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TRT T RETRAINING NEUROFISICAL PATTERN PARAMETERS

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The document discusses Tinnitus Retraining Therapy (TRT) as a treatment for tinnitus, emphasizing that while tinnitus may not subside, patients can learn to manage their symptoms and improve their quality of life. It outlines the neurophysiological basis of tinnitus, the psychological factors involved, and the significant efficacy of TRT based on clinical trials. The document also highlights the importance of truthful patient information and the potential negative impacts of tinnitus on mental health.

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TREATMENT of TINNITUS Tinnitus Retraining Therapy-TRT VESTIBULAR DISORDERS AND TINNITUS TRAINING COURSE May 9-10, 2013, Madrid (Spain) Teresa Heitzmann ENT Department. Clínica Universidad de Navarra-Madrid
DIAGNOSTIC!!! …we have followed protocol to exclude retrochoclear, central, vascular pathologies… Madrid, 9 -10/05/2013
but tinnitus annoys…. What can we do? Madrid, 9 -10/05/2013
ESSENTIAL!!! the information we give to the patient at that time is: WE SHOULD GIVE TRUTHFUL INFORMATION! - Tinnitus will not fade away - There is no solution and nothing to be done - There is no possibility of improvement - You must learn to live with it - Some people even commit suicide because of it! Madrid, 9 -10/05/2013
the information we give to the patient at that time is WE MUST INSIST ON… - frequent and not significant symptom (Heller & Bergman) - It is not inherited - It won’t make you become deaf - you do not have a tumor - explain the underlying disease, when it exists, and that tinnitus is not the cause ESSENTIAL!!! Madrid, 9 -10/05/2013
with Tinnitus Retraining Therapy (TRT) • The annoyance of tinnitus is because of the way the signal is processed in the central parthway • We can restore normality to the auditory parthway if we know what has changed it and we can give the appropriate stimuli Yes, we CAN help you Madrid, 9 -10/05/2013
- Tinnitus Retraining Therapy (TRT): 80-84 % - In every group that follows the neurophysiological pattern Madrid, 9 -10/05/2013
- n: 137 - Data were obtained after 6 and 12 months - Parámetros: 1. ¿Is your tinnitus better, same, or worse due to the treatment (patient’s selfevaluation) 2. VAS on tinnitus intensity and 3. THI (1) The efficacy of TRT for tinnitus relief has been demonstrated recently by our team through a clinical trial (1) Herraiz et al. Tinnitus Retraining Therapy: prognosis factors. American Journal of Otolaryngology–Head and Neck Medicine and Surgery 28 (2007) 225 – 229 Madrid, 9 -10/05/2013
3.1. TINNITUS RETRAINING THERAPY RESULTS (1) AFTER 6 AND 12 MONTHS, 78 % AND 82 % of the sample, respectively, referred an improvement in their tinnitus according to PES. Tinnitus Handicap Inventory and VAS average scores showed a statistical difference at 6 and 12 months of control (P < .01 for THI, P = .001 for VAS) (1) The efficacy of TRT for tinnitus relief has been demonstrated recently by our team through a clinical trial (1) Herraiz et al. Tinnitus Retraining Therapy: prognosis factors. American Journal of Otolaryngology–Head and Neck Medicine and Surgery 28 (2007) 225 – 229 Madrid, 9 -10/05/2013
NEUROPHYSIOLOGICAL PATTERN - The origin of tinnitus is irrelevant in the discomfort it produces - The annoyance is due to the way the tinnitus signal is processed in the central pathway Madrid, 9 -10/05/2013
- In the central processing of tinnitus different systems will be involved. These systems are linked to the auditory pathway which are interconnected and there is some feedback among them - Those structures are governed by the principles of conditioned reflexes Madrid, 9 -10/05/2013
The principal systems involved in the negative reactions : - The Limbic System (LS) (emotions and learning) and the Autonomous Nervous System (ANS) - They are linked to others systems like the prefrontral cortex, the thalamus, the reticular formation and the cerebellum It is necessary to take them into account in the tinnitus generation, disturbance and treatment Madrid, 9 -10/05/2013
Madrid, 9 -10/05/2013
- Continuos activation of the connections between these systems reinforce them and it increases the overactivation created between LS and del ANS - Increased activation is also produced in the reciprocal connections (feedback) causing, at de same time, increase of the activity in the system through which tinnitus arrives - Thus, an increase of activation of the ANS causes an increase of activation in the LS, cortical areas and the auditory pathway The tinnitus will become problem if the systems linked to the auditory pathway are activated innapropriately or overactivated Madrid, 9 -10/05/2013
Tinnitus signal activates the LS and ANS by two loops - HIGH route: cortical areas are involved (conscious) where cognitive processes ocurr • Percepcion, evaluation, conscious association and fears It is crucial in the initial stage of a tinnitus that begins to be significant - LOW route: subcortical centers (subconscious) are involved. Auditory pathway, at level of medial geniculate body, reaches the lateral nucleus of the amygdala and other parts of the LS, reaching ANS centers Responsible and predominant centers in development of chronic tinnitus Madrid, 9 -10/05/2013
Inferior Colliculus Medial geniculate body Secondary Cortex Primary Cortex Madrid, 9 -10/05/2013
Both routes contribute to the activation of the ANS and to the negative reaction caused by tinnitus Madrid, 9 -10/05/2013
Auditory & Other Cortical Areas Perception & Evaluation (Consciousness, Memory, Attention) Auditory Periphery Source Auditory Subconscious Detection / Processing Limbic System Emotions Reactions Autonomic Nervous system Madrid, 9 -10/05/2013
The tinnitus signal in the auditory pathway acts as a conditioned stimulus that, because of one or more reflex arcs, active the limbic system and triggers the negative reactions How can the conditioned reflex be created? • Conection will become stronger if it is frequently activated • If it is not activated, it will became weaker and weaker Madrid, 9 -10/05/2013
• Negative Counselling: Doctor tells the patient something by which the patient associates tinnitus with a threat, or something unpleasant, a hazardous situations:“tinnitus will not fade away ”, “nothing can be done”, “ you must learn to live with it”, “MR/CT has to be done to see if there is a tumor” • Stress situations, such as retirement, divorce, unemployment …that have nothing to do with health problems • Certain personality profiles: analytic, obsessive, controller, perfectionist, with fears or phobias Madrid, 9 -10/05/2013
The negative effects of tinnitus give rise to two response categories: 1. Anxiety, depression, sleep disturbances, stress… 2. Attention and concentration problems, sadness, interference with daily activities like family, work, social relationships Madrid, 9 -10/05/2013
- Causes of tinnitus can be many although the most frequent is exposure to noise - But these ones are not the cause of the tinnitus annoyance • Conditioned Reflex is created by the temporal association of a signal conditioned factor (tinnitus) and its reinforcement (emotional reaction) - Sudden onset of tinnitus with levels of stress or emotional situations give rise to a significant tinnitus bothering (e.g. sudden hearing loss) - It is more frequent in professions with exposure to noise and stress like policemen, firefighters, soldiers, … Madrid, 9 -10/05/2013
Is processing reversibility of tinnitus possible? Can you act on conditioning reflex and restore normality to the auditory pathway ? If so, tinnitus annoyance would dissapear and tinnitus would no longer be a problem… Madrid, 9 -10/05/2013
Madrid, 9 -10/05/2013
Neural plasticity “great capacity of change” that can modify neural connections - Changes in the information processing result: - Redirecting the rearrangement information in the CNS - Changes in the excitation-inhibition balance - Increased neurones activity Madrid, 9 -10/05/2013
Neuronal Plasticty “great capacity of change” • It may be beneficial: facilitates reorganization to compensate injury (loss of function) or adapts CNS to changes (e.g. CI) • It may be pathological or harmful: pathological changes in plasticity allowing symptoms such as tinnitus (and associated symptoms such as hyperacusis and distortion of sounds), amputee limb pain... Madrid, 9 -10/05/2013
- Deprivation, overstimulation, agressions and unknown intrinsic factors - The pathologycal neural pasticity is due to changes in synaptic plasticity that open inactive synapses or close the active ones - The abnormal activation of subcortical structures such as the LS and the ANS are an expression of that plasticity What does it produce or active it? Neuronal Plasticity Madrid, 9 -10/05/2013
- Neural plasticity allows Habituation - Habituation: extinction of the response to stimulus present because it is irrelevant. Extinction of the conditioned reflex Madrid, 9 -10/05/2013
- When a significant signal becomes neutral or indifferent: Habituation of reaction - and you can also get to ignore the signal, decreasing the contrast at the cortical level: Habituation of perception Habituation Madrid, 9 -10/05/2013
How can we do it? Madrid, 9 -10/05/2013
- Extinction of conditioned reflex - Lack of response to a stimulus present because it is irrelevant TRT GOAL: HABITUATION Madrid, 9 -10/05/2013
- Habituation of reaction: when a significant signal becomes neutral or indifferent - Habituation of perception: you can also get to ignore the signal, decreasing the contrast at the cortical level HABITUATION ¡¡ Neuronal Plasticity !! Madrid, 9 -10/05/2013
CNS • Identification and selection of signals • Amplifying and detecting contrasts Madrid, 9 -10/05/2013
Identification and selection of signals 1. New signal: new things always attract attention 2. Experiences associated with the signal (the limbic system) 3. Concentration on another task, which ignores the signal 4. Contrast with which the signal is perceived: silence. (Heller and Bergman, 1953) Madrid, 9 -10/05/2013
Amplifying and detecting contrasts (e.g. candle) - An amplification of the pathway is produced, which is conformed to the mean intensity of the input signals (e.g. eye in darkness). Heller and Bergman, 1953 - an increase is caused in the gain of the pathway ► The Tinnitus: weak signal that can be enhanced on its way to the cortex ► Hyperacusis may occur: increased sensitivity to external sounds In addition .... Madrid, 9 -10/05/2013
HYPERACUSIS Hypersensitivity to every external sound, which causes discomfort MISOPHONIA Aversion to certain external sounds. It is related to meaning of sounds. LS Madrid, 9 -10/05/2013
Madrid, 9 -10/05/2013
Madrid, 9 -10/05/2013
- Questionnaires: VAS (Sheldrake), THI and SHT (Nelting) - Detailed anamnesis - ENT exploration and somatosensorial test - Audiological study with pure tone audiometry, speech audiometry and tympanometry - Measurement of tinnitus (tinnitus more annoying) with MML e RI - Uncomfortable Thresholds: hyperacusis PROTOCOL Madrid, 9 -10/05/2013
- How well you can hear. Which problem is the most important (tinnitus, hearing loss, hyperacusis, all of them) - Location. Time evolution. How much noise you have. Loudness (0- 10). Hour percentaje you notice (10-100%) - Effect y annoyance (0-10) - Activities with which it interferes (work concentration, reading, conversation and social life, family life, leisure activities, shows). Sleep disturbance (late sleep, sleep deprivation, awakenings) - Worst moments or days. Loud noise disturbance. External noise repercussion on tinnitus (increase-decrease) VAS (Sheldrake) Madrid, 9 -10/05/2013
YOU THINK OR THOUGHT THAT… At this moment At the onset This problem will worsen It will last for good It is a physical desease It has no treatment In fact, I have a tumor It will lead to a brain stroke I will never sleep well I will became deaf I will became mad. I won’t bear it any longer It prevents me from solving problems My social and family life will get ruined (tick or cross) Madrid, 9 -10/05/2013
1f Because of your tinnitus is it difficult for you to concentrate? Yes Sometimes No 2f Does the loudness of your tinnitus make it difficult for you to hear people? Yes Sometimes No 3f Does your tinnitus make your angry? Yes Sometimes No 4f Does your tinnitus make your confused? Yes Sometimes No 5c Because of yout tinnitus are you desperate? Yes Sometimes No 6e Do you complain a great deal about your tinnitus? Yes Sometimes No 7f Because of your tinnitus do you have a trouble falling asleep at night? Yes Sometimes No 8c Do you feel as though youcannot escape from your tinnitus? Yes Sometimes No 9f Does your tinnitus interfere with your ability to enjoy social activities (such as going out to dinner, to the cinema)? Yes Sometimes No 10e Because of your tinnitus do you feel frustrated? Yes Sometimes No 11c Because of your tinnitus do you feel that you have a terrible disease? Yes Sometimes No 12f Does your tinntus make it difficult to enjoy life? Yes Sometimes No 13f Does your tinnitus interfere with your job or houdehold responsabilities? Yes Sometimes No 14f Because of your tinnitus do you find that you are often irritable? Yes Sometimes No 15f Because of your tinnitus is it difficult for you to read? Yes Sometimes No 16e Does your tinnitus make you upset? Yes Sometimes No 17e Do you feel that your tinnitus has placed stress on our relationships with members of your family and frieds? Yes Sometimes No 18f Do you find it difficult to focus your attention away from your tinnitus and on to others things? Yes Sometimes No 19c Do you feel that you have no control over your tinnitus? Yes Sometimes No 20f Because of your tinnitus do you often feel`tired? Yes Sometimes No 21e Because of your tinnitus do you feel depressed? Yes Sometimes No 22e Does your tinnitus make you feel anxious? Yes Sometimes No 23c Do you feel you can no longer cope with your tinnitus? Yes Sometimes No 24f Do you tinnitus get worse when you undert stress? Yes Sometimes No 25e Does your tinnitus make you feel insecure? Yes Sometimes No ================================================================================== Total Score Per Column f = /52 Total Score: _ c= /20 e= /28 TINNITUS HANDICAP INVENTORY (Newman & Jacobson) Madrid, 9 -10/05/2013
Score: yes (4 points), sometimes (2 points), no (0 points) - 0 disability 0-16% - Mild disability 18-36% - Moderate disalility 38-56% - Severe disability 58-100% - Functional subscale: inability at mental level (difficulty in concentration, reading), working and physical difficulty (interference in hearing) - Emotional subscale: affective responses (frustration, anger, anxiety and depression) - Catastrophic subscale: level of desperation and inability to solve the patient's problem * Herráiz C et al. Evaluación de la Incapacidad en pacientes con acúfenos. Acta Otorrinolaringol Esp 2001; 52: 534-538 TINNITUS HANDICAP INVENTORY * (Newman & Jacobson) Madrid, 9 -10/05/2013
• If noises bothered more than the people around you • Activities that bother outside noise (0-10): Going to concerts, restaurants, movies, shopping, going to church, attending sporting events, social life, work, driving, cleaning house or babysitting HIPERACUSIS Madrid, 9 -10/05/2013
Madrid, 9 -10/05/2013
15 items 4 responses: - never or not true 0 points - sometimes 1 points - frequently 2 points - always 3 points Mild disability 1-10 Grade I Moderate disability 11-17 Grade II Severe disability 18-25 Grade III Very severe disability 26-45 Grade IV * Herráiz C et al. Evaluación de la Hiperacusia: test de hipersensibilidad al sonido. Acta Otorrinolaringol Esp 2006; 57: 303-6 SOUND HYPERSENSITIVITY TEST (Nelting) * Madrid, 9 -10/05/2013
- Onset/trigger - Accompanying symptoms. Hiperacusis - Influence on your mood: worried, irritated, depressed, character change - Personality: nervous, worrying, perffeccionist, controller, depressed, phobic - Changes in the family or at work - Suggested advice or opinions ANAMNESIS Madrid, 9 -10/05/2013
• Counselling: what the matter is and why it happens • Sound Therapy: it enables to reduce contrast at cortical level and corrects the increase of gain in the auditory pathway TRT Madrid, 9 -10/05/2013
With Counselling we get habituation of reaction: Removing the negative connotations of tinnitus (the limbic system) and discomfort (the autonomic nervous systems) ► This way the negative influence of the limbic system at subcortical level and its connection to the autonomic nervous system cease to exist Madrid, 9 -10/05/2013
With Sound Therapy we get habituation of perception • This way tinnitus stays at subcortical level • If it ever reaches the cortex: it will not bother and it will be quickly forgotten Madrid, 9 -10/05/2013
► Annoyance: impact on patient's life ► Existence of subjective hearing loss ► Existence of hyperacusis ► Effects of noise exposure on tinnitus Standard CATEGORIES in TRT Patients should ALWAYS be CATEGORIZED Madrid, 9 -10/05/2013
Madrid, 9 -10/05/2013 CATEGORIES OF PATIENTS WITH TINNITUS AND HYPERACUSIS Category Impact on life Subjective Hearing Loss Hyperacusis Noise Effects Treatment 0 1 2 3 4 Low High High High High - - Relevant Irrelevant Irrelevant - - - Present Present - - - - Present Counselling Sound G. Hearing Aid Sound G. on Hearing Threshold Sound G. on Threshold/ Desensibilizing T.
• Every patients receives: - Counselling - Sound Therapy: Avoid silence • According to each Category we will used: - Sound Generators - Hearing Aids - Desensibilizing T. TRT Madrid, 9 -10/05/2013
GOAL: HABITUATION of REACTION • Contents: through PLATES which make explanation easier 1. We explain the audiometry. Tinnitus doesn’t cause deafness 2. Irrelevant origin of tinnitus in the disturbance 3. Explain the functioning of our ear, auditory pathway and CNS structures involved, and how important sounds are processed 4. What happens in his/her specific case: structures involved. Conditioned Reflex 5. Explain TRT objetive (habituation), its meaning and what to do 6. Sound Therapy 7. Follow-up in each case Counselling Madrid, 9 -10/05/2013
… giving truthful information if the patient has been told that… - Tinnitus will not dissapear - There is no solution and nothing to be done - There is no possibility of improvement - You must learn to live with it - There are even some people who commit suicide! We will have to act…. Madrid, 9 -10/05/2013
We should give truthful information WE MUST INSIST ON… - frequent and not significant symptom (Heller & Bergman) - It is not inherited - It won’t make you become deaf - you don’t have a tumor - explain the underlying disease, when it exists, and that tinnitus is not the cause Madrid, 9 -10/05/2013
Counselling Madrid, 9 -10/05/2013
Madrid, 9 -10/05/2013
• Goal: HABITUATION OF PERCEPTION It allows us to reduce the contrast at the cortical level and correct the increased gain in the auditory pathway Subject-matter: 1. Explain the sound therapy needed according to categorization and how it works 2. Devices: sound generators, hearing aids according to category of the patient/ Desensibilizing T. Sound Therapy ALWAYS AVOID SILENCE Madrid, 9 -10/05/2013
• Avoid silence • Sound generators • Hearing Aids • Desensibilizing Therapy Unilateral Cophosis : • C + hearing aids system CROSS o BICROSS/ BAHA device • Protocol: new indication CI Sound Therapy Madrid, 9 -10/05/2013
Follow-up • Goal: help to habituation assessing in each medical visit the factors which were identified as the cause of disturbance and follow evolution. Insisting on Counselling • Guideline: - monthly follow-up if there is hyperacusis - a monthly visist after wearing hearing aid/s. generators - Three months (2) - Six months (2) • Questionnaires: every six months Madrid, 9 -10/05/2013
Follow-up • Guideline: 5-6 medical visit for 18 months-2 years • Time to get habituation: it depends on each patient. It is estimated an average between 18 months-2 years, but there is response (70-78 % improvement)1,2 in 6 months 1.Sheldrake JB, Hazell JWP, Graham RL. Results of Tinnitus Retraining Therapy. Proceedings of de Sixtth International Tinnitus Seminar. Cambridge, UK. September 5th-9th 1999 2. Herraiz C. et al. Tinnitus Retraining Therapy: prognosis factors. American Journal of Otolaryngology–Head and Neck Medicine and Surgery 28 (2007) 225 – 229 IMPORTANT !! Not getting it in this period of time, It does not mean failure Madrid, 9 -10/05/2013
• Specific consultation: - The firt visit lasts a two hours and a half approximately. The follow-up visits last from one hour to a half - Extra appoiments as well as usual ENT consultation • Multidisciplinary team : - ENT - Audiologyc Technician. Nurse - Audio-prosthetic - Psychosomatic Medicine / Psychologist-Psychiatrist Features Madrid, 9 -10/05/2013
1. TRT is an effective treatment to deal with tinnitus discomfort 2. Knowing the neurophysiological pattern and its clinical application (Counselling and Sound Therapy by Categories) 3. Suitable assessment and follow-up to get Habituation 4. Specific consultations and multidisciplinary team Conclusions Madrid, 9 -10/05/2013
Conclusions 5. We help to perform habituation in a physiological way, without pharmacology 6. Everybody should know about the neurophysiological model to help the patient and refer him to this treatment if necessary Madrid, 9 -10/05/2013
THANK YOU VERY MUCH! Madrid, 9 -10/05/2013
General López Pozas, 10 28036 Madrid 91 353 19 20 heitzmann@unav.es 25/01/2013 9-10/05/2013

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TRT T RETRAINING NEUROFISICAL PATTERN PARAMETERS

  • 1. TREATMENT of TINNITUS Tinnitus Retraining Therapy-TRT VESTIBULAR DISORDERS AND TINNITUS TRAINING COURSE May 9-10, 2013, Madrid (Spain) Teresa Heitzmann ENT Department. Clínica Universidad de Navarra-Madrid
  • 2. DIAGNOSTIC!!! …we have followed protocol to exclude retrochoclear, central, vascular pathologies… Madrid, 9 -10/05/2013
  • 3. but tinnitus annoys…. What can we do? Madrid, 9 -10/05/2013
  • 4. ESSENTIAL!!! the information we give to the patient at that time is: WE SHOULD GIVE TRUTHFUL INFORMATION! - Tinnitus will not fade away - There is no solution and nothing to be done - There is no possibility of improvement - You must learn to live with it - Some people even commit suicide because of it! Madrid, 9 -10/05/2013
  • 5. the information we give to the patient at that time is WE MUST INSIST ON… - frequent and not significant symptom (Heller & Bergman) - It is not inherited - It won’t make you become deaf - you do not have a tumor - explain the underlying disease, when it exists, and that tinnitus is not the cause ESSENTIAL!!! Madrid, 9 -10/05/2013
  • 6. with Tinnitus Retraining Therapy (TRT) • The annoyance of tinnitus is because of the way the signal is processed in the central parthway • We can restore normality to the auditory parthway if we know what has changed it and we can give the appropriate stimuli Yes, we CAN help you Madrid, 9 -10/05/2013
  • 7. - Tinnitus Retraining Therapy (TRT): 80-84 % - In every group that follows the neurophysiological pattern Madrid, 9 -10/05/2013
  • 8. - n: 137 - Data were obtained after 6 and 12 months - Parámetros: 1. ¿Is your tinnitus better, same, or worse due to the treatment (patient’s selfevaluation) 2. VAS on tinnitus intensity and 3. THI (1) The efficacy of TRT for tinnitus relief has been demonstrated recently by our team through a clinical trial (1) Herraiz et al. Tinnitus Retraining Therapy: prognosis factors. American Journal of Otolaryngology–Head and Neck Medicine and Surgery 28 (2007) 225 – 229 Madrid, 9 -10/05/2013
  • 9. 3.1. TINNITUS RETRAINING THERAPY RESULTS (1) AFTER 6 AND 12 MONTHS, 78 % AND 82 % of the sample, respectively, referred an improvement in their tinnitus according to PES. Tinnitus Handicap Inventory and VAS average scores showed a statistical difference at 6 and 12 months of control (P < .01 for THI, P = .001 for VAS) (1) The efficacy of TRT for tinnitus relief has been demonstrated recently by our team through a clinical trial (1) Herraiz et al. Tinnitus Retraining Therapy: prognosis factors. American Journal of Otolaryngology–Head and Neck Medicine and Surgery 28 (2007) 225 – 229 Madrid, 9 -10/05/2013
  • 10. NEUROPHYSIOLOGICAL PATTERN - The origin of tinnitus is irrelevant in the discomfort it produces - The annoyance is due to the way the tinnitus signal is processed in the central pathway Madrid, 9 -10/05/2013
  • 11. - In the central processing of tinnitus different systems will be involved. These systems are linked to the auditory pathway which are interconnected and there is some feedback among them - Those structures are governed by the principles of conditioned reflexes Madrid, 9 -10/05/2013
  • 12. The principal systems involved in the negative reactions : - The Limbic System (LS) (emotions and learning) and the Autonomous Nervous System (ANS) - They are linked to others systems like the prefrontral cortex, the thalamus, the reticular formation and the cerebellum It is necessary to take them into account in the tinnitus generation, disturbance and treatment Madrid, 9 -10/05/2013
  • 14. - Continuos activation of the connections between these systems reinforce them and it increases the overactivation created between LS and del ANS - Increased activation is also produced in the reciprocal connections (feedback) causing, at de same time, increase of the activity in the system through which tinnitus arrives - Thus, an increase of activation of the ANS causes an increase of activation in the LS, cortical areas and the auditory pathway The tinnitus will become problem if the systems linked to the auditory pathway are activated innapropriately or overactivated Madrid, 9 -10/05/2013
  • 15. Tinnitus signal activates the LS and ANS by two loops - HIGH route: cortical areas are involved (conscious) where cognitive processes ocurr • Percepcion, evaluation, conscious association and fears It is crucial in the initial stage of a tinnitus that begins to be significant - LOW route: subcortical centers (subconscious) are involved. Auditory pathway, at level of medial geniculate body, reaches the lateral nucleus of the amygdala and other parts of the LS, reaching ANS centers Responsible and predominant centers in development of chronic tinnitus Madrid, 9 -10/05/2013
  • 17. Both routes contribute to the activation of the ANS and to the negative reaction caused by tinnitus Madrid, 9 -10/05/2013
  • 18. Auditory & Other Cortical Areas Perception & Evaluation (Consciousness, Memory, Attention) Auditory Periphery Source Auditory Subconscious Detection / Processing Limbic System Emotions Reactions Autonomic Nervous system Madrid, 9 -10/05/2013
  • 19. The tinnitus signal in the auditory pathway acts as a conditioned stimulus that, because of one or more reflex arcs, active the limbic system and triggers the negative reactions How can the conditioned reflex be created? • Conection will become stronger if it is frequently activated • If it is not activated, it will became weaker and weaker Madrid, 9 -10/05/2013
  • 20. • Negative Counselling: Doctor tells the patient something by which the patient associates tinnitus with a threat, or something unpleasant, a hazardous situations:“tinnitus will not fade away ”, “nothing can be done”, “ you must learn to live with it”, “MR/CT has to be done to see if there is a tumor” • Stress situations, such as retirement, divorce, unemployment …that have nothing to do with health problems • Certain personality profiles: analytic, obsessive, controller, perfectionist, with fears or phobias Madrid, 9 -10/05/2013
  • 21. The negative effects of tinnitus give rise to two response categories: 1. Anxiety, depression, sleep disturbances, stress… 2. Attention and concentration problems, sadness, interference with daily activities like family, work, social relationships Madrid, 9 -10/05/2013
  • 22. - Causes of tinnitus can be many although the most frequent is exposure to noise - But these ones are not the cause of the tinnitus annoyance • Conditioned Reflex is created by the temporal association of a signal conditioned factor (tinnitus) and its reinforcement (emotional reaction) - Sudden onset of tinnitus with levels of stress or emotional situations give rise to a significant tinnitus bothering (e.g. sudden hearing loss) - It is more frequent in professions with exposure to noise and stress like policemen, firefighters, soldiers, … Madrid, 9 -10/05/2013
  • 23. Is processing reversibility of tinnitus possible? Can you act on conditioning reflex and restore normality to the auditory pathway ? If so, tinnitus annoyance would dissapear and tinnitus would no longer be a problem… Madrid, 9 -10/05/2013
  • 25. Neural plasticity “great capacity of change” that can modify neural connections - Changes in the information processing result: - Redirecting the rearrangement information in the CNS - Changes in the excitation-inhibition balance - Increased neurones activity Madrid, 9 -10/05/2013
  • 26. Neuronal Plasticty “great capacity of change” • It may be beneficial: facilitates reorganization to compensate injury (loss of function) or adapts CNS to changes (e.g. CI) • It may be pathological or harmful: pathological changes in plasticity allowing symptoms such as tinnitus (and associated symptoms such as hyperacusis and distortion of sounds), amputee limb pain... Madrid, 9 -10/05/2013
  • 27. - Deprivation, overstimulation, agressions and unknown intrinsic factors - The pathologycal neural pasticity is due to changes in synaptic plasticity that open inactive synapses or close the active ones - The abnormal activation of subcortical structures such as the LS and the ANS are an expression of that plasticity What does it produce or active it? Neuronal Plasticity Madrid, 9 -10/05/2013
  • 28. - Neural plasticity allows Habituation - Habituation: extinction of the response to stimulus present because it is irrelevant. Extinction of the conditioned reflex Madrid, 9 -10/05/2013
  • 29. - When a significant signal becomes neutral or indifferent: Habituation of reaction - and you can also get to ignore the signal, decreasing the contrast at the cortical level: Habituation of perception Habituation Madrid, 9 -10/05/2013
  • 30. How can we do it? Madrid, 9 -10/05/2013
  • 31. - Extinction of conditioned reflex - Lack of response to a stimulus present because it is irrelevant TRT GOAL: HABITUATION Madrid, 9 -10/05/2013
  • 32. - Habituation of reaction: when a significant signal becomes neutral or indifferent - Habituation of perception: you can also get to ignore the signal, decreasing the contrast at the cortical level HABITUATION ¡¡ Neuronal Plasticity !! Madrid, 9 -10/05/2013
  • 33. CNS • Identification and selection of signals • Amplifying and detecting contrasts Madrid, 9 -10/05/2013
  • 34. Identification and selection of signals 1. New signal: new things always attract attention 2. Experiences associated with the signal (the limbic system) 3. Concentration on another task, which ignores the signal 4. Contrast with which the signal is perceived: silence. (Heller and Bergman, 1953) Madrid, 9 -10/05/2013
  • 35. Amplifying and detecting contrasts (e.g. candle) - An amplification of the pathway is produced, which is conformed to the mean intensity of the input signals (e.g. eye in darkness). Heller and Bergman, 1953 - an increase is caused in the gain of the pathway ► The Tinnitus: weak signal that can be enhanced on its way to the cortex ► Hyperacusis may occur: increased sensitivity to external sounds In addition .... Madrid, 9 -10/05/2013
  • 36. HYPERACUSIS Hypersensitivity to every external sound, which causes discomfort MISOPHONIA Aversion to certain external sounds. It is related to meaning of sounds. LS Madrid, 9 -10/05/2013
  • 39. - Questionnaires: VAS (Sheldrake), THI and SHT (Nelting) - Detailed anamnesis - ENT exploration and somatosensorial test - Audiological study with pure tone audiometry, speech audiometry and tympanometry - Measurement of tinnitus (tinnitus more annoying) with MML e RI - Uncomfortable Thresholds: hyperacusis PROTOCOL Madrid, 9 -10/05/2013
  • 40. - How well you can hear. Which problem is the most important (tinnitus, hearing loss, hyperacusis, all of them) - Location. Time evolution. How much noise you have. Loudness (0- 10). Hour percentaje you notice (10-100%) - Effect y annoyance (0-10) - Activities with which it interferes (work concentration, reading, conversation and social life, family life, leisure activities, shows). Sleep disturbance (late sleep, sleep deprivation, awakenings) - Worst moments or days. Loud noise disturbance. External noise repercussion on tinnitus (increase-decrease) VAS (Sheldrake) Madrid, 9 -10/05/2013
  • 41. YOU THINK OR THOUGHT THAT… At this moment At the onset This problem will worsen It will last for good It is a physical desease It has no treatment In fact, I have a tumor It will lead to a brain stroke I will never sleep well I will became deaf I will became mad. I won’t bear it any longer It prevents me from solving problems My social and family life will get ruined (tick or cross) Madrid, 9 -10/05/2013
  • 42. 1f Because of your tinnitus is it difficult for you to concentrate? Yes Sometimes No 2f Does the loudness of your tinnitus make it difficult for you to hear people? Yes Sometimes No 3f Does your tinnitus make your angry? Yes Sometimes No 4f Does your tinnitus make your confused? Yes Sometimes No 5c Because of yout tinnitus are you desperate? Yes Sometimes No 6e Do you complain a great deal about your tinnitus? Yes Sometimes No 7f Because of your tinnitus do you have a trouble falling asleep at night? Yes Sometimes No 8c Do you feel as though youcannot escape from your tinnitus? Yes Sometimes No 9f Does your tinnitus interfere with your ability to enjoy social activities (such as going out to dinner, to the cinema)? Yes Sometimes No 10e Because of your tinnitus do you feel frustrated? Yes Sometimes No 11c Because of your tinnitus do you feel that you have a terrible disease? Yes Sometimes No 12f Does your tinntus make it difficult to enjoy life? Yes Sometimes No 13f Does your tinnitus interfere with your job or houdehold responsabilities? Yes Sometimes No 14f Because of your tinnitus do you find that you are often irritable? Yes Sometimes No 15f Because of your tinnitus is it difficult for you to read? Yes Sometimes No 16e Does your tinnitus make you upset? Yes Sometimes No 17e Do you feel that your tinnitus has placed stress on our relationships with members of your family and frieds? Yes Sometimes No 18f Do you find it difficult to focus your attention away from your tinnitus and on to others things? Yes Sometimes No 19c Do you feel that you have no control over your tinnitus? Yes Sometimes No 20f Because of your tinnitus do you often feel`tired? Yes Sometimes No 21e Because of your tinnitus do you feel depressed? Yes Sometimes No 22e Does your tinnitus make you feel anxious? Yes Sometimes No 23c Do you feel you can no longer cope with your tinnitus? Yes Sometimes No 24f Do you tinnitus get worse when you undert stress? Yes Sometimes No 25e Does your tinnitus make you feel insecure? Yes Sometimes No ================================================================================== Total Score Per Column f = /52 Total Score: _ c= /20 e= /28 TINNITUS HANDICAP INVENTORY (Newman & Jacobson) Madrid, 9 -10/05/2013
  • 43. Score: yes (4 points), sometimes (2 points), no (0 points) - 0 disability 0-16% - Mild disability 18-36% - Moderate disalility 38-56% - Severe disability 58-100% - Functional subscale: inability at mental level (difficulty in concentration, reading), working and physical difficulty (interference in hearing) - Emotional subscale: affective responses (frustration, anger, anxiety and depression) - Catastrophic subscale: level of desperation and inability to solve the patient's problem * Herráiz C et al. Evaluación de la Incapacidad en pacientes con acúfenos. Acta Otorrinolaringol Esp 2001; 52: 534-538 TINNITUS HANDICAP INVENTORY * (Newman & Jacobson) Madrid, 9 -10/05/2013
  • 44. • If noises bothered more than the people around you • Activities that bother outside noise (0-10): Going to concerts, restaurants, movies, shopping, going to church, attending sporting events, social life, work, driving, cleaning house or babysitting HIPERACUSIS Madrid, 9 -10/05/2013
  • 46. 15 items 4 responses: - never or not true 0 points - sometimes 1 points - frequently 2 points - always 3 points Mild disability 1-10 Grade I Moderate disability 11-17 Grade II Severe disability 18-25 Grade III Very severe disability 26-45 Grade IV * Herráiz C et al. Evaluación de la Hiperacusia: test de hipersensibilidad al sonido. Acta Otorrinolaringol Esp 2006; 57: 303-6 SOUND HYPERSENSITIVITY TEST (Nelting) * Madrid, 9 -10/05/2013
  • 47. - Onset/trigger - Accompanying symptoms. Hiperacusis - Influence on your mood: worried, irritated, depressed, character change - Personality: nervous, worrying, perffeccionist, controller, depressed, phobic - Changes in the family or at work - Suggested advice or opinions ANAMNESIS Madrid, 9 -10/05/2013
  • 48. • Counselling: what the matter is and why it happens • Sound Therapy: it enables to reduce contrast at cortical level and corrects the increase of gain in the auditory pathway TRT Madrid, 9 -10/05/2013
  • 49. With Counselling we get habituation of reaction: Removing the negative connotations of tinnitus (the limbic system) and discomfort (the autonomic nervous systems) ► This way the negative influence of the limbic system at subcortical level and its connection to the autonomic nervous system cease to exist Madrid, 9 -10/05/2013
  • 50. With Sound Therapy we get habituation of perception • This way tinnitus stays at subcortical level • If it ever reaches the cortex: it will not bother and it will be quickly forgotten Madrid, 9 -10/05/2013
  • 51. ► Annoyance: impact on patient's life ► Existence of subjective hearing loss ► Existence of hyperacusis ► Effects of noise exposure on tinnitus Standard CATEGORIES in TRT Patients should ALWAYS be CATEGORIZED Madrid, 9 -10/05/2013
  • 52. Madrid, 9 -10/05/2013 CATEGORIES OF PATIENTS WITH TINNITUS AND HYPERACUSIS Category Impact on life Subjective Hearing Loss Hyperacusis Noise Effects Treatment 0 1 2 3 4 Low High High High High - - Relevant Irrelevant Irrelevant - - - Present Present - - - - Present Counselling Sound G. Hearing Aid Sound G. on Hearing Threshold Sound G. on Threshold/ Desensibilizing T.
  • 53. • Every patients receives: - Counselling - Sound Therapy: Avoid silence • According to each Category we will used: - Sound Generators - Hearing Aids - Desensibilizing T. TRT Madrid, 9 -10/05/2013
  • 54. GOAL: HABITUATION of REACTION • Contents: through PLATES which make explanation easier 1. We explain the audiometry. Tinnitus doesn’t cause deafness 2. Irrelevant origin of tinnitus in the disturbance 3. Explain the functioning of our ear, auditory pathway and CNS structures involved, and how important sounds are processed 4. What happens in his/her specific case: structures involved. Conditioned Reflex 5. Explain TRT objetive (habituation), its meaning and what to do 6. Sound Therapy 7. Follow-up in each case Counselling Madrid, 9 -10/05/2013
  • 55. … giving truthful information if the patient has been told that… - Tinnitus will not dissapear - There is no solution and nothing to be done - There is no possibility of improvement - You must learn to live with it - There are even some people who commit suicide! We will have to act…. Madrid, 9 -10/05/2013
  • 56. We should give truthful information WE MUST INSIST ON… - frequent and not significant symptom (Heller & Bergman) - It is not inherited - It won’t make you become deaf - you don’t have a tumor - explain the underlying disease, when it exists, and that tinnitus is not the cause Madrid, 9 -10/05/2013
  • 59. • Goal: HABITUATION OF PERCEPTION It allows us to reduce the contrast at the cortical level and correct the increased gain in the auditory pathway Subject-matter: 1. Explain the sound therapy needed according to categorization and how it works 2. Devices: sound generators, hearing aids according to category of the patient/ Desensibilizing T. Sound Therapy ALWAYS AVOID SILENCE Madrid, 9 -10/05/2013
  • 60. • Avoid silence • Sound generators • Hearing Aids • Desensibilizing Therapy Unilateral Cophosis : • C + hearing aids system CROSS o BICROSS/ BAHA device • Protocol: new indication CI Sound Therapy Madrid, 9 -10/05/2013
  • 61. Follow-up • Goal: help to habituation assessing in each medical visit the factors which were identified as the cause of disturbance and follow evolution. Insisting on Counselling • Guideline: - monthly follow-up if there is hyperacusis - a monthly visist after wearing hearing aid/s. generators - Three months (2) - Six months (2) • Questionnaires: every six months Madrid, 9 -10/05/2013
  • 62. Follow-up • Guideline: 5-6 medical visit for 18 months-2 years • Time to get habituation: it depends on each patient. It is estimated an average between 18 months-2 years, but there is response (70-78 % improvement)1,2 in 6 months 1.Sheldrake JB, Hazell JWP, Graham RL. Results of Tinnitus Retraining Therapy. Proceedings of de Sixtth International Tinnitus Seminar. Cambridge, UK. September 5th-9th 1999 2. Herraiz C. et al. Tinnitus Retraining Therapy: prognosis factors. American Journal of Otolaryngology–Head and Neck Medicine and Surgery 28 (2007) 225 – 229 IMPORTANT !! Not getting it in this period of time, It does not mean failure Madrid, 9 -10/05/2013
  • 63. • Specific consultation: - The firt visit lasts a two hours and a half approximately. The follow-up visits last from one hour to a half - Extra appoiments as well as usual ENT consultation • Multidisciplinary team : - ENT - Audiologyc Technician. Nurse - Audio-prosthetic - Psychosomatic Medicine / Psychologist-Psychiatrist Features Madrid, 9 -10/05/2013
  • 64. 1. TRT is an effective treatment to deal with tinnitus discomfort 2. Knowing the neurophysiological pattern and its clinical application (Counselling and Sound Therapy by Categories) 3. Suitable assessment and follow-up to get Habituation 4. Specific consultations and multidisciplinary team Conclusions Madrid, 9 -10/05/2013
  • 65. Conclusions 5. We help to perform habituation in a physiological way, without pharmacology 6. Everybody should know about the neurophysiological model to help the patient and refer him to this treatment if necessary Madrid, 9 -10/05/2013
  • 67. General López Pozas, 10 28036 Madrid 91 353 19 20 heitzmann@unav.es 25/01/2013 9-10/05/2013