families, with the
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understanding DIAMO OR that no individSPONS ual diagnosis or treatment will be offered. For more information, visit the University of Iowa’s website: https://medicine. uiowa.edu/oto/education/conferences-and-events/internationalconference-managementtinnitus-and-hyperacusis
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YOUR HEALTH
Mindfulness-Based Tinnitus Stress Reduction
In recognition of May as Meditation Month, the ATA spoke with Jennifer Gans, PhD, an early advocate and researcher of Mindfulness-Based Tinnitus Stress Reduction (MBTSR), to hear her thoughts on why people with tinnitus and patient providers should turn their focus, if even for a few minutes per day, to meditation. Joy Onozuka (JO): Why is meditation a practice worth cultivating if you have tinnitus or treat tinnitus patients? Jennifer Gans (JG): There are two things we know about tinnitus: Stress increases tinnitus bother, and relaxation decreases tinnitus bother. We can apply this truism to most things in life that we find difficult, including our role as hearing healthcare providers. This speaks to the heart of why a meditation practice is worth cultivating. For both the patient and the healthcare provider, the practice of meditation involves training the mind to focus attention and then allowing www.ATA.org
whatever thoughts, feelings, and emotions come to mind, without getting wrapped up in intractable stories, which often results in undue stress and anxiety. Not unlike practicing good dental hygiene, it is helpful to think of a meditation practice as good mental hygiene. In the same way we generally don’t leave the house in the morning without brushing our teeth, leaving the house in the morning not having practiced meditation can be tantamount to poor self-care. For this reason, a consistent meditation practice for anyone can help shift a benign, but intrusive, body sensation, such as tinnitus, from “bothersome” to “non-bothersome.” JO: Why is meditation enhanced by practicing yoga and mindfulness? JG: When most people think of meditation, they bring to mind an image of a person sitting quietly and still on a mat or chair with eyes
closed. But a sitting meditation is only one form of meditation. If meditation is the practice of bringing awareness to our mind in the present moment, while not getting caught up in the chatter that we observe, then this is a practice we can cultivate while doing yoga, driving our car, standing in the shower, waiting in line at the grocery, and the like. I look at the practice of yoga as moving meditation—bringing awareness to the mind and its maturations while our body is moving through space. I encourage patients to try all kinds of meditation as different opportunities arise so that they can figure out what they’re drawn to and what they’re not. In a similar vein, there are many schools of meditation practice (Transcendental Meditation, Guided Meditation, Vipassana Meditation, Loving Kindness Meditation, Chakra Meditation, to name a few), and mindfulness is just one example of a TINNITUS TODAY SPRING 2019
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practice helpful in enhancing wellbeing and stress reduction. JO: How often and how long do you need to meditate to experience and sustain positive change? JG: As with most skills that we wish to cultivate, practice makes perfect. That said, even a minute of meditation practice a day can certainly be of great benefit. The Mindfulness-Based Tinnitus Stress Reduction program created and researched at the University of California, San Francisco, in 2013, was designed as an eight-week program, with anywhere from 30 to 60 minutes of daily practice. Learning theory has taught us that it takes, on average, eight weeks for a person to learn a new habit or skill. The practice of mindfulness meditation is cultivated through
consistent daily practice. That said, practicing meditation for even one minute per day can be helpful in reducing stress and creating a sense of well-being. JO: There are many meditation and sleep apps. Are there any that you recommend? JG: Smartphone technology in the form of apps has really done a great job of bringing a challenging practice like meditation to the masses. It seems like a day doesn’t go by without my hearing about a new meditation or sleep app being offered or sold. While I have my personal favorites, I can’t say there is one in particular that I can recommend because I encourage my clients to explore app options to see if they find a practice or guide that connects with them.
Jennifer Gans, PhD, is a clinical psychologist specializing in the psychological impact of deafness and hearing on well-being. In her private practice in San Francisco, CA, she treats clients with tinnitus, hyperacusis, misophonia, and other hearing-related difficulties. She recently completed research at the University of California, San Francisco (UCSF), in the Department of Otolaryngology’s Audiology Clinic on Mindfulness-Based Tinnitus Stress Reduction, with promising results. She is the founder and chief executive officer of MindfulTinnitusRelief.com, the first-ever selfguided 8-week online skill-building course for learning how to live comfortably with tinnitus. Gans speaks regularly at audiology conferences on how to integrate device fittings and tinnitus patient counseling, which can be critical components in managing bothersome tinnitus.
The only difference between meditation and the ordinary, everyday process of thinking, feeling, and sensation is the application of the simple, bare awareness that occurs when you allow your mind to rest simply as it is – without chasing after thoughts or becoming distracted by feelings or sensations.
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—Y ongey Mingyur Rinpoche, teacher of Buddhist philosophy and meditation
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TINNITUS RESOURCES
Meditation Apps for Improving Relaxation and Sleep Research into the benefits of meditation and mindfulness to relieve the stress and negative emotions associated with bothersome tinnitus shows encouraging results.* Less is known about the benefits of using smartphone apps for meditation, but, here too, preliminary research suggests that apps are an effective tool for practicing meditation to increase a sense of well-being, if
used regularly. Which is to say, “the best” app is the one you like – and they differ in what they offer – and can integrate easily into your life.
Things to consider: Free trial: Most paid apps offer a trial period to explore basic features of the app. Design and sound: Consider the visual appeal and whether you enjoy the voices of the speakers.
Extra features: Some meditation apps are geared toward reducing anxiety and improving sleep, while others come with additional tools that can be helpful for managing tinnitus, such as sleep and music. Prices current as of 2/17/2019. Note that subscription prices vary depending on level of access and subscription term. For simplicity, we list the monthly subscription price, where applicable. For more information, visit the Apple iStore, Google Playstore, or app website.
Buddhify ($4.99 per month)
Calm (from $9.99)
Headspace ($12.99 per month)
Insight Timer ($9.99 per month)
Oak (free)
10% Happier ($9.99 per month)
To hear more about one researcher’s investigation into the benefits of meditation and its effect on the brain, see: https://www.youtube.com/watch?time_continue=510&v=m8rRzTtP7Tc
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SCIENCE & RESEARCH NEWS
An Assessment of Tinnitus Apps Summary by John A. Coverstone, AuD
A common tool in the treatment of tinnitus is sound therapy. Sounds may be presented through a variety of devices, but mobile apps for this purpose are growing in popularity and number. Some mobile apps may also be used for relaxation or other exercises to help cope with tinnitus. Researchers at the National Institute for Health Research in the United Kingdom recently conducted a survey of mobile app use for tinnitus and subsequently analyzed the apps people indicated using.1 Of a total of 643 people completing the online survey, 75 percent indicated that they did not use apps for tinnitus. There was a significant correlation between people reporting severe tinnitus and non-use of mobile apps. The majority of people indicating they did not use mobile apps cited being
unaware that mobile apps existed for tinnitus. Other reasons included lack of comfort with technology, not believing an app would help their tinnitus, and not having a device that supported apps. From the results of those who used mobile apps, the authors created a list of 18 apps that more than one person had tried for tinnitus. Apps fell into six main categories: sound generation; meditation & mindfulness; information & education; hypnosis; relaxation; and assessment. Quality of the apps was also rated using the Mobile Apps Rating Scale, a tool designed for health-related mobile apps.2 Scores ranged from 1.6 to 4.2 out of a possible 5, with two apps failing to meet the minimum acceptable rating of 3.0. Sound therapy was the most common use and included a variety of strategies, such as sound enrichment, masking, notched music, binaural
beats, and isochronic tones (regular beats of a single tone used for brain entrainment). The authors noted that six apps were specifically designed for tinnitus, four apps mentioned tinnitus as a use, and eight apps made no mention of tinnitus (nature sounds, relaxation, hypnosis). The authors concluded from this survey that mobile apps are being used for tinnitus management, but mostly without direction from a healthcare professional. Apps are primarily used as a self-help tool. The authors recommended that future research should consider the place of mobile apps in tinnitus management. 1 Sereda, M., Smith, S., Newton, K., & Stockdale, D. (2019). Mobile apps for management of tinnitus: Users’ survey, quality assessment, and content analysis. JMIR mHealth and uHealth, 7(1), e10353. 2 Stoyanov, S. R., Hides, L., Kavanagh, D. J., Zelenko, O., Tjondronegoro, D., & Mani, M. (2015). Mobile App Rating Scale: A new tool for assessing the quality of health mobile apps. JMIR mHealth and uHealth, 3(1), e27.
I love your magazine and would not be making any progress at all without it. — Jan P.
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www.ATA.org
TINNITUSTODAY Editorial Calendar Tinnitus Today magazine is a print and electronic media magazine published in April, August, and December, and circulated to 25,000+ ATA contributors, donors, patients, supporters, researchers, and healthcare professionals. The magazine editorial team empowers readers with information, including up-to-date medical and research news, feature articles on urgent tinnitus issues, questions and answers, self-help suggestions, and letters to the editor from others with tinnitus. Strong service journalism, compelling storytelling, first-person narrative, and profiles are presented in a warm, vibrant, and inviting format to encourage readers to reflect, engage, and better understand a medical condition that affects millions. Editorial Copy Due
Photos Due
Ad Close
Digital Launch
Issue Mailed
Cultivating a Safe Hearing Space
5/1
5/1
5/1
7/15
August
Winter—Dec 2019
Annual Research Issue
10/1
10/1
10/1
12/1
December
Spring—Apr 2020
Causes of Tinnitus
2/1
2/1
2/1
4/15
April
Issue
Theme
Summer—Aug 2019
Editorial Calendar is subject to change.
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MISSION AND CORE PURPOSE The mission and core purpose of the ATA are to promote relief, help prevent, and find cures for tinnitus evidenced by its core values of compassion, credibility, and responsibility.
CORE VALUES AND GUIDING PRINCIPLES Compassion: Evidenced in a spirit of hope reflected in the commitment to finding a cure, preventing the condition, and supporting those affected by the condition. Credibility: Evidenced in accurate information from reliable sources, transparency in decisionmaking, and an earned reputation for trustworthiness. Responsibility: Evidenced in patient-centered advocacy by a collaborative community of forward thinking leaders accountable to its mission and members. www.ATA.org
DEPT 424049 WASHINGTON, DC 20042-4049
Open Access ATA’s Conversations in Tinnitus, with John A. Coverstone, AuD, and Dean Flyger, AuD
Tune In to Conversations in Tinnitus to Stay Abreast of Tinnitus Research and News The American Tinnitus Association’s podcasts are available 24/7 to help you stay abreast of tinnitus research and other tinnitus topics. Just like listening to music on your smartphone or computer, you can tune in to Conversations in Tinnitus podcasts, cohosted by John A. Coverstone, AuD, and Dean Flyger, AuD, while you work out, take a walk, relax at home, or commute to work. To access and learn more about this unique and compelling series, visit our website at www.ata.org. To enhance listening comprehension and accommodate those with noise sensitivity, transcripts are available with each podcast. ALL PODCASTS ARE FREE AND OPEN ACCESS
Podcast 10: Habituation to Tinnitus Using Cognitive Behavioral Therapy SUBJECT MATTER EXPERT: Bruce Hubbard, PhD TOPIC: For over 20 years, Dr. Hubbard has helped people improve their lives using cognitive behavioral therapy (CBT), mindfulness, and relational therapy strategies. He explains how CBT and mindfulness are applied to treatment of tinnitus and what patients should expect in regard to habituation. Dr. Hubbard, who has tinnitus, also offers insights into using the internet and support systems to manage tinnitus distress.
Podcast 11: Benefits and Pitfalls of an Online Support Community SUBJECT MATTER EXPERT: Hazel Goedhart and Markku Vasala of TinnitusTalk TOPIC: Hazel Goedhart and Markku Vasala discuss their own journey with tinnitus and what they learned through seeking help for their condition and joining the online community of people with tinnitus. As content strategist and co-founder of TinnitusTalk, respectively, Hazel and Markku share their insights regarding the benefits, limitations, and pitfalls of an online support community focused on tinnitus.
Podcast 12: Talking About Tinnitus with Children SUBJECT MATTER EXPERTS: David Baguley, PhD, and Claire Benton, MSc TOPIC: Dr. Baguley and Claire Benton discuss their efforts to educate parents, teachers, and healthcare providers on talking to children about tinnitus. The widespread misconception that children don’t have tinnitus has meant children suffer alone and miss critical opportunities for early intervention. They also discuss their research findings on the topic and tools to help children manage tinnitus.
Podcast 13: Interdisciplinary Approach to Tinnitus Treatment SUBJECT MATTER EXPERTS: Tara Zaugg, AuD, and Caroline Schmidt, PhD TOPIC: Drs. Zaugg and Schmidt discuss the benefits of providing integrated services to people with bothersome tinnitus. They elaborate on their extensive clinical and research experience working with veterans and service members struggling to cope with hearing loss, traumatic brain injury, post-traumatic stress disorder, and tinnitus. They concurrently address audiological issues, such as hearing loss and sound therapy, and provide mental health services, such as cognitive behavioral therapy (CBT), to increase positive outcomes that improve quality of life.
To subscribe to the print and digital issues of Tinnitus Today, which is published three times a year, visit www.ata.org or email tinnitus@ata.org
