by James A. Henry, Tara L. Zaugg, Paula J. Myers, and Martin A. Schechter
Audiologists are arguably the most qualified of all health care professionals to offer clinical services for tinnitus. Yet many audiologists lack a high level of training in appropriate interventions, leaving them wondering how to most effectively treat "tinnitus patients."
Audiologic tinnitus management (ATM) was first described as a detailed and comprehensive protocol in 2005 (Henry et al., 2005a, b). The ATM methodology has since undergone further development and includes a more detailed education protocol to assist patients in learning self-management for tinnitus. In addition, the methodology was integrated into a hierarchical program so that clinical intervention occurs only to the degree necessary. The expanded and updated method, referred to as progressive ATM (PATM), is a sound-based method. It is distinguished from other sound-based methods (specifically, tinnitus masking, tinnitus retraining therapy, and Neuromonics tinnitus treatment) because the protocol is adaptive to meet each patient's unique needs.
About 10% to 15% of all adults experience chronic tinnitus, and 20% of this group require some degree of clinical intervention. The American Tinnitus Association (Portland, Oregon) estimates that more than 50 million Americans experience chronic tinnitus. Of these, 12 million individuals seek professional help and 2 million are "debilitated" by the condition.
The "tinnitus pyramid" (Figure 1 at right [PDF]) shows that the majority of people who experience the condition either are not bothered or require only basic education (Dobie, 2004). Approaching the tip of the pyramid are people with progressively more severe problems caused by tinnitus. The tip contains the very few patients who are debilitated by tinnitus. The pyramid makes clear that patients have different needs, ranging from provision of simple information to long-term individualized therapy. This range is what necessitates a progressive management approach.
Five Levels of Management
A hierarchical approach minimizes the impact of tinnitus on the patient's life as efficiently as possible while simultaneously providing cost-effective management. Figure 2 [PDF] shows the overall flow of tinnitus services using PATM. The hierarchy of services starts with the Level 1 triage at the bottom of the figure. It should be noted that Level 1 triage provides guidelines for all clinics where patients with tinnitus are likely to be encountered. Levels 2–5 are specific to services provided by audiologists, with the stipulation that patients are referred appropriately to other clinics.
PATM was developed specifically for efficiency in clinical implementation. The model is based on a series of clinical trials completed at the National Center for Rehabilitative Auditory Research and on many years of clinical experience working with tinnitus patients.
Level 1: Triage
Patients may report tinnitus to health care providers in the areas of otolaryngology, primary care, psychology, psychiatry, neurology, and oncology. These providers may be unaware of available tinnitus evaluation and management resources. Guidelines are needed so that all clinicians can refer patients for appropriate care. The triaging guidelines (shown in Figure 2 [PDF]) are appropriate for audiologists, but are designed mainly for non-audiologists who encounter patients with tinnitus. The guidelines are consistent with accepted clinical practices (Harrop-Griffiths et al., 1987; Henry et al., 2005a; Henry & Wilson, 2001; Wackym & Friedland, 2004).
Level 2: Audiologic Evaluation
Tinnitus usually is associated with some degree of hearing loss, requiring tinnitus patients to receive standard hearing testing. The evaluation should assess the potential need for medical, audiologic, and/or mental health intervention. (Audiologic intervention can address hearing loss, tinnitus, and/or reduced sound tolerance.) It also may be necessary to screen for mental health conditions that could interfere with any efforts to manage tinnitus.
The Level 2 evaluation always includes brief written questionnaires to assess the relative impact of hearing and tinnitus problems. Recommended questionnaires include the Tinnitus Handicap Inventory (THI), a statistically validated questionnaire that provides an index score of self-perceived tinnitus handicap; Tinnitus and Hearing Survey; and Hearing Handicap Inventory (HHI), used to document patients' self-perceived hearing handicap. Different versions of the HHI assess patients both younger and older than 65 years; brief screening versions also are available.
Patients may report a severe problem with tinnitus, when in reality it is a hearing problem. An important objective of the Level 2 audiologic evaluation is to determine if patients need audiologic intervention for hearing, tinnitus, or both. The Tinnitus and Hearing Survey (Figure 3 [PDF]) is a brief questionnaire designed specifically to help patients and clinicians determine which types of audiologic intervention are needed. The survey includes four questions about tinnitus-specific problems (section A) addressed in Level 3 group education, and four questions about hearing-specific problems (section B) that would not be addressed in group education. Results, along with the hearing assessment, should determine if intervention is needed for tinnitus (usually Level 3 group education), and if intervention for a hearing problem is appropriate. Section C includes two questions to screen for reduced sound tolerance (hyperacusis). Patients with hyperacusis require special procedures that have been described elsewhere (Henry et al., 2005a, b).
The Tinnitus-Impact Screening Interview (TISI) is an option for use at the end of the Level 2 audiologic evaluation. The eight-question TISI can be helpful if the written questionnaires and the audiometric testing provide insufficient information about the need for future tinnitus intervention. However, the TISI's primary value is facilitating a brief counseling session that focuses on patients' main tinnitus concerns. This interview also can be quite valuable in establishing rapport with patients and helping them to feel that the clinician fully understands their concerns.
Tinnitus patients who require amplification are fitted with hearing aids, which often can result in satisfactory tinnitus management with minimal education and support specific to tinnitus. Special considerations for the use of hearing aids with tinnitus patients include leaving the ear canal open as much as possible (by using larger vent diameters or feedback reduction circuitry that can facilitate the use of open-ear design). Noise suppression circuitry or reduced levels of internal noise may actually be detrimental. The floor noise of older hearing aids often was helpful for tinnitus patients by making the tinnitus less noticeable. Many modern hearing aids can be programmed to minimize use of features intended to suppress circuit noise and other background sounds.
Some people with problematic tinnitus have mental health needs—which may or may not be related to the tinnitus problem—that can interfere with successful tinnitus management, such as post-traumatic stress disorder (PTSD) or anxiety. If indicated by the patient's comments or behavior during the Level 2 tinnitus evaluation, screening for mental health issues should be performed. Audiologists can screen for anxiety, using the six-item short form of the Spielberger State-Trait Anxiety Inventory; depression, using the seven-item screening version of the Beck Depression Inventory; and PTSD, using the primary care PTSD screening tool. Mental health screening can be done at any stage of PATM at the audiologist's discretion.
Patients who require further information about tinnitus can use a workbook (How to Manage Your Tinnitus: A Step-by-Step Workbook) that focuses on implementing self-help strategies. The workbook is a practical, detailed, patient-friendly guide to developing a personalized sound-based management plan focused on the issues most important to the patient. It also provides general information about tinnitus. Patients who are appropriate candidates for tinnitus intervention typically are given the workbook and simultaneously scheduled to attend Level 3 group education. However, the workbook can be provided without further intervention. (See "Providing PATM to Patients" later in this article for information about obtaining the workbook.)
Level 3: Group Education
Level 3 group education, the first PATM stage in which the clinician teaches comprehensive tinnitus management principles to patients, involves two sessions. During the first session, principles of sound management are explained, and patients use the PATM worksheet to develop a plan for managing tinnitus. Patients are asked to return for a follow-up session approximately two weeks later; their "homework" is to implement the plan.
At the second session, the sound plan from the first session is reviewed and modified, and additional information is presented about tinnitus management. The primary focus is to ensure that patients understand how to use the sound plan worksheet for any tinnitus-problem situation. Some new information also is covered, and it is important for patients to attend both sessions. Any patient who does not attend the second session should have the opportunity for telephone follow-up.
Studies support the use of group education for basic tinnitus intervention. Data from a major tinnitus clinic show that group education is effective in conjunction with a hierarchical tinnitus rehabilitation program (Newman & Sandridge, 2005; Sandridge & Newman, 2005). Overall findings revealed that the majority of participants had a reduction in self-perceived tinnitus handicap following the session and found it beneficial. In addition, a randomized clinical trial was completed to evaluate group education (based on counseling used with tinnitus retraining therapy) with 269 patients (Henry et al., 2007). Results of that trial showed significant reduction in tinnitus severity for patients in the year-long education group. The two control groups (traditional support and no intervention) showed no significant improvement.
The use of group education offers several advantages for clinical management of tinnitus: one clinician can provide intervention to several patients at the same time; patients are empowered to make informed decisions about self-management that involve minimal expense; and intervention is provided in an environment of supportive and encouraging peers.
Level 4: Tinnitus Evaluation
Many patients can self-manage tinnitus adequately after participating in Level 3 group education. Patients who need further support and education can progress to the PATM Level 4 tinnitus evaluation, which includes an intake interview and a tinnitus psychoacoustic assessment. The intake interview is the primary means of determining if one-on-one individualized tinnitus management is needed. Special testing procedures are used to evaluate the effectiveness of tinnitus management devices, including ear-level noise generators, combination instruments (combined hearing aid and noise generator), and personal-listening devices. At the Level 4 tinnitus evaluation, mental health screening (specified above for Level 2) is recommended as routine practice. Patients also should be screened for sleep disorders, which are the most common problem reported by tinnitus patients.
Patients must meet certain criteria to progress to Level 5 individualized management: PATM Levels 2–4 have all been completed; all appropriate referrals have been made to otolaryngology, mental health, etc.; and the patient understands Level 5 individualized management and is motivated to participate. If these criteria are met, the patient is scheduled for an initial appointment to start the individualized program.
Level 5: Individualized Management
Relatively few patients progress to Level 5, which involves the same principles of using sound to manage tinnitus presented during Level 3 group education. Maintaining the same management capitalizes on all the education provided to the patient up to this point. Patients receive individual counseling at Level 5, thus increasing the intensity of interaction. Some patients who reach Level 5 will be using ear-level sound generators or combination instruments—unlike patients at Level 3 who would be using only hearing aids.
Although PATM provides comprehensive tinnitus management through Level 5, some patients may not achieve satisfactory progress. It is important that patients are aware that other strategies are available. Any of these strategies become options after about six months of Level 5 management with unsatisfactory results (in alphabetical order): cognitive-behavioral therapy (CBT), Neuromonics tinnitus treatment, tinnitus masking, and tinnitus retraining therapy. We have no definitive evidence that any of these behavioral methods is more effective than any other.
Providing PATM to Patients
Although PATM can be described in detail, some materials are still in development (in association with ongoing clinical research). Every effort is being made to make materials available to audiologists. An 18-module comprehensive PATM online training course is currently undergoing beta-testing by audiologists. The patient education workbook has been developed for research purposes within the Veterans Health Administration and will become commercially available (anticipated for release in 2009). The Level 3 group education involves PowerPoint presentations that are available to audiologists upon request. Most of the questionnaires and forms are available and all will be included in the upcoming PATM text. Please contact the first author for information.
Future Directions
PATM is not a static method of tinnitus management. Further work is needed to expand and improve the program. The plan is to integrate principles of CBT into the intervention protocol. This approach to tinnitus management was adapted from its use for pain management and is the leading psychological method, with a number of studies verifying its efficacy.
Future iterations of the PATM counseling model will include greater emphasis on facilitating development of patient self-efficacy—how confident a patient is about his or her abilities based on feelings of self-confidence and control. Self-efficacy has been shown to be a good predictor of motivation and behavior. These concepts are particularly relevant to PATM because the goal is for patients to develop and implement individualized plans for using sound to manage their tinnitus. Success in achieving this goal depends largely upon patients acquiring confidence in applying self-management strategies.
Finally, a dedicated wearable device will be developed that can incorporate the different sound-management strategies used with PATM. This device will initially be an MP3-player type of device with ear buds. Eventually, wireless ear-level devices will become available, enabling wireless implementation of PATM sound-management options in addition to meeting any needs for amplification. This is a unique time, as new means of delivering complex acoustic signals, memory storage in small devices, and increasingly sophisticated hearing aids converge to create new tinnitus management possibilities.
James A. Henry is a research career scientist with the Veterans Affairs (VA) National Center for Rehabilitative Auditory Research (NCRAR), Portland, Oregon, and associate professor in the Department of Otolaryngology/Head and Neck Surgery, Oregon Health and Science University (OHSU), Portland. Contact him at james.henry@va.gov.
Martin A. Schechter, NCRAR audiology consultant, can be contacted at shekta@aol.com.
Tara L. Zaugg, NCRAR research audiologist, can be contacted at tara.zaugg@va.gov.
Paula J. Myers is chief of audiology at the James A. Haley VA Medical Center, Tampa, Florida, and assistant professor in the Department of Communication Science and Disorders, University of South Florida, Tampa. Contact her at paula.myers@va.gov.
Acknowledgments: Funding for this work was provided by Veterans Health Administration, and Veterans Affairs Rehabilitation Research and Development (RR&D) Service. All figures were created by Lynn Kitagawa, Medical Media Service, Portland VA Medical Center.
Disclaimer: Any commercial development of PATM or its materials will not financially benefit the authors of this manuscript, who are employees of the Veterans Health Administration.