Associations Between Traumatic Brain Injury and Severity of Tinnitus-Related Functional Impairment Among US Military Veterans: A National, Population-Based Study.

OBJECTIVE: To describe associations between a history of traumatic brain injury (TBI) and the severity of tinnitus-related functional impairment among a national, stratified random sample of veterans diagnosed with tinnitus by the Department of Veterans Affairs (VA) healthcare system. SETTING: A multimodal (mailed and internet) survey administered in 2018. Participants: VA healthcare-using veterans diagnosed with tinnitus; veterans with comorbid TBI diagnosis were oversampled. DESIGN: A population-based survey. MAIN MEASURES: TBI history was assessed using International Classification of Diseases (ICD) diagnosis codes in veterans' VA electronic health records. The severity of participants' overall tinnitus-related functional impairment was measured using the Tinnitus Functional Index. Population prevalence and 95% confidence intervals (CIs) were estimated using inverse probability weights accounting for sample stratification and survey nonresponse. Veterans' relative risk ratios of very severe or moderate/severe tinnitus-related functional impairment, versus none/mild impairment, were estimated by TBI history using bivariable and multivariable multinomial logistic regression. RESULTS: The population prevalence of TBI was 5.6% (95% CI: 4.8-6.4) among veterans diagnosed with tinnitus. Veterans with a TBI diagnosis, compared with those without a TBI diagnosis, had 3.6 times greater likelihood of rating their tinnitus-related impairment as very severe (95% CI: 2.1-6.3), and 1.5 times greater likelihood of rating their impairment as moderate/severe (95% CI: 1.0-2.4), versus none/mild. CONCLUSIONS: These findings suggest an important role of TBI in the severity of tinnitus-related functional impairment among veterans. This knowledge can help inform the integration of tinnitus management services into the care received by veterans with TBI.

The influence of tinnitus and hearing loss on the functional status of military Service members and Veterans.

OBJECTIVE: This study evaluated the influence of tinnitus and hearing loss on the functional status of military Service members and Veterans. DESIGN: Participants completed audiologic testing and self-report instruments to assess tinnitus, hearing, and general functioning. We conducted multiple linear regression analyses using cross-sectional data with functional status as the dependent variable. The primary independent variables were tinnitus and average low-, high-, and extended high-frequency hearing thresholds. Secondary independent variables were subjective tinnitus severity and hearing difficulties. Each of the independent variables was modelled separately for Service members and Veterans; covariates for each multivariable model were identified a priori and, depending on the association being modelled, included age, gender, blast-wave exposure, and history of military traumatic brain injury. STUDY SAMPLE: Data were analysed from 283 Service members and 390 Veterans. RESULTS: After controlling for potential confounders, presence of tinnitus, tinnitus severity, average low-frequency hearing thresholds, and subjective hearing difficulties were significantly associated with functional status in Service members and Veterans. CONCLUSIONS: These results suggest that tinnitus and poorer low-frequency hearing, and the perceived severity of tinnitus and hearing difficulties, may be associated with poorer functional status among Service members and Veterans.

Associations between medical conditions and auditory dysfunction in US Veterans.

OBJECTIVE: To examine associations between non-otologic medical conditions and auditory dysfunction. DESIGN: Cross-sectional analysis of baseline data from the Noise Outcomes in Service members Epidemiology (NOISE) study. Logistic regression was used to estimate the association between medical conditions (0, 1, and 2 or more conditions) and auditory dysfunction (hearing loss pure tone average ≥20 dB HL and tinnitus), adjusting for key confounders including noise exposure. Secondarily, the association between specific medical conditions and auditory dysfunction was examined. All variables were self-reported. STUDY SAMPLE: United States military Veterans (n = 580) with mean age 34.1 years (standard deviation = 9.2), who were within approximately 2.5 years of separation from service. RESULTS: Compared to Veterans reporting no medical conditions, Veterans reporting two or more had increased odds on low-frequency hearing loss and on tinnitus but not on high or extended-high frequency hearing loss. Furthermore, specific conditions sleep disorder and arthritis were associated with auditory dysfunction. CONCLUSIONS: Non-otologic medical conditions were associated with low-frequency hearing loss and tinnitus in this sample of young Veterans. This suggests medical conditions may play a role in Veterans' hearing health. Whether management of medical conditions earlier in life reduces the risk of hearing loss and tinnitus requires further study.

Cognitive Behavioral Therapy for Tinnitus: Addressing the Controversy of Its Clinical Delivery by Audiologists.

Audiologists' role in providing care for tinnitus typically includes conducting an audiologic evaluation, fitting hearing aids when appropriate, assessing the impact of tinnitus, and facilitating use of sound to improve quality of life with tinnitus when appropriate. Cognitive behavioral therapy (CBT) is consistently judged by systematic reviews as having the strongest evidence relative to other therapies for improving quality of life with tinnitus. Because audiologists are already playing an active role in providing care for tinnitus, and the relative paucity of behavioral health providers who are experienced in implementing CBT for tinnitus, a logical question is whether audiologists can provide CBT and whether it is within their scope of practice. In this article, we present both sides of the argument as to whether audiologists can provide CBT and we make recommendations for appropriate administration of CBT for tinnitus management.

Randomised controlled trial of interventions for bothersome tinnitus: DesyncraTM versus cognitive behavioural therapy.

OBJECTIVE: Compare the relative efficacy of DesyncraTM and Cognitive Behavioural Therapy (CBT). DESIGN AND STUDY SAMPLE: Sixty-one participants were randomly assigned to receive either DesyncraTM (n = 29) or CBT (n = 32). Randomisation included stratification regarding current hearing aid (HA) use. Depending on group assignment, participants attended approximately 7-12 visits. Tinnitus distress was measured using the Tinnitus Questionnaire (TQ). RESULTS: Mean TQ scores decreased post-baseline from 5-15 points across treatment arms and strata. Model-based findings for the no-HA stratum showed a difference of -2.0 TQ points favouring Desyncra at 24-weeks, with a 90% posterior interval varying from -5.4 points favouring Desyncra to 0.8 TQ points favouring CBT. For the HA stratum, results show a difference of -1.0 TQ points favouring Desyncra, with a 90% posterior interval ranging from -4.7 points favouring Desyncra to 2.9 points favouring CBT. CONCLUSIONS: The difference between Desyncra and CBT on average showed greater improvement with Desyncra in the no-HA stratum by about 2 TQ points. To the extent that the study sample represents a clinical population and recognising the assumptions in the design and analysis, these results suggest Desyncra is just as effective or more so than CBT in reducing tinnitus distress.

Occupational Noise Exposure and Longitudinal Hearing Changes in Post-9/11 US Military Personnel During an Initial Period of Military Service.

OBJECTIVES: Auditory impairments, particularly those resulting from hazardous occupational noise exposures, are pressing concerns for the US Departments of Defense (DoD) and Veterans Affairs (VA). However, to date, no studies have estimated the rate of hearing threshold change that occurs during service or how changes may vary by military occupation. Hearing threshold changes during military service have historically been reported as the proportion of Service members demonstrating a significant threshold shift. This approach does not capture the rate of the hearing threshold change or the specific audiometric frequencies impacted. Determining the rate of hearing threshold change, and factors that affect the rate of change, is important to elucidate the impact of military service on hearing and to guide prevention strategies and subsequent hearing health care. Our primary objective was to estimate the annual rate of hearing threshold change during military service as a consequence of military occupational noise exposure ranking. DESIGN: We linked audiometric data, collected from military personnel as part of a DoD hearing conservation program, to data describing demographic and military-service characteristics obtained from individuals enrolled in the Noise Outcomes In Service members Epidemiology Study. The analytic cohort included Veterans who enlisted in military service after September 2001 (n = 246). We examined the longitudinal association between military occupations categorized as having a low, moderate, or high noise exposure ranking and pure-tone hearing thresholds (500 to 6000 Hz) using a hierarchical linear model. The average annual rate of hearing threshold change and their 95% confidence intervals were estimated by service branch, military occupational noise exposure ranking, and audiometric test frequency. RESULTS: On average, hearing threshold change ranged between -0.5 and 1.1 dB/year and changes over time varied by service branch, audiometric test frequency, and military occupation noise ranking. Generally, higher test frequencies (3000 to 6000 Hz) and military occupations with moderate or high noise exposure rankings had the greatest average annual rates of hearing threshold change; however, no dose-response relationship was observed. Among Marine Corps personnel, those exposed to occupations with high noise rankings demonstrated the greatest average annual rate of change (1.1 dB/year at 6000 Hz). Army personnel exposed to occupations with moderate noise rankings demonstrated the greatest average annual rate of change (0.6 dB/year at 6000 Hz). CONCLUSIONS: This study (1) demonstrates the unique use of DoD hearing conservation program data, (2) is the first analysis of hearing threshold changes over time using such data, and (3) adds to the limited literature on longitudinal changes in hearing. The difference in hearing threshold changes across military branches is likely indicative of their varying noise exposures, hearing protection device use and enforcement, and surveillance practices. Results suggest Marine Corps and Army personnel are at risk for hearing threshold changes and that, among Army personnel, this is most pronounced among those exposed to moderate levels of occupational noise exposure. Estimates of the rate of hearing threshold change by frequency and factors that impact hearing are useful to inform the DoD's efforts to protect the hearing of their Service members and to the Veterans Affairs's efforts to identify and rehabilitate those most likely to experience hearing threshold change.

Noise Outcomes in Servicemembers Epidemiology (NOISE) Study: Design, Methods, and Baseline Results.

OBJECTIVES: Military Service members and Veterans commonly report hearing loss and tinnitus, both of which can result in significant disability. During military service, Service members are exposed to many different types of loud noise, which is strongly associated with hearing loss and tinnitus. Other military-related exposures, such as chemicals and traumatic brain injury (TBI), are also linked with auditory problems. The purpose of the "Noise Outcomes in Servicemembers Epidemiology" (NOISE) study is to gather information from Active-Duty Service members and recently separated Veterans about their military and nonmilitary noise exposures, other relevant military and nonmilitary exposures, and potential outcomes of these exposures including tinnitus, hearing loss, and other hearing-related health concerns. DESIGN: The NOISE study assesses lifetime noise exposures, chemical and blast exposures, TBI, physical and psychiatric comorbidities, and other military and nonmilitary exposures and outcomes that can affect auditory function. Participants undergo comprehensive in-person audiologic examinations; those who experience tinnitus undergo a complete tinnitus assessment. Exposures and select outcomes are reassessed annually by mail, and the comprehensive in-person assessment is completed every 5 years. This report presents descriptive, baseline data obtained from the first 690 participants enrolled between 2014 and 2018. RESULTS: Some notable findings from this analysis include: (1) the prevalence of hearing loss in the sample was 8% for low frequencies (0.25 to 2 kHz), 20% for high frequencies (3 to 8 kHz), and 39% for extended high frequencies (9 to 16 kHz); (2) the prevalence of tinnitus was 53%; (3) the prevalence of both hearing loss and tinnitus was higher among those with higher age, more years of military service, greater degree of noise exposure, and exposures to blasts and/or TBI in the military; and (4) tinnitus was most prevalent among participants who serve/served in the Army relative to the other military branches. CONCLUSIONS: The NOISE study is acquiring comprehensive data on military-related auditory dysfunction. It is the first of its kind to enroll active Service members and recently separated Veterans into a longitudinal study to examine the etiology and outcomes of tinnitus and hearing loss in this population. Although these data do not necessarily represent the entire military and Veteran populations, ongoing enrollment is focused on increasing generalizability and will also provide the statistical power to conduct multivariable analyses. This will allow us to examine longitudinal associations of interest while controlling for potential confounders and other possible sources of error. These data will provide critical knowledge to refine future military hearing conservation efforts and inform efforts to develop future treatments.

Telephone-Based Progressive Tinnitus Management for Persons With and Without Traumatic Brain Injury: A Randomized Controlled Trial.

OBJECTIVES: This randomized controlled trial evaluated the efficacy of delivering coping skills education from Progressive Tinnitus Management (PTM) by telephone (Tele-PTM). The trial followed a previous pilot study that showed positive results for Tele-PTM. DESIGN: Participants included individuals with bothersome tinnitus (N = 205) located anywhere within the United States. A special emphasis was given to including individuals who had experienced one or more traumatic brain injuries (TBIs). Participants were randomized to either Tele-PTM intervention or 6-month wait-list control (WLC). The Tele-PTM intervention involved five telephone appointments-two led by an audiologist (teaching how to use therapeutic sound) and three by a psychologist (teaching coping skills derived from cognitive-behavioral therapy). It was hypothesized that Tele-PTM would be more effective than WLC in reducing functional effects of tinnitus as measured with the Tinnitus Functional Index. Additional outcome measures included the Self-Efficacy for Managing Reactions to Tinnitus questionnaire and the Hospital Anxiety and Depression Scale. The effect of Tele-PTM on outcomes was estimated using linear mixed models. RESULTS: Overall results showed convincingly that the Tele-PTM group had significantly better outcomes than the WLC group. These results were consistent across all outcome measures, indicating not only a reduction of tinnitus functional distress but also increased self-efficacy. Improvements in measures of anxiety and depression were also observed. Tele-PTM participants in all TBI categories showed significant improvement. CONCLUSIONS: Results provide strong support for use of Tele-PTM methodology for persons with bothersome tinnitus, regardless of whether the person also has TBI symptoms. The effect size for Tele-PTM was high for the primary outcome measure, the Tinnitus Functional Index, and all other outcome measures showed significant improvement. Combined with our previous pilot study, the Tele-PTM method is validated for potential nationwide provision of tinnitus services.

Comparison of acoustic therapies for tinnitus suppression: a preliminary trial.

OBJECTIVE: This study obtained preliminary data using two types of sound therapy to suppress tinnitus and/or reduce its functional effects: (1) Notched noise (1000-12,000 Hz notched within a 1-octave range centred around the tinnitus pitch match [PM] frequency); and (2) Matched noise (1-octave wide band of noise centred around the PM frequency). A third (Placebo) group listened to low frequency noise (250-700 Hz). DESIGN: Participants with bothersome tinnitus were randomised into one of the three groups and instructed to listen to the acoustic stimulus for 6 hours a day for 2 weeks. Stimuli were delivered using an iPod Nano, and tinnitus counselling was not performed. Outcome measures were recorded at the 0, 2 and 4 week study visits. STUDY SAMPLE: Thirty participants with constant and bothersome tinnitus were recruited and randomised. RESULTS: All groups showed, on average, overall improvement, both immediately post-treatment and 2 weeks following treatment. Outcomes varied between groups on the different measures and at the two outcome points. CONCLUSION: This study showed improvement for all of the groups, lending support to the premise that any type of sound stimulation is beneficial for relieving effects of tinnitus. These results may serve as a preliminary evidence for a larger study.

Development and field testing of a smartphone "App" for tinnitus management.

OBJECTIVE: This study's objective was to develop and test a smartphone app that supports learning and using coping skills for managing tinnitus. DESIGN: The app's content was based on coping skills that are taught as a part of progressive tinnitus management (PTM). The study involved three phases: (1) develop a prototype app and conduct usability testing; (2) conduct two focus groups to obtain initial feedback from individuals representing potential users; and (3) conduct a field study to evaluate the app, with three successive groups of participants. STUDY SAMPLE: Participants were adults with bothersome tinnitus. For Phase 2, two focus groups were attended by a total of 17 participants. Phase 3 involved three consecutive rounds of participants: five from the focus groups followed by two rounds with 10 participants each who had not seen the app previously. RESULTS: In both the focus groups and field studies, participants responded favourably to the content. Certain features, however, were deemed too complex. CONCLUSION: Completion of this project resulted in the development and testing of the delivery of PTM coping skills via a smartphone app. This new approach has the potential to improve access to coping skills for those with bothersome tinnitus.

Multisite Randomized Controlled Trial to Compare Two Methods of Tinnitus Intervention to Two Control Conditions.

OBJECTIVES: In this four-site clinical trial, we evaluated whether tinnitus masking (TM) and tinnitus retraining therapy (TRT) decreased tinnitus severity more than the two control groups: an attention-control group that received tinnitus educational counseling (and hearing aids if needed; TED), and a 6-month-wait-list control (WLC) group. The authors hypothesized that, over the first 6 months of treatment, TM and TRT would decrease tinnitus severity in Veterans relative to TED and WLC, and that TED would decrease tinnitus severity relative to WLC. The authors also hypothesized that, over 18 months of treatment, TM and TRT would decrease tinnitus severity relative to TED. Treatment effectiveness was hypothesized not to be different across the four sites. DESIGN: Across four Veterans affairs medical center sites, N = 148 qualifying Veterans who experienced sufficiently bothersome tinnitus were randomized into one of the four groups. The 115 Veterans assigned to TM (n = 42), TRT (n = 34), and TED (n = 39) were considered immediate-treatment subjects; they received comparable time and attention from audiologists. The 33 Veterans assigned to WLC were, after 6 months, randomized to receive delayed treatment in TM, TRT, or TED. Assessment of outcomes took place using the Tinnitus Handicap Inventory (THI) at 0, 3, 6, 12, and 18 months. RESULTS: Results of a repeated measures analysis of variance using an intention-to-treat approach showed that the tinnitus severity of Veterans receiving TM, TRT, and TED significantly decreased (p < 0.05) relative to Veterans in the WLC group at 3 months (effect sizes = 0.44, 0.52, and 0.27, respectively) and at 6 months (effect sizes = 0.52, 0.56, and 0.40, respectively). Analyses comparing effectiveness of TM, TRT, and TED over 18 months revealed that the three conditions were not significantly different, but that tinnitus severity in the combined groups significantly decreased (p < 0.01) from baseline to 3 months (5.6 THI points) and from 3 to 6 months (3.7 THI points). With respect to clinically significant change, about half of Veterans who received TM (55%), TRT (59%), or TED (46%) showed strong or modest improvement on the THI by 18 months. Without treatment, the WLC group did not show significant change. Treatment effectiveness did not differ by study site. CONCLUSIONS: Audiologists who provided interventions to Veterans with bothersome tinnitus in the regular clinic setting were able to significantly reduce tinnitus severity over 18 months using TM, TRT, and TED approaches. These results suggest that TM, TRT, and TED, when implemented as in this trial, will provide effectiveness that is relatively similar by 6 months and beyond.

Hearing impairment and tinnitus: prevalence, risk factors, and outcomes in US service members and veterans deployed to the Iraq and Afghanistan wars.

Hearing loss and tinnitus are the 2 most prevalent service-connected disabilities among veterans in the United States. Veterans of Operations Enduring Freedom, Iraqi Freedom, and New Dawn have been exposed to multiple hazards associated with these conditions, such as blasts/explosions, ototoxic chemicals, and most notably high levels of noise. We conducted a systematic literature review of evidence on 1) prevalence of, 2) risk and protective factors for, and 3) functional and quality-of-life outcomes of hearing impairment and tinnitus in US Operations Enduring Freedom, Iraqi Freedom, and New Dawn veterans and military personnel. We identified studies published from 2001 through 2013 using PubMed, PsycINFO, REHABDATA, Cochrane Library, pearling, and expert recommendation. Peer-reviewed English language articles describing studies of 30 or more adults were included if they informed one or more key questions. A total of 839 titles/abstracts were reviewed for relevance by investigators trained in critical analysis of literature; 14 studies met inclusion criteria. Of these, 13 studies presented data on prevalence and 4 on risk/protective factors, respectively. There were no included studies reporting on outcomes. Findings from this systematic review will help inform clinicians, researchers, and policy makers on future resource and research needs pertaining to hearing impairment and tinnitus in this newest generation of veterans.

Validation of a novel combination hearing aid and tinnitus therapy device.

OBJECTIVES: Most patients with tinnitus also have hearing loss. Hearing aids have been well-documented to provide amelioration for both hearing and tinnitus problems. Some hearing aids have built-in noise/sound generators that are intended to provide added benefit to patients with tinnitus. It has not been proven, however, whether these "combination instruments" are more effective for tinnitus management than hearing aids alone. The purpose of this study was to collect initial data addressing this question. DESIGN: Thirty individuals meeting study requirements (bothersome tinnitus, hearing aid candidate, and no use of hearing aids for the previous 12 months) were enrolled. All participants initially completed the primary outcome questionnaire (Tinnitus Functional Index [TFI]) and then returned to be fitted with combination instruments. The hearing aid portion of the devices was adjusted to optimize hearing ability. Participants were then randomized to either the experimental group (n = 15) or the control group (n = 15). The experimental group had the noise feature of the instruments activated and adjusted to achieve optimal relief from tinnitus. The control group did not have the noise portion activated. Following the hearing aid fitting, all study participants also received brief tinnitus counseling. Participants returned 1 to 2 weeks later for a follow-up appointment to confirm proper fit of the instruments and to make any necessary programming adjustments. Additionally, they returned 3 months after the fitting to complete the TFI, which also concluded their participation in the study. RESULTS: Both groups revealed significant improvement, as indicated by reductions in mean TFI index scores. Differences between groups at 3 months were not statistically significant. However, the experimental group showed a mean reduction in the TFI score that was 6.4 points greater than that for the control group. The difference approached significance (p = 0.09), suggesting that a larger group of participants may have resulted in a significant difference between groups. This possibility is tempered by the fact that effect sizes, which control for variation, were very similar between groups. CONCLUSIONS: Results of this study suggest that the use of hearing aids alone or hearing aids plus the use of sound generators both provide significant benefit with respect to alleviating effects of tinnitus. A larger controlled clinical trial is needed to obtain more definitive results regarding the two configurations of hearing aids.

A Bayesian perspective on tinnitus pitch matching.

OBJECTIVES: New tinnitus therapies are being developed and marketed that target the patient's tinnitus frequency. This frequency is estimated clinically by pitch matching, which has the patient identify the pure tone that is closest to the perceived tinnitus frequency. Though widely used, pitch matching is heavily criticized as unreliable, and the degree of reliability varies among patients. At the very least, it is recommended that multiple pitch matches be used to identify the patient's tinnitus frequency. Even so, it is not clear how many pitch matches to collect, how they should be combined, or how doing so will enhance the audiologist's certainty about the true tinnitus frequency. In this article, we describe a simple Bayesian method of sequentially combining pitch matches until acceptable precision is achieved and illustrate the method in 10 patients with chronic tinnitus. DESIGN: Subjects were recruited from previous study participants and support group attendees at the National Center for Rehabilitative Auditory Research. Thirty tinnitus pitch matches were elicited from 10 patients with chronic, monotonal tinnitus. RESULTS: A Bayesian sequential analysis yielded estimated tinnitus frequencies for 7 patients that were within one-quarter octave of their true value with 90% certainty. Between four and twenty pitch matches were required to achieve acceptable results in these seven patients. CONCLUSIONS: Despite criticism, pitch matching is widely used to estimate tinnitus frequency. We address reliability concerns with a Bayesian sequential analysis to jointly estimate tinnitus frequency and reliability. The method is easily applied.

Toward development of a tinnitus magnitude index.

OBJECTIVES: The aim of the study was to provide preliminary evidence of a unique "tinnitus magnitude" domain describing intensity of tinnitus perception that will assist in the development of a cognitive-behavioral mediation model of psychological distress associated with tinnitus. DESIGN: A sample of 347 participants with tinnitus was previously recruited from four audiology clinics for the purpose of developing a tinnitus distress measure, the Tinnitus Functional Index (TFI). From the questions used for TFI development, potential tinnitus magnitude items were selected by including those that minimally overlapped with tinnitus reactions. The three items having the least overlap were analyzed retrospectively to assess internal consistency, test-retest reliability, group differences using demographics and tinnitus-relevant descriptive variables, and discriminant validity. The three-item scale was developed in an effort to establish a model for prospective development of a Tinnitus Magnitude Index (TMI) that would assess the magnitude of tinnitus variables independent of reactions to tinnitus. RESULTS: Internal consistency (α = 0.86) and repeated measures tests (r = 0.74, df = 29, p < 0.001) indicate the three-item scale is reliable. Discriminant validity was supported by only moderate correlations (r≥ 0.30 and r ≤ 0.69) of the scale with the Tinnitus Handicap Inventory (r = 0.62), the Beck Depression Inventory for Primary Care (r = 0.38), and the seven independent domains of tinnitus reactions measured using subscales of the TFI (r = 0.49 to 0.72). Correlations between the scale and two tinnitus reactions (distress) subscales were high (r > 0.70) as compared with moderate correlations. CONCLUSIONS: This study involved a retrospective analysis of data from questions that were originally evaluated for use in a tinnitus outcome questionnaire. The analysis was conducted to establish a model for prospective development of a TMI. Results of this analysis suggest that a TMI can be developed that would provide a reliable and valid measure of tinnitus magnitude that overlaps minimally in content with measures of cognitive, behavioral, and emotional tinnitus reactions. A fully validated TMI would provide a measure of tinnitus magnitude that is not confounded by emotional reactions to tinnitus or general depressive symptoms and would be useful in developing a testable model of psychological distress due to tinnitus. Although the primary goal is to develop a measure of tinnitus magnitude that predicts cognitive, behavioral, and emotional reactions to tinnitus, a TMI may also have utility in assessing this construct in clinical settings.

Rehabilitation Service Needs and Preferences among Veterans with Tinnitus: A Qualitative Study.

Tinnitus is prevalent among military Veterans, yet there is a gap between the demand and the provision of services for tinnitus rehabilitation services within the Veterans Health Administration (VHA). We sought to understand tinnitus rehabilitation service needs and preferences among Veterans with bothersome tinnitus who use Veterans Affairs (VA) services. We conducted semistructured telephone interviews in 2019 with Veterans diagnosed with tinnitus, who reported it as bothersome. Veterans were purposively sampled to represent national VA users, with and without comorbid traumatic brain injury (TBI), and who were or were not interested in tinnitus rehabilitation services. Qualitative data were analyzed using a modified grounded theory approach. Among 40 Veterans interviewed (32 men, 8 women; 50% with TBI), 72.5% endorsed being somewhat/very likely to be interested in tinnitus rehabilitation services while 27.5% were very/somewhat unlikely. Themes related to Veterans' interest in tinnitus rehabilitation services included barriers and facilitators to participation and preferences for receiving tinnitus services (e.g., individual vs. group-based; in-person vs. remote access). Our findings highlight factors that influence Veterans' reported need and preferences for, and readiness to engage in, rehabilitation services for tinnitus. Personalized or otherwise adaptable approaches to program delivery may help ensure maximal uptake among Veterans.

A Pilot Study to Evaluate a Residual Inhibition Technique in Hearing Aids for Suppression of Tinnitus.

Tinnitus acoustic therapy is defined as any use of sound where the intent is to alter the tinnitus perception and/or the reactions to tinnitus in a clinically beneficial way. The parameters of sound that may cause beneficial effects, however, are currently only theorized with limited data supporting their effectiveness. Residual inhibition is the temporary suppression or elimination of tinnitus that is usually observed following appropriate auditory stimulation. Our pilot study investigated the effects of a therapeutic acoustic stimulus that was individually customized to maximize residual inhibition of tinnitus and extend its duration to determine if there could be a sustained suppression of the tinnitus signal (i.e., reduced tinnitus loudness) and a reduction in the psychological and emotional reactions to tinnitus. This pilot study had two objectives: (1) to evaluate the feasibility of residual inhibition technique therapy through daily use of hearing aids and (2) to determine its effects by measuring reactionary changes in tinnitus with the Tinnitus Functional Index (TFI) and perceptual changes in tinnitus loudness. A total of 20 adults (14 males, 6 females; mean age: 58 years, SD = 12.88) with chronic tinnitus were enrolled in a four-visit study that consisted of the following: (1) baseline visit and initiation of the intervention period, (2) a 1-month postintervention visit, (3) 2-month postintervention visit and initiation of a wash-out period, and (4) a 3-month visit to assess the wash-out period and any lasting effects of the intervention. The intervention consisted of fitting bilateral hearing aids and creating an individualized residual inhibition stimulus that was streamed via Bluetooth from a smartphone application to the hearing aids. The participants were instructed to wear the hearing aids and stream the residual inhibition stimulus all waking hours for the 2-month intervention period. During the wash-out period, the participants were instructed to use the hearing aids for amplification, but the residual inhibition stimulus was discontinued. At all visits, the participants completed the TFI, study-specific self-report measures to document perceptions of tinnitus, a psychoacoustic test battery consisting of tinnitus loudness and pitch matching, and a residual inhibition test battery consisting of minimum masking and minimum residual inhibition levels. At the end of the trial, participants were interviewed about the study experience and acceptability of the residual inhibition treatment technique. Repeated measures analyses of variance (ANOVA) were conducted on the two main outcomes (TFI total score and tinnitus loudness) across all four visits. The results showed a significant main effect of visit on the TFI total score ( p < 0.0001). Specifically, the results indicated a significant reduction in TFI total scores from baseline to the 1-month post-intervention period, which remained stable across the 2-month post-intervention period and the wash-out period. The ANOVA results did not show a significant change in tinnitus loudness as a function of visit ( p = 0.480). The majority of the participants reported a positive experience with the study intervention at their exit interview. This pilot study demonstrated that residual inhibition as a sound therapy for tinnitus, specifically through the daily use of hearing aids, was feasible and acceptable to individuals suffering from chronic tinnitus. In addition, participants showed improvement in reactions to tinnitus as demonstrated by sustained reduction in TFI scores on average over the course of the treatment period. Achieving residual inhibition may also provide patients a feeling of control over their tinnitus, and this may have a synergistic effect in reducing the psychological and emotional distress associated with tinnitus. There was no significant reduction in long-term tinnitus loudness resulting from the residual inhibition treatment; however, the current pilot study may not have had sufficient power to detect such a change. The combination of tinnitus suppression and improved psychosocial/emotional reactions to tinnitus may result in a better quality of life in both the short and long term. A larger-scale study is needed to determine the validity of using residual inhibition as a clinical therapy option and to ascertain any effects on both perception and reactions to tinnitus.

History of Tinnitus Research at the VA National Center for Rehabilitative Auditory Research (NCRAR), 1997-2021: Studies and Key Findings.

The Veterans Affairs (VA) Rehabilitation Research & Development (RR&D) National Center for Rehabilitative Auditory Research (NCRAR) was first funded by the RR&D Service in 1997 and has been funded continuously since that time. The overall purpose of the NCRAR is to "improve the quality of life of Veterans and others with hearing and balance problems through clinical research, technology development, and education that leads to better patient care" ( www.ncrar.research.va.gov ). An important component of the research conducted at the NCRAR has been a focus on clinical and rehabilitative aspects of tinnitus. Multiple investigators have received grants to conduct tinnitus research and the present article provides an overview of this research from the NCRAR's inception through 2021.

The Impact of Tinnitus Severity on Work Functioning among U.S. Military Veterans with Tinnitus.

Tinnitus is highly prevalent among military Veterans. Severe tinnitus can be associated with negative impacts on daily life. Veterans with severe tinnitus may also have greater difficulties in functional roles, including work. However, few studies have explicitly explored this relationship. Traumatic brain injury (TBI), also prevalent among Veterans, is associated with tinnitus and can additionally impair work functioning. This quantitative investigation used a population-based survey to assess the relationship between tinnitus severity, measured using the Tinnitus Functional Index (TFI), and the impact of tinnitus on work, measured using a composite score from the Tinnitus History Questionnaire, among a stratified random sample of VA healthcare-using Veterans diagnosed with tinnitus, with and without comorbid TBI. Analyses were weighted to account for sampling design and Veteran non-response; multiple imputation was used to account for missing data. Results indicated that for every 1-point increase in TFI score, there was an average 8% increase in the odds of reporting a high level of impact on work functioning (OR: 1.08; 95% CI: 1.06, 1.11). Veterans with a comorbid TBI diagnosis, compared with those without, were more likely to have high tinnitus-related impact on work functioning (OR: 2.69, 95% CI: 1.85, 3.91), but the relationship between tinnitus severity and the impact of tinnitus on work functioning did not differ by TBI status. These data can help researchers and clinicians understand complex symptoms experienced by Veterans with tinnitus, with and without TBI, supporting the improved provision of clinical services to these patients.

Computer-automated tinnitus assessment: noise-band matching, maskability, and residual inhibition.

BACKGROUND: Psychoacoustic measures of tinnitus typically include loudness and pitch match, minimum masking level (MML), and residual inhibition (RI). We previously developed and documented a computer-automated tinnitus evaluation system (TES) capable of subject-guided loudness and pitch matching. The TES was further developed to conduct computer-aided, subject-guided testing for noise-band matching (NBM), MML, and RI. PURPOSE: The purpose of the present study was to document the capability of the upgraded TES to obtain measures of NBM, MML, and RI, and to determine the test-retest reliability of the responses obtained. RESEARCH DESIGN: Three subject-guided, computer-automated testing protocols were developed to conduct NBM. For MML and RI testing, a 2-12 kHz band of noise was used. All testing was repeated during a second session. STUDY SAMPLE: Subjects meeting study criteria were selected from those who had previously been tested for loudness and pitch matching in our laboratory. A total of 21 subjects completed testing, including seven females and 14 males. RESULTS: The upgraded TES was found to be fairly time efficient. Subjects were generally reliable, both within and between sessions, with respect to the type of stimulus they chose as the best match to their tinnitus. Matching to bandwidth was more variable between measurements, with greater consistency seen for subjects reporting tonal tinnitus or wide-band noisy tinnitus than intermediate types. Between-session repeated MMLs were within 10 dB of each other for all but three of the subjects. Subjects who experienced RI during Session 1 tended to be those who experienced it during Session 2. CONCLUSIONS: This study may represent the first time that NBM, MML, and RI audiometric testing results have been obtained entirely through a self-contained, computer-automated system designed specifically for use in the clinic. Future plans include refinements to achieve greater testing efficiency.