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.

Prevalence of Somatosensory Tinnitus in Veterans With Tinnitus.

OBJECTIVES: The primary objective was to estimate the prevalence of somatosensory tinnitus (ST) among Veterans with tinnitus. DESIGN: Three hundred four Veterans with tinnitus were phone screened for ST by performing and reporting on a series of head/neck/jaw maneuvers. A random sample of 12 individuals who screened positive and five who screened negative attended an in-person visit to confirm the presence/absence of ST. RESULTS: Of the 304 Veterans, 12 could not complete the screening maneuvers, 205 screened positive, and 87 screened negative. A Bayesian estimator that combines phone screening and in-person exam results establishes the prevalence of ST among Veterans with tinnitus at 56% with a 90% Bayesian confidence interval of 45% to 65%. CONCLUSIONS: At least half of Veterans with tinnitus have ST, suggesting that a sizable at-need population exists. Treatment addressing the biomechanical component has the potential to improve tinnitus symptoms.

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.

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.

Noise sensitivity or hyperacusis? Comparing the Weinstein and Khalfa questionnaires in a community and a clinical samples.

Noise sensitivity and hyperacusis are decreased sound tolerance conditions that are not well delineated or defined. This paper presents the correlations and distributions of the Noise Sensitivity Scale (NSS) and the Hyperacusis Questionnaire (HQ) scores in two distinct large samples. In Study 1, a community-based sample of young healthy adults (n = 103) exhibited a strong correlation (r = 0.74) between the two questionnaires. The mean NSS and HQ scores were 54.4 ± 16.9 and 12.5 ± 7.5, respectively. NSS scores displayed a normal distribution, whereas HQ scores showed a slight positive skew. In Study 2, a clinical sample of Veterans with or without clinical comorbidities (n = 95) showed a moderate correlation (r = 0.58) between the two questionnaires. The mean scores were 66.6 ± 15.6 and 15.3 ± 7.3 on the NSS and HQ, respectively. Both questionnaires' scores followed a normal distribution. In both samples, participants who self-identified as having decreased sound tolerance scored higher on both questionnaires. These findings provide reference data from two diverse sample groups. The moderate to strong correlations observed in both studies suggest a significant overlap between noise sensitivity and hyperacusis. The results underscore that NSS and HQ should not be used interchangeably, as they aim to measure distinct constructs, however to what extent they actually do remains to be determined. Further investigation should distinguish between these conditions through a comprehensive psychometric analysis of the questionnaires and a thorough exploration of psychoacoustic, neurological, and physiological differences that set them apart.

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.

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.

Tinnitus Screener: Short-Term Test-Retest Reliability.

PURPOSE: The Tinnitus Screener was introduced in 2015 as a four-item algorithmic instrument to assess the temporal characteristics of a person's reported tinnitus. The Tinnitus Screener was then revised as a six-item version to include a new temporal category and to capture tinnitus duration (acute < 6 months vs. chronic ≥ 6 months). When contrasted with audiologist assessment, the four-item Tinnitus Screener was determined to be highly valid, but the short-term reliability of either version remained unknown. The present analysis focused on determining the test-retest reliability of the six-item Tinnitus Screener. Additionally, we sought to determine whether reliability differed by respondent age, sex, military status, and hearing loss. METHOD: The Tinnitus Screener was administered to 190 military Service members and 250 military Veterans at two time points separated by 7-31 days. Our analysis focused on test-retest reliability of responses as measured by the kappa coefficient, overall and within subsamples. Percent agreement of tinnitus categorization (temporal categories) and classification (positive/negative) between the two time points was also evaluated. RESULTS: Constant or intermittent tinnitus was found in 31% of Service members and 53% of Veterans. Overall, kappa reliability coefficients were high, near .80, indicating substantial reliability. The majority (96%) of reliability coefficients for the Tinnitus Screener within subsamples were similarly high, ranging from .68 to .88. CONCLUSIONS: The updated version of the Tinnitus Screener is shown to be a reliable instrument. The Tinnitus Screener is recommended to inform clinical decision making by determining the temporal characteristics of tinnitus.

Feasibility of ecological momentary assessment of hearing difficulties encountered by hearing aid users.

OBJECTIVES: Measurement of outcomes has become increasingly important to assess the benefit of audiologic rehabilitation, including hearing aids, in adults. Data from questionnaires, however, are based on retrospective recall of events and experiences, and often can be inaccurate. Questionnaires also do not capture the daily variation that typically occurs in relevant events and experiences. Clinical researchers in a variety of fields have turned to a methodology known as ecological momentary assessment (EMA) to assess quotidian experiences associated with health problems. The objective of this study was to determine the feasibility of using EMA to obtain real-time responses from hearing aid users describing their experiences with challenging hearing situations. DESIGN: This study required three phases: (1) develop EMA methodology to assess hearing difficulties experienced by hearing aid users; (2) make use of focus groups to refine the methodology; and (3) test the methodology with 24 hearing aid users. Phase 3 participants carried a personal digital assistant 12 hr per day for 2 weeks. The personal digital assistant alerted participants to respond to questions four times a day. Each assessment started with a question to determine whether a hearing problem was experienced since the last alert. If "yes," then up to 23 questions (depending on contingent response branching) obtained details about the situation. If "no," then up to 11 questions obtained information that would help to explain why hearing was not a problem. Each participant completed the Hearing Handicap Inventory for the Elderly (HHIE) both before and after the 2-week EMA testing period to evaluate for "reactivity" (exacerbation of self-perceived hearing problems that could result from the repeated assessments). RESULTS: Participants responded to the alerts with a 77% compliance rate, providing a total of 991 completed momentary assessments (mean = 43.1 per participant). A substantial amount of data were obtained with the methodology. It is important to note that participants reported a "hearing problem situation since the last alert" 37.6% of the time (372 responses). The most common problem situation involved "face-to-face conversation" (53.8% of the time). The next most common problem situation was "telephone conversation" (17.2%) followed by "TV, radio, iPod, etc." (15.3%), "environmental sounds" (9.7%), and "movies, lecture, etc." (4.0%). Comparison of pre- and post-EMA mean HHIE scores revealed no significant difference (p > 0.05), indicating that reactivity did not occur for this group. It should be noted, however, that 37.5% of participants reported a greater sense of awareness regarding their hearing loss and use of hearing aids. CONCLUSIONS: Results showed participants were compliant, gave positive feedback, and did not demonstrate reactivity based on pre- and post-HHIE scores. We conclude that EMA methodology is feasible with patients who use hearing aids and could potentially inform hearing healthcare (HHC) services. The next step is to develop and evaluate EMA protocols that provide detailed daily patient information to audiologists at each stage of HHC. The advantages of such an approach would be to obtain real-life outcome measures, and to determine within- and between-day variability in outcomes and associated factors. Such information at present is not available from patients who seek and use HHC services.

Pilot study to evaluate ecological momentary assessment of tinnitus.

OBJECTIVES: Because audiometric evaluation, symptom histories, questionnaires, and similar standard assessment tools may not adequately sample the effects of chronic tinnitus on day-to-day activities, there is a need for alternative methodological approaches to study the impact of tinnitus on day-to-day life. An innovative methodological approach that has shown great promise in the study of chronic health problems characterized by reported temporal and/or situational variability in symptoms and distress is known as ecological momentary assessment (EMA). EMA involves the real-time measurement of states, situational factors, and symptoms by individuals as they go about their day-to-day activities. The objective of this pilot investigation was to explore the feasibility of using EMA methods to examine within- and between-day effects of tinnitus. DESIGN: This study was conducted in three phases: (1) design and development of an EMA methodology that could be used to assess effects of tinnitus; (2) refinement of the methodology through the use of two focus groups; and (3) field-test the methodology with individuals who experienced bothersome tinnitus. For Phase 3, each of the 24 participants wore, throughout their waking hours for 2 weeks, a personal digital assistant that produced alerts four times a day. The alerts prompted participants to respond to 19 questions, including 9 relating to situational and mood factors and 10 comprising the Tinnitus Handicap Inventory-Screening version (THI-S). To evaluate for potential reactive effects of performing the EMA protocol, each participant completed the paper-and-pencil version of the full 25-item THI before and after the 2-week EMA period. RESULTS: Participants responded to the alerts with a 90% compliance rate, providing a total of 1210 completed surveys. At the time of their response, participants indicated that they were in their house or apartment (67.7%), alone (50.2%), happy (50%), and calm (54.5%). Across most responses, participants could hear their tinnitus (97%), and the loudness of their tinnitus averaged 4.7 on a 7-point increasing-loudness scale. The mean THI-S index score (out of a possible maximum 40 points for greatest tinnitus severity) was 17.0 (moderate self-perceived tinnitus handicap). Repeated THI-S index scores varied considerably both within and between participants. Mean 25-item THI scores were not significantly different before and after the EMA period, suggesting little reactivity of the EMA. CONCLUSIONS: The high compliance rate, positive feedback from participants, lack of reactivity as a result of performing the EMA protocol, and data collected indicate that EMA methodology is feasible with patients who have tinnitus. Outcome data obtained with this methodology cannot be obtained any other way because retrospective questionnaires cannot capture the day-to-day reactions. This methodology has the potential to provide more in-depth and accurate assessments of patients receiving therapy for tinnitus.

Progressive Tinnitus Management Level 3 Skills Education: A 10-Year Clinical Retrospective.

PURPOSE: The purpose of this study was to examine progressive tinnitus management (PTM) Level 3 skill utilization among Veterans in the Bay Pines Veterans Affairs Healthcare System 6-10 years after completing the PTM workshops. METHOD: In fiscal year 2020, the Tinnitus Workshop Follow-Up form was mailed to Veterans who completed the workshops during fiscal years 2010-2014. Veterans were identified as receiving care via the traditional face-to-face method or clinical video telehealth (CVT). Data were compiled to determine which, if any, PTM skills were being used 6-10 years later and the impact on self-reported ratings of well-being. RESULTS: More than half of the respondents reported using all four self-management skills up to 10 years postcompletion; relaxation was utilized by more Veterans than the other three skills. Approximately 69% reported improved ability to control reactions to tinnitus. At least half reported ratings of improved well-being. Eighty-eight percent of the respondents said they would recommend the workshops to someone with bothersome tinnitus. Veterans who received care via CVT reported using fewer skills than those who received care face-to-face; however, the CVT respondents reported the same or slightly better ability to cope with tinnitus, less bothersome tinnitus, and improved ratings of well-being. Finally, most participants who responded to an open-ended question about their workshop experience reported it as positive. CONCLUSIONS: This clinical focus project suggests that PTM Level 3 skills continue to be utilized up to 10 years after participation in the workshops. Although there were reductions in the number of skills used, Veterans' ability to manage reactions to tinnitus and improvement in self-reported ratings of well-being indicate successful ongoing tinnitus management efforts. Respondents who received care via CVT did not report lower self-reported ratings of well-being or appear less likely to recommend Level 3 group PTM to other Veterans with bothersome tinnitus.

Tinnitus: An Epidemiologic Perspective.

Tinnitus is commonly referred to as "ringing in the ears." Epidemiologic studies highlight challenges associated with clinical determination of tinnitus and ascertainment of its etiology, functional effects, temporal characteristics, psychoacoustic parameters, and risk factors. Because no standards exist for capturing these factors as measures, direct comparison of data between studies is not possible. This report suggests terminology and definitions to promote standardization, with a brief overview of findings from selected population-based epidemiologic studies. Tinnitus-specific data are presented from the Noise Outcomes in Servicemembers Epidemiology study. Further epidemiologic studies are needed to develop tinnitus treatment and a cure for this chronic condition.

Factors affecting the implementation of evidence-based Progressive Tinnitus Management in Department of Veterans Affairs Medical Centers.

PURPOSE: Progressive Tinnitus Management (PTM) is an evidence-based interdisciplinary stepped-care approach to improving quality of life for patients with tinnitus. PTM was endorsed by Department of Veterans Affairs (VA) Audiology leadership in 2009. Factors affecting implementation of PTM are unknown. We conducted a study to: 1) estimate levels of PTM program implementation in VA Audiology and Mental Health clinics across the country; and 2) identify barriers and facilitators to PTM implementation based on the experiences of VA audiologists and mental health providers. METHOD: We conducted an anonymous, web-based survey targeting Audiology and Mental Health leaders at 144 major VA facilities. Quantitative analyses summarized respondents' facility characteristics and levels of program implementation (full PTM, partial PTM, or no PTM). Qualitative analyses identified themes in factors influencing the implementation of PTM across VA sites. RESULTS: Surveys from 87 audiologists and 66 mental health clinicians revealed that few facilities offered full PTM; the majority offered partial or no PTM. Inductive analysis of the open-ended survey responses identified seven factors influencing implementation of PTM: 1) available resources, 2) service collaboration, 3) prioritization, 4) Veterans' preferences and needs, 5) clinician training, 6) awareness of (evidence-based) options, and 7) perceptions of scope of practice. CONCLUSION: Results suggest wide variation in services provided, a need for greater engagement of mental health providers in tinnitus care, and an interest among both audiologists and mental health providers in receiving tinnitus-related training. Future research should address barriers to PTM implementation, including methods to: 1) improve understanding among mental health providers of their potential role in tinnitus management; 2) enhance coordination of tinnitus-related care between health care disciplines; and 3) collect empirical data on Veterans' need for and interest in PTM, including delivery by telehealth modalities.

Vitreo-retinal traction and anastrozole use.

PURPOSE: This study tested a prediction stemming from the hypothesis that anastrozole users experience heightened vitreo-retinal traction. This hypothesis was based on the knowledge that menopause increases the risk of intraocular tractional events such as posterior vitreous detachments (PVDs). METHODS: Retinal thickness was measured for 3 groups of amenorrheic women: (1) anastrozole users and (2) tamoxifen users undergoing adjuvant therapy for early-stage breast cancer, and (3) control subjects not using hormonal medication. Foveal shape indices were derived for subjects without PVDs. RESULTS: For anastrozole users, the distance to the temporal side of the fovea became less than the distance to the nasal side at a sufficient height above the foveal base. This effect did not exist for control subjects; the between-group difference was appreciable. Results concerning tamoxifen users were inconclusive. CONCLUSIONS: The foveas of women using anastrozole appear to be subjected to more tractional force than are the foveas of women not using any hormonal medication.

Perception Versus Reaction: Comparison of Tinnitus Psychoacoustic Measures and Tinnitus Functional Index Scores.

Purpose Psychoacoustic characteristics of tinnitus include its loudness and pitch. These characteristics are commonly measured and reported; however, it has not been shown that they are associated with the impact, or bothersomeness, of tinnitus. This study addressed this question by determining correlations between measures of tinnitus loudness, tinnitus pitch, and functional effects of tinnitus. Method Tinnitus loudness matches, pitch matches, a numeric rating scale (NRS) of tinnitus loudness, and responses to the 25-item tinnitus functional index (TFI) were obtained from 223 participants who experienced tinnitus for at least 6 months. Estimates of tinnitus pitch were calculated by use of a Bayesian sequential analysis technique. Results The total TFI score, as well as each of its 8 subscales, had weak or no correlations with both loudness matches and pitch matches, but moderate correlations with the NRS. Conclusions Psychoacoustic measurements used to estimate aspects of tinnitus perception appear unrelated to the impact of tinnitus, as assessed by a subjective outcome instrument. These psychoacoustic measurements do not assess reactions to tinnitus. These reactions should be measured by validated questionnaires, such as the TFI, which are designed to measure tinnitus impact. The moderate correlations between the NRS and the TFI suggest that self-reported tinnitus loudness is more a measure of tinnitus reactions than perception.

Comparison of Tinnitus Loudness Measures: Matching, Rating, and Scaling.

Purpose Chronic tinnitus ("ringing in the ears") is a phantom auditory perception with no cure. A goal of treatment is often to reduce the loudness of tinnitus. However, tinnitus loudness cannot be measured objectively. It is most commonly assessed by obtaining a loudness match (LM) with a pure tone and by using a numeric rating scale (NRS). Constrained loudness scaling (CLS) is a more recent measure of tinnitus loudness that utilizes auditory training of a fixed loudness scale to guide tinnitus loudness judgments. The purpose of this study was to compare results using these 3 measures of tinnitus loudness. Method This study obtained tinnitus loudness measures of LM, NRS, and CLS with 170 participants. These participants are part of a larger study obtaining repeated measures over 6 months. Only baseline data are presented. Results Correlations between all measures were weak to moderate: LM versus CLS ( r = .46), CLS versus NRS ( r = .49), and LM versus NRS ( r = .38). Conclusion Further systematic research is needed to more fully understand the relationships between these different measures and to establish a valid measure of tinnitus loudness.