Traumatic Brain Injuries Through Research

Transcription

1 TINNITUSTODAY To Promote Relief, Help Prevent, and Find Cures for Tinnitus Vol. 43, No. 3, Winter 2018 Understanding Tinnitus and Traumatic Brain Injuries Through Research What Is Known About Tinnitus and the Injured Brain The Emotional Impact of Tinnitus and Brain Injuries Taking Care of Children With Concussions Tinnitus Tools Tinnitus Apps and Sound Machines Understanding Tinnitus Assessment Questionnaires A publication of the Visit & Learn More About Tinnitus at ATA.org

2 Gratitude to Tinnitus Researchers and Healthcare Providers The American Tinnitus Association would like to express its gratitude to researchers around the world who are dedicating their careers to unraveling the mysteries of the auditory and neurological systems to help explain tinnitus so that treatments and cures can be found for the millions of people who are burdened by it. In this issue, we feature many articles from researchers and audiologists with the U.S. Department of Veterans Affairs who work not only in tinnitus research but also in the ongoing care of our active-duty service members and veterans, who live with hearing loss, tinnitus, and in some cases posttraumatic stress disorders and traumatic brain injuries resulting from their service to our country. We thank Marc Fagelson, PhD, who is a professor of audiology in the Department of Audiology and Speech-Language Pathology at East Tennessee State University, for his suggestions and assistance bringing together key researchers and audiologists to write on what is being learned about tinnitus stemming from traumatic brain injuries, which are often accompanied by tinnitus, insomnia, depression, anxiety, fatigue, and concentration problems. Support the American Tinnitus Association by Shopping at When you re shopping for friends and family on Amazon, the American Tinnitus Association hopes you ll link your shopping account to, the online retailing company s generous program that enables you to shop and contribute to your favorite nonprofit organization at the same time. Amazon pays all program expenses and donates half of a percent of the cost of your eligible purchases to your favorite earmarked charity. Won t you choose the American Tinnitus Association to help us advance tinnitus research and treatments?

3 Table of Contents Vol. 43, No. 3, Winter 2018 TINNITUS AND TBI RESEARCH SCIENCE & RESEARCH NEWS Tinnitus Within the Context of Traumatic Brain Injury and PTSD Traumatic Brain Injury and Tinnitus in Military Veterans and Active-Duty Service Members The Emotional Impact of Tinnitus and a Patient s Coping Ability Gentle Amplification for Those With Negligible Hearing Loss, Traumatic Brain Injury, and Tinnitus 30 Audiological Management of Patients With Traumatic Brain Injuries and Tinnitus The Relationship of Tinnitus, TBI, and PTSD in Military Service Improving Accessibility of Cognitive Behavioral Therapy for Tinnitus Patients A Sound Therapy System While You Sleep ATA NEWS Head Injury, Tinnitus, and Mental Health Symptoms The Emotional Impact of Mild Traumatic Brain Injuries and Tinnitus What Audiologists and Parents Should Know About Caring for Children with TBI and Tinnitus Iowa Conference Research Papers on Medical and Psychological Findings FDA Approves First Self-Fitting Hearing Aid Are There Negative Effects from White Noise Sound Therapy? ATA Connects with 46 the Tinnitus World 47 Increasing Awareness of Tinnitus Treatment PERSONAL STORIES 28 Tinnitus: Part of a Larger Puzzle and Challenge YOUR HEALTH Tinnitus Enters the Quiet Sanctuary of the Library Why I m Leaving a Legacy to the American Tinnitus Association TINNITUS TOOLS & RESOURCES 14 Understanding Tinnitus Assessment Questionnaires Spotlight on Patient Providers Support Group Calendar Dana Day s Suggested Sound and Sleep Apps and Machines to Mask Tinnitus A Step Forward in Analyzing a Blow to the Head 58 Does Earwax Cause Tinnitus? Putting Quiet on the Menu: App Rates Restaurants, Bars, and Cafes for Sound

4 FROM THE BOARD CHAIR LaGuinn P. Sherlock, AuD Chair, Board of Directors The Invisible Challenges of Head Injuries and Tinnitus Every year, 2.8 million people in the United States suffer head injuries from falls, auto accidents, sports, and military service. Concussions, which are called mild TBIs (mtbis), are the most common traumatic brain injury and are accompanied by a range of symptoms, including pain, fatigue, memory problems, and tinnitus. Like tinnitus, mtbis are invisible and can be challenging to live with and treat. One of the biggest frustrations expressed by patients with mtbis is the lack of attention medical professionals give to the functional limitations of mtbi that are worsened by tinnitus. Both mtbi and tinnitus increase stress, resulting in poor sleep, poor concentration, depression, and/or anxiety. Even when other symptoms of mtbi are managed, the stress response, also known as fight-or-flight response, can be triggered by the onset of tinnitus. Tinnitus management protocols can help by providing strategies to counteract the stress response, including relaxation and sound therapy. Various approaches can be used to facilitate relaxation, including deep breathing, visualization of pleasant scenes, meditation, and yoga. The spectrum of sound therapy ranges from simple sound enrichment with low-volume background sounds (e.g., white noise, pink noise, pleasant environmental sounds, or music) to professionally guided sound therapy with devices. There are many free apps readily available to facilitate relaxation and sound therapy (see These strategies have been shown to reduce disruptions to sleep, concentration, and mood. I d like to know about your experiences with mtbi and tinnitus, so please write me at tinnitus@ata.org. MANAGING EDITOR Joy Onozuka American Tinnitus Association PUBLISHER Torryn P. Brazell, CAE American Tinnitus Association PODCAST PRODUCER AND WRITER John A. Coverstone, AuD Sentient Healthcare, Inc. EDITOR-AT-LARGE Robert Sweetow, PhD EDITORIAL ADVISORY PANEL James A. Henry, PhD National Center for Rehabilitative Auditory Research (NCRAR) U.S. Department of Veterans Affairs Gail M. Whitelaw, PhD Department of Speech and Hearing Science The Ohio State University DIGITAL DESIGN & PRODUCTION TEAM JML Design, LLC ADVERTISING Tinnitus Today is the official publication of the American Tinnitus Association. It is published three times per year in April, August, and December and mailed to members and donors. The digital version is available online at: To grow your company s brand reach, contact tinnitus@ata.org. ATA HEADQUARTERS American Tinnitus Association 8300 Boone Blvd, Suite 500 Vienna, VA USA T: (Toll Free) T: TINNITUS TODAY WINTER 2018 Letters to the ATA The ATA encourages readers to write to Joy Onozuka with comments on articles, podcasts, and general concerns. Letters selected for publication may be edited for brevity, clarity, and grammar. Letters should be sent to: editor@ata.org TO GIVE TO THE ATA American Tinnitus Association PO Box Washington, DC The American Tinnitus Association is a nonprofit corporation, tax-exempt under 501(c) (3) of the Internal Revenue Code, engaged in educational, charitable, and scientific activities. Tinnitus Today magazine is copyrighted by the American Tinnitus Association. ADVERTISEMENT Publication of any advertisement does not in any way or manner constitute or imply ATA s approval or endorsement of any advertised product or service.

5 FROM THE PUBLISHER ATA BOARD OF DIRECTORS LaGuinn P. Sherlock, AuD, Bethesda, MD Chair Ted Turesky, PhD, Boston, MA Vice Chair Scott C. Mitchell, JD, Houston, TX Secretary Gary P. Reul, EdD, Issaquah, WA Treasurer David Hadley, MBA, San Francisco, CA Michael E. Hoffer, MD, Miami, FL David Hopkins, DO, Edmond, OK Jeannie Karlovitz, AuD, Downington, PA Thomas Lobl, PhD, Valencia, CA Jill Meltzer, AuD, Chicago, IL John Minnebo, MBA, Philadelphia, PA Joseph Trevisani, New York, NY Melissa Wikoff, AuD, Atlanta, GA Ron Zagel, Grand Rapids, MI Jinsheng Zhang, PhD, Detroit, MI Torryn P. Brazell, Vienna, VA Ex-officio HONORARY DIRECTOR William Shatner, Los Angeles, CA ATA SCIENTIFIC ADVISORY COMMITTEE Michael E. Hoffer, MD, FACS Chair University of Miami Health System Miami, FL USA Shaowen Bao, PhD Helen Wills Neuroscience Institute Berkeley, CA USA Susan M. Bowyer, PhD Henry Ford Health Systems, Detroit, MI USA Marc Fagelson, PhD East Tennessee State University Johnson City, TN USA Fatima T. Husain, PhD University of Illinois, Urbana-Champaign Champaign, IL USA Mark S. Mennemeier, PhD University of Arkansas, Little Rock, AR USA Larry E. Roberts, PhD McMaster University, Hamilton, ON, Canada Maria Rubio, PhD, MD University of Pittsburgh, Pittsburgh, PA USA Jeremy G. Turner, PhD Illinois College, Jacksonville, IL USA Roland Schaette, PhD UCL Ear Institute, London, England Grant D. Searchfield, PhD University of Auckland, Auckland, NZ Athanasios Tzounopoulos, PhD University of Pittsburgh, Pittsburgh, PA USA Pim Van Dijk, PhD University Medical Center Groningen Groningen, Netherlands Fan-Gang Zeng, PhD University of California, Irvine, Irvine, CA USA How Traumatic Brain Injury and Tinnitus Are Intertwined Why focus on research on traumatic brain injury (TBI) and tinnitus? Because neuroscience research that reveals what happens to the brain when it s injured adds to our understanding of tinnitus. By mapping brain data, researchers are learning how TBIs and tinnitus are intertwined in the processing of mood-related conditions, such as depression and anxiety, which could lead to better interventions and more effective treatments that improve the lives of patients with TBIs and tinnitus and their loved ones. Moreover, understanding how changes in the brain affect the auditory system and the perception of tinnitus could lead to treatments and cures that are tailored to the individual. By recognizing the impact of TBIs and tinnitus, we help to ensure that medical professionals treating patients with TBIs are aware that tinnitus can be a significant symptom and hence should be addressed early. In this issue, you ll hear from leading researchers many of whom are with the U.S. Department of Veteran Affairs (VA) who work daily researching, treating, and teaching how tinnitus and brain functions overlap. Both the U.S. Department of Defense and the VA are key players in research initiatives aimed at unraveling the mysteries of the brain because millions of active-duty service members, veterans, and their loved ones are depending on advances to protect and improve their quality of life. Importantly, their research shows that when tinnitus is addressed, it can lead to quicker recoveries and fewer long-term problems. The opinions expressed by contributors to Tinnitus Today are not necessarily those of the publisher or the American Tinnitus Association. This publication provides a variety of topics related to tinnitus for informational purposes only. ATA s publication of any advertisement in any kind of media does not, in any way or manner, constitute or imply ATA s approval or endorsement of any advertised product or service. ATA does not favor or endorse any commercial product or service. Torryn P. Brazell, CAE Publisher Correction: In the summer issue of Tinnitus Today, sound pillow was used incorrectly as a generic noun in the article Techniques to Improve Sleep Without Medication on pages Sound Pillow is a brand name and registered trademark of Armbruster Enterprises, Inc., in the United States and European Union. TINNITUS TODAY WINTER

6 TINNITUS AND TBI RESEARCH Tinnitus Within the Context of Traumatic Brain Injury and PTSD By Marc Fagelson, PhD If tinnitus has the potential to change the way a person evaluates their hearing, emotional state, and outlook on life, then sudden onset tinnitus has the potential to change a person suddenly and substantially. A person s resilience and adaptability may be profoundly challenged following an event that produces tinnitus. Tinnitus may be associated with traumatic memories that superimpose powerful negative emotions on the tinnitus sound. Such memories and emotions have the potential to amplify the salience of a tinnitus experience to the extent that neural networks are activated by tinnitus in a manner similar to the activation that would be associated with overt threats or psychological stress. The experiences of some patients with tinnitus resemble those of trauma victims in the sense that the patients must manage durable and negative thoughts regarding their condition. In such cases, interventions for trauma victims focus on assessing and challenging inaccurate beliefs regarding the patient s reactions to events and memories that reinforce the affected individual s negative evaluations of the world and of themselves. Psychological interventions are intended to provide a patient the lexicon and understanding of their physical and mental state through dialogue and counseling centered upon the specific experiences of the individual. Indeed, cognitive behavioral therapy (CBT), which targets patients unsound beliefs and impressions, is the intervention with the strongest evidence base, not just for victims of trauma but also for patients with tinnitus.1 Events that cause traumatic brain injury (TBI) may result in sudden onset tinnitus whose appearance and effect go unrecognized in the short Compared to counseling of trauma survivors, audiological rehabilitation and associated counseling is in its infancy. 4 TINNITUS TODAY WINTER 2018 term, and with good reason, because of the overarching/overwhelming neurological outcomes of the injury. Nevertheless, Fagelson reported that patients with tinnitus and posttraumatic stress disorder (PTSD) were twice as likely to experience sudden onset tinnitus as were patients without trauma diagnoses.2 Tinnitus may be related to emotional and traumatic memories of events that, even without tinnitus, could have the potential to link environmental events, smells, sounds, and tactile sensations to reminders of the trauma in affected patients. Carlson et al. reviewed 32 studies in which TBI was linked to PTSD diagnosis in both civilian and military populations.3 The authors reported PTSD prevalence rates of 0 to 89 percent in patients with mild TBI (mtbi), 8 to 55 percent in those with moderate TBI, and 0 to 19 percent in patients with severe TBI. Other large-scale analyses, such as those conducted by the RAND Corporation, indicated PTSD prevalence at 34 percent in patients with militaryrelated mtbi, and civilian prevalence rates are 12 to 27 percent.4 Although triage following trauma unfortunately may not address tinnitus, Kreuzer et al. suggest

7 TINNITUS AND TBI RESEARCH tinnitus with a sudden onset places an increased burden on the patient relative to effects of a gradual onset tinnitus.5 The burden may not be readily apparent, despite its involving psychological and physiological mechanisms; after all, tinnitus usually cannot be heard outside its owner s head. Consider the possibility that a person endures a TBI, and upon regaining consciousness or awareness, that individual suddenly notices tinnitus. The notion of traumatic reminders influencing a person s arousal and emotional valence lay at the heart of counseling approaches that prioritize enhancing the patient s understanding of the features or details related to the traumatic event, in addition to recognizing their importance in real time. Psychological interventions intended to improve a patient s adaptability and resilience must minimize the often-experienced fear and arousal that accrue to events that trigger traumatic reminders; such approaches to management may be adapted for use in other settings. It may be useful, for example, to consider tinnitus in a light similar to that of other traumatic reminders and to ensure that patients are provided the means to navigate the events or circumstances that challenge their ability to cope with tinnitus. Compared to counseling of trauma survivors, audiological rehabilitation and associated counseling is in its infancy. When addressing management of traumatic exposures durable effects on patients, Brewin emphasized the value of enhancing patients recognition and understanding of trauma reminders as means to improve coping and resilience in the face of challenging environments and circumstances.6 Previously, Brewin et al. proposed a dual representation theory that specified two types of memory stored in different representational formats. 7 Verbally accessible memory (VAM) was specified as autobiographical memory, a form of declarative memory, that could be retrieved and edited and that interacted with an individual s autobiographical knowledge base. VAM could be put into words and shared with others verbally; however, the depth of such memories, their completeness and accuracy, relies upon limited-capacity processes, such as attention. Because attention would be adversely affected or otherwise engaged during periods of high arousal, a traumatic occurrence demanding attention could impair the consolidation, and ultimate utility, of VAM. Brewin further distinguished VAM from situationally accessible memory (SAM), the latter putatively associated with flashbacks or dreams that include elements of the traumatic experience. SAM was thought to arise from perceptual processing of the traumatic scene or circumstance, including visuospatial information that received little conscious processing, as well as the affected individual s physical (autonomic, motor) response to the trauma.8 It should be no surprise that criteria for PTSD diagnoses considered the physical effects (i.e., injury, uncontrollable shaking, vomiting) of a traumatic exposure in addition to psychological effects such as a patient experiencing a dissociative state. Brewin suggested that whereas coherent narration characterized VAM, recalled SAM would be associated with descriptions of sensations chills, colors, smells whose presence did not readily serve the patient s narrative recall of a traumatic event. It is worth considering, for the audiologist, that tinnitus features, such as onset, quality, and reactivity to external sound, may not be well understood or conceived of accurately by patients. In either case, facilitating the patient s ability to recognize and accept challenging aspects of tinnitus should support their resilience and coping in a manner not unlike that observed for trauma survivors who may be triggered by seemingly innocuous environmental events. Diamond et al. reviewed the consolidation of memories associated with traumatic events and, to a first approximation, their model addressed issues raised in Brewin s prior analysis.9 Diamond s review distinguished activation of two structures typically associated with the limbic system, the amygdala and the hippocampus, during and immediately following a traumatic exposure. In summary, the authors reported upon decades of animal and human research that showed both structures were involved in traumatic and emotional memory consolidation. Both structures displayed activity consistent with long-term potentiation (LTP), or learning, during traumatic events; however, the time course TINNITUS TODAY WINTER

8 TINNITUS AND TBI RESEARCH of their activation differed. Specifically, both amygdala and hippocampus responded vigorously at the onset of a traumatic event, but inhibition of both structures followed within seconds to hours. The hippocampus activity decreased first, or sooner, during or following the event than did the amygdala. Diamond et al. considered the inhibition of LTP of both structures as evidence of a time period during which memory consolidation occurred. The reviewers then considered that different brain structures were likely responsible for different aspects of the resulting traumatic memory. The hippocampus was associated with declarative, narrative memory, essential for VAM, while the amygdala was associated with emotional memories that would serve SAM. The disparate time periods during which amygdala and hippocampus are active might be responsible, at least in part, for the observation that trauma descriptions are often disjointed, containing snatches of narrative interspersed with holes, or periods of time absent from the patient s recall. In Brewin s model, the trauma survivor suffers in part from an inability to respond reasonably to environments or conditions that contain trauma reminders or features. Affected individuals benefit substantially from interventions that focus on restoring, or repairing, their narrative abilities with 6 TINNITUS TODAY WINTER 2018 reference to the trauma, its features, and its durable effects. Several strategies, such as CBT, acceptance and commitment therapy, hypnosis, and mindfulness meditation, among others, can support the patient s development of or effectiveness in using narrative devices to support coping. Although drug therapies for some patients may provide temporary relief, it remains of great value to consider the words of Anna O., who completed years of intensive counseling and therapy as she recovered from debilitating anxiety and hallucinations following the death of her father. It was debated whether she suffered from a psychological or a neurological disorder, but in either case, as her powerful aversions and fears were discovered, discussed, and managed, she found the strength to advocate for others and to support what she termed the talking cure. 10 The durable effects of trauma on her ability to live a reasonable life were addressed with words and ways of thinking that she made her own, and that she applied to her own narrative, or VAM. Her recovery provided a reminder that seemingly impossible situations resulting from horrific tragedies and abuses can be appraised and reappraised by the victim in a manner that fosters the ability to coexist with the memories and their intrusive nature. Such reappraisal, if supported by understanding of tinnitus mechanisms and triggers, could benefit patients in audiology clinics as well. The author does not make the argument here that tinnitus contributes to trauma or that tinnitus causes PTSD. However, tinnitus and PTSD share many attributes and mechanisms, with a partial list that includes the following: both are related to central nervous system hyperactivity and neural circuits associated with the salience of sensory events; they affect concentration, sleep, emotional valence, and hence quality of life; drug administration produces at best inconsistent outcomes; and they are both invisible injuries whose presence is often misunderstood or doubted by others. Such overlapping mechanisms and effects suggest that tinnitus and PTSD have the potential to be mutually reinforcing, similar to the interactions between tinnitus and depression, or tinnitus and anxiety.11, 12 We reported previously that patients with PTSD and tinnitus rated their level of handicap as greater than did patients without PTSD.13, 14 Further, as indicated above, the patients with trauma/tbi histories were twice as likely to have sudden onset tinnitus and three times as likely to have tinnitus that got louder, or changed for the worse, when the patient was exposed to loud or sudden (usually impulsive) noises (so-called reactive tinnitus). Distress associated with exposure to loud or potentially loud sounds was pronounced; patients with tinnitus and PTSD were twice as likely as patients without PTSD to report that sound tolerance problems were more challenging than their tinnitus, and all such patients reported avoidance of social situations as well as use of hearing protection in environments that were not uncomfortable for others. Given the putative value of sound therapy in tinnitus cases, patients with substantial

9 TINNITUS AND TBI RESEARCH sound intolerance present a challenge for clinicians who must implement audiological interventions available for bothersome tinnitus. Case reports illustrate the obstacles faced by patients and clinicians when tinnitus is associated with TBI and traumatic exposures. The Mountain Home VA Medical Center in Johnson City, Tennessee, houses a tinnitus clinic with more than 1,000 patients currently enrolled. Nearly 35 percent of those patients have service connection for PTSD, meaning that they completed a diagnostic battery of psychological assessments that ultimately endorse the diagnosis. One such patient s experience is both informative and, in ways, encouraging as audiologists and other professionals consider intervention opportunities. Mr. T was a Vietnam-era veteran who suffered a close-range explosion during basic training. The training exercise employed live ammunition, and this individual was accidentally put in harm s way by his squad leader. The event nearly cost the man his life and resulted in hearing loss, tinnitus, concussion, and PTSD. His tinnitus was reportedly unchanged from its initial, sudden appearance, and when the patient was seen for audiological examination, he had not yet accessed services at the VA for his mental health condition. Pure-tone testing revealed normal hearing through 1,000 Hz, with a moderate high-frequency sensorineural hearing loss, bilaterally. Word recognition scores exceeded 80 percent, and immittance testing indicated normal middle ear function. The patient reported sound tolerance issues that limited his ability to socialize and to attend large functions with family members and friends. Primary tinnitus-related complaints included sleep disturbance, concentration problems, and communication difficulties. The Tinnitus Handicap Inventory (THI) was administered, and a score of 54/100 recorded.15 Note that this patient was seen in the clinic prior to the Tinnitus Functional Index s publication. Psychophysical tinnitus matching was conducted as were minimum masking levels, which indicated that 48 db white noise AD, 52 db white noise AS, and 48 db white noise AU completely masked the patient s tinnitus. Pitch matching and loudness matching of tinnitus suggested a high-frequency (4 khz) tone-like tinnitus at less than 10 db SL with pure-tone thresholds at 4 khz. The patient was counseled extensively regarding his audiometric results, tinnitus mechanisms, and the need to access interdisciplinary care for his mental health concerns. In order to address his main complaint sleep disturbance a bedside masker was demonstrated and ordered. He was scheduled to return for hearing aid selection and evaluation, and a consult was sent to the psychology section to enroll him in PTSD group and individual sessions. The bedside masker worked as intended, and when Mr. T returned for hearing aid appointments, he reported improved sleep. His contact with the providers in psychology was admittedly difficult; however, he felt the need to stay with the program, to tell his story, and to listen to others tell their stories despite the emotions anger, fear, hatred that often arose during sessions. He mentioned that, during a group session, tinnitus tinnitus and PTSD share many attributes and mechanisms increased substantially and contributed to a strong feeling of stress and frustration. He was reminded of the likelihood that tinnitus can be exacerbated by stress and that such occurrences, although unsettling, were not unusual. He was subsequently fit with in-the-ear hearing aids and completed hearing aid orientation. Approximately six weeks later, he returned to the clinic for tinnitus follow-up. He reported consistent and satisfactory sleep and, now more importantly, improved communication. The ability to interact with friends and family was an unexpected development for this patient, and the increased level of social engagement reduced tinnitus intrusiveness. He was now aware that communication problems, previously attributed to tinnitus, were the result of hearing loss. Psychophysical tinnitus testing was repeated and revealed results nearly identical to those reported above. The only difference was a 2 db decrease in the minimum masking level when the signal was presented diotically (i.e., noise the same level in both ears). In other words, although his perception of the tinnitus sound was essentially unchanged, the disturbance produced by tinnitus was markedly decreased. Several factors must be considered: The patient had hearing loss, and in such cases, the audiologist should TINNITUS TODAY WINTER

10 TINNITUS AND TBI RESEARCH manage hearing loss prior to managing tinnitus.16 Although we counseled prior to hearing aid fitting, the fitting was part of the management plan from initial contact. The benefit of mental health clinic intervention cannot be overstated because the patient s understanding of his challenging symptoms, signs, and negative thoughts were addressed both by audiologists and psychologists. The support from peers in the counseling groups, family members, and friends also contributed to the veteran s ability to reappraise tinnitus and the response it produced, and all such communication was of course improved by hearing aid use. Mr. T presented himself as a country boy, someone who had not traveled other than in the military, and someone who had experienced an admittedly informal relation with public school throughout his early years. The potential benefit of offering counseling focused on tinnitus mechanisms, hyperarousal, and limbic system activity was therefore tempered given the possibility that the patient would not easily understand the material. Such thoughts were immediately dismissed because the patient was engaged, provided comments, asked questions, and expressed that on many occasions his experience was consistent with what he was learning in the clinic. This case experience illustrates that tinnitus expertise belongs to patients, in many situations and of all backgrounds, more thoroughly than it belongs to practitioners. Marc Fagelson, PhD, is a professor of audiology in the Department of Audiology and SpeechLanguage Pathology at East Tennessee State University. He earned undergraduate and master s degrees at Columbia University in New York City and his PhD at the University of Texas at Austin. His clinical and academic teaching includes hearing science, audiological evaluation, pathologies of the auditory system, and tinnitus management. He co-edited Tinnitus: Clinical and Research Perspectives and a companion text, Disorders of Sound Tolerance, with Dr. David Baguley; both books were published by Plural. Dr. Fagelson has published more than 35 times and has presented more than 100 times at conferences and workshops. He opened the James H. Quillen Mountain Home VA Medical Center Tinnitus Clinic in 2001; the clinic now enrolls more than 1,000 patients. Dr. Fagelson provides extensive and collaborative counseling for patients, as well as a variety of sound therapy strategies, to support their ability to manage tinnitus. A substantial proportion of the veterans seen in the clinic experience tinnitus that is complicated by the influence of co-occurring psychological conditions, and in particular post-traumatic stress disorder. This challenging and underserved population is the focus of Dr. Fagelson s research. He is also a member of the ATA s Scientific Advisory Committee. 1 Cima, R. F., Maes, I. H., Joore, M. A., Scheyen, D. J., El Refaie, A., Baguley, D. M., Vlaeyen, J. W. (2012). Specialised treatment based on cognitive behaviour therapy versus usual care for tinnitus: A randomised controlled trial. Lancet, 379, Fagelson, M. A. (2007). The association between tinnitus and posttraumatic stress disorder. American Journal of Audiology, 16, Carlson, K., Kehle, S., & Meis, L. (2009). The assessment and treatment of individuals with history of traumatic brain injury and post-traumatic stress disorder. Washington, DC: Department of Veterans Affairs. 4 Carlson et al., The assessment and treatment of individuals with history of traumatic brain injury and post-traumatic stress disorder. 5 Kreuzer, P. M., Landgrebe, M., Schecklmann, M., Staudinger, S., Langguth, B., & the TRI Database Study Group. (2012). Trauma-associated tinnitus: Audiological, demographic and clinical characteristics. PLoS One, 7(9), e doi: /journal.pone Brewin, C. R. (2001). A cognitive neuroscience account of posttraumatic stress disorder and its treatment. Behaviour Research and Therapy, 39, Brewin, C. R., Dalgleish, T., & Joseph, S. (1996). A dual representation theory of post traumatic stress disorder. Psychological Review, 103(4), Brewin, A cognitive neuroscience account, Diamond, D. M., Campbell, A. M., Park, C. R., Halonen, J., & Zoladz, P. R. (2007). The temporal dynamics model of emotional memory processing: A synthesis on the neurobiological basis of stress-induced amnesia, flashbulb and traumatic memories, and the Yerkes-Dodson law. Neural Plasticity, 2007, doi: /2007/ Herman, J. L. (1997). Trauma and recovery. New York, NY: Basic Books. 11 Sullivan, M. D., Katon, W., Dobie, R., Sakai, C., Russo, J., & Harrop-Griffiths, J. (1988). Disabling tinnitus: Association with affective disorder. General Hospital Psychiatry, 10, McKenna, L. (2004). Models of tinnitus suffering and treatment compared and contrasted. Audiological Medicine, 2, doi: / Fagelson, The association between tinnitus and posttraumatic stress disorder. 14 Fagelson, M. A., & Smith, S. L. (2016). Tinnitus Self-Efficacy and other tinnitus self-report variables in patients with and without post-traumatic stress disorder. Ear and Hearing, 37(5), doi: /aud Newman, C. W., Jacobson, G. P., & Spitzer, J. B. (1996). Development of the Tinnitus Handicap Inventory. Archives of Otolaryngology Head & Neck Surgery, 122(2), Langguth, B., Kreuzer, P. M., Kleinjung, T., & De Ridder, D. (2013). Tinnitus: Causes and clinical management. Lancet Neurology, 12, This case experience illustrates that tinnitus expertise belongs to patients, in many situations and of all backgrounds, more thoroughly than it belongs to practitioners. 8 TINNITUS TODAY WINTER

11 SCIENCE & RESEARCH NEWS The Relationship of Tinnitus, TBI, and PTSD in Military Service Summary by John A. Coverstone, AuD According to the U.S. Department of Veterans Affairs, tinnitus is the most frequently claimed disability among former service members. Most clinicians specializing in tinnitus care also recognize that bothersome tinnitus frequently includes an underlying psychological condition. Three researchers from the University of Texas Health Science Center in San Antonio sought to investigate and describe the relationship of tinnitus with traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) from prior research.1 Their findings were published late in 2017 in the International Society of Behavioral Medicine. According to the authors, current conflicts in the Middle East have the highest proportion ever of injuries and death from explosive blasts as compared with other combat-related causes. Explosive blasts are the most common cause of TBI. Over half of individuals with TBI also experience tinnitus, and a relationship may exist between the severity of each. In one study of active duty personnel, prior TBIs were correlated with increased likelihood of tinnitus after deployment. This relationship occurred in the absence of other psychiatric disorders. The same study showed that soldiers with a single instance of TBI were 1.8 times more likely to develop tinnitus than those with no TBIs. Soldiers with a history of multiple TBIs were 2.3 times more likely to develop tinnitus. The authors state that blast exposure is also believed to be the most common cause of PTSD in recent military personnel. One study cited in this review found that brain regions associated with tinnitus have also been linked to psychiatric disorders and may indicate a link between tinnitus and PTSD. Those with both tinnitus and PTSD have reported greater handicap from tinnitus than people having tinnitus comorbid with other psychological health disorders. The authors suggest that PTSD can increase negative reactions to tinnitus and worsen tinnitus perception. They also state that tinnitus can serve to exacerbate PTSD symptoms. They explain that PTSD can cause stimuli present during traumatic events to become associated with natural responses of fear, anxiety, and hopelessness. If tinnitus is caused or is envisioned as being caused by the same event that caused PTSD, it may be perceived as a conditioned stimulus and elicit the same reactions. The authors further point out the ability of tinnitus to disturb sleep, invoke strong autonomic nervous system responses (bodily functions that do not require conscious thought or direction), cause anxiety, and result in irritability from lack of sleep. These reactions to tinnitus overlap the hypervigilance symptoms of PTSD. In conclusion, tinnitus, TBI, and PTSD often have a shared cause among military personnel, with blast injury being a common event associated with each. The symptoms associated with each condition frequently overlap and may have an additive effect. However, the authors found that more research is needed both to define the physiological and neurological systems involved in each disorder and to develop treatments that address these conditions when they are concurrent. 1 Moring, J., Peterson, A., & Karzler, K. (2018). Tinnitus, traumatic brain injury, and posttraumatic stress disorder in the military. International Journal of Behavioral Medicine, 25, TINNITUS TODAY WINTER

12 TINNITUS AND TBI RESEARCH Traumatic Brain Injury and Tinnitus in Military Veterans and Active-Duty Service Members By James A. Henry, PhD, Kelly Reavis, MPH, and Tara Zaugg, AuD A traumatic brain injury (TBI) is a structural injury to the brain or the physiological disruption of brain function that results from an external force to the head. 1 It is usually categorized as mild, moderate, or severe, with mild being synonymous with concussion. 2 It can be caused by contact sports, motor vehicle accidents, assaults, falls, and explosions (blasts). With an estimated incidence of 2.8 million persons per year in the United States, TBI is a leading cause of death and disability. 3 TBI is a major concern for the U.S. Departments of Defense (DoD) and Veterans Affairs (VA). 4 Since 2000, nearly 380,000 service members have been diagnosed with TBI. 5 Similar to the general population, an estimated 80 to 85 percent of TBI events experienced by military service members and veterans can be classified as mild. 6 Even a mild TBI, however, can be associated with long-term physical, cognitive, and emotional problems. 7, 8 These longterm effects may be more prevalent in service members and veterans than in the general population as a result of factors such as multiple TBI events, including military-related blasts, and comorbid post-traumatic stress disorder (PTSD). 7 Studies have demonstrated an association between TBI and hearing loss and tinnitus. 9, 10 One study found that 76 percent of a veteran sample with a history of mild TBI reported tinnitus. 11 Tinnitus may be perceived as the lesser of many problems immediately following a TBI event. As recovery takes place, however, persistent tinnitus can become increasingly problematic. 12 Tinnitus can be further complicated by cooccurring mental health problems. 13 Noise Outcomes in Servicemembers Epidemiology (NOISE) Study Numerous studies documented associations between exposure to high-intensity noise and hearing loss and tinnitus. 14 These studies spurred the United States Congress to direct the VA to contract with the Institute of Medicine (IOM) to clarify the associations. The IOM completed and published its study, 15 outlining areas in which additional research was needed. One recommendation was for research to document the types and amount of noise veterans are exposed to during and following discharge from service and to study the short- and long-term effects of military noise exposure. Our research group responded to that recommendation by initiating the Noise Outcomes in Servicemembers Epidemiology (NOISE) Study in The NOISE Study focuses on hazardous levels of sound and other military exposures, including blasts and TBI that might be associated with auditory injury. One of the main research questions being addressed is: What are risk factors for hearing loss and tinnitus in the military population? NOISE Study participants include veterans recently separated from the military (within about 2.5 years) and active-duty service members. The study has two data collection sites: the National Center for Rehabilitative Auditory Research (NCRAR), located at the VA Portland Health Care System in Portland, Oregon; and the DoD Hearing Center of Excellence (HCE), located at Joint Base San Antonio in 10 TINNITUS TODAY WINTER

13 TINNITUS AND TBI RESEARCH San Antonio, Texas. Data collection includes a comprehensive audiologic evaluation and 15 questionnaires. For participants with tinnitus, three additional questionnaires are administered as well as a tinnitus psychoacoustic evaluation. Participants agree to complete questionnaires every year and to return for full testing every five years. To date, over 630 participants have enrolled in the NOISE Study. Data analyses are conducted at different times, so different numbers of participants are included in each analysis. Of the first 589 participants, 234 were active service members (69% male; mean age 35.1 years) and 355 were recently discharged veterans (88% male; mean age 34.3 years). Tinnitus was experienced by 43 percent of the service members and 66 percent of the veterans. Eightyfour percent of these participants had average hearing thresholds within normal limits (that is, 20 decibels hearing level [db HL] or better) on a conventional audiogram (250 8,000 Hz). Average hearing thresholds were, however, 8 db poorer at the higher frequencies (3,000 8,000 Hz) for participants with tinnitus than for those without tinnitus. Associations Between TBI and Auditory Injuries Analyses were conducted to examine the associations between self-reported TBI and hearing and tinnitus among our veteran sample. We found that veterans with two or more TBIs were nearly six times more likely to self-report moderate or worse hearing problems than those with no history of TBI. Also, veterans with one or more TBIs were three times as likely to report tinnitus. The combined effects of TBI and self-reported PTSD on tinnitus were also analyzed. Veterans with both TBI and PTSD were almost seven times more likely to report tinnitus compared to veterans with neither TBI nor PTSD. We found that TBI was also associated with more severe tinnitus effects on a range of activities assessed using the Tinnitus Functional Index. 16 For example, compared to veterans with no TBI, veterans with blast-related TBI were 4.0 times more likely to report severe tinnitus problems. Chronic tinnitus can lead to anxiety, depression, sleep disorders, and other troubling comorbidities related to a decreased quality of life. Chronic tinnitus is usually a permanent condition, and affected individuals must learn how to manage its functional effects for a lifetime. Providing Tinnitus Services for Individuals with TBI Research at the NCRAR has focused on developing effective What is the NCRAR? methods of tinnitus management for veterans with bothersome tinnitus. These efforts led to the development of Progressive Tinnitus Management (PTM), a program that involves educational counseling to assist patients in learning effective coping strategies for tinnitus. 17, 18 The NOISE Study revealed that 82 percent of veterans with a history of TBI reported tinnitus when they were enrolled in the study (58% of those without TBI also reported tinnitus). Because of this high prevalence of tinnitus in veterans who had experienced TBI, we explored the feasibility of providing PTM via telehealth to veterans with TBI to improve access to care for this vulnerable 19, 20 population. Home-based telehealth refers to the provision of healthcare services remotely to patients in their home environment and is an appropriate option for chronic conditions when in-person appointments may not be necessary. The evidence base supporting its use continues to grow. 21 Bell et al. 22 conducted a trial to measure the effectiveness of telephone counseling for people with The National Center for Rehabilitative Auditory Research (NCRAR), located in Portland, Oregon, is one of 14 centers funded by the VA Rehabilitation Research and Development Service and is the only one dedicated to researching and providing cutting-edge solutions for auditory disorders. Drawing on evidence-based research, it provides practical solutions for veterans with hearing impairment. It also educates the public on how to prevent hearing loss and cope with tinnitus. TINNITUS TODAY WINTER

14 TINNITUS AND TBI RESEARCH One study found that 76 percent of a veteran sample with a history of mild TBI reported tinnitus. TBI. The telephone counseling resulted in improved overall outcomes when compared with usual outpatient care; the trial s findings supported the idea of conducting home-based tinnitus management for veterans and military personnel with TBI. We completed a pilot study to develop and test the feasibility and potential efficacy of a telephone-based tinnitus-management approach for veterans and military personnel with TBI who also reported bothersome tinnitus. 23 The telephone intervention used the PTM counseling, which includes cognitive behavioral therapy (CBT). 24 The counseling was administered to veterans and nonveterans who were grouped with respect to TBI: mild TBI, moderate to severe TBI, and no TBI. All three groups showed similar improvement in mean outcome scores, resulting in moderate to large effect sizes. The telephone PTM (Tele-PTM) used in the pilot study was modified slightly, and a randomized controlled trial (RCT) to evaluate its efficacy was completed with 205 individuals (both veterans and nonveterans) with bothersome tinnitus located anywhere in the United States. 25 Enrollment of individuals with a history of TBI was prioritized. Participants were randomized to either Tele-PTM intervention or 6-month wait-list control (WLC). The Tele-PTM intervention involved five telephone appointments two led by an audiologist (teaching how to use sound to improve comfort with tinnitus) and three by a psychologist (teaching CBTbased coping skills). The lack of face-to-face contact with Tele-PTM did not preclude positive outcomes, with overall results showing convincingly that the Tele-PTM group had significantly better outcomes than the WLC group. Most notably, the Tele-PTM group had a mean reduction in TFI score (indicating improvement) of 21 points, compared to a 1-point reduction for the WLC group. Results were consistent across all outcome measures, indicating not only a reduction of tinnitus functional distress but also increased self-efficacy in managing reactions to tinnitus. Improvements in measures of anxiety and depression were also observed. Participants in all TBI categories showed significant improvement. The telephone counselors were able to establish good rapport with the participants, who often commented that the intervention was positive and beneficial. Conclusions TBI has become a particularly prevalent problem for military service members and veterans over the past two decades. However, these injuries are common in all populations, and tinnitus is often a side effect of TBI. We are conducting studies both to determine the extent of the problem of having both TBI and bothersome tinnitus and to provide effective care. The association between TBI and tinnitus is clear, although it is unknown exactly how TBI causes tinnitus. Many labs are conducting research to discover the mechanisms of tinnitus, including tinnitus associated with TBI. Over time, we will gain an understanding of these mechanisms, which should lead to treatments directed toward curing the underlying cause. In the meantime, results of our Tele-PTM studies provide strong support for use of that methodology nationwide to improve quality of life for persons with bothersome tinnitus, regardless of whether the person also has TBI symptoms. Acknowledgments The research reported here was supported by grants from the Department of Defense Congressionally Directed Medical Research Programs (CDMRP; PR and JW160036/W81X- WH ) and the Department of Veterans Affairs, Rehabilitation Research & Development (RR&D) Service (C7452I and C9247S). Special thanks to the many contributors to this work, including Kathleen Carlson, PhD; Susan Griest, MPH; Christine Kaelin, MBA; Paula Myers, PhD; Caroline Schmidt, PhD; and Emily Thielman, MS. James Henry, PhD, is a certified and licensed audiologist with a doctorate in Behavioral Neuroscience. He is employed at the Department of Veterans Affairs, Rehabilitation Research & Development, National Center for Rehabilitative Auditory Research (NCRAR) located at the VA Portland Health Care System. He is also research professor in the Department of Otolaryngology Head & Neck Surgery at Oregon Health & Science University. For the past 23 years, he has devoted his career to tinnitus research. His overall goals are to develop and validate clinical methodology for 12 TINNITUS TODAY WINTER

15 TINNITUS AND TBI RESEARCH effectively helping individuals who are afflicted with bothersome tinnitus, and to increase accessibility to evidence-based tinnitus care. Kelly Reavis, MPH, MS, CCC-A, is a licensed audiologist with over 15 years of auditory research experience at the Department of Veterans Affairs, Rehabilitation Research & Development, National Center for Rehabilitative Auditory Research (NCRAR) located at the VA Portland Health Care System. She is also a fourth-year PhD student in epidemiology at Oregon Health & Science University. Her research interests include reducing the prevalence and impact of hearing loss and tinnitus, particularly among aging and veteran populations. Tara Zaugg is a certified, licensed, and clinically privileged research audiologist employed at the National Center for Rehabilitative Auditory Research (NCRAR) located at the Department of Veterans Affairs Portland Health Care System. Through involvement in tinnitus clinical trials over the last 18 years, she has acquired extensive experience with tinnitus assessment and management methods. She also teaches audiologists to implement tinnitus management methods. She co-developed Progressive Tinnitus Management (PTM), which is endorsed by the Department of Veterans Affairs Central Office as the standard method of tinnitus management for VA hospitals. Dr. Zaugg strives to understand the perspective of clinicians and patients using PTM, and to incorporate their needs and insights into PTM as it evolves. 4 Dillahunt-Aspillaga, C., & Powell-Cope, G. (2018). Community reintegration, participation, and employment issues in veterans and service members with traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 99(2S), S1 S3. 5 Defense and Veterans Brain Injury Center (DVBIC). DoD worldwide numbers for TBI, Defense Medical Surveillance System (DMSS), Theater Medical Data Store (TMDS), provided by the Armed Forces Health Surveillance Branch. Retrieved from 6 Hoge, C. W., McGurk, D., Thomas, J. L., Cox, A. L., Engel, C. C., & Castro, C. A. (2008). Mild traumatic brain injury in U.S. soldiers returning from Iraq. New England Journal of Medicine, 358(5), Combs, H. L., Berry, D. T., Pape, T., Babcock- Parziale, J., Smith, B., Schleenbaker, R., High, W. M., Jr. (2015). The effects of mild traumatic brain injury, post-traumatic stress disorder, and combined mild traumatic brain injury/post-traumatic stress disorder on returning veterans. Journal of Neurotrauma, 32(13), Nordstrom, A., Edin, B. B., Lindstrom, S., & Nordstrom, P. (2013). Cognitive function and other risk factors for mild traumatic brain injury in young men: Nationwide cohort study. BMJ, 346, f Gondusky, J. S., & Reiter, M. P. (2005). Protecting military convoys in Iraq: An examination of battle injuries sustained by a mechanized battalion during Operation Iraqi Freedom II. Military Medicine, 170(6), Oleksiak, M., Smith, B. M., St. Andre, J. R., Caughlan, C. M., & Steiner, M. (2012). Audiological issues and hearing loss among veterans with mild traumatic brain injury. Journal of Rehabilitation Research and Development, 49(7), Lew, H. L., Cifu, D. X., Crowder, A. T., & Grimes, J. B. (2012). Guest editorial: Sensory and communication disorders in traumatic brain injury. Journal of Rehabilitation Research and Development, 49(7), vii x. 12 Lew, H. L., Guillory, S. B., Jerger, J., & Henry, J. A. (2007). Auditory dysfunction in traumatic brain injury and blast related injury. Journal of Rehabilitation Research and Development, 44(7), Fagelson, M. A. (2007). The association between tinnitus and posttraumatic stress disorder. American Journal of Audiology, 16(2), Yankaskas, K. (2013). Prelude: Noise-induced tinnitus and hearing loss in the military. Hearing Research, 295, Humes, L. E., Joellenbeck, L. M., & Durch, J. S. (Eds.). (2006). Noise and military service: Implications for hearing loss and tinnitus. Washington, DC: National Academies Press. 16 Meikle, M. B., Henry, J. A., Griest, S. E., Stewart, B. J., Abrams, H. B., McArdle, R., Vernon, J. A. (2012). The Tinnitus Functional Index: Development of a new clinical measure for chronic, intrusive tinnitus. Ear and Hearing, 33(2), Henry, J. A., Thielman, E. J., Zaugg, T. L., Kaelin, C., Schmidt, C. J., Griest, S., Carlson, K. (2017). Randomized controlled trial in clinical settings to evaluate effectiveness of coping skills education used with progressive tinnitus management. Journal of Speech, Language, and Hearing Research, 60(5), Henry, J. A., Zaugg, T. L., Myers, P. M., & Kendall, C. J. (2010). Progressive tinnitus management: Clinical handbook for audiologists. San Diego, CA: Plural Publishing. 19 Wakefield, B. J. (2001). Telehealth. Journal of Gerontological Nursing, 27(1), Tuerk, P. W., Fortney, J., Bosworth, H. B., Wakefield, B., Ruggiero, K. J., Acierno, R., & Frueh, B. C. (2010). Toward the development of national telehealth services: The role of Veterans Health Administration and future directions for research. Telemedicine Journal and E-Health, 16(1), Hersh, W. R., Hickam, D. H., Severance, S. M., Dana, T. L., Krages, K. P., & Helfand, M. (2006). Telemedicine for the Medicare population: Update. Evidence Report/Technology Assessment No. 131 (Prepared by the Oregon Evidence-Based Practice Center under Contract No ) AHRQ Publication No. 06-E007. Rockville, MD: Agency for Healthcare Research and Quality. 22 Bell, K. R., Temkin, N. R., Esselman, P. C., Doctor, J. N., Bombardier, C. H., Fraser, R. T., Dikmen, S. (2005). The effect of a scheduled telephone intervention on outcome after moderate to severe traumatic brain injury: A randomized trial. Archives of Physical Medicine and Rehabilitation, 86(5), Henry, J. A., Zaugg, T. L., Myers PJ, Schmidt, C. J., Griest, S., Legro, M. W., Carlson, K. F. (2012). Pilot study to develop telehealth tinnitus management for persons with and without traumatic brain injury. Journal of Rehabilitation Research and Development, 49(7), Martinez-Devesa, P., Perera, R., Theodoulou, M., & Waddell, A. (2010). Cognitive behavioural therapy for tinnitus. Cochrane Database of Systematic Reviews, (9), CD Henry, J. A., Thielman, E. J., Zaugg, T. L., Kaelin, C., McMillan, G. P., Schmidt, C. J., Carlson, K. F. (2018, May 29). Telephone-based progressive tinnitus management for persons with and without traumatic brain injury: A randomized controlled trial. Ear and Hearing. Advance online publication. doi: /aud Okie, S. (2005). Traumatic brain injury in the war zone. New England Journal of Medicine, 352(20), McCrea, M. A. (2008). Mild traumatic brain injury and postconcussion syndrome: The new evidence base for diagnosis and treatment. New York: Oxford University Press. 3 Taylor, C. A., Bell, J. M., Breiding, M. J., & Xu, L. (2017). Traumatic brain injury related emergency department visits, hospitalizations, and deaths United States, 2007 and Morbidity and Mortality Weekly Report. Surveillance Summaries, 66(9), doi: /mmwr.ss6609a1 The telephone counselors were able to establish good rapport with the participants, who often commented that the intervention was positive and beneficial. TINNITUS TODAY WINTER

16 TINNITUS TOOLS Understanding Tinnitus Assessment Questionnaires By David Strom Trying to assess tinnitus can be difficult, in part because there are numerous questionnaires used by both clinicians and laypeople. It helps to understand the different purposes and intentions of these assessments and how patients can use them to explore their own issues and progress with tinnitus. Some surveys are useful in measuring the outcomes of various clinical trials, and others are better suited for a patient s self-assessment. A review of the medical literature shows that there are at least 10 different formulations. Here are just a few of them. Tinnitus Handicap Questionnaire Two of the oldest originated at the University of Iowa and can be downloaded from its website. 1 The first is the Tinnitus Handicap Questionnaire, which was developed and psychometrically measured by Dr. Francis Kuk and others in It examines three different factors: The physical, emotional, and social consequences of tinnitus The hearing ability of the patient The patient s view of tinnitus It consists of 27 questions and uses a scale from 0 to 100 to score how the patient agrees or disagrees with the statements. Though this large scale can be daunting for patients, it does offer clinicians more precision in determining the impact of tinnitus on various functions. Tinnitus Activities Questionnaire The second Iowa assessment is the Tinnitus Activities Questionnaire, which consists of 20 questions, also on a scale from 0 to 100. It looks at the emotional aspect of tinnitus as well as problems associated with concentration, hearing, and sleep, which are common complaints among those with bothersome tinnitus. Both of the Iowa questionnaires can be downloaded in their original and revised versions. Both of the Iowa questionnaires focus on four broad functional areas: Thoughts and emotions Hearing Sleep impact Concentration This is a useful organizational method to help patients who haven t ever done a self-assessment to start thinking about their tinnitus. Tinnitus Functional Index Looking elsewhere, there is the Tinnitus Functional Index, which is described on the American Academy of Audiology s website. 2 Released in 2014, it includes eight categories, such as degree of intrusiveness and sense of patient control. The index has 14 TINNITUS TODAY WINTER

17 TINNITUS TOOLS 25 questions on quality of life, with a scale from 1 to 10, and can be useful for measuring the clinical effectiveness of treatments. It can be downloaded from a separate link. 3 Tinnitus Handicap Inventory The Tinnitus Handicap Inventory was developed in It has 25 questions with three possible answers (yes, sometimes, and no) that are scored numerically. Higher scores indicate greater difficulty in functioning, or a higher tinnitus handicap. The THI is a self-report measure of the impact of tinnitus on a person s daily life that can also be used by clinical practices. As you can imagine, the range of questions varies tremendously among these surveys. Most ask whether a patient s sleep is disturbed, while only a few ask about whether patients avoid noisy environments or feel tired or fatigued. Fatima Husain, PhD, of the University of Illinois, Urbana- Champaign, summarized nine different questionnaires in her paper and concluded, No single questionnaire covers everything, and there isn t any reliable psychoacoustic tinnitus test. All of the questionnaires differ in regard to question format, scales, and specific wording, making them difficult to use in comparing treatment effects among different clinics. 5 If you are interested in a selfassessment, download one or more of these surveys and spend some time answering questions as truthfully as you can to see how you are affected by tinnitus. Please note that selfassessment is not a substitute for working with a qualified healthcare provider well versed in tinnitus management strategies. 1 University of Iowa Carver College of Medicine, Department of Otolaryngology Head and Neck Surgery. (n.d.). Tinnitus questionnaires. Retrieved fromhttps://medicine.uiowa.edu/oto/research/ tinnitus-and-hyperacusis/tinnitus-questionnaires 2 American Academy of Audiology. (2015, January 7). Tinnitus Functional Index. Retrieved fromhttps:// 3 Download the TFI here: com/wolterskluwer_vitalstream_com/permalink/ EANDH/A/EANDH_2011_09_27_HENRY_200593_ SDC15.pdf 4 Download the THI here: default/files/tinnitus_handicap_inventory.pdf 5 Husain, F. (2018). Using brain imaging techniques to find the tinnitus signal [Slide show]. Retrieved from Documents/PPT/Husain.pdf Tinnitus assessment questionnaires should be used for informational purposes only and should not take the place of consultation and evaluation by a qualified healthcare professional well versed in tinnitus management. You don t need to have an ear to have tinnitus. But you do need to have a brain to have tinnitus. Don McFerran, MD, and Trustee of the British Tinnitus Association, responding to a question at the BTA s Annual Conference + Expo, September 14-15, 2018, Birmingham, UK TINNITUS TODAY WINTER

18 TINNITUS AND TBI RESEARCH The Emotional Impact of Tinnitus and a Patient s Coping Ability By Paula Myers, PhD According to the Centers for Disease Control and Prevention (CDC), each year 2.8 million Americans sustain a traumatic brain injury (TBI), with most experiencing mild TBI as the result of falls, motor vehicle crashes, assaults, and sports injuries. 1 Common causes of TBI in the military are blasts, assaults, gunshot wounds, sports, and falls, and audiologists learn a lot about TBI by researching this condition in military personnel. Between 75 and 90 percent of TBI cases are mild, while a small subset (10 15%) sustain persistent post-concussive symptoms. 2 Military personnel exposed to blasts experience auditory dysfunction that can include pinna damage from burns and flying debris, rupture of the eardrum from the overpressure wave, ossicular disruption from the pressure shock wave (seen in larger blasts), and blast wave damage to the vestibular and cochlear systems, with tinnitus commonly reported. 3 Civilians can also be harmed by blast exposure from celebratory fireworks, 4 terrorist bombings, and industrial explosions. Lessons learned from the April 19, 1995, bombing of the Alfred P. Murrah Federal Building in Oklahoma City, which were compiled by Injury Prevention Services, helped define the prevalence and long-term persistence of tinnitus after blast exposure. 5 Clinical reports of hearing injuries, tinnitus, and dizziness were similar to the findings seen in veterans with blast exposure from war conflicts. More recent otologic outcomes were observed following the Boston Marathon bombing on April 15, 2013, 6 the West Fertilizer Company industrial explosion near Waco, Texas, on April 17, 2013, 7 and among survivors of the subway explosions in Manchester, United Kingdom, and Manhattan, New York, in Although TBI is the signature injury of the recent war conflicts, tinnitus remains the most prevalent service-connected disability for all veterans receiving compensation; indeed, the financial consequences of tinnitus are substantial. At the end of fiscal year 2016, 1,610,911 veterans were receiving tinnitus compensation and 1,084,069 were receiving hearing loss compensation. There were 149,429 new tinnitus disability compensation recipients and 77,622 new hearing loss compensation recipients. 8 Tinnitus prevalence is much greater for service members and veterans with blast and/or TBI and/or post-traumatic stress disorder (PTSD) Even more important than the financial impact of tinnitus, the emotional impact of tinnitus can overwhelm a patient s coping ability. tinnitus remains the most prevalent service-connected disability for all veterans receiving compensation; indeed, the financial consequences of tinnitus are substantial. 16 TINNITUS TODAY WINTER

19 TINNITUS AND TBI RESEARCH In many cases, tinnitus serves as a direct reminder of the traumatic event that caused it. Anecdotal reports suggest that there may be an indirect relationship through an association of PTSD and tinnitus with brain injury. Though it is important for healthcare providers to ask questions and listen to patients describe their journey, chief concerns, and symptoms, it is equally important to direct focus away from a problem list and for provider and patient to create a strengths/assets list that collaboratively builds the management plan moving forward. Patients with TBI often present with post-concussive symptoms that may interact, persist, and worsen if not evaluated and managed. The Department of Veterans Affairs (VA) hospital TBI interdisciplinary teams have noted that returning service members and veterans frequently report sensory auditory, vestibular, and visual symptoms. These sensory issues are likely to influence the ability of people with TBI to process cognitive information and perform activities of daily living. While researchers are investigating the effects of sensory and communication disorders on rehabilitation outcome, preliminary data show that dual sensory impairment may adversely influence functional outcomes in patients with TBI. An issue of the VA Journal of Rehabilitation Research and Development was dedicated to the single topic of sequelae of TBI: sensory and communication dysfunction that provides context for the nature of these deficits and their prevalence. 13 Depending on the brain injury locus, several secondary injuries or symptoms may occur. Some secondary symptoms of TBI include but are not limited to headaches, nausea, visual difficulties, dizziness, hearing loss, tinnitus, sensitivity to light and sound, irritability, and difficulty with concentration, memory, and attention. These symptoms vary depending on the individual and the severity of the brain injury. Audiologic assessment of individuals with TBI should begin with a comprehensive case history questionnaire that elicits medical history and information about the TBI. Items should include physical and cognitive functioning pre- and post-injury, visual history pre- and post-injury, audiologic history preand post-injury (including exposures to loud noise), dizziness history preand post-injury, and tinnitus history pre- and post-injury. Information about the TBI should focus on the nature of the injury, use of protective gear, loss of consciousness at time of injury, any prior head injuries, and current medications. Standardized questionnaires that assess the impact of hearing loss, tinnitus, and/or dizziness, such as the Hearing Handicap Inventory for Adults, 14 the Tinnitus Functional Index, 15 the Dizziness Handicap Inventory, 16 and the Vestibular Disorders Activities of Daily Living Scale, 17 should be used when warranted. It is important to obtain additional information from significant others because patients with TBI may have poor self-assessment of their problems. 18 Patients with TBI usually are good historians regarding their pre-injury function, but during assessment family members can provide valuable information about post-injury function. The audiologic consequences of TBI are unique to the individual because of the variety of ways that TBI can be acquired (blast, motor vehicle crash, sports related, falls), the variety of classifications of the severity of the injury, and unique personality and emotional characteristics of the person with TBI. Because of the variability of TBI, it is to be expected that the audiologic and vestibular symptoms will also differ for each person. Following a TBI, hearing problems and tinnitus can occur for many reasons, both mechanical and neurological, particularly when the inner ear or temporal lobes have been damaged. 3, 19 External bleeding in the ear canal, eardrum rupture and middle ear damage, cochlear or eighth nerve complex injury, axonal injury, and temporal lobe lesions can all cause auditory dysfunction. Some individuals may have only dysfunction of the auditory or vestibular system, whereas others may suffer dysfunction of both or neither system. When tinnitus is reported, because of the multiple causes and effects of this symptom, appropriate medical and mental health referrals are made, with urgency for referral determined by the referring physician, for example: sudden onset tinnitus and hearing loss referrals for same-day assessment by otolaryngology and audiology; symptoms of somatic origin, such as pulsatile tinnitus, for otolaryngology TINNITUS TODAY WINTER

20 TINNITUS AND TBI RESEARCH and audiology assessment without undue delay; and problematic tinnitus causing severe distress/ coping referrals for psychology and audiology assessment. It is recommended that persons with severe TBI who are unable to undergo behavioral audiometry receive an audiologic evaluation of objective measures to include otoscopy, otoacoustic emissions, immittance, and a comprehensive electrophysiological evaluation to assess peripheral and central function. Although tinnitus and hearing loss are two of the most widely reported auditory side effects of a TBI, some other hearing problems that may occur following a TBI include hyperacusis, difficulty hearing in adverse listening environments, and other central auditory manifestations of TBIrelated complaints. Because hearing impairment limits or takes away one of the primary means we use to communicate, hearing loss has the potential to complicate many of the other side effects of TBI, mainly cognitive and psychosocial problems. Many people with TBI suffer cognitive, physical, emotional, or behavioral issues, and these problems are exacerbated if the patient cannot hear what is going on or is unable to effectively manage reactions to tinnitus. When tinnitus and hearing loss co-occur, the hearing loss should be managed prior to clinical focus being placed on tinnitus. Fortunately, for some people with TBI, hearing problems and other post-concussive symptoms may resolve several weeks after the trauma that led to the TBI, but other auditory symptoms such as tinnitus or post-concussive symptoms may be persistent. Because the patient may not immediately detect some hearing problems and tinnitus after the TBI, it is recommended that anyone suffering a TBI be evaluated by an audiologist, even if auditory complaints are denied. Paula Myers, PhD, is chief of the Audiology Section at the James A. Haley Veterans Hospital in Tampa, Florida, where she has worked for 31 years. Her expertise and research focus on development of audiology educational materials, tinnitus management, traumatic brain injury, and auditory rehabilitation. She chaired the VA Audiology Southern Professional Standard Board and National Audiology Patient Education Workgroup, and is a former teacher of the Deaf and Deaf- Blind and assistant professor at University of South Florida. 1 Centers for Disease Control and Prevention. Traumatic brain injury & concussion.tbi: Get the facts. Retrieved from traumaticbraininjury/get_the_facts.html 2 VA/DoD Clinical Practice Guidelines: Management of concussion/mild traumatic brain injury (mtbi) (2016). Retrieved from va.gov/guidelines/rehab/mtbi 3 Myers, P. J., Wilmington, D. J., Gallun, F. J., Henry, J. A., & Fausti, S. A. (2009). Hearing impairment and traumatic brain injury among soldiers: Special considerations for the audiologist. Seminars in Hearing, 30(1), Van Rijswijk, J. B., & Dubach, P. (2017). Binaural tympanic-membrane perforations after blast injury. New England Journal of Medicine, 376, e41. doi: /nejmicm Van Campen, L. E., Dennis, J. M., Hanlin, R. C., King, S. B., & Velderman, A. M. (1999). One-year audiologic monitoring of individuals exposed to the 1995 Oklahoma City bombing. Journal of the American Academy of Audiology, 10, Remenschneider, A. K., Lookabaugh, S., Aliphas, A., Brodsky, J. R., Devaiah, A. K., Dagher, & W. Quesnel, A. M. (2014). Otologic outcomes after blast injury: The Boston Marathon experience. Otology and Neurotology, 35, doi: /mao Dodd-Murphy, J. (2014). Auditory effects of blast exposure. Retrieved from Articles/Auditory-Effects-of-Blast-Exposure/ 8 U.S. Department of Veterans Affairs. (2017). VBA annual benefits report: Fiscal year Retrieved from archive.asp 9 Toyinbo, P., Vanderploeg, R., Belanger, H., Spehar, A. M., Lapcevic, W. A., & Scott, S. (2017). A systems science approach to understanding polytrauma and blast-related injury: Bayesian network model of data from a survey of the Florida National Guard. American Journal of Epidemiology, 185(2), doi: /aje/kww Swan, A. A., Nelson, J. T., Swiger, B., Jaramillo, C. A., Eapen, B. C., Packer, M., & Pugh, M. J. (2016). Prevalence of hearing loss and tinnitus in Iraq and Afghanistan veterans: A Chronic Effects of Neurotrauma Consortium study. Hearing Research, 349, doi: /j.heares Yurgiil, K.A., Clifford, R.E., Risbrough, V.B., Geyer, M. A., Huang, M., Barkauskas, D.A., MRS Team, & Baker, D.G. (2016). Prospective associations between traumatic brain injury and postdeployment tinnitus in active-duty Marines. Journal of Head Trauma Rehabilitation, 31, doi: /htr Theodoroff, S., Lewis, S., Folmer, R., Henry, J., & Carlson, K. (2015). Hearing impairment and tinnitus: Prevalence, risk factors, and outcomes in US service members and veterans deployed to the Iraq and Afghanistan wars. Epidemiology Review, 37, doi: /epirev/mxu Sensory and communicative disorders in traumatic brain injury [Special issue]. (2012). Journal of Rehabilitation Research and Development, 49(7). Retrieved from jour/2012/497/pdf/contents497.pdf 14 Newman, C. W., Weinstein, B. E., Jacobson, G. P., & Hug, G. A. (1990). The Hearing Handicap Inventory for Adults: Psychometric adequacy and audiometric correlates. Ear and Hearing, 11, Meikle, M. B., Henry, J. A., Griest, S. E., Stewart, B. J., Abrams, H. B., McArdle, R., & Vernon, J. A. (2012). The Tinnitus Functional Index: Development of a new clinical measure for chronic, intrusive tinnitus. Ear & Hearing, 33(2), Jacobson, G. P., & Newman, C. W. (1990). The development of the Dizziness Handicap Inventory. Archives of Otolaryngology Head & Neck Surgery, 116(4), Cohen, H. S., & Kimball, K. T. (2000). Development of the Vestibular Disorders Activities of Daily Living Scale. Archives of Otolaryngology Head & Neck Surgery, 126(7), Lux, W. S. (2007). A neuropsychiatric perspective on traumatic brain injury. Journal of Rehabilitation Research and Development, 44(7), Kraus, N., & Krizman, J. (2018). An auditory perspective on concussion. Audiology Today, 30(3), TINNITUS TODAY WINTER

21 HEALTHCARE PROVIDERS Spotlight on Patient Providers GOLD LEVEL Professional Members Listing current as of October 25, 2018 When making an appointment, please mention that you learned of the provider from the ATA, thereby ensuring that providers understand the importance of being a part of the ATA s tinnitus patient-provider network. Eugene Antonell, BC-HIS Hear Better Now, LLC N. Dartmouth, MA Theodore Benke, MD Benke Ear Nose & Throat Clinic Cleburne, TX Judith Bergeron, BC-HIS, CDP Beauport Hearing Care Gloucester, MA Granville Brady, Jr., AuD East Brunswick, NJ Diana Callesano, AuD Hearing and Tinnitus Center Woodbury, NY Collin Campbell, LAc Campbell Acupuncture & Herbal Medicine Clinic New York, NY Phoebe Clouser, AuD Hearing Partners of South Florida Delray Beach, FL Lois N. Cohen, LCSW, ACSW, BCD Tinnitus Counseling Northport, NY Shahrzad Cohen, AuD Auditory Processing Centers: Hearing Solutions Sherman Oaks, CA Lindsay Collins, AuD Sound Relief Hearing Center Centennial, CO Jean Couchman, MA Hearing Solutions, PLLC Midlothian, VA Theresa Cullen, AuD Cape Cod Hearing Center Hyannis, MA Ali Danesh, PhD Labyrinth Audiology Florida Atlantic University Boca Raton, FL Nikki DeGeorge, AuD Fayette Hearing Clinic Newnan, GA Kristen DesErmia, AuD Ascent Audiology & Hearing Bradenton, FL Patrick DeWarle, AuD Winnipeg Hearing Centres Winnipeg, MB, CANADA Stelios Dokianakis, AuD Holland Doctors of Audiology Holland, MI Sara Downs, AuD Hearing Wellness Center Duluth, MN Kaela Fasman, AuD Sound Relief Hearing Center Golden, CO Lisa Fox-Thomas, AuD UNCG Speech & Hearing Center Greensboro, NC Noreen Gibbens, AuD Middle Tennessee Audiology Hendersonville, TN Belinda Gonzales, HIS NuSound Hearing Center Topeka, KS MaryRose Hecksel, AuD Audiology & Hearing Aid Center Lansing, MI Veronica Heide, AuD Audible Difference, LLC Madison, WI James Henry, PhD VA Portland Health Care System Portland, OR John Hoglund, BC-HIS, ACA SW Florida Hearing & Tinnitus Center Estero, FL Bruce Hubbard, PhD, ABPP CBT for Tinnitus, LLC New York, NY Jeannie Karlovitz, AuD Advanced Hearing Solutions Exton, PA Deborah Lain, MSc, RPsych Hope for Tinnitus Calgary, AB, CANADA Kate Landowski, AuD Sound Relief Hearing Center Denver, CO Malvina Levy, AuD Hearing and Speech Center San Francisco, CA Larena Lewchuk, MCISc Audiology Clinic of Northern Alberta Edmonton, AB, CANADA Ha-Sheng Li-Korotky, AuD, PhD Pacific Northwest Audiology Bend, OR Mario Hearing & Tinnitus Clinics 1208 VFW Parkway, #103 West Roxbury-Boston, MA Robert Mario, BC-HIS, PhD Mario Hearing & Tinnitus Clinics Canton, MA Stephanie McGuire, AuD McGuire Hearing & Tinnitus Center Dayton, OH Jill Meltzer, AuD North Shore Audio-Vestibular Lab Highland Park, IL Leah Mitchell, AuD Sound Relief Hearing Center Westminster, CO Jeanne Perkins, AuD Audiologic Services Glen Ellyn, IL Julie Prutsman, AuD Sound Relief Hearing Center Highlands Ranch, CO Ann Rhoten, AuD Kentucky Audiology & Tinnitus Services Lexington, KY Sharon Rophie, AuD Harbor Hearing, P.A. Palm Harbor, FL Christine Russell, AuD Sound Relief Hearing Center Fort Collins, CO Mimi Salamat, AuD Dr. Mimi s Audiology Clinic Walnut Creek, CA Allison Sayer, AuD Sound Relief Hearing Center Scottsdale, AZ Susan Schmidt, AuD Arizona Balance & Hearing Aids, LLC Phoenix, AZ Cindy Ann Simon, AuD South Miami Audiology Consultants South Miami, FL Jacqueline Smith, AuD Sound Relief Hearing Center Highlands Ranch, CO Randall Solomon, MD Island Psychiatry Port Jefferson Station, NY Dustin Spillman, AuD Audiologists Northwest Bremerton, WA William Stubbeman, MD TMS Psychiatry Los Angeles, CA Melissa Theis, AuD McGuire Hearing & Tinnitus Center Dayton, OH Gail Whitelaw, PhD OSU Speech-Language-Hearing Clinic Columbus, OH TINNITUS TODAY WINTER

22 HEALTHCARE PROVIDERS Thea Wickey, AuD Sound Relief Hearing Center Scottsdale, AZ Melissa Wikoff, AuD Peachtree Hearing Marietta, GA Carolyn Yates, AuD Hearing Evaluation Services of Buffalo, Inc. Amherst, NY SILVER LEVEL Professional Members Listing current as of October 25, 2018 When making an appointment, please mention that you learned of the provider from the ATA, thereby ensuring that providers understand the importance of being a part of the ATA s tinnitus patient-provider network. Kimberly Abeyta, AuD Hearing Resources Center Fredericksburg, VA Catherine Ahrens-Berke, BC-HIS Ahrens Hearing Center Fair Lawn, NJ Jason Aird, AuD Iowa Audiology Coralville, IA Nicole Ball, AuD Hearing Evaluation Services of Buffalo, Inc. Tonawanda, NY Randall Bartlett, F-AAA Tinnitus & Audiology Center of Southern CA Los Angeles, CA Carol Bass, AuD All Ears Audiology Ithaca, NY Samantha Bayless The Hill Hear Better Clinic Cincinnati, OH Linda Beach Voorhees, NJ Samantha Beaton, AuD Hearing Evaluation Services of Buffalo, Inc. Orchard Park, NY Lisa Blackman A Hearing Healthcare Center Philadelphia, PA Nashlea Brogan, AuD Bluewater Hearing Sarnia, ON, CANADA Mindy Brudereck, AuD Berks Hearing Professionals Reading, PA Lisa Caldwell, MA The Hearing Coach Glossop, UNITED KINGDOM Anne Carter, AuD Pasadena Hearing Care St. Petersburg, FL Linda Centore, PhD, NP University of California School of Dentistry San Francisco, CA Maura Chippendale, AuD Chippendale Audiology Cape Coral, FL Patrick Coughlin, AuD Hearing Care Professionals Aberdeen, SD Ann DePaolo, AuD The Audiology Offices, LLC Kilmarnock, VA Ericka DeVore, AuD All About Hearing Longwood, FL Susana Dominguez, AuD Hospital Italiano de Bs, AS, Argentina Capital Federal, BA, ARGENTINA Phillip Elbaum, LCSW Stritch School of Medicine, Loyola University, Chicago Deerfield, IL Nafisa Entezar Healthcare Pharmacy Tustin, CA Kimberly Eskritt, AuD Lambton Audiology Associates Sarnia, ON, CANADA Julie Farrar-Hersch, PhD Augusta Audiology Associates Fisherville, VA Brittany Fauble, AuD The American Institute of Balance Largo, FL Michael Flores, AuD University of New Mexico Speech and Hearing Sciences Albuquerque, NM Anna Forsline, AuD National Center for Rehabilitative Auditory Research Portland, OR Kristen Furseth, AuD Willamette ENT Salem, OR Amy Greer, AuD ENT Associates of Johnstown Johnstown, PA Kenneth Grundfast, MD Boston University School of Medicine Boston, MA Sean Hagberg PhD Cranston, RI Peter Harakas, PhD Cognitive Behavioral Therapy Associates, LLC Lexington, MA Jamie Hawkins, AuD Clarity Hearing Conroe, TX Hannah Heet, AuD Duke Otolaryngology of Raleigh Raleigh, NC Donna Hill, AuD Audiology Professionals Eugene, OR Sherry Hodge, AuD Advanced Hearing Care Anderson, IN Sara Holcomb, AuD Audiology Center of St. Johns Saint Johns, MI Alan Hopkirk Invisible Hearing Clinic Glasgow, UNITED KINGDOM Gail Hubbard, AuD Dent MD ENT Carlsbad, CA Wan Syafira Ishak, PhD Universiti Kebangsaan Malaysia Kuala Lumpur, MALAYSIA S. Moosa Jaffari, MD Sound Hearing Center Lakewood, NJ Keun Kang Happy Sound Corporation Bayside, NY Edward Keels, MA Hear Now Hearing Aid Center Philadelphia, PA Kristen Keener, AuD IlluminEar Audiology Austin, TX Suzanne Kimball, AuD Univ. of Oklahoma Sciences Center Oklahoma City, OK Dan Arthur Kirk Hi Health Innovations Cumming, GA Vanessa Lee, MA Auglaize Audiology Wapakoneta, OH Jason Leyendecker, AuD Tinnitus and Hyperacusis Clinic of Minnesota Edina, MN Brandon Lichtman, AuD Wheeling Hospital Wheeling, WV Terence Limb, AuD Evergreen Speech & Hearing Clinic Kirkland, WA Virginia Lindahl, PhD Psychologist Alexandria, VA Robyn Lofton, BC-HIS Hearing Associates of Las Vegas Las Vegas, NV Dan R. Malcore Hyperacusis Network Green Bay, WI Abigail McMahon, AuD Sound Relief Hearing Center Fort Collins, CO 20 TINNITUS TODAY WINTER

23 HEALTHCARE PROVIDERS Brooke Means, AuD North Georgia Audiology Gainesville, GA Brian Melzian, PhD US Environmental Protection Agency Jamestown, RI Mary Miller, PhD Premier Hearing and Balance Hammond, LA Marni Novick, AuD Silicon Valley Hearing Clinic, Inc. Los Gatos, CA James Orban, BC-HIS Miracle-Ear Hearing Aid Center Columbia, MD Melissa Palmer, AuD High Point Audiological Clayton, NC Christine Peacock, AuD Naples Audiology & Hearing Center Naples, FL Tracy Peck, AuD Hearing and Speech Center San Francisco, CA Ashley Penrod, PA-C Alta View Specialty Clinic Sandy, UT Ann Perreau, PhD Augustana College Rock Island, IL Jay Piccirillo, MD, FACS Washington University School of Medicine Saint Louis, MO Bruce Piner, AuD Hearing and Balance Center Encino, CA Andrea Plotkowski, AuD ENT Consultants of East Tennessee Knoxville, TN Susan Rawls, AuD Cary Audiology Associates Cary, NC Jennifer Reekers, AuD Heartland Hearing Center Cedar Rapids, IA Deanna Ross, AuD Albany ENT & Allergy Services, PC Albany, NY Kelly Rostorfer, AuD Luebbe Hearing Services Columbus, OH Sandra Royle-Tabak, AuD Carolina East Ear, Nose, & Throat Morehead City, NC Kristen Rubin, AuD Keystone Audiology Warwick, RI Mandy Rutta, AuD Gundersen Health System La Crosse, WI Christina Seaborg, AuD Hearing and Balance Center Charlotte, NC Paul Shea, MD Shea Ear Clinic Memphis, TN Susan Sheehy, AuD Alabama Hearing Associates Madison, AL LaGuinn Sherlock, AuD Walter Reed National Military Medical Center, Bethesda, MD Martin Smith, PsyD Associates in Managed Care Denver, CO Rivka Strom, AuD Advanced Hearing NY, Inc. Brooklyn, NY Jennifer Sutton, AuD Hearing Evaluation Services of Buffalo, Inc. Williamsville, NY Robert Traynor, EdD, CH-TM Robert Traynor Audiology Fort Collins, CO Peter Van Ostaeyen Antwerp, BELGIUM The Noisy Planet logo is a registered trademark of the U.S. Department of Health and Human Services (HHS). TINNITUS TODAY WINTER

24 SCIENCE & RESEARCH NEWS Improving Accessibility of Cognitive Behavioral Therapy for Tinnitus Patients Summary by John A. Coverstone, AuD Cognitive behavioral therapy (CBT) is established as a key treatment for people with bothersome tinnitus. However, a common limitation of CBT is that it be administered by specially trained psychologists and is therefore not readily available in many places in the United States and other countries, particularly in areas with low population density. This means patients may have to travel great distances for therapy, accept other treatments that may not be as effective, or go without treatment. Two studies recently conducted in the United Kingdom studied alternative methods for providing CBT to patients with tinnitus. Each study engaged audiologists for the delivery of CBT intervention. Audiologists are already frontline providers of care for tinnitus patients, performing diagnostic examinations, providing counseling, and administering sound therapy. As such, providing CBT may be a natural extension of the services they already provide. Audiologist-Delivered CBT for Tinnitus and Hyperacusis in a Practice Setting The first study utilized audiologists for delivery of CBT in a clinical setting. 1 Four audiologists from Royal Surrey County Hospital in the U.K. participated in the study. Each specialized in tinnitus and hyperacusis and received formal training in a tinnitus and hyperacusis master class that included CBT as one of its four primary subjects. Formal training was followed by six months of supervised practice. Patients were recruited from the hospital and screened out if psychological disorders were identified. The study included six weekly sessions. In the first session, patients underwent a diagnostic examination and completed tinnitus The second study focused on use of the internet to deliver tinnitus care as a way to improve accessibility of CBT for people with tinnitus. Feelings Behavior Cognitive Behavioral Therapy Thoughts and hyperacusis questionnaires. Participants were briefed on study procedures and given the opportunity to opt out during this visit. After the weekly sessions of CBT, during the final visit, all questionnaires were administered again. Participants who completed all visits with the audiologists showed significant improvements in tinnitus handicap, hyperacusis handicap, tinnitus loudness, tinnitus annoyance, and effect on life from tinnitus. In this study, the authors reported improvement in tinnitus and hyperacusis that was similar to improvements shown in a previous study. That study compared outcomes for patients receiving CBT and those receiving no intervention. Effectiveness of Guided CBT Versus Clinical Care Treatment for Tinnitus The second study focused on use of the internet to deliver tinnitus care 22 TINNITUS TODAY WINTER

25 SCIENCE & RESEARCH NEWS as a way to improve accessibility of CBT for people with tinnitus. 2 This study was a follow-up to a pilot published in 2017 and included 92 adults who received either online care or personal care at one of three National Health Service hospitals. Participants assigned to online care received eight weeks of guided CBT. Those assigned to clinical care received two to three individualized visits at a tinnitus specialty clinic. Participants were randomly assigned to one group or the other and all were tested on tinnitus distress, insomnia, anxiety, depression, hearing loss, hyperacusis, cognitive decline, and satisfaction with life. Pre- and post-treatment measures were compared and positive outcomes were achieved on all measures after CBT for both groups of participants. There were no significant differences in the amount of improvement between groups. Both methods of administering CBT resulted in similar improvements on all scales. These studies indicate that CBT may be more accessible when healthcare providers other than psychologists use CBT in their treatment of tinnitus and when CBT is provided through unconventional means such as online. If either of these alternative strategies can be used without compromising the quality of care, then CBT may be made available to many more patients with distressing tinnitus who could benefit from CBT intervention. This can include people in areas of low population density, those whose work schedules are not conducive to treatment during typical business hours, and people who cannot easily reach clinical settings. 1 Aazh, H., & Moore, B. C. J. (2018). Effectiveness of audiologist-delivered cognitive behavioral therapy for tinnitus and hyperacusis rehabilitation: Outcomes for patients treated in routine practice. American Journal of Audiology. Advance online publication. doi: /2018_aja Beukes, E. W., Andersson, G., Allen, P.M., Manchaiah, V., & Baguley, D. M. (2018). Effectiveness of guided internet-based cognitive behavioral therapy vs face-to-face clinical care for treatment of tinnitus: A randomized clinical trial. JAMA Otolaryngology Head & Neck Surgery. Advance online publication. doi: / jamaoto The ATA Thanks You for Your Ongoing Support The ATA extends its heartfelt appreciation to the Haar family and friends for their donation of $7,132, raised for the second annual Silence Was Stolen: Tinnitus Awareness Fundraiser, which was held in memory of Michael Haar, who struggled with burdensome tinnitus and died at age 50. The event, which was held September 23 at Eisenhower Park, New York, included a walk and a gathering in the park, where guest speakers highlighted the importance of tinnitus management and support. Haar family and friends at Eisenhower Park, NY, September 23, Your donations support efforts to find cures for tinnitus and strengthen the tinnitus community. To see a complete list of donors and monies received between July 1, 2017, and June 30, 2018, visit our website: TINNITUS TODAY WINTER

26 ADVERTISEMENT Stimulating tinnitus research Neuromod Devices is dedicated to validating its breakthrough tinnitus treatment approach in large randomized clinical trials in tinnitus patients. Neuromod Devices is an innovative company formed in late 2010 to clinically investigate ground-breaking tinnitus treatment technology that originated in the National University of Ireland, Maynooth. Tinnitus is a complex neurological condition that involves hearing, attention and emotion centers in the brain. Unlike sound therapies and noise maskers that only deliver one type of stimulus to the brain (sound), Neuromod s approach combines auditory stimulation (sound) with trigeminal nerve stimulation, which is achieved noninvasively as gentle energy pulses delivered to the surface of the tongue by a proprietary tonguetip device. By combining these neuromodulatory stimuli, Neuromod believes that greater and more sustained efficacy may be achieved. Visit for more information To test and confirm the scientific hypothesis underlying this ground-breaking approach, Neuromod has embarked on a unprecedentedly robust clinical programme: 2010: Proof of principle in 20 patients¹ 2012: TAVSS single arm trial in 60 patients² 2016: Randomized double-blind multi-arm trial in 326 patients with 12 month long-term post-treatment follow up (TENT-A1)³ 2018: Randomized double-blind multi-arm confirmatory trial in 191 patients with 12 month long-term post-treatment follow up (TENT-A2)⁴ Neuromod will share the results of the TENT trials once complete and will work with regulatory authorities to make the product available to patients as soon as possible. For further reference: 1. WO A1; Method and apparatus for sensory substitution; Paul O grady. Ross O Neill, Barak A. Pearlmutter 2. Hamilton, Caroline, et al. An Investigation of Feasibility and Safety of Bi-Modal Stimulation for the Treatment of Tinnitus: An Open-Label Pilot Study. Neuromodulation: Technology at the Neural Interface 19.8 (2016): ; ClinicalTrials.gov Identifier: NCT D Arcy, Shona, et al. Bi-modal stimulation in the treatment of tinnitus: a study protocol for an exploratory trial to optimise stimulation parameters and patient subtyping. BMJ open 7.10 (2017): e ; ClinicalTrials.gov Identifier: NCT ClinicalTrials.gov Identifier: NCT Treatment Evaluation of Neuromodulation for Tinnitus - Stage A2 (TENT-A2)

27 TINNITUS AND TBI RESEARCH Gentle Amplification for Those With Negligible Hearing Loss, Traumatic Brain Injury, and Tinnitus By Steven Benton, AuD Approximately 2.8 million people in the United States are diagnosed with traumatic brain injury (TBI) every year, 1 and roughly 56 million Americans (17% of the population) experience tinnitus, 17 million of whom report that it is disturbing enough to be a moderate to very big problem in their lives. 2 Both TBI and tinnitus patients often experience hearing difficulties regardless of the presence or absence of hearing loss. The use of hearing aids, once provided only to individuals with moderate hearing loss or worse, has been expanded to include the delivery of low-level amplification to individuals with normal or near-normal hearing. Such gentle amplification is commonly used as a tinnitusmanagement strategy in the U.S. Department of Veterans Affairs (VA) healthcare system: 96 percent of VA audiologists responding to an informal survey reported using gentle amplification with their normal-hearing tinnitus patients. Understanding the potential benefits of gentle amplification requires understanding the impact of tinnitus and TBI on auditory processing. TBI and Tinnitus TBI can cause tinnitus because of damage to the ear itself or because of damage to the auditory nerve pathways and/or the brain s auditory processing centers. 3 More than half of individuals who sustain TBI develop some degree of tinnitus. 4 Tinnitus can be a major contributor to TBI symptoms, 5 and studies indicate More than half of individuals who sustain TBI develop some degree of tinnitus. TINNITUS TODAY WINTER

28 TINNITUS AND TBI RESEARCH tinnitus is perceived as louder by TBI patients than by non-tbi patients. 6 In other words, the relation between TBI and tinnitus is bidirectional: tinnitus can worsen TBI symptoms, and TBI can worsen tinnitus symptoms. As a result, the impact of tinnitus and TBI when they coexist is greater than that of only TBI or only tinnitus. 90 percent of normal-hearing tinnitus patients report some degree of hearing difficulty and nearly half (45%) report severe hearing difficulties. TBI, Tinnitus, and Working Memory Working memory is a brain function responsible for attention, problem solving, and memory. 7 People with impaired working memory demonstrate difficulty with multitasking, require more time to recall information, and are slower taking in and making sense of information. Both TBI and tinnitus negatively influence working memory by increasing the total amount of mental effort required in any one moment (cognitive load). Speech is rapid and requires intact working memory for retention, processing of, and responding to auditory information. 8 Environments in which speech is degraded, such as noisy places, put an even greater burden on working memory. 9 The cognitive effort needed to identify speech in challenging listening situations requires brain resources that would otherwise be used for sentence comprehension and for storage in memory. TBI, Tinnitus, and Central Auditory Processing In audiology, symptoms of impaired working memory can manifest as central auditory processing disorders (CAPDs). Individuals with CAPD demonstrate hearing problems comparable to those of individuals with hearing impairment. 10 Therefore, it is not surprising that 90 percent of normal-hearing tinnitus patients report some degree of hearing difficulty and that nearly half (45%) report severe hearing difficulties. 11 TBI often results in CAPD because of damage to the brain s auditory processing centers: approximately 60 percent of all TBI patients demonstrate CAPD, 12 and up to a third of mild TBI patients exhibit CAPD and normal hearing. 13 In cases where TBI and tinnitus coexist, CAPD may be expected to interfere substantially with speech processing, resulting in an even greater impact on hearing. One of the most common complaints of individuals with CAPD is understanding speech in noise. 14 Personal FM listening systems that allow a speaker to transmit his or her voice wirelessly to a receiver with headphones have been used to help TBI patients in difficult listening situations. 15 Personal FM systems increase the loudness of the desired signal relative to environmental noise. Improving the signal-to-noise ratio in this way may reduce cognitive load and improve speech processing. Hearing problems reported by patients with TBI and tinnitus are not limited to noisy situations. Other common complaints include difficulty hearing and understanding TV and radio, frustration and arguments when communicating with family members and friends; such hearing difficulties may lead to social isolation. Gentle Amplification Gentle amplification is the provision of low-level amplification through state-of-the art digital hearing aids for individuals with disturbing tinnitus and normal or near-normal hearing. Gentle amplification has been shown to improve performance on auditory processing tasks in children with CAPD, 16 in hearing-impaired adults, 17, 18 and in blast-exposed veterans with TBI. 19 To date there is no standardized protocol for fitting gentle amplification on either TBI or tinnitus patients. At the Atlanta VA Medical Center, gentle amplification for tinnitus management is provided in the context of Progressive Tinnitus Management Level 5, Individualized Tinnitus Management. 20 Regular follow-up appointments are scheduled to verify progress and outcome. Providers are cautioned against using gentle amplification as a single-visit attempt to provide tinnitus 26 TINNITUS TODAY WINTER

29 TINNITUS AND TBI RESEARCH relief. Providing gentle amplification requires an understanding of the responsibility to provide ongoing care and support. In addition to providing aid adjustments as necessary and caregiver support, the provider should be documenting progress and providing directive counseling to help patients understand the principles of brain function, the causes of tinnitus, and tinnitus disturbance. By itself, reclassification of tinnitus from the unknown ( a potential threat ) to the known ( a common experience ) can substantially reduce tinnitus disturbance. At the Atlanta VA, real-ear measures allow the audiologist to verify aid performance, and programming is adjusted so the aid provides 5 db of flat gain across the hearing aid range. Maximum output is controlled carefully to minimize the risks of hearing changes or of producing an aversive and excessive loudness experience. Others have recommended 10 db of gain, 16 but there are no data comparing outcomes using various levels of gentle amplification. At the Atlanta VA, use of a 5 db protocol has resulted in an average 60 percent decrease in tinnitus-related distress and an average 55 percent decrease in subjective hearing problems in tinnitus patients with normal hearing thresholds. 21 Conclusion Gentle amplification is a potentially valuable method for decreasing both tinnitus disturbance and subjective hearing difficulties in individuals with tinnitus and TBI. The impact of impaired working memory when tinnitus and TBI coexist may be expected to be greater than when patients experience only TBI or only tinnitus. Gentle amplification may take advantage of existing working memory resources to allow more effective and efficient speech processing, thereby improving overall quality of life for both TBI and tinnitus patients. Steven Benton, AuD, is the Tinnitus Program Manager at the Atlanta, Georgia, VA Medical Center. He completed his doctorate at Salus University and his master s degree in health services administration at Barry University. His research interests include the bidirectional relationship of mental health status and tinnitus severity, and tinnitus management for individuals with normal hearing. Dr. Benton has presented his research at numerous national and international scientific meetings, including those of the American Academy of Audiology, the American Auditory Society, the Joint Defense-Veterans Audiology Conference, and the International Tinnitus Seminar. 1 Centers for Disease Control and Prevention. Traumatic brain injury & concussion.tbi: Get the facts. Retrieved from traumaticbraininjury/get_the_facts.html 2 Fausti, S., Wilmington, D., Gallun, F., Myers, P., & Henry, J. (2009). Auditory and vestibular dysfunction associated with blast-related traumatic brain injury. Journal of Rehabilitation Research and Development, 46(6), Valderas, J., Starfield, B., Sibbald, B., Salisbury, C., & Roland, M. (2009, July). Defining comorbidity: Implications for understanding health and health services. Annals of Family Medicine, 7(4), TraumaticBrainInjury.com (n.d.). Symptoms of TBI. Retrieved from symptoms-of-tbi/ 5 Moring, J., Peterson, A., & Kanzler, K. (2018). Tinnitus, traumatic brain injury, and posttraumatic stress disorder in the military. International Journal of Behavioral Medicine, 25(3), Vernon, J., & Press, L. (1994). Characteristics of tinnitus induced by head injury. Archives of Otolaryngology Head Neck Surgery, 120(5), Ilkowska, M., & Engle, R. (2010). Working memory capacity and self-regulation. In R. Hoyle (Ed.), Handbook of personality and self-regulation (pp ). Malden, MA: Blackwell Publishing. 8 Baddeley, A. (1992). Working memory. Science, 31(255), Lönnqvist, S. (2017, June). Working memory [is] heavily loaded after hearing loss. Paper presented at the Fourth International Conference on Cognitive Hearing Science for Communication, Linköping, Sweden. 10 Ferre, J. (2015). Auditory dysfunction beyond the 8th nerve: Understanding central auditory processing disorders. Perspectives on Hearing and Hearing Disorders: Research and Diagnostics, 19, Benton, S. (2017). Subjective hearing problems in tinnitus subjects with clinically normal hearing thresholds. Paper presented at the annual meeting of the Joint Defense/Veterans Audiology Conference, Anaheim, CA. 12 Bergemalm, P., & Lyxell, B. (2005). Appearances are deceptive: Long-term cognitive and central auditory sequelae from closed head injury. International Journal of Audiology, 44(1), Oleksiak, M., Smith, B., St. Andre, J., Caughlan, C., & Steiner, M. (2012). Audiological issues and hearing loss among veterans with mild traumatic brain injury. Journal of Rehabilitation Research and Development, 49(7), Weihing, J. (2005, October). FM systems as a treatment for CAPD. Hearing Journal, 50(10), Kuk, F., Jackson, A., Keenan, D., & Lau, C. (2008). Personal amplification for school-age children with auditory processing disorders. Journal of the American Academy of Audiology, 19(6), Saunders, G., Frederick, M., Chisolm, T., Silverman, S., Arnold, M., & Myers, P. (2014). Use of a frequency-modulated system for veterans with blast exposure, perceived hearing problems, and normal hearing sensitivity. Seminars in Hearing, 35(3), Doherty, K., & Desjardins, J. (2015). The benefit of amplification on auditory working memory function in middle-aged and young-older hearing-impaired adults. Frontiers in Psychology, 6, Desjardins, J. (2016). The effects of hearing aid directional microphone and noise reduction processing on listening effort in older adults with hearing loss. Journal of the American Academy of Audiology, 27(1), Kokx-Ryan, M., Nousak, J., Jackson, J., DeGraba, T., Brungart, D., & Grant, K. (2016). Improved management of patients with auditory processing deficits fit with low-gain hearing aids. Paper presented at the International Hearing Aid Research Conference, Lake Tahoe, CA. 20 Henry, J., Zaugg, T., Myers, P., & Kendall, C. (2010). How to manage your tinnitus: A step-by-step workbook. 3rd ed. Portland, OR: National Center for Rehabilitative Auditory Research/Department of Veterans Affairs Employee Education System. 21 Benton, S. (2018). Gentle amplification for tinnitus patients with normal hearing thresholds. Manuscript in preparation. TINNITUS TODAY WINTER

30 PERSONAL STORY Tinnitus: Part of a Larger Puzzle and Challenge By Tom Bowen My life dramatically changed March 2013, while I was shopping with my wife and trying out a patio chair. I sat down and the chair fell backward, causing me to hit my head on several metal shelves before slamming into the concrete floor. Yes, it hurt, but the pain wasn t that bad and the bump on my head wasn t that big, so we carried on with our day. Three days later, I developed a constant headache. My head felt like it was about to explode, so I saw my doctor, who said it was post-concussion syndrome, which is a complex disorder with various symptoms, such as headaches and dizziness, stemming from a concussion, or mild Traumatic Brain Injury. I tried various medications to reduce the pain, but none of them worked. Not long after the headache started, I felt pressure in my ears and began hearing occasional whistles and locust noises in my left ear. Just like the headache, the noise in my ear turned into a 24-hour nightmare becoming more annoying and louder magnifying a sense of chaos. I downloaded the sample tinnitus sounds from the American Tinnitus Association s website to share with my doctor so he could hear what I was hearing. He confirmed it was tinnitus and sent me to an ear, nose, and throat (ENT) doctor. After examining me and testing my hearing, the ENT said I had about a 30 percent hearing loss, which hearing aids could address along with the tinnitus. I was in my late 50s at the time and thought to myself, I m not old. There was no way I was going to wear hearing aids, so I turned to the internet for a cure. I found a program claiming to reduce tinnitus that I could do at home. To my disappointment, it didn t work. Typical of post-concussion syndrome and bothersome tinnitus, I couldn t concentrate long enough to complete the program, which added to my frustration. I started to realize neither the medical professionals nor the internet had magical answers to make the noises and headache go I ve learned that head trauma, tinnitus, and fibromyalgia are linked, even though the exact causes are not understood. away. I was going to have to live with both conditions. Tinnitus Meets Depression and Anxiety The tinnitus and headache became so debilitating that it was hard to function at work, at home, and with friends. I couldn t handle it. I wasn t easy to live with and suffered from mood swings. I was fortunate that my friends, family doctor, and wife were understanding and supportive. My wife kept encouraging me to continue my search for a way to get better. My doctor took a holistic approach and didn t simply scribble off prescriptions. Nonetheless, I was plagued by negative thoughts. Do I want to live like this the rest of my life? I stopped caring, so I went to a psychologist to get through this dark time. My family doctor prescribed antianxiety and antidepressant medications to help mitigate the symptoms. While searching the internet, I came across the University of Iowa s International Conference on the Management of the Tinnitus and Hyperacusis Patient, which was aimed at professionals but open to patients. My wife and I decided to attend and spent several days listening to lectures. We learned hearing aids could deliver white noise to my problematic ear, masking the tinnitus to provide some relief. 28 TINNITUS TODAY WINTER

31 PERSONAL STORY Once home, I was ready to see an audiologist to get fitted for hearing aids. The white noise from the masker was much easier to adapt to than the various noises from my tinnitus. But I wasn t happy with temporary relief and consequently my depression and anxiety grew worse. While reading a magazine, I came across an article on transcranial magnetic stimulation (TMS) to treat depression and anxiety. I decided to give it a try since the medications weren t helping. For TMS, I wore a padded helmet, which resembled a hair dryer like you see at beauty salons. The TMS helmet delivered magnetic pulses, which felt like tapping on the helmet, to stimulate nerve cells in the region of my brain thought to involve mood control. Going to the treatment center, twenty minutes a day, five days a week for six weeks was a big commitment. To my surprise, my depression lifted. I no longer felt hopeless, even though there was no change in my tinnitus. For a time, life felt more manageable. Tinnitus Meets Fibromyalgia About three years after my fall, I started to feel random pain throughout my body and my tinnitus became unrelenting. Sometimes my back ached. Sometimes I had a burning sensation in my leg. Sometimes I had sharp pain in my chest, which led me to the emergency room in case it was a heart attack. My arms, hands, legs, and feet became tingly and numb. I lost strength and endurance. And I was constantly tired. My depression and anxiety came back in full force. My doctor diagnosed me with fibromyalgia. I saw a rheumatologist, who confirmed the diagnosis and explained that fibromyalgia is a chronic pain condition caused by the way the brain processes pain signals. Once again, no cure and more prescriptions to cope. At work, I couldn t handle the stress. I had trouble concentrating. I missed deadlines. And I made mistakes. At home, I didn t sleep well, and I was irritable. Finally, my doctors recommended that I apply for permanent disability, which I did reluctantly. That was a difficult turning point for me, because I enjoyed my work. Determined not to give up hope, I attended the Mayo Clinic s fibromyalgia program an interdisciplinary approach to pain management that includes traditional medical, educational, self-management, and occupational/ physical therapy components to help manage pain. I ve learned that head trauma, tinnitus, and fibromyalgia are linked, even though the exact causes are not understood. Over the course of five and half years since that fall, I have come to accept my tinnitus and fibromyalgia as chronic stressors, along with all the emotions involved with having both conditions. The noise and pain never vanish completely, so they re part of my new normal. Chronic conditions are truly challenging, but we can move forward with support from family, friends, and good healthcare professionals. Tom Bowen worked in marketing and communications for a Fortune 500 company for over 20 years. He lives in Des Moines, Iowa, with his wife and a small comfort dog. I m determined to make the most of my future, so I set two goals: (1) Help myself I applied and was approved to attend an intensive threeweek fibromyalgia program at the Mayo Clinic Pain Rehabilitation Center, which can help me regain strength, rebuild stamina, and relearn tools to better manage pain. A reset, of sorts, to keep me headed in the right direction toward a better quality of life. (2) Help others I recently launched and lead a monthly support group for others with chronic pain. I want to motivate others and encourage people to never give up. I also wrote a children s book to explain tinnitus to them so they wouldn t feel alone if they have it. Lastly, I entertain children and adults as a clown, which is something I began in Little did I know at that time that clowning around and putting smiles on other people s faces would provide me today with joy and distraction from my own struggles. TINNITUS TODAY WINTER

32 TINNITUS AND TBI RESEARCH Audiological Management of Patients With Traumatic Brain Injuries and Tinnitus By Paula Myers, PhD Q: Are there any standards for the diagnosis and management of audiological consequences of traumatic brain injury (TBI)? A: It s important for audiologists to determine all of the factors that may have a negative impact on the communication function of individuals with TBI. Because the population with TBI can vary greatly in terms of TBI severity, peripheral and central function, speech perception abilities in quiet and degraded conditions, cognition, and emotional, behavioral, and physical health, there is no universal standardized approach to audiological management of persons with TBI. However, a comprehensive case history and audiological evaluation should be obtained and appropriate referrals made to include evaluation for central auditory processing manifestations of TBI, vestibular evaluation, tinnitus management, ears, nose, and throat (ENT), mental health, and/or others. Q: What are the challenges of diagnosing and managing the audiological effects of TBI? A: Like hearing impairment and tinnitus, brain injuries often are not readily visible. Unlike the obvious external blunt or penetrating open TBIs with affected focal areas, closed TBIs from acceleration-deceleration movement of the brain within the skull are invisible to the naked eye and often to magnetic resonance imaging or computed tomography scans, especially concussion/mild TBIs. As mentioned above, because the population with TBI can vary greatly in terms of peripheral and central function, speech perception abilities in quiet and degraded conditions, cognition, and emotional, behavioral, and physical health, there is no universal standardized approach to audiological management of people with TBI. At the James A. Haley Veterans Hospital in Tampa, Florida, our interdisciplinary TBI team evaluates and treats the patient with TBI holistically, studying sensory modalities and physical, emotional, behavioral, cognitive, and psychosocial function. Q: How would you say the audiology community s current level of awareness is when it comes to the audiological consequences of concussion? How might it be improved, if needed? 30 TINNITUS TODAY WINTER

33 TINNITUS AND TBI RESEARCH A: The media has helped improve awareness of TBI from spotlighting the injuries of returning service members from the current conflicts as well as spotlighting sports-related injuries of athletes. This in turn has improved the audiology community s level of awareness evidenced by the many topics on the audiological consequences of TBI presented by professionals at national Audiology and Speech Language Pathology conferences, webinars, and journal readings. Improved awareness among audiologists regarding the possibility of cognitive, physical (to include auditory dysfunction), emotional, and behavioral consequences among people with TBI can enhance understanding and empathy for patients, help audiologists identify reasons for noncompliance, and justify the need for screening and/or clinical referral for further evaluation and treatment of TBI, post-traumatic stress disorder (PTSD), and other emotional sequelae. Displaying posters and handouts on TBI and signs of depression (and where to get help) in an audiology clinic can help increase awareness about the conditions and can be a lifesaving source of information. We need to continue to increase audiologists awareness of the diverse sensory and communication disorders that may result from a TBI so that a team-oriented, patientcentered rehabilitation plan can be formulated and implemented efficiently, thereby enhancing the likelihood of improved outcomes. Q: What are some examples of a team-oriented, patient-centered rehabilitation plan at your facility? A: Interdisciplinary therapies have been formed to provide TBI management. Recreational and physical therapists work together to lead participation in team-building exercises with other PTSD/mild TBI patients to target multisensory, cognitive, and physical skills under challenging dual conditions such as a low ropes course. Speech and physical therapists lead cognitivebalance groups in performing a variety of balance tasks while participating in group cognitive challenges (dual tasking). The audiologist and psychologists lead tinnitus management workgroups, with the audiologist providing sound-based therapy education and provision of devices and psychologists providing cognitive behavioral therapy (CBT) coping skill techniques and prolonged exposure imaginal sessions for PTSD as well as other complementary therapies. The interdisciplinary team-oriented therapies have the common goal to help patients enhance their ability to address the everyday challenges and demands of life. The patientcentered goals are the unique, specific challenges that the patient and family identify and that the team collaboratively addresses. Q: What happens when the audiological effects of TBI are ignored? A: Because hearing loss limits or takes away one of the primary means we use to communicate, hearing loss has the potential to complicate many of the other side effects of TBI, mainly cognitive and psychosocial problems. Many people with TBI already suffer cognitive, physical, and emotional issues, and these problems are only exacerbated if the patient cannot hear what is going on or is distressed and unable to effectively manage reactions to severe tinnitus. Because hearing loss, tinnitus distress, and vestibular dysfunction can influence all other areas of rehabilitation outcomes, it is important that patients receive audiologic evaluation and rehabilitation concurrently with their physical, mental health, and cognitive rehabilitation for their TBI and any additional injuries in an interdisciplinary manner. Screening for hearing impairment, tinnitus, and other sensory disorders across disciplines will help accomplish two important goals: (1) increase awareness about the various disorders to which people with TBI are susceptible and (2) help ensure rehabilitation is carried out as soon as possible after injury to take full advantage of the neuroplasticity of the brain that enables it to repair and retrain itself. Q: Do you have any advice or tips for audiologists about how they can better diagnose and manage the audiological sequelae of TBI in their patients? A: Audiologists should evaluate and counsel patients according to patient needs. Some patients with TBI require more evaluation and manage- TINNITUS TODAY WINTER

34 TINNITUS AND TBI RESEARCH ment than others, particularly when they have overlapping cognitive, mental, behavioral, or other physical conditions, problematic tinnitus, central auditory manifestations of TBI, or vestibular complaints. The family s involvement is a very important factor in a patient s recovery. The audiologist should support the patient and family and provide education and training for real-world success in self-management. Rehabilitation and education are crucial elements in treating TBI. When counseling patients with TBI, the audiologist should: provide a calm and structured environment with minimal auditory and visual distractions, reduce the complexity and talk about one topic, repeat key points, speak slowly, pause, use tag words (first, last, before, after), provide supplemental written and graphic information, and ask the patient to teach back the information provided to assess learning and reteach as warranted. Q: Is the Clinical Practice Guideline: Tinnitus, which was issued by the American Academy of Otolaryngology Head & Neck Surgery Foundation in 2014, applicable to those with TBI? A: Yes. According to those evidence-based guidelines, clinicians should: Perform a targeted history and exam to identify conditions that might be remediated. Perform a comprehensive audiological exam for patients with tinnitus that is unilateral, chronic, or associated with hearing difficulties. Distinguish patients with chronic tinnitus from those with recent-onset tinnitus (to prioritize clinical services). Provide education about intervention options. Recommend a hearing aid evaluation (or sound generator) for patients with bothersome tinnitus and/or hearing loss. Recommend CBT for patients with chronic, bothersome tinnitus. The Progressive Tinnitus Management (PTM) approach the U.S. Department of Veterans Affairs (VA) uses is a structured protocol that provides services mostly consistent with the cited guidelines. PTM studies reveal the feasibility of telephone-based tinnitus management for patients with TBI with future implications for expansion into VA Video Connect on-demand visits or scheduled visits via telephone, tablet, or computer. (See related article on page 10). Q: Are there specific resources audiology providers can turn to for help with TBI management? A: The Departments of Defense (DoD) and VA are recognized leaders in TBI care for veterans, but most patients with TBI will seek care in private healthcare clinics. Therefore, all audiologists should learn about TBI symptoms and manifestations from the following resources: VA and DoD Clinical Practice Guidelines: Management of Concussion/mild Traumatic Brain Injury (mtbi) (2016) guidelines/rehab/mtbi Traumatic Brain Injury, Veterans Health Initiative Study Guide Centers for Disease Control and Prevention: Brain Injury Basics Brainline: All About Brain Injury and PTSD Defense and Veterans Brain Injury Center American Speech-Language-Hearing Association: Traumatic Brain Injury in Adults Practice Portal Paula Myers, PhD, is chief of the Audiology Section at the James A. Haley Veterans Hospital in Tampa, Florida, where she has worked for 31 years. Her expertise and research focus on development of audiology educational materials, tinnitus management, traumatic brain injury, and auditory rehabilitation. She chaired the VA Audiology Southern Professional Standard Board and National Audiology Patient Education Workgroup, and is a former teacher of the Deaf and Deaf-Blind and assistant professor at University of South Florida. 32 TINNITUS TODAY WINTER

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36 TINNITUS AND TBI RESEARCH Head Injury, Tinnitus, and Mental Health Symptoms By Caroline J. Schmidt, PhD While tinnitus is often associated with hearing loss, for some people its onset accompanies a head injury. 1 Today we are just beginning to understand the complex relations among overlapping syndromes that result from blast waves, blunt force trauma, and acquired brain injuries (e.g., strokes) on the brain. Modern medicine increases the survival rate of those with head injuries, and these syndromes and their associated problems are increasingly gaining attention. Head injury can create a large number of downstream symptoms and problems. 2 During patient assessment, one symptom alone may not stand out as especially concerning to a provider, but when the provider looks at the entire person and the cumulative effect of damage on functioning, a more challenging set of problems emerges. Post-traumatic stress disorder (PTSD) is a collection of symptoms that can result from the effects of trauma. It can be helpful for providers to screen patients for the hallmark symptoms of PTSD, which include the following: Hypervigilance or always being on guard Feeling numb or detached from others Avoiding thoughts or situations that might be reminders of the trauma Nightmares or reexperiencing traumas 3 Additionally, the following symptoms of depression and anxiety are not uncommon among people with a history of head injury and/or tinnitus: Low mood Diminished interest in activities Sleep disturbance Feeling slowed, tense, or restless Fatigue Feeling worthless or guilty Reduced concentration Morbid or suicidal thoughts Irritability 3 During clinical assessment and intervention, symptoms that cause greater impairment of functioning, such as difficulty walking, receive greater medical attention than tinnitus. Therefore, tinnitus is likely to be overlooked initially, and management services delayed, because it is perceived as a less important symptom than others that affect quality of life. Yet many patients find tinnitus exacerbated by mental health symptoms. Those who have also experienced a traumatic head injury are even more vulnerable to such symptoms. Some head injuries are acquired through a toxin s effect on the brain and other slower progressing diseases, whereas others result from the head making traumatic contact with an object or surface. Fortunately, the brain is resilient. When connections are disrupted 34 TINNITUS TODAY WINTER

37 TINNITUS AND TBI RESEARCH through head injury, new connections can form because of the brain s neuroplasticity, which refers to its ability to reorganize itself and rebuild lost neural connections. Neuroplasticity is similar to when a car takes a detour around construction blocking a road. Although a detour may be a slower, less efficient, and often frustrating route to take, it connects to the desired destination; new neural connections over time may be able to compensate for prior damage in the brain. Immediately following a head injury, patients should focus on rest and recovery, especially when they continue to experience symptoms such as headache, dizziness, nausea, fatigue, disorientation, or more alarming symptoms such as seizures. 2 Continuous monitoring and evaluation of symptoms during this acute phase are critical to the recovery process, which can last from hours to weeks. Once cleared for increased activity, patients should be assessed to determine whether they are distressed by any of their symptoms, such as tinnitus, or are experiencing mental health symptoms. Once their symptoms are identified, patients can be taught strategies for coping and regaining lost functioning. Various multidisciplinary coping strategies have been suggested for patients with head injuries and tinnitus. In our recent randomized clinical trial of telephonedelivered Progressive Tinnitus Management (PTM), participants with bothersome tinnitus were given at least three sessions of cognitive behavioral therapy (CBT) with a psychologist and two sessions of sound therapy with an audiologist. Participants with symptoms of head injuries (n=62) were able to learn coping skills for tinnitus. It was observed that participants with more severe symptoms of head injuries (n=18) were less consistent regarding keeping appointments. Additionally, on average they had shorter appointments; their focus and stamina may have limited the length of time they could engage in a therapy session. 4 Of note, victims of traumatic head injury are likely to experience other injuries that require specialized clinical intervention by even larger multidisciplinary teams. Pain, headache, and hearing loss may exacerbate the deleterious effects of head injuries and require specialized care. Patient-centered care enables individuals with head injuries to take the lead in deciding their care plan. However, providers should take immediate action if patients experience suicidal thoughts. Just as the tinnitus experience is unique for individuals, each head injury must be managed specifically for each individual. Recovery varies greatly from person to person. A combination of small steps and giant leaps in recovery may assist in keeping patients motivated to reach treatment goals. Setbacks are natural and the need for compassionate care should be balanced by other providers desire for patients to consistently improve in their functioning. Caroline Schmidt, PhD, is a clinical psychologist and researcher at the VA Connecticut Healthcare System and Assistant Clinical Professor at Yale University School of Medicine s Department of Psychiatry. Her broad interests include understanding phenomena associated with auditory perception in the absence of external stimuli. She conducts research and provides behavioral interventions for tinnitus, conducts pre-surgical cochlear implant candidacy psychological evaluations, and offers culturally sensitive mental-health services with D/deaf persons. She also works in the Primary Care Mental Health Integration (PCMHI) program, offering care to veterans with general health needs, such as sleep disorders, and other chronic health conditions. 1 Lew, H.L., Jerger, J.F., Guillory, S.B., & Henry, J.A. (2007). Auditory dysfunction in traumatic brain injury. Journal of Rehabilitation Research and Development, 44, Moring, J.C., Peterson, A.L. & Kanzler, K.E. (2018). Tinnitus, traumatic brain injury, and posttraumatic stress disorder in the military. International Journal of Behavioral Medicine, 25, doi: 3 American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author. 4 Henry, J.A., Thielman, E., Zaugg, T.L., Kaelin, C., McMillan, G.P., Schmidt, C.J., Myers, P. & Carlson, K. (2018, May 29). Telephone-based Progressive Tinnitus Management for persons with and without traumatic brain injury: A randomized controlled trial. Ear & Hearing. Advanced online publication. doi: /AUD TINNITUS TODAY WINTER

38 YOUR HEALTH Does Earwax Cause Tinnitus? No, earwax doesn t cause tinnitus. It may, however, lead to it by obstructing the ear canal. Earwax plays an important role by trapping dirt and slowing growth of bacteria in the ear canal. If too much wax accumulates, it can form a plug, leading to tinnitus and hearing loss. You should never attempt to remove earwax by using a cotton swab or other items, which can push the wax farther into the ear and cause injury to the ear canal or eardrum. If you have concerns about earwax buildup, see your doctor, who can examine your inner ear with an otoscope. ADVERTISEMENT 36 TINNITUS TODAY WINTER

39 SCIENCE & RESEARCH NEWS A Sound Therapy System While You Sleep Summary by John A. Coverstone, AuD Many devices are marketed as tools for decreasing the severity of tinnitus. However, few have been subjected to independent research to study their effectiveness. Otoharmonics approached the Department of Veterans Affairs Rehabilitation Research & Development (RR&D) National Center for Rehabilitative Auditory Research in Portland, Oregon, to do just that with the Levo System. The Levo System uses software on an ipad Air to deliver customized sound therapy during sleep. Sixty participants were recruited for this study. 1 Candidates had to have tinnitus for at least six months, score at least 25/100 on the Tinnitus Functional Index (TFI), pass a screening test for dementia, have sufficient hearing to enable perception of the sound therapy stimulus, and speak English. Individuals were excluded if they had intermittent tinnitus; had conductive hearing loss (a medical problem of the outer portion of the ear); were unable to respond properly to instructions on a computer screen; had a history of loud noise exposure, behavioral problems, mental conditions, or emotional disorders; or had previously used a tinnitus treatment system. While controlling for demographics, participants were randomly assigned to one of three groups: One group was given the Levo System with tinnitus-matched stimulus; another group was provided with the Levo System using a noise stimulus (white noise and/or band noise but not the stimulus intended for this system); the third group was given a bedside sound generator device and allowed to choose a stimulus comfortable to them. All participants received the same counseling and used their assigned devices for three months. Participants were clinically tested and given a series of measures at the beginning of the study, during all follow-up visits, and at the end of the study. Measures included the TFI, NRS (numeric rating scale for tinnitus loudness), Tinnitus and Hearing Survey (THS), and tinnitus loudness match (LM). As measured by the TFI, all three groups exhibited overall improvement in tinnitus reaction. Those using the Levo System versus the bedside sound generator showed slightly more improvement, although it did not matter whether participants used the Levo System s tinnitus-matched stimulus or a generic noise stimulus. The Levo System using tinnitus-matched stimulus led to a greater reduction in tinnitus loudness (as measured by the NRS) compared to the system using noise or the bedside sound generator. There was no clear difference for LM measurements between the three groups. Overall, this study shows a greater reduction in tinnitus reaction when using the Levo System (regardless of stimulus) and a greater reduction in tinnitus loudness perception when using the tinnitus-matched stimulus. The authors acknowledged that a fully blinded study was not possible and that participants knew that some would be receiving a device with custom ear molds, as is used by the Levo System, and some would be receiving a bedside sound generator. Therefore, potential psychological effects cannot be ignored. It was also not possible to account for the effects of placebo, and those effects are likely present in all tinnitus treatment. These results should be replicated to ensure reliability. Other factors also need to be studied, such as who is a good candidate for the system versus other therapies. However, based on these results, the Levo System appears to hold promise for improvement in tinnitus perception. This study is presented as independent research. No compensation has been provided to the American Tinnitus Association and this article is not an endorsement of the Levo System or Otoharmonics by the ATA, the Veterans Administration, or any part of the U.S. government. 1 Theodoroff S.M., McMillan G.P., Zaugg T., Cheslock M., Roberts C., Henry J.A. (2017). Randomized controlled trial of a novel device for tinnitus sound therapy during sleep. American Journal of Audiology, 26, TINNITUS TODAY WINTER

40 SCIENCE & RESEARCH NEWS Iowa Conference Research Papers on Medical and Psychological Findings By David Strom At the 26th annual International Conference on the Management of the Tinnitus and Hyperacusis Patient in Iowa City this past summer, several researchers presented papers about their latest medical and psychological findings. 1 As a layperson, the research was at times difficult to follow but nonetheless fascinating. PHILLIP GANDER, PhD We heard about work being done by Phillip Gander, PhD, of the University of Iowa s Department of Neurosurgery and Department of Otolaryngology, researching where tinnitus occurs along the auditory pathway. He proposes three potential phases: generation, detection, or the brain itself. He referenced his craniotomy studies with epileptic patients that used 200 electrodes to detect patient responses to white noise. Like other researchers, he has found numerous brain locations that respond to this stimulus. HUBERT LIM, PhD Hubert Lim, PhD, at the University of Minnesota s Department of Biomedical Engineering, is testing various hypotheses about nerve combinations between the ear and the tongue that could account for certain kinds of tinnitus. Using guinea pigs, he is experimenting with placing electrodes under the tongue and sensors in different parts of the brain to track the stimulus and response. Lim s research examines whether simultaneous exposure to noise and tongue stimulation suppresses or enhances the noise heard in the brain. The tongue stimulation he described is akin to the sensation of tasting Pop Rocks candy and delivers small electrical currents. His research team found that results depend on the subject s state of mind and level of stress. STEVEN GREEN, PhD Steven Green, PhD, at the University of Iowa Biology Department, presented research on using electrode arrays to monitor brain activity to study the effects of cochlear hair cell loss and hearing damage. He noted that many biological models attempt to explain tinnitus. One model assumes that the brain amplifies sounds to compensate for reduced auditory nerve activity, in this case overcompensating for lost sound, which is why we perceive tinnitus. Another model assumes that loud noise has damaged inner ear sensory cells or the synapses of nerves connecting the hearing hair cells and the cochlea. Dr. Green has found differences in hearing damage between male and female mice in his experiments. SHELLEY WITT, AuD Shelley Witt, an audiologist with the University of Iowa, spoke about Tinnitus Activities Treatment, which includes counseling the whole person and considering individual differences and needs. The picturebased program includes homework and activities to engage the patient and facilitate progress. One tool she 38 TINNITUS TODAY WINTER

41 SCIENCE & RESEARCH NEWS highlighted was keeping a diary to track such things as when tinnitus is better/worse and which activities draw attention away from tinnitus. Witt suggested that through writing diary entries, we can learn to cope with our tinnitus more effectively. She also said patients should give themselves a year to adjust to tinnitus, noting that adjustment can happen sooner for some people and take longer for others. FATIMA HUSAIN, PhD Fatima Husain, PhD, of the University of Illinois at Urbana- Champaign Department of Speech & Hearing Science, spoke about the use of brain imaging techniques to find where tinnitus signals originate. 2 She uses functional magnetic resonance imaging (fmri) to map brain areas more precisely and develop biomedical markers. One goal is to obtain a more objective measurement of brain functions to understand which brain areas are responsible for the tinnitus signal. 1 For more information on next year s conference, visit conferences-and-events/international-conferencemanagement-tinnitus-and-hyperacusis. 2 Husain, T. Fatima. (2018). Using brain imaging techniques to find the tinnitus signal [Slide show]. Retrieved from Conference/Documents/PPT/Husain.pdf FDA Approves First Self-Fitting Hearing Aid By Joy Onozuka In early October, the U.S. Food and Drug Administration (FDA) approved marketing for the Bose Hearing Aid. The device enables users to fit, program, and control the hearing aid on their own, without assistance from an audiologist. The wireless device, which has not yet been released, can be controlled using a smartphone app and is intended for adults ages 18 and older with perceived mild to moderate hearing loss. The announcement came as a surprise because the FDA is currently conducting a three-year comment period, which began with the passage of the Over-the-Counter Hearing Aid Act of 2017, before publishing regulatory guidelines for a new category of over-the-counter hearing aids. In the FDA press release, Malvina Eydelman, MD, director of the Division of Ophthalmic, and Ear, Nose and Throat Devices at the FDA s Center for Devices and Radiological Health, said, The FDA is committed to ensuring that individuals with hearing loss have options for taking an active role in their health care. It was noted that approximately 37.5 million adults 18 years and older in the United States are reported to have trouble hearing, and increased use of hearing aids would enable them to communicate more effectively. The Bose Hearing Aid will include labeling instructions on when consumers should consult a hearing healthcare professional. The FDA reviewed the hearing aid under its De Novo premarket pathway, a program designed to expedite approval for some low- to moderate-risk devices that are novel and for which there is no prior legally marketed device. In authorizing the marketing of the Bose device, the FDA reportedly reviewed a clinical study of 125 participants that concluded that outcomes for those who self-fitted the hearing aid were comparable to those of participants who underwent a professional fitting of the same device with regard to the amount of amplification selected, speech in noise testing, and overall benefit. 1 1 U.S. Food and Drug Administration/U.S. Department of Health and Human Services. FDA allows marketing of first self-fitting hearing aid controlled by the user. Retrieved from PressAnnouncements/ucm htm TINNITUS TODAY WINTER

42 TINNITUS AND TBI RESEARCH The Emotional Impact of Mild Traumatic Brain Injuries and Tinnitus By Fatima Husain, PhD Mild TBI and Tinnitus With better treatment and management of traumatic brain injury (TBI), attention has focused on symptoms associated with TBI, such as tinnitus. Apart from a higher incidence of tinnitus, patients with TBI report consequences ranging from loss of consciousness lasting a few seconds to seizures; from confusion and disorientation to memory dysfunction; and, in some cases, TBI results in coma or death. Thus, as with tinnitus and its related effects, the signs of TBI can range from mild to severe. In this article, I focus on tinnitus associated with mild TBI (mtbi). It should be noted that tinnitus can arise from both the injury causing mtbi as well as medications used to treat the problematic symptoms associated with TBI. 1 Figure 1. The limbic system. Hypothalamic Nuclei Medical organizations in the United States and around the world use somewhat different criteria in diagnosing mtbi and differentiating it from other more severe forms of TBI. Nevertheless, the emerging consensus is that persistent symptoms associated with mtbi include headaches, sleep disturbances, mental health disorders, cognitive difficulties, balance and vision dysfunction, and fatigue. As individuals with tinnitus know, some of these symptoms associated with mtbi also occur with tinnitus, such as sleep disturbance, emotional problems, concentration difficulties, and fatigue. The rate of incidence of tinnitus in the mtbi population is between 38 and 53 percent, varying depending on the cause of injury. 2, 3 In a retrospective study of Cingulate Gyrus Corpus Callosum Thalamus Amygdala Hippocampus Source: OpenStax College, Anatomy & Physiology. OpenStax CNX. July 30, Retrieved from military personnel diagnosed with mtbi, about 67 percent of patients exposed to blasts and 58 percent of those not exposed to blasts developed tinnitus. 4 This brief report focuses on what happens in the brain when patients experience emotional problems associated with tinnitus and mtbi. The main processor of emotions is the amygdala, and the hippocampus is essential in forming new and, in particular, declarative memories. It s not surprising that the amygdala has been ascribed a major role in theories of tinnitus generation. In these theories, the sound of tinnitus grabs our attention because it stands out from other sounds of daily life (such as people talking or passing cars, which are evaluated as neutral and familiar, and hence more easily tuned out ). When one attaches negative meaning to the unwanted tinnitus sound, one attends to it even more, thus ensuring its persistence. This is not unlike the reaction to a mosquito bite; the more one thinks about it, the more it itches, and vice versa. Despite being unable to make the mosquito bite simply go away, the mind has the capability to amplify or dampen the strength of the 40 TINNITUS TODAY WINTER

43 TINNITUS AND TBI RESEARCH sensation, depending upon what our thoughts are focused on. Likewise, with tinnitus, shifting thoughts away from the unwanted sound and toward a positive goal or activity can lead to the ability to minimize the itch of tinnitus, thereby supporting habituation. After the onset of tinnitus, managing the emotional response to it, possibly mediated by the limbic system, plays an important role in learning to habituate to chronic tinnitus sound(s). The 2018 Spring issue of Tinnitus Today magazine was devoted to the topic of habituation and serves as a useful resource on the process of habituation and how a tinnitus patient can work to achieve it. In our own studies, we have shown that if one has bothersome or severe tinnitus, a likely contributor is a hyperresponsive amygdala, that is, one that comes online quicker and with great effect when hearing speech or environmental sounds. 5 7 In cases of mild tinnitus, the patient may be habituated to tinnitus, and therefore suppressing the powerful response from the amygdala with emotionally relevant external sounds. What Does This Mean When One Has Both mtbi and Tinnitus? Individuals who develop mtbi may report tinnitus, but both they and their healthcare providers may not pay attention to tinnitus, compared with other more acutely debilitating symptoms of mtbi, until after the symptoms have stabilized and tinnitus has become chronic. Further, as noted earlier, medications used to treat mtbi symptoms may also facilitate the onset of tinnitus. In mtbi, the size of the amygdala may be reduced and its connections with the rest of the brain altered. Recent studies of mtbi have reported on the diminished response of the amygdala as well as reduced size of this structure. 8 This in turn has been linked to deficits in cognitive control or inhibitory control; the authors of this paper liken it to the cognitive deficits and trauma symptoms seen in cases of post-traumatic stress disorder (PTSD). 9 In cases of PTSD, reduced function and size of the hippocampus are noted with an increased functioning of the amygdala. 10 The co-occurrence of PTSD and mtbi has also been reported in epidemiological studies (which look at how different conditions interact and affect various populations) of U.S. military personnel. 11, 12 Although behavioral studies are beginning to investigate the impact of these conditions when they co-occur, few imaging studies of brain function have been published. 13 In particular, the functioning of the amygdala when PTSD and mtbi co-occur with tinnitus has to be worked out. As suggested earlier, patients with mtbi and tinnitus require unique treatment plans, involving diverse healthcare professionals, because the type of injury (blunt or blast-related) may affect the type of deficits seen in the patients. 14 Further, the neuropsychological symptoms may vary from person to person. As a first step, given the commonality of symptoms between PTSD and mtbi and that their mechanisms overlap, tinnitus management in mtbi cases may require individualized and multidisciplinary approaches. 15 PTSD and Tinnitus Events causing PTSD often include loud sounds that can result in damage to hearing, such as explosions or gunshots. As a result, PTSD is often accompanied by tinnitus. Although the actual etiology of tinnitus is often unknown, it likely has several factors that interact with PTSD, heightening the perception of tinnitus. 16 Perception of tinnitus is affected by how individuals direct their thoughts, and the thoughts of people with PTSD are influenced by the event that led to their PTSD. This event is often the same trauma that initiated their tinnitus. 17 Consequently, PTSD and tinnitus may serve to amplify each other s effects. A thought about PTSD may trigger thoughts about tinnitus, and vice versa. PTSD results in a condition called hypervigilance, in which the brain becomes acutely aware of incoming stimuli and sensations. 18 In terms of neural networks, there is evidence to suggest that the equilibrium between the salience network and the default mode network is altered in PTSD, and this is noted even at rest (see the accompanying box); 19 the association between activity in these networks and hypervigilance remains speculative but of great interest to researchers. TINNITUS TODAY WINTER

44 TINNITUS AND TBI RESEARCH Figure 2. The salience network switches between the default mode and dorsal attention networks. Default Mode Network Hypervigilance associated with PTSD may influence tinnitus by heightening awareness of incoming sounds, a defensive mechanism intended to protect individuals from further traumatic events. 20 Unfortunately, as a result, tinnitus can receive increased attention, or increase in loudness, particularly in the presence of startling sounds that exacerbate the perceived tinnitus handicap. Avoiding situations that can trigger tinnitus (such as social outings to restaurants, movies, or parties) can result in the individual becoming Salience Network Anticorrelation Central Executive Network Source: Nekovarova, T., Fajnerova, I., Horacek, J., & Spaniel, F. (2014, May 30). Bridging disparate symptoms of schizophrenia: A triple network dysfunction theory. Frontiers in Behavioral Neuroscience, 8, 171. doi: /fnbeh Note: Central executive function here may be considered to be the dorsal attention network. ACC, anterior cingulate cortex; DLPFC, dorsolateral prefrontal cortex; INS, insula; mpfc, medial prefrontal cortex; PCC, posterior cingulate cortex; PPC, posterior parietal cortex. isolated. 21 Increased isolation increases time spent focusing and ruminating on negative thoughts and emotions linked to PTSD and tinnitus. This further exacerbates the discomfort from tinnitus. Decreasing anxiety and rumination associated with PTSD can lessen tinnitus, leading to improved quality of life. Cognitive behavioral therapy (CBT) is one approach that can help individuals feel more at ease with their thoughts and, in fact, is the only treatment to show improvements in tinnitus-related measures in randomized controlled trials The goal of CBT is for individuals to take note of what thoughts they are thinking, assess the validity and usefulness of the thoughts, and then challenge and change the thoughts as needed. This can be an effective way to develop a mind-set geared toward positive coping skills and decreased negative ruminations about the discomfort caused by tinnitus and PTSD. Although CBT and other interventions may not necessarily cure either condition, they can be helpful in managing tinnitus and PTSD effects. CBT can improve self-efficacy beliefs, which have been shown to improve treatment outcomes. 25 This same concept can be applied to patients with mtbi and tinnitus. Changing thoughts cannot change the past the mtbi remains part of the patient s history but such intervention can help the patient cope with the consequences of traumatic exposures in the present and the future, thereby reducing the negative impact exerted by the mtbi and associated tinnitus. Fatima Husain, PhD, is a cognitive and computational neuroscientist by training, with a special interest in speech and hearing. For the past 12 years, the major focus of her lab has been the study of tinnitus. Her lab at the University of Illinois at Urbana-Champaign has studied tinnitus using a variety of methods, from behavior and surveys to several types of brain imaging. Dr. Husain s goal is to better understand the brain-based mechanisms of tinnitus with a view toward testing and improving existing treatment options and eventually developing customized treatment plans. 42 TINNITUS TODAY WINTER

45 TINNITUS AND TBI RESEARCH Neural Networks of Tinnitus Apart from the auditory pathways or network, that is, the brain regions involved in sound perception and by extension implicated in generating tinnitus sounds, a number of neural networks may be involved in the psychological reaction to tinnitus. Prominent among these networks are the attention network, the emotional processing network, the default mode network, and the salience network. The limbic system is the primary system for processing emotions (e.g., joy, fear, anger), memories, and arousal, or base rate of stimulation. It is composed of those regions that can be thought of as the older or more primitive brain, namely, the amygdala, hippocampus, thalamus, hypothalamus, basal ganglia, but also parts of the neocortex such as the insula, the orbitofrontal cortex, and the cingulate gyrus (see Figure 1, p. 40). The attention network is engaged in focusing on important tasks and orienting to signals and can be further divided into dorsal and ventral attention networks. The default mode network, sometimes termed the tasknegative network, is more engaged and responsive at rest, when the brain is not performing a goaldirected task. Regions of the default mode network include the posterior cingulate cortex and the medial prefrontal cortex. The dorsal attention network and the default mode network exhibit a push-pull relation, with one gaining ascendance at rest (the default mode) and the other, when performing a task (the dorsal attention network). The salience network is a more recently termed network, and its connections and functionality are less well understood. Its major role appears to be in determining which stimuli to focus attention on, and coordinating the neural responses necessary to respond to such stimuli. Apart from other regions, the canonical regions of the salience network are the insula and the anterior cingulate cortex, which are also part of the limbic system. One way to think about the salience network is as a fulcrum between the default mode and dorsal attention networks, switching between attention and resting state (see Figure 2, p. 42). fmri Facts and Points of Speculation Tinnitus affects the neural bases of cognition, attention, and emotion processing. Functional MRI (fmri) allows us to vividly see the brain regions that are engaged in a task; we can compare between patients and controls and locate possible networks, thus allowing us to infer neural mechanisms of tinnitus. Because of the individual differences within the patient population and several methods of acquiring data or performing analysis, findings from different labs may vary. But over numerous studies, as evidence accumulates, our understanding of the neural mechanisms of tinnitus will improve. Below are a few studies and their findings from our lab. Husain et al. (2011): 1 o Elevated activation in auditory attention and short-memory networks in individuals with tinnitus. o Although no behavioral differences were found between patients and controls, TINNITUS TODAY WINTER

46 TINNITUS AND TBI RESEARCH fmri Facts and Points of Speculation (continued) the alterations in the attention network point to different adaptions due to chronic tinnitus. Schmidt et al. (2013) 2 and Schmidt et al. (2017): 3 o Increased coupling between limbic regions and the auditory and dorsal attention resting-state networks. o Decreased coupling between precuneus and default mode resting-state network in people with long-term tinnitus, exaggerated by tinnitus severity. o Individuals with tinnitus are still using their attention network even when not doing a task; possibly they are paying attention to the tinnitus sound and are not completely at rest. This may explain some of the fatigue individuals with tinnitus often experience. Carpenter-Thompson, Schmidt, McAuley, et al. (2015) 4 and Carpenter-Thompson, Schmidt, and Husain (2015): 5 o Heightened activation of limbic system (posterior cingulate and insula) in the initial emotional responses to tinnitus, after recent onset. o Heightened activation of frontal regions (e.g., middle frontal gyrus) but reduced activation of the amygdala for those with mild longterm tinnitus, indicating habituation. o Heightened response of the amygdala but reduced response of the frontal regions in those with bothersome long-term tinnitus, indicating unsuccessful habituation. 1 Husain, F. T., Pajor, N. M., Smith, J. F., Kim, H. J., Rudy, S., Zalewski, C., Horwitz, B. (2011). Discrimination task reveals differences in neural bases of tinnitus and hearing impairment. PLoS One, 6(10), e Schmidt, S. A., Akrofi, K., Carpenter-Thompson, J. R., & Husain, F. T. (2013). Default mode, dorsal attention and auditory resting state networks exhibit differential functional connectivity in tinnitus and hearing loss. PLoS One, 8(10), e Schmidt, S. A., Carpenter-Thompson, J., & Husain, F. T. (2017). Connectivity of precuneus to the default mode and dorsal attention networks: A possible invariant marker of long-term tinnitus. NeuroImage: Clinical, 16, Carpenter-Thompson, J. R., Schmidt, S., McAuley, E., & Husain, F. T. (2015). Increased frontal response may underlie decreased tinnitus severity. PLoS One, 10(12), e Carpenter-Thompson, J. R., Schmidt, S. A., & Husain, F. T. (2015). Neural plasticity of mild tinnitus: An fmri investigation comparing those recently diagnosed with tinnitus to those that had tinnitus for a long period of time. Neural Plasticity, 2015, Kreuzer, P.M., Landgrebe, M., Schecklmann, M., Staudinger, S., Langguth, B., & the TRI Database Study Group. (2012). Trauma-associated tinnitus: Audiological, demographic and clinical characteristics. PLoS One, 7(9), e Kreuzer et al. (2012). 3 Jury, M. A., & Flynn, M. C., (2001). Auditory and vestibular sequelae to traumatic brain injury: A pilot study. New Zealand Medical Journal, 114(1134), Karch, S. J., Capó-Aponte, J. E., McIlwain, D. S., Lo, M., Krishnamurti, S., Staton, R. N., & Jorgensen-Wagers, K. (2016, October December). Hearing loss and tinnitus in military personnel with deployment-related mild traumatic brain injury. U.S. Army Medical Department Journal, (3 16), Carpenter-Thompson, J. R., Akrofi, K., Schmidt, S. A., Dolcos, F., & Husain, F. T. (2014). Alterations of the emotional processing system may underlie preserved rapid reaction time in tinnitus. Brain Research, 1567, Carpenter-Thompson, J. R., Schmidt, S., McAuley, Ed., & Husain, F. T. (2015). Increased frontal response may underlie decreased tinnitus severity. PLoS One, 10(12), e Carpenter-Thompson, J. R., Schmidt, S. A., & Husain, F. T. (2015). Neural plasticity of mild tinnitus: An fmri investigation comparing those recently diagnosed with tinnitus to those that had tinnitus for a long period of time. Neural Plasticity, 2015, Palmer, C. P., Metheny, H. E., Elkind, J. A., & Cohen, A. S. (2016). Diminished amygdala activation and behavioral threat response following traumatic brain injury. Experimental Neurology, 277, Depue, B. E., Olson-Madden, J. H., Smolker, H. R., Rajamani, M., Brenner, L. A., & Banich, M. T. (2014). Reduced amygdala volume is associated with deficits in inhibitory control: A voxel- and surfacebased morphometric analysis of comorbid PTSD/ mild TBI. Biomedical Research International, 2014, Bremner, J. D. (2002). Neuroimaging studies in post-traumatic stress disorder. Current Psychiatry Reports, 4(4), Eskridge, S. L., Macera, C. A., Galarneau, M. R., Holbrook, T. L., Woodruff, S. I., MacGregor, A. J., Shaffer, R. A. (2013). Influence of combat blastrelated mild traumatic brain injury acute symptoms 44 TINNITUS TODAY WINTER

47 TINNITUS AND TBI RESEARCH on mental health and service discharge outcomes. Journal of Neurotrauma, 30(16), MacGregor, A. J., Dougherty, A. L., Tang, J. J., & Galarneau, M. R. (2013). Postconcussive symptom reporting among US combat veterans with mild traumatic brain injury from Operation Iraqi Freedom. Journal of Head Trauma Rehabilitation, 28(1), Betthauser, L. M., Brenner, L. A., Cole, W., Scher, A. I., Schwab, K., & Ivins, B. J. (2018). A clinical evidence-based approach to examine the effects of mtbi and PTSD symptoms on ANAM performance in recently deployed active duty soldiers: Results from the Warrior Strong Study. Journal of Head Trauma Rehabilitation, 33(2), Hoffer, M. E., Donaldson, C., Gottshall, K. R., Balaban, C., & Balough, B. J. (2009). Blunt and blast head trauma: Different entities. International Tinnitus Journal, 15(2), Myers, P. J., Henry, J. A., Zaugg, T. L., & Kendall, C. J. (2009). Tinnitus evaluation and management considerations for persons with mild traumatic brain injury. American Speech-Language-Hearing Association. Retrieved from Considerations-for-Persons-with-Mild-Traumatic- Brain-Injury/ 16 Fagelson, M. A., & Smith, S. L. (2016). Tinnitus self-efficacy and other tinnitus self-report variables in patients with and without post-traumatic stress disorder. Ear and Hearing, 37(5), Moring, J. C., Peterson, A. L., & Kanzler, K. E. (2018). Tinnitus, traumatic brain injury, and posttraumatic stress disorder in the military. International Journal of Behavioral Medicine, 25(3), Moring et al. (2018). 19 Sripada, R. K., King, A. P., Welsh, R. C., Garfinkel, S. N., Wang, X., Sripada, C. S., & Liberzon, I. (2012). Neural dysregulation in posttraumatic stress disorder: Evidence for disrupted equilibrium between salience and default mode brain networks. Psychosomatic Medicine, 74(9), Fagelson, M. A. (2007). The association between tinnitus and posttraumatic stress disorder. American Journal of Audiology, 16(2), Budd, R. J., & Pugh, R. (1996). Tinnitus coping style and its relationship to tinnitus severity and emotional distress. Journal of Psychosomatic Research, 41(4), Cima, R. F., Andersson, G., Schmidt, C. J., & Henry, J. A. (2014). Cognitive-behavioral treatments for tinnitus: A review of the literature. Journal of the American Academy of Audiology, 25(1), Martinez-Devesa, P., Perera, R., Theodoulou, M., & Waddell, A. (2010). Cognitive behavioural therapy for tinnitus. Cochrane Database of Systematic Reviews, (9), CD Jun, H. J., & Park, M. K. (2013). Cognitive behavioral therapy for tinnitus: Evidence and efficacy. Korean Journal of Audiology, 17(3), Smith, S. L., & Fagelson, M. (2011). Development of the self-efficacy for tinnitus management questionnaire. Journal of the American Academy of Audiology, 22(7), What s Functional Magnetic Resonance Imaging? At any given moment, millions of electrical impulses whirl through your brain. Electricity is what drives this vast and complex network, with four key elements in neurological wiring: neurons, axons, dendrites, and synapses. At junctures between synapses, these impulses trigger neurotransmitters, which in turn modulate electrical activity in the next cell. Somehow these processes of neural communication underpin every thought, feeling, and action. By measuring changes in oxygenation, functional magnetic resonance imaging (fmri) indirectly reveals the consequences of neural activity. (Active brain areas consume more oxygen, which increases blood flow to those areas.) The fmri is the workhorse in cognitive neuroscience for studying brain function and is used regularly to study how tinnitus affects the brain. TINNITUS TODAY WINTER

48 ATA NEWS The ATA Connects You With the Tinnitus World NATIONAL DEAFNESS AND OTHER COMMUNICATION DISORDERS ADVISORY COUNCIL ATA BOARD OF DIRECTORS AT WORK The ATA board members discuss strategic goals during their September meeting at the ATA headquarters in Vienna, VA. NORTHERN VIRGINIA TINNITUS SUPPORT GROUP Torryn Brazell, ATA s chief executive officer, with Fan-Gang Zeng, PhD, at the National Deafness and Other Communication Disorders (NDCD) Advisory Council meeting on September 7 in Bethesda, Maryland. Fan-Gang Zeng, PhD, was appointed to the 18-member National Deafness and Other Communication Disorders (NDCD) Advisory Council, which advises the secretary of Health and Human Services, the director of the National Institutes of Health, and the director of the National Institute on Deafness and Other Communication Disorders (NIDCD). The council provides guidance on issues relating to research and research training, health information dissemination, and other programs related to hearing disorders and other communication processes. Dr. Zeng serves as director of the Research Division of the University of California, Irvine. He is also a member of the ATA s Scientific Advisory Committee. From left: Jeannie Karlovitz, David Hadley, Ted Turesky, LaGuinn Sherlock, David Hopkins, Scott Mitchell, Jill Meltzer, Michael Hoffer. BRITISH TINNITUS ASSOCIATION S ANNUAL CONFERENCE + EXPO Torryn Brazell, ATA s chief executive officer, was a featured guest speaker at the British Tinnitus Association s Annual Conference + Expo, held September in Birmingham, United Kingdom. Brazell works closely with her BTA counterpart David Stockdale, chief officer, to increase global awareness of tinnitus and cooperation, where feasible, between the organizations. By attending such events, the ATA is able to build relationships with Europeanbased researchers and healthcare professionals, who utilize different frameworks for tinnitus research and treatment than those used in the United States. LaGuinn Sherlock, AuD, chair of the ATA board of directors, speaks to the Northern Virginia Tinnitus Support Group. American Tinnitus Association board chair LaGuinn Sherlock, AuD, attended the Northern Virginia Tinnitus Support Group, where she was the guest speaker for their meeting on September 18. Sherlock gave an overview of the history of the ATA and her recent research on establishing an objective measure of tinnitus, which would aid in health insurance reimbursement for tinnitus treatment. To read more about her research, see Measuring Concentration: The Future of Evaluating Tinnitus on page 13 of the Spring 2018 issue of Tinnitus Today. To find a support group near you, see page 48. If you re interested in forming a support group, tinnitus@ata.org for materials and help. 46 TINNITUS TODAY WINTER

49 ATA NEWS Increasing Awareness of Quality Care AMERICAN ACADEMY OF OTOLARYNGOLOGY ANNUAL MEETING AUDACITY, THE AMERICAN DOCTORS OF AUDIOLOGY CONFERENCE Torryn Brazell and LaGuinn Sherlock present at the American Academy of Otolaryngology s 2018 conference in Atlanta, Ga. Torryn Brazell and LaGuinn Sherlock delivered The Criticality of Reframing Your Advice and Counseling of Tinnitus Patients at the American Academy of Otolaryngology s annual meeting, October 7 10, in Atlanta, Ga. The Monday afternoon session was at standing-room capacity with 97 attendees, most of whom were Ear, Nose, and Throat (ENT) doctors. In addition, the 30-minute Q&A period addressed questions on how ENTs, who are typically the first to meet a patient with tinnitus, should advise and refer patients to other healthcare professionals so that patients are able to access valuable resources and effective treatment for tinnitus management. This was the first time the ATA presented at the conference. Organizers noted it was one of the highest attended sessions. From left to right: Torryn Brazell, Bill Slattery and LaGuinn Sherlock at the AAO conference in Atlanta, Ga. Bill Slattery, MD, is president of the House Ear Institute and appeared in the movie A Star Is Born at the request of his patient Bradley Cooper to offer an authentic representation of counseling to patients on protecting and preserving hearing. The three discussed trends in doctor-patient dialogue and ATA goals for improving how tinnitus patients are treated when seeking care. Jill Meltzer (right), AuD, offers insights into building a thriving tinnitus practice to attendees of her session, given with Torryn Brazell (left), at the AuDACITY conference in Orlando, Fla. Torryn Brazell, ATA s chief executive officer, and Jill Meltzer, AuD, and member of the ATA board of directors, attend AuDACITY, the American Doctors of Audiology conference held October 22 24, in Orlando, Fla. In an effort to increase the number of healthcare professionals serving patients with tinnitus, Brazell and Meltzer presented on how to build a successful clinical practice that offers tinnitus treatment. Torryn Brazell with Dr. Abraham Shulman at the AAO Conference. Torryn Brazell with Dr. Abraham Shulman, a highly-regarded tinnitus researcher, otolaryngologist and neurotologist, following a session at the AAO conference. TINNITUS TODAY WINTER

50 TINNITUS RESOURCES Support Group Calendar People with tinnitus at every stage in their journey, from the first few days after onset to many years later, can benefit from membership in a support group. Each tinnitus support group operates somewhat differently; but, they all share a passion for providing meaningful discussion and a caring environment where one can be understood through shared experience. Below is a list of groups and meeting dates, current at time of print. To reconfirm dates and times, please /call the point-of-contact person listed. As new groups continue to be formed, we advise you to check our website periodically for new locations at: California Los Angeles/Orange County Tinnitus Support Group Mariposa Women and Family Center 812 Town and Country Rd., Bldg. C Orange, CA Contact: Barry Goldberg E: bargold06@yahoo.com January 19 1:30 pm February 16 1:30 pm March 16 1:30 pm San Diego Tinnitus and Hyperacusis Support Group San Diego City Library North University City Branch 8820 Judicial Dr. San Diego, CA Contact: Michael J. Fischer, Dave Phaneuf E: michaeljohnfischer@hotmail.com E: djphaneuf@yahoo.com December 5 6 pm January 2 6 pm February 6 6 pm March 6 6 pm San Francisco Tinnitus Support/ Education Group Hearing and Speech Center of Northern CA Conference Room 1234 Divisadero St. San Francisco, CA Contact: Malvina Levy, AuD, Tracy Peck, AuD T: E: mlevy@hearingspeech.org E: tpeck@hearingspeech.org December 18 5:30 pm January 15 5:30 pm February 19 5:30 pm March 19 5:30 pm Los Altos Hills Tinnitus Support Group Congregation Beth AM 2670 Arastradero Road, Room 15 Los Altos Hills, CA Contact: Ken Adler, Amy Nelson, AuD, Brandon Cyrus, AuD E: karmtac@aol.com E: Amy.Nelson@kp.org E: brandon@landmarkhearing.com December 13 7 pm January 10 7 pm February 14 7 pm March 14 7 pm Colorado Denver Tinnitus Support Group Lutheran Medical Center 2nd Floor Learning Center 8300 West 38th Arvada, CO Contact: Rich Marr T: E: r.marr@comcast.net December 10 7 pm January 14 7 pm February 11 7 pm March 11 7 pm Mesa County Tinnitus Support Group Community Hospital 2351 G Road, Legacy Room 1 Grand Junction, CO Contact: Elaine Conlon T: E: conlonelaine@aol.com January 16 7 pm February 20 7 pm March 20 7 pm Florida Clermont Tinnitus Support Group Citrus Hearing Clinic 835 7th St. Suite 2 Clermont, FL Contact: Laura Pratesi, AuD T: E: drlaura@citrushearing.com December 10 1 pm January 14 1 pm February 11 1 pm March 11 1 pm Sarasota Tinnitus Support Group Silverstein Institute 1901 Floyd St. Sarasota, FL Contact: Carmen Trotta, Tom Terrenzi T: , E: sarasota.ata@gmail.com Meeting dates and times TBD.* The Villages Tinnitus Support Group Churchill Recreation Center 2375 Churchill Downs Lady Lake, FL Contact: Sal Gentile E: tvtinnitus@gmail.com December 27 3:30 pm January 24 3:30 pm February 28 3:30 pm March 28 3:30 pm 48 TINNITUS TODAY WINTER

51 TINNITUS RESOURCES Tinnitus Self-Help Group of Palm Beach County South County Civic Center Jog Road Delray Beach, FL Contact: Ellen Gartner T: Meeting dates and times TBD.* Georgia Atlanta Tinnitus Support Group Dekalb County Public Library Dunwoody Branch, Meeting Room 5339 Chamblee Dunwoody Rd. Dunwoody, GA Contact: Erica Caplan E: Meeting dates and times TBD.* Illinois Chicago Suburban Tinnitus Support Group Glenview Public Library 1930 Glenview Rd. Glenview, IL Contact: Margie B E: maggie138@yahoo.com Meeting dates and times TBD.* Maryland D.C. Tinnitus Support Group Potomac Audiology Rockville Pike, Ste. 105 Rockville, MD Contact: David Treworgy, Gerry Baill E: david_treworgy@yahoo.com E: gsbaill@yahoo.com Meeting dates and times TBD.* Massachusetts Boston Tinnitus Support Group Athan s Bakery 407 Washington St. Brighton, MA Contact: Kevin Plovanich E: KPMA@aol.com Meeting dates and times TBD.* Michigan Holland Tinnitus Support Group Holland Doctors of Audiology 399 E 32nd St. Holland, MI Contact: Stelios Dokianakis, AuD T: E: info@holaud.com Meeting dates and times TBD.* Missouri St. Louis Tinnitus Support Group St. Louis County Library Headquarters East Room 1640 S. Lindbergh Blvd. St. Louis, MO Contact: Tim Busche T: E: tennisfancincy@gmail.com Meeting dates and times TBD.* Nevada Reno/Sparks Nevada Tinnitus Support Group Modern Audiology of Sparks 634 Pyramid Way Sparks, NV Contact: Scott Sumrall T: E: scottsumrall@sparkshearing.com Meeting dates and times TBD.* New Jersey Tinnitus Self-Help Group, Ewing First Presbyterian Church 100 Scotch Road Ewing, NJ Contact: Dhyan Cassie, AuD T: E: Dhyan1@verizon.net Meeting dates and times TBD.* South Jersey Tinnitus Support Group 1020 North Kings Highway Ste. 201 Cherry Hill, NJ Contact: Linda Beach, MaryAnn Halladay, Barbara Kennedy E: linda.beach@gmail.com E: mhalladay@verizon.net E: harleyonholly@comcast.net December 6 7 pm January 3 7 pm February 7 7 pm March 7 7 pm New York Bronx Tinnitus Support Group 260 W. 231st St. Bronx, NY Contact: Dr. S. Karie Nabinet T: or E: kkwn12u@aol.com Meeting dates and times TBD.* The Long Island Tinnitus Group Long Island Jewish Hospital 2nd Floor Conference Room 900 Franklin Ave. Valley Stream, NY Contact: Lisa Kennedy, Anthony Mennella T: , E: aem830@verizon.net December 17 7:30 pm January 28 7:30 pm February 25 7:30 pm March 25 7:30 pm NEW! NYC Tinnitus Support Group Campbell Acupuncture PLCC 141 East 55th St., Suite 6d New York, NY Contact: Sara Higgins E: cliniccampbell@hotmail.com December 11 7 pm January 8 7 pm February 12 7 pm March 12 7 pm TINNITUS TODAY WINTER

52 TINNITUS RESOURCES North Carolina Raleigh Tinnitus Support Group Raleigh Hearing and Tinnitus Center Falls of Neuse Rd., Ste. 12 Raleigh, NC Contact: Saranne Barker, AuD, Sheri Mello, AuD T: E: December 20 6 pm January 15 6 pm February 19 6 pm March 19 6 pm Oregon VA Portland Health Care System Tinnitus Education Group National Center for Rehabilitative Auditory Research 3710 SW US Veterans Hosp. Rd. Portland, OR Contact: Bryan Shaw E: Bryan.Shaw2@va.gov Meeting dates and times TBD.* South Carolina Greenville Tinnitus Support Group Contact: Anthony Russo E: AnthonyRussoSC@outlook.com Meeting dates and times TBD.* Texas Dallas/Ft. Worth Tinnitus Support Group Texas Health Presbyterian Hospital Plano 6200 W Parker Rd. Plano, TX or Callier Center for Communication Disorders 1966 Inwood Road Dallas, TX Contact: John Ogrizovich E: dfwtsg@yahoo.com Meeting dates and times TBD.* Virginia Northern Virginia Tinnitus Support Group Northern Virginia Resource Center for Deaf & Hard of Hearing Persons (NVRC) 3951 Pender Drive, Ste. 130 Fairfax, VA Contact: Elaine Wolfson, Marian Patey E: erwolfson@comcast.net E: mjpatey@fcps.edu Meeting dates and times TBD.* Washington Seattle Tinnitus Support Group Broadview Public Library Greenwood Ave N. Seattle, WA or Greenwood Public Library 8016 Greenwood Ave. N Seattle, WA Contact: Keith Field T: E: keith_r_field@outlook.com Meeting dates and times TBD.* Wisconsin NEW! Madison Tinnitus Support Group Doric Masonic Center 85 S. Stoughton Rd. Madison, WI Contact: Deb Holmen T: E: dholmenihearu@gmail.com January 23 6:30 pm February 27 6:30 pm March 27 6:30 pm Each support group referenced here is independently operated and led by volunteers who wish to provide education and support to the tinnitus community. The American Tinnitus Association (ATA) does not sponsor nor endorse these activities and expressly disclaims any responsibility for the conduct of any independent support group or the information they may provide. The ATA is not a healthcare provider and you should consult with a primary care physician or hearing healthcare professional for qualified medical advice on tinnitus and related hearing disorders. *Some groups do not/cannot schedule meetings far in advance to allow for flexibility in planning. We update information on our online events calendar at ATA.org when we receive new information. The above dates and times were provided to ATA staff at the time the magazine went to print; therefore, please confirm meeting details with the contact person prior to a meeting or reference our website at: This is a partial listing of support groups and scheduled meetings. A complete list can be found at New groups continue to be organized so please check the website for updates periodically. If you re interested in forming a group, contact Jennifer Born at: tinnitus@ata.org. If there isn t a group in your area, the ATA has an extensive network of volunteers who provide and telephone support and educational information as an alternative form of support. To connect with a volunteer in your time zone, see: managing-your-tinnitus/support-network/telephone -support-listing 50 TINNITUS TODAY WINTER

53 YOUR HEALTH A Step Forward in Analyzing a Blow to the Head By Joy Onozuka By the age of 20, Ian Ross had sustained over a dozen concussions playing ice hockey. I didn t always make the best decisions, but I have no regrets, Ross said. Tinnitus, which comes and goes, is a minor lingering symptom compared to ongoing attention and memory issues, which make his university studies more challenging. It takes a lot more time to get things done, he said, reflecting on the long-term ramifications of so many head injuries. Tinnitus usually faded after a week or so after a concussion. Yes, it s on the list of concussion symptoms, but it wasn t something I focused on, Ross said, noting other problems, such as anxiety, dizziness, and fatigue, were of greater concern to him and his doctors. Ross thinks his coaches did a good job emphasizing head safety and checking to see whether players were alright after being hit. However, coaches often had to rely on feedback from Ross to determine whether he was okay in the rink. I wanted to compete, so I said, I m good. At one point during his senior year of high school, after sustaining two concussions in a brief period of time, his parents asked him if it was time to walk away from the sport he had played since childhood. They left the decision to me, and I kept on playing. For any parent with a child in competitive sports from dance, to swimming, to soccer, to baseball head injuries are a concern, thanks to increased awareness about the dangers of traumatic brain injuries (TBIs). If your child is engaged in high-impact sports, such as ice hockey and lacrosse, every practice and every game have a heightened sense of tension because everyone understands that concussions, even mild ones, damage the brain. Not surprisingly, the number of children playing sports, particularly football, has declined. Today, all 50 states have legislation requiring evaluation of children and adolescents prior to return to play after a sports-related TBI. Earlier this year, the Food and Drug Administration (FDA) announced approval for a blood test for concussions, called the Banyan Brain Trauma Indicator. The indicator works by measuring levels of proteins that are released from the brain into the blood following a head injury. The levels of protein can help predict whether a patient has intracranial lesions that would be visible with a computed tomography (CT) scan, with results available within a few hours. For those with mild TBIs, the device would potentially reduce the need for CT scans, thereby reducing unnecessary exposure to radiation and healthcare costs. The device was fast-tracked for approval by the FDA, based on data from a 1,947-person clinical trial funded by the U.S. Department of Defense. The military wanted a device that could be used in the field by medical personnel to determine whether someone with a head injury required a higher level of care. 1 A blood-testing option for the evaluation of mtbi not only provides healthcare professionals with a new tool but also sets the stage for a more modernized standard of care for testing of suspected cases, said FDA commissioner Scott Gottlieb. 2 Banyan Biomarkers, Inc., maker of the device, is currently working on a clinical trial for a device to evaluate injured children. Such a device would be welcomed by everyone involved in the children s and adolescent sports worlds, where players like Ross are eager to continue the game no matter what the risk. It s important to note, though, that the Brain Trauma Indicator is not a replacement for screening patients for concussions, because the absence of bleeding does not mean the patient is concussion-free. 1 Kaplan, S., Belson, K. (2018, February 14). Concussions can be detected with new blood test approved by F.D.A. New York Times. Retrieved from concussion-fda-bloodtest.html 2 FDA authorizes marketing of first blood test to aid in the evaluation of concussion in adults. (2018, February 14). Retrieved from NewsEvents/Newsroom/PressAnnouncements/ ucm htm TINNITUS TODAY WINTER

54 ADVERTISEMENT Venous Sinus Stenting for Pulsatile Tinnitus A minimally invasive treatment option that can reduce or eliminate symptoms Dr. Athos Patsalides Weill Cornell Medicine Venous sinus stenting is: Clinically tested at Weill Cornell Medicine Highly effective Most patients have: Improved quality of life Total or partial relief Quick recovery More information at: weillcornellbrainandspine.org/vss

55 SCIENCE & RESEARCH NEWS Are There Negative Effects from White Noise Sound Therapy? Summary by John A. Coverstone, AuD Sound therapy is one of the most commonly prescribed treatments for tinnitus as well as a common self-prescribed method for dealing with tinnitus. The majority of sound therapy treatments either professionally prescribed or selfincepted use white noise to mitigate the relative loudness of tinnitus. A recent article published in JAMA Otolaryngology Head & Neck Surgery calls into question the longterm effects of using white noise for tinnitus therapy. 1 The authors of this study, two of whom are on staff (one is a founder) of Posit Science, a private company offering a brain training system, performed a literature review of white noise research and effects on cognitive function, cognitive decline, and cognitive development. Based on their review, the authors assert that white noise may have negative consequences on central auditory function and brain functioning in general. They recommend that white noise should be avoided as a treatment for tinnitus. The authors cite a handful of studies showing various effects on brain function. In one study, researchers found that young rats exposed to eight weeks of continuous noise had brain processing function that was indistinguishable from brain function of normally aging rats. 2 They also found that the effects reversed when the rats were restored to a normal environment. In another study, researchers demonstrated that continuous noise exposure over an eight-week period induced plastic changes in brain function of rats of various ages. 3 A third study cited as evidence for the negative effects of low-level noise exposure studied the effects on the brains of rats of both constant noise exposure and intermittent noise exposure for 10 hours per day, which yielded similar results. 4 What all the studies cited in the article have in common is research involving rats with constant and exclusive noise exposure. This is a significant drawback to the conclusions of the paper because none of the supportive evidence was gathered in human studies. Furthermore, the rat subjects referenced in each supporting article were generally exposed to noise 24/7 (with one exception) and exposed to only noise. This is difficult to compare to the daily experiences of humans, who are typically engaged in social interaction, including listening to conversation, music, and a wide variety of sounds. These structured sounds potentially have significant positive consequences on brain function, as shown by research linking hearing loss and cognitive decline. 5 The exception to this might be individuals who are socially isolated, which has been shown to have its own negative effects, including in rodents. At this point, there is no direct evidence of deleterious cognitive effects from noise therapy used with humans. Noise exposure has been shown to have negative effects on humans in the form of annoyance, sleep disturbance, educational performance, and cardiovascular health. However, no conclusive evidence could be found for any negative cognitive effects when noise exposure is below minimum harmful levels (80 85 db sound pressure level). Readers are encouraged to maintain current regimens prescribed by their audiologist, psychologist, or physician until discussing further any possible side effects. 1 Attarha, M., Bigelow, J., & Merzenich, M. M. (2018, August 30). Unintended consequences of white noise therapy for tinnitus Otolaryngology s Cobra Effect: A review. JAMA Otolaryngology Head & Neck Surgery. Advance online publication. doi: /jamaoto Kamal, B., Holman, C., & de Villers-Sidani, E. (2013). Shaping the aging brain: Role of auditory input patterns in the emergence of auditory cortical impairments. Frontiers in Systems Neuroscience, 7, 52. doi: /fnsys Zhou, X., Panizutti, R., de Villes-Sidani, E., Madeira, C., & Merzenich, M. (2011, April 13). Natural restoration of critical period plasticity in the juvenile and adult primary auditory cortex. Journal of Neuroscience, 31(15), doi: / JNEUROSCI Zhou, X., & Merzenich, M. (2012, May 15). Environmental noise exposure degrades normal listening processes. Nature Communications, 3, 843. doi: /ncomms Lin, F. R., Yaffe, K., Xia, J., Xue, Q.-L., Harris, T. B., Purchase-Helzner, E., Simonsick, E. M. (2013). Hearing loss and cognitive decline in older adults. JAMA Internal Medicine, 173(4), TINNITUS TODAY WINTER

56 TINNITUS AND TBI RESEARCH What Audiologists and Parents Should Know About Caring for Children with TBI and Tinnitus By Dana Day, AuD The Urban Dictionary defines the phrase bell rung, a football term, as when a player undergoes such a huge blow to the head that he can hear a ringing noise in his head. 1 You might say the phrase I got my bell rung was a precursor to the 2011 class action suit filed by the NFL players that focused national attention on concussions in competitive sports. On January 7, 2017, the National Football Players Concussion Injury Litigation class action settled to the tune of $1 billion. That legal action started a conversation that led to the establishment of concussion centers and concussion policies in sports, with particular focus on football. For healthcare providers working in the area of concussion and traumatic brain injury (TBI), the conversation was welcome, although long overdue. The NFL lawsuit spoke directly to the professional athlete, specifically the professional football player; however, it is well known that concussions can happen to anyone of any age at any time. It is my belief that younger patients are being overlooked, underdiagnosed, and undertreated at an alarming rate. The consensus within the medical community is that in all cases of suspected head trauma, there needs to be rapid intervention in the form of patient assessment and implementation of concussion management protocols. Unfortunately, consensus is lacking regarding the most appropriate tests and intervention guidelines for both adult and pediatric concussed patients. Consensus regarding tinnitus intervention remains elusive as well; telling pediatric patients with TBI and tinnitus to just give it time and it will go away and that nothing can be done, so learn to live with it is inadequate at best, and more likely counterproductive to the patient s ability to cope. Recent reviews indicate that adults require 10 to 14 days to recover from a concussion; however, comparisons of high school, college, and adult athletes affirm that the time course and recovery vary substantially with respect to injury severity and age. Manzanero et al. s (2017) review indicates that although we typically use 18 years as the cutoff age to distinguish pediatric plans of action and recovery times from those of adults, disparities reported in several studies regarding recovery time and symptomatology highlight the individual differences observed across patients, regardless of age. 2 In our experience, pediatric concussions are usually treated casually, if at all, with a few days of rest in a dark room, and then back to school. This notion may be based on the observation that the adolescent brain typically recovers from a concussion within several weeks. But for those young brains that do not follow the average recovery time course, parents are left wondering why their child sleeps so much and is not as happy as he or she was before the concussion, or worse why their child has drastic mood swings. Unfortunately, parents and providers may fail to link changes in grades, activities, mood, and health over time to a concussion that occurred six weeks, six months, or a year prior. At our practice, we ve been seeing concussed patients for more than 15 years, but only recently in the past four or five years have we been receiving referrals for the testing of pediatric patients 54 TINNITUS TODAY WINTER

57 TINNITUS AND TBI RESEARCH experiencing dizziness, headaches, and tinnitus secondary to a blow to the head or whiplash. Lacking published protocols or standards of care for these patients, we developed our own extensive set of procedures and assessments to comprehensively evaluate the concussed pediatric or adolescent patient s auditory and vestibular systems. Not all patients are administered all tests; rather, clinical decisions are based on symptomatology at the time of the visit. If the patient reports no ringing or head noise, then a tinnitus evaluation of pitch matching and masking is not done. Our protocols are intended to ensure that all appropriate testing is done at the initial visit, thereby facilitating identification of appropriate interventions. For this article, our focus is our pediatric concussed population, those between the ages of 11 and 19, and findings as they relate to tinnitus. The full battery of tests is listed in Table 1. We completed a retrospective chart review of the nine pediatric patients seen at Arizona Balance & Hearing Aids (ABHA) over the past year and a half, from January 1, 2017 to June 30, 2018, for concussion or TBI diagnosis. We examined the number of patients who reported tinnitus, the onset, whether the tinnitus was constant or intermittent and whether the tinnitus had resolved by the time of their appointment. In gathering the data, we also noted the amount of time that elapsed between the injury and initial contact at ABHA. The chart review indicated: Of the nine patients seen, seven (78%) reported sudden onset tinnitus after their concussion, even before they were aware of any other symptoms, such as headache, dizziness, or fogginess. Of those seven patients, only four reported tinnitus at the time of their visit. Two patients reported no tinnitus at all, either immediately after injury or longer post injury. In three of the four who reported tinnitus at their visit, the tinnitus could be characterized via pitch matching. One reported fluctuating tinnitus that changed from no tinnitus during pitch matching in the audio booth to tinnitus during vestibular testing. Of the four who reported tinnitus, three stated their tinnitus was constant while one reported it as intermittent. Three patients reported intermittent tinnitus immediately following the concussion event that lasted anywhere from 10 to 30 minutes; however, their tinnitus subsided within a few days of their event and they had no tinnitus by the time they were seen in our office. The average time before a pediatric patient was referred to our office for testing was 49 days, with a range from 2 to 182 days postinjury. Table 1. Full Test Battery for Pediatric Patients with TBI 1. Comprehensive videonystagmography (VNG), with ocular motor testing, positional testing, bi-thermal water calorics 2. Dynamic visual acuity 3. Vestibular-evoked myogenic potential (VEMP) (ovemp and cvemp) vhit 4. Audiogram with ultra-high-frequency testing and pitch matching, tinnitus masking, if patient reports tinnitus 5. Speech in noise testing TINNITUS TODAY WINTER

58 TINNITUS AND TBI RESEARCH One patient, who reported tinnitus and who was seen in our office two days post-concussion, noted fluctuating tinnitus. Upon rising in the morning, he observed a low-pitch ringing; when he was exposed to light, his tinnitus changed to a mid-frequency (matched at 1,250 Hz). When the patient became more active or was tired he reported a very high-pitched tinnitus. (Patient was light sensitive after concussion, requiring a dark room or dark sunglasses when exposed to light.) The definition of concussion from the Centers for Disease Control and Prevention mentions that the average pediatric or adolescent brain appears to recover in several weeks. 3 Tinnitus due to a concussion or TBI in our patients resolved within 3 to14 days, suggesting that post-concussion interventions such as plenty of rest, no or low screen times, reduced school schedules, no physical exertion, clean/ healthy eating, and head pain management were contributing factors to the resolution of the reported tinnitus. In our clinic and for two of our adolescent patients with active tinnitus, an app was used to provide classical music. Patients noted the music to be therapeutic because it allowed for longer hours of continuous sleep. One patient reported a decrease in the severity of his headaches associated with the therapeutic use of music. I acknowledge that our sample size is small and that more research on the pediatric patient and concussion needs to be completed. As audiologists, we play an important role in evaluating, following, and managing pediatric concussion and TBI. In our clinic, we strive to advance independent research, education, and public awareness of TBI and tinnitus in the following ways: Educating pediatricians, urgent care physicians, emergency department doctors, coaches, and parents about the importance of following TBI protocols and allowing children to rest to facilitate recovery following head trauma. Researching and recommending the use of sound therapies intended to promote habituation or musical therapies to reduce anxiety associated with tinnitus to support symptom management. One might propose that if the patient s tinnitus resolves on its own then there is no reason to do testing within the first two to four days of injury; however, I believe that it is more important to test patients when they are symptomatic to identify therapies or strategies that can benefit these patients. My experience affirms that audiologists have a key role to play in concussion diagnoses and interventions. Audiologists should not be afraid to advocate for their patients as part of a multidisciplinary team approach in the care of pediatric patients and their families. Early testing and identification support the treatment provided by other medical professionals to the younger patient and facilitate the patient returning to pre-concussion life activities and school. Dana Day, AuD, is the founder and owner of Arizona Balance & Hearing Aids in Phoenix, Arizona. She, along with her colleagues, developed a concussion protocol for testing pediatric patients and adults. She recently added a tinnitus clinic to her practice, which offers a comprehensive management approach that includes tinnitus devices, sound therapies, Tinnitus Retraining Therapy, and hearing aids, which gives patients multiple management options. Her areas of interest are treatment of Vestibulocerebellar disorders, tinnitus stemming from concussions (TBI), tinnitus, and other auditory processing disorders. 1 Bell rung. (n.d.). Urban Dictionary. Retrieved from php?term=bell%20rung 2 Manzanero, S., Elkington, L.J., Praet, S.F., Lovell, G., Waddington, G., & Hughes, D.C. (2017) Postconcussion recovery in children and adolescents: A narrative review. Journal of Concussion, 1, Centers for Disease Control and Prevention. (2017, January 31). What is a concussion? Retrieved from whatis.html Noisy Planet Parents Lead by Example Children learn healthy behaviors by following the examples of others. Let your preteen see you protecting your hearing, and she will be more likely to protect her own. The Noisy Planet logo is a registered trademark of the U.S. Department of Health and Human Services (HHS). 56 TINNITUS TODAY WINTER

59 TINNITUS TOOLS Dana Day s Suggested Sound and Sleep Apps and Machines to Mask Tinnitus White Noise Ambience Lite ReSound Tinnitus Relief Whist Tinnitus Relief HoMedics SS-2000 Sound Spa Relaxation Sound Machine with 6 Nature Sounds available at Amazon.com, Target, and Walmart Big Red Rooster White Noise Machine available at Amazon.com The American Tinnitus Association does not endorse products for tinnitus relief. The above apps are free of charge. The sound machines have not been evaluated for their effectiveness in aiding sleep, relaxation, and habituation to tinnitus. Concussion Guidelines Issued for Children The U.S. Centers for Disease Control and Prevention (CDC) issued the first ever set of guidelines for specifically diagnosing and treating children who have sustained mild traumatic brain injuries (mtbis), or concussions. The guidelines, which were released in September, represent current best practices based on a systematic review of literature, spanning 25 years of research. The guidelines have 19 sets of recommendations on diagnosis, prognosis, and treatment of pediatric concussions, with assigned levels of obligation (must, should, or may). For more information, see: traumaticbraininjury/pediatricmtbiguideline.html TINNITUS TODAY WINTER

60 YOUR HEALTH Putting Quiet on the Menu: App Rates Restaurants, Bars, and Cafes for Sound By Joy Onozuka Finding quiet restaurants, bars, and cafes is a challenge for anyone with tinnitus, hyperacusis, and/or hearing loss. That quest has become easier even entertaining with the advent of SoundPrint, a crowdsourcing app released in April that allows you to search for and rate noise levels at restaurants, bars, and cafes across the United States. The app was created specifically to help those within the hearing loss and other sensory disorder (blind, autism) communities, said Gregory Scott Farber. He developed the app and expanded its usage after discovering widespread interest among normalhearing friends in finding venues where conversation was easy no matter what the time and day. It addresses a real problem. Venues in general have gotten too loud and this impacts people whether they have hearing loss or not, Farber said, noting that Zagat s 2018 National Dining Trends survey of 13,000 avid diners listed noise as the top complaint (24%). We knew venues were loud generally, and that having a conversation is difficult in the majority of them. But we were surprised by the high number of venues showing sound levels that actually endanger the hearing health of patrons and venue employees, he said. Sound Ranking While many people with hearing difficulties routinely measure restaurant noise with apps, such as NIOSH Sound Level Meter and Decibel X, it s an exercise that can leave one feeling like noise is a personal problem since many successful establishments are loud and proud of the bustle. When you measure sound with the SoundPrint app, the data is aggregated, giving venues a ranking once three sound readings have been submitted during peak dining hours. Venues that qualify as quiet, meaning safe for hearing and great for conversation based on a decibel reading of less than 70, are added to a quiet list. Also, the sound readings and rankings are an easy way to start a conversation about acoustics with a manager. I show the readings to venue managers and employees frequently, and more often than not, the employees are very surprised by how loud or dangerous their noise levels are, said Farber. It s easy to fool ourselves into thinking that because most places are loud, that it s normal, SoundPrint find a quiet spot Soundprint LLC NIOSH Sound Level Meter EA LAB Decibel X: db, dba Noise Meter Sound Spectrum Analyzer & FFT SkyPaw Co. Ltd 58 TINNITUS TODAY WINTER

61 YOUR HEALTH healthy, and no harm is being done. That is not the case. Noise Pollution and the Bottom Line Some restaurant owners understand that excessive noise contributes to mistakes made by servers when taking orders, stress, and reduced return visits by patrons. Noise was a huge issue when we reopened our restaurant in July 2018, said Anna da Silva, who owns and operates Pepe Giallo in New York City, with her husband, Rosso. Relocating their Italian restaurant was fraught with difficulties, resulting in delays and unexpected expenditures. When it finally opened, da Silva was stunned that the carefully crafted space had serious sound problems. Sound was bouncing off the walls. People would make a reservation, sit down, then leave because they couldn t hear, she said. It was heartbreaking. When she mentioned the problem to an architect friend, she was told acoustic ceiling tiles would help. Da Silva hired Pinta Acoustic, a company that resolves acoustical problems. Fifteen to 20 percent of our business is restaurants, said Anthony Antonelli, the company s creative director. We re in the age of the foodie, Antonelli said. Some people like it loud, and others want it comfortable. When diners are comfortable, they re more apt to have an enjoyable time. For Pepe Giallo, he created triple ellipses to complement the interior design. We added sound absorption to the space by gluing [custom] panels to the ceiling, he said. The idea was to fit out 30 to 50 percent of the ceiling to reduce sound. The lightweight material, which is similar to Mr. Clean Magic Eraser, can be cut and installed easily. I thought it was going to cost a lot of money, said da Silva, who was surprised by the reduction in noise and the quality of the design, which was created to blend with the interior. It just blew me away everyone should do it. I show the readings to venue managers and employees frequently, and more often than not, the employees are very surprised by how loud or dangerous their noise levels are. Encouraging Restaurants to Quiet Down To help restaurant owners understand the ease with which sound can be mitigated, Farber includes a page on his website devoted to the topic. He also incentivizes restaurant owners to improve sound quality by publicizing them on SoundPrint s Quiet Lists. 1 We promote quieter restaurants on our website through Quiet Lists. Once a city hits a critical number of submissions, we re able to analyze the data and create such lists, he said. Earlier this year, SoundPrint released a list of the top 29 quiet venues in New York City, reflecting data taken over a two-year betatesting period for the app. One of the restaurants that made the cut was Gabriel s Bar and Restaurant, located in Midtown. I left a restaurant in Tribeca in 1990 hyperaware of sound, said restaurant owner Gabriel Aiello. I was tired of going to bed every night with ringing in my ears. In planning his restaurant, Aiello added acoustic tiles to the ceiling and walls to absorb sound, as well as carpeting, curtains, and other features that mitigate unpleasant and irritating noise. Sound is overlooked because it s something that s not demanded by the [New York State] Department of Health. I was sick of sound, Aiello said. He said the investment paid off because he attracts a clientele that puts a premium on the ability to converse with ease. Noise Pollution Diminishes Quality of Life As an analyst and someone with hearing loss, Farber decided to use the sound-level data collected from the 2,376 restaurants and bars in New York City during the two-year beta testing for a research study. The study examined how noise pollution in restaurants and bars negatively affects quality of life, with loud noise shown as a potential danger to the hearing health of venue staff and patrons. For people with hearing difficulties, he argued, noisy venues contributed to social withdrawal, which negatively affects mental health. TINNITUS TODAY WINTER

62 YOUR HEALTH The large-scale study, which was published earlier this year in the Open Journal of Social Sciences, found: A significant number of New York City venues had sound levels that were not conducive to conversation and that could be endangering the hearing health of patrons and employees. Venue managers tended to underestimate actual sound levels of establishments, as reflected in reports found on online public business pages. Average sound levels in restaurants and bars correlated by neighborhood and type of cuisine, with Mexican restaurants being the loudest, followed by Latin, Spanish, American, Mediterranean, Italian, and French. On the quiet side were Indian restaurants, followed by Chinese and Japanese restaurants. 2 We promote quieter restaurants on our website through Quiet Lists. Farber believes increased noise pollution is creating a hearing health epidemic. Currently, many people lose their hearing in their 60s, but [I] fear given the rise in noise pollution via loud restaurants, streets, music via smartphones, the next generation may lose their hearing at younger ages, in their 40s and 50s, which are prime earning years. That will be a big loss in productivity, Farber said. Join the Survey on Sound To be a part of SoundPrint s campaign to create a soundscape of quiet restaurants, bars, and cafes across the United States, download the app, which is currently available only for iphones, and begin taking sound prints of your local establishments. You don t have to eat at the venue to record sound levels. Farber suggests telling the host that you re submitting sound levels to highlight places where it s easy to converse. 1 Other cities with Quiet Lists include Ann Arbor, Baltimore, Las Vegas, Nashville, New Orleans, Philadelphia, and the San Francisco Bay Area. Cities scheduled for release are Chicago, Denver, and Washington, D.C. 2 To read the study, see: Scott, G. (2018). An exploratory survey of sound levels in New York City restaurants and bars. Open Journal of Social Sciences, 6, doi: jss I honestly have never thought to donate for a cause until I went through this. Now I can see the need and the reasons, said Alex S., when speaking with one of the ATA s tinnitus advisors, who provide telephone guidance on how to cope with tinnitus. 60 TINNITUS TODAY WINTER

63 PERSONAL STORY Tinnitus Enters the Quiet Sanctuary of the Library By Glenn Masuchika I ve been an academic librarian with Pennsylvania State University Libraries for decades. While libraries have evolved into data centers, reflecting rapid advances in technology and how information is accessed, the library remains a sanctuary for silent study and contemplation. For years, I have worked and thrived in this quiet environment. However, on a Sunday night in late 2014, a loud sizzling sound suddenly erupted. At first, I thought the sound was coming from the television but then realized it was in my head. It persisted into the evening and followed me into my library office the next morning. What puzzled me was how the sound changed over time. Sometimes it was a loud tea kettle whistle, which would wake me abruptly with a jolt. Sometimes the sound resembled the chugging of a steam locomotive barreling through my head. I understood immediately that I was in trouble and sought medical help. I explained to the Ear, Nose and Throat (ENT) doctor that the sound began suddenly, I had no history of neck or head injuries, and I hadn t been exposed to loud noise. The ENT performed a cursory exam and gave me a clean bill of health. Nonetheless, I was overwhelmed by the noises and desperate for some type of relief from the doctor. Instead, I heard the one dreaded sentence that all those with tinnitus loathe: You have to get used to it. Making matters worse was the heartless comment, I ll show you where to pay your bill. I left the office and sat in my car, contemplating the quickest way to end my life. Over the next few months, I visited otolaryngologists at Johns Hopkins Hospital and the Cleveland Clinic. Although the medical staff were knowledgeable and understanding, they couldn t offer me any medical, surgical, or pharmacological relief. After my hospital visits, I began experimenting with different tinnitus management techniques, thinking I could find some type of solution. I tried yoga and meditation, with little effect. My dentist reassured me that I didn t have temporomandibular joint (TMJ) dysfunction, which sometimes causes tinnitus. I visited chiropractors and physical therapists to no avail. All the while, my tinnitus was like an ominous shadow growing larger and larger. A major breakthrough happened when I discovered I could mask the highs and lows of the changing noise with various mobile apps downloaded to my smartphone. TINNITUS TODAY WINTER

64 PERSONAL STORY Tinnitus was negatively affecting all aspects of my life, particularly my work as an academic librarian. One of my duties that I particularly enjoyed was working one-on-one with students and scholars, helping them with informational needs. With my tinnitus, however, the sound and intensity were so erratic that I could barely help anyone. A major portion of my job description was teaching classes to undergraduate students on how to find information. On days when my tinnitus was severe, teaching was extremely difficult, especially managing the classes, answering questions, and taking a leading role in important conversations. It was hard to participate in online meetings with other library faculty because their voices were reduced to mangled, electronic screeches. My sense of frustration and helplessness was compounded when my tinnitus flared up while I was giving a presentation to the entire faculty of librarians at the academic library where I work. In midsentence, the volume increased so loud that I couldn t hear myself speak. I stood there feeling humiliated, not knowing if I was being understood by my peers or being heard as a babbling child. I seriously considered resigning, but I was fearful that leaving my job would only deepen my problems since tinnitus would fill my every waking moment. I decided to increase, not decrease, my professional tasks to keep myself distracted from the sounds. I had to constantly remind myself that my worth was not dependent on my inability to perform tasks I had previously done well; but, to persevere at my work to the best of my abilities. To maintain my determination, I had to find ways that would soften my noisy world. I had tried many techniques over the months but nothing was sufficient. A major breakthrough happened when I discovered I could mask the highs and lows of the changing noise with various mobile apps downloaded to my smartphone. Using earphones, I played the sound of waterfalls, rain, crackling fire, wind, and even white noise to mitigate the distressing sounds and, to a certain extent, lessen their dominance over me. At night, I slept with white noise turned up in the background. Relax Melodies: Sleep Sounds White Noise, Calm & Meditation Ipnos Software Inc. When my tinnitus was less intrusive, I made the most of that quieter time to work, talk with students and colleagues, and plan my projects. My greatest concern was that my tinnitus would prevent me from teaching my undergraduate classes. To get a handle on that, I restructured my teaching to limit my lecturing time and include more group work among students. As they talked with each other, I could adjust myself. Sometimes it s as simple as finding the right place to stand in a room, with my back to a hard wall, to catch the echoes of their voices as they speak. One of the most important things I learned was that tinnitus was not It took a long time for me not to feel less of a person or inferior because of the roaring noise between my ears. a condition I had to be ashamed of. It took a long time for me not to feel less of a person or inferior because of the roaring noise between my ears. My tinnitus was so present in my life that I couldn t conceal it. I informed my supervisor and colleagues about my situation, and was surprised by how supportive many of them were and their willingness to accommodate my limitations because of the tinnitus. Tinnitus has caused me much pain and suffering, and I would give anything to be rid of the constant thrumming, hissing, and squealing in my head. However, having tinnitus gave me a chance to reevaluate my professional life. Without the added barriers, I would not have developed the deeper appreciation I have of myself and the reassurance of my worth as an academic librarian. In that sense, when I decided to work with my disability, I proved to myself that my worth as an academic librarian could not be diminished by tinnitus. Glenn Masuchika 62 TINNITUS TODAY WINTER

65 PERSONAL STORY Why I m Leaving a Legacy to the American Tinnitus Association By Gary Reul In 1994, my wife and I were enjoying another warm day traveling through the Everglades when I spotted a sign that read AIR BOAT RIDES. I had seen these boats in movies, skimming across the water off into the sunset or some new adventure. We bought tickets for what we thought would be a pleasant ride, and, as we watched a craft pull into the dock making very little noise, I never imagined what we were about to encounter. We boarded the boat last, so we had to sit in front of the 350-horsepower engine that propels the enormous fan blades. The ride started slowly and somewhat quietly, but when the boat driver hit the gas, we went roaring literally through the tall grasses. We later found out the engine, which was right behind our heads, was producing 110 continuous decibels, which damage hearing after just one minute. Our ride lasted 30 minutes. As I got off the boat, I heard loud noise in my head, even though the engine had returned to a low hum. It didn t go away, and later I learned I had developed hyperacusis, which is sensitivity to sound that doesn t bother someone with normal hearing, in addition to tinnitus. Once home, I followed the usual pattern of doctor s appointments for those struggling with tinnitus, starting with my family physician, then audiologist, otolaryngologist, and neurologist. Each said, Go home and learn to live with it. One physician mentioned that he had heard of a psychiatrist who had done research on tinnitus at a local university pain clinic. I met briefly with that research physician, who prescribed the antidepressant Paxil (paroxetine hydrochloride), because it had helped other tinnitus patients. It took about two weeks to take effect, and, although it did not relieve the sound, it allowed me to function with my tinnitus. At the time, I was a school district administrator and had to attend and It is fitting that an organization that has helped me, my family, and thousands of others should be remembered in a legacy gift, no matter how large or small. TINNITUS TODAY WINTER

66 PERSONAL STORY facilitate many daily meetings, which put a real strain on me. Before each meeting, I d explain to the group that I had tinnitus and hyperacusis, adding a brief explanation of what those conditions were and the need for a quiet environment. One day, another administrator stopped by my office to share that he also had tinnitus and had joined the American Tinnitus Association, which offered useful information about the condition. That was when my long journey with the American Tinnitus Association began. After joining in the 1990s, I discovered the ATA committees, so I applied to join one. After two years of committee work, I was asked to join the ATA board of directors, and a year after joining the board, I was elected vice chair for a two-year term. As my term was coming to an end, the ATA executive director (ED) resigned unexpectedly, creating an immediate need for a temporary replacement. I agreed to that role for a year, which gave the board enough time to find a qualified candidate. I moved to Portland, where the ATA headquarters was until 2017 and served as ED for one year and one day. Interacting with fellow patients with tinnitus all over the country was a rewarding experience. When we found our next ED, I returned to the board as chair for a two-year term. My journey with the ATA continues. I m the current ATA board treasurer and spend several hours a week fulfilling this duty. My tinnitus has not subsided. In fact, it has grown worse over the years. The severity of my hyperacusis has essentially made me a recluse in my home. My wife, daughter, and granddaughter have had to live with my many ups and downs over the years, and I appreciate greatly the sacrifices they have made to accommodate me over the past 24 years since that fateful 30-minute boat ride through the Everglades. At the age of 80, though I now have a few other health issues besides tinnitus and hyperacusis, my wife and I wish to continue supporting the ATA, so we listed it as a beneficiary in our wills. It is fitting that an organization that has helped me, my family, and thousands of others should be remembered in a legacy gift, no matter how large or small. I know through my many years of leadership in the ATA that each time we are remembered in someone s will, we are humbled and emboldened to continue our mission to serve the tinnitus community. Importantly, the ATA is funded entirely through individual donations, so as you continue your journey living with tinnitus, I hope you, too, will consider making ongoing contributions to the ATA and a gift in your will that will help us carry on the valuable work this organization does on behalf of patients, healthcare providers, and researchers. Gary Reul, EdD, was an educator for 48 years, working in various positions, including junior and high school teacher, university professor, counselor, principal, and school superintendent in Issaquah, Washington, where he is currently retired. Dr. Reul is current treasurer of the ATA board of directors. Ring in the New Year and Avoid Ringing in Your Ears Use Hearing Protectors The Noisy Planet logo is a registered trademark of the U.S. Department of Health and Human Services (HHS). 64 TINNITUS TODAY WINTER

67 TINNITUSTODAY Editorial Calendar Tinnitus Today magazine is a print and electronic media magazine published in April, August, and December, and circulated to 65,000+ ATA contributors, donors, patients, supporters, researchers, and healthcare professionals. The magazine editorial team empowers readers with information, including up-to-date medical and research news, feature articles on urgent tinnitus issues, questions and answers, self-help suggestions, and letters to the editor from others with tinnitus. Strong service journalism, compelling storytelling, first-person narrative, and profiles are presented in a warm, vibrant, and inviting format to encourage readers to reflect, engage, and better understand a medical condition that affects millions. Issue Theme Editorial Copy Due Photos Due Ad Close Digital Launch Issue Mailed Spring Apr 2019 Sound Therapy: Research & Evidence Hearing Aids 2/1 2/1 2/1 4/15 April Summer Aug 2019 Living with Sound Cultivating Your Own Safe Hearing Space 5/1 5/1 5/1 7/15 August Winter Dec 2019 Annual Research Issue 10/1 10/1 10/1 12/1 December Editorial Calendar is subject to change. To advertise, contact: tinnitus@ata.org MISSION AND CORE PURPOSE The mission and core purpose of the ATA are to promote relief, help prevent, and find cures for tinnitus evidenced by its core values of compassion, credibility, and responsibility. CORE VALUES AND GUIDING PRINCIPLES Compassion: Evidenced in a spirit of hope reflected in the commitment to finding a cure, preventing the condition, and supporting those affected by the condition. Credibility: Evidenced in accurate information from reliable sources, transparency in decisionmaking, and an earned reputation for trustworthiness. Responsibility: Evidenced in patient-centered advocacy by a collaborative community of forward thinking leaders accountable to its mission and members.

68 DEPT WASHINGTON, DC Open Access ATA s Conversations in Tinnitus, with John A. Coverstone, AuD, and Dean Flyger, AuD Tune Into Conversations in Tinnitus to Stay Abreast of Tinnitus Research and News The American Tinnitus Association s podcasts are available 24/7 to help you stay abreast of tinnitus research and other tinnitus topics. Just like listening to music on your smartphone or computer, you can tune in to Conversations in Tinnitus podcasts, cohosted by John A. Coverstone, AuD, and Dean Flyger, AuD, while you work out, take a walk, relax at home, or commute to work. To access and learn more about this unique and compelling series, visit our website at To enhance listening comprehension and accommodate those with noise sensitivity, transcripts are available with each podcast. OPEN TO THE PUBLIC Podcast 10: Habituation to Tinnitus Using Cognitive Behavioral Therapy SUBJECT MATTER EXPERT: Bruce Hubbard, PhD TOPIC: For over 20 years, Dr. Hubbard has helped people improve their lives using cognitive behavioral therapy (CBT), mindfulness, and relational therapy strategies. He explains how CBT and mindfulness are applied to treatment of tinnitus and what patients should expect in regard to habituation. Dr. Hubbard, who has tinnitus, also offers insights into using the internet and support systems to manage tinnitus distress. Podcast 11: Research on Mindfulness-Based Cognitive Therapy for Tinnitus Treatment SUBJECT MATTER EXPERT: Laurence McKenna, PhD TOPIC: Dr. McKenna discusses recent research findings from his largescale study on the effectiveness of Mindfulness-Based Cognitive Behavioral Therapy (MBCT) for treating tinnitus. As a cognitive behavioral therapist, specializing in the psychological aspects of tinnitus and hearing loss, he offers unique insights into the challenges that patients face and best practices for treatment. He also elaborates on why he s pushed for greater usage of MBCT for tinnitus treatment in recent years. Podcast 12: Talking About Tinnitus with Children SUBJECT MATTER EXPERTS: David Baguley, PhD, and Claire Benton, MSc TOPIC: Dr. Baguley and Claire Benton discuss their efforts to educate parents, teachers, and healthcare providers on talking to children about tinnitus. The widespread misconception that children don t have tinnitus has meant children suffer alone and miss critical opportunities for early intervention. They also discuss their research findings on the topic and tools to help children manage tinnitus. Podcast 13: Interdisciplinary Approach to Tinnitus Treatment SUBJECT MATTER EXPERTS: Tara Zaugg, AuD, and Caroline Schmidt, PhD TOPIC: Drs. Zaugg and Schmidt discuss the benefits of providing integrated services to people with bothersome tinnitus. They elaborate on their extensive clinical and research experience working with veterans and service members struggling to cope with hearing loss, traumatic brain injury, post-traumatic stress disorder, and tinnitus. They concurrently address audiological issues, such as hearing loss and sound therapy, and provide mental health services, such as cognitive behavioral therapy (CBT), to increase positive outcomes that improve quality of life. To subscribe to the print and digital issues of Tinnitus Today, which is published three times a year, visit or tinnitus@ata.org The digital issue of Tinnitus Today is available as an open resource to individuals who make an online donation of an amount of their choice. To activate your one-year subscription, go to and click donate on the home page. Customized donation amounts can be made under other.