Tinnitus retraining therapy
Tinnitus retraining therapy (TRT) is a form of habituation therapy designed to help people who suffer from tinnitus, a ringing, buzzing, hissing, or other sound in the ears when no external sound is present. Two key components of TRT directly follow from the neurophysiological model of tinnitus. One of these principles includes directive counseling aimed at reclassification of tinnitus to a category of neutral signals,[clarification needed] while the other includes sound therapy which is aimed at weakening tinnitus related neuronal activity.
The goal of TRT is management of tinnitus; there is no evidence that TRT can attenuate or eliminate tinnitus.
An alternative to TRT is tinnitus masking, the use of noise, music or other environmental sounds to obscure or mask the tinnitis, similar to the way flowery or other scents can be used to cover up bad odors. Hearing aids can provide a partial masking effect for the condition. Results from a review of tinnitus retraining therapy trials indicate that it may be a more effective treatment than tinnitus masking.
- 1 Prevalence of tinnitus
- 2 Applicability
- 3 Physiological basis
- 4 Psychological model
- 5 Methodologies
- 6 Efficacy
- 7 Clinical practice
- 8 Research
- 9 Alternatives
- 10 See also
- 11 References
- 12 External links
Prevalence of tinnitus
In a recent survey, 50 million American adults (20%) reported any tinnitus, and 6.5 million adults (6.5%) reported frequent tinnitus in the past year. 2 million adults (1.3%) are unable to lead a normal life. While tinnitus gets more common with advancing age and is most prevalent from age 60-69,[medical citation needed] many children also have tinnitus,and may be at risk for learning disabilities.
Tinnitus and hyperacusis are frequently a consequence of, or accompaniment to high frequency hearing loss, though persons with normal hearing can exhibit tinnitus without other symptoms. According to one survey, 80% of those with significant hearing loss have tinnitus, and 80% of those with tinnitus have measurable hearing loss. That's a high correlation, but not quite strong enough to rise to the level of causation.
Not everyone who experiences tinnitus suffers from it. However, some of the problems caused by tinnitus include annoyance, anxiety, panic, and loss of sleep and/or concentration. TRT may offer real although moderate improvement in tinnitus suffering for adults with moderate-to-severe tinnitus, in the absence of hyperacusis, significant hearing loss and/or depression.
Other secondary hearing symptoms
Despite the fact that there haven't been any recent studies which concluded in its optimal treatment, tinnitus retraining therapy has been applied to treating hyperacusis, misophonia, and phonophobia.
There is no evidence that TRT or any other treatment can attenuate or eliminate tinnitus. It is important to keep in mind that tinnitus is a symptom, not a disease. As such, the optimal treatment strategy should be directed toward eliminating the disease, rather than simply alleviating the symptom. More than half of tinnitus sufferers have a comorbid psychological injury or illness (eg, post-traumatic stress disorder, depression, anxiety, obsessive compulsive disorder, stress, dysfunction of the temporomandibular joint, etc) that can exacerbate the tinnitus.
It has been proposed that tinnitus is caused by mechanisms that generate abnormal neural activity, specifically one mechanism called discordant damage (dysfunction) of outer and inner hair cells of the cochlea.
The psychological basis for TRT stems from the fact that the brain exhibits a high level of plasticity. In turn, this allows it to adjust to any sensory signals as long as they do not lead to negative effects. TRT is imputed to work by interfering with the neural activity causing the tinnitus at its source, in order to prevent it from spreading to other nervous systems such as the limbic and autonomic nervous systems.
Heller and Bergman experiment
In this experiment, the researchers placed normal hearing subjects in an anechoic chamber for a short time, and most subjects reported hearing non-existent sounds similar to what others have described as tinnitus. This demonstrates that even normal hearing persons have tinnitus, but that it's masked by environmental sounds. 
The first component of TRT, directive counseling, may change the way tinnitus is perceived. The patient is taught the basic knowledge about the auditory system and its function, the mechanism of tinnitus generation and the annoyance associated with tinnitus. The repetition of these points in the follow-up visits helps the patient to perceive the signal as a non-danger.
The basis of sound therapy discovered over a century ago, is a psychological phenomenon known as residual inhibition: the tendency of a loud enough sound of the right pitch to damp out or inhibit the annoying ringing of tinnitus. The use of a portable music player as a control instrument in TRT has produced successful results in recent analysis, offering patients a more cost-efficient treatment.
It must be noted that while there few available studies, most show that tinnitus naturally declines over time (years) in a large proportion of subjects surveyed, without any treatment. The annoyance of tinnitus also tends to decline over time. In at least some, tinnitus spontaneously disappears. This raises questions about the efficacy of any treatment including TRT.
A recent Cochrane review found only one study of TRT suitable for inclusion, and noted that while the study suggested significant benefit of TRT in the treatment of tinnitus, the study quality was not good enough to draw firm conclusions. A separate Cochrane review of sound therapy (though they called it masking), an integral part of TRT, found no convincing evidence of the efficacy of sound therapy in the treatment of tinnitus.
A summary in The Lancet concluded that in the only decent study, TRT was more effective than masking; in another study in which TRT was used as a control methodology, TRT showed a small benefit. A study which compared cognitive behavior therapy (CBT) in combination with the counselling part of TRT versus standard care (ENT, audiologist, maskers, hearing aid) found that the specialized care had a positive effect on quality of life as well as specific tinnitus metrics.
Progressive tinnitus management (PTM) is a 5-step structured clinical protocol for management of tinnitus which may include tinnitus retraining therapy. The five steps are: 1) triage - determining appropriate referral, i.e. audiology, ENT, emergency medical intervention, or mental health evaluation; 2) audiologic evaluation of hearing loss, tinnitus, hyperacusis and other symptoms; 3) group education about causes and management of tinnitus; 4) interdisciplinary evaluation of tinnitus; 5) individual management of tinnitus
- Sound therapy for tinnitus may be more effective if the sound is patterned (i.e. varying in frequency or amplitude) rather than static.
- For persons with severe or disabling tinnitus, techniques that are minimally surgical involving magnetic or electrical stimulation of areas of the brain involved in auditory processing may suppress tinnitus.
- Notched music therapy, in which ordinary music is altered by a one octave notch filter centered at the tinnitus frequency, may reduce tinnitus.
If tinnitus is associated with hearing loss, a tuned hearing aid that amplifies sound in the frequency range of the hearing loss (usually the high frequencies) may effectively mask tinnitus by raising the level of environmental sound, in addition to the benefit of restoring hearing.
White noise generators or environmental music may be used to provide a background noise level that is of sufficient amplitude that it wholly or partially 'masks' the tinnitus (tinnitus masker). Composite hearing aids that combine amplification and white noise generation are also available.
Numerous other non-TRT methods have been suggested for the treatment or management of tinnitus.
- pharmacological - No drug has been approved by the U.S. Food and Drug Administration (FDA) for treating tinnitus. However, various pharmacological treatments, including antidepressants, anxiolytics, vasodilators and vasoactive substances, and intravenous lidocaine have been prescribed for tinnitus
- lifestyle and support - Things like loud noise, alcohol, caffeine, nicotine, quiet environments and psychological conditions like stress and depression may exacerbate tinnitus. Reducing or controlling these may help manage the condition.
- alternative medicine - vitamin, antioxidant and herbal preparations (notably ''Ginkgo biloba'' extract, also called EGb761) are advertised as treatments or cures for tinnitus. However, none are approved by the FDA, and controlled clinical trials on their efficacy are lacking.
- Tinnitus Retraining Therapy Implementing the Neurophysiological Model, Jastreboff, P.J. and Hazell, J.W.P. (2004). Cambridge University Press, Cambridge
- Jastreboff, P.J. (2007). "Tinnitus retraining therapy". Progress in Brain Research 166: 415–423. doi:10.1016/s0079-6123(07)66040-3. ISSN 0079-6123. Retrieved 23 March 2013.
- Tyler et.al., R.S. (2012). "Tinnitus Retraining Therapy: Mixingpoint and Masking are Equally Effective.". Ear and Hearing 33 (5): 588-594.
- Phillips, John S; Don McFerran (2010). "Tinnitus Retraining Therapy (TRT) for tinnitus". Cochrane Database of Systematic Reviews (3). doi:10.1002/14651858.CD007330.pub2.
- Shargorodsky, et.al., J (2010). ". doi: 1Prevalence and characteristics of tinnitus among US adults". Am J Med. 123 (8): 711-8.
- Douglas L. Beck, AuD, Christine DePlacido, PhD, and Colin Paxton, MA. "Issues in Tinnitus 2014-2015". Hearing Review.
- Bauer, et.al., CA (2011). "Effect of Tinnitus Retraining Therapy on the Loudness and Annoyance of Tinnitus: A Controlled Trial.". Ear & Hearing 32 (2): 145-55.
- Jastreboff, PJ (1990). "Phantom auditory perception (tinnitus): mechanisms of generation and perception.". Neurosci Res. 8 (4): 221-54.
- Heller, Bergman, MF (Mar. 1953). "Tinnitus aurium in normally hearing persons.". Ann Otol Rhinol Laryngol 62 (1): 73-83. Check date values in:
- Spalding, J.A. (1903). "Tinnitus, with a plea for its more accurate musical notation.". Archives of Otology 32 (4): 263-272.
- Fukuda S, Miyashita T, Inamoto R, Mori N. (2011) "Tinnitus retraining therapy using portable music players". Auris Nasus Larynx, Volume 38, Issue 6, 692-696.
- Phillips, JS (2010). "Tinnitus Retraining Therapy (TRT) for tinnitus". Cochrane Review.
- Hobson, J (2012). "Sound therapy (masking) in the management of tinnitus in adults". Cochrane Review.
- Baguley, D (2013). "Tinnitus". The Lancet 382 (9904): 1600-07. doi:DOI: http://dx.doi.org/10.1016/S0140-6736(13)60142-7 Check
- Henry, et.al., J. "VA Clinical Practice Recommendations for Tinnitus" (PDF). National Center for Rehabilitative Auditory Research (NCRAR).
- Reavis, et.al., KM (2010). "Patterned sound therapy for the treatment of tinnitus. Hear Jour. 2010;60(11):21-24". Hear jour. 60 (11): 21-24.
- Ridder, et.al., DD (2004). "Magnetic and electrical stimulation of the auditory cortex for intractable tinnitus". J Neurosurg (100).
- Henning, et.al., S (2010). "Customized notched music training reduces tinnitus loudness". Commun Integr Biol 3 (3): 274-277. PMID 2918775.