Therapeutic Sound for Tinnitus Management: Subjective Helpfulness Ratings Steven Benton, Au.D. VA M e d i c a l C e n t e r D e c a t u r, G A 3 0 0 3 3
The Neurophysiological Model According to Jastreboff and Hazell (2004): The subconscious auditory filter allows us to ignore most incoming sounds to which we are constantly exposed and to focus on those that suggest something bad might happen. (p. 44). After repeated exposure to a sound that is not expected and not understood, negative cortical evaluation and negative limbic and autonomic nervous system reactions can result. Specifically, tinnitus patients may develop negative thoughts regarding the cause, potential danger and medical significance of this unexpected and misunderstood sound which in turn can result in negative limbic and autonomic nervous system reactions. A reflex (vicious cycle) is created in which merely perceiving the tinnitus immediately results in fear, anxiety, muscle tension and sleeplessness.
Simplified Neurophysiological Model
Simplified Neurophysiological Model A Reflex (Vicious Cycle) is Created Awareness
Progressive Tinnitus Management PTM (Henry, Zaugg, Myers, Kendall & Turbin, 2009) emphasizes patient education and the use of therapeutic sound to manage tinnitus disturbance. The goals of PTM are to help the patient: Feel less stressed about tinnitus; Have fewer emotional reactions to tinnitus; Almost never think about tinnitus; Feel like tinnitus has little effect on daily activities Feel like tinnitus is not much of a problem; and Feel like there is no need for further tinnitus help. Optimal therapeutic sounds address the negative limbic and autonomic nervous system activity described by the Neurophysiological Model. The most suitable specific use of sound depends on the situation in which the tinnitus is disturbing the patient. Sound Plans facilitate the identification of optimal sounds.
Soothing Sound Soothing Sound provides relief from the anxiety, tension and stress that is caused by, or that exacerbates, tinnitus by creating the relaxation response. The fight or flight response is a state of extreme physiological alertness and arousal. The relaxation response is the counterpart of "fight or flight" and returns the body's status to normal. Inducing the relaxation response through Soothing Sound actively fights negative limbic and autonomic nervous system activity created by the tinnitus signal. The body transitions from a state of physiological arousal and alertness to a state of physiological relaxation. Improving the patient s emotional and physiological status reduces the significance of tinnitus. Reducing the significance of tinnitus reduces frustration and improves quality of life. Perhaps most importantly, Soothing Sound allows relaxation which improves sleep, resulting in improved concentration while reducing mood swings and irritability.
Soothing Sound: Relaxation Two specific types of Soothing Sound which counteract stress and tension are Guided Relaxation and Guided Imagery. Guided Relaxation: a soothing recorded voice directs the patient through relaxation (deep breathing) exercises. Guided Imagery: the recorded voice assists the patient in creating a vivid mental image of a safe, relaxing place. Two well-known benefits of relaxation are specific to tinnitus management: Reduced negative limbic system activity (e.g., anger, frustration, anxiety) Reduced negative autonomic nervous system activity (e.g., muscle tension, stress) By addressing negative limbic and autonomic nervous system activity, sleep is improved and patients experience greater calmness, happiness and energy.
Background Sound Background Sound reduces auditory contrast and is the very definition of environmental sound enrichment. Background Sound decreases the perceived loud ness of the tinnitus signal, thereby reducing its strength as it travels from the ear to the brain. We judge the loudness of a sound in relation to the loudness of other sounds in the environment. Tinnitus in a silent environment is perceived as being louder than tinnitus in a sound-enriched environment. Because the tinnitus signal is weaker when embedded in Background Sound, activation of the limbic and autonomic nervous systems also is weaker. Background Sound restores lateral inhibition and reduces abnormal internal auditory gain. Reduced limbic and autonomic system activity reduces tinnitus-related distress which, in turn, improves quality of life.
Interesting Sound Interesting Sound redirects attention away from tinnitus by addressing selective perception, the process whereby the most attention is paid to sounds that are most important. Because the tinnitus signal already has been classified as significant, tinnitus is attended to and is frequently monitored. Frequent monitoring increases negative emotional and physiological reactions, resulting in frustration, inability to concentrate, greater sleeplessness and reduced quality of life. Interesting Sound impacts tinnitus by reducing the subconscious importance of tinnitus, thereby reducing the negative consequences of constant tinnitus monitoring. Reduced monitoring behavior improves concentration which, in turn, reduces frustration and improves quality of life.
Current Study We examined outcome questionnaires returned by mail from 39 consecutive patients who completed PTM Level 3, Tinnitus Group Education. The questionnaires asked subjects to use a 0-10 scale to rate the helpfulness of specific strategies and skills taught in PTM Level 3, Group Education.
Arbitrary Interpretation of 0-10 Scale 0 = 0% relief 1 = 10% relief 2 = 20% relief 3 = 30% relief 4 = 40% relief 5 = 50% relief 6 = 60% relief 7 = 70% relief 8 = 80% relief 9 = 90% relief 10 = 100% relief Inadequate Helpfulness Adequate Helpfulness
Helpfulness Ratings Soothing Sound: n=30 Background Sound: n=36 Interesting Sound: n=32 30% 30% 30% 25% 47% 53% 53% 47% 41% 59% 25% 25% 20% 20% 20% 15% 15% 15% 10% 10% 10% 5% 5% 5% 0% 0 1 2 3 4 5 6 7 8 9 10 0% 0 1 2 3 4 5 6 7 8 9 10 0% 0 1 2 3 4 5 6 7 8 9 10 The percentage of subjects reporting different 0-10 ratings is shown for each tinnitus management strategy and skill. The RED LINE denotes the arbitrary limit of ADEQUATE vs. INADEQUATE helpfulness. The red and green values indicate the percentage of subjects reporting adequate(green) or inadequate (red) helpfulness.
Helpfulness Ratings Deep Breathing: n=32 Guided Imagery: n=30 30% 30% 25% 50% 50% 53% 47% 25% 20% 20% 15% 15% 10% 10% 5% 5% 0% 0 1 2 3 4 5 6 7 8 9 10 0% 0 1 2 3 4 5 6 7 8 9 10 The percentage of subjects reporting different 0-10 ratings is shown for each tinnitus management strategy and skill. The RED LINE denotes the arbitrary limit of ADEQUATE vs. INADEQUATE helpfulness. The red and green values indicate the percentage of subjects reporting adequate(green) or inadequate (red) helpfulness.
Helpfulness Ratings Changing Thoughts: n=17 Pleasant Activities: n=18 30% 30% 25% 41% 59% 22% 78% 25% 20% 20% 15% 15% 10% 10% 5% 5% 0% 0 1 2 3 4 5 6 7 8 9 10 0% 0 1 2 3 4 5 6 7 8 9 10 The percentage of subjects reporting different 0-10 ratings is shown for each tinnitus management strategy and skill. The RED LINE denotes the arbitrary limit of ADEQUATE vs. INADEQUATE helpfulness. The red and green values indicate the percentage of subjects reporting adequate(green) or inadequate (red) helpfulness.
Mean Helpfulness Rating (SD) Average Helpfulness Ratings 10 9 8 7 6 5 4 3 2 1 0 Soothing Sound Background Sound Interesting Sound Deep Breathing Guided Imagery Changing Thoughts Pleasant Activities A Kruskal-Wallis One Way ANOVA on Ranks revealed that no single strategy or skill was significantly more helpful than any other (H = 7.12, df = 6, p =.302).
Mean Helpfulness Rating (SD) Average Helpfulness Ratings 10 9 8 7 6 5 4 3 2 1 0 Average Sound Help Average Relaxation Help Changing Thoughts Help Pleasant Activities Help A Kruskal-Wallis One Way ANOVA on Ranks revealed that no single strategy or skill category was significantly more helpful than any other (H = 6.05, df = 3, p =.109).
% of Subjects Adequate vs. Inadequate Helpfulness 100% 90% 80% Rating 0-4 Rating 5-10 70% 60% 50% 40% 30% 20% 10% 0% Soothing n=30 Background n=36 Interesting n=32 Thoughts n=17 Activities n=18 Breathing n=32 Imagery n=30
Conclusions and Discussion