Atlanta VA Medical Center Tinnitus Program

Transcription

Atlanta VA Medical Center Tinnitus Protocol: March 2013
Atlanta VA Medical Center
Tinnitus Program
Steven L. Benton, Au.D.
Revised March, 2013
1670 Clairmont Road
Decatur, GA 30033
Ph. 404-235-3036
Progressive Tinnitus Management (PTM) Level 1:
Triage
1. On the standard case history form, patients are asked if they have tinnitus and to describe
the sound they perceive. As noted, those who experience tinnitus are asked to grade the
severity of their tinnitus using the THI-based grade levels described by McCombe et al
(2001).
2. Patients also are asked to describe how often they hear the tinnitus. Patients may have
difficulty with this task.
a. Audiologists are encouraged to guide patients to provide an awareness
percentage (percentage of waking hours the patient hears the tinnitus).
b. Otherwise, audiologists may ask “ how often do you hear your tinnitus? Once a
day, once a week…?” and “how long does it last when you hear it? A few
seconds, a few minutes…?”
3. Patients who grade the tinnitus a 1, 2 or 3 typically require no further tinnitus assessment.
4. Patients who grade the tinnitus a 4 or 5 require further tinnitus screening.
a. The Tinnitus Severity Index, or TSI (Meikle 1995) is completed. This questionnaire
is best completed in an INTERVIEW FORMAT rather than by PAPER/PENCIL.
Patients often confuse hearing problems with tinnitus problems. Interview
format allows the audiologist to maintain a focus on issues related to tinnitus,
not hearing loss.
b. The questionnaire includes a 0-10 visual analog scale as well, where 0 means
"my tinnitus is not a problem at all," and 10 means "my tinnitus is the biggest
problem you can imagine."
c. Benton (2013) reported that a linear regression completed to evaluate the
predictive relationships between the independent variables 0-10 Problem and 15 Tinnitus Grade and the dependent variable, TSI Score, resulted in the finding
that "Not all of the independent variables appear necessary. The following
appear to account for the ability to predict TSI (P < 0.05): 0-10 VA.”As a result,
the clinic now uses ONLY the 0-10 VAS as its single Triage measure.
Audiological Evaluation
1. Comprehensive audiological assessment is completed:
a. Immittance.
b. Tympanometry.
c. Acoustic reflexes and reflex decay.
i. The possibility of loudness tolerance problems requires that reflex
measurement be begun at very low presentation levels.
ii. Patients should be instructed that if they cannot tolerate the tones
they should notify the audiologist and the test will be discontinued
immediately ; as a result, accurate measurement of reflex thresholds
or reflex decay may not be possible.
d. Spondee thresholds.
e. Pure-tone thresholds.
i. If thresholds are normal from .25-8 kHz:
1. Measure ultra high-frequency thresholds (9, 10, 11.2, 12.5 kHz)
2. Measurement of DPOAEs is minimally helpful and is not
recommended. Benton (2013) reported that up to 60% of normalhearing tinnitus patients have normal DPOAEs across all tested
frequencies depending on the criterion used. Such poor specificity
and sensitivity renders the standard DPOAES useless.
f. Word-recognition scores (PI-PB function if indicated)
2. If the patient is unwilling or unable to provide valid behavioral test results, further tinnitus
management is not possible. Do not refer to Tinnitus Group Education.
a. Invalid/functional/nonorganic results preclude appropriate counseling regarding
environmental sound enrichment as well as any other management strategy, all
of which utilize sound and require accurate hearing threshold information.
b. Invalid voluntary responses also call into question the validity of tinnitus
complaints. Counseling regarding the negative impact of invalid behavioral
responses on provision of tinnitus management services should be provided.
c. The audiologist should make every attempt to obtain valid behavioral responses
through retest following reinstruction in test procedures and counseling
regarding observed intra- and inter-test inconsistencies.
d. If invalid responses do not resolve, retest at another time may be considered at
the audiologist's discretion and/or per clinic policy.
3. All tinnitus findings are noted appropriately in the Tinnitus Section of the Audiology
Assessment Progress Note template.
4. At this point, regardless of responses to the Tinnitus Grading Scale and any score on the
Tinnitus Severity Index, after audiologic evaluation, all tinnitus patients should receive:
a. Appropriate counseling AND
b. Assistive devices (e.g., Marsona Bedside Sound Generator Kit) if indicated
AND/OR
c. Hearing aids if appropriate.
5. Regarding the Marsona Bedside Sound Generator and Kit.
a. Demonstration of the device and available accessories is recommended.
b. Provision of the complete kit rather than individual items is strongly encouraged.
During Tinnitus Group Education Class, the vast majority of veterans who did not
receive the entire kit from their primary audiologist request the other
components when they hear of the benefits other veterans receive from the
various accessories.
i. The audiologist should immediately put in the appropriate consult
request to Prosthetics and instruct the veteran to pick up the kit there in
person.
ii. If the veteran’s appointment ends after 4:30pm, Prosthetics will be
closed. In such cases, Prosthetics should be instructed to mail the kit and
the veteran should be instructed to expect the kit within 3 weeks of their
audiological evaluation appointment. In the event the kit is not received
within 3 weeks, the veteran should contact Prosthetics directly to inquire.
c. Audiologists are encouraged to provide the Marsona Kit handout and the Helpful
Tinnitus Information handout for the patient’s reference at home.
6. If hearing aids are not appropriate, schedule for Tinnitus Group Education if Triage criteria
are met.
a. Provision of the bedside sound generator and any accessories is NOT an
acceptable substitute for Tinnitus Group Education unless the patient's ONLY
complaint is sleep disturbance and the patient concurs that attending Tinnitus
Group Education is not warranted.
b. NOTE: Current hearing aid technology has expanded fitting ranges. Careful
consideration should be given to providing hearing aids to patients whose
hearing levels are normal through 3000 Hz or whose high-frequency thresholds
are 30-35 dB HL, given the proven significant tinnitus relief with aid use in this
population (Parazzini et al, 2011).
7. If hearing aids are appropriate.
a. Although the conventional wisdom is that open fittings should be recommended
for tinnitus patients, the main focus of the fitting should be audibility of
environmental sounds; appropriate acoustic coupling for the individual patient
should be the primary consideration. Progressive Tinnitus Management is based
upon the use of sound to manage tinnitus. For sound to be effective, it must be
audible.
b. Real-ear verification is required to assure that environmental sounds are audible
to the patient. For tinnitus patients, it is not JUST about speech.
i. Ricketts (JDVAC, 2011) demonstrated that subjective fittings that rely
solely on the patient's input regarding pleasantness or naturalness of the
hearing aid sound typically result in grossly inadequate gain.
ii. Manufacturers’ “first fit” algorithms typically do not provide appropriate
amplification; most often, there is a gross under-fit relative to NALNL1
prescriptive gain targets.
iii. Although speech mapping is a valid tool for verifying the audibility of
speech, comparison of hearing aids fit by this method compared to the
same aids fit using NALNL1 prescribed gain targets (65 dB SPL input)
reveal that speech mapping typically provides substantially less
amplification for soft and moderate inputs. Traditional real-ear measures
(REIG) are recommended.
c. Maximum output of the aids must be verified to account for any tolerance
problems. To evaluate both the effect of various algorithms on impulse sounds
as well as MPO, loud clapping and very loud talking in the office have proven
effective.
d. Advanced features must be carefully considered during the fitting.
i. Expansion should be turned off or minimized (increasing gain for very soft
sounds) to avoid placing the patient in situations of distressing silence
where perceived tinnitus severity may be enhanced.
ii. Frequency-lowering methods differ significantly among the three oncontract vendors offering this feature. Non-linear frequency compression
limits high-frequency output above the cut-off frequency whereas
spectral feature identification does not. Although no research exists to
suggest that either is better or worse for tinnitus patients (let alone that
either provides significant real-world benefit), limiting output in the high
frequencies where auditory contrast may most be needed may be a less
effective strategy for tinnitus patients.
iii. Experience with learning volume controls suggests that many patients –
especially new users – progressively turn their aids down and may
eventually reach the point of minimal if any amplification over time.
Although this concern has been addressed by some manufacturers who
limit the maximum adjustment over time their aids can learn,
audiologists are encouraged strongly to consider the possible impact of
learning VC on sound input for tinnitus patients.
iv. The possible impact of fast-acting noise management algorithms that
purport to reduce sound input between the syllables of speech also
should be carefully evaluated.
v. Data-log capabilities vary significantly among different brands of hearing
aids. Some hearing aids provide average input data which can be useful in
counseling regarding environmental sound enrichment.
vi. Availability of accessories such as media streamers should be considered
when recommending hearing aids as a means of facilitating the use of
sound to manage tinnitus.
e. During the aid delivery but after programming while evaluating subjective
response to the aid(s), audiologists should inquire about any tinnitus relief:
i. "How is your tinnitus now with your new hearing aids in place?"
ii. The following numerical scale has proven useful: On a scale of 0-10,
where 0 means "My hearing aids provide no tinnitus relief”, and 10 means
"My hearing aids provide complete tinnitus relief,” how would you rate
your tinnitus right now?" Notate the immediate effect of the aids on the
tinnitus, if any, in the CPRS progress note:
iii.
1. Veteran was asked to utilize a 0-10 scale to assess the impact of
the new hearing aids on the tinnitus, where 0 means "My hearing
aids provide no tinnitus relief" and 10 means "My hearing aids
provide complete tinnitus relief." Veteran rated the relief from
the hearing aids a _, confirming that the aid(s) are/are not
providing adequate tinnitus relief.
f. HEARING AIDS MUST BE FIT AND THEIR EFFECTIVENESS FOR TINNITUS RELIEF
MUST BE EVALUATED PRIOR TO SCHEDULING FOR TINNITUS GROUP
EDUCATION.
i. Previous review of responses from hearing-impaired tinnitus patients at
the Atlanta VA indicates that 82% reported at least some tinnitus relief
from their hearing aids and fully 56% reported "moderate" to
"major/complete relief" from their hearing aids.
ii. If the patient reports no tinnitus relief during the fitting, counsel
appropriately but do not schedule Tinnitus Group Education until after
the patient returns the IOI-HA/Satisfaction questionnaire 30 days later.
The patient's experiences in the sound-filled real world may differ
substantially from those in the quiet office.
1. If the tinnitus patient returns the questionnaire and marks that
tinnitus relief is a 5 or less, schedule the patient for Tinnitus
Group Education.
2. An addendum to the HAE note must be added to document the
IOI-HA/Satisfaction questionnaire responses and whether or not
Tinnitus Group Education was scheduled.
g. All patients who are referred to Tinnitus Group Education in person should be
given a copy of the handout “Why Should I Attend the Tinnitus Classes?”
Audiologists should be prepared to answer any questions about the potential
benefits of attendance.
Group Education
1. Group Education Class #1 (currently held on the second Tuesday of each month).
a. Two hours in length.
b. Prior to the beginning of the class
i. Patients are provided an envelope that they address to themselves. This
envelope is later used to mail the Group Education outcome measure to
the patient.
ii. Patients are guided through completion of the Tinnitus Functional Index,
or TFI (Meikle et al, 2012) and the Physical Health Questionnaire, or PHQ9
(Kroenke et al, 2001). A different questionnaire previously utilized in the
Audiology Group Education session for baseline and outcome
measurement was the Tinnitus Reaction Questionnaire, or TRQ (Wilson et
al, 1991).
iii. Patients are guided to provide estimates of the percentage of waking
hours that they are aware of their tinnitus (the Awareness %) and the
percentage of waking hours that they hear their tinnitus that it actually
disturbs them (the Disturbance %) on average over the past two weeks.
These two values then are multiplied to calculate the "Total Disturbance
%:" the percentage of waking hours the veteran is disturbed by the
tinnitus.
iv. Benton (in progress) demonstrated a powerful correlation between
scores on the TFI and the PHQ9. The PHQ9 is a screening instrument for
depression for use by non-mental healthcare providers.
1. Atlanta VA policy recommends that non-mental healthcare
providers complete the PHQ9 if a patient demonstrates suicidal
ideation.
2. Benton (2010) reported that 33% of patients attending Group
Education reported suicidal ideation as a result of tinnitus based
on responses to Question 24 of the Tinnitus Reaction
Questionnaire, or TRQ (Wilson et al, 1991), the instrument
previously used for baseline and outcome measurements. This
observation resulted in mental health screening via the PHQ9
being integrated into the Atlanta VA Tinnitus Program.
3. Audiologists are encouraged to pursue an understanding of the
scoring guide to the PHQ9 and to utilize it only if they are
comfortable doing so.
4. Based on the results of the PHQ9, primary care and/or mental
health providers are added as cosigners to the Group Education
progress note and appropriate referrals are made.
v. The utility of the Tinnitus-Hearing Survey, or THS (Henry, et al, 2008) is
being evaluated at this time. Data thus far indicate that the majority of
tinnitus patients with clinically normal hearing thresholds respond that
hearing difficulty causes more problems than the tinnitus. The findings
thus far suggest that the Tinnitus-Hearing Survey is not a helpful measure
and so it is not used.
vi. Patients are guided to estimate the percentage of waking hours that they
are aware of their tinnitus (Awareness % Value) and the percentage of
the time they are aware of their tinnitus that it is truly disturbing
(Disturbance Value). These values are multiplied together to obtain a
single "Total Disturbance %" value as a baseline measure.
c. Interactive slide presentation.
i. Various additional handouts are provided.
ii. Suicide prevention hotline information is included.
1. Any attendees who respond positively to question 9 of the PHQ9
(“Thoughts of hurting yourself or that you might be better off
dead”) are spoken to privately after the session and are offered
walk-in services at the Mental Health Clinic; the audiologist
accompanies the patient if required or desired.
iii. The underlying causes of tinnitus generation and tinnitus disturbance
(discordant damage/dysfunction theory and neurophysiological model of
tinnitus).
iv. The use of different types of sound to manage tinnitus in different
problem situations is discussed, and patients are guided to create Sound
Plans as a means of systematically evaluating different sounds for their
tinnitus-management effectiveness.
v. Homework is assigned (implementation and evaluation of Sound Plans)
and patients are reminded to be prepared to discuss their experiences at
the next session.
d. The Tinnitus Management Workbook (Henry et al, 2010) is provided to each
attendee, along with a demonstration of the CD and DVD included in each
workbook.
e. Progress note is entered into CPRS, including information about mental health
diagnoses and hearing aid status are included.
2. Group Education Class #2 (currently held on the fourth Tuesday of each month).
a. Two hours in length.
b. Review of previously provided information.
i. The underlying causes of tinnitus generation and tinnitus disturbance
(discordant damage/dysfunction theory and neurophysiological model of
tinnitus).
ii. Use of different types of sound to manage tinnitus in different problem
situations.
iii. Use of Sound Plans to systematically evaluate different sounds for their
effectiveness in providing tinnitus relief.
c. Review and discussion of homework - Sound Plan experiences.
d. Interactive slide presentation.
e. Various additional handouts are provided.
f. Progress note is completed.
3. Outcome Measurement
a. Four weeks after Class 2, all patients are mailed two outcome questionnaires:
Self-Efficacy for Managing Reactions to Tinnitus, or SMRT (VA NCRAR, 2010) and
the PHQ9.
i. A cover letter is included that asks the patients to provide comments and
to share examples of any Sound Plans they've utilized, Relaxation
Exercises from which they've benefited, Pleasant Activities they've tried,
and how they may have been Changing Thoughts and Reactions to
Tinnitus. General comments regarding their subjective impression of the
classes also are requested. Finally, the cover letter includes the critical
question “Do you feel you need further assistance working with your
tinnitus? YES NO”
ii. The outcome measure is sent to the patient using the self-addressed
envelope created at Class 1. A pre-addressed VA business-reply envelope
is included to facilitate return of the questionnaire at no charge to the
patient.
b. A total score is calculated for the SMRT.
i. All responses are added and divided by the number of questions
answered. Total SMRT scores range from 0-10.
ii. The SMRT contains six items that are near-verbatim duplicates of the
items that make up the Self-Efficacy for Managing Chronic Disease 6-Item
Scale, or SEMCD6 (Lorig et al, 2001). Original psychometric data revealed
a mean score of 5.2 among 605 individuals with multiple chronic
diseases. More recent normative data are available for a German version
of the scale (Freund et al, 2011) and revealed a mean score of 6.7among
244 individuals with multiple chronic diseases.
iii. At the Atlanta VA, we averaged the 849 SEMCD6 scores from the two
previous studies which resulted in a score of 5.6. We adopted this
composite score as the cutoff for the SMRT scale.
iv. The SMRT questionnaire also includes questions asking the veteran to
estimate his or her average Awareness % and Disturbance % for the
previous week.
c. Total Disturbance % values also are calculated and compared.
d. Question 9 of the PHQ9 (“Thoughts of hurting yourself or that you might be
better off dead”) is given special consideration, with proper notation in the
progress note with cosigners added as noted before if indicated.
e. Those patients who attended only Class 1 and who fail to demonstrate adequate
confidence based on SMRT responses and/or Total Disturbance % are
rescheduled for Class 2.
f. Patients are scheduled for an Individual Tinnitus Consultation if they attended
both classes and:
i. Fail to demonstrate adequate confidence indicated by a total SMRT score
of < 5.6.
ii. Respond YES to the question “Do you feel you need further assistance
working with your tinnitus?”
g. NOTE: it is not infrequent that patients will respond they do not feel they need
further assistance working with their tinnitus even though the SMRT and Total
Disturbance % suggest otherwise. In these cases, the veteran is NOT scheduled
for Individual Tinnitus Consultation.
Individual Tinnitus Consultation
1. The Individual Tinnitus Consultation varies depending on hearing aid status.
2. For aided tinnitus patients, optimal amplification must be verified.
a. These patients should have provided low responses on the 0-10 scale of tinnitus
relief related to hearing aids. If their scores were 7.0 or greater, they should have
exited PTM at Level 2 (prior to Level 3, Group Education).
b. Please review the hearing aid considerations for tinnitus patients discussed
above.
c. Different audiologists often have different orientations to hearing aid fittings,
especially when it comes to verification of amplification. It is therefore typical to
observe substantial differences in fitting paradigms and therefore in fitting
results.
d. Recommended procedure during the Individual Tinnitus Consultation:
i. Perform real ear measures to verify current aid performance.
ii. Adjust the aids’ performance to NALNL1 prescribed gain values.
iii. NOTE: NALNL1 is based on monaural fittings. As a result, most patients
will remark that while their binaural aids sound good when fit to NALNL1,
they are too loud. Reducing binaural overall gain by 4 dB usually results
more comfortable loudness and better sound quality. When adequate
high-frequency gain cannot be attained, gain reduction should be limited
to those frequencies where target was matched.
iv. After programming adjustments, the audiologist should inquire about
tinnitus relief: "On a scale of 0-10, where 0 means "My hearing aids
provide no tinnitus relief”, and 10 means "My hearing aids provide
complete tinnitus relief,” how would you rate your tinnitus right now?"
v. In our experience, most patients will report far better tinnitus relief if
substantial adjustments were required. For most aided tinnitus patients,
hearing aid reprogramming is all that is required to facilitate successful
tinnitus management.
3. For unaided tinnitus patients, completion of any required aspects of the audiologic
evaluation should be completed, including ultra-high frequency thresholds. For most
“normal-hearing” tinnitus patients (thresholds < 25 dB HL at 250-8000 Hz), abnormal
thresholds will be observed between 9000-12000 Hz.
a. Review the patient's audiological test results.
b. Again, owing to differences in various audiologists’ orientations to amplification,
it is typical to meet with a patient whose hearing is abnormal only at 4kHz and
above, or even at 6kHz and above, or have abnormal thresholds of only 30-35 dB
in the high frequencies. Careful consideration should be given to providing
hearing aids to patients whose hearing levels are normal through 3000 Hz or
whose high-frequency thresholds are 30-35 dB HL, given the potential for
significant tinnitus relief with aid use in this population.
c.
d. For those hearing-impaired patients who declined recommended amplification
at the original audiologic evaluation appointment, intensive counseling should
be provided to encourage the patient to undergo trial use of amplification since
hearing aid use is the least intensive, and often most successful, tinnitus
management strategy.
e. The patient's Completed Sound Plans and Changing Thoughts and Feelings
Worksheets are examined, reviewed and discussed.
i. If the patient demonstrates that he or she has not made a good faith
effort to implement the discussed strategies, Intensive counseling:
inability or unwillingness to at least try the various "easy" strategies
suggests that the patient likely would not be compliant with either of
more intensive individual treatments (i.e., Tinnitus Retraining Therapy or
Neuromonics Tinnitus Treatment), each of which requires substantially
greater patient effort.
ii. If the patient has demonstrated attempts to implement the various
strategies and has not been able to manage the tinnitus successfully:
i. Review the patient’s SMRT responses and provide further review
and directive counseling:
1. The underlying causes of tinnitus generation and tinnitus
disturbance (discordant damage/dysfunction theory and
neurophysiological model of tinnitus). Relate the patient's
audiological results to this discussion.
2. Review and creation of additional Sound Plans to manage
tinnitus in different problem situations through systematic
evaluation of different sounds for their effectiveness in
providing tinnitus relief.
b. Aided patients whose aids have been reprogrammed should be
allowed another use period before further management services
are provided. Typically, the patient is given a 30-day follow-up
appointment, at which time aided tinnitus relief is verified and
additional counseling is provided as appropriate.
c. Unaided tinnitus patients also may be given additional follow-up
appointment(s) as deemed appropriate.
d. For all patients additional appointments are considered PTM Level
5: Individualized Management
Individualized Management
The audiologist must determine based on multiple patient-related factors whether or not the
use of specific device-oriented treatment becomes necessary. Once the patient's individualized
management method has been chosen, proceed per the appropriate protocol.
Tinnitus Section: Atlanta VA Audiology Clinic Case History Form
TINNITUS (RINGING, BUZZING OR OTHER EAR OR HEAD NOISES)
Do you have tinnitus? __NO TINNITUS
__YES-BOTH EARS
How does it sound?
__YES-RIGHT EAR ONLY
__YES-LEFT EAR ONLY
__Ringing __Roaring __Hissing __Buzzing __Pulsing
__Other: ___________________________________
When do you hear your tinnitus?
__Crickets
__ Rarely (0-10% of the time)
__ Infrequently (11-25% of the time)
__ Sometimes (26-50% of the time)
__ Frequently (51-80% of the time)
__ Almost always (81-100% of the time)
IF YOU HAVE TINNITUS, MARK THE STATEMENT THAT BEST DESCRIBES YOUR TINNITUS
___ Grade 1. I only notice my tinnitus in quiet environments. It does not interfere with
my sleep or with my daily activities. I'm not really troubled by my tinnitus.
___ Grade 2. My tinnitus is easily covered up by background sounds and easily forgotten
during activities. It may rarely interfere with my sleep but it does not interfere
with my daily activities or quality of life.
___ Grade 3. I hear my tinnitus even in the presence of background sounds, but it doesn't
interfere with my daily activities. My tinnitus is not quite as noticeable when I'm
focused on other activities. My tinnitus occasionally interferes with my sleep and
occasionally interferes with quiet activities.
___ Grade 4. I hear my tinnitus almost always. It is rarely if ever covered up by background
sounds. My tinnitus regularly interferes with my sleep and can interfere with my
ability to carry out normal daily activities.
___ Grade 5. My tinnitus is always disturbing. It is a dominating problem that reduces my
overall quality of life.
On a scale of 0 to 10, where 0 means that your tinnitus is not a problem at all and 10 means it is
the worst problem imaginable, how do you rate your tinnitus?
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7-------- 8 -------- 9 -------- 10
Reference
McCombe et al (1999). Guidelines for the grading of tinnitus severity: the results of a working
group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons:
1999. Clinical Otolaryngology and Allied Sciences, Oct: 26(5): 388-93.
Tinnitus Severity Index
(This form is best completed by the audiologist in an interview format.)
Meikle MB, Griest SE, Stewart BJ, Press LS. Measuring the negative impact of tinnitus: a brief
severity index. (1995). Abstracts of the Association for Research in Otolaryngology, 1995; 167.
Never
Rarely
Sometimes
Usually
Always
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Does your tinnitus make it
uncomfortable to be in a quiet room?
1
2
3
4
5
Does your tinnitus make it difficult to
concentrate?
1
2
3
4
5
Does your tinnitus make it harder to
interact pleasantly with others?
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
How much of an effort is it for you to
ignore your tinnitus when you hear it?
1
Can easily
ignore it
2
Some
effort
3
Considerable
effort
How much discomfort do you usually
experience when your tinnitus is
present?
1
No
discomfort
2
Mild
discomfort
3
Moderate
discomfort
1
No
2
Sometimes
3
Often
4
Can never
ignore it
4
A great deal
of
discomfort
4
Always
Does your tinnitus make you feel
irritable or nervous?
Does your tinnitus make you feel tired
or stressed?
Does your tinnitus make it difficult for
you to relax?
Does your tinnitus interfere with your
required activities (work, home care, or
other responsibilities)?
social activities or other things you do in
your leisure time?
overall enjoyment of life?
Does your tinnitus interfere with sleep?
On a scale of 0 to 10, where 0 means that your tinnitus is not a problem at all and 10 means it is the worst problem
imaginable, how do you rate your tinnitus? 0 ---- 1 ---- 2 ---- 3 ---- 4 ---- 5 ---- 6 ---- 7---- 8 ---- 9 ---- 10
Circle any factors below that apply (possible etiological or exacerbating factors):
Tinnitus runs in the family
High doses of aspirin
Ear problems
Poor sleep / fatigue
Quinine or malaria drugs
Blood flow condition
High stress levels Mental health condition
Upper respiratory infection High blood pressure
Noise exposure
Thyroid condition
Diabetes
Lupus
Shingles
Audiological Assessment Progress Note: Tinnitus Section
Choices here are:
Rarely: 0-10% of the time
Infrequently: 11-25% of the time
Sometimes: 26-50% of the time
Frequently: 51-70% of the time
Most of the time: 71-99% of the time
Always: 100% of the time.
Choices here are:
No apparent need for specific tinnitus services.
Possible need for specific tinnitus services.
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Using Your Bedside Sound Generator
Most tinnitus patients tell us their tinnitus seems louder and more bothersome in silent places, like
when they are trying to go to sleep. A ticking clock in a sound-filled room sounds softer than the same
ticking clock in a very quiet or silent room. In the same way, tinnitus will sound softer in a sound-filled
room that in a silent room. Your sound generator creates low-level relaxing nature sounds that make it
harder for your brain to detect your tinnitus, and this makes it easier for you to relax and fall asleep.
There are eight different nature sounds to choose from, such as Thunderstorm, Lake Shore and Country
Eve. You may need to try different sounds to find the one that works best for you. You also can add any
number of different "overlay" sounds, such as Seagulls, Frogs or Loons, to make the nature sound more
realistic. The overlay sounds occur randomly without warning. If the overlay sounds are startling and not
beneficial, turn the overlay sounds off.
The sound generator has a one-hour timer; we recommend that you DO NOT USE IT. Let the device play
all night so that if you wake up, you will hear a relaxing nature sound instead of just your tinnitus.
Many patients report that using the separate speakers under their personal pillow makes the sound
generator even more helpful. The speakers fit into Velcro pockets on the custom pillow cover, allowing
the speakers to be removed so the pillow cover can be washed. These accessories can be especially
useful if your sleeping partner does not want to hear the nature sounds.
Remember: the sound generator is designed to create LOW-LEVEL relaxing nature sounds. The volume
of the nature sounds should never be turned up so loud that they actually cover up your tinnitus.
How Do I Use the Different Parts of My Sound Generator Kit?
Your kit comes with stereo pillow speakers, an extension cord for the speakers and a battery pack. These
items help you get the most use out of the sound generator. For bedtime use, set the sound generator
on your bedside table and plug the power cord and stereo speakers into the correct jacks on the back of
the device.
The battery pack lets you move the sound generator to other places without climbing behind your bed
to unplug the first power cord. Simply unplug the power cord and stereo speakers from the back of the
sound generator and carry it to any location where you wish to listen to it (such as your desk, your
favorite recliner, or for travel). Then plug the battery pack into the back of the sound generator in the
other location.
Use the extension cord for earbuds if you need them. You can easily return your sound generator to
your bedside by just plugging it back in to the other cords. .
You can use any headphones or earbuds that have a 1/8” headphone jack with your bedside sound
generator as well. Also, you can plug your pillow speakers into any sound device with a standard 1/8”
headphone jack, such as a mp3 player, a portable CD player, or your cell phone) so you can enjoy other
soothing sounds.
Helpful Tinnitus Information
What is Tinnitus?
Tinnitus is the medical term for the perception of sound in one or both ears or in the head
when no external sound is present. It is often referred to as "ringing in the ears," although
some people hear hissing, roaring, whistling, chirping, or clicking. Tinnitus can be intermittent
or constant-with single or multiple tones-and its perceived volume can range from subtle to
shattering.
How many people have tinnitus?
The ATA estimates that over 50 million Americans experience tinnitus to some degree. Of
these, about 12 million have severe enough tinnitus to seek medical attention. And about two
million patients are so seriously debilitated that they cannot function on a "normal," day-to-day
basis.
I have heard two different pronunciations. Which is correct?
Tinnitus has two pronunciations: tin-NIGHT-us or TIN-it-us. Both are correct, though the
American Tinnitus Association uses tin-NIGHT-us. The word comes from Latin and means "to
tinkle or to ring like a bell."
What causes tinnitus?
The exact physiological cause or causes of tinnitus are not known. There are, however, several
likely sources, all of which are known to trigger or worsen tinnitus.
Noise-induced hearing loss - Exposure to loud noises can damage and even destroy hair
cells, called cilia, in the inner ear. Once damaged, these hair cells cannot be renewed or
replaced. Hearing loss can also be caused by excessive noise exposure. Coincidentally,
up to 90 % of all tinnitus patients have some level of hearing loss.
Wax build-up in the ear canal - The amount of wax ears produce varies by individual.
Sometimes, people produce enough wax that their hearing can be compromised or their
tinnitus can seem louder. If you produce a lot of earwax, speak to your physician about
having excess wax removed manually - not with a cotton swab, but by a qualified health
care professional.
Certain medications - Some medications are ototoxic-that is, the medications are toxic
to the ear. Other medications will produce tinnitus as a side effect without damaging
the inner ear. Effects, which can depend on the dosage of the medication, can be
temporary or permanent. Before taking any medication, make sure that your prescribing
physician is aware of your tinnitus, and discuss alternative medications that may be
available.
Ear or sinus infections - Many people, including children, experience tinnitus along with
an ear or sinus infection. Generally, the tinnitus will lessen and gradually go away once
the infection is healed.
Jaw misalignment - Some people have misaligned jaw joints or jaw muscles, which can
not only induce tinnitus, but also affect cranial muscles and nerves and shock absorbers
in the jaw joint. Many dentists specialize in this temporomandibular jaw misalignment
and can provide assistance with treatment.
Cardiovascular disease - Approximately 3 percent of tinnitus patients experience
pulsatile tinnitus; people with pulsatile tinnitus typically hear a rhythmic pulsing, often
in time with a heartbeat. Pulsatile tinnitus can indicate the presence of a vascular
condition-where the blood flow through veins and arteries is compromised-like a heart
murmur, hypertension, or hardening of the arteries.
Certain types of tumors - Very rarely, people have a benign and slow-growing tumor on
their auditory, vestibular, or facial nerves. These tumors can cause tinnitus, deafness,
facial paralysis, and loss of balance.
Head and neck trauma - Physical trauma to the head and neck can induce tinnitus. Other
symptoms include headaches, vertigo, and memory loss.
Certain disorders - such as hypo- or hyper-thyroidism, lyme disease, fibromyalgia, and
thoracic outlet syndrome, can have tinnitus as a symptom. When tinnitus is a symptom
of another disorder, treating the disorder can help alleviate the tinnitus.
Do children get tinnitus?
Tinnitus does not discriminate: people of all ages experience tinnitus. However, tinnitus is not a
common complaint from children. Children with tinnitus are less likely than adults to report
their experience, in part because children with tinnitus are statistically more likely to have been
born with hearing loss. They may not notice or be bothered by their tinnitus because they have
experienced it their entire lives.
Children, like people of all ages, can be at risk for tinnitus if they are exposed to loud noises.
Recreational events like fairs or car races or sports games can all include high-decibels activities
that can damage kids' ears. Hearing protection is always recommended, as is a discussion about
the danger of loud noises and the choices kids have to turn it down or walk away.
My neighbor’s tinnitus doesn't bother her. Mine drives me nuts. Why the difference?
Approximately 50 million Americans experience tinnitus, but not everyone experiences it to the
same degree. Some people hear ringing or other noises in their ears immediately following
exposure to excessive noise, like right after a concert, but the sound is temporary. Other people
report hearing a slight noise all the time if they listen for it, but most of the time cannot
distinguish the noise over all the other sounds in their environment. Other factors can affect
the severity of the condition from patient to patient, such as different degrees of hearing loss
and different kinds of noises heard. Interestingly, the loudness of the tinnitus, when measured
in a laboratory setting, did not correlate to the severity of the tinnitus as rated by the patients
themselves. Every person has his or her own level of tolerance to the tinnitus sounds. It is a
very personal and individual experience.
Is tinnitus hereditary?
There appears to be a predisposition based on heredity for some people when they are
exposed to loud sounds, but whether or not tinnitus is genetically indicated is not certain.
Scientists working on the Human Genome Project, for example, have not discovered a "tinnitus
gene," but they have identified genes that are responsible for a few rare varieties of hearing
loss, temporomandibular joint (TMJ) dysfunction, Ménière's Disease, and acoustic Neuroma.
These conditions frequently include tinnitus as a side effect, which suggests that there might be
a connection. For now, however, a connection between your mother's tinnitus and your
tinnitus is still unknown.
Can a one-time exposure to loud noise cause tinnitus?
Many people write to the American Tinnitus Association asking if a one-time exposure to loud
noise experienced many years ago can cause tinnitus. Noise is damaging if you must shout to be
heard, if your ears hurt, or if your hearing is lessened immediately following noise exposure.
The noise exposure could occur just one time or over months or years. The level of noise can
affect the degree of hearing loss. For example, sounds of 100 decibels experienced for more
than 15 minutes can cause hearing loss. Sounds of 110 decibels experiences for more than a
minute can cause hearing loss.
A one-time exposure to loud noise is not guaranteed to cause tinnitus or permanent hearing
loss, since people's ears vary in sensitivity. It is also possible that the damage from noise
exposure might not be noticeable for many years.
Does tinnitus cause depression?
In some cases, yes. The chronic sound of tinnitus can cause difficulty with sleep, concentration,
reading, interpersonal relationships, and other everyday activities – all of which can lead a
person, especially one who is predisposed to it, towards a state of depression.
In a 2003 study on depression and tinnitus, researchers found that most people with tinnitus
were neither depressed nor seriously bothered by their tinnitus. But the patients who were
depressed were far more disabled by their tinnitus than the non-depressed patients. If
depression is a problem for you, it would be wise to seek help from a mental health
professional.
Is there anything I can do to protect myself from tinnitus?
First, protect your hearing. At work, make sure Occupational Safety & Health Administration
(OSHA) regulations are met: hearing protection is required under OSHA for any job in which
noise levels exceed 90 decibels over the course of an eight-hour workday. Many hearing
specialists counsel that this sound level is too high, and for some people, 90 decibels is still too
loud. Further, as noise levels increase, the recommended time of exposure decreases. OSHA
mandates that workplaces with excessive noise levels must protect workers by implementing a
continuing, effective hearing conservation program. In other words, wear your earplugs or
earmuffs, limit the amount of time you spend in noisy environments, and follow hearing
conservation guidelines established by your employer.
Recreational noise also has an impact on your hearing. The next time you are around a noise
that bothers your ears—for example, a sporting event, concert, or while hunting—wear hearing
protection, which can reduce noise levels 15 to 20 decibels. For extremely loud situations,
earmuffs over earplugs might be necessary. Be aware of other activities or situations that
include loud noises, like hair drying or lawn-mowing. Make it easy for yourself to protect your
ears by hanging earmuffs over the lawn mower handle. Repeated exposure to loud noises can
have a cumulative, damaging effect on your hearing.
If your physician prescribes you medications, be sure to ask if the prescribed medications are
ototoxic, or harmful to the ears, or if the drugs are associated with tinnitus as a side effect. This
information is easily obtained in the Physicians Desk Reference.
Frequently Asked Questions About Tinnitus
1. Can anything make tinnitus worse?
Exposure to loud noises, as mentioned earlier, can have a negative effect on your hearing and
exacerbate tinnitus. Be sure to protect yourself with earplugs, earmuffs, or by simply not taking
part in noisy events.
Some medications can make tinnitus worse. Tell all of your physicians—not just your ear, nose,
and throat doctor—about all prescription and over the counter medications you are currently
taking or have recently taken.
Many people find that alcohol, nicotine, and caffeine can worsen their tinnitus, as can eating
certain foods. Some people find that foods with a high sugar content or any amount of quinine
(tonic water) make their tinnitus seem louder. Monitor how you respond to different stimuli,
and find a healthy balance where you do not eliminate all the foods that you love, but also
where you do not unnecessarily exacerbate your tinnitus.
Finally, stress and fatigue can affect your tinnitus. Make time to relax, and understand that life
events can manifest themselves in your body in the form of increased tinnitus. Of course, this is
easier said than done. Finding a good support network can help.
What kinds of drugs are available to treat tinnitus?
There is no drug on the market designed specifically for tinnitus treatment. There are, however,
several medications that have provided many tinnitus patients with relief. But they are not
without their own caveats. For example, some medications that can help tinnitus are also habit
forming and should only be used when under the care of a physician who understands tinnitus.
The ATA has more information about various medications that can help, although ATA staff
cannot recommend medications. The ATA also distributes a list -- compiled by the Physician's
Desk Reference -- of medications that can cause tinnitus. This listing is available by calling the
ATA at (800) 634-8978. We do not have copyright permission to make this listing available
online.
What does "loud" mean?
We measure the loudness of sound in decibels (dB). Most experts recommend that you use
earplugs when exposed to 85 dB and above. But what does 85 dB mean? The following chart
shows common sounds and their associated sound levels.
20 dB
30 dB
40 dB
50 dB
60 dB
70 dB
80 dB
Ticking watch
Quiet whisper
Refrigerator hum
Rainfall
Sewing machine
Washing machine
Alarm clock (two feet away)
85 dB
95 dB
100 dB
105 dB
110 dB
120 dB
130 dB
Average traffic
MRI
Blow dryer, subway train
Power mower, chainsaw
Screaming child
Rock concert, thunderclap
Jackhammer, jet engine plane (100 feet away)
Noisy workplaces
The National Institute for Occupational Safety and Health (NIOSH) – an arm of the Centers for
Disease Control and Prevention – says that workers and others in loud environments should not
be exposed to sounds over 85 dB over an eight-hour period.
Noise-induced hearing loss (NIHL)
For many people, tinnitus is a symptom of hearing loss. More than 90 percent of American
Tinnitus Association members with tinnitus also report some hearing loss. For many, loss is at
the higher frequencies, which is often induced by exposure to loud noise.
Noise-induced hearing loss can be caused by a one-time exposure to a loud sound or by
repeated exposure to sounds over an extended period of time. You cannot "toughen up" your
hearing by regularly listening to loud noises.
Healthy hearing habits can help prevent hearing loss and tinnitus. However, the effects of loud
noises can worsen existing tinnitus and further degrade hearing. If you already have one or
both of these conditions, protect your ears from further damage. If you do not have them, learn
how to protect your hearing.
How damage occurs
Sounds of less than 80 dB, even after long exposure, are unlikely to cause hearing loss. It's
impossible to predict how individuals respond to loud noises – each person’s sensitivity to
sound is different. However, we know that exposure to a one-time-only or continuous noise can
cause temporary hearing loss. If hearing recovers, this temporary loss is called temporary
threshold shift, which typically disappears 16 to 48 hours after exposure.
Hearing loss can also be permanent if loud sounds damage or destroy the delicate ear cells in
your inner ear called cilia. Once these cells are damaged or destroyed, they cannot be repaired.
Research into regenerating inner ear cells is underway but has not yet advanced to the
treatment stage.
When you need hearing protection
This is the standard recommendation: use earplugs, earmuffs or other protection devices
when exposed to sounds above 85 dB. You probably don’t have a sound meter with you to test
decibel levels everywhere you go, so you can’t always be sure when your environment is too
loud. In general, if you are standing three feet away from someone and cannot hear what they
are saying, the noise level could be damaging your hearing.
How loud is too loud — an interactive Web site
Check out Dangerous Decibels, a great Web site for kids and adults alike, that tests your
knowledge of noise risk and just how loud sounds in our everyday lives can be. Hint: click on the
site’s “Virtual Exhibit” and have some fun.
MP3 players, iPods & your ears
One in three teens owns an MP3 player or iPod. Can listening to loud music with these personal
players damage their hearing? YES, and that can result in tinnitus.
Hearing conservation tips
In general, if you are standing three feet away from someone and cannot hear what they are
saying, the noise level could be damaging your hearing. Hearing conservation means protecting
your ears from excessively loud sounds:
Walk away from loud noises.
Turn down the volume.
Limit the intensity of the noise by not standing directly near its source.
Limit the time you expose your ears to loud noises.
Wear earplugs when you’re around sounds of 85 dB and above. Disposable foam
earplugs are inexpensive, easy to insert and effective.
Turn down your CD/cassette player, stereo or iPod.
Cross the street when you hear someone operating a leaf blower.
Wear earplugs at concerts/go to the back of the nightclub or outside to give your ears a
break.
Cover your ears with your hands when you’re walking past a jackhammer.
About earplugs
Keep a clean pair handy in your purse, backpack, wallet or pocket.
Wear earplugs during the trailers at the movies – their volume is typically cranked up.
Ask the manager at the movie theater to turn the volume down if it is too loud. Theater
staff will very often comply with this request.
Wear earplugs at amusement parks and concerts. Earplugs cut out just 15-20 dB so
you'll still be able to hear.
Wear earplugs or protective earmuffs when using power devices, e.g., lawn mower,
tool, vacuum and other noisy household appliances.
Read the labels for noise levels on appliances, children's toys and any product that
generates sound.
Learning to Manage Tinnitus
Learning to manage your tinnitus takes time. People who follow the techniques described
below habituate to their tinnitus. To the point where they are not emotionally disturbed by it
and they can lead full and productive lives. The fundamentals of learning to manage your
tinnitus are based on 4 steps that will be explained more fully in this section.
1. Overcoming your underlying fears of tinnitus
When you first get tinnitus, it is common to have many fears regarding your tinnitus such as:
Do I have a serious illness, brain tumor or blood clot?
Although 96% of all tinnitus sufferers have no treatable medical condition causing the
tinnitus, it is important that this possibility be eliminated by a thorough examination by
your General Practitioner and an ENT (Ear Nose and Throat) Specialist.
Will my tinnitus drive me insane?
There have been no reported cases of tinnitus causing insanity
Will it get louder?
Generally not
Will it continue forever?
Although there are cases where tinnitus has spontaneously disappeared, it is the
exception rather than the rule. It is best to assume that you have it for the longer term
and learn to manage it.
It can't be cured
There are many researchers that are working on more fully understanding tinnitus,
however do not live in hope of a miracle cure. Learn to manage it and get on with your
life.
I will have no more peace and quiet
Very rarely do we have absolute quiet. Most times there are ambient and
environmental noises around us. Being in an absolutely quiet environment is unnatural
for humans. You still able to enjoy peace and tranquility.
It will interfere with my concentration
The ability to concentrate will improve over time as you habituate to the tinnitus.
2. Having the Correct Perception of your Tinnitus
Orr brain takes in sounds and classifies them according to whether they are threatening,
neutral or non-threatening sounds. When the conscious mind classifies these sounds, the sub
conscious mind has an automatic reaction to the sound the next time it is heard. This pattern
will continue unless the conscious mind re-classifies the sound.
When the conscious mind first hears tinnitus, it cannot correlate the sound with anything that it
has heard, so our survival instincts means the brain will classify it as possibly threatening and
will place the body and mind in a state of high alert for possible 'fight or flight'.
If the conscious mind maintains that perception of tinnitus, each time that you hear your
tinnitus, the sub-conscious mind will put your body and mind into a state of high anxiety which
no person or animal can maintain for long without becoming dysfunctional.
It is therefore crucial that you perceive tinnitus as it truly is
i.e. non-threatening. Although it is annoying, it cannot
harm you in any way. The objective for any tinnitus
sufferer is to habituate to the tinnitus. If you perceive
tinnitus as threatening, you are in a vicious cycle of stress
and anxiety as illustrated by the following example and
you cannot habituate to your tinnitus.
3. The Importance of Not Focusing on your Tinnitus
The more a person focuses on their tinnitus, the louder it will appear and the more distressed
they will become. One of the critical aspects of learning to manage your tinnitus is shifting your
focus from the tinnitus to something more pleasurable. This can be an activity such as walking,
gardening, reading (although this can be difficult in the early stages), listening to relaxing music
or any activity that you enjoy that absorbs your mind.
An example of how this works is the case of a small child that falls over and grazes its knee. The
child runs crying and distressed to its mother. After inspecting the knee and giving the child a
hug, the mother will ask whether the child would like a chocolate biscuit, the child stops crying
and the pain of the grazed knee disappears as the focus of the child's mind is shifted from the
knee to the chocolate biscuit.
It is worthwhile writing down the things that you enjoy doing so that when your tinnitus is bad,
you can mentally refer to this list and do one or more of the activities that you have identified
as likely to shift your focus from the tinnitus. In the early stages shifting your focus is not always
easy. It takes practice and perseverance. As you become better at it, you will notice that there
are more and longer periods each day when you become aware that you have not been
listening to your tinnitus and you are on the way to successful management and habituation to
your tinnitus.
4. Adjusting your Lifestyle
The anecdotal evidence of a link between stress and the exacerbation of tinnitus is very strong.
It is therefore important that you reduce the amount of stress in your life whenever possible.
Although stress is a part of everyday life, recognizing those periods of stress and being
proactive about reducing the stress levels by undertaking relaxation therapies is important in
managing your tinnitus.
Exposure to loud noise
Loud noise will exacerbate tinnitus. Ear muffs or ear-plugs should be worn when activities such
as mowing the lawn or using a chainsaw are undertaken. Venues such as nightclubs or
entertainment venues that have excessively loud noise should be avoided or ear protection
used. If you have to shout to make yourself heard by someone standing within 1 to 1.5 meters
of you, the noise level is considered excessive and it will exacerbate your tinnitus.
Excessive use of alcohol or recreational drugs
Different people's tinnitus reacts to different stimuli. Some of the more common everyday
products that cause a temporary increase in tinnitus when used in excess are caffeine
(chocolate, cola drinks, coffee - more than 6 cups per day), red wine, nicotine and spicy foods.
Many prescription and non-prescription drugs also exacerbate tinnitus . When your doctor
prescribes a drug for you, ask them to check whether the drug has a side effect of tinnitus. If it
has, ask whether there is an alternative that could be used. It is also worth noting when your
tinnitus is more troublesome whether you have had anything unusual in your diet that may
have caused the increase. That is not to say that you should avoid those items altogether. Just
be aware that they may cause a temporary increase in your tinnitus. Living with tinnitus is
difficult enough without giving up things that you enjoy.
Environmental Sound Enrichment
Jonathan Hazell, Director, Tinnitus and Hyperacusis Centre, London
Tinnitus frequently emerges in quiet places. The auditory system evolved in the presence of
continuous nature sound. Silence is unnatural and associated with danger and evokes a warning
response. Environmental sound enrichment is required 24 hours a day with non-stimulating
sounds that are pleasant, and never result in an aversive reaction.
Modern sound environments versus nature
In nature, there is a continuous background of nature sounds. Silence is a warning signal,
usually indicating the arrival of a predator. In modern society, we have constructed solid
buildings, which exclude sound, and are often double-glazed to reduce heat-loss. This means
that the rooms we live and work in can have very low levels of natural back ground noise,
particularly at night.
In many countries, especially in the west, there is a tendency for smaller social units, with more
people, particularly older people, living alone in very quiet surroundings. The ready availability
of earplugs means that they are often used, not just to protect the ear from damage, but also
to avoid hearing any sounds, particularly at night. With an increasing number of older people in
our populations, there are many more with varying degrees of hearing loss. Proper use of
hearing aids is far below what is needed, and this has the effect of imposing relative silence as
well.
One feature of our western culture is the way in which silence is imposed in childhood. We are
told be quiet when we go to bed / do your homework etc. It is during these times that
childhood tinnitus emerges, as well as the development of behavioral patterns for seeking
silence in adult life. We even have the saying ‘Silence is golden.’ It is NOT!
Effects of reduced environmental sound
Tinnitus is experienced by anyone who listens carefully in a quiet room for 5 minutes. Most of
us do this every night of our life when we retire to a quiet study, lounge or bedroom. It is
perhaps surprising that we can do this for so many years without having any experience of
tinnitus. Animal experiments have shown us that the auditory system itself increases in
sensitivity when background noise drops below a certain level, resulting in increased gain, or
amplification, of external sounds. This means that there is more chance of picking up very weak
sounds in silence, rather than in enriched environments.
Loudness of any sound depends on the contrast between the signal and any background noise.
Consider listening to a car radio on the motorway, with the volume up at a comfortable
listening level, and then driving onto a quiet side road or a garage. The radio can then cause
loudness discomfort for a normal listener. In silence, the loudness of even quiet sounds may be
perceived as very loud, particularly if they have strong meaning (e.g. a burglar alarm at night
200 yards down the street). For the same reason, tinnitus will sound very loud if there is no
other sound in the environment (no enrichment). In silence, the attention focus of the brain can
only be directed to the one sound that is present: tinnitus. There is no possibility of not hearing
it.
Changes in the auditory system can only occur if it is being stimulated with sound. These
changes are necessary for the habituation (or blocking) of intrusive external sounds and
tinnitus. Plasticity (the ability to change or reprogram) is reduced by silence. Reduced
stimulation of hearing nerve connections, such as without amplification or as a result to an
aversive reaction to sound, results in habituation being slowed down significantly.
These effects continue during sleep. The cortex is in a low state of activity in sleep, so we have
no conscious awareness of ourselves, or our environment. However, at this time, subconscious
pathways and auditory filters needed for selective hearing, function normally. The failure to
enrich our sound environment during sleep means the effectiveness of sound stimulation in
increasing plasticity, is reduced by at least one third.
Reasons for seeking silence
There are many reasons why we have a natural tendency to seek silence. Many people try to
live in a silent world because of the dislike of unwanted, unannounced visitors, or a telephone
call, or the sounds of a noisy city. The belief is "no sound = no intrusion." However the quieter it
becomes, the more easily we can hear softer and further-away sounds, which in turn results in
a greater need for greater protection from even these soft sounds. Silence may be considered
by many to be peaceful and relaxing, but our autonomic nervous system activity actually
increases in silence, getting us ready for the possibility of predator attack! The best
environment for relaxation is one enriched by nature sounds.
It is common to develop quite strong views about what is acceptable in terms of other people
making noise. Decreased tolerance for sound is often considered normal behavior. The dislike
for ordinary everyday sounds is much more common in patients with tinnitus, and indeed 40%
have pre-existing sound sensitivity.
Normality of environmental sound enrichment
The art of sound enrichment is very old and found in many ancient civilizations, most notably
perhaps in Japan, where waterfalls, fountains and wind chimes have always been a part of
architecture and landscaping. A very important job in Japan is that of the "waterfall tuner."
Most people find that the sounds of nature are enjoyable and relaxing. Being in the garden or
on the beach is, for most people, a relaxing experience. Even tinnitus and hyperacusis patients
find these places peaceful, and often report that tinnitus disappears completely when they are
on vacation. The sounds of rain can be soothing and calming, and generally is not intrusive in
the way that man-made sounds may be.
Part of the reason for this is that our hearing system developed in a sound-rich environment,
with nature sounds always present. It is only over the last few hundred years that buildings
have effectively excluded nature sounds.
Sleep is a problem for many people. Sound enrichment improves sleep quality in everyone, and
it for this reason that devices simulating the sounds of nature, or CDs with recordings of nature
sounds, are being sold widely for this purpose.
Types of sound enrichment
Perhaps the best natural sound enrichment is nature itself. For country-dwellers, it may be
possible to have the window open all the time; otherwise, it is important to create sounds
inside the home where we spend the majority of our time. In the past, household equipment
has been recommended as a simple available sound source, such as large fans, fish tanks, etc.
Where these sounds are a normal part of the home environment, they can be helpful, but the
volume is not easy to control. Water features are excellent, such as indoor and outdoor
fountains and waterfalls which are widely available. The sounds of water are particularly liked
and well tolerated.
Radios, TV and music should be used only when they are part of normal recreation, when you
normally would listen to them. Just leaving these devises on all the time as sound enrichment is
not recommended. All music and speech has meaning, and thus they stimulate the autonomic
system at a time when we are trying to reduce reactivity. The use of quality equipment for
presenting any sound enrichment ensures good quality and realistic sounds which will be more
relaxing.
We encourage the use of sound generators which have a selection of electronically reproduced
nature sounds. These devices are much easier to control, to move about, or even to take away
on trips. CDs and tapes of nature sounds are useful, but the content may vary and change,
making them attention-seeking and therefore less effective and less relaxing. All sound
enrichment should be continuous and not just used for a short period, such as just for getting
to sleep; instead, leave the device on all night.
Features and requirements of sound enrichment
Sound enrichment should not mask or cover up your tinnitus. Habituation cannot occur to a
sound you cannot hear. When you first turn on your sound source check that you can still hear
your tinnitus, and that is hasn’t altered or changed. If you have a hearing loss then test them
with your hearing aids turned to their normal listening setting.
It is essential that any sound enrichment never produces any aversion, dislike or results in
increased arousal. Introducing a new sound into the environment that evokes a negative
reaction will simply make matters worse. It may take some time and experimentation to find
the sound that you like that that produces relaxation. It is also important that the family should
also find the sounds pleasant and non-intrusive. Usually this is not a problem since family
members realize the importance of this part of treatment and usually understand that sound
enrichment is good for everyone.
Sound enrichment should be used 24 hours a day, particularly at night. Not using sound
enrichment at night reduces the effectiveness of treatment by at least one third (the time you
are asleep!). Because the parts of the hearing mechanism that are important in tinnitus
management are ‘awake’ during sleep, sound enrichment should always be used at this time. It
is a good idea to leave the sound enrichment source on at all times in the bedroom, so that it
becomes a part of the "bedroom furniture". For those who have a hearing impairment and a
partner who cannot tolerate the sound enrichment, a pillow speaker can be very valuable.
The benefits of sound enrichment
Many patients experience an immediate reduction in tinnitus intrusiveness and severity with
sound enrichment, although this is a very individual response. Soon there should be improved
sleep and reduced wakefulness. Environmental sounds will be less intrusive. Sound enrichment
produces an overall reduction in activity in the autonomic nervous system. Autonomic nervous
system activity levels are high in patients with tinnitus - sound enrichment helps to reduce this
overall high level of activity. Sound enrichment also reduces the contrast between or tinnitus
and the background and therefore reduces the perceived loudness of tinnitus.
Helpful Hints for Better Sleep
Poor sleep habits are among the most common problems encountered in our society. We stay
up too late and get up too early. We interrupt our sleep with drugs, chemicals and work, and
we over-stimulate ourselves with late-night activities such as television. Below are some
essentials of good sleep habits. Many of these points will seem like common sense. But it is
surprising how many of these important points are ignored by many of us. Click on any of the
links below for more information:
Your Personal Habits
Fix a bedtime and an awakening time. Do not be one of those people who allow
bedtime and awakening time to drift. The body "gets used" to falling asleep at a certain
time, but only if this is relatively fixed. Even if you are retired or not working, this is an
essential component of good sleeping habits.
Avoid napping during the day. If you nap throughout the day, it is no wonder that you
will not be able to sleep at night. The late afternoon for most people is a "sleepy time."
Many people will take a nap at that time. This is generally not a bad thing to do,
provided you limit the nap to 30-45 minutes and can sleep well at night.
Avoid alcohol 4-6 hours before bedtime. Many people believe that alcohol helps them
sleep. While alcohol has an immediate sleep-inducing effect, a few hours later as the
alcohol levels in your blood start to fall, there is a stimulant or wake-up effect.
Avoid caffeine 4-6 hours before bedtime. This includes caffeinated beverages such as
coffee, tea and many sodas, as well as chocolate, so be careful.
Avoid heavy, spicy, or sugary foods 4-6 hours before bedtime. These can affect your
ability to stay asleep.
Exercise regularly, but not right before bed. Regular exercise, particularly in the
afternoon, can help deepen sleep. Strenuous exercise within the 2 hours before
bedtime, however, can decrease your ability to fall asleep.
Your Sleeping Environment
Use comfortable bedding. Uncomfortable bedding can prevent good sleep. Evaluate
whether or not this is a source of your problem, and make appropriate changes.
Find a comfortable temperature setting for sleeping and keep the room well
ventilated. If your bedroom is too cold or too hot, it can keep you awake. A cool (not
cold) bedroom is often the most conducive to sleep.
Block out all distracting noise, and eliminate as much light as possible.
Reserve the bed for sleep and sex. Don't use the bed as an office, workroom or
recreation room. Let your body "know" that the bed is associated with sleeping.
Getting Ready For Bed
Try a light snack before bed. Warm milk and foods high in the amino acid tryptophan,
such as bananas, may help you to sleep.
Practice relaxation techniques before bed. Relaxation techniques such as yoga, deep
breathing and others may help relieve anxiety and reduce muscle tension.
Don't take your worries to bed. Leave your worries about job, school, daily life, etc.,
behind when you go to bed. Some people find it useful to assign a "worry period" during
the evening or late afternoon to deal with these issues.
Establish a pre-sleep ritual. Pre-sleep rituals, such as a warm bath or a few minutes of
reading, can help you sleep.
Get into your favorite sleeping position. If you don't fall asleep within 15-30 minutes,
get up, go into another room, and read until sleepy.
Getting Up in the Middle of the Night
Most people wake up one or two times a night for various reasons. If you find that you get up in
the middle of night and cannot get back to sleep within 15-20 minutes, then do not remain in
the bed "trying hard" to sleep. Get out of bed. Leave the bedroom. Read, have a light snack, do
some quiet activity, or take a bath. You will generally find that you can get back to sleep 20
minutes or so later. Do not perform challenging or engaging activity such as office work,
housework, etc. Do not watch television.
A Word about Television
Many people fall asleep with the television on in their room. Watching television before
bedtime is often a bad idea. Television is a very engaging medium that tends to keep people up.
We generally recommend that the television not be in the bedroom. At the appropriate
bedtime, the TV should be turned off and the patient should go to bed. Some people find that
the radio helps them go to sleep. Since radio is a less engaging medium than TV, this is probably
a good idea.
Other Factors
Several physical factors are known to upset sleep. These include arthritis, acid
reflux with heartburn and headaches
Psychological and mental health problems like depression, anxiety and stress are
often associated with sleeping difficulty. In many cases, difficulty staying asleep
may be the only presenting sign of depression. A physician should be consulted
about these issues to help determine the problem and the best treatment.
Many medications can cause sleeplessness as a side effect. Ask your doctor or
pharmacist if medications you are taking can lead to sleeplessness.
To help overall improvement in sleep patterns, your doctor may prescribe sleep
medications for short-term relief of a sleep problem. The decision to take sleeping
aids is a medical one to be made in the context of your overall health picture.
Always follow the advice of your physician and other healthcare professionals. The
goal is to rediscover how to sleep naturally.
Examples: Factory "First-Fit" NAL-NL1 Algorithm vs. REM NALNL1
Speech-Mapping vs. Real-Ear Measures.
Custom Clinic Hearing Aid Questionnaire
Hearing Aid/Tinnitus Questionnaire
Progress Note Addendum
S:
A completed survey evaluating the outcome of the veteran's
recent hearing aid fitting was received today.
O/A:
The outcome survey consisted of three parts:
1. The International Outcomes Inventory for Hearing Aids (IOI-HA:
Cox, Hyde & Gatehouse, 2000), a valid and reliable tool
consisting of seven questions using a 5-point rating scale.
The IOI-HA was designed to assess benefit, satisfaction, and
quality-of-life changes associated with hearing aid use.
Veteran's responses to the IOI-HA were compared to normative
values (Cox, Alexander & Beyer, 2003).
-----------------------------------------------------------------QUESTION
NORM
VETERAN'S SCORE
-----------------------------------------------------------------1. Use
3-5
2. Benefit
3-4
3. Residual Activity Limitation
2-4
4. Satisfaction
2-5
5. Residual Participation Restriction
3-4
6. Impact on Others
2-5
7. Quality of Life
3-4
8. Difficulty Without Aid
n/a
-----------------------------------------------------------------*** Veteran's responses to all items are within the normative range.
No further actions related to IOI-HA responses are necessary at
this time.
***Veteran's responses to all items are within the normative range
with the exception of _.
*** Further actions related to the veteran's IOI-HA responses may be
warranted to improve treatment outcome.
2. Other factors contributing to successful aid use, including
practical issues related to physical comfort, sound quality and
communication success in different sound environments. Veteran's
responses indicated:
*** appropriate adjustment to the new aids; veteran denied any
desire for a follow-up appointment at this time.
*** specific practical issue(s) impacting successful use of the
hearing aids that may warrant further actions: _
3. Assessment of possible tinnitus relief provided by the hearing aids.
On a scale of 0 to 10, where 0 means the hearing aids provide no relief from
the tinnitus and 10 means the hearing aids provide complete relief, veteran
rated the tinnitus relief from his hearing aids as _, indicating the aids are
providing adequate / inadequate relief from the tinnitus.
Patients who report minimal tinnitus relief may require further tinnitus
services and may benefit from attending Tinnitus Group Education.
P:
Veteran to contact clinic for hearing aid assistance as needed.
Veteran declined offer of appointment for hearing aid adjustment.
Need for Tinnitus Group Education will be assessed at that
appointment.
Veteran was scheduled for Tinnitus Group Education.
Veteran was scheduled for a HEALTH TECH SUPPORT appointment on a
routine basis within 30 days.
The veteran was scheduled for a hearing aid fitting follow-up
appointment on a routine basis within the next 60 days to address
factors resulting in unsuccessful hearing aid treatment outcome.
Why Should I Attend the Tinnitus Classes?
The Tinnitus Classes help veterans manage their tinnitus successfully. Each of the two Tinnitus
Classes class is two hours long. Please make sure you can stay for the entire length of each class by
double-checking for any conflicts (such as your VA appointments). If you have some a conflict and
will not be able to stay for the entire class, you will not get the results you need. If this happens,
please reschedule the classes. You must attend Class #1 first and then Class #2.
Class #1
Tinnitus Class #1 is two-hour program that helps veterans learn the main theories about what
causes of tinnitus, why it can be so disturbing and annoying and how to use different types of sound
to get your tinnitus under control so it doesn't control you. You will learn:
 How to use Interesting Sound to help direct your attention away from the tinnitus;
 How to use Soothing Sound to experience relief from anxiety, tension and stress that
causes, or is caused by, your tinnitus
 How to use Background Sound to make it harder for your brain to detect your tinnitus.
You will learn how to create effective Sound Plans to figure out which sounds work best for you for
specific problem situations. Also, you will learn relaxation techniques to reduce stress and tension
associated with your tinnitus. You will receive the Managing Your Tinnitus workbook and handouts
of all of the Tinnitus Class materials for review and use at home. The workbook includes a DVD of all
the material presented for reviewing at home along with a CD of different types of interesting,
soothing (relaxing) and background sounds for you to try out. Additionally, you will receive a list of
internet resources for free music, nature sounds, guided relaxation, guided imagery and other
sounds to help you get your tinnitus under control so it doesn't control you.
Class #2
Tinnitus Class #2 also is a two-hour program that builds on the information given in Class #1. You
must attend Class #1 first and then Class #2. We will briefly review the information you learned in
Class #1 and we will review your Sound Plans and how they worked for you. Then, you will learn
new information about changing your reactions to tinnitus and changing your thoughts about
tinnitus. More information is provided about relaxation techniques, and we will talk about other
ways to direct your attention away from your tinnitus. Our goal is to help you control your tinnitus
so it doesn’t control you.
How Will the Tinnitus Classes Help Me?
After attending both Tinnitus Classes, most veterans find that they feel less stressed about tinnitus,
almost never think about tinnitus, feel like tinnitus is not much of a problem and feel like there is no
need for further help with their tinnitus.
Tinnitus Functional Index
Meikle et al (2012). The tinnitus functional index: development of a new clinical measure for chronic,
intrusive tinnitus. Ear and Hearing, Mar-Apr;33(2):153-76.
Patient Health Questionnaire (PHQ-9)
Kroenke, K, Spitzer, R, Williams, J (2001). The PHQ-9: Validity of a Brief Depression Severity Measure. Journal of
General Internal Medicine, 16(9): 606-613
Tinnitus Reaction Questionnaire (TRQ)
Wilson, P, Henry J, Bowen, M and Haralambous, G. (1991). Tinnitus Reaction Questionnaire: Psychometric
properties of a measure of distress associated with tinnitus. Journal of Speech and Hearing Research, 34: 197-201.
Percentage of time you were awake that you were AWARE of your tinnitus: _______ %
Percentage of time that you HEAR your tinnitus that it DISTURBS you:
_______ %
This questionnaire is designed to find out what sort of effects tinnitus has had on your lifestyle, general well-being,
etc. Some of the effects below may apply to you and some may not. Please answer ALL questions by circling the
number that best reflects how your tinnitus has affected you OVER THE PAST WEEK.
A little Some
A good
Almost
Not
of the of the
deal of
all of
at all
time
time the time the time
1. My tinnitus has made me unhappy.
2. My tinnitus has made me feel tense.
3. My tinnitus has made me feel irritable.
4. My tinnitus has made me feel angry.
5. My tinnitus has led me to cry.
6. My tinnitus has led me to avoid quiet situations.
7. My tinnitus has made me less interested in going out.
8. My tinnitus has made me depressed.
9. My tinnitus has made me feel annoyed.
10. My tinnitus has made me confused.
11. My tinnitus has "driven me crazy."
12. My tinnitus has interfered with my enjoyment of life.
13. My tinnitus had made it hard for me to concentrate.
14. My tinnitus has made it hard for me to relax.
15. My tinnitus has made me feel distressed.
16. My tinnitus has made me feel helpless.
17. My tinnitus has made me feel frustrated with things.
18. My tinnitus has interfered with my ability to work.
19. My tinnitus has led me to despair.
20. My tinnitus has led me to avoid noisy situations.
21. My tinnitus has led me to avoid social situations.
22. My tinnitus has made me feel hopeless about the future.
23. My tinnitus has interfered with my sleep.
24. My tinnitus has led me to think about suicide.
25. My tinnitus has made me feel panicky.
26. My tinnitus has made me feel tormented.
Suicide Risk Flag
Tinnitus-Hearing Survey (Henry et al, 2008)
Not a
problem
Over the last week, I couldn’t
understand what others were saying
in noisy or crowded places.
understand what people were saying
on TV or movies.
Over the past week, I couldn’t
understand people with soft voices.
understand what was being said in
group conversations.
Over the last week, tinnitus kept me
from sleeping.
from concentrating on reading.
from relaxing.
Over the last week, I couldn’t get my
mind off my tinnitus.
Over the last week, every day sounds
were too loud for me.
Being in a meeting with 5 to 10
people would be too loud for me.
A small
problem
A moderate
problem
A big
problem
A very big
problem
For a Number of Internet Sound Resources, Please Visit:
http://www.SteveBentonAuD.weebly.com
Tinnitus Group Education Class # 1 Progress Note
S:
Patient attended Tinnitus Group Education Class #1 of 2.
Veteran has previously been identified as having disturbing
tinnitus which might benefit from further management.
*** Veterans with co-existing mental health disorders report greater
disturbance from tinnitus than those without co-existing mental
health disorders (Benton, 2011). Veteran's CPRS *Problems* tab
and other NOTES include the following mental health diagnos(es):
*** Veteran previously was diagnosed with hearing loss. Hearing aid(s)
were provided by the veteran's primary audiologist.
*** Veteran previously was diagnosed with hearing loss. Hearing aids
were recommended by the audiologist but veteran declined.
*** Veteran previously was diagnosed with hearing loss. Veteran's
primary audiologist reported that hearing aids were not warranted
due to the nature and/or configuration of the loss.
*** Veteran previously has been found to have normal hearing thresholds
through 8000 Hz.
O/A:
Prior to the start of the program, all attendees were asked to
provide four measures:
1. A global perception of overall tinnitus severity using a 5-point
response scale:
Not a Problem
A Small Problem
A Moderate Problem
A Big Problem
A Very Big Problem.
2. The Tinnitus Functional Index, or TFI (Meikle et al, 2012), a
reliable and valid measure of overall tinnitus severity covering
eight domains with excellent sensitivity to treatment-related change.
TFI scores range from 0-100 with higher numbers indicating greater
tinnitus severity.
3. Estimates of the total percentage of waking hours over the
past week that veteran has been aware of the tinnitus
(Awareness %) and the percentage of that time veteran was truly
disturbed by the tinnitus (Disturbance %). These estimates then
are used to calculate the veteran's Total Disturbance Value;
that is, the percentage of waking hours that veteran was
disturbed by the tinnitus.
4. The PHQ9 (Kronke et al), is a concise, self-administered
screening tool for depression. It is designed to improve the
recognition rate of depression and anxiety, thus facilitating
diagnosis and treatment.
The veteran's pre-Group Education responses were:
----------------------------------------Global Severity
----------------------------------------TFI - Score
----------------------------------------Tinnitus Awareness %
Tinnitus Disturbance %
Total Disturbance % (A x D)
----------------------------------------PHQ-9 Score
----------------------------------------(n/a = not answered)
TFI scores range from 0-100 and may be interpreted as follows:
0-25 Little or no need for intervention
26-50 Possible need for intervention
51+
Likely need for intervention
PHQ9 scores range from 0-27 and may be interpreted as follows:
1-4
Minimal depression
5-9
Mild depression
10-14 Moderate depression
15-19 Moderately severe depression
20-27 Severe depression
Veteran responded YES NO to the PHQ9 question, "In the past 2 years, have
you felt depressed or sad on most days, even if you felt okay sometimes?"
Veteran responded to the PHQ9 question 10, "If you checked off any
problems, how difficult have these problems made it for you to do
your work, take care of things at home, or get along with other people?"
as:
"not difficult at all."
"somewhat difficult."
"very difficult."
"extremely difficult."
Because a small percentage of veterans with disturbing tinnitus
report that their tinnitus has led to thoughts of suicide, all
attendees were informed about VA suicide prevention services and
were given the Suicide Prevention Hotline phone number. Attendees
also were informed that question 9 of the PHQ9 asks specifically
about suicidal ideation related to tinnitus. Attendees were instructed
to speak with the audiologist immediately following the Tinnitus Class
for immediate referral to Mental Health Service (Walk-In) if they had
active plans for suicide, had attempted to obtain the means for
committing suicide or had previously attempted suicide.
*** Veteran denied any suicidal ideation per response to
Question 9 of the PHQ9.
*** Veteran reported suicidal ideation related to tinnitus per
response to Question 9 of the PHQ9.
*** Records indicate that veteran IS NOT currently being followed
by VA mental health clinic(s).
*** Veteran's most recent MH progress note was dated:
*** The patient's primary care provider and/or mental health care provider
if the patient currently is being seen by MH Clinic) was/were added
as cosigner(s) to this note to assure their awareness of veteran's
status.
Tinnitus Group Education Class #1 then consisted of a two-hour program
which included numerous educational components, including the nature
and causes of tinnitus, the use of sound to manage tinnitus disturbance
and annoyance through contrast reduction and the use of music and other
relaxation techniques to reduce stress associated with tinnitus.
Veteran was provided a personal copy of the workbook "Managing Your
Tinnitus" for reference at home and reproducible copies of all
associated worksheets. The workbook includes a DVD of the material
presented today for viewing at patient's convenience for review as
well as a CD of different types of interesting, relaxing and
background sounds. Additionally, veteran was provided a listing of
internet resources for free music, nature sounds, guided relaxation,
guided imagery and other sounds to facilitate proactive selfmanagement of tinnitus.
Diagnosis is 388.31 - tinnitus.
P:
Patient was encouraged to implement the strategies discussed
today for reduction of tinnitus annoyance.
Veteran to return for Tinnitus Group Education Class #2 in two weeks
for Sound Plan review and discussion of additional strategies for
managing disturbing tinnitus.
The clinic will mail a follow-up TFI/PHQ9 questionnaire to veteran
approximately 4 weeks after Tinnitus Group Education Class #2 to
assess management outcome, allowing adequate time for veteran to
develop and evaluate Sound Plans and other strategies for reduction
of tinnitus annoyance. A determination then will be made regarding
any possible need for an individualized tinnitus management
appointment.
Using Sound During Pleasant Activities
1. What type of PLEASANT ACTIVITY are you enjoying? Remember: do something you WANT
or LIKE to do, not something you HAVE to do!
a. Educational? Learning how to operate a computer.
b. Artistic? Paint a mural on the living room wall.
c. Social? Call a buddy.
d. Athletic? Take a walk around the neighborhood.
e. Relaxation? Read a book.
2. What TYPE OF SOUND is most appropriate for that PLEASANT ACTIVITY?
a. Background Sound. Eliminates silence which makes your tinnitus less noticeable.
i. Music (usually without words).
1. Computer speakers.
2. Mp3 player.
ii. Environmental Sound.
1. Sound generator.
2. Open the windows (on a nice day).
iii. Speech – typically not recommended, but some people do well with a TV
playing in the background.
b. Interesting Sound.
i. Music (usually with words).
2. Mp3 player.
3. Portable "boom box."
1. Sound generator.
2. Open the windows (on a nice day).
3. Could ask a friend to work with you (Interesting Sound-conversation).
iii. Speech
1. Cell phone conversation.
a. Bluetooth headset for cell phone conversation.
b. Cell phone by itself.
2. Home phone conversation.
3. Face-to-face conversation.
4. Books on tape (mp3 player, CD player).
5. Speeches, sermons (recorded via mp3 player, CD player, TV, Radio)
c. Relaxing Sound.
i. Music (usually without words).
2. Mp3 player.
1. Sound generator.
2. Open the windows.
iii. Ask a friend to work with you (Interesting Sound-conversation, speech).
1. Cell phone conversation.
a. Bluetooth headset for cell phone conversation
b. Cell phone by itself.
2. Home phone conversation.
3. Face-to-face conversation.
4. Books on tape (mp3 player, CD player).
Tinnitus Group Education Class # 2 Progress Note
S:
Patient attended the Tinnitus Group Education - Class 2 program.
Veteran had previously attended Audiology Tinnitus Group Education Class 1,
at which time veteran was provided a personal copy of the workbook
"Managing Your Tinnitus" for reference at home and reproducible copies of
all associated worksheets. The workbook includes a DVD of the material
presented today for viewing at patient's convenience for review as well as
a CD of different types of interesting, relaxing and background sounds.
Additionally, veteran was provided a listing of internet resources for free
music, nature sounds, guided relaxation, guided imagery and other sounds to
facilitate proactive self-management of tinnitus.
O/A:
Class 2 consisted of a two-hour program which included numerous educational
components, including a brief review of information provided in Class 1:
Primary causes of tinnitus
Why tinnitus can be so disturbing
Using sound to manage tinnitus
Creating and implementing Sound Plans
New information was then introduced according to Progressive Tinnitus
Management protocol regarding changing reactions to and thoughts about
tinnitus as a complement to the use of Sound Plans.
Specifically, information was divided into three sections:
Relaxation
Pleasant Activity Planning
Changing Thoughts About Tinnitus
Various exercises were completed within a supportive group environment
to demonstrate the information provided.
Diagnosis is 388.31 - tinnitus.
P:
The clinic will mail a follow-up questionnaire to veteran in
approximately 4 weeks to assess management outcome, allowing adequate time
for veteran to implement and evaluate the discussed strategies for
reduction of tinnitus annoyance. Based on a comparison of pre- and postGroup Education TFI scores, a determination then will be made regarding
any possible need for an individualized tinnitus management appointment.
All attendees were informed that if an individualized tinnitus management
appointment is indicated, they will be required to bring their completed
Sound Plans and other worksheets for review. They also were informed that
failure to demonstrate a good-faith effort to implement the strategies
would preclude progression to more intensive tinnitus management strategies.
Tinnitus Group Outcome Progress Note Addendum
S:
Veteran's Tinnitus Group Outcome questionnaire was received today.
The questionnaire was composed of:
1. The Self-Efficacy for Managing Reactions to Tinnitus, or SMRT
(Henry, et al ), a 17-item questionnaire evaluating a patient's
confidence that he or she can manage tinnitus successfully using
sound and other strategies and skills taught as part of the
Atlanta VA's Progressive Tinnitus Management program.
The SMRT contains six items that are near-verbatim duplicates of
the items that make up the Self-Efficacy for Managing Chronic Disease
6-Item Scale, or SEMCD6 (Lorig et al, 2001). Original psychometric
data revealed a mean score of 5.2 among 605 individuals with multiple
chronic diseases. More recent normative data are available for a
German version of the scale (Freund et al, 2011) and revealed a mean
score of 6.7 among 244 individuals with multiple chronic diseases.
At the Atlanta VA, we averaged the 849 SEMCD6 scores from the two
previous studies which resulted in a score of 5.6. We adopted this
composite score as the cutoff for the SMRT scale.
The mean of all 17 SMRT responses is the total SMRT score. Lower
scores indicate lower self-confidence for managing tinnitus.
Although norms are not yet available, in this clinic total SMRT
scores above 5.6 are considered indicative of adequate confidence
for managing tinnitus and are consistent with no need for further
tinnitus management.
2. The PHQ9 (Kronke et al), is a concise, self-administered
screening tool for depression. It is designed to improve the
recognition rate of depression and anxiety, thus facilitating
diagnosis and treatment.
O/A:
The veteran's current total SMRT score and current and previous PHQ-9 scores
are shown below. post-Group Education Outcome measures are compared to
veteran's pre-Group Education measure below:
------------------------------------------------Measure
Current
Previous
------------------------------------------------SMRT Score
XXX
------------------------------------------------Awareness %
Disturbance %
Total Disturbance % (A X D)
------------------------------------------------PHQ-9 Score
------------------------------------------------(n/a = not answered)
Veteran responded YES NO to the PHQ9 question, "In the past 2 years, have
you felt depressed or sad on most days, even if you felt okay sometimes?"
Veteran responded to the PHQ9 question 10, "If you checked off any
problems, how difficult have these problems made it for you to do
your work, take care of things at home, or get along with other people?"
as:
"not difficult at all."
"somewhat difficult."
"very difficult."
"extremely difficult."
Because a small percentage of veterans with disturbing tinnitus report that
their tinnitus has led to thoughts of suicide, all Tinnitus Group Education
attendees have been informed about VA suicide prevention services and have
been given the Suicide Prevention Hotline phone number. Question 9 of the
PHQ-9 asks specifically about suicidal ideation.
*** Veteran denied any suicidal ideation per response to PHQ-9
Question # 9.
*** Veteran reported suicidal ideation per response to PHQ-9
Question # 9.
*** Records indicate that veteran IS NOT currently being followed
for mental health issues.
*** The patient's primary care provider and mental health care provider
(if the patient currently is being seen by MH Clinic) have already
been made aware of the veteran's status.
*** Veteran's total SMRT score is consistent with NO need for further
Tinnitus management.
*** Although veteran's post-group responses are consistent with an
improvement in overall tinnitus disturbance, results continue
to indicate significant tinnitus disturbance.
*** Veteran continues to experience disturbing tinnitus and is unable to
manage his tinnitus successfully using only the knowledge, tools and
skills provided at Audiology Tinnitus Group Education.
*** Veteran's outcome are consistent with no need for any further tinnitus
management. Veteran has demonstrated the ability to manage the tinnitus
successfully using only the knowledge, tools and skills provided at
Audiology Tinnitus Group Education.
*** Veteran wrote the following regarding use of the information provided
in the classes (these are exact transcriptions):
1. Sound Plans:
2. Relaxation:
3. Planning Pleasant Activities:
4. Changing Thoughts About Tinnitus:
5. The Tinnitus Classes in General:
6. Do you feel you need more help to manage your tinnitus?
P:
*** Veteran's total SMRT score is consistent with no need for further
tinnitus management. Veteran will contact the clinic for assistance on an
as needed basis.
*** However, veteran failed to attend Class # 2 of tinnitus Group Education.
Veteran will be scheduled for Class # 2.
*** Although the total SMRT score suggests that veteran may benefit
from further tinnitus services from VA, veteran reported there was no
need for further tinnitus services from VA.
*** Veteran was scheduled for individual tinnitus consultation, at which
time we will review the various strategies veteran has implemented
per previous recommendations. Determination of any need for
comprehensive tinnitus assessment and any individualized tinnitus
management will be made after review of these strategies.
Group Education Outcomes: SMRT and PHQ9
Dear Veteran,
It has been about four weeks since Tinnitus Class # 2, so I've enclosed a questionnaire to find
out how you are doing since you learned various strategies and skills to manage your tinnitus.
In the classes, we talked about Sound Plans, Relaxation, Planning Pleasant Activities and
Changing Thoughts About Tinnitus. I hope you have learned to use these strategies to control
your tinnitus, rather than have it control you.
Also, I am very interested in any comments you may be able to provide about what you learned
from the classes. Please return this sheet with the attached questionnaires. Thank you!
NAME: ______________________________ SSN: _____________________ DATE: _______________
1. Please share one of your Sound Plans _______________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
2. Please share an example of Relaxation you tried _______________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
3. Please share an example of how you Planned Pleasant Activities __________________
_____________________________________________________________________________________
_____________________________________________________________________________________
4. How have you been Changing Thoughts About Your Tinnitus? ____________________
_____________________________________________________________________________________
_____________________________________________________________________________________
5. What did you think of the Tinnitus Classes? ________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
6. Do you feel you need further assistance working with your tinnitus?
YES
NO
Please send back THIS SHEET along with THE QUESTIONNAIRES in the enclosed postage-paid
pre-addressed envelope. I look forward to learning how you've been and what you think.
Thank you!
SBenton, Au.D.
Tinnitus Questionnaire 1
Over the PAST TWO WEEKS:
What percentage of waking hours were you AWARE of your tinnitus? ______%
What percentage of the time you were AWARE of your tinnitus did it actually BOTHER you? ______%
Tinnitus Questionnaire 2
Over the last 2 weeks, how often have you been bothered by
any of the following problems concerns?
Not
at all
Several
days
In the past 2 years, have you felt depressed or
sad on most days, even if you felt okay
sometimes?
Yes
No
If you checked off any of the above problems,
how difficult have these problems made it for
you to do your work, take care of things at
home, or get along with other people?
Not
difficult
at all
Somewhat
difficult
More than
half the
days
Nearly
every day
Very
difficult
Extremely
difficult
Little interest or pleasure in doing things.
Feeling down, depressed or hopeless.
Trouble falling or staying asleep, or sleeping
too much
Feeling tired or having little energy.
Poor appetite or overeating.
Feeling bad about yourself – or that you are
failure or have let yourself or your family
down.
Trouble concentrating on things, such as
reading the newspaper or watching television.
Moving or speaking so slowly that other
people could have noticed. Or the opposite –
being so fidgety or restless that your have
been moving around a lot more than usual.
Thoughts that you would be better off dead,
or of hurting yourself in some way.
4-dB Gain Reduction for NALNL1 Binaural Loudness Effect
Best Match to NALNL1
-4dB at All
Matched
Frequencies
Best Match to NALNL1
-4dB at All
Matched
Frequencies

Atlanta VA Medical Center Tinnitus Program

Transcription

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