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A Practical Approach to Tinnitus Treatment & Management: Lessons from the Trenches Pennsylvania Academy of Audiology September 23, 2011 Gail Whitelaw, Ph.D. Craig A. Kasper, Au.D ., FAAA. Tinnitus Treatment & Management Gail Whitelaw, Ph.D. Clinic Director

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slide1

A Practical Approach to Tinnitus Treatment & Management: Lessons from the Trenches

Pennsylvania Academy of Audiology

September 23, 2011

Gail Whitelaw, Ph.D.

Craig A. Kasper, Au.D., FAAA

slide2

Tinnitus Treatment & Management

Gail Whitelaw, Ph.D.

Clinic Director

Speech-Language Hearing Clinic

The Ohio State University

Columbus, Ohio

goals to discuss
Goals to discuss
  • Basic model for efficiency and effectiveness in managing tinnitus patients at all levels of clinical need
  • Do not need to be in a “specialized” tinnitus clinic to make this work
  • Efficiency and effectiveness difficult to address when time constraints are significant, constraining patients who want to talk is a challenge, and the lack of predictability in an already unpredictable day complicates issues
what we do about an issue is related to what we understand about the issue
What we do about an issue is related to what we understand about the issue…
  • Must believe in what we choose to do
  • Must be authentic in what we recommend
  • Difficult patients: Call in reinforcements
    • Hyperacusis for example
hierarchy of addressing tinnitus perception
Hierarchy of addressing tinnitus perception
  • Hyperacusis
  • Tinnitus
  • Hearing Loss
  • Auditory processing disorder
begin with the end in mind stephen covey discussing management first
Begin with the end in mind (Stephen Covey)…discussing management first
  • What does the patient expect?
  • A “cure”?
  • Need to have a clear understanding of what the person is looking for…
  • We have to know what we think…clear understanding of what we can do…
  • “No cure”…does not invalidate all we have to offer…last I looked, hearing aids do not cure hearing loss, we still prescribe them!
begin with the end in mind stephen covey discussing management first1
Begin with the end in mind (Stephen Covey)…discussing management first
  • Work together as a team to build a program…
  • “Tools in the tool box”
  • I don’t “fix” the patient, they fix themselves…
  • The “personal trainer scenario”
  • The case of John, former drummer turned personal trainer, and his success with tinnitus treatment
    • “Don’t you think I should wait”
    • Gave it 4 days
positive psychology
Positive psychology
  • Research from the University of Pennsylvania
  • Research by Martin Seligman, Ph.D.
  • Three central premises: positive emotions, positive individual traits, and positive institutions. Understanding positive emotions entails the study of contentment with the past, happiness in the present, and hope for the future
  • The issue of tinnitus: “There’s nothing you can do about this”
    • We have such a significant number of things that people can do…we hold the key to these
    • Easily within the scope of audiology
positive psychology1
Positive psychology
  • Many patients differentiate the two questions:
    • When did you first notice your tinnitus?
    • When were you first disturbed by your tinnitus?
      • Often described as the first time that someone (often a physician) told them that there was nothing they could do about their tinnitus
      • Patients who state that the quality of their day is based on their perception of their tinnitus when they awake on a given day
positive psychology2
Positive psychology
  • Authentic Happiness
    • http://www.authentichappiness.sas.upenn.edu
    • Tinnitus patient who teaches health promotion at OSU…what we say and how we “behave” as professionals has a direct influence on what the patient believes will work
    • Flourish: A Visionary New Understanding of Happiness and Well-being (2011)
brain plasticity
Brain plasticity
  • Ties into the Neurophysiologic model of tinnitus proposed by Jastreboff
  • The Brain that Changes Itself (2007) by Norman Doidge
  • Plastic is fantastic …for your brain
    • http://www.psychologytoday.com/blog/prime-your-gray-cells/201108/plastic-is-fantastic-your-brain
talking about tinnitus
Talking about tinnitus
  • Talking about tinnitus puts emphasis on it…draws attention to it (Sweetow)
  • How does one address/manage/treat tinnitus without talking about it?
  • Being aware of this issue…
  • However, ask “What is your goal in pursuing treatment?”
assessing where to go with the information that a person reports tinnitus
Assessing where to go with the information that a person reports tinnitus
  • Mention it in passing?
  • Tremendously disturbed?
  • Tinnitus Reaction Questionnaire:
    • How disturbed during the past week
    • If we administer, we try to give it to them every time they come in (even if annually)
  • Rank ordering of tinnitus/hearing/sound tolerance
  • How often do you notice it (%age of time) and how bothersome is it (%age of time)
american tinnitus association

ata.org

Recommend that this be the ONLY source of tinnitus information that they follow

“Dangers” of searching online

Counterintuitive to treatment goals

American Tinnitus Association
diagnostic process
Diagnostic process
  • Complete audiologic
  • High frequency phones
  • Use Neuromonics suggested assessment as a guide
    • Pitch match
    • Tinnitus match
    • NBN masking
    • BBN masking
    • Loudness discomfort level
    • Residual inhibition
educating the patient and others
Educating the patient and others
  • Case of Pete
    • Lives an hour from our clinic, his wife lives in California
    • When they sleep together, disaster
      • She loves silence, he loves sound
      • Stress around this; increases his tinnitus
    • Set up parameters that he reported on tinnitus and had her listen
      • Enlightening for her
    • Neurmonics patient…he uses it for sleep; preferred masking device
lessons from the successful patient sandra
Lessons from the successful patient: Sandra
  • Triggers: modified her behavior at first to make her life “liveable”
  • Psychological impact—significant yet surprising. “Why can’t I kick this thing…I’m strong”
    • Discuss of it being OK, needing someone to talk with
  • Silence as the enemy of the person with tinnitus
  • Audiology thinking on silence vs. hearing
lessons from the successful patient sandra1
Lessons from the successful patient: Sandra
  • Willingness to modify her behavior, worked at “getting better”
    • In her case, took some time off of work
    • Explored some options that might
  • Moving away from being a victim
    • Words that are used:
      • No victim
      • No sufferer
  • Listening and supporting from an audiologist is important and from others
  • Network: who’s in the network
  • Sleep helps!
working the program
Working the program
  • Issues with ownership—our responsibility to listen and give info
  • Their responsibility to implement the program as they see fit
    • Door always open, “no judgment”
acoustic therapies
Acoustic therapies
  • Options for audiologists
    • Hearing aids
    • Neuromonics
    • “Traditional” maskers and combo devices
  • Focus here will be some information on amplification…can be done by any audiologist that dispenses hearing aids
hearing aids and the patient with tinnitus
Hearing aids and the patient with tinnitus
  • Kochkin and Tyler: 2007…60% of patients with tinnitus who had concomitant hearing loss found significant reduction in their tinnitus
  • Trotter and Donaldson (2008): Approximately 70% of patient noted an improvement (reduction) in tinnitus perception while wearing appropriately fit hearing aids
hearing aids and the patient with tinnitus1
Hearing aids and the patient with tinnitus
  • The concept of appropriately fit
    • Kochkin data (in press): At least 50% of patients report benefit on tinnitus from hearing aid wear, but the number goes up as verification and validation of amplification are addressed
    • Critical feature is to assure that the hearing aid is appropriately fit
    • Tinnitus referrals of patients who have worn hearing aids previously yet have been “under fit”
hearing aids and the patient with tinnitus2
Hearing aids and the patient with tinnitus
  • The concept of appropriately fit
      • Explaining this to tinnitus patients
      • Case study
        • Linda
          • 50 year old woman, tinnitus since 9 years of age (dad and brother, also)
          • Fit with CICs
          • Under fit, did not wear all the time
          • Boosted aids…noticeable decrease in tinnitus
          • Her “happy hour” story
hearing aid benefits
Hearing aid benefits
  • Del Bo and Ambrosetti (2007) Progress in Brain Research
  • Hearing aids in patients with tinnitus have two specific benefits: 1) the hearing aid makes the patient less aware of the their tinnitus and 2) provides improved communication by reducing the sensation of annoyance perceived and the perception that the tinnitus masks voices
hearing aid benefits1
Hearing aid benefits
  • Del Bo and Ambrosetti (2007) Progress in Brain Research
  • Amplification appears to provide sufficient activation of the auditory nervous system to reduce the tinnitus perception and it MAY elicit expression of neural plasticity that can reprogram the auditory nervous system and have a long term benefit on tinnitus by restoring neural function
  • Best results were obtained in binaural fittings, open fit is best with widest “band amplification possible”, suggest disabling noise reduction controls
  • Our experience: Hearing aids sell themselves in this population, if one spends the time and selects the product appropriately (e.g. Widex products with Zen)
extended bandwidth
Extended bandwidth
  • Extended bandwidth amplification seems to have more impact on tinnitus perception (reduction of tinnitus) than products that are more “standard”
    • Even if fitting an aid without a “masking option”, extended high frequency is a benefit
    • Correlates to concept of evaluating high frequencies…the neurophysiologic model approach
supportive counseling
Supportive counseling
  • Australian version of “tinnitus coach”
  • Our tinnitus coach is a neuropsychologist with background in pain management
  • Generally a standard referral for a number of reasons
    • Skill and scope of practice
    • Time (and reimbursable time!)
cognitive behavioral therapy cbt
Cognitive behavioral therapy (CBT)
  • Very effective for tinnitus management
  • Anxiety disorders, phobias
  • “OCD personality”…what separates those who learn to ignore tinnitus from those who can’t
  • Minimize impact of tinnitus on one’s life—making tinnitus a “non-issue”
  • Idea of replacing non-helpful, irrational thoughts with “functional” thoughts
cognitive behavioral therapy cbt1
Cognitive behavioral therapy (CBT)
  • For tinnitus:
    • Short term
    • Replacing non-functional approaches (e.g. my day is determined by the loudness of my tinnitus) with functional approaches (e.g. I determine how I react to what happens to me today)
cognitive behavioral therapy cbt2
Cognitive behavioral therapy (CBT)
  • Case
    • 63 year old patient; Dean of a college at OSU
    • Tinnitus due to misfiring of nerve in sinus area
    • “Constantly hearing frying of bacon without the benefit of the smell”
    • Desperation…nothing audiologic helped (not surprising, based on the etiology of his tinnitus)
    • CBT very effective…but the caveat…
cognitive behavioral therapy
Cognitive behavioral therapy
  • Suicide
    • Controversial as to how this is addressed
    • Many tinnitus patients discuss the desire to no longer live
    • Many say they want to end their live—press this a bit
      • Does the patient have a plan?
      • Hyperacusis case
slide35

Tinnitus:

Lessons from the Clinic & Concepts You Can Easily Incorporate Into Your Clinical Routine

Craig A. Kasper, Au.D., FAAA

Chief Audiology Officer

Audio Help Hearing Centers

New York, NY

welcome introductions
Welcome & Introductions
  • Welcome!
  • Thank you!
  • Brief background…
    • Practicing audiologist for about 15 years
    • UB and U of F graduate
    • Columbia-Presbyterian Medical Center
    • Consultant
    • NYOG
    • AHAoM
    • ACS Custom USA
welcome introductions1
Welcome & Introductions
  • Q: How many of you consider yourselves tinnitus care providers?
agenda
Agenda
  • T is a very deep and complex subject
    • Share how my mindset of being a student of T has helped me develop strategies to help patients.
    • “The 10 Lessons” I’ve learned over the years
    • Case studies
  • Our goal:
    • Begin to remove the “fear factor” associated with tinnitus patients so we see tinnitus as an opportunity…
      • To help more patients
      • To grow our personal brand & business
toe may to or toe mah to
Toe-may-to or Toe-mah-to?!
  • Tinn-ih-tus or tinn-eye-tus?
  • What’s in a name…..
tinnitus defined
Tinnitus Defined
  • Tinnitus – the perception of sound in the absence of a corresponding external acoustic stimulus
incidence
Incidence
  • 50 million Americans have tinnitus
    • 16 million severe enough to seek help
    • 2 million severe enough that is halts “normal day-to-day activities”
    • 50% of combat soldiers develop T
    • In 2009, the cost to VA system to compensate veterans for tinnitus disability = $1.1 B
    • 2009 available research funding for tinnitus in the US = $10 M
key points
Key points…
  • Tinnitus is a SYMPTOM, not a disease or health condition.
key points1
Key points…
  • T is associated with hearing loss in 80% of cases
    • Opportunity to help more patients hear better while addressing their T
  • T is associated with hyperacusis in 40% of cases

(Kaltenbach, AAA ARC Conference, 2011)

evaluating patients with tinnitus
Evaluating Patients with Tinnitus

A Comprehensive Protocol

a multidisciplinary approach
A Multidisciplinary Approach
  • Otologist
  • Audiologist
  • Psychology professional
  • Potentially other healthcare professionals
    • Neurologist
    • Radiologist
    • Physical therapist
    • Nutritionist
    • Sleep expert
the audiological assessment
The Audiological Assessment
  • Otoscopy
  • Tympanometry (Reflexes & AR decay not recommended) – WHY?
  • Otoacoustic emissions
  • Pure-tone AC & BC (HF audiometry recommended)
  • SRT & WDS
  • Tinnitus matching, masking (value questionable?)
  • LDLs (500 Hz – 4000 Hz)
audiology assessment overview
Audiology Assessment - Overview
  • Post-medical clearance
  • Audiological case history
  • Standardized measures of psychological disturbance (THI, TRQ)
  • Comprehensive audiological evaluation, OAEs
  • Tinnitus matching, masking
  • LDLs
  • Review of results
assessment outcomes
Assessment Outcomes
  • Otologist/ ENT rules out medically-treatable causes
  • Audiology examination reveals clues to underlying issues (such as non-medically treatable hearing loss; 95% of cases)
  • Contributing sound sensitivity issue identified?
  • Understanding the degree of emotional impact (may result in immediate psychology assessment)
  • What techniques/ technologies/ information would help?
counseling the key to success
Counseling: The Key to Success

What we say to our patients, and how we say it, is critical.

ten lessons learned
Ten Lessons Learned

(maybe one, or two, more…)

lesson one be humble
Lesson One: Be Humble
  • Be humble
    • The more I learn the more I realize I have more to learn.
    • Patients might expect you to have all the answers; easy to fall into the trap of the “expert”
    • Our understanding of T (and science overall) moves forward faster that we can all keep up sometimes
    • Variability inherent in T
    • Answer questions to the best of your ability, and be honest when you don’t have all the answers.
      • Key is to create a level of confidence for the patient so they understand you are on the same team and will work to help them improve their situation.
lesson two t is a business opportunity
Lesson Two: T is a Business Opportunity
  • Providing services for those who are affected by tinnitus represents an outstanding business opportunity.
  • Tinnitus is an opportunity to see challenging patients, but it also helps you to build your professional brand (within your community, MDs, etc.)
  • More patients, increase image, increased opportunity for patient referrals, etc.
business opportunity
Business Opportunity
  • Initial Tinnitus Consultation (approx. 2 hours)
    • Billable codes for: CAE, tymps, Dx OAEs, T matching/ masking
    • Additional consultation fee (example: $300)
    • Dispense/ sale of T technologies and/ or hearing aids
      • 80% of those with T also have HL
    • Referrals to and from others – build awareness through report writing
    • Patient referrals – trip around the block is over
    • Further development and recognition of services and personal brand in the community
lesson three 3 rd party is ok by me
Lesson Three: 3rd Party is OK By Me
  • Recruit and involve the 3rd party
  • Patients who present with tremendous anxiety and depression
  • Significant other has been placed in a challenging position as a result
  • Everyone wants a solution to T immediately/ quick solutions
  • Develop the team
lesson three 3 rd party is ok by me1
Lesson Three: 3rd Party is OK By Me
  • In many cases, we have worked on the 3rd party before (also in parallel with) we work with the T patient
  • If we can help the 3rd party understand tinnitus and how to support their significant other, we have seen significant impact on the outcomes
lesson four take a holistic approach
Lesson Four: Take a Holistic Approach
  • Take a holistic approach to patient care
  • T presents a complex emotional, psychosocial and physical problem
    • As an audiologist, I don’t feel qualified to unravel this by myself
    • But I am starting to look at potential contributing factors/ solutions from interesting angles
doc is it all in my head
Doc, is it all in my head?

Probably your neck and brainstem, too….

lesson four take a holistic approach1
Lesson Four: Take a Holistic Approach
  • Nutrition/ Diet
  • Exercise
  • Sleep hygiene
  • Dental
  • Neck/ Spine health
  • Meditation/Mindfulness, Yoga
    • Saki Santorelli, Ed.D., Heal Thy Self: Lessons on Mindfulness in Medicine
lesson five this is a process
Lesson Five: This is a Process
  • If it was easy, everyone would do it.
  • No shortcuts: do the work = get better
  • The message is simple, the process is challenging
  • Get discouraged when patients would be doing better and then seem to fall off suddenly again
historic view of t
Historic View of T
  • The generators of tinnitus are in the inner ear.
  • What is wrong with this view?
    • Surgeons would cut the VIII N. in an attempt to treat the T
    • What happened? (House & Brackman, 1981)
current view of t
Current View of T
  • T generators are centrally located
  • Peripheral (for example: cochlear) changes are the catalyst for plastic changes in the central auditory nervous system
lesson six patients need normal
Lesson Six: Patients Need “Normal”
  • Encourage patients to pursue normal, everyday activities
  • Most patients experience a “vacation” from their T when they’re involved in something they like to do
  • This will help to reduce some of the small triggers that may set off the catastrophic thinking
  • Over time it contributes to the rewiring
lesson seven sleep is good
Lesson Seven: Sleep is Good
  • Restful sleep is key
  • Poor sleep = physical and emotional stress
  • Contributes to the motion of the T cycle
  • Discuss issues such as:
    • Apnea
    • Enhanced sound environment at night
    • Proper sleep hygiene
    • Other professionals, as needed
lesson eight musicians are wired differently
Lesson Eight: Musicians are Wired Differently
  • Set of “work” conditions makes musicians frequent T patients; MIHL
  • Many studies have demonstrated that the musician’s mind is wired differently than a non-musician (temporal lobe)
  • Musician’s think about and process sound differently
lesson eight musicians are wired differently1
Lesson Eight: Musicians are Wired Differently
  • Tinnitus, hyperacusis and diplacusis are common issues musicians present with
  • Sound is a huge part of their life. T feels like a huge loss.
  • Tinnitus
    • Many musicians will come in already having identified the exact pitch and intensity of their T
    • How it interacts with their instrument(s)
    • What their friends’ tinnitus sounds like (compare notes)
    • Hard-wired to observe and analyze sound
lesson nine i am only the facilitator
Lesson Nine: I am only the Facilitator
  • I am not as important as I once thought
    • The patient does all the real work – WE MUST EMPOWER THEM TO TRUST THE PROCESS AND THEMSELVES.
    • The psychologist is a major key to success
key points to share with pts
Key Points to Share With Pts
  • Although tinnitus might start out as an “ear thing”, it’s really a “brain thing”.
  • “My brain got me into this situation, my brain will get me out of it.” – patient who was debilitated by his tinnitus
lesson ten low tech is making a comeback
Lesson Ten: Low-Tech is Making a Comeback!
  • Low-tech is OK
    • Some patients are unable to afford certain tech
    • iPod & portable spa
question
QUESTION?
  • What is the most relaxing/ enjoyable place for many who suffer from tinnitus?
plasticity tinnitus in sum
Plasticity & Tinnitus, in sum…
  • Change (positive change) is always possible
  • Like any other rehabilitation, patients will need:
    • The right tools and information for their specific situation.
    • Dedicated effort to heal themselves.
    • Time & patience.
    • An educated, empathetic clinician who will facilitate the process.
key point
Key Point…
  • We need to use the concept of brain plasticity to our benefit. We have to “unlearn” the level of tinnitus awareness and emotional disturbance that we experience.
  • We need to demonstrate to patients that we are knowledgeable yet we might not have all the answers.
  • Most important: maintain a positive outlook as there are always options to help patients improve their current circumstances.
case study
Case Study

From suicidal thoughts to serenity and good health.

history
History
  • 41 year old male, married, two children, gainfully employed
  • Referred by ENT and audiologist following sudden-onset SNHL (AS) and rapid escalation of tinnitus
  • Overweight, depressed, lethargic
  • Exhausted due to lack of sleep; also uses CPAP for apnea
  • Father recently passed away
  • Construction on house – significant issues, expensive
initial assessment results
Initial Assessment - Results
  • TRQ – 74
  • Audiogram, etc.
  • Recommended – Widex Mind 440 with an open fit, Zen programs
  • Provided patient with guidelines for use
    • HA as many hours as possible/ day
    • Zen in times of rest/ quiet, when T is most bothersome
    • Pt encouraged to be “kind” to himself and also get back to exercising/ eating healthy, etc.
other recommendations
Other Recommendations
  • Consultation with psychologist
  • Consultation with sleep therapist/ center
  • Full physical with MD including blood work
  • Consultation with a nutritionist
outcomes
Outcomes
  • Ongoing (18 months of work)
  • Most recent update:
    • Feeling better than he has in years; smiles again
    • Exercising every morning, eating healthier
    • Blood work revealed vitamin D deficiency, thyroid abnormality, insulin resistance (supplementing and modified diet)
    • GOES DAYS WITHOUT NOTICING HIS TINNITUS. WHEN HE NOTICES IT, HE HAS THE ABILITY TO PUSH IT TO THE BACKROUND. HIS TINNITUS IS A NON-ISSUE NOW.
lessons learned
Lessons Learned
  • Lesson One – Be Humble
    • Explained early on to the patient that I did not have all the answers.
  • Lesson Two – Business Opportunity
    • The frequent communication with this ENT and other healthcare providers opened the door for more patient referrals.
  • Lesson Three – 3rd Party
    • His wife became a strong foundation of support in the time between appointments and phone calls.
lessons learned1
Lessons Learned
  • Lesson Four– A Holistic Approach
    • He felt his situation improved significantly when he pursued the recommendation to seek assessment from the psychologist, nutrition team and sleep hygiene professional
  • Lesson Five – This is a Process
    • >18 months of ups and downs; and he still works on it every day.
  • Lesson Six – Patients Need Normal
    • Once he gathered enough energy to get back to his “normal day to day” he took off.
lessons learned2
Lessons Learned
  • Lesson Seven – Sleep is Good
    • It took medication at the beginning, but he slowly (and safely) tapered. Also addressed his apnea through professional help/ losing weight.
  • Lesson Nine – I am only the Facilitator
    • This particular patient believes I had the “magic” solution. In reality, I just served as a coach to help him perform the necessary work on himself.
in sum
In Sum….
  • We have a wonderful opportunity to grow our practices and help many patients who would not normally walk through our doors.
  • I’ve found that the key to success is to be confident in what you do know, be honest about what you don’t know and maintain a mindset of a student throughout our professional life.
thank you
Thank you!

E ckasper@audiohelp.org

O 212 774 1971