According to the American Tinnitus Association (ATA) there are 30 to 50 million Americans who experience tinnitus. Many are crowding the health food stores -- buying products that claim to help tinnitus. Others go to the herbalist or acupuncturist after being repeatedly told by their physicians, 'learn to live with it.' Many patients do not do well when told to 'live with it.' They feel abandoned and they suffer. I believe we can, and should, do more.
I have developed a tinnitus control program which is useful for many patients. Although it can work well as a 'stand alone,' I believe it will work best with guidance and management by an audiologist as part of a multi-disciplinary approach to tinnitus management. Besides the otologist, no one is better equipped by clinical training, formal education and experience to treat tinnitus than the audiologist. Audiologists understand how the ear works and they are scientifically trained. Audiologists know when to refer (i.e., unilateral tinnitus, aural pain, asymmetric hearing loss, vertigo, draining ears, etc.). Audiologists understand masking and how to mask tinnitus without causing further damage to the auditory system. Most importantly, audiologists are best positioned to work with the patient for tinnitus relief.
In 1975, I wrote about biofeedback for tinnitus management. In 1976, I detailed the results of 60 patients with tinnitus treated by biofeedback. In essence, by reducing the 'anxiety reinforcement' (see below) many of these tinnitus patients were helped.
Many clinics today use electromyography to help reinforce and manage the tinnitus patient using 'classical' biofeedback techniques.
Currently, I use a mirror to teach patients to control and verify muscle relaxation. Simply, patients view themselves in the mirror, and the mirror serves as a 'visual feedback' device.
I explain to the patient that you cannot have anxiety when the muscles are relaxed. You can see the muscles relax when using the mirror correctly and importantly, relaxation interrupts the anxiety reinforcement cycle.
By measuring breathing and by seeing the face, jaw, and shoulders relax, the patient learns to take control and participate in managing their tinnitus.
KEY POINTS OF THE PROGRAM:
Interrupt the anxiety reinforcement. In every illness or symptom, anxiety and stress have the potential to make it worse. For example, the more it itches, the more you worry, the more you worry, the more nervous you get, the more nervous you get, the more it itches. I have found this cyclical behavior to be true regarding tinnitus. Relaxed muscles break the anxiety reinforcement cycle.
Cognition : Patients sometimes come to me as the third or fourth ENT doctor they have seen. It often turns out that no one explained to them what tinnitus is, or showed them a chart or a picture of the ear! A simple explanation of how the ear works, and how common tinnitus is, may be highly therapeutic.
Focus elsewhere. All day long the patient thinks about, and worries about their tinnitus. If we can get them to pay attention to their breathing, rather than their tinnitus, as outlined in the program, every hour on the hour, they focus elsewhere, away from their tinnitus.
My program uses a watch with a rotating bezel to remind them to focus on breathing 10 times a day, for one minute at a time. Inhalation is a contraction, exhalation a relaxation. While inhaling they count to four, while exhaling they count to six. The '4 - 6 count' allows a longer relaxation mode than contraction mode. More intentional muscle relaxation potentially leads to less tension/anxiety, and consequently, less annoyance from tinnitus!
Going to a healing place. Throughout history, there have been places of healing - temples, spas and special clinics. These special places work, in part, because the person participating anticipates being healed. They are able to rest in a relaxed atmosphere which stopped the reinforcement cycle and allowed their exhausted cortisone system to recover. In the program, I provide a 50-minute CD of guided visualizations - in essence, going to healing places.
Support. The TinnitusRelief.net program provides a website and bulletin board where the program user (patient) can ask questions and get responses.
Kinetic assistance. In many great religions, physical movement of the body is used to reinforce and support thought. For example, spin the prayer wheel, genuflect, turn toward Mecca, count the prayer beads, etc.
Wearing and utilizing the watch (with the rotating bezel) allows the patient to perform a physical movement that helps reinforce the program. You wear the watch all the time. Every time you look to see what time it is, you are reminded to follow the program. Because you turn the bezel each time you do one of the steps, this helps people stay on the program.
Guide the body to therapy. Guided visualizations have been successful in treating certain pain syndromes. In the tinnitus program, we ask the patient to recall a time before they had tinnitus. Sometimes the body changes and the tinnitus stops. This visualization may be the best one for certain individuals because it suggests changes from within.
Having a plan. As soon as the patient learns of a plan he can follow, and a plan that has worked for others, this may allow immediate relaxation. The patient no longer feels hopeless.
The TinnitusRelief.net program:
The program consists of a book on tinnitus, the watch worn all the time with the rotating bezel, the 50-minute CD with the guided visualization, and support on the web site.
The book describes what tinnitus is, why it happens, and gives 'cognitive' details. The book describes a 10 step program that can be performed in 10 minutes a day. There is also information regarding life style changes that help.
The watch is worn just like a regular watch. Each time the patient performs one of the steps, they rotate the bezel. Each time the patient checks the time, they are reminded to do the steps.
The CD is an auditory presentation of the 10 steps with various guided visualizations.
The Audiologist's Role in TinnitusRelief.net:
The actual program is quite simple and administering it does not require special training or facilities. The audiologist schedules 2 to 3 appointments with the patient.
At the first appointment, an audiogram is obtained, a comprehensive case history is obtained and tinnitus measurement is accomplished. Some audiologists use questionnaires and related tools to help determine the impact of the tinnitus, as well as a detailed description of it's characteristics and history. Suggested tinnitus measurements include; loudness discomfort levels, tinnitus pitch matching, tinnitus loudness matching, and minimal masking level (see AAA, 2001). Specific questions and issues regarding tinnitus and tinnitus management are addressed by the audiologist, referrals are made for appropriate patients.
The audiologist outlines and demonstrates the TinnitusRelief.net program. The patient is seated before a mirror, breathing is timed and demonstrated to a count of four for inhalation and a count of 6 for exhalation. The patient is asked to look in the mirror and make his jaw and shoulders relaxed. The patient is instructed to work on these techniques at home and during the day and a follow-up appointment is scheduled.
At the second appointment, the audiologist reviews the patient's progress and documents the same. The second appointment is also an ideal time to review the program and answer questions regarding the program, it's implementation, tinnitus in general and to review any of the ten steps (from the book) which may need clarification.
If needed, the third appointment is used to chart progress, clarify any issues which remain, and to reinstruct or clarify as needed.
Clinical Notes:
This program is not psychotherapy. In my experience, most tinnitus patients can be improved without psychotherapy. Those that need psychotherapy should be referred. I have always treated tinnitus patients without psychotherapy. Certainly there are some patients who might need this therapy, but in my practice, they are rare. Additionally, I have not prescribed Xanax or Prozac for my tinnitus patients.
Cognitive therapy by a psychologist is helpful and is known to be effective for tinnitus. The patient learns to understand that tinnitus is not a threat to him. However this treatment takes considerable time and can cost thousands of dollars. The cognitive therapist doesn't have the advantage that the audiologist has in understanding this problem.
There are cautions to be taken in using this program. Although no drugs are used, persons who have hypertension and are on anti-hyertensive therapy must be monitored because as they have less stress and anxiety, their blood pressure may reduce and the medications may need to be reduced or stopped. Patients should consult with their physicians, and they should check their blood pressure twice a week (or as recommended by their physician) if they are on anti-hypertensive medication.
An added benefit of the program is that the patient gets instruction on stress reduction and improving their life habits.
Conclusion:
Each patient is unique. What works effectively for one patient may have no impact on another. While working with tinnitus patients, the audiologist has the distinct advantage of observing and documenting auditory changes and perceptions which may require intervention or referral, such as cerumen management, hearing aid adjustments, tinnitus masker alternatives and adjustments, support groups, and other treatment issues.
Statistics are difficult to present here because the program is new. Nonetheless, from a clinical viewpoint, it appears to me that tinnitus patients benefit from the program when I demonstrate it and follow-up with them.
Because millions of tinnitus patients are not being helped at this time, and because this program is relatively simple and inexpensive, I would like to recommend that audiologists review this program for three reasons;
- To help their tinnitus patients manage their tinnitus.
- To determine the clinical utility of the program, and
- To establish outcome measures relating to his treatment modality.
References:
AAA (2001): American Academy of Audiology Position Paper 'Audiologic Guidelines for the Diagnosis and Management of Tinnitus Patients' Audiology Today, March/April, 2001. Pages 23-24.
Grossan: A Brief Introduction to Biofeedback for Otolaryngologists. O.R.L. Digest, February 1975
Grossan: Treatment of Subjective Tinnitus with Biofeedback. Ear Nose and Throat Monthly Nov 1976.
Grossan: The Twenty Dollar Tinnitus Masker-a drug free approach to Managing Tinnitus. The Hearing Journal. June 1995. 48:39-40
Wolpe, J. Behavior Therapy Techniques. Perganon Press New York. 1966
Suggested Readings:
AAA (2001): American Academy of Audiology Position Paper 'Audiologic Guidelines for the Diagnosis and Management of Tinnitus Patients' in Audiology Today, March/April, 2001. Pages 23-24.
Davies S, McKenna L, Hallam R.S. (1995): Relaxation and Cognitive Therapy: A controlled trial in Chrnic Tinnitus. Psychology & Health 10, 129-144.
Erlandsson SI, Rubenstein B. Carlsson SC (1991): Tinnitus: evaluation of biofeedback and stomatognathic treatment. Br. J. Audiol. 25: 151-161.
Gold SL, Gray WC, Jastreboff PJ (1995): Selection and fitting of noise generators and hearing aids for tinnitus patients. In Proceedings of the Fifth International Tinnitus Seminar. Portland, Oregon. 312-314.
Meikle MB (1997) Electronic Access to Tinnitus Data: The Oregon Tinnitus Data Archive. Otolaryngol-Head and Neck Surg., 117. Pages 698-700.
Sweetow RW (2000): Cognitive-Behavioral Modification. In Tinnitus Handbook. Ed Tyler RS, Chapter 13, pages 297-312, Singular Press, San Diego, 2000.
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DISCLOSURE:
The TinnitusRelief.net program is sold by Hydro Med, Inc to professionals at a discounted price. For information: Please call 1-800-560-9007 or see www.TinnitusRelief.net. Dr. Grossan is a principle of Hydro Med, Inc.
