Client centred sound therapy selection: Tinnitus assessment into practice. G D Searchfield

Client centred sound therapy selection: Tinnitus assessment into practice G D Searchfield

Definitions Sound (or Acoustic) therapy is a generic term used to describe the use of sound to have a postive effect on tinnitus, either to directly or indirectly reduce tinnitus perception and negative effects on quality of life. Sound therapy can be implemented through many devices Hearing aids Sound generators Combination instruments Music players Computers Portable stimulators Clarence_H._White (1871-1925)-Drops of rain (1903)

Speech sounds Music/Fractals Counseling & Devices Soundscape Therapuetic Noise

Adaptation Level Theory Residual Cognition Memory Prediction Arousal Personality Feature Analysis Feature Detection Sensory output Tinnitus Attention Orientation Feature Analysis Feature Detection Sensory output Sound Exposure to & meaning/context of an external sound can change tinnitus perception and affect

ALT: perceptual relativity

ALT a simple analogy What is a BIG car? Our perception of tinnitus depends on the normal level of sound we are exposed to and memories of what silence should be like.

Adaptation Level Theory Feature Analysis Feature Detection Sensory output Tinnitus Residual Cognition Memory Prediction Arousal Personality Attention Orientation Feature Analysis Feature Detection Sensory output Sound AL=X p B q R r Helson (1964) AL is the adaptation level, X is the geometric mean of the focal stimuli (tinnitus), B is the therapeutic, R are residuals (e.g. memory, arousal, and personality). The weighting coefficients p, q, and r determine the relative contributions to adaptation level and are related to attention and ASA.

Ecological view Psychosocial factors Customs Relationships Beliefs Time of day Stimulants Environment Residual Cognition Memory Prediction Arousal Personality Social venue Work Values Exercise Home Feature Analysis Attention Feature Analysis Feature Detection Sensory output Tinnitus Orientation Feature Detection Sensory output Sound Psychophysical factors

Making decisions on therapy direction

Client/person centered "Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions." IOM (Institute of Medicine) Skills Personality Beliefs Whole-person care. Coordination and communication Patient support and empowerment Ready access Family Goals Environment

Assessment Person Management Axis I Psychological Questionnaires Case History Axis II Audiological Audiometry Axis III Psychophysical Tinnitus pitch, loudness, location COSI-T Axis I Counseling to Psychological referral Axis II Communication training to Hearing aids/cochlear implants Axis III Avoid silence to Sound therapy

Tinnitus needs assessment Modification of: Dillon H, James A and Ginis J (1997). The Client Oriented Scale of Improvement (COSI) and its relationship to several other measures of benefit and satisfaction provided by hearing aids. Journal of the American Academy of Audiology, 8:27-43.

TALT 3 components Stage 1. Counseling Stage 2. Sound therapy magnitude modification and relief Stage 3 Adaptation (the result of stage 1 & 2)

ALT counselling - AREA Identification & categorization (What is it?) Unexplained self relevant events (Don t understand it) Explained or not self relevant events (Understand it) ATTEND REACT EXPLAIN Sound therapy ADAPT No further processing, lowered access to event, weak affective reaction Counseling (Based on Wilson & Gilbert, 2008. Explaining away: A model of Affective Adaptation)

Sound therapy tool selection 1. Hearing aids

Hearing aids Psychosocial factors Customs Relationships Beliefs Time of day Stimulants Environment Residual Cognition Memory Prediction Arousal Personality Social venue Work Values Exercise Home Feature Analysis Attention Feature Analysis Feature Detection Sensory output Tinnitus Orientation Feature Detection Sensory output Sound Psychophysical factors

Hearing aids Psychosocial factors Physical Relationships Customs Relationships Quality of Life Beliefs Time of day Stimulants Exercise Environment Residual Cognition Memory Prediction Arousal Personality Values Environment Psychological Social venue Work Home Feature Analysis Attention Feature Analysis Feature Detection Sensory output Tinnitus Orientation Feature Detection Sensory output Sound Psychophysical factors

Hearing aids Psychosocial factors Physical Relationships Customs Relationships Quality of Life Beliefs Time of day Stimulants Exercise Environment Residual Cognition Memory Prediction Arousal Personality Values Environment Psychological Social venue Work Home Feature Analysis Attention Feature Analysis Feature Detection Orientation Feature Detection Distraction Masking Sensory output Tinnitus Sensory output Sound Perception Psychophysical factors Magnitude Adaptation

To achieve this interference NR-off Expansion-off low compression kneepoint high compression ratio Prescription that is audibility based (e.g DSL)

Frequency specific masking Frequency Tinnitus Feldman (1971), Tyler and Conrad-Armes (1984)

Background noise Frequency Tinnitus

Amplification of Background noise Frequency Tinnitus

Change in Factor 1 Score Change in Factor 2 Score Treatment effects no counseling 15 5-5 -15-25 TFI-Overall -35 Baseline Fitting 3rd Mt Fu 6th Mt Fu 5 THQ (Factor 1) 5 THQ (Factor 2) 0 0-5 -5-10 -10-15 -15-20 -20-25 Baseline Fitting 3 Mt Fu 6 Mt Fu -25 Baseline Fitting 3 Mt Fu 6 Mt Fu Shekhawat G, Searchfield GD, Stinear C. 20 Participants

Change in THQ Score Treatment effects compared to counseling 30 Hearing 25 20 15 10 5 0 Factor 1 Factor 2 Factor 3 Total Tinnitus Handicap Questionnaire Searchfield GD, Kaur M, Martin WH. (2010) Int J Audiol.49(8):574-9. 58 participants 2 groups

Change in THQ Score Treatment effects compared to counseling 30 25 20 15 10 5 0 Social and emotional effects Factor 1 Factor 2 Factor 3 Total Tinnitus Handicap Questionnaire Searchfield GD, Kaur M, Martin WH. (2010) Int J Audiol.49(8):574-9. 58 participants 2 groups

Frequency Tinnitus Tinnitus

TRQ score Masking effects 70 60 50 40 30 20 10 0 No Masking Partial Masking Total Masking TRQ pre Hearing aid fitting TRQ Post McNeill C, Távora-Vieira D, Alnafjan F, Searchfield GD, Welch D. (2012) Int J Audiol. 51(12):914-9. 70 Participants

Hearing Threshold Level (db HL) Masking effects Frequency (Hz) 100 1000 10000 0 10 20 30 40 50 60 70 80 No Masking Partial Masking Total Masking 90 McNeill C, Távora-Vieira D, Alnafjan F, Searchfield GD, Welch D. (2012) Int J Audiol. 51(12):914-9. 70 Participants

Sound therapy tool selection 2. Combination aids

Combination Frequency Tinnitus Tinnitus

Adaptation? 10 8 6 4 2 0 Intensity Annoyance Life effects Before After 3 months After 6 months Rating scale 80 70 60 50 40 30 20 10 0 before after 3 months THI after 6 months Del Bo L, Berto V, Carrabba L, Costantini M, Forti S, Kaur M, Kobayashi, K, Paglialonga A, Searchfield GD, Wise K, Dyrlund, O 30 participants

Combination aids Psychosocial factors Physical Relationships Customs Relationships Quality of Life Beliefs Time of day Stimulants Exercise Environment Residual Cognition Memory Prediction Arousal Personality Values Environment Psychological Social venue Work Home Feature Analysis Attention Feature Analysis Feature Detection Orientation Feature Detection Distraction Masking Sensory output Tinnitus Sensory output Sound Perception Psychophysical factors Magnitude Adaptation

Combination aids Psychosocial factors Customs Relationships Beliefs Time of day Stimulants Environment Residual Cognition Memory Prediction Arousal Personality Social venue Work Values Exercise Home Feature Analysis Attention Feature Analysis Feature Detection Sensory output Tinnitus Orientation Feature Detection Sensory output Sound Psychophysical factors

Sound therapy tool selection 3. Sound generators

Frequency Tinnitus

130 120 110 100 90 80 70 dbspl 60 50 40 30 20 10 prog1(tsg -6dB) Prog2(TSG -40dB) 0 10 100 1000 10000

Tinnitus arousal [annoyance scale (0-10)] Annoyance & Audibility 10 Annoyance (N=16) 9 8 Tinnitus magnitude Tinnitus annoyance Noise annoyance 7 6 5 4 3 2 1 0 Mixing Point MML 0 10 20 30 40 50 60 70 80 90 100 MML Noise level (%)

Summary

Sound therapy selection based on audiogram ENT & Audiology News

Sound generators Hearing aids Combination aids Informal (MP3) Ear-level High frequency Desktop Normal low freq hearing - Mild High freg HL, Low-mid freq tinnitus NR-off, low kneepoint, high compression ratio, DSL prescription Mild-moderate HL Set at Comfort point (& individual preference) Transition higher levels lower levels of therapeutic sound over time Cochlear implants/cros/baha Hearing loss

Pathway Referral Self assessment Audiometry (30 mins) ORL Neurology Discharge Tinnitus Assessment & counselling (90 mins) Musculoskeletal Psychology Discharge Device fitting (60 mins) Ongoing counseling (60-180 mins over 12 months)

Summary Focus on the individual 3 axis for simplicity (Psychological, Audiological, Psychophysical) Hearing loss a strong factor in device selection Selection of sound level is complicated and must consider the person, their tinnitus, and their response to sounds Many opportunities to improve sound therapies and take novel approaches Be pragmatic not dogmatic

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