Tinnitus Retraining Therapy: guidelines and exercises for patients
Jonathan Hazell FRCS
This makes a useful checklist to work with when you are doing retraining therapy for tinnitus or hyperacusis. There is no doubt that the best way to do this is with an experienced therapist, but those trained in TRT are few and far between, so you may find yourself working on your own with these guidelines. Do share them with the audiologist who looks after you. Do not attempt to follow these instructions until you are completely clear about the Jastreboff Model . feel you understand it well, and that it applies to you directly. Remember that the results we have published on our success rates relate to patients who are working with trained therapists. This means that progress without appropriate guidance is likely to be slower and less certain. Remember the aim of TRT is to habituate or remove the REACTION to tinnitus, the CONDITIONED RESPONSE. Habituation of perception usually follows, but is not the primary aim of the therapy.
1.Identify effect of tinnitus and category
Your specialist needs to take a careful history taking about the effect of tinnitus, hyperacusis and how it emerges and develops. There is a guide to categories in teh TRT book.
2.Teaching : demystification
You need to learn the real mechanism of tinnitus and hyperacusis. The knowledge and information is quite different from old classical views still prevalent in text books, and still being taught in some medical schools. If you have a good understanding, now, of the Jastreboff model, you will appreciate that tinnitus is in fact a natural phenomenon rather than a disease. If you don’t believe this, then go back and read it again. In a high proportion of tinnitus sufferers, tinnitus becomes a problem because of the belief that a there is nothing that can be done about it. As your beliefs about this changes do, and it takes on a much more benign picture, so habituation is able to start. The story of the new neighbour illustrates this principle very well.
Imagine a new neighbour has moved next door. You exhibit mild interest to start with, but your anxiety increases very soon when you observe small packages being delivered to the front door on a regular basis by different individuals who quickly depart. You guess that you neighbour is perhaps a drugs dealer, and the prospect of spending many years next door to such criminal activity fills you with great alarm. You are constantly looking through the window monitoring the activities next door, and experiencing much anxiety and depression, by constantly thinking of the inevitable and desperate outcome for yourself and your young family of living next door to such a person. Some time later you learn quite by chance, that your neighbour is involved in collecting food parcels for the homeless. The realization that you have wrongly assessed the situation results in a sudden change of attitude. You loose your dislike for your neighbour, and stop monitoring his activities. You even feel foolish at your inappropriate initial assessment, realising you are all too likely to think the worst of people.
Because of the common traditional beliefs about tinnitus being an untreatable disease, which can destroy life quality, it is very understandable that those perceiving it, often become anxious and depressed, and find it impossible not to monitor every tiny variation of its behaviour. Once the truth about tinnitus, its natural, benign and fundamentally normal origin is known and understood, all the unpleasant reactions gradually disappear. Think of
a) Heller and Bergman 1953
b) Music of the Brain
c) Subcortical filters.
Review the tinnitus article carefully if you don’t understand this
3. Otological and audiological diagnosis
It is essential to be seen by an ENT specialist/Audiologist who is able to make an ‘ear’ diagnosis and exclude any simple treatable ear condition, like ear wax .
All patients with tinnitus should have as a very minimum, a pure tone audiogram, loudness discomfort levels, and an impedance audiogram to check that middle ear function is normal. If your impedance measurements are normal you do not have a problem with ‘catarrh’ or sinus affecting the ear.
Sound enrichment is an essential part of all retraining therapy. It is not easy to choose the appropriate sound or sounds which should be present in the background throughout 24 hours of the day. The important message is to avoid silence. This is something which is not particularly easy to do for some patients. There are many ways of enriching the sound environment, but it must be with a sound that is not irritating or intrusive itself. The best sounds are those that are like nature. In summer it may be possible to have the window open. Otherwise sounds coming from a a large slow moving domestic fan or radio tuned just of the station may be suitable.
It is essential that the sounds do not mask or block out the tinnitus when present, as it is not possible to habituated to a sound that you cannot hear. Many people with hyperacusis spend a lot of time in silence because of the dislike for external environmental noise. Some resort to ear plugs*. This is the worst thing to do, because it results in an increase of sensitivity in the central auditory system ( increase of gain) which makes external sounds louder still. In hyperacusis it is usually essential to be fitted with binaural white noise generators by someone who has been trained in TRT. They are frequently also necessary in treating significant tinnitus. It should be realized to that the wrong kind of sound therapy, for instance, listening to distorted music tapes, or using devices to mask tinnitus completely, can actually be harmful in certain cases.
Commercial devices which produce sounds like the sea or rain can be very useful, but everyone has an individual preference. Just leaving the television or radio on all the time is not really the answer, as this tends to be stimulating or intrusive at times, or to mask any tinnitus that may be present. Where there is a significant hearing loss causing a problem in hearing speech, patients will require amplification with appropriate hearing aids. These must be a properly fitted by ‘ best practice’ only and the two ears must be as evenly balanced as is possible.
* Ear plugs should only be worn when noise levels are know to be harmful to ANYONE. If you have been wearing ear plugs a lot, then only stop wearing them gradually over a period of time.
5. Retraining tactics (‘The 10 second exercise’)
1) Examine your reaction to tinnitus or unpleasant external sounds (in decreased sound tolernace) for some (short) periods each day. 10 seconds is long enough
2) Practice relaxation techniques to reduce the body (autonomic activity) part and try to reduce you annoyance / irritation / fear (limbic part) by an ‘act of diplomacy’. Don’t worry if you can’t reduce these things by much, every little counts, and each time the exercise will be easier.
3) Reduce the impact by sound enrichment or use of instruments according to TRT principles.
4) Try and identify your emotional and body reaction to the sound, and reduce this by a small amount each time. This is an aversive conditioned reflex response. It takes a long time to retrain conditioned reflexes (like hand writing, or your golf swing!). Be patient.
Do all these exercises for only such time as you experience no unpleasant reaction (may be 10 seconds to start with). Do this perhaps 10 times a day only. The rest of the time you maybe reacting as before, with distress, that’s OK in the initial stages.
This is an exercise in facing the object of your disaffection / dislike without reacting to it so strongly, an ‘exercise in diplomacy’. The principle works with everything in your life that annoys you or upsets you! It is important not to do too much to start with. Flooding yourself with unpleasant tinnitus experiences, or too much environmental sound which you dislike, can make things worse. As with desensitiation to an allergy, progress must be very slow and deliberate. An average period for retraining might be 18 months, or more in severe cases.
5) Think positively about the REAL meaning of tinnitus or external sound during this time, as described in the Jastreboff model.
6) Increase the period of these exercises gradually, by seconds, then maybe minutes. Slow progress, little and often, works best! If you try to rush it, you can go backwards.
RESULT: Experience decreased periods of reaction to, or awareness of tinnitus / external sounds and WITHOUT annoyance = progress (Habituation). If you notice any improvement, then you must be on the right track