A Clinician’s Perspective of Neuromonics Tinnitus Treatment

This is a transcript of a Neuromonics live webinar on AudiologyOnline.  Please download supplemental course materials.

Marta Hecocks: Hello and welcome everyone. We are so glad that you are with us today for this live presentation of A Clinician’s Perspective of Neuromonics Tinnitus Treatment.  I am Marta Hecocks with Neuromonics, and I am pleased to introduce Dr. Barbara Jenkins, CEO of Advanced Audiology and also President of the Tinnitus Treatment Center, both located in Centennial, Colorado.  Dr. Jenkins holds a Doctorate of Audiology Degree from the Arizona School of Health Sciences and was the first board certified audiologist in the state of Colorado.  She has over 25 years of hospital and clinical experience and, during those years, has been passionate about improving the lives of individuals with auditory impairments.

Some of Dr. Jenkins’ accomplishments include being an esteemed fellow of the Tinnitus Practitioners Association and a forensic audiologist and legal expert.  She founded the Hear to Work Program for the Sertoma Organization.  She is the founder and sponsor of the Samaritan House Health Fair for Homeless Children of Colorado and the co-founder of Mexico’s first school for deaf children.  Dr. Jenkins has received numerous awards and recognitions, which include being selected by the Governor to serve as Colorado’s State Commissioner for the Deaf and Hard of Hearing, being an American Academy of Audiology (AAA) Scholar for numerous years, receiving the National Audiology Humanitarian of the Year Award in 2008, and receiving the 2010 Leo Doerfler Award for Excellence in Clinical Care and Lifetime of Dedication to Others.  In addition, Dr. Jenkins is currently writing a book on tinnitus and tinnitus treatment due out sometime next year.  Dr. Jenkins, it is wonderful to have you with us today, and I am turning the microphone over to you.

Dr. Barbara Jenkins: Good morning.  This class is not a class for learning about tinnitus in rote numbers; we are not going to go over the specifics of tinnitus.  I am going to ask each of you how much tinnitus experience you have and, specifically, how much Neuromonics experience you have.  This class is going to give my perspective on the tinnitus patients that I have seen and how Neuromonics has worked for some of those patients.  This class is really for you and for me to learn more about how Neuromonics can help us so that we can help our tinnitus patients.

The purpose of this class is to get information as to how to best determine if this treatment is what is best for your patient.  Then when we determine, yes, this may be what is best for my patient, how do we go about fitting it most proficiently and effectively for that patient so that the end result is as good as possible?  I want each of you to type in your response box and let me know how much tinnitus experience you have, and if you are proficient in Neuromonics, then we can gear the class to that.  I do want you to keep that in mind, though, your other classmates may not have the same experience you do, so there may be some aspects of the class that we go over that you already know even better than I do, in fact.  That is okay; bear with it.  There will be snippets of information throughout the class that will help every one of you, even if you are proficient in it.  If you have never used Neuromonics before or are new to treating tinnitus in any respect, I think this is going to be a very good class for you to determine whether you should move forward with Neuromonics.

A disclaimer here: I am not paid by Neuromonics; I have never been paid by Neuromonics.  I do use the Neuromonics Oasis for some of my patients.  I do use other treatments for some of my patients.  I use my own behavioral treatment for some of my patients.  So, this is not specifically what Neuromonics will tell you, and there might be some aspects or things in here that I tell you that may go off the beaten path a little bit, and that is okay, I want you to take those into consideration and use those specifically for what you need.  Furthermore, if there are ever any questions, call the Neuromonics audiologist and say, “Hey, I learned this in a class.  What do you recommend?”  It can be just like when you are a beginning audiologist first learning hearing aids; you have to follow protocol specifically because that is how you learn and get better. However, after you have had 10, 15, or 20 years of experience treating patients with hearing aids, you may do things a little off-protocol because you have learned some things in your clinic that may be better for your patients. 

One example I have here is for some of our pediatric patients. When we do conditioned play, sometimes we will put on the audiogram “less than or equal to 10dB,” and we will test no lower than 10 dB.  That will show us that that patient has normal hearing, but we are not going to spend the time to go below that because that little child may, in fact, tire too easily and then we would miss a lot of information.

Consequently, if you read about some of the things I am going to tell you here in the Neuromonics book and what I say is different, I would say follow the Neuromonics book until you feel comfortable making your own decisions and changes as you see fit.  It would not be smart for me today to come here and presume that I am a better tinnitus or hearing aid provider than you.  Just as there are many different styles in determining which hearing aids are best for each patient, you will create your own style and your own expertise, so to speak, with regard to how you evaluate and treat your tinnitus patients.

I can have four different patients walk into the office a day, each one a tinnitus patient, and they may in fact have similar hearing loss, but each one I may leave with a different idea of what treatment might be best for them.  It is going to be your job as the audiologist to hone your expertise so that you are better able to offer different treatments for the patient.

Today, we are just going to talk about one of those possible treatments, and that is going to be because we want you to become conversant with Neuromonics as much as possible.  By utilizing my experience and my failures in Neuromonics, hopefully you will become more proficient at it, and when you determine that it is the right treatment for your patient, you will be better prepared to treat that patient.  Also, I do want to give you a forewarning, this is not a visual class, and that is because the information that I am giving to you today is not textbook information, per se.  It is information gained on experience that is not necessarily protocol, so keep that in mind.  If there is one slide up for quite a long time, just listen to what we say, pay attention to those aspects that you need extra help in, and the parts that you think you are proficient in, feel good about that and say, “I do know this, and what I do is copasetic with what she does, so maybe we are all doing the right thing.”

Let’s see.  Instead of trying to write everything down, just write down the things that you garner important for you.  Every student in today’s class will be writing down different things.  If you are listening closely the test should not be that difficult for you.  Sit back, hopefully you have your cup of coffee, and we will learn together on this.

The wonderful thing about advice is that you do not have to take it. Listen a lot, learn some and implement what works for you.  So many audiologists shy away from tinnitus patients.  In fact, I know a few otologists and ear-nose-throat physicians (ENTs) that do as well.  Perhaps that could make you the audiologist you need to be, the go-to audiologist in your state or area.  Dealing with tinnitus is no more difficult than dealing with hearing loss.  With proper training you will learn to treat a tinnitus patient with as much expertise and finesse as you do your hearing aid patients. 

Think back to the very first hearing aid you provided.  I have heard people say that they tried Neuromonics in their clinic and it did not work.  Well, if you think back to the first hearing aid you tried and if you did not have someone helping you and that patient returned the hearing aid, are you going to say, “I am sorry, hearing aids do not work for hearing loss.”  No, that is not what it is at all.  With proper training and experience, we can help everyone to hear better, no matter the hearing loss, configuration or severity. You can help 90 percent of hearing loss patients.

Can you cure their hearing loss?  No, not at all, but maybe with hearing aids, you can lessen the severity and you can teach them to cope with the hearing loss they continue to have.  Tinnitus is no different, with proper training and experience, you will be able to take almost any patient with tinnitus and treat it, and then help your patient to cope more effectively with whatever remains.  Just like with hearing loss, our goal is not necessarily to cure it, but to lessen its severity.  By teaching your patient to cope with the tinnitus, you will have done your job.

A little bit about me- you heard the introduction.  I have been around for a long time, but for the last 15 years I have been focusing on tinnitus and becoming more and more of a tinnitus expert.  It all started when I had a decorated military officer who had had tinnitus since World War II and, together, for years and years, we tried to work on anything.  We tried everything we could think of that the American Tinnitus Association would give us, and finally when Neuromonics came up, he was my first Neuromonics patient, and what a doll.  He knew he was a guinea pig, and he had no problem being a guinea pig.  Now his tinnitus is greatly reduced.  Does he still have it?  Yes.  Does it bother him?  Not nearly as much as it did before.  So I am hoping that you can do that for your patients as well.

Do All Roads Lead to Oasis?

It sounds nice.  Each clinic is going to be different, and each patient that you see will be different.  I do use Neuromonics for many of my patients, and it is one thing I fall back on if one of the other treatments that I like to use does not work.  We are going to go over which patients have the most success with the Neuromonics device.  Some of the guidelines that I have learned over the years are not the same guidelines that Neuromonics has; they are not in conflict, I just may add a little bit to them.

Personality

First off is personality information.  Personality, in my opinion, is one of the more important factors in determining which patient will best utilize the Neuromonics device and is most likely to succeed.  Usually I can tell within a few minutes of meeting the patient.  I am not using a protocol to determine personality, but there are four guidelines that I would like to give you. 

The first person is a details person or an engineer.  The details person will probably walk in with a pile of paperwork, folders and pencils ready to garner more information from you.  This is the same person you see and identify when they are coming in for hearing aids.  They are cognizant about all the aspects and conversant on all the aspects of hearing aids.  They probably have researched more about tinnitus than some audiologists, and they definitely know more about tinnitus and possibly Neuromonics than their own physician.

Just a little sideline here: most physicians get about an hour and a half treatment and therapy information in medical school; I have learned that from primary care physicians.  Yes, ENTs get more, but your primary physician needs your input on tinnitus, and they want that information.  The details person has some benefits to him, because he is going to be one of the most compliant patients you have ever had for the Oasis device.  Unfortunately, he is going to focus on the device and the treatment, which can be a detriment because we want the patient to put it on and forget it.

The other type of person is a trained musician.  You will even see this on the Neuromonics information sheet.  The trained musician listens to details of music more than most of us, and this can be detrimental to the treatment if they do not listen to it and forget it.  If you and I walked into a symphony and after the symphony you would say, “Did you hear that B flat?” And I would say, “What B flat?  I do not know a B flat from an F sharp.” But if I practiced and focused, the next time I went to the symphony I might hear the B flat and the F sharp.  Well, we are not hearing anything different; it is just my brain is better able to focus on those details with that experience.  To the musician, though, that extra focusing on sound can be detrimental, just like the details person can have some detrimental side effects to it.  Just keep these things in mind.

The next patient I want you to consider is the needy person, as we call it in our clinic.  This is the person that needs an attachment or a crutch to some disease, and they identify with it.  This will be the person who has been going to tinnitus therapy treatments for years and they tell everyone about their tinnitus; tinnitus is an identifier for them.  And the problem is, if you take this crutch away from them, if you try to take this tinnitus away from them, they have nothing else by which to identify; it has become one of their primary focuses.

We have a psychologist here in Denver, Dr. Smith, who actually is an expert on tinnitus, and we have discussed many joint patients together, especially those that we give another crutch.  If I see a patient like this, I may refer to him specifically to Dr. Smith because I want him to be able to get them away from thinking about the tinnitus so much as a part of who he is.  We need to separate the tinnitus from the patient for the Neuromonics treatment to work.

The last patient would be the compensated patient.  I had a compensated patient just yesterday, and although he is very compliant with the treatment, he is not seeing much benefit.  I am not sure if that is because he is not actually getting much benefit, one, because he says he likes it, it works, it is comforting for him, but then if he notes no benefit, his compensation goes down and he is not going to be getting the compensation he had.  It is just another thing to keep in mind.  None of these factors are precluding factors for using Neuromonics; you just have to be aware of them, and if your patient comes with one of these factors, deal with it appropriately so that when problems come up later you know how to deal with them.

Cost

Cost factors are real and have to be dealt with.  First off, tinnitus treatment itself does not necessarily have to be expensive, but I would like to use the term value on the treatment more than cost on the treatment.  I am not getting away from the cost.  Neuromonics is probably the most expensive treatment that I provide, but I do it because it is also one of the most beneficial for many of my patients.  The reason for that is because of your time involved.  You are not simply selling an Oasis transmitter.  You are providing a six-month or more treatment modality to your patient to deal with that tinnitus.  Their tinnitus has affected them for months, maybe years, and it can take their brain a lot of time to unlearn the habit of listening to it.  This treatment modality is the best one to do that, but with your expertise and your time and the Neuromonics device, that can be expensive for the patient.

At our office, we charge the patient about $245.00 to sit down with me for about 45 minutes of my time and discuss their treatment options, what may be causing their tinnitus, underlying medical aspects and all of that.  After we have decided that we are going to move forward with tinnitus treatment, we charge $395.00 for the physical tinnitus evaluation.  The tinnitus evaluation is the part on the Neuromonics form where you go into the sound booth and you do your due diligence in specifically finding where their tinnitus is, within 2 dB.  The reason I split that out separate from the device and other treatment is that if the patient does not qualify or if a patient decides not to go ahead with it, then you have still been appropriately compensated for your time.

What you charge for the device is going to be predicated on what you, as an audiologist, pay for the device, which is pretty much the same for most people, and your area.  We have some places here that charge $5,500 to $5,600 for the device and treatment; we have some that charge only $3,900 for the device and some of the treatment.  It depends on your office.  We have not had any luck billing in the cost for insurance, and that is why we have set up the Tinnitus Treatment Center as a specific independent clinic.  When someone comes in for a tinnitus evaluation, in the beginning it may be at our Advanced Audiology Clinic, but if they want the Neuromonics device, they have to come to our tinnitus clinic, Tinnitus Treatment Center.  The reason for that is that we do not take any insurance at the Tinnitus Treatment Center.  If they want to bill insurance for it, they can file the claim themselves, but we are not then bound by having to take an insurance company’s 50 percent or no payment scenario, which we have all heard happens with hearing aids. It is just not worth our time to do it that way.

I look at it similar to a dentist's work - the cost is high but is it worth it.  If you need a dental implant, yes, you need a dental implant.  And no, dental insurance usually does not cover it or they cover a lessor version of it, but if you need that and want that, it is worth it to the patient.  If that patient is really having problems with their tinnitus, it is your job as the audiologist to let them know that this is a viable treatment with a more-than-90-percent success rate at reducing tinnitus by at least 30 percent.  It is a real option, and it is a very good value for the correct patient.

Audiometric Data

Sometimes not all patients are going to benefit from the Neuromonics device, pending audiometric changes.  Most patients with hearing loss are going to be able to use the Neuromonics device.  There is a protocol in the book.  The single-sided deafness patient is a little bit more difficult.  The Neuromonics device does, though, have a protocol for that, and if you are new to the Neuromonics device, you may not know that.  If you have a patient with a specific type of hearing loss that is outside the typical range, that is another time to talk to the audiologist at Neuromonics and give them the specific details.  It may or may not be a precluding factor for that patient, and if it is, then you need to sort out different treatments that that patient may use.

Other than single-sided deafness, we have patients come to the clinic a lot of times saying that they do not have any hearing loss, and I look at their audiogram, and it was only tested out to 8,000 Hz.  You, as the tinnitus provider, know that that is not sufficient; you must test the higher frequencies.  In our clinic it is standard to test at 9,000 10,000 and 11,000 Hz as well.  Now, if you do not have that built into your audiometer, it can be built in.  Call your technical support person for your audiometer.  However, most audiometers have at least 8,000 and 12,000 Hz built in.

It is not fair to your patient to say that you are a tinnitus provider who can diagnose and treat tinnitus but not test out further where the tinnitus can occur.  I have had actually two in the last month come in with “normal audiograms” and when they are tested at 9, 10 or 11kHz, we can see a significant drop-off in both ears.  That would be a perfect patient for the Neuromonics treatment.  Always look over and above if they tell you they do not have a hearing loss.  Let them know that your evaluation is more detailed and that it may still be something that they can use.

Lifestyle

I think this is one of the most overlooked considerations, by me included, because compliance after you start using the device is such an important factor.  I had a patient in last week for his eight-week follow-up, and his compliance was horrible even though our follow-up phone call seemed fine.  However, the day after he got his device he went on vacation and then he came back and he was doing all this engineer stuff, and he did not have the time to be compliant.  If I had asked him ahead of time, we could have either postponed the treatment so it could have been more viable for him instead of him trying to get it in and then getting frustrated because the treatment was not working for him.  He got upset with the treatment because it was a burden to him instead of something he was looking forward to.  So do look at all those factors before you decide on the Neuromonics, and even if they are Neuromonics patient, you will want to decide if this is, in fact, the right time for them to try Neuromonics.

Tinnitus Reaction Questionnaire

The Tinnitus Reaction Questionnaire (TRQ; Wilson, Henry, Bowen & Haralambous, 1991) is probably the most important tool you have in treating any tinnitus patient. I do not care if it is Neuromonics; I do not care if they have mild to intermittent tinnitus; I do not care how severe it is.  The TRQ is one of the most important tools you will ever use.  When a patient calls our office, our front desk person will ask them, “Are you here for hearing or ringing in the ears or both?” If a patient says, “Well, I have some ringing in my ears,” we are going to hand them the TRQ when they walk into the office along with their intake sheet.  This is important for any patient who says they have tinnitus.  How severe is their tinnitus?  Sometimes they say, “Oh, it is not severe at all,” but you look at the TRQ and you find there are some aspects where it is affecting their life.  Sometimes they will say it is horrible, but then when they start to fill out this form they say, “Wow, I guess my tinnitus is not as bad as I thought.”  It is verification for the patient and verification for you.

If you do not give them the TRQ, it is like a patient going to see their doctor telling them their hearing loss is not so bad so they do not need a screening and the doctor says, “Okay, then we will not do it.”  That is like a patient telling you that they have tinnitus but it is not too bad so we do not need to screen it, and so we do not even bother with it.  The doctor should screen for hearing loss whether the patient thinks it is severe or not, and you as the audiologist should screen for tinnitus no matter what the patient says.  Many times we give this questionnaire to the patient and they mark all 0s, report they hear their tinnitus maybe 5 percent of the time and it bothers them 0 percent of the time, even though they denoted tinnitus that is great.  We have that verification in their chart and then we can spend all our time focusing on what their needs are.

In our clinic, we have added a couple of questions to the TRQ.  How severe is your tinnitus, what percentage of the day do you notice your tinnitus, and what percent of the time does your tinnitus bother you.  Those are critical aspects, and I will show you the reason why we added those to the TRQ.

Most patients have never rated their tinnitus before, and in doing so, it actually opens their mind up and helps them to think a little bit.  This first question, “Is my tinnitus mildly obtrusive, moderately, significant, severe, or profound,” is eye opening, but it actually can be a little confusing for the patient.  They may say, “Well, sometimes it is mild, sometimes it is severe.”  I have had patients circle mildly obtrusive and then write in during the day and severe at night.  That is going to help you, and it will help determine how to move forward with their tinnitus.  This is their perception on it.  If you have a details person, though, they are going to have a problem filling this out; let them know that any answer is fine; we want a quick answer- we do not want them thinking about it.  If you ask, “In the last week, how severe was your tinnitus?” they might respond, “Oh, in the last week it has been about moderate, but two months ago…” It does not matter; in the last week it was moderate.

The next addition to the TRQ is I notice my tinnitus what percent of the time and it bothers me what percent of the time. I did notice that a couple years ago Neuromonics did not have this on their TRQ and now they do, but a couple years ago one of the reps came to my office and saw it on mine so I am taking credit for it.  Anyway, it does not matter either way.  Most patients have never rated their tinnitus, and this one could be as confusing as well.  This is the question that is most often confusing to the patient, so you want to frame the question for them if they need clarification.  Yes, they may have tinnitus all the time, but how much do they actually notice it?  I have my tinnitus 100 percent of the time but I only notice it 70 percent of the day.  Pop in a number; there are no rights and wrongs to this.

And also, what is meant by bothered?  If they are confused by that, you can use the word frustrated, aggravated, annoyed, bugged, anything like that.  This is just getting a perception of how much it is in their frontal cortex.  This is actually a neurological question for me.  The first part, I notice my tinnitus what percent of the day, is how much their amygdala or limbic system is sending the signal to their frontal cortex.  The second part, how much it bothers me, the percentage of time that it actually bothers them to any degree, is how much their limbic system or amygdala is involved in the process. This is very important diagnostically later on and it will tell you a lot about the patient.  I notice my tinnitus 100 percent of the day, but it bugs me 0 percent of the day is a lot different than the person who notices their tinnitus 20 percent of the day but it bugs them 100 percent of that time.  Each of those patients should be treated differently in that regard.  If a patient has not filled out a TRQ before, we do have our staff go ahead and help them fill it out before they see us.

Scoring

I like to tell the patient to fill this out quickly and not to think too much or do too much second guessing in this area.  This is, again, difficult for the details person, but it is very important to have them fill it out with reference to the last week.   There are specific areas in here I want to focus on.  After they have filled it out, look at columns 3 and 4 for the information.  If there are any 3s or 4s circled, I want to look at those and ask the patient specifically about those areas.  Questions 5, 8, 16, 19, 22, 24, 25 and 26 are the strongest emotionally, but that does not mean you need to disregard the other ones.  Any one of these can affect a patient’s understanding of their tinnitus and how it affects their life.

There are two questions specifically that I want to look at as medically significant.  The first one is number 23, because it has to do with sleep issues.  If a patient scores a 3 or 4 on this question, it needs to be addressed because this is also going to help determine if Neuromonics or a hearing aid is going to be most beneficial for this patient.  Let’s say you have a patient coming in and their tinnitus only bothers them a little bit of the time but, boom, you see it is a level 4 for sleep.  Is a hearing aid going to help that patient?  Probably not. Neuromonics might be the perfect device for that patient, even if they score lower than the official 17 score that they need to be considered significant for a Neuromonics device.

The second important question is number 24, addressing suicidal thoughts.  Any score above 0 on question 24 needs to be addressed specifically, and a referral should be made to their doctor or a psychologist.  Again, let me emphasize that on question 24, any score above 0 needs to be addressed and a referral should be made.  We do not know what suicidal thoughts really mean.  We do get patients in saying they circled it, but they are not serious. But others are serious.  If you just look at the bottom score of the whole questionnaire and you do not look at those questions specifically, you may be missing something severe.  It is not very frequent, but I have had patients who have had thoughts of suicide.  I have been called by one of the hospitals here because a patient actually did hang himself.  He was not successful, thankfully, but when asked why he did it, he said it was this ringing in the ears.  Well, the patient had never been asked about it, so there was no fault involved.  But if you have a TRQ filled out and they are considering it, you need to determine if they are serious or not.

There is another question on there regarding depression.  Look at that one as well, because there are depression inventories that the psychologist and family doctors would have you fill out.  They are very easy; it is a screening.  You can do the depression inventory to see if they are actively thinking about doing something and then make a referral if necessary. If you do not want to do that screening, that is okay, but at least let their primary care physician know or tell them that you think they should get at least one session with a psychologist just to make sure everything is okay.

A score of 17 or more on the TRQ is considered clinically significant for Neuromonics.  With a lower score it is harder to show a significant percentage of improvement with a patient, but I have started Neuromonics treatments on a patient with a score of less than 7, and again, that was one of those patients who had sleep issues.  The hearing aids were helping the tinnitus during the day but not during the night when it was most bothersome.  Use your own judgment.  The more you use the Neuromonics, the better you will be at using your judgment in this regard, just as you are with treating hearing aids.

In summary of this section, there are more patients who will be successful with Neuromonics than others, and you need to consider personality type, income data and other factors.  The TRQ is the most powerful tool that you can use for any of your tinnitus patients, whether they are Neuromonics patients or not.  Use it wisely and proficiently.  A patient may judge their tinnitus to be severe and evaluate it differently on the bottom, so those indicators together need to be looked at as well.  You may have a patient who says their tinnitus bothers them 100 percent of the time, but then they score all 0s.  It happens all the time.  You need to address that and see how severely that tinnitus patient really grades their tinnitus.  We want them to be treated if they need to be treated.

Beginning Treatment

After you have done a complete audiometric evaluation and discussed all your options with your patient, including hearing aids, Neuromonics or other devices, and referrals to other specialists, this is the time when we want them to start getting ready for Neuromonics.  Once we decide that Neuromonics might work for them, I have them do some research.  I tell them to go on the Internet and research everything about tinnitus.  “Research Neuromonics, research pills or drops, anything you can about tinnitus now, because when you come in for your next appointment, I am going to cut you off on that.”  We want them to do that so that when they come back for their Neuromonics evaluation, they can be an informed patient.  We want them to have all their questions answered about anything out there, so that when they are ready to start the Neuromonics, they can confidently move forward instead of splintering out.  We want them focused on Neuromonics at that time, so let them do that.

One of the best things we do in our office is a Dear Me letter as well.  When we know the patient has severe tinnitus and they want to try Neuromonics, we have them write a letter to themselves or to me or a friend explaining tinnitus, telling them how it affects their life, how severe it is, when it started, et cetera.  This is going to be critical when you are in the middle of treatment and they are not seeing any benefit, or at the end of treatment and they are not sure of benefit.  This is going to help them come to grips with what benefit they will receive, and it is also going to open them up and get ready for that initial visit.

Counseling

Then the next session is counseling.  Now, they have come back with they have the letter they have written.  They have either emailed it or hand copied it to you.  They have their questions from the Internet and their research.  You have done your initial tinnitus evaluation and it looks like they may be a good candidate.  You have looked at the personality types, and everything is going well.  We need to make sure that they know at this visit when they order the Neuromonics that the Neuromonics is a helpful tool that the patient uses to control his or her own tinnitus.  It is not going to cure their tinnitus, but is a tool.  It is similar to Pavlov’s theory.  With Pavlov’s Dog, a bell rings, at which time you give the dog a bone.  The dog will start salivating after a while because he has made the neural connections that a bell correlates to the biscuit.  Tell the patient that their Neuromonics device is going to be similar to untraining Pavlov’s Dog.  What we want to do is take that biscuit away.  If you ring the bell and stop giving the dog his biscuit, what is going to happen?  He is going to salivate for a while.  That reflex is still going to be there because the axons in the brain are still there.  But slowly, as those axons die off and new ones are created that do not have that conditioned response, the salivation will slowly go away.

This is similar to what the Neuromonics device does.  They have ringing in the ears.  The biscuit is their response, their emotion, their reaction to it, and we want to take that away.  Oasis helps to take that reaction away.  I am not going to go into specific details because you will learn that when you go through your Neuromonics courses; they go into quite a bit of detail.  But for your patient to understand, if we take that biscuit away by giving them the Oasis treatment, what is going to happen at first, yes, they are still going to hear their tinnitus, just like the dog still salivates, but slowly the axonal connections to the negative tinnitus reaction do die off.  If there are no new connections replacing them, the tinnitus will slowly die down or be reduced, or at least their reaction to it will be reduced.  I have learned that this is the best way for me to explain the Neuromonics treatment to patients.

Expectations are everything.  We want realistic expectations.  Do not tell them this is a cure for tinnitus, or within a few weeks they are going to notice benefit.  Yes, some patients do and if you go to the Neuromonics site, it shows where some patients do.  That is wonderful, but we want them to know it is a neurological course.  This is not hokey; this is a real neurological change, and those axons have to die off.  Unlearning a habit takes time.

Say a patient comes back or they give you a phone call in eight weeks, and they are saying, “I have been using this consistently and I still have tinnitus,” that is where the counseling comes in.  It is okay to still have tinnitus at eight weeks.  The first eight weeks is for control and comfort of the tinnitus.  It is conditioning the brain for control and comfort.  Again, I am not going to go into detail with that because Neuromonics does itself, but reiterate that to the patient.  Just in case you did not hear me, control and comfort are the two most important goals of the first eight weeks of tinnitus treatment.

For your initial patient treatment, I want you to tell them that they need to go cold turkey.  They cannot be on the Internet anymore researching tinnitus for any reason.  If they are a member of a tinnitus support group, they cannot go anymore; they cannot talk to those friends about tinnitus anymore, they cannot read books about tinnitus.  If you have an engineer, we do not want them to log their tinnitus anymore, because that happens too.  What is happening every time you do that?  You are reinforcing that tinnitus.  It is like learning Spanish and you keep flashing the flash card.  How are you going to forget your tinnitus if you keep flashing the flash card?  You need to put those flash cards away.

So at that first visit when you are fitting the Neuromonics device, you are going to let them know that if they want to go and research, they are only allowed to go to the Neuromonics tinnitus site.  I actually want them in their first week to go to that Neuromonics site and learn all they can about the Neuromonics device.  We want them to feel proficient in using the device.  We want them to know that every aspect of tinnitus that they are thinking about is a positive aspect.  If they go on the Internet and do anything else, they may get some non-positive aspects.

The Neuromonics device has to be used two to four hours a day, every day.  Some days they will get more, some days they will get less, but the real impetus for that use is going to be when the tinnitus is most bothersome to them.  Even if they are hearing tinnitus and are stressed by something that is not the tinnitus, that is a good time to use it, too.  If their wife just yelled at them and they are hearing their tinnitus, we want to separate it, so those neural connections do not connect.  They can use their Neuromonics at that time, or when they are generally anxious because of the tinnitus.  The more they use it, the better. 

Although Neuromonics does say more than five hours is okay, I have found that patients who try to use it more than four hours are the ones who are perseverating on it, and that is detrimental because they are thinking too much about it.  The best patient for Neuromonics is the one who is going to set it and forget it and the one who can listen to his tinnitus sometimes and forget about it other times.  That is going to be the best patient for your Neuromonics device, and that is because we want them to put the device in when they need to, but when they do not need to, we want them to completely forget about their tinnitus.

Follow-up

Neuromonics does state that we should have a two-week visit, follow-up call or visit.  I sometimes use this and sometimes do not.  They my cringe at me saying that, but it depends on the patient, just as with the follow-up hearing aid visit.  Sometimes it may be your protocol in the office that they always get the two-week follow-up for adjustments.  If your patient is proficient and you know they are going out of town or if you know that they may not be available for a two-week visit, a follow-up call is fine.  I have had patients who are from out of state or out of the country.  We are not going to have them fly in for a two-week visit.  A patient from Belgium came in for his initial, his fitting and his eight-week transition and that was fine, but it is predicated on each patient.  Use that as a guideline for your office.

The eight-week transition period is necessary and mandatory.  I do have all patients, even those out of state, fly in for this one.  We need to download that device and see how much they are working on it.  If they have been compliant and wearing it so that little yellow diamonds come up, then we will send them to the eight-week transition and get them set on the active phase, which is where the tinnitus does decrease more specifically and quickly over time.  Again, I am not going to get into the details of that; go to your Neuromonics provider for that.  As far as the 16-week evaluation, I do require that if they are an in-state patient.  We do a re-evaluation at that time as well, re-measuring their tinnitus and the degree of masking needed because we want to prepare for the graduation.

Graduation

I have had some patients graduate a lot quicker than protocol suggests, and that is fine.  After 16 weeks, you are going to see patients say they cannot get in two hours because they are not even noticing the tinnitus enough to use it for two hours. That is great.  Even though protocol says to get the two to four hours in, I am not going to tell a patient to go put their device on for two hours if they have not heard or focused on their tinnitus all day.  That is counterintuitive.  Use your own judgment, and let the patient know that if their tinnitus is reducing that much, that the device is there for them when they need it.  They can use it as much as they need, but that may only be an hour or a half hour at a time at the end of the treatment, and that is great.

Neuromonics is a great choice for 20 percent of my patients.  You may say, “Oh, only 20 percent of patients? I thought you would use it 80 percent or more.”  One in five patients comes into my office with tinnitus and ends up getting the Neuromonics device, or at least I highly recommend it at that level.  We do have a lot of other treatments that we recommend; some of them are over the Internet.  The one I use here is my own behavioral treatment.  We use the behavioral treatment with the Neuromonics.  Consider how many patients of yours have tinnitus.  Every patient that you ask about tinnitus should get a TRQ.  If you notice that they are having problems sleeping and a hearing aid may not be what is best for them, then one in five patients is about right.  There may be patients who know they have tinnitus but it is so mild that they say, “Yeah, I have it, but I do not care now that I know about it. I am fine.”  Let them know that there are solutions for them later on down the road if they do start to care, either by reducing it or providing coping techniques that they can do themselves.

Medical Issues

Some patients come in and we deal with them medically.  In those cases, we are not going to necessarily recommend a Neuromonics device.  If someone comes in with a medicine that may cause tinnitus, we ask them to get off that medication after checking with their physician first.  This is where you need to know a little bit more of the chemical analysis.  I have had a patient who had tinnitus for two years, was a member of the American Tinnitus Association, went to club meetings, drove all the way down to see me from two cities away, and I said, “Can you get off that medicine for a while?” She called three days later; her tinnitus was gone and it never came back.

Now, how ethical would I have been if I would have said, “No, you need to get on that Neuromonics treatment and I am going to make $3,000 from it, so we need you to do that.”  That is not ethical.  Do whatever we can to relieve those issues, medically if we can.  If the tinnitus is still severe enough, go with the Neuromonics and/or hearing aids.  If you have a patient with the tinnitus that only bothers them during the day and they have a significant hearing loss, I might try hearing aids first.  There is no protocol that says you have to try one treatment before the other.

Is Neuromonics Worth it?

For me, with the right patient, Neuromonics is the most reliable and efficacious patient treatment I have used.  If you have not used Neuromonics treatment, I do suggest calling them and having an audiologist come out, or look into completing the training wherever they do it.  I had to fly out to New Jersey and pay for the training.  I have no problem doing that, though. I take my tinnitus patients seriously, and if you do too, whatever training you need is an investment.  Go to the Neuromonics site under Professionals and read everything on there. It is a treasure trove of basic tinnitus information as well.

Neuromonics treatment will work as long as you are properly trained and confident in the treatment.  This is one of the things we often forget.  Some audiologists who try the device and say it does not work may not be giving the patient any reinforcement or proper training because the audiologist is not confident in it.  That is not right.  It is a very viable treatment option.  I think any tinnitus clinic should provide Neuromonics.  That does not mean they have to use it all the time. Again, I only use it 20 percent of the time, but every tinnitus clinic should provide it and every audiology clinic should be aware of it and know that it is something that may help for your patients.

I received a letter in the mail recently.  This is what we call a graduation letter.  At graduation, I ask the patient to write down what the tinnitus treatment has meant for them, any specific details that they can remember about their tinnitus, and anything that may or may not have worked for them that will help me.  Graduation does not mean they are done and I am not seeing them again.  Graduation is when I show them how to deal with their tinnitus as needed with the device, like a security blanket.

This patient said, “I was tempted to run out of the house at night and just keep running.  You were the first doctor to offer me any hope.  I thank you for encouraging me to keep at it and telling me that I WOULD get better. And I did!  I am so thankful to have my life back!”  It is letters like these that really help.  When I first started with her, she was in tears when she came in here.  To know that we can do this for a patient is wonderful.  There is no reason not to be able to.  Do we get all letters like this?  No. Some of our graduation letters are just okay.  But it is like any treatment.  You need to tell them, “You are a specific individual.  You will benefit from the Neuromonics treatment as much as your physiology, your emotions and your compliance will allow.”  Someone else with the same physiology may have different compliance or emotions and may benefit differently.  Some patients get full benefit.

I had a patient come in with a TRQ score of an 87 once.  Now, think about that - 17 is significant, and this person scored 87.  This patient was sent to me because he was actively considering suicide.  After 12 weeks of treatment, he had all zeroes on his TRQ.  After graduation, he had all zeroes.  He did not notice his tinnitus.  I said, “Well, is it still there.”  He says, “Well, let me listen.  It is still there, but I do not notice it.”  I had him back in a year because I have all my tinnitus patients back, and you should, too. I send a follow-up TRQ in six months and have them back in a year whether they are Neuromonics or not.  A year later after the treatment he still had a full score of zeroes on the TRQ.  Not everyone is not going to benefit that much.  You will have difficult cases, but even those difficult cases we will help as much as possible.

There is so much more information on this; I could do a second class.  We could have a class just on the TRQ and go over specific cases of difficult patients.  We could go over other specific tinnitus treatments as well.  Please let the AudiologyOnline know if this is of interest to you.  I would love to teach courses like that, but they are only going to have them available if you say that it is something that will benefit you.

Thank you for your time.  I hope you have garnered a few things that are helpful for you.

Reference

Wilson, P. H., Henry, J., Bowen, M., & Haralambous, G. (1991). Tinnitus reaction questionnaire: psychometric properties of a measure of distress associated with tinnitus. Journal of Speech and Hearing Research, 34(1), 197-201.