NEUROMONICS TINNITUS TREATMENT CLINICIAN COUNSELING GUIDE

Transcription

1 NEUROMONICS TINNITUS TREATMENT CLINICIAN COUNSELING GUIDE Etiam sit amet est Recapturing Everyday Mments with Breakthrugh Tinnitus Treatment Trubleshting Techniques Cunseling Suggestins Frequently Asked Questins 1

2 Welcme Dear Clinicians, Cngratulatins n yur decisin t becme a Neurmnics Tinnitus Treatment prvider. Neurmnics cntinues t raise the bar in terms f clinically efficacy and validatin, which is supprted by the mst extensive bdy f clinical research f any tinnitus treatment n the market. This Clinician s Cunseling Manual aims t utline the key recmmendatins fr cunseling patients during the curse f their Neurmnics Tinnitus Treatment prgram. Many prminent current authrs view the cunseling prcess as a unique interactin between the clinician and the patient. It is imprtant t remember that cunseling appraches are bth highly tailred t the unique needs f the patient while als reflecting the persnal style f the clinician. An integral part f this prcess invlves nt nly general tinnitus educatin, but als hw Neurmnics wrks t specifically address the individual needs f patients. Expectatin management is certainly ne f the central aspects f Neurmnics cunseling, as ur tinnitus patients almst invariably hpe the prcess wuld be quicker and mre dramatic than what we knw is physically and neurlgically pssible. The key areas t ensure that yur patient understands are as fllws: Neurmnics can t cure hearing lss (nr can anything else), r the fact ur auditry system is nisy. Hwever, it can gradually reduce hw much the brain tries t amplify that neurlgical nise flr. The initial gal f treatment is t btain relief frm the tinnitus while using the device, and in this way immediately vercming its effects n lifestyle. The usual mid-term gal is cntinuing use f the device at the key times t develp a sense f cntrl ver the tinnitus, thus makes the tinnitus seem s much less frmidable. The lnger-term gal is reducing hw ften we are disturbed by the tinnitus, and imprving ur sund tlerance (if this was previusly a prblem). Mst patients cut back n using the device when it n lnger is a prblem, but sme still keep wrking twards als reducing hw ften they are aware f the tinnitus as well. Writing specific lifestyle gals that have als been negtiated is always a gd idea, s it can be shared with the patients significant thers and als be revisited later. It can be a reminder f hw much life has imprved since beginning Neurmnics, and great insurance against patients inadvertently mving the galpsts as time ges n. As always, realistic expectatins but a psitive utlk is key! Anther fundamental ntin that needs t be appreciated by bth the clinician and patient is the central rle f relaxatin in getting maximum effect frm Neurmnics. When dispensing the device, it is thus critical t emphasize that cnditining a relaxatin respnse t the music is key t full benefit. Frtunately, that is a very pleasant prescriptin. The practical aspects f Neurmnics cunseling have a lt t d with the applicatin f the prtcl t the patient s particular lifestyle requirements. Much f this is related t vlume setting. In the first few mnths, the gal t use higher levels f vlume t get mst relief, but the verriding cnsideratin is t always maintain cmfrt and relaxatin. Once the Neurmnics Treatment is prviding the apprpriate sense f cntrl, then vlume can be reduced t a mre intermittent level s that a mre permanent reductin in disturbance can gradually be affrded. Measuring their current MML thrugh the device and then crss-referencing the actual usage frm the data lgging can help verify adherence t the prtcl. A very useful ntin t impress upn the patient is that successful treatment utcmes are linked t the amunt f time spent listening t their device (and definitively related nt the ludness it is played at). 2

3 The third Neurmnics clinical trial fund clear dse-relatinship with success. S in the initial treatment stages f mderate t severe tinnitus, they shuld be using the device a great deal since their tinnitus wuld be a prblem fr a large part f the day. As their tinnitus becmes less f a prblem, the treatment can be used crrespndingly less. As treatment prgresses, a typical challenge is that the patient feels that they are nt making as much prgress as they did initially. This is nrmal, and the average respnse in the clinical trials is fr the biggest gains t be in the first tw mnths, and then mre gradual thereafter. Hwever, these further incremental imprvements d really add up, and we need t use external benchmarks like TRQ, MMLs and LDL s t mnitr this prgress and then be able t prvide feedback n the usually happy news. This is far mre reliable than the patient trying t mnitr their tinnitus, and nt at crss purpses with the gal f eventually reducing awareness. Truble-shting is the next majr area f Neurmnics cunseling, and is the main fcus f this manual. A fundamental ntin that yur patients need t understand is that all the usual things that make tinnitus wrse still can still d during treatment. These exacerbating factrs can reduce ptential benefit, s they shuld be prperly cntrlled. Despite the time spent in the clinic tailring the treatment t the individual, there is still a huge rle fr als making full use f the written and nline infrmatin we have made available. This aids tremendusly in recalling the necessary infrmatin and gals, and is wnderfully helpful in invlving the patients significant thers as allies in the rehabilitatin prcess. Neurmnics ffers a number f such patient-use tls in the Clinicians Guidelines CD/Manual and nline. These tls can greatly increase efficiency, and reduce clinical time. This streamlining f the cunseling prcess, in cmbinatin with a far mre sphisticated and tailred acustic stimulus, are the main reasns why Neurmnics nly requires at least half the 15 hurs f clinic time required fr TRT, and yet btains the same success rate in a third f the therapy time elapsed. The fllwing pages utline the mst cmmn challenges encuntered by clinicians when administering Neurmnics, and hw they can be apprached thrugh cunseling. Of curse sme patients have very unique circumstances that may nt neatly fit in with these mre general recmmendatins, s yur clinical judgment may smetimes be required t tailr treatment t that patient. Please dn t hesitate t als cntact Neurmnics s that yu can avail the invaluable input f the Clinical Specialists. Thanks again and I hpe yu enjy the experience f helping yur patients get relief frm their tinnitus. Paul B Davis PhD Funder/Scientific Advisr 3

4 Table f Cntents Welcme... 3 In Their Wrds... 5 Cmmn Everyday Life Issues... 6 Patient with recent illness/ change in medicatin... 6 Recent Nise Expsure... 6 Extended perids f Straining t Hear Clearly... 6 Managing Stress... 6 Psychlgical Factrs Affecting Treatment... 7 Excessive Tinnitus Mnitring... 7 Tinnitus Tpic Mnitring... 7 Cunting Clicks and Device Settings Stress... 7 Changes in Hearing... 8 Managing Patient Expectatins... 9 Overcming Mindset Barriers/Cgnitive Distrtins/Unrealistic Expectatins 9 Managing Patient Expectatins... 9 Anxiety Prhibiting Milestne Achievement Addressing Anxiety/Depressin and Suicidal Ideatins Nn-Standard Patient Trubleshting Addressing Obstacles t Success Managing Decreased Sund Tlerance and Hyperacusis Reactive Tinnitus Managing Lw TRQ Patients Managing High TRQ Patients Patient is Experiencing Lw Treatment Interactin Managing Hearing Lss Managing Multi-Tnal Tinnitus Managing Pulsatile Tinnitus Managing Treatment Specific Issues Incrrect Device Usage Patient is nt Using Device at Right Vlume Patient is nt Meeting Usage Requirements Patient is nt Using Treatment in Right Auditry Envirnment Patient is nt Using Treatment Apprpriately Stage Prgressin Cnsideratins Questins t Cnsider Befre Transitin t Stage Tw Mving t the Maintenance Phase f Treatment Pssible Patient Cmplaints My Tinnitus is Getting Wrse Tinnitus Perceptin is Wrse Since Initiatin f Treatment My Tinnitus is Wrse in Quiet My Tinnitus is Mre Nticeable Fllwing Treatment Sessin Tinnitus is Impacted by Expsure t Certain Sunds My Tinnitus is Changing Managing Issues with Neurmnics Stimulus Patient is Experiencing Lw r N Interactin Patient is Unable t Achieve High Level f Interactin Patient Dependent n High Interactin/Fearful f Transitin Phase One Stimulus Prduces Anxiety Patient Sees Treatment as a Chre/Causing Anxiety Specific Tracks Cause Annyance r Anxiety Reducing Returns and Keeping Patients in Treatment Use Yur Resurces Trubleshting Suggestins Be Prepared fr Patient Setbacks and Issues Yu Are The Expert FAQ s Cnclusin

5 In Their Wrds I think cunseling is the mst critical aspect f any tinnitus management prgram. I use lts f examples abut sensatins that are regularly habituated. Things such as the feeling f a wrist watch, yur feet in yur shes, a ring n the finger, etc.; these are sensatins that ne culd turn their attentin t, but generally ignre. This can happen with the tinnitus. It may be present, but des nt have t be an annyance r disturbing sensatin. Reviewing the auditry and central anatmy and discussing where the tinnitus may be cming frm and hw it gt t be an annyance can help reduce the fear and mystery f hw this became such a disturbing sensatin. -Jill Meltzer, Au.D. - Nrth Shre Audi-Vestibular Lab, Highland Park, IL Neurmnics Prvider since 2006 I like t remind patients that treatment is a jurney with the ultimate gal being t reclaim their lives frm tinnitus. The Neurmnics device is a shrt-term slutin fr lng-term benefit. It is a tl that allws them t functin and participate in activities they enjy. Over time, the treatment helps them t re-priritize tinnitus s that it is n lnger a cnsideratin in their daily lives. My rle is t partner with them in this jurney by answering their questins, mnitring their prgress, being their cheerleader, hlding them accuntable, and even prviding tugh lve when necessary. I have fund the Neurmnics Tinnitus Treatment wrks best when yu cnnect with patients n a persnal level and they feel yu have their best interest at heart. -Lisa Fx-Thmas, Ph.D., CCC-A, UNCG Speech and Hearing Center, Greensbr, NC. Neurmnics Prvider since 2007 Onging supprt and encuragement are keys t successful utcmes. Availability is als critical: invlvement with Neurmnics Tinnitus Treatment requires a strng cmmitment t being available t yur patients. -Steve Bentn, Au.D., Atlanta VA Medical Center Neurmnics Prvider since 2007 I think tinnitus patients must want t get help, be mtivated t imprve, be cmmitted t whatever treatment ptin they chse. Patients shuld understand there is n quick fix and imprvement will take at least a mnth r tw at the quickest and usually lnger fr mst patients. Patients shuld als knw that treatment ptins are available and there is hpe even if their dctr has tld them they need t learn t live with it. Fr any clinicians beginning the Neurmnics Treatment, please realize that it is easy t use and successful 85% f the time, hwever it typically takes anywhere frm 6-10 mnths t achieve the desired results.. -Mark Sanfrd, M.S., CCC-A, CSG Better Hearing Center, Walnut Creek, CA Neurmnics Prvider since 2007 I begin by telling patients that educatin is the first step in managing tinnitus. I walk them thrugh a review f the ear anatmy and the prcess f hw sund reaches yur brain. Then I talk abut hw yur brain deals with sund. By using lts f examples, I create an image f the tinnitus and its effect n yu, the patient. Effective cunseling is the strngest cmpnent f all tinnitus management slutins including Neurmnics. -Beth Albert, Au.D., Hearing Care f Summerville, SC Neurmnics Prvider since 2007 Tinnitus patients are all different, and their individual prblems related t emtins, hearing, sleep and cncentratin need t be addressed in a cllabrative, nt directive, fashin. Engaging patients in practice activities, where they take respnsibility fr changing their reactins, is helpful fr mst. -Rich Tyler, Ph.D. Department f Otlarynglgy and Department f Cmmunicatin Sciences and Disrders, The University f Iwa Neurmnics Prvider since

6 Cmmn Everyday Life Issues Patients with a Recent Illness and /r a Change in Medicatin: A cld, flu, allergy, r excessive ear wax can enhance tinnitus. Changes in medicatin r dsage may als affect tinnitus. Recent Nise Expsure: What T D: In these instances, cunsel yur patient t return t their practitiner t rule ut, r receive treatment fr, any underlying medical prblems/medicatin change that may be aggravating their tinnitus. A perid f nise expsure at a sprting event, wedding, etc can exacerbate tinnitus. What T D: A gd standard t use is that that if the envirnment is lud enugh fr the patient t shut, then wearing hearing prtectin is indicated. Als remind yur patient that expsure t lud nise withut prtectin can be a setback t their treatment. The setback is nt irreversible, but ear prtectin shuld be used in similar situatins mving frward. Extended Perids f Straining t Hear Clearly: Based n the neurphysilgical mdel f tinnitus, straining t hear places the brain n high alert searching fr sund and amplifying internal sunds. This is turn leads t an increased tinnitus awareness. Managing Stress: What T D: Cunsel regarding patient-specific examples f strenuus listening envirnments/ situatins fr the patient t avid. Als advise yur patient t nt listen t their treatment at times when they are straining t hear. Stress and tinnitus are intercnnected. It is imprtant t manage stress befre and during tinnitus treatment. Previus studies and patient feedback indicates that stress management supprt and cunseling prir t, r in cnjunctin with, NTT will enhance the prbability fr a successful treatment. What T D: Prvide/review general tinnitus management strategies as cvered in patient handuts. Brainstrm with the patient t identify and priritize issues that have the mst impact n the patient and treatment success. If yur patient exhibits excessive levels f stress, then a referral t a prfessinal specializing in Cgnitive Behavir Therapy is recmmended. The gal f Cgnitive Behavir Therapy is t help the patient identify any unhelpful r incrrect thinking and t bring abut a mre realistic understanding and apprach t deal with this way f thinking. Relaxatin training is ften incrprated int this prcess. Bth Cgnitive Behaviral Therapy and relaxatin training have been prven effective in the management f the tinnitus patient. Additinal ways f managing stress include regular exercise, minimizing stimulants and cnsistent sleep patterns. Refer yur patient t the website fr tips in stress management and relaxatin techniques. 6

7 Psychlgical Factrs Affecting Treatment Excessive Tinnitus Mnitring Patients attempting t mnitr their tinnitus are being cunterprductive t the gal f reducing awareness. Changes in tinnitus tend t be gradual and hard t benchmark s reductins can be hard t determine withut prper mnitring by a clinician. Tinnitus perceptin als tends t fluctuate in ludness and the ludness experienced is als affected by attentin. When patients attend t their tinnitus, they may actually begin t perceive it as luder. What t D: Remind yur patient that they shuld nt ver mnitr their tinnitus. The idea is t teach the brain t put the tinnitus in the backgrund, s if they are cntinually checking in with their tinnitus they are inhibiting that prcess. There is n need t jurnal, chart r make ntes abut their tinnitus perceptin n a daily basis. This is what their fllw-up visits are fr. Additinal clinic appintments r fllw-up phne calls can be added in rder t mnitr effective use f treatment. Advise the patient t be invlved with an activity while wearing the device (wrk, reading etc.). This will prvide the ability t set and frget the treatment. Advise patient t distract the brain with pleasant music etc. when nt using the treatment and avid the temptatin t mnitr their tinnitus. Tinnitus Tpic Mnitring: Patients need, and will benefit frm, current, accurate, and research based infrmatin abut their tinnitus and treatment. If patients have unreslved questins and issues regarding tinnitus tpics and it s management, then prgressin thrugh treatment may be cmprmised until the patient ascertains up-t-date and valid infrmatin. Surfing the internet r spending time in chat rms r message bards can actually inhibit a patient s prgress in treatment. It is vital t advise yur patients that the mre time they spend researching and fcusing n their tinnitus the mre likely they are t further cement their awareness. Restricting and limiting the time spent n these activities can greatly benefit the verall treatment utcme. What t D: Suggest expsure t nly up-t-date internet sites/written infrmatin: r Prviding cpies f the Neurmnics Clinical Data Summary r ther published articles will ften prvide cmfrt t yur patients as they can better understand the time frame f expected changes as well as the mechanisms yu are using t gauge prgress. Cunting Clicks and Device Setting Stress There may be times data lgging and patient reprts cnfirm that the patient is cunting clicks t determine vlume level. Remember thugh that the first and mst imprtant factr is that the treatment be cmfrtable and pleasant while prviding as much relief as pssible. The vlume level shuld allw the patient t set and frget the treatment. What t D: Cunsel patient nt t be hesitant t push the envelpe and use mre vlume while still aviding any vlume level that prevents the treatment frm being pleasant and relaxing. Remind yur patient that apprpriate vlume levels wuld be expected t vary frm day t day as tinnitus perceptin as well as listening envirnments may vary. 7

8 Changes in Hearing: The Neurmnics treatment is based n stimulating the auditry system with a custmized acustic stimulus prescribed fr the auditry threshlds f each ear. If a significant change in hearing ccurs, an SD card change may be necessary t accmmdate a change in hearing prfile. What t D: In this situatin, cunsel yur patients regarding hearing lss change and management, and hw hearing change can enhance tinnitus perceptin. Assure the patient that a new SD card will allw treatment t resume per prtcl. Cnsult yur Clinical Specialist t cnsider and discuss suspending treatment until a new SD card is available. Did Yu Knw? 91% f peple wh used the Neurmnics Tinnitus Treatment reprted a significant reductin in the tinnitus disturbance 86% had a significant reductin in the tinnitus awareness 70% had a significant reductin in the tinnitus vlume 78% had a significant imprvement in their tlerance t lud sunds 97% wuld recmmend the treatment t thers (Davis, Paki and Hanley; Ear and Hearing) Dn t frget t register at t gain access t everything yu will need t help yur patients and practice thrive with the Neurmnics Tinnitus Treatment 8

9 Managing Patient Expectatins As a clinician it is imperative that yu cnvey the apprpriate expectatins t yur patient. Neurmnics is nt a cure fr their tinnitus. Impacts f the treatment are dse related and prgress is largely determined by the amunt f effrt put frth by the patient. Sme apprpriate treatment expectatins include: Incremental reductins in tinnitus disturbance levels Fr Tier 1 candidates, Clinical Trial results are apprpriate benchmarks fr success Tier 2 and Tier 3 candidates shuld adjust expectatins accrdingly. Refer t the Neurmnics Private Practice data fr specific results by patient type. Expectatins can be divided int shrt, medium and lng-term gals. It is ften helpful t write ut patient specific gals and reasnable time frames fr patients at the fitting appintment. Using the treatment fr specific lifestyle issues such as helping with sleep nset r cncentratin while reading are cmmnly achieved gals. Overcming Mindset Barriers /Cgnitive Distrtins/Unrealistic Expectatins Cgnitive Behavir Therapy, r CBT, is a cmmn tl used t hep patients deal with the impact f tinnitus n their verall well being. CBT is ften used t help patients cpe with majr life changes r events that have intruded n their day-t-day existence. The purpse f Cgnitive Behavir Therapy is t alter negative thinking and t bring abut a mre realistic assessment and understanding f a prblem. This type f therapy has been prven effective in the management f the tinnitus patient. What t D: Direct questining can be used t identify the presence f cgnitive distrtins, mindset barriers, and unrealistic expectatins Direct questining can be used t assist patients in gaining a realistic, balanced perspective. Apprpriate questins are, what evidence supprts this idea? and what is the evidence that this idea is nt true? Alternative perspectives and ratinales can be ffered. Writing ideas dwn n paper t review may bring a mre balanced perspective than trying t hld ideas in the mind. Cunsel patient t cnsider if further cunseling and supprt is indicated. Prvide patient advice sheets including, Hw Can A Psychlgist Help? Prvide patient with a list f clinics that specialize in Cgnitive Behavir Therapy. Mst remedial actins and cunseling guidelines in this sectin wuld be pertinent fr this type f patient. Managing Patient Expectatins Tinnitus patients ften want an immediate fix and cure fr their prblem. This is understandable cnsidering what they have gne thrugh. At times, this mindset can lead t unrealistic expectatins fr treatment. Often times, when a patient is meeting their treatment gals and expectatins early in treatment, the bar f expectatins will get raised. When this happens yu need t be ready. 9

10 What t D: Review and restate patient-specific infrmatin and recmmendatins frm their assessment and ther previus appintments. Use evidence tls t reinfrce that incremental prgress has been made, that treatment is prgressing and milestnes are being met. Specifically yu shuld refer t: TRQ changes MML and LDL changes Treatment Specific Gals set at the fitting appintment Yu may als want t refer t the patient expectatins dcument cmpleted during the fitting appintment. This can help bring expectatins back int alignment. It als imprtant t validate that treatment is ging well, and staying the curse can lead t greater dividends dwn the rad. It can be useful at this time t ask the patient t cnsider activities nce eliminated because f the negative impact f their tinnitus and then an actin plan shuld be devised t identify steps that can be taken t resume nce pleasurable activities. Help the patient t brainstrm a future nt restricted by tinnitus. Anxiety Prhibiting Milestne Achievement: Excessive levels f anxiety can reduce the ptential benefit f the Neurmnics treatment. If yur patient s level f anxiety is inhibiting their prgress, then they shuld cnsider utside help fr stress and anxiety management. Since tinnitus severity is psitively crrelated with patients level f anxiety it is quite pssible that their anxiety will hinder their success with treatment. What t D: Suggest t yur patient that they cnsider additinal cunseling and supprt. Prvide patient advice sheets including, Hw Can A Psychlgist Help? Remember t prmte the patient s feelings f hpe and t reinfrce realistic expectatins. Yu can als suggest up-t-date internet sites/written infrmatin: and advise f lcal self-help grups r tinnitus supprt grups. Addressing Anxiety, Depressin and Suicidal Ideatins Any scre ther than 0 n questin 24 f the TRQ must be addressed. Due t the nature f tinnitus and the debilitating impact it can have n patients, suicidal thughts are ften present. As a clinician, yu shuld be prepared fr this type f situatin and have a prtcl in place in the event this tpic presents itself. What t D: If there is indicatin f active cntemplatin f suicide reprted by patient, refer t patient s PCP/GP r psychlgist r fllw yur clinic s practice guidelines in managing patients with suicidal tendencies. Strngly advise that In parallel with the NTT, a referral t a tinnitus cach (psychlgist) is indicated fr patient s well being and prgressin with treatment. Prvide patient with a list f clinics that specialize in Cgnitive Behavir Therapy Cnsider delaying the start f treatment until the patient has begun treatment fr additinal psychlgical factrs that are utside the scpe f yur practice. 10

11 Nn-Standard Patient Trubleshting Addressing Obstacles t Success The Neurmnics Tinnitus Treatment is a prgram that lasts, n average, 6-8 mnths, hwever sme individuals have nn-standard individual characteristics which may lengthen the duratin f treatment. These variables need t be addressed as a patient mves thrugh treatment. Remember that individuals respnd at different speeds and may have a variety f experiences, therefre mdificatins f, r additins t, the standard treatment prtcl may be recmmended. When cnsidering mdificatin t the standard prtcl be sure t cnsult yur Neurmnics Clinical Specialist. What t D: Assure yur patient that yu will wrk tgether with a Neurmnics Clinical Specialist t identify the variable(s) impeding treatment prgress and will cllabrate t develp a remediatin plan. Remind the patient that cmpliancy with suggested remedial actins is vital s that ptential treatment gains are nt cmprmised. Additinal regular clinic appintments r fllw-up phne calls can be added as indicated fr mnitring effective use f treatment. Managing Decreased Sund Tlerance (DST) and Hyperacusis DST is a cmmn phenmenn fund with the presence f tinnitus. In rder t maximize the chance f success this cnditin cannt be verlked during their treatment. Often these patients have such a reduced sund tlerance that they are nt able t gain sufficient relief frm their Neurmnics treatment. A mdified prtcl is suggested in rder t address sund tlerance issues s that the tinnitus can then be treated. Please refer t the Hyperacusis Prtcl fr a cmprehensive discussin n dealing with this tpic. Belw are sme principles t cnsider when DST is an issue. After cmpleting the tinnitus evaluatin always review the patient s Ludness Discmfrt Levels even if tinnitus is the primary cmplaint. Hyperacusis can easily becme a cnditin that the patient is blivius t as ften times they will alter their envirnment t accmmdate the cnditin. Be sure t cnsider misphnia and phnphbia as well. If LDL s are nt nrmal, there may be specific sunds that the patient is averse t. This cnditin can be due t a negative psychlgical experience assciated with a sund as ppsed t actual decreased sund tlerance. IF decreased sund tlerance is present, in additin t tinnitus, then the patient must g thrugh the prcess f desensitizing t sund by using the Neurmnics treatment. Once this has ccurred, tinnitus can be addressed. If nt addressed, sund tlerance issues can prevent the treatment frm being used at the apprpriate vlume and ften times cntribute t stress which will make tinnitus relief less likely. Cnsult yur Neurmnics Clinical Specialist t determine whether a hyperacusis prtcl is warranted. 11

12 Reactive Tinnitus Reactive tinnitus is a rare and extreme cnditin whereby an individual s tinnitus is wrsened after expsure t a mild t mderate level f sund. With reactive tinnitus this increase tends t last fr mre than a day. Reactive tinnitus is suspected in individuals wh reprt an veruse f hearing prtectin, have fund nthing reduces their awareness f tinnitus, and when trials f ther acustic based treatments clearly aggravated their tinnitus. Reactive tinnitus may nt be identified at an assessment appintment r, in very rare cases it is pssible fr reactive tinnitus t develp during treatment. If patient reprts tinnitus perceptin appears luder after treatment and it stays that way, immediately cnsult yur Neurmnics Clinical Specialist. What t D: Emphasize t yur patient that this is nt a cause fr grave cncern, that a prtcl designed fr Reactive Tinnitus will be fllwed. It differs frm the standard prtcl in that nly the Phase 2 stimulus will be used and vlume will be set at a lwer vlume. It is imprtant t mnitr patients carefully if the exhibit these symptms. Any patient with reactive tinnitus symptms may need the assistance f a Tinnitus cach t facilitate a successful treatment. If pssible prvide a list f clinics in yur area that specialize in Cgnitive Behavir Therapy. Als prvide apprpriate patient advice sheets (e.g. Prgressive Relaxatin Training). Patients that reprt their tinnitus is wrsening ften times have issues related t cmpensatin and/ r pre-existing anxiety issues that shuld be addressed befre cntinuing treatment. 12

13 Managing Lw TRQ patients Yu may encunter a patient with a TRQ scre belw 17 that wuld like t prceed with treatment. Even thugh this TRQ scre is nt cnsidered clinically significant, there are still numerus benefits which can be achieved with the Neurmnics Tinnitus Treatment. The Neurmnics Tinnitus Treatment will still address numerus effects measured n the TRQ i.e. tensin, cncentratin, ability t relax, decreased sund tlerance, ability t sleep. What t D: Yu can cunsel yur patient t expect apprpriate efficacy utcmes despite their lw TRQ scre. While mre dramatic/ nticeable utcmes fr higher TRQ scres are cmmn, their levels f imprvement are likely t be mre subtle. Make a list f persnal gals that the patient wuld like t achieve frm their treatment, then develp a treatment plan and usage schedule t meet these bjectives. Managing High TRQ Patients Patients with a TRQ scre abve 70 are typically cnsidered nn-standard patients. This des nt mean that they can nt achieve significant benefit frm the Neurmnics treatment, rather it is in indicatin that there are additinal factrs cntributing t the patient s level f disturbance. In these instances it is ften apprpriate t cnsider utside interventin prir t beginning the Neurmnics treatment. What t D: In these instances, additinal supprt, thrugh the use f a Tinnitus Cach, is indicated. Cunsel that withut this additinal supprt, ptential treatment utcmes may be cmprmised. Infrm yur patient that a lnger time may be needed t realize treatment benefits. Additinal clinic appintments are ften recmmended fr this patient type. Prvide yur patient with a list f clinics in the area that specialize in Cgnitive Behavir Therapy and Psychiatry Did yu Knw? Neurmnics prvides assistance with cnsumer seminars including direct mail, advertising and public relatins assistance. Fr mre infrmatin cntact Neurmnics Custmer Service at

14 Patient is Experiencing Lw Treatment Interactin The gal f the Neurmnics stimulus is t blend with the patient s tinnitus at a cmfrtable and relaxing level while ultimately reducing the vlume t create a mre intermittent interactin with the tinnitus. DST and r a very high level f hearing lss can make it difficult fr sme patients t achieve a high level f interactin with the treatment. What t D: Infrm yur patient that the vlume level will be regulated by cmfrt rather than degree f interactin. Cunsel patient that the initial lw vlume level may nt prvide satisfactry interactin, but the ability t increase the vlume level may imprve ver time (see DST/ Hyperacusis remedial actin sectin) fr a mre satisfactry interactin. Expectatins shuld be set fr the treatment f the DST prir t tinnitus treatment. If, after fllwing the DST/ Hyperacusis prtcl the vlume level f the stimulus is able t be increased t a level f ffering sme degree f relief, then tinnitus treatment can be initiated. Set expectatins that nce tinnitus treatment begins, extra time (>2 mnths) may be needed in Stage One t meet milestnes befre transitining t Stage Tw. Cunsel that LDLs and BBN MML will be measured at intervals t dcument prgress. Managing Hearing Lss When a large degree f asymmetry exists between ears, sme patients find that relief is achieved at a mre cmfrtable listening level when a cntralateral prescriptin is used. This prescriptin prvides less stimulatin t the prer ear. In this instance, the effective stimulus is nly (r largely) delivered thrugh the better ear. When cnsidering the use f the cntralateral prescriptin, it is imprtant t factr in the patient s wrd discriminatin scres. While their audimetric threshlds may be within the recmmended fitting range, if pr WDS s are present, the treatment will sund distrted just as speech des. If this is the case, the cntralateral prescriptin may be a better chice. Always cnsult with a Neurmnics Clinical Specialist if yu believe a cntralateral prescriptin is warranted. What t D: If patient has been fit with a cntralateral prescriptin yu shuld be aware f the fllwing pssible cmplaints: lw interactin, lack f stere effect, the music is nt engrssing, r slw prgress with treatment. If yu hear this then review expectatins with yur patient. Remember that the amunt f stimulatin and degree f interactin achievable is lwer than wuld be the case with a standard prescriptin due t asymmetrical hearing lss cnsideratins. Infrm yur patient that gd utcmes are expected hwever there may be a lnger treatment curse (>8 mnths). They shuld als knw that gradual and incremental prgress is t be expected rather than dramatic imprvement. Cnsult yur Neurmnics Clinical Specialist t determine if the patient shuld listen t the treatment thrugh nly the earphne in the better ear and nt in the ther ear. Yu will still use the wrst tinnitus side as the ne t mask. 14

15 Managing Multi-Tnal Tinnitus It is nt uncmmn fr patients t reprt that their tinnitus has many tnes and iteratins. This can cause wrry that the treatment will nt be effective due t the nature f their tinnitus. What t D: Remind yur patient that during assessment, measurements were cmpleted n the tne that was reprted by the patient t be the mst prminent and disturbing. Set expectatins that the aim is t have treatment interacting with the mst prminent tnal tinnitus, but treatment is likely t have effect n ther tnes due t multi-frequency nature f the stimulus. Managing Pulsatile Tinnitus If pulsatile tinnitus is present with classical tinnitus (and classical tinnitus is mst disturbing) cunsel that the aim is t have treatment interacting with the classical tinnitus t allw fr sme reductin r masking f symptms. Set expectatins that there may r may nt be any benefit n the pulsatile cmpnent. If pulsatile tinnitus is the mst disturbing but has at least a partial interactin with the treatment, set expectatins that the gal f treatment will be primarily t reduce the negative assciatin with the tinnitus perceptin which may in sme cases lead t a reductin in awareness. Did Yu Knw? Neurmnics will train additinal clinicians at an existing clinics free f charge. Check with yur Neurmnics Clinical Specialist fr details and access t the Neurmnics Prfessinal Website 15

16 Managing Treatment Specific Issues Incrrect Device Usage The Neurmnics prtcl clearly defines that the right time t use the treatment is when tinnitus perceptin is mst bthersme. What t d: Cunsel t use treatment when the patient is mst disturbed by tinnitus (e.g. at a 7, 8, 9, r 10 when thinking f tinnitus n a 1 t 10 scale). Cunsel yur patient t think abut device use in the same sense as using an aspirin fr a headache. When their tinnitus is bthersme, then use their device. Assist the patient in cnsidering the times and situatins that are impacted mst by tinnitus and cunsel t fcus the use f treatment at thse times t get relief and cntrl. Cunsel t use treatment as sn as the tinnitus becmes bthersme rather than t fight thrugh the tinnitus and allw it t escalate. Patient is Nt using Treatment at the Right Vlume The prtcl defines the apprpriate vlume level fr listening as a cmfrtable level t allw fr relaxing and pleasant listening. Listening at t high f a vlume can take away frm the desired relaxatin element f the treatment and can actually becme a surce f irritatin. What t D: Cunsel n setting vlume t a level that is always cmfrtable and pleasant, but prvides as much relief as pssible. An apprpriate vlume level shuld allw the patient t set and frget the treatment. Cunsel patient nt t be hesitant t push the envelpe and use mre vlume while still aviding any vlume level that prevents the treatment frm always being pleasant and relaxing. Remind patient that relief frm tinnitus, within this pleasant and relaxing cntext, is what will break any negative emtinal invlvement with the tinnitus. Patient is Nt Meeting Usage Requirements The prtcl defines apprpriate usage time as 2-4 hurs per day, when tinnitus is mst bthersme, fr an apprximate duratin f 6-8 mnths (varies per individual). What t D: If cmplaint is regarding anxiety/auditry fatigue while using device: Cunsel t avid a t lng and t lud scenari that can cntribute t anxiety and auditry fatigue. Remind yur patient that usage can be in small segments f time: 15 r 30 minute sessins based upn individual needs. Remind patient that a daily ttal f 2 hurs is prven sufficient fr utcme success if additinal treatment time is nt needed, hwever there is a clear dse related utcme effect in terms f usage. Patients wh use the device between 2-4 hurs per day tend t get better results. 16

17 If a patient cmplaint is regarding lack f time in their day fr treatment, cunsel regarding 2 hur daily ttal (see abve). Review the cnvenient aspects f the treatment, and brainstrm specific situatins in which the patient can fit the treatment int daily life. Patient is Nt Using Treatment in the Right Auditry Envirnment The NTT prtcl defines a quieter listening envirnment as a necessary cmpnent f the treatment. A nisy ambient envirnment requires the vlume f the device t be increased beynd a cmfrtable, relaxing vlume level. What t D: Strngly advise against using treatment in nisy ambient envirnments. Brainstrm with yur patient t identify specific envirnments that shuld be avided. Reinfrce that the auditry envirnment during listening shuld be cnducive t a set and frget vlume level. Patient is Nt Using Treatment Apprpriately The NTT prtcl defines suitable activities t perfrm while using the treatment as: ffice wrk, reading writing, leisure walking, nn-strenuus/quiet hbbies, and nn-strenuus husewrk. The prtcl defines nn-suitable activities that must be avided as: driving, straining t hear, TV viewing, when heart rate is increased thrugh exercise, and activities that might get the device wet. What t D: Brainstrm with the patient t cnsider activities within the patient s daily life that are apprpriate times fr treatment. Strngly advise against using treatment during cntraindicated activities. Dn t frget that the sixty day return perid fr a patient can be extended based n a cnversatin with a Neurmnics Clinical Specialist. If yu are having truble with a patient let us knw and we can wrk with yu t give the patient mre time t experience the benefits f the treatment. 17

18 Stage Prgressin Cnsideratins Due t persnal attributes and circumstances, many patients are nt ready t prgress frm Stage One until they cmplete sme additinal time in the current stage. Remember that it s better t use treatment in the mst effective manner and t meet prerequisite milestnes then it is t prematurely mve yur patient frward. Questins t Cnsider Befre the Transitin t Stage Tw Prir t making the the mve t Phase 2 and the Active Treatment Stage these questins shuld be answered: Is the patient maintaining prtcl cmpliancy? Des the patient have unmanaged stress? Has the apprpriate relaxatin respnse been cnditined? Des yur patient reprt f a sense f cntrl regarding tinnitus? Have all milestnes thrugh Stage One been met? Is there a prgressin tward treatment gals (while using device)? Is there significant prgress tward decreased tinnitus disturbance and TRQ scre? Has the patient indicated that they are ready fr the transitin? Be sure t review any prgress made t date by using the TRQ t cmpare pre-treatment t current levels in rder t assess whether transitin criteria have been met. If necessary cunsel as t the imprtance f delaying transitin t the Phase 2 stimulus until all prerequisite criteria have been achieved. Assess current degree f interactin and relief. If nt apprpriate, see Managing Issues with Neurmnics Stimulus sectin. Measure LDLs, BBN MML, and audigram if indicated. Encurage patient t fllw trubleshting instructins which are necessary in rder t use treatment in the mst effective manner and t achieve the milestnes/gals f Stage One. Remind patient that nt fllwing identified remedial actins may cmprmise ptential treatment gains. Psitively reinfrce that delaying the transitin is nt a bad thing, in fact it is quite the ppsite. Patients that spend additinal time in Phase One are merely making sure that they are ding all the things necessary t ensure a psitive treatment utcme. 18

19 Mving T the Maintenance Phase f Treatment Meeting the fllwing criteria is required befre entering the maintenance phase f treatment: Patient has met all Stage Tw milestnes Individual treatment gals have been met Tinnitus desensitizatin has ccurred Patients is ready t cmplete treatment In the event the abve criteria are nt met cnsider the fllwing cunseling tls: Reassure yur patient that is nt uncmmn fr many patients t require an additinal 1-3 mnths in active treatment. Recmmend a prgress mnitring ffice visit in ne mnth. Review prgress made t date using evidence t cmpare pretreatment t current level f prgress and demnstrating the prgress the patient has made. Assess current degree f interactin and relief. Assess if patient is using the treatment at the apprpriate intermittent interactin level (50/50 blending) and achieving apprpriate relief. Reach fr the device nly when bthered by tinnitus, adjust t a set and frget vlume level that is cvering and expsing tinnitus fifty percent f the time. Use the device n the single setting and prceed with apprpriate activities. Psitively reinfrce that the patient is making great strides in treatment and that they need t stay the curse with their treatment. 19

20 Pssible Patient Cmplaints My Tinnitus Is Getting Wrse - Cntact Yur Neurmnics Clinical Specialist It is imprtant fr yur patient t knw that n sund cntained within the device will make tinnitus wrse (exceptin Reactive tinnitus). Tinnitus changes can be caused by factrs nt directly related t the use f the device fr example stress r life factrs. What t D: Assure patient that yu will wrk tgether t find the variable(s) that impede treatment prgress and will cllabrate t develp a remediatin plan. Remind patient that cmpliancy with fllwing identified remedial actins is vital s ptential treatment gains are nt cmprmised. Cnsider scheduling additinal clinic appintments r fllw-up phne calls t mnitr effective use f treatment. Tinnitus Perceptin Is Greater Since Initiatin f Treatment- Cntact Yur Neurmnics Clinical Specialist If this ccurs within the first few weeks f the fitting, cunsel that it may be part f the nrmal cyclic nature f tinnitus respnding t interventin and it is gd a prgnstic indicatr. Cnsider and cunsel t all life factrs (see Cmmn Everyday Life Issues sectin) that culd be aggravating the tinnitus. Cnsider and cunsel t all treatment-specific factrs that the patient needs t be cmpliant with. Ask the patient what he/she feels may have caused the wrsening and cunsel accrdingly. Prvide/review general tinnitus management strategies as cvered in patient advice sheets. Recmmend t use the device mre t take advantage the relief it prvides. My Tinnitus is Wrse When It s Quiet This is a cmmn statement heard frm tinnitus patients and a tpic that is easily managed. Cunsel yur patient t avid situatins where there are n backgrund sunds when nt wearing the device. Cunsel t use sund/pleasant music t distract the brain when nt using treatment. Suggest using the device n single setting with a Track that prvides the mst relaxatin at bedtime. 20

21 Tinnitus is Mre Nticeable Fllwing a Treatment Sessin After a perid f enjying relief frm their tinnitus while using the device, a patient may be mre cnscius f their tinnitus by way f cntrast (termed relief cntract ) even thugh it is actually unlikely t be wrse. Unfrtunately, just the wrry abut smething making the tinnitus wrse is enugh t actually make it wrse, s it is imprtant t emphasize the imprtance f stress management during treatment. Relief cntrast ccurs because tinnitus appears luder in cmparisn t the relief experienced while using the device. What t D: Reinfrce the cncept f relief cntrast with the example f eyeglass wear. There is a cntrast effect when peple remve their glasses until their eyes have time t adjust. Yu can als advise yur patient t turn the device t a lwer vlume a few minutes befre cmpleting treatment much as yu wuld use a dimmer switch fr lights. By gradually easing back int perceiving tinnitus, it can be less nticeable when the treatment is ended. Als, ending a treatment sessin and remving the device, if pssible, in an envirnment that is nt cmpletely quiet can be helpful. Cunsel t avid a t lng and t lud scenari that can cntribute t anxiety. Tinnitus Impacted by Expsure t Certain Sunds See Reactive Tinnitus under Nn Standard Patient Attributes Sectin. Cnsult yur Neurmnics Clinical Specialist t determine if the Reactive tinnitus prtcl is apprpriate. My Tinnitus is Changing If yur patient experiences a change in their tinnitus, and it is within the first few weeks f their fitting, cunsel that it may be part f the nrmal cyclic nature f tinnitus respnding t interventin and this is a gd prgnstic indicatr f future success. Reassure yur patient that a change in tinnitus is a gd sign as it indicates that the tinnitus is breaking dwn. Help alleviate anxiety and cncern ver tinnitus change t prevent increased mnitring f tinnitus Sme patients reprt that prir t treatment initiatin, their tinnitus varied in intensity frm time t time. Fr such patients, an increase in tinnitus that is experienced during treatment may be part f their natural cycle f variatin. Refer t THQ r any case histry infrmatin t cnfirm if tinnitus variatin ccurred with the patient prir t treatment t help patient gain perspective Remember t encurage yur patients t visit the website. They will find answers t many questins, infrmatinal vides, relaxatin exercises and many ther useful tls. 21

22 Managing Issues with the Neurmnics Stimulus Patient is Experiencing Lw r N Interactin Hw well sund is tlerated can impact the level which the Neurmnics treatment will blend with a patient s tinnitus. Hyperacusis/DST can inhibit interactin as the device cannt be turned t a vlume sufficient t blend with tinnitus and prvide relief. A clue t pssible lw interactin becming a prblem may cme frm the initial audimetric evaluatin if a patient is unable t cmfrtably reach the minimum masking level with brad band nise. Lw interactin cases can still gradually reduce their tinnitus awareness even withut cmplete masking. Cnsult yur Neurmnics Clinical Specialist abut ptentially keeping the patients in Stage One f treatment. If a large degree f asymmetry exists between ears, sme patients find that relief is achieved at a mre cmfrtable listening level when a cntralateral prescriptin is used. Under this prescriptin, less stimulatin is directed t the prer ear. If yur patient has been fit with a cntralateral prescriptin and reprts lw interactin, reinfrce apprpriate expectatins fr the patient. This means that the amunt f stimulatin and degree f interactin achievable is lwer due t asymmetrical hearing lss. An additinal expectatin may include extra time (>2 mnths) in Stage One t meet milestnes befre transitining t Stage Tw. If yur patient s interactin level has changed since their fitting date, it culd invlve: device and/r earphne malfunctin, a change in hearing status r change in tinnitus perceptin What t D: Let yur patient knw that all pertinent variables causing a change in interactin will be explred and then cntact yur Neurmnics Clinical Specialist t explre pssible slutins Patient is Unable t achieve a high degree f interactin r tinnitus is nt cmpletely blended What t D: Reassure the patient that the gal f the treatment is t prvide sme degree f relief frm the tinnitus while als prviding relaxatin. It is nt necessary fr the tinnitus t be cmpletely cvered fr the treatment t be effective. Fr patients with DST/Hyperacusis, interactin can imprve as a result f the relaxatin assciated with the treatment (as they can begin t push the envelpe f vlume) r thrugh the additinal supprt f a Tinnitus Cach. Once sund tlerance issues have been addressed and imprved, the fcus can turn tward higher interactin with their tinnitus. 22

23 Patient is Dependent n High Level f Interactin- Fearful f Transitin Lng term desensitizatin t tinnitus, and therefre lng term relief frm tinnitus disturbance, ccurs after a graded increase in expsure t tinnitus in a relaxed state. This means that in rder t receive lng-term benefit, the patient will need t prceed t the next phase f treatment. Gently cunsel that if initially the patient is nt getting the same relief as they did in Stage One that this is nrmal and nt a cause fr cncern. Over time mst users reprt that the treatment and tinnitus g int the backgrund during Stage Tw and there is less disturbance frm the tinnitus, even when nt using treatment. Reassure that a very gradual decline f the Phase One stimulus and therefre gradual increase in expsure can be used in preparatin fr transitin. Transitin des nt need t ccur until the patient feels it can be managed. Acknwledge that it may be hard fr the patient wh has been used t receiving a high degree f relief t nw aim fr a lwer level f interactin t increase expsure t tinnitus. This is n cause fr cncern since this is part f the evlutin f their treatment prgram and necessary t achieve the lng term gal f verall reductin in tinnitus disturbance and awareness. Remind the patient that if they are having a bad tinnitus day r increase in perceptin, they shuld feel free t increase the vlume n the device t achieve mre relief. That ptins is always there and can be very reassuring t a patient during this phase. That being said, they shuld wrk twards 50/50 cverage f their tinnitus n days when it is less severe. Phase One Stimulus Prduces Anxiety The Phase One stimulus is a custmized acustic stimuli with an added brad band neural stimulus that is mre nticeable t sme patients. What t D: If the patient has just been fit with the device, ver the next few weeks, as the acustic stimulus becmes less nvel and mre familiar, it shuld becme less distracting and easier t let sink int the backgrund f cnsciusness. Remind yur patient t set vlume at a cmfrtable level t allw the patient t set and frget the treatment. It is pssible that the patient is reacting negatively t the brad band neural stimulatin and a change t the Phase Tw stimulus with the brad band neural stimulatin remved can be tried. Befre taking this apprach cnsult yur Neurmnics Clinical Specialist. 23

24 Patient Sees Treatment as a Chre Causing Frustratin r Anxiety A treatment prtcl f 2-4 hurs daily can ften seem verwhelming t new patients. What t D: Remind yur patient that their daily dse is cumulative. Their treatment will be effective even in 15 minute increments as lng as their daily ttal reaches tw hurs. Cunsel t avid a t lng and t lud scenari that can cntribute t anxiety, auditry fatigue and frustratin. Remind yur patient that using the treatment at times when tinnitus is mst bthersme, will prvide them with relief and cntrl ver their tinnitus. This shuld help ease their frustratin and anxiety. Treatment shuld never becme a chre and will ultimately hinder prgress if it is viewed as such. Specific Tracks Cause Annyance r Anxiety On ccasin patients have reprted an adverse reactin t ne f the tracks played by the Oasis. What t D: Remind yur patient that the music is intended t fade int the backgrund and t nt actively listen t the tracks if pssible Advise patient t skip listening t Tracks that cause anxiety r annyance then wrk t get them back int their listening schedule. If abslutely necessary, the tracks that are causing prblems can be remved 24

25 Reducing Returns and Keeping Patients In Treatment Neurmnics Tinnitus Treatment utcmes have been published in numerus peer reviewed, published jurnals demnstrating the efficacy f the treatment. In rder replicate these utcmes, it is imperative that yu trublesht issues in a detailed, efficient fashin s patients stay the curse with their treatment and ultimately reduce their tinnitus disturbance. Use Yur Resurces Neurmnics Clinical Specialists are here t help yu with ANY and ALL patient issues yu encunter. If yu have a patient that is struggling in treatment, yur first step shuld be t cntact yur Neurmnics Clinical Specialist. Befre returning a device r accepting that yur patient has decided t terminate treatment, it is imperative t speak with a Neurmnics Clinical Specialist. Our Clinical Specialists are here t supprt yu as yur patients prgress thrugh treatment. Trubleshting Suggestins The best way t reduce treatment issues it t take a systematic apprach t trubleshting. The first thing t cnsider is hw lng the patient has been in treatment. Yu shuld als review the data lg and examine the vlume settings fr crrect usage. Depending n the length f time in treatment and the usage patterns f the patient, treatment benefits can vary significantly. Knwing the crrect milestne timeline fr a patient is crucial t cunseling them crrectly. Once yu have determined where the patient fits int the treatment timeline yu can use the apprpriate apprach t help them. Stage One Gals: Relief while wearing the device, sense f cntrl ver tinnitus, relaxatin while wearing the device, significant reductin in tinnitus disturbance. Stage Tw Gals: Reduced awareness while nt wearing the device. Here is where yu shuld start seeing carry ver with the device ff. Be Prepared fr Patient Setbacks and Issues Very rarely will yu have a patient that ges thrugh treatment withut sme frm f a setback. Stress is a knwn trigger fr tinnitus and is difficult t cmpletely eliminate frm ur life, despite ur best effrts. Remember, that the majrity f tinnitus patients have been debilitated by their cnditin fr a number f years and thus it makes sense that prgress will be gradual. If a patient cmes in fr the tw-week fllw up and feel they have nt imprved yet, that is OK and in fact is quite nrmal. Yur jb in this situatin is t remind the patient that whatever they are experiencing is manageable and they shuld maintain a psitive utlk. Being a cheerleader and a supprtive element in the patient s treatment is critical when dealing with setbacks and issues. Wrk with yur patient t frmulate a specific treatment plan t meet their individual needs. Hw will they need t wear the device in rder t achieve ptimal success? What usage pattern will be mst beneficial in btaining their treatment gals set at the fitting appintment? This is where yur clinical expertise will shine. Feel free t cnsult yur Clinical Specialist fr ideas and ways that yu can help yur patients maximize benefit frm treatment. Yu Are the Expert Dn t be surprised if ne f yur patients arrives fr an appintment armed with infrmatin frm the internet r ther reliable surces regarding tinnitus and their treatment. The reality is the average tinnitus patient spends a tremendus amunt f time and energy trying t diagnse and treat themselves. Yur jb is t gently encurage them t refrain frm these activities. As the clinician yu are expert when it cmes t the Neurmnics Tinnitus Treatment prcess and part f that bligatin is cnvincing yur patient t stp researching and fcusing n their tinnitus. Their bligatin is t be the patient nt the audilgist. 25

26 Frequently Asked Patient Questins Will my tinnitus get wrse using this device? A: N, there isn't anything cntained within the device that will make yur tinnitus wrse. While initially wearing the device, yu may have immediate relief and relaxatin frm yur tinnitus and nce the device is remved yur tinnitus may seem luder fr a brief time, but will gradually begin t decrease. This is similar t individuals wh wear eyeglasses; there is a cntrast effect that ccurs nce they remve their glasses, until their eyes adjust. It is als cmmn that yur tinnitus changes pitch during the treatment. If yu have any cncerns abut yur tinnitus perceptin while using treatment, cntact yur clinician. Q: If smene else in my family has tinnitus, can they use my device? A: Since the Neurmnics device is individually prescribed and cntured t yur hearing prfile and being classified as a FDA Cleared Medical Device, it cannt be shared with smene else (The FDA mandates that it is a ne patient, ne use device). Q: If I fall asleep with my device n, des it cunt twards my 2-4 hurs a day? A: The 2-4 hurs per day nly includes waking hurs. Due t the relaxatin prvided by the device, it is an excellent way t help fall asleep at night. And it is safe t use while sleeping. Hwever, keep in mind that it is imprtant t wear yur device thrughut the day when yur tinnitus is mst bthersme (fr a minimum f 2 hurs ttal usage per day). Q: Can I have different musical tracks fr my device? A: N additinal r alternate musical tracks can be prgrammed n the device. The musical tracks cntained in the Neurmnics device are very specific and have been chsen t help cunteract yur tinnitus. In rder t retrain yur brain t ignre yur tinnitus, the music needs t be redundant in nature. The sner yu can put the music int the backgrund, the mre quickly yu will be able t put yur tinnitus there as well. Q: If I use hearing aids and Neurmnics, when shuld I use Neurmnics vs. hearing aids? A: If yu use hearing aids, make sure that they are used fr cmmunicatin purpses and nt while wearing yur Neurmnics device. The Neurmnics device may be used during quieter times when there is nthing fr the hearing aids t amplify. Yu will need t remve yur hearing aids while using the Neurmnics device. Remember t reach fr the yur Neurmnics device when the tinnitus is mst bthersme. Q: Can I use my wn earphnes? A: N. Due t limitatins f the frequency respnse, ther earphnes will nt be calibrated t prvide the full prescriptin f yur treatment. If yu have prblems with the prescribed earphnes, please cntact yur prvider. Q: What if the treatment is nt cmpletely cvering my tinnitus? A: It is nt necessary fr the treatment t cver yur tinnitus in rder t be effective. The gal f the treatment is t prvide sme degree f relief frm yur tinnitus, while als prviding relaxatin. Factrs that influence hw much the treatment will blend with yur tinnitus include yur hearing lss, the perceived vlume f yur tinnitus and hw well yu can tlerate sunds. 26

27 Q: What if my earphnes dn t sund balanced? A: Fr mre balanced ludness perceptin, first adjust the earphne placement. Due t the size and shape f each patient's ear canal; ludness perceptin can vary. Yu can experiment with earphne placement in rder t balance the ludness. Als be sure t check that the earphne jack is securely cnnected and inserted cmpletely. Fr further tips n trubleshting earphne issues, please see the Device Trubleshting sectin f yur Oasis wrkbk. Q: Hw lud shuld I play my device? A: Yur first gal shuld always be t listen at a cmfrtable vlume level. If the device is t lud it can take away frm the relaxatin yu shuld experience frm the music. Be sure t turn up the vlume if yu feel yu need mre relief, but be certain it is a cmfrtable level. Q: Will I have t use the device frever? A: At the cmpletin f yur 6-8 mnth treatment plan, we recmmend that yu cntinue t stimulate yur auditry system by using the device frm 2-4 hurs per week. This additinal perid is called the maintenance phase and will vary frm patient t patient. Q: When am I dne with treatment? A: Cmpletin f the treatment prcess varies frm patient t patient. This will depend upn a number f factrs including hw yu have prgressed thrugh the treatment prcess and whether r nt yu have accmplished the gals yu set ut t achieve. Yur clinician will be able t help yu determine when this has been accmplished. 27