(PTM) Progressive Tinnitus Management (PTM) Overview and Resources

(PTM) Overview and Resources Progressive Tinnitus Management (PTM) Overview and Resources Paula Myers, PhD CCC A Chief, Audiology Section James A. Haley VA Hospital, Tampa, FL James Henry PhD, Tara Zaugg AuD, Caroline Schmidt PhD ASHA November 22, 2014

Disclaimer The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the US Government. This presentation does not endorse any particular manufacturer or product. There are no financial disclosures.

PTM Developers: Jim Henry PhD Tara Zaugg, AuD Paula Myers, PhD Caroline Kendall Schmidt PhD

Acknowledgments Robert Baldwin, PhD Samantha Boris, PhD, MPH Stephen Fausti, PhD Gino Galvez, PhD Johnna Gonzalez, MS Susan Griest, MPH Christine Kaelin, MBA Lynn Kitagawa, MFA Marjorie Leek, PhD Marcia Legro, PhD Dan McDermott, MS Michael Moody Sara Ruth Oliver, AuD Cheri Ribbe, AuD Martin Schechter, PhD Barbara Stewart, PhD Emily Thielman, MS Janet Wood Lucille Beck, PhD Kyle Dennis, PhD VA RR&D and others

Agenda Overview of PTM PTM Resources

Magnitude Of the Problem Tinnitus

What Do We See in VA Audiology Clinics? Increased Claims for Tinnitus and Hearing Loss Disability American Tinnitus Association Help us PREVENT it!

Tinnitus is #1 unfortunately Tinnitus was the most prevalent service connected (SC) disability for Veterans receiving compensation at the end of Fiscal Year 2013 (1,121,709 Veterans SC for tinnitus). Tinnitus was also the most prevalent SC disability for Veterans who began receiving compensation during FY13 (135,229). Source: FY13 Annual Benefits Report

1,000 900 Number of Veterans (thousands) 800 700 600 500 400 300 200 100 0 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 Year

JAHVA Forum 2006 Year in Review 33 yo Marine vividly recalls the incident that took both his legs while on combat patrol led by members of the Iraqi Army. It was surreal. The blast was so loud I couldn t hear anything except for the ringing in my ears. My legs were literally blown off below my knee-i saw them lying on the road about 30 feet away from me.

War Vets: Heroes and Hearing 7/4/2008 HealthyHearing Former Staff Sgt. Ryan Kelly, 27, still carries the sounds of war with him even four years after his return home. He experienced the concussive force of three IEDs exploding simultaneously in Baghdad. It s funny, you know. When it happened, Kelly explained, I didn t feel my leg gone. [Kelly lost his leg below the knee] What I remember is my ears ringing. Today, Staff Sgt. Kelly wears a prosthetic leg, but the ringing in his ears [tinnitus] is still present.

War Vets: Heroes and Hearing (con t) 7/4/2008 www.healthyhearing.com It is constantly there, Sgt. Kelly said. It constantly reminds me of getting hit. I don t want to sit here and think about getting blown up all the time but that s what it does. It is a condition that has no cure or even many treatment options. Distraction techniques help those with tinnitus hear through the ringing in the ears, but the effectiveness of this therapy has yet to be confirmed sufficiently.

What Can be Done About Tinnitus? Tinnitus itself is not the problem reactions to tinnitus are the problem Patients can be helped if they learn to manage their reactions to tinnitus

How Can Patients Learn How to Manage Their Reactions to Tinnitus? Bottom line: They need to learn how to regulate their stress and emotions by: Using sound Using relaxation techniques Using distraction strategies Changing negative thoughts All of this requires education leading to skill building

Which Method is the Most Effective? No evidence proving any one method is more effective than any other Much more research is needed to determine which specific components of intervention are most effective In the meantime, use a method that involves education, therapeutic sound, and behavioral and cognitive based coping skill techniques

Research Leading to PTM

Overall Purpose of Research Develop methods of tinnitus management for Veterans that are effective, efficient, and implementable at VA hospitals 153 VA hospitals 773 VA outpatient clinics

Controlled Clinical Studies VA RR&D Comparison of masking and TRT (n=126) Group education using TRT counseling (n=269) Multi site study to compare masking, TRT, and tinnitus education (n=149) Development of PTM (n=221) Adaptation of PTM for telephone based counseling of TBI patients (n=36) Pilot Study of CBT for Tinnitus (n=33)

Three New Studies Wrapping Up... Multi site controlled study of PTM Memphis VA Medical Center VA Connecticut Healthcare System (West Haven, CT) Telephone tinnitus education for patients with TBI nationwide study Clinical trial of transcranial magnetic stimulation (TMS) for relief of tinnitus

Who Have We Learned From? Total of 834+ research participants in six studies all Veterans Thousands of candidates screened Participants must have a tinnitus problem warranting the intervention Hundreds of participants in three new studies wrapping up we continue to learn

Development of PTM Research data supporting PTM come primarily from these trials, but also from numerous studies that have documented the effectiveness of using therapeutic sound in different ways & cognitive behavioral therapy/coping techniques for tinnitus management. http://otosage.pub.com/content/151/2_suppl/s1.full.pdf AAO HNS Tinnitus Clinical Practice Guideline (2014) http://www.cochrane.org/cochrane reviewshttp://www.cochrane.org/cochrane reviews Cochrane Review (2010) http://www.ncbi.nlm.nih.gov/pubmedhealth/pmh0060209/ AHRQ Comparative Effectiveness Review (2013) Effectiveness Review of tinnitus ://www.cochrane.org/cochrane reviews Review 2010) ww.cochrane.org reviews (Cochrane Review 2010)

13 Principles of Tinnitus Management Learned from This Research Led to the Development of PTM...

1. Clinical services for tinnitus should be progressive 10 15% of all adults experience chronic tinnitus Tinnitus is clinically significant for only about 20% of those who experience tinnitus

Henry JA, Zaugg TL, Myers P, Schechter MA (2008). Progressive Audiologic Tinnitus Management. The Asha Leader.

2. Use an interdisciplinary team approach Refer as appropriate Medical examination (otolaryngologist, otologist, neurotologist) Mental health screening Other disciplines Mental health services should be provided routinely for patients with clinically significant tinnitus

3. Clinicians need training in tinnitus management Standardized guidelines for tinnitus management do not exist Most graduate programs do not provide adequate training The result: tinnitus services are random and generally insufficient Henry, JA, Zaugg, TL, Myers, PJ, Kendall, CJ. (2010). Progressive Tinnitus Management: Counseling Guide. San Diego: Plural Publishing. Henry, JA, Zaugg, TL, Myers, PJ, Kendall, CJ. (2010). Progressive Tinnitus Management: How to Manage Your Tinnitus: A Step-by-Step Workbook. San Diego: Plural Publishing Henry, JA, Zaugg, TL, Myers, PJ, Kendall, CJ. (2010). Progressive Tinnitus Management: Clinical Handbook for Audiologists. San Diego: Plural Publishing.

Online Tinnitus Training Course First 12 modules specific to PTM Completed & online for VA clinicians Additional modules (13 19) Covers various aspects of tinnitus management to supplement PTM for VA clinicians Training for psychologists in development Online modules are in process of being shared with DoD and ATA Myers PJ, Twitchell DG, Henry JA, Bennett RL, Schmidt CJ. (2012). Progressive Tinnitus Management Training: A development model for constant currency in a field of flux. Paper Abstract No 12169 Page 1-10. Industry Training, Simulation and Education Conference (I/ITSEC) 2012.

PTM Materials in Development for Psychologists Clinical Handbook for Clinicians Counseling Guide for Clinicians Power Point Presentations DVDs Online Training

PTM Books 1. Progressive Tinnitus Management: Clinical Handbook for Audiologists 2. How to Manage Your Tinnitus: A Step by Step Workbook 3. Progressive Tinnitus Management: Counseling Guide

Progressive Tinnitus Management: Clinical Handbook for Audiologists Includes forms, questionnaires, handouts, & clinical guidelines Videos of two Level 3 workshops by audiologists (to be viewed by groups) Videos demonstrating deep breathing & imagery techniques CD containing PowerPoint presentations for Level 3 workshops by audiologists Henry, JA, Zaugg, TL, Myers, PJ, Kendall, CJ. (2010). Progressive Tinnitus Management: Clinical Handbook for Audiologists. San Diego: Plural Publishing.

How to Manage Your Tinnitus: A Step by Step Workbook Workbook for patients self help guide Corresponds with Level 3 workshops by audiologists & psychologists Videos of two Level 3 workshops by audiologists (to be viewed by individuals) Videos demonstrating deep breathing & imagery techniques 75 minute CD describing & demonstrating therapeutic sound Henry, JA, Zaugg, TL, Myers, PJ, Kendall, CJ. (2010). Progressive Tinnitus Management: How to Manage Your Tinnitus: A Step-by-Step Workbook. San Diego: Plural Publishing

Progressive Tinnitus Management: Counseling Guide Intended for one on one counseling by audiologists Corresponds with Level 3 workshops by audiologists Special section for hyperacusis counseling 75 minute CD describing and demonstrating therapeutic sound Henry, JA, Zaugg, TL, Myers, PJ, Kendall, CJ. (2010). Progressive Tinnitus Management: Counseling Guide. San Diego: Plural Publishing.

4. All patients reporting tinnitus need an audiologic evaluation Over 90% have hearing loss Essential to evaluate auditory function Patients may need hearing aids Hearing aids can be effective for tinnitus Hearing evaluation and hearing aids help many patients who complain of tinnitus Henry, J.A., Zaugg, T.L., Myers, P.J., & Schechter, M.A. (2008). The role of audiologic evaluation in Progressive Audiologic Tinnitus Management. Trends in Amplification. 12(3): 170-187.

5. Determine if the problem is clinically significant Does tinnitus disrupt at least one important life activity and/or cause emotional reactions, resulting in a noticeable reduction in quality of life? Decision for patient: Would the benefit from intervention outweigh the cost and effort (i.e., would the effort would be worth it )?

6. Questionnaires are the best way to determine tinnitus severity Using the right combination of questionnaires is critical to properly interpret responses The same combination should be used to assess outcomes of intervention Meikle MB, Henry JA, Griest SE, Stewart BJ, Abrams HB, McArdle R, Myers PJ, Newman CW, Sandridge S, Turk DC, Folmer RL, Frederick EJ, House JW, Jacobson GP, Kinney SE, Martin WH, Nagler SM, Reich GE, Searchfield G, Sweetow R, Vernon JA. (2012). The Tinnitus Functional Index: A new clinical measure for chronic, intrusive tinnitus. Ear & Hearing Mar-Apr;32(2):153-76

7. Is it really a tinnitus problem? Many patients blame tinnitus for hearing problems Responses on tinnitus questionnaires can be inflated accordingly Assessment needs to differentiate tinnitus problems from hearing problems

8. Intervention should start with patient education Education empowers patients Enables them to make informed decisions about different forms of therapy Requires a structured program of patient education with clear objectives Henry JA, Zaugg TL, Myers PJ, Kendall CJ, & Turbin, MB. (2009). Principles and application of educational counseling used in progressive audiologic tinnitus management. Noise and Health, 11(42), 33-48.

9. Address the problem of low health literacy Nearly one third of Englishspeaking adults in U.S. have low health literacy Suffer reduced health outcomes overall Make sure all spoken and written health information is easily understood by patients http://www.ahrq.gov/qual/literacy/healthliteracytoolkit.pdf

10. Patients are best served if they learn self efficacy skills Most patients will have tinnitus for a lifetime Sound of tinnitus is not the problem reactions to the sound are the problem Patients need to learn self management skills to manage reactions to tinnitus Henry JA, Zaugg TL, Myers PJ, Kendall CJ, & Turbin, MB. (2009). Principles and application of educational counseling used in progressive audiologic tinnitus management. Noise and Health, 11(42), 33-48.

11. Patients should learn different methods of using therapeutic sound There are many ways to use sound Each method helps some patients no one method is proven superior Patients should be educated about the different ways sound can be used to selfmanage reactions to tinnitus Henry, J.A., Zaugg, T.L., Myers, P.J., & Schechter, M.A. (2008). Using therapeutic sound with Progressive Audiologic Tinnitus Management. Trends in Amplification. 12(3): 188-209.

12. Patients should learn psychological coping techniques Cognitive behavioral therapy (CBT) is the leading psychological method of tinnitus management All patients with clinically bothersome tinnitus should learn basic CBT based coping skills

13. Patient education can be provided effectively by telephone/telehealth Audiologists and psychologists can provide effective telephone based/telehealth tinnitus education Reduces travel burden on patients while still meeting their needs Efficient method of intervention Henry JA, Zaugg TL, Myers PJ, Kendall CJ, Kaelin C, Thielman E, Griest S, Legro M, Storzbach D, McMillan G, Carlson K. Pilot study to develop telehealth tinnitus management for persons with and without traumatic brain injury. Journal of Rehabilitation Research and Development 49(7):1025-1042, 2012.

Progressive Tinnitus Management: Progressive Education for Your Patient

Progressive Tinnitus Management: Progressive Education for the Patient Start with brochure

Progressive Tinnitus Management: Progressive Education for the Patient Entertaining 17 minute DVD Ringing in the Ears: What Can I do About It?

Progressive Tinnitus Management: Progressive Education for the Patient Further Progressive Educational Options at Audiological Evaluation (Level 2): Invite to Attend Skill Education Workshops (Level 3) if bothersome tinnitus is reported Provide Self Management Workbook

Overview of PTM

Five Hierarchical Levels of Clinical Services with PTM

Level 1 Triage Referring patients at initial point of contact

Triaging Patients Who Complain of Tinnitus At the triage level, there normally are four possibilities for needed referrals: Emergency triage Urgent Care or ENT Mental Health ENT Audiology Tinnitus Triage Guidelines should be distributed to clinics that are likely to encounter patients who complain about tinnitus Henry JA, Zaugg TL, Myers PJ, Kendall CJ, Michaelides EM. A triage guide for tinnitus. The Journal of Family Practice 59(7):389-393, 2010.

Tinnitus Triage Guidelines (My Patient Complains About Tinnitus What Should I Do?) If the patient: 1. Has physical trauma, facial palsy, or unexplained sudden hearing loss Has any other urgent medical condition 2. Has suicidal/homicidal ideations Manifests obvious mental health problems 3. Has ANY of the following: Symptoms suggest somatic origin of tinnitus (example: tinnitus that pulses with heartbeat) Ear pain, drainage, or malodor Vestibular symptoms (example: dizziness/vertigo) 4. Has ALL of the following: Symptoms suggest neural origin of tinnitus (example: tinnitus does not pulse with heartbeat) No ear pain, drainage, or malodor No vestibular symptoms (example: no dizziness/vertigo) No unexplained sudden hearing loss or facial palsy Refer to: Emergency Care or Otolaryngology (If unexplained sudden hearing loss Audiology referral prior to Otolaryngology visit same day) (emergency referral) Emergency Care or Mental Health report suicidal ideation (may be emergency if so escort patient to Emergency Care or Mental Health) Otolaryngology (urgency determined by clinician; refer to audiologist for follow-up management) Can refer to Primary Care if ear pain, drainage, or malodor Audiology (not urgent)

Level 2 Audiologic Evaluation Includes brief assessment of tinnitus impact

Level 2 Audiologic Evaluation Includes: Standard audiological assessment Brief assessment of tinnitus impact Three tinnitus questionnaires Decide with patient if tinnitus specific intervention is required If so, patient is invited to Level 3 Workshops Henry, J.A., Zaugg, T.L., Myers, P.J., & Schechter, M.A. (2008). The role of audiologic evaluation in Progressive Audiologic Tinnitus Management. Trends in Amplification. 12(3): 170-187. Myers, P.J., Henry, J.A., Zaugg, T.L, Kendall, C.J. (2009 March/April issue). Tinnitus evaluation and management considerations for persons with mild traumatic brain injury. ASHA Access Audiology, 8(2) http://www.asha.org/members/aud/tinnitustbi

Three Tinnitus Questionnaires To establish baseline Tinnitus Handicap Inventory (THI) or Tinnitus Functional Index (TFI) Self efficacy for Managing Reactions to Tinnitus (SMRT) Tinnitus and Hearing Survey (THS) Each of these questionnaires assesses a different aspect of tinnitus all are important Meikle et al. (2012). The Tinnitus Functional Index: A new clinical measure for chronic, intrusive tinnitus. Ear & Hearing Mar Apr;32(2):153 76 Newman CW, Jacobson GP, Spitzer JB. Development of the Tinnitus Handicap Inventory. Arch Otolaryngol Head Neck Surg. 1996;122(2):143 148.

Remainder of Level 2 Assessment is Routine Audiology Assessment of auditory function Hearing aid or combination instrument evaluation (if warranted) Assess for need to refer to ENT Assess for need for mental health screening Determine if assessment of sleep disorder is indicated Refer to other clinics PRN (Dental, PT, PCP)

Level 2 also includes screening for a sound tolerance (hyperacusis) problem

Components of STEM In depth Sound Tolerance Interview Loudness discomfort levels (optional) Educate patient to surround self with comfortable sound, listen to sounds he/she enjoys and use earplugs only when needed Patient Handout Counseling Guide Flip Chart (Chapter 3) Trial use of ear level devices (optional) Refer to Level 3 skills education PRN

Level 3 Skills Education Workshops for patients who require tinnitusspecific intervention

Level 3 Skills Education is the HEART of PTM

Managing Reactions to Tinnitus Chronic tinnitus usually is permanent Tinnitus cannot be quieted, but patients can learn to manage their reactions to it May need to be managed for a lifetime PTM counseling focuses on educating patients to become self sufficient in managing their reactions to tinnitus

Level 3 Workshops Series of patient education group sessions Called workshops because of their emphasis on interaction and participation Standard protocol: five weekly workshops two presented by an audiologist and three by a psychologist or mental health provider Myers PJ, Griest S, Kaelin C, Legro MW, Schmidt CJ, Zaugg TL, Henry JA. Development of a progressive audiologic tinnitus management program for Veterans with tinnitus. J Rehabil Res Dev. 2014;51(4):60922. http://dx.doi.org/10.1682/jrrd.2013.08.0189

Workshop Alternative DVD of workshops with audiologist included with self help workbook that is provided at workshop Patients can view interactive videos of five sessions at home to develop and modify plans for using sound to manage reactions to tinnitus Each video ideally should be followed up by phone call from audiologist and/or mental health provider

PTM Approach to Self Management Modeled closely after current methods of chronic pain management Now recognized that effective management depends much more on patients own efforts and expectations than on their passively receiving a treatment

Chronic Pain Management Stepped Care Model Interdisciplinary Pain Sensations/perceptions can be measured subjectively (subjective condition) Variety of causes Not just one mechanism behind pain sensation Often unable to cure underlying cause of pain, but can often manage resulting problems (primary suffering of symptom itself and secondary suffering of way one reacts to symptom) to minimize impact Concerned with management vs. cure Individualized plan of care Progressive Tinnitus Management Hierarchical Care Model Interdisciplinary Tinnitus symptom is subjective report (rare cases of objective tinnitus) Variety of causes Not just one mechanism behind tinnitus perception Often unable to cure underlying cause of tinnitus, but can often manage resulting problems (primary suffering of symptom itself and secondary suffering of way one reacts to symptom) to minimize impact Concerned with management vs. cure Individualized plan of care (sound plan and changing thoughts and feeling worksheet)

To Learn More about Similarities between Chronic Pain Management and PTM Schmidt CJ, Henry JA, Myers PJ, Zaugg TL, Boris Karpel S, Similarities Between Chronic Pain Management and Progressive Tinnitus Management (PTM). Presentation for the HSR&D Pain Cyberseminar Program: Spotlight on Pain Management, February 7, 2012. (invited presentation) It was recorded and posted on the archive of their catalog Access the recorded presentation: http://www.hsrd.research.va.gov/cyberseminars/catalogarchive.cfm

PTM Approach to Using Therapeutic Sound Not limited to a single method or device Provide knowledge and skills to use sound and devices in adaptive ways to manage any life situation disrupted by tinnitus Accomplished by teaching different ways of using sound, and helping patients develop and implement custom sound based management plans that address their unique needs

Workshops Conducted by an Audiologist PowerPoint presentation given during each workshop Managing Your Tinnitus: What to Do and How to Do It Focus is to assist patients in learning how to self manage their reactions to tinnitus using therapeutic sound in adaptive ways

Managing Your Tinnitus: What to Do and How to Do it (Session 1 of 2)

Three Uses of Sound for Tinnitus Soothing sound

Soothing Sound What is it? Sound that makes you feel better as soon as you hear it How can it help? By giving you a sense of relief from tension and stress caused by tinnitus When can it help? Any time your tinnitus bothers you

Let s try it! Tinnitus Relief Scale 1. Listen to the sound 2. While you listen, choose the amount of relief you feel 3. Choose either 0, 1, 2, 3, 4, or 5 4. Be ready to share your rating with the group

Background Sound What is it? Any sound that is neutral (not soothing and not interesting) How can it help? Reduces contrast to make it easier to ignore your tinnitus (we ll explain!) When can it help? Any time

Background Sound Changing the sounds around the tinnitus Makes it easier to ignore the tinnitus Tinnitus harder to ignore Tinnitus easier to ignore

Same Candle Different Backgrounds

Same Tinnitus Different Backgrounds

Let s try it! Tinnitus Contrast Scale 1. Spend a few moments listening to your tinnitus in quiet 2. Now turn on some background sound 3. Notice the reduced contrast 4. Reducing contrast makes it easier to ignore your tinnitus

INTERESTING SOUND! What is it? Sound that keeps your attention Sound that involves active listening How can it help? Shifts your attention away from your tinnitus When can it help? When you do not need to concentrate on something else When you want to relax or sleep

Attention Scale Let s try it! While you listen to the sound passage, choose the percent of attention focused on the passage Choose either 0, 25, 50, 75, or 100% Be ready to share your rating

Raise your hand if 0% of your attention was focused on the passage

Raise your hand if 25% of your attention was focused on the passage

Raise your hand if 50% of your attention was focused on the passage

Raise your hand if 75% of your attention was focused on the passage

Raise your hand if 100% of your attention was focused on the passage

Three Types of Sound to Manage Tinnitus Environmental sound Music Speech

Environmental Sound 1. Interesting 2. Soothing 3. Background

This image cannot currently be displayed. This image cannot currently be displayed. This image cannot currently be displayed. This image cannot currently be displayed. Music 1. Interesting 2. Soothing 3. Background

Speech 1. Interesting 2. Soothing 3. Background

Questionnaires for Level 3 Group End of each workshop Education Workshop Evaluation Form 6 weeks after end of workshops Six Week Post Workshop Interview (conducted by clinicians to determine if further services are needed) Tinnitus Workshop Follow up

Managing Your Tinnitus: What to Do and How to Do it (Session 2 of 2)

Level 3, Session 2 Primary focus: ensure that patients understand how to use the Sound Plan Worksheet to generate a sound plan for any tinnitus problem situation Some new information provided Sound based methods of tinnitus management Lifestyle factors that can affect tinnitus and hearing Hearing conservation Session 2 is a continuation of the first, and it is important for patients to attend both sessions

Sound based Methods of Tinnitus Management PTM PTM Soothing sound Tinnitus Masking Neuromonics TRT PTM

New Information During Second Workshop with Audiologist Different types of sound producing devices Ideas for using sound to improve sleep Sound based methods & how they relate to Sound Grid Lifestyle factors that can affect tinnitus and hearing Participants should attend both workshops to maximize their benefit

Correspondence Between Workshops and Workbook Patient learning in all Level 3 workshops facilitated by use of self help workbook Each component taught during Level 3 is described in workbook After each session, patients practice their new skills by using worksheets and activities in the workbook

Three Components of CBT Level 3 Workshops Conducted by MH 1. Stress management Provider Skills: Relaxation exercises 2. Distraction Skill: Planning pleasant activities 3. Cognitive restructuring Skills: Mindfulness and changing thoughts stepby step

CBT Coping Technique Skills Focus on: Relaxation Techniques Cognitive Thoughts Adding meaningful activities

Level 4 Interdisciplinary Evaluation In depth tinnitus evaluation by audiologist and psychologist

Who Needs a Level 4 Interdisciplinary Evaluation? Most patients can satisfactorily self manage their tinnitus after participating in Level 3 Skills Education Patients who need more support and education than is available at Level 3 can progress to the Level 4 evaluation to determine their needs for further intervention

Main Purpose of Level 4 Interdisciplinary Evaluation Determine if individualized clinical services are needed to address tinnitus specific problems If these services are needed, then patients progress to Level 5 Individualized Support Level 5 involves primarily one on one counseling from an audiologist and/or a mental health provider

Audiologic Assessment Tinnitus and Hearing Survey in conjunction with structured Tinnitus Interview is primary means of determining if one on one individualized support is appropriate. Optional procedures: Tinnitus psychoacoustic assessment Evaluation for use of (or reprogramming of) earlevel devices or other devices

Mental Health Assessment Level 4 patients are more likely to have comorbid MH conditions or sleep disorders that would require an interdisciplinary approach to intervention Screening for MH conditions and sleep disorders is conducted routinely by a MH provider

Criteria for Patients to Progress to Level 5 Individualized Support Levels 1 4 of PTM have not adequately addressed tinnitus concerns Evaluated and referred as appropriate for care in other clinics Understand nature of services available from psychologist and audiologist Motivated and capable of participating in activities proposed by clinicians

Level 5 Individualized Support One on one support from audiologist and/or psychologist

Overview of Level 5 Individualized Support Audiology Needed by relatively few patients Involves use of same principles of using sound and coping techniques to manage tinnitus presented in Level 3 workshops Focus may involve ear level noise/sound generators or combination instruments or other devices Trials of soothing/interesting/background sounds directly streamed to sound generators or combination hearing instruments

Demonstrating Personal Listening Devices and Stationary Devices Augmentative sound can be very effective for helping to manage reactions to tinnitus Should be demonstrated in clinic so patients know what they are and how they work

Some Customized Tinnitus Management Devices

Sleep Problems from Tinnitus Sound Option Examples

Options for Further Intervention Further PTM audiologic counseling (modified as necessary) Further CBT counseling (with new components of CBT) or Mindfulness Training, Biofeedback, ACT (evidence based for depression treatment) or other therapeutic interventions PRN Tinnitus masking Tinnitus retraining therapy Neuromonics tinnitus treatment Other devices Other education / referrals No evidence that one method is superior

. Options: Tinnitus Masking

Options: Formal Tinnitus Retraining Therapy (TRT) Henry, JA, Trune, DR, Robb, MA, Jastreboff, PJ (2007) Tinnitus Retraining Therapy: Patient Counseling Guide, Plural Publishing: San Diego CA.

Tinnitus Activities Therapy (TAT) Dr. Richard Tyler Revised 2006 Considers body s reaction to tinnitus Based upon Drs. Peter Wilson and Jane Henry s work in Australia Thoughts and Emotions Hearing and Communication Sleep Concentration Tyler, R.S. and The University of Iowa, Copyright 2006.

Options: Neuromonics Tinnitus Treatment (NTT) Inventor: Paul Davis, PhD Neuromonics formed in 2001 FDA clearance 2005 Perception Device uses a wide frequency music/noise stimulus customized for patient s hearing loss Attention Exposing patient to tinnitus in the context of relaxation Positive Reaction Relaxing music and counseling

Options: Other Devices

Options: Referral to Other Clinicians Music Therapist Recreational Therapist These therapists can also assist patients with sound therapy (music therapy) and adding meaningful activities for attention diversion (recreational therapy) Patient Education Classes Other referrals to Physical Therapy, Neurology, Dental, ENT, Sleep Clinic, Patient Education etc may be warranted if there are medical factors

Options: Referral to Patient Education Programs

Options: Referrals to Support Groups PRN

Conclusions Relatively few audiologists have received adequate training in providing clinical services for tinnitus PTM is a definable program of care based primarily on: Goal oriented counseling of various uses of sound for managing reactions to tinnitus Provision of specific coping skills based on CBT

Importance of Patient Education Effectiveness of PTM depends on effectiveness of patient education Essential that evidence based methods of patient education are utilized PTM adheres to a number of principles that have been demonstrated to optimize effective patient learning of skills for self management of health

Summary The five levels of PTM provide a logical, sequential means of working collaboratively with a patient to best determine what their needs are and to provide only what they need It is a basic philosophy of PTM that educating the patient is the most important concern

Summary Con t PTM education clearly explains the different ways that sound can be used to manage reactions to tinnitus As part of that education, patients get a general idea of how sound is used with the sound based methods of TM, TRT, and NTT Patients should have this understanding before committing to time consuming clinical protocols

PTM is a Dynamic Program PTM provides a framework of hierarchical tinnitus management PTM is not a static program but is evolving as we continue to learn from research and clinical practice The program also must be adaptable to clinicians' preferences and to address patients' individualized needs

To Learn More about the PTM Protocol Created for VA http://www.va.gov/health/newsfeatures/20110524a.asp

This link opens to a webpage that provides various free PTM resources including Handbook Chapters, Power Point files for Level 3 Skills education classes, Patient Self Help Workbook, articles and other tools. http://www.ncrar.research.va.gov/education/documents/tinnitusdocuments/index.asp

The studies discussed were funded by the Veteran s Administration Office of Rehabilitative Research & Development

REFERENCES Henry JA, Zaugg TL, Myers, PJ, Kendall CJ, Michaelides EM. (2010). A Triage Guide for Tinnitus. The Journal of Family Practice, 59 (7), 389 393. Henry, JA, Zaugg, TL, Myers, PJ, Kendall, CJ. (2010). Progressive Tinnitus Management: Counseling Guide. Long Beach, CA: VA Employee Education System. (also available from Plural Publishing, Inc.) Henry, JA, Zaugg, TL, Myers, PJ, Kendall, CJ. (2010). Progressive Tinnitus Management: How to Manage Your Tinnitus: A Step by Step Workbook. Long Beach, CA: VA Employee Education System. (also available from Plural Publishing, Inc.) Henry, JA, Zaugg, TL, Myers, PJ, Kendall, CJ. (2010). Progressive Tinnitus Management: Clinical Handbook for Audiologists. Long Beach, CA: VA Employee Education System. (also available from Plural Publishing, Inc.) Henry JA, Zaugg TL, Myers PJ, Kendall CJ, & Turbin, MB. (2009). Principles and application of educational counseling used in progressive audiologic tinnitus management. Noise and Health, 11(42), 33 48. Myers, PJ, Henry JA, Zaugg TL, Kendall CJ. (2009 March/April issue). Tinnitus evaluation and management considerations for persons with mild traumatic brain injury. ASHA Access Audiology, 8(2). Henry JA, Zaugg TL, Myers PJ, Schechter MA. (2008). The role of audiologic evaluation in Progressive Audiologic Tinnitus Management. Trends in Amplification. 12(3): 170 187. Henry JA, Zaugg TL, Myers PJ, Schechter MA. (2008). Using therapeutic sound with Progressive Audiologic Tinnitus Management. Trends in Amplification. 12(3): 188 209. Henry JA, Zaugg TL, Myers P, Schechter MA (2008). Progressive Audiologic Tinnitus Management. The Asha Leader 13(8):14 17. Henry JA, Zaugg TL, Myers PJ, Kendall CJ, Kaelin C, Thielman E, Griest S, Legro M, Storzbach D, McMillan G, Carlson K. Pilot study to develop telehealth tinnitus management for persons with and without traumatic brain injury. Journal of Rehabilitation Research and Development 49(7):1025-1042, 2012. Myers PJ, Griest S, Kaelin C, Legro MW, Schmidt CJ, Zaugg TL, Henry JA. Development of a progressive audiologic tinnitus management program for Veterans with tinnitus. J Rehabil Res Dev. 2014;51(4):60922. http://dx.doi.org/10.1682/jrrd.2013.08.0189 Henry JA, Zaugg TL, Myers PJ, Kendall CJ, Kaelin C, Thielman E, Griest S, Legro M, Storzbach D, McMillan G, Carlson K. Pilot study to develop telehealth tinnitus management for persons with and without traumatic brain injury. Journal of Rehabilitation Research and Development 49(7):1025 1042, 2012. Myers PJ, Twitchell DG, Henry JA, Bennett RL, Schmidt CJ. (2012). Progressive Tinnitus Management Training: A development model for constant currency in a field of flux. Paper Abstract No 12169 Page 1 10. Industry Training, Simulation and Education Conference (I/ITSEC) 2012.