The use of sound therapy is a fundamental component of the widely used tinnitus management approaches, namely masking (Vernon & Meikle, 2000) and habituation including Tinnitus Retraining Therapy (TRT; Jastreboff, 2000). Sound therapy is used in the management of tinnitus in that it:
- decreases the perception of tinnitus by increasing the level of background sound, making the tinnitus less noticeable;
- provides immediate relief for many patients reducing the emotional consequences such as frustration, anxiety and even depression;
- promotes patient control over the tinnitus rather than tinnitus control over the patient;
- promotes habituation to the tinnitus by neutralizing the threatening quality of the tinnitus;
- acts as an attention-getting sound that distracts the listener away from the tinnitus; and
- contributes to the reorganization of the central auditory nervous system pathways and centers responsible for tinnitus generation and perception (Folmer, Martin, Shi & Edlefsen, 2005; Henry, Zaugg, & Schechter, 2005a).
A number of different sound sources are available to provide relief from the annoying and bothersome consequences of the tinnitus sensation/s. Most practitioners, however, feel ill-equipped to select the most appropriate form of sound therapy for a given individual. Not surprisingly, this is in direct contrast to the comfort level experienced by most audiologists in the hearing aid selection and fitting process. In this connection, Henry, Zaugg, and Schechter, (2005a) found that 72% of the 47 (out of 60) Au.D. programs that responded to their survey did not offer a course of training dedicated to the clinical management of tinnitus. On the other hand, 87% of the respondents indicated that there is a need to include tinnitus management in the scope of practice for audiologists. These findings clearly indicate the lack of student preparation in the provision of clinical services for patients with tinnitus.
The purpose of this article, therefore, is to provide some practical suggestions for audiologists in a busy clinical practice when faced with the decision of what sound generator to recommend and fit for their patients. It is not, however, a review of specific sound generators. The reader is referred to several excellent sources that describe in detail the clinical application of different sound therapy devices (see, Henry, Zaugg, & Schechter 2005a; 2005b; Folmer et al., 2005; Henry, Rheinsburg & Zaugg, 2004; Robb, 2006a; 2006b). Instead, we describe an 11-item income tool, the Sound Therapy Option Profile (STOP), which guides the clinician in the selection of the most appropriate sound therapy device for a given patient in an efficient and effective manner.
Sound Therapy Device Options
Although sound therapy is a critical element of our Tinnitus Management Clinic, it is used within the framework of a management program including medical evaluation and treatment (when appropriate), group and individual education, and psychological/ cognitive behavioral therapy. Accordingly, our core tinnitus management team includes audiologists, otolaryngologists, and psychologists. Further, our philosophy is not to employ a singular sound therapy approach/philosophy (e.g., masking, TRT), but to develop a more individualized treatment plan for each patient incorporating principles of those established treatment protocols.
Several types of sound therapy device options are available, including assistive sound enrichment devices, hearing aids, in-the-ear sound generators, combination units (hearing aid plus sound generator in the same case), and personal listening devices. Each category provides a "sound-enhanced" environment by maintaining a low-level of background noise whether used in a sound-field arrangement or directly coupled to the ear. Recall, the goal of any form of sound therapy is to decrease the tinnitus signal-to-background noise ratio in order to reduce the contrast between the environment and the patients tinnitus percept. In this way, the brain interprets the tinnitus as less noticeable, and therefore, less annoying and troublesome. Background sound can include such things as fan noise, broadband noise, nature sounds, and/or environmental sounds. In addition to using sound as a backdrop to the tinnitus, that is, to provide a sound-enriched environment, sound may also be used as attention-getting strategy designed to distract the patient from his or her tinnitus. Drawing the attention away from the tinnitus by allowing the patient to concentrate on another sound source can take the form of books on tape/CD or talk show TV/radio. Music is another type of sound source and can serve as either an attention-getter sound or as a background noise. Again, readers are referred to the above noted references for a detail description of devices and the clinical application of different sound therapy devices.
Tinnitus Questionnaires are Helpful, But...
Several tinnitus questionnaires have been developed and standardized to quantify tinnitus disability/activity limitation (i.e., effects of tinnitus sensation on reducing an individual's ability to function in a normal manner including loss of concentration, sleep disturbance, intrusiveness, loss of control, and so forth) and tinnitus handicap/participation restriction (i.e., psychosocial manifestation of disability including difficulty in relationship with family, friends, and/or coworkers, avoidance of situations, and so forth). For example, the Tinnitus Reaction Questionnaire (Wilson, Henry, Bowen, & Haralambous, 1991) quantifies the psychological distress associated with tinnitus. The Tinnitus Handicap Inventory (Newman, Jacobson and Spitzer, 1996), evaluates the functional (e.g., role limitation in the areas of mental, social/occupational, and physical functioning), emotional (e.g., anger, frustration, irritability), and catastrophic (e.g., desperation, loss of control) reactions to tinnitus. For a complete review of tinnitus questionnaires the reader is directed to Newman and Sandridge (2005). While such tinnitus questionnaires are helpful by identifying individuals who are particularly bothered by tinnitus or as serving as outcome measures when administered in a pre- and posttreatment paradigm, they are not especially effective as income measures. That is, disability/handicap questionnaires are not particularly helpful in directing the clinician in the selection of specific devices.
Tinnitus Assessment is Helpful, But...
In addition to disability/handicap questionnaires, it remains critical that the clinician obtain a detailed tinnitus history in order to arrive at a thorough understanding of the nature of tinnitus. A number of areas need explored including (Newman and Sandridge, 2004):
- perceptual features (e.g., location, descriptors, magnitude estimations of pitch and loudness);
- duration (e.g., initial onset, recent experiences);
- exacerbating factors (e.g., sound environment such as quiet or loud listening situations, diet, stress, activity, time of day);
- reducing factors (e.g., sound environment such as quiet or loud listening situation, medications);
- psychosocial and functional consequences (e.g., annoyance, sleep disturbance, suicidal ideation, concentration difficulty);
- hearing (e.g., assessment of hearing impairment, disability, and handicap; sound tolerance problems such as hyperacusis or phonophobia); and
- treatment history (e.g., medical, surgical, audiologic, benefits from treatment).
Recently, Henry and colleagues (2005b, Appendix A) developed a Sound Treatment Worksheet that can be used to recommend specific self-management strategies. The worksheet requires the patient to list up to 3 specific situations when the tinnitus is most bothersome and provides a checklist for recommending the use of a specific augmentative sound (e.g., tabletop sound generator, wearable CD player, ear-level noise generator). The worksheet can be updated on follow-up visits with the patient commenting on how helpful (e.g., 5 point checklist ranging from "not at all" to extremely") he or she found the recommended sound device. Further, the clinician can indicate if the sound strategy employed is used primarily for purposes of enriching the environment or as a distracter to the tinnitus.
Sound Therapy Option Profile (STOP)
In our last Audiology Online contribution (Sandridge & Newman, 2006) we introduced a new self-report questionnaire, the Characteristics of Amplification Tool (COAT), to be used in the hearing aid selection process. The purpose of the COAT is to guide clinicians in the selection of specific amplification devices in an efficient manner. Similar to the COAT, we have developed a questionnaire that is useful in prescribing a specific sound therapy device. The 11-item tool is known as the Sound Therapy Option Profile (STOP).
A copy of the STOP in Microsoft Word format can be downloaded here. (MS Word Document)
It is noteworthy, however, that the STOP has not been designed to recommend a particular tinnitus treatment or philosophy (e.g., tinnitus masking, TRT) and is not a substitute for an in-depth tinnitus intake questionnaire. Rather, it was developed primarily as a guiding tool in the selection of the optimal sound therapy device given the patient's particular set of needs.
Unlike the COAT, administration of the STOP should be after the patient has been counseled about the various sound therapy options. For example, in our practice the STOP is administered at the individual tinnitus evaluation appointment, which occurs only after the patient has participated in the Group Education Session. During the 1 to 1.5 hour Group Education Session, a picture-based presentation using a slide show format is used to counsel patients about treatment options, including sound therapy philosophies and devices, cognitive-behavioral therapy, stress management, and biofeedback, among a variety of other topics (for a complete review see Newman & Sandridge, 2005). Accordingly, the patient has a good knowledge base about audiologic tinnitus treatment in general, and specific sound therapies and devices in particular, prior to the administration of the STOP.
Like the COAT, we set out to develop a questionnaire that would meet the following criteria:
- short in length so that it could be completed in 10 minutes or less;
- easy to administer and interpret;
- designed to obtain the critical non-audiologic information useful in determining the type of sound therapy device style and level of technology required by the patient;
- function as a basis for counseling during the tinnitus assessment appointment;
- serve as a measure for clinician accountability in this era of evidence-based practice; and
- useful as a teaching tool for student externs.
A copy of the STOP in Microsoft Word format can be downloaded here. (MS Word Document)
Item 1: How much does your tinnitus affect your overall quality-of-life?
This item provides the clinician with a global estimate of the patient's perceived consequences of tinnitus on his or her health-related quality of life (HRQOL). In general, HRQOL provides a way of thinking about quality-of-life as it relates to well-being and health status, and the interrelationship among such domains as impairment, functional status and health perceptions (Kane, 1997). For a more in-depth analysis of the impact of tinnitus on everyday life, it is recommended that clinicians administer a psychometrically robust tinnitus instrument such as the Tinnitus Effects Questionnaire (Hallam, Jakes, & Hinchcliffe, 1988), Tinnitus Handicap Inventory (Newman, Jacobson, & Spitzer, 1996), or Tinnitus Handicap Questionnaire (Kuk, Tyler, Russell, & Jordan, 1990).
Item 2: Do you feel that you have a hearing loss, if so, how important is it for you to hear better?
The importance of improving communication function, independent of the tinnitus, is addressed in this item. This assists the clinician in determining whether hearing aids alone or combination units (hearing aid plus sound generator in same unit) may be the most appropriate choice for tinnitus relief. By default, hearing aids increase the level of ambient environmental noise thus, decreasing the tinnitus-to-background noise ratio while compensating for the hearing loss. The current open-ear devices are excellent options as they allow for lower frequency ambient noise to arrive at the tympanic membrane unaltered (i.e., unamplified) and not blocked. In addition, based on our clinical observation, there is a greater acceptance of the open-ear fittings. If there is uncertainty whether the patient is a hearing aid candidate or not, we recommend the adjunctive administration of the Hearing Handicap Inventory for the Elderly/Adult (HHIE, Ventry and Weinstein, 1982; HHIA, Newman, Weinstein, Jacobson, & Hug, 1990). For example, if the patient's hearing loss has little or no impact on the patients psychosocial and/or communication function (e.g., 18 point), the audiologist should consider combination units.
Item 3: How motivated are you to use some form of sound therapy to help provide tinnitus relief?
Motivation is one of the most important cognitive variables affecting adaptation to chronic disease and resultant disability (Kemp, 1990). Accordingly, for chronic tinnitus sufferers' motivation has great impact on the success of audiologic treatment. A patient who is not motivated to follow the recommendations established by the audiologist sets the stage for failure. Therefore, it is critical to assess motivational levels that incorporate the concepts of desires, wishes, needs, and goals relative to the audiologic treatment (Kemp, 1990).
Item 4: Are you willing to use sound therapy? Response options include: a). only at those times when your tinnitus is bothering you; b). at least 2-3 hours per day for at least six months; c). at least 6-8 hours per day possibly up to 12 to 18 months?
An individual's willingness to commit to more or less time will direct you to a particular therapy approach. For example, if the patient is only willing to use sound therapy when the tinnitus is bothersome (i.e., desiring immediate relief) they are probably less-than-optimal candidates for long-term treatments that might employ personal sound generators over the course of several months (e.g., TRT). If tinnitus is problematic primarily at bedtime, the use of a tabletop sound generator, pillow sound generator, or CD playing nature sounds to aid in falling asleep may be most appropriate.
Item 5: How well do you think sound therapy will be in providing tinnitus relief?
The expectations performance theory suggests that customer satisfaction is related to the customer's product expectation and perceived performance (Kotler & Clark, 1987). More specifically, if the relief provided by a particular sound device matches expectation, the patient with tinnitus will be satisfied. In contrast, if the relief provided by the sound therapy device falls short, the individual will be dissatisfied with the treatment program. Unrealistically high or low expectations of sound device performance will likely lead to poor outcome. In fact, unrealistic expectations can result in decreased satisfaction with, or complete rejection of the devices.
Item 6: What is your most important consideration regarding sound therapy treatment?
Four important considerations for selecting specific sound device options are ranked ordered by the patient in order of importance. These include: Improved hearing, Tinnitus relief, Improved hearing while gaining relief from tinnitus, Cost of treatment. The rankings will guide the clinician as to whether it is best to fit hearing aids (improved hearing ranked first), fit sound generators (tinnitus relief ranked first), fit combination units (improved hearing with tinnitus relief) and whether cost is the overriding factor.
Item 7: How acceptable would you find the following sounds in the treatment of your tinnitus? Responses include: a). Nature sounds (e.g., waterfall, surf, wind, etc.); b). Gentle white noise; c). Music
The need to determine the acceptability for each form of sound therapy is critical for patient compliance and adherence to specific recommendations. For example, many patients complain that a sound generator using a broadband noise is more bothersome than their own tinnitus perception. Others feel that music is distracting. To assess this, it is highly recommended that the different sounds (e.g., broadband noise, CDs, and music) be demonstrated in the office as part of the assessment. Accordingly, it necessitates that the clinic has units available to demonstrate such as stock hearing aids, sound generators, combination instruments, music CDs, music sound processors, and /or devices to play environmental sounds (e.g., CDs, tabletop units). One caveat - the patient must understand that the demonstration is to determine acceptability of the various sounds and not a demonstration of effectiveness of the sound due to the short listening duration in the clinical setting.
Item 8: Would you be willing to pursue any of the following forms of treatment: Response options are a). wearable ear-level devices; b). wearable device that looks like an iPod or MP3 player; c). non-wearable assistive sound generating device such as tabletop devices; and d). psychological treatment?
Responses to this item provide insight into the patient's motivation and willingness to try various treatment devices as well as to seek counseling. If a patient marks YES to all of the items, this would indicate that the patient was willing to try almost anything to gain relief from the tinnitus. Likewise, if the patient responded NO to all of the items, additional counseling may be necessary if you expect to have a successful device fitting.
The last item in this question deals with willingness to seek psychological counseling as part of treatment. Educating the patient in the mind-body connection is a major focus of intervention used in the psychological treatment of tinnitus. Most patients readily admit that stress in general, and specifically negative emotions, will exacerbate the intensity of tinnitus. Psychological treatment, although initially viewed with apprehension and reluctance, has been quite effective for patients with significant self-perceived tinnitus disability/handicap.
Item 9: How confident do you feel that you will gain relief from tinnitus through the chosen treatment plan.
Determining the degree of self-efficacy is a powerful predictor of behavior change and successful audiologic treatment. Self-efficacy is the confidence an individual has in performing a set of skills needed to succeed at a specific task or goal (Bandura 1986, 1997) and has recently been linked to the effective management of tinnitus (Smith & West, 2006). A patient indicating low self-efficacy (i.e., Not Very Confident) will alert the clinician to explore what concerns the patient has in using a specific sound therapy device. For example, the patient may have concerns about manipulating small objects such as an in-the-ear sound generator due to poor manual dexterity. In this case, a tabletop unit with large controls may be more appropriate. Or the patient may have concerns about using a device that looks like a MP3 player - guiding the clinician away from such a device. In addition, a rating of low self-efficacy may also indicate the need for psychological involvement whereas too high of a rating may suggest unrealistic expectations.
Item 10: In the past, have you tried any of the following forms of tinnitus treatment: tinnitus masking; tinnitus retraining therapy; assistive sound generating devices; medical/surgical; psychological; other?
This item sets the stage for a discussion about the benefits and limitations of previous treatments including specific philosophical approaches and techniques (e.g., masking versus TRT) as well as types of devices used in the management approach (e.g., hearing aids versus combination units). Further, information about the previous use of any sound device permits a frank discussion about current expectations (relating to Item #5) for trying new devices.
Item 11: Select the cost category that represents the maximum amount you are willing to spend for your tinnitus treatment.
The patient's willingness-to-pay for specific sound devices and associated treatments is assessed in this last item. Knowing the patient's desired financial investment guides the clinician in selecting an approach and device option that falls within that range. For example, a patient indicating a preference for Category A (cost below $100) limits your recommendations to tabletop devices or music CDs. Recall, that the patient has already been informed of the various devices and associated cost during the group session.
Conclusion
As in the case of the COAT, we are advocating the use of an income measurement tool as part of the overall assessment of tinnitus. Following similar principles to the COAT, the STOP was developed to be a brief and easy to complete tool that serves as a springboard for patient counseling while providing guidance in the selection of specific sound generator devices. Completion of the 11-items creates a profile of the patient including his/her motivation, willingness to seek treatment and pay for that treatment, preference for specific type of sound generators, expectation level (realistic or not), and the need for psychological involvement. Within a few short minutes, the profile directs the clinician to the selection of broadband noise versus music, ear level devices versus body worn/hand held devices; and custom versus non-custom products. Finally, the tool promotes accountability for both the patient and clinician - an important feature given the increased emphasis on evidence-based practice.
A copy of the STOP in Microsoft Word format can be downloaded here. (MS Word Document)
References:
Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.
Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY: Freeman.
Folmer, R.L., Martin, W.H., Shi, Y, & Edlefsen, L.L. (2005). Tinnitus sound therapies. In R.S. Tyler (Ed.), Tinnitus treatment clinical protocols (pp. 176-186). New York, NY: Thieme Medical Publishers, Inc.
Hallam, R.S., Jakes, S.C., & Hinchcliffe, R. (1988). Cognitive variables in tinnitus annoyance. British Journal of Clinical Psychology, 27, 213-222.
Henry, J.A., Schechter, M.A., Zaugg, T.L., Griest, S, Jastreboff, P.J., Vernon, J.A., Kaelin, C, Meikel, M.B., Lyons, K.S., & Stewart, B.J. (2006). Outcomes of clinical trials: Tinnitus masking versus tinnitus retraining therapy. Journal of the American Academy of Audiology, 17, 104-132.
Henry, J.A., Zaugg, T.L., & Schechter, M.A. (2005a). Clinical guide for audiologic tinnitus management I: Assessment. American Journal of Audiology, 14, 21-48.
Henry, J.A., Zaugg, T.L., & Schechter, M.A. (2005b). Clinical guide for audiologic tinnitus management II: Treatment. American Journal of Audiology, 14, 49-70.
Henry, J.A., Rheinsburg, B., & Zaugg, T. (2004). Comparison of custom sounds for achieving tinnitus relief. Journal of American Academy of Audiology, 15, 585-598.
Jastreboff, P.J. (2000). Tinnitus habituation therapy (THT) and tinnitus retraining therapy (TRT). In R.S. Tyler (Ed), Tinnitus handbook (pp. 357-376). San Diego, CA: Singular Publishing Group.
Kane, R.L. (1997). Understanding health care outcomes research. Gaithersburg, MD: Aspen Publishers, Inc.
Kemp, B. (1990). Motivational dynamics in geriatric rehabilitation: toward a therapeutic mode. In B. Kemp, K. Smith, & J. Ramsdell (Eds), Geriatric rehabilitation, Boston, MA: College Hill Press.
Kotler, P., & Clark, R. (1987). Marketing for Health Care Organizations. Englewood Cliffs, NJ: Prentice Hall.
Kuk, F.K., Tyler, R.S., Russell, D, & Jordan, H. (1990). The psychometric properties of the tinnitus handicap questionnaire. Ear and Hearing, 11, 434-442.
Newman, C.W., Jacobson, G.P., & Spitzer, J.B. (1996). Development of the tinnitus handicap inventory. Archives of Otolaryngology-Head & Neck Surgery, 122, 143-148.
Newman, C.W., & Sandridge, S.A. (2004). Tinnitus questionnaires. In J.B. Snow (Ed.), Tinnitus: Theory and management (pp. 237-254). Hamilton, Ontario: BC Decker, Inc.
Newman, C.W. & Sandridge, S.A. (2005). Incorporating group and individual sessions into a tinnitus management clinic. In R.S. Tyler (Ed.), Tinnitus treatment clinical protocols (pp. 187-197). New York, NY: Thieme Medical Publishers, Inc.
Newman, C.W., Weinstein, B.E., Jacobson, G.P., & Hug, G.A. (1990). The hearing handicap inventory for adults: Psychometric adequacy and audiometric correlates. Ear and Hearing, 11, 430-433.
Robb, M.J.A. (2006a). Tinnitus device directory, Part III. Tinnitus Today, 31(1), 14-16.
Robb, M.J.A. (2006b). Tinnitus device directory, Part IV. Tinnitus Today, 31(2), 9-11.
Sandridge, S.A., & Newman, C.W. (2006, April 6). Improving the efficiency and accountability of the hearing aid selection process. Audiology Online, Article 1541. Retrieved August 16, 2006 from the Articles Archive on www.audiologyonline.com. Direct access URL located at: www.audiologyonline.com/articles/article_detail.asp?article_id=1541
Smith, S.L., & West, R.L. (2006). The application of self-efficacy principles to audiologic rehabilitation: A tutorial. American Journal of Audiology, 15, 46-56.
Ventry, I., & Weinstein, B. (1982). The hearing handicap inventory for the elderly: A new tool, Ear and Hearing, 3, 128-134.
Vernon, J.A. & Meikle, M.B. (2000). Tinnitus masking. In R.S. Tyler (Ed), Tinnitus handbook (pp. 313-356). San Diego, CA: Singular Publishing Group.
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 Language Hearing Research, 34, 197-201.
