Research Highlights
A more sensible approach to managing tinnitus
March 20, 2009
Some perceive it as a whistling noise in their ears. Others hear ringing or buzzing. In fact, the auditory condition known as tinnitus can involve one sound or many sounds, and each person with the disorder may hear something a bit different.
What everyone agrees on, though, is that tinnitus—like hearing loss—is a huge problem among veterans. According to Kyle Dennis, PhD, of VA's Audiology and Speech Pathology National Program Office, "Hearing loss and tinnitus are the first or second most common disabilities in all periods of service since World War II." A recent study on disability compensation by VA's Office of Policy and Planning noted tinnitus as "the most prevalent condition for new enrollees" between 2001 and 2007.
How to manage and treat tinnitus has thus become a huge issue for VA—both because of the impact on veterans' lives and the cost. Figures from 2005 showed that VA paid more than $418 million that year in tinnitus compensation.
Progressive approach has five levels of care
Thanks to work at VA's National Center for Rehabilitative Auditory Research (NCRAR), the agency is crafting a new approach to the problem. The approach hinges on a stepwise method of assessing and treating tinnitus developed by NCRAR scientist Jim Henry, PhD.
The program is called "Progressive Audiologic Tinnitus Management," or PATM. It was described in a June 2008 article for the American Speech-Language-Hearing Association's ASHA Leader publication, available online at www.asha.org.
PATM involves five levels of care. Henry says that to understand the progression, it's helpful to think of the tinnitus patient population in terms of a pyramid. (This model was coined by Robert Dobie, MD, formerly with the National Institutes of Health.) About 80 percent of people—those at the base—are actually not bothered at all by their tinnitus. Others, further up the pyramid, need only basic education on how to manage it. At the top of the pyramid are the relatively few patients who are debilitated by the condition and need longterm individualized therapy.
The key is appropriately assessing patients and getting them the right level and type of care. Each patient should receive a higher level of care only as needed, and care should be tailored to each patient's needs.
"Not everybody needs therapy or an intervention—maybe education is enough," notes Stephen Fausti, PhD, director of the NCRAR. "You have to look at the whole situation for each individual and go through the appropriate diagnostic work-up. It's not one size fits all."
Adds Henry: "We try to be resourceful and efficient in conducting the lower levels of PATM." He says the higher levels are "reserved for patients who really need them."
The first PATM level is triage—making sure health care providers make appropriate referrals for patients complaining of tinnitus symptoms. The next level is audiologic evaluation. Many patients who complain of tinnitus actually have a hearing problem that can be helped by a hearing aid or other treatment. Sorting out the symptoms— determining whether the complaint is due mainly to hearing loss or tinnitus—is crucial, and Henry's program offers screening instruments to help providers know the difference.
"We're finding out that a lot of people think tinnitus is the reason they're having trouble hearing," says Henry. "So we had to come up with ways to determine whether it is really a hearing problem or a tinnitus problem, or a little of both. Now, we say that what they really need first is to have a hearing evaluation and a tinnitus screening. If you just do that, you're probably going to take care of 90 percent of patients who come in and complain of tinnitus."
Hearing aids often help
When the condition is a mix of hearing loss and tinnitus, some patients find that the amplification provided by a hearing aid helps make the tinnitus less noticeable. That and some basic education on tinnitus can be enough to help them manage the condition. Patients also receive an NCRAR-developed manual—How to Manage Your Tinnitus: A Step-by-Step Workbook—that can be used with or without further support from clinicians.
Those patients who need more help go on to Level 3, group education. This is a cost-effective way to teach patients how to manage tinnitus, says Henry, and patients benefit from the peer support. One thing they learn is how to use sound. From an NCRAR fact sheet: "Being in a quiet room may make your tinnitus more noticeable. To help with this, try being around lowvolume, pleasant sounds, such as music or nature sounds (especially water). Devices that produce sound include radios, CD players, tabletop fountains, sound generators, and electric fans." Says Henry, "The whole progressive approach is based on education more than anything else."
PATM's Level 4 involves in-depth evaluation. Referrals may be made to address issues with sleep, mental health or other areas, and patients are tested to see if they might benefit from devices such as earlevel sound generators.
Level 5 offers individualized management, building on the skills taught in the earlier group work. At this point, some patients will be wearing sound generators or "combination instruments"—hearing aids with built-in generators. If patients still need help after six months or so of Level 5 care, they may be referred for sound-based treatments such as tinnitus masking or tinnitus retraining therapy. Cognitive behavioral therapy is another option shown to help.
PATM model in clinical trial
The PATM model is now being tested at the James A. Haley VA Medical Center in Tampa. One group of patients is receiving "usual care" while the other is being evaluated and treated through the five-tier approach. Henry is also testing a telephonebased version of PATM designed for patients with tinnitus and traumatic brain injury. "It will involve a similar approach but will obviously be modified because we can't see the patients in person. And it includes psychological components we haven't used before. We're educating the patients about different techniques for relaxation and stress reduction."
Henry and colleagues are also teaching PATM to VA audiologists nationwide and developing a system to test for tinnitus. As of now, tinnitus disability claims rely mainly on patients' self-reports of symptoms. Unlike hearing loss—which can be objectively measured with instrumentation—tinnitus, in most cases, is totally subjective. No one else can hear the noise. Says Henry: "We're working on a computer-automated technique for measuring what we call the psychoacoustic parameters of tinnitus—loudness, pitch, how easily it is masked by noise. We don't think you can take one test and run it on a person and determine if they have tinnitus. But the more tests you run, the more evidence you have of whether the person has tinnitus or not. We anticipate running a battery of six or seven tests and seeing how the patient responds across all of them."
One test, for example, would have patients indicate when a machine-produced tone matches the one they hear in their ears. A patient who does not truly have tinnitus might not be able to respond consistently.
Meanwhile, NCRAR audiologists are working closely with VA clinical policymakers to "develop a comprehensive tinnitus management protocol based on [the PATM protocol]," says Dennis, of VA's national audiology office. He also notes that the topic should receive even greater attention in the future, as Congress recently mandated the establishment of a Department of Defense (DoD) "center of excellence" for hearing loss, tinnitus and other ear disorders. Dennis said VA is collaborating with DoD in planning the center
This article originally appeared in the March 2009 issue of VA Research Currents.