One Step Closer towards a Reliable Tinnitus Pitch-Match Frequency Determination Using Repetitive Recursive Matching.

INTRODUCTION: The determination of the tinnitus pitch-match (PM) frequency is not straightforward but an important audiological assessment recommended for clinical and research purposes. We evaluated repetitive recursive matching using an iPod-based matching procedure as a method to estimate a patient's PM frequency without audiometric equipment. METHODS: One hundred and seventeen patients with chronic tonal tinnitus (uni- and bilateral tinnitus) measured their tinnitus in 10 sessions using a self-administered automated iPod-based procedure comprising a recursive 2 interval forced-choice test. RESULTS: Mean SD of the PM frequency of all participants across sessions was 0.41 octaves. The internal consistency measured by Cronbach's α was very high (0.8->0.95). As an example, 7 PMs obtained excellent internal consistency (α = 0.93). The exclusion of the first and/or second session led to more definite PMs with a decreased SD. Outliers were identified by PMs departing 2 SDs (i.e., 0.94 octaves) from the mean variability (n = 5). CONCLUSION: Repetitive recursive matching together with recommendations for the exclusion of initial and redundant sessions as well as outlier identification and treatment can enable a reliable estimation of the PM frequency.

A preliminary study on time-compressed speech recognition in noise among teenage students who use personal listening devices.

OBJECTIVE: To compare speech perception obtained with different time compression rates in teenagers that do or do not use personal listening devices (PLDs). DESIGN: Teenagers in a high school were recruited to complete questionnaires reporting their recreational noise exposure using PLDs. The dose of individual recreational noise exposure was calculated. The individuals with the most and least doses of recreational noise were selected and grouped into PLD users and non-PLD users. Normal rate and time-compressed (60% and 70%) speech recognition in quiet and noisy conditions was measured. STUDY SAMPLE: PLD user and non-PLD user group each included 20 participants. RESULTS: ANOVA analysis showed that the effect of group, background, compression rate, and interactions between any two factors are significant. Post hoc analysis showed that the speech recognition scores with normal rate in quiet and noise and those obtained from time-compressed speech in the quiet condition were not significantly different between PLD users and non-PLD users. However, differences in the time-compressed speech recognition scores (60% and 70%) in noisy conditions between the two groups were statistically significant. CONCLUSIONS: The fast-speed speech recognition in noise decreased significantly in PLD users compared with that in non-PLD users selected by extreme entertainment exposure.

No Reliable Association Between Recreational Noise Exposure and Threshold Sensitivity, Distortion Product Otoacoustic Emission Amplitude, or Word-in-Noise Performance in a College Student Population.

OBJECTIVES: The purpose of this study was to evaluate the relationship between recreational sound exposure and potentially undiagnosed or subclinical hearing loss by assessing sound exposure history, threshold sensitivity, distortion product otoacoustic emission (DPOAE) amplitudes, and performance on the words-in-noise (WIN) test. DESIGN: Survey data were collected from 74 adult participants (14 male and 60 female), 18 to 27 years of age, recruited via advertisements posted throughout the University of Florida campus. Of these participants, 70 completed both the survey and the additional functional test battery, and their preferred listening level was measured in a laboratory setting. RESULTS: There were statistically significant relationships between hearing thresholds and DPOAE amplitude. In contrast, performance on the WIN was not reliably related to threshold sensitivity within this cohort with largely normal hearing. The two most common exposures included bars or dance clubs, followed by music player use. There were no statistically significant relationships between individual or composite measures of recreational sound exposure, including preferred listening level, years of music player use, number of reported sound exposures, previous impulse noise exposure, or previous noise-induced change in hearing, and functional measures including threshold, DPOAE amplitude, and WIN measures. Some subjects were highly consistent in listening level preferences, while others were more variable from song to song. CONCLUSIONS: No reliable relationships between common recreational sound exposure or previous noise-induced changes in hearing were found during analysis of threshold sensitivity, DPOAE amplitude, or WIN performance in this cohort. However, the study sample was predominantly female and Caucasian, which limits generalizability of the results.

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.

A feasibility study of predictable and unpredictable surf-like sounds for tinnitus therapy using personal music players.

OBJECTIVE: To evaluate the feasibility of predictable or unpredictable amplitude-modulated sounds for tinnitus therapy. DESIGN: The study consisted of two parts. (1) An adaptation experiment. Loudness level matches and rating scales (10-point) for loudness and distress were obtained at a silent baseline and at the end of three counterbalanced 30-min exposures (silence, predictable and unpredictable). (2) A qualitative 2-week sound therapy feasibility trial. Participants took home a personal music player (PMP). STUDY SAMPLE: Part 1: 23 individuals with chronic tinnitus and part 2: seven individuals randomly selected from Part 1. RESULTS: Self-reported tinnitus loudness and annoyance were significantly lower than baseline ratings after acute unpredictable sound exposure. Tinnitus annoyance ratings were also significantly lower than the baseline but the effect was small. The feasibility trial identified that participant preferences for sounds varied. Three participants did not obtain any benefit from either sound. Three participants preferred unpredictable compared to predictable sounds. Some participants had difficulty using the PMP, the average self-report hours of use were low (less <1 h/day). CONCLUSIONS: Unpredictable surf-like sounds played using a PMP is a feasible tinnitus treatment. Further work is required to improve the acceptance of the sound and ease of PMP use.

Headphone listening habits, hearing thresholds and listening levels in Swedish adolescents with severe to profound HL and adolescents with normal hearing.

OBJECTIVE: Research has minimally focussed on the music listening habits and preferred sound volumes among adolescents with severe to profound congenital HL. Listening to music played at loud sound volumes and for a long duration of time could imply risks of worsening the HL. Therefore, it is important to investigate the listening habits in adolescents with HL. The aim of the present study was to describe the use of personal music devices, subjective estimated sound levels, measured sound levels, listening habits, and hearing symptoms in adolescents with severe to profound hearing loss compared with adolescents with normal hearing. DESIGN: The study was conducted in two steps. First, a questionnaire was given to students with or without hearing loss. In step two, hearing and sound level measurements were made in a subsample from both groups. STUDY SAMPLE: The study sample were based on 112 seventeen-year-old students with severe to profound hearing loss and 279 adolescents with normal hearing. Hearing thresholds and listening levels was measured on two subsamples based on 29 adolescents with severe to profound hearing loss and 50 adolescents from the group with normal hearing. RESULTS: The results showed that adolescents with severe to profound hearing loss listened to significantly louder sound levels for longer periods. For both groups, those listening at louder sound levels had poorer hearing thresholds. This finding is especially alarming for subjects with hearing loss. Among those listening above 85 dB per occasion, the sound level ranged between 85.8 dB up to 109 dB for those with hearing loss, whereas the sound level ranged between 85.5 dB and 100 dB for those with normal hearing. CONCLUSIONS: Adolescents with congenital hearing loss used portable music devices in the same manner as adolescents with normal hearing. However, adolescents with hearing loss listened to louder sound volumes most likely to compensate for their hearing loss, which significantly increases the risk of further damage to their hearing. From a hearing rehabilitation perspective it could be concluded that aspect of music listening habits should be focussed in order to prevent noise induced hearing loss among individuals with congenital hearing loss.

Longitudinal analysis of leisure noise exposure among adolescents with special focus on portable listening devices: the OHRKAN cohort study.

The aim was to investigate leisure noise exposure and sociodemographic determinants of risky leisure noise exposure over five years in 2148 students visiting grade 9 of any school type in a German city from 2009-2011. Within the OHRKAN cohort study, leisure noise exposure was calculated from literature-retrieved sound pressure levels (SPLs) and self-reported duration of 18 leisure activities at baseline and two follow-ups. Risky exposure was defined as exceeding 85 dB(A) averaged over a 40-h-week. Determinants of risky total leisure noise (TLN) exposure and risky exposure to portable listening devices (PLDs) were investigated using generalised estimating equations (GEEs). Up to 73% of students exceeded noise levels of 85 dB(A) at some timepoint. The noise exposure and importance of different leisure activities changed with increasing age. Risky exposure to TLN and PLDs was associated with lower education, single parent households and being male. Risky PLD exposure was additionally associated with a migrant background. Current prevention measures for leisure noise exposure must be extended to at-risk groups. Besides enhancing campaigns in lower education schools, acoustical insulation in sports halls, noise warnings on tools or in videogames could address especially men. Migrants need education about healthy PLD use in their native language if necessary.

OBAT: An open-source and low-cost operant box for auditory discriminative tasks.

Operant-conditioning boxes are widely used in animal training, allowing researchers to shape specific behaviors through reinforcements and/or punishments. Commercially available devices are expensive and run with proprietary software and hardware, hampering adaptations for the specific needs of an experiment. Therefore, many low-cost and open-source devices have recently been developed, but there are still few options for studying auditory behaviors. To overcome this problem, we developed a device based on a computer and an Arduino Mega 2560 board, named OBAT (Operant Box for Auditory Tasks), designed to present two different auditory stimuli to small primates. It has three modules: sound delivery, response bars, and reward system. We estimate that OBAT is at least 4-10 times cheaper than commercially available operant-conditioning boxes. Data from a behavioral pilot test ensured that the device can be used to train a marmoset in an auditory discrimination task. In addition, despite its low cost, accuracy tests showed that the OBAT operates with a high temporal precision. All schematics and software source code are available so that other groups can easily replicate the experiment or adapt the device to their own needs.

Extended high frequency audiometry in users of personal listening devices.

PURPOSE: Noise exposure leads to high frequency hearing loss. Use of Personal Listening Devices may lead to decline in high frequency hearing sensitivity because of prolonged exposure to these devices at high volume. This study explores the changes in hearing thresholds by Extended High Frequency audiometry in users of personal listening devices. MATERIAL AND METHOD: A descriptive, hospital based observational study was performed with total 100 subjects in age group of 15-30years. Subjects were divided in two groups consisting of 30 subjects (Group A) with no history of Personal Listening Devices use and (Group B) having 70 subjects with history of use of Personal Listening Devices. Conventional pure tone audiometry with extended high frequency audiometry was performed in all the subjects. RESULT: Significant differences in hearing thresholds of Personal Listening Device users were seen at high frequencies (3kHz, 4kHz and 6kHz) and extended high frequencies (9kHz, 10kHz, 11kHz, 13kHz, 14kHz, 15kHz and 16kHz) with p value <0.05. Elevated hearing thresholds were observed in personal listening devices users which were directly proportional to volume and duration of usage. CONCLUSION: In present study no significant changes were noted in hearing thresholds in PLD users before 5years of PLD use. However, hearing thresholds were significantly increased at 3kHz, 10kHz, 13kHz in PLD users having >5years usage at high volume. Thus, it can be reasonably concluded that extended high frequencies can be used for early detection of NIHL in PLD users.

Usage of personal music players in adolescents and its association with noise-induced hearing loss: A cross-sectional analysis of Ohrkan cohort study data.

OBJECTIVE: To describe personal music player (PMP) usage among adolescents, sociodemographic determinants and association with audiometric notches. DESIGN: Audiometric evaluation to assess hearing status, and standardized questionnaires to evaluate PMP listening behaviors, leisure noise exposures and self-reported hearing loss symptoms. Sociodemographic information was collected using a parent questionnaire. Noise exposure by PMP usage equivalent for a 40 h week was estimated based on self-reported volume and duration of use. STUDY SAMPLE: A total of 2143 students (54% females) attending 9th grade in Regensburg, Germany, during 2009 to 2011. RESULTS: Overall, 85% of the students reported using PMPs. Exposure level exceeded 80 dB(A) in approximately one third, and 85 dB(A) in one quarter, of those who used PMP. An audiometric notch was found in 2.3% of participants, but was not significantly associated with higher PMP exposure. CONCLUSIONS: PMP exposure above the occupational limits of 80 and 85 dB(A) set by the Directive 2003/10/EC may be a risk factor for developing noise-induced hearing loss. Educational measures to ameliorate high risk behaviors in PMP usage are needed, particularly for socially disadvantaged groups.

Listening to music with personal listening devices: monitoring the noise dose using a smartphone application.

OBJECTIVES: To monitor listening habits to personal listening devices (PLDs) using a smartphone application and to compare actual listening habits to self-report data. DESIGN: Two stages: self-report listening habits questionnaire, and real-time monitoring of listening habits through a smartphone application. STUDY SAMPLE: Overall 117 participants aged 18-34 years (mean 25.5 years) completed the questionnaire, and of them, 40 participants (mean age: 25.2 years) were monitored for listening habits during two weeks. RESULTS: Questionnaire main findings indicated that most of the participants reported listening for 4-7 days a week, for at least 30 min at high listening levels with volume control settings at 75-100%. Monitored data showed that actual listening days per week were 1.5-6.5 d, with mean continuous time of 1.56 h, and mean volume control setting of 7.39 (on a scale of 1-15). Eight participants (22%) were found to exceed the 100% noise dose at least once during the monitoring period. One participant (2.7%) exceeded the weekly 100% daily noise dose. Correlations between actual measurements and self-report data were low to moderate. CONCLUSIONS: Results confirmed the feasibility of monitoring listening habits by a smartphone application, and underscore the need for such a tool to enable safe listening behaviour.

Using Smart Devices to Measure Intermittent Noise in the Workplace.

PURPOSE: To determine the accuracy of smart devices (iPods) to measure intermittent noise and integrate a noise dose in the workplace. MATERIALS AND METHODS: In experiment 1, four iPods were each paired with a Larson Davis Spark dosimeter and exposed to randomly fluctuating pink noise in a reverberant sound chamber. Descriptive statistics and the mean difference between the iPod and its paired dosimeter were calculated for the 1-s data logged measurements. The calculated time weighted average (TWA) was also compared between the devices. In experiment 2, 15 maintenance workers and 14 office workers wore an iPod and dosimeter during their work-shift for a maximum of five workdays. A mixed effects linear regression model was used to control for repeated measures and to determine the effect of the device type on the projected 8-h TWA. RESULTS: In experiment 1, a total of 315,306 1-s data logged measurements were made. The interquartile range of the mean difference fell within ±2.0 A-weighted decibels (dBA), which is the standard used by the American National Standards Institute to classify a type 2 sound level meter. The mean difference of the calculated TWA was within ±0.5 dBA except for one outlier. In experiment 2, the results of the mixed effects model found that, on average, iPods measured an 8-h TWA 1.7 dBA higher than their paired dosimeters. CONCLUSION: This study shows that iPods have the ability to make reasonably accurate noise measurements in the workplace, but they are not as accurate as traditional noise dosimeters.

Headphone listening habits and hearing thresholds in swedish adolescents.

INTRODUCTION: The aim of this study was to investigate self-reported hearing and portable music listening habits, measured hearing function and music exposure levels in Swedish adolescents. The study was divided into two parts. MATERIALS AND METHODS: The first part included 280 adolescents, who were 17 years of age and focused on self-reported data on subjective hearing problems and listening habits regarding portable music players. From this group, 50 adolescents volunteered to participate in Part II of the study, which focused on audiological measurements and measured listening volume. RESULTS: The results indicated that longer lifetime exposure in years and increased listening frequency were associated with poorer hearing thresholds and more self-reported hearing problems. A tendency was found for listening to louder volumes and poorer hearing thresholds. Women reported more subjective hearing problems compared with men but exhibited better hearing thresholds. In contrast, men reported more use of personal music devices, and they listen at higher volumes. DISCUSSION: Additionally, the study shows that adolescents listening for ≥3 h at every occasion more likely had tinnitus. Those listening at ≥85 dB LAeq, FF and listening every day exhibited poorer mean hearing thresholds, reported more subjective hearing problems and listened more frequently in school and while sleeping. CONCLUSION: Although the vast majority listened at moderate sound levels and for shorter periods of time, the study also indicates that there is a subgroup (10%) that listens between 90 and 100 dB for longer periods of time, even during sleep. This group might be at risk for developing future noise-induced hearing impairments.

Daily music exposure dose and hearing problems using personal listening devices in adolescents and young adults: A systematic review.

OBJECTIVE: This systematic review aimed to explore the evidence on whether the preferred listening levels (PLLs) and durations of music listening through personal listening devices (PLDs) in adolescents and young adults exceed the current recommended 100% daily noise dose; together with the impact on hearing and possible influential factors of such listening behaviours. DESIGN: A systematic search was conducted using multiple online bibliographic databases. STUDY SAMPLE: The 26 studies were included on the basis of the inclusion and exclusion criteria. RESULTS: The results showed that up to 58.2% of participants exceeded the 100% daily noise dose, particularly in the presence of background noise. Significantly positive correlations were found among background noise levels and mean PLLs, as well as the proportion of participants exceeding the 100% daily noise dose. Moreover, significantly worse hearing thresholds were found in PLD users using audiometry, and significantly poor results in otoacoustic emission (OAE), even in the participants with self-reported 'normal hearing'. CONCLUSION: It is crucial to develop appropriate standards and safe recommendations for daily music exposure dose in future studies. Providing an essential guide and effective education to adolescents and young adults will help raise awareness, increase knowledge, and consequently change attitudes and listening habits.

Hearing thresholds, tinnitus, and headphone listening habits in nine-year-old children.

OBJECTIVE: Investigate hearing function and headphone listening habits in nine-year-old Swedish children. DESIGN: A cross-sectional study was conducted and included otoscopy, tympanometry, pure-tone audiometry, and spontaneous otoacoustic emissions (SOAE). A questionnaire was used to evaluate headphone listening habits, tinnitus, and hyperacusis. STUDY SAMPLE: A total of 415 children aged nine years. RESULTS: The prevalence of a hearing threshold ≥20 dB HL at one or several frequencies was 53%, and the hearing thresholds at 6 and 8 kHz were higher than those at the low and mid frequencies. SOAEs were observed in 35% of the children, and the prevalence of tinnitus was 5.3%. No significant relationship between SOAE and tinnitus was found. Pure-tone audiometry showed poorer hearing thresholds in children with tinnitus and in children who regularly listened with headphones. CONCLUSION: The present study of hearing, listening habits, and tinnitus in nine-year old children is, to our knowledge, the largest study so far. The main findings were that hearing thresholds in the right ear were poorer in children who used headphones than in children not using them, which could be interpreted as headphone listening may have negative consequences to children's hearing. Children with tinnitus showed poorer hearing thresholds compared to children without tinnitus.

Texting Dependence, iPod Dependence, and Delay Discounting.

We gave 127 undergraduates questionnaires about their iPod and texting dependence and 2 hypothetical delay discounting scenarios related to free downloaded songs and free texting for life. Using regression analyses we found that when iPod dependence was the dependent variable, Text2-excessive use, Text4-psychological and behavioral symptoms, iPod2-excessive use, and iPod3-relationship disruption were significant predictors of discounting. When texting dependence was the dependent variable, Text4-psychological and behavioral symptoms and iPod3-relationship disruption were significant predictors of discounting. These are the first data to show that delay discounting relates to certain aspects of social media, namely iPod and texting dependence. These data also show that across these 2 dependencies, both psychological and behavioral symptoms and relationship disruptions are affected.

[Direct Drive Simulation - Sound-Simulation of the Vibrant Soundbridge®]. / Direct Drive Simulation - Klangsimulation des Vibrant Soundbridge®-Hörens.

BACKGROUND: The Direct-Drive-Simulation (DDS) tends to simulate the sound quality of hearing with the active middle ear implant Vibrant Soundbridge(®) (VSB). Up to now a scientific evaluation of the validity is missing. Furthermore, the test procedure has not been described yet. Aim of this study was to evaluate the test validity and to describe the test realization in detail. MATERIAL AND METHODS: 10 patients evaluated their sound impression on scales from 1 to 10 concerning sound quality during DDS, postoperative free field testing at least 3 month after the first fitting of the VSB and in the everyday life situation. 3 patients were implanted bilaterally. Together, 36 data sets could be analyzed. RESULTS: Coupling of the Floating Mass Transducer (FMT), which was placed inside of a silicone probe during DDS was successful in all cases. In 11 out of 13 cases the coupling quality was judged as "good" an only in 2 cases as "medium". None of the patients needed local anesthesia. Comparing the evaluation of the sound impression during DDS preoperatively, and with the implanted VSB in free field testing and in everyday life no significant differences were found. CONCLUSION: The DDS offers the possibility of a realistic preoperative sound simulation of the "VSB-hearing" in case of sensorineural hearing loss. Thus, the test is supposed to facilitate the patient's decision towards possible treatment options. The specialist gets additional information regarding the indication especially when audiologic indication criteria are critical. The DDS should be a basic part of the preoperative diagnostic prior to VSB-implantation.

Feasibility of using an iPod touch device and acceptability of a stigma reduction intervention with HIV-infected women in the Deep South.

As with many infectious diseases throughout history, stigma is a part of the trajectory of the HIV disease process. HIV-related stigma impedes women from being tested for HIV. Once infected, HIV-related stigma hinders women from disclosing their HIV status to sexual partners and health care providers, engaging in medical care, effectively self-managing the disease after infection, and adhering to anti-retroviral therapy. After three decades of the HIV epidemic, no evidenced-based, culturally relevant, gender-specific interventions exist to help women infected with HIV manage the stigma associated with HIV infection. This manuscript reports the feasibility of using an iPod touch device and acceptability of a stigma reduction intervention with HIV-infected women in the Deep South in a mixed-method, randomized clinical trial. Results from the study demonstrate that it is feasible to utilize an iPod touch device to deliver an HIV-related stigma intervention to women. Further, women report that the HIV-related stigma intervention is acceptable and meaningful.

A study of the effectiveness of MP3 players to support family carers of people living with dementia at home.

BACKGROUND: Music can be therapeutic to people with dementia; however, little is known about its effect on the family carers. This project aimed to (1) assess the effects of MP3 player use by a person with dementia on caregivers' mental health and wellbeing, including their self-care and health-promoting behavior and (2) determine whether MP3 player use increases caregivers' self-reported capacity to cope with their role. METHODS: A pre-post quantitative and qualitative design was used. Carers completed a survey prior to commencing and four weeks after using the player. The survey included validated measures to assess the level of stress and coping among carers. Carers also kept a diary of the way they used the MP3 player. Half of the carers were interviewed about their experiences at the end of the study. RESULTS: Of 59 people who started using the MP3 player, 51 carers completed the four-week study period and surveys. Use of the MP3 player significantly decreased psychological distress, significantly improved the mental health and wellbeing of carers, significantly increased caregiver self-efficacy to manage symptoms of dementia, and was reported to provide valued respite from the high level of vigilance required for caring for a person with dementia. CONCLUSION: An MP3 player loaded with music can be a low cost and relatively simple and effective additional strategy to support families caring for people with dementia in the community.

A feasibility pilot study on the use of complementary therapies delivered via mobile technologies on Icelandic surgical patients' reports of anxiety, pain, and self-efficacy in healing.

BACKGROUND: Complementary therapies (CT), such as relaxation technique, massage, guided imagery, and accupuncture have shown to benefit patients undergoing surgery. The aim of this study was to determine the feasibility of using audio relaxation technique (ART), music intervention (MI), nature video application with music (NVAM), and nature video application without music (NVA) delivered via mobile technologies in a clinical setting. Secondary, the effects of ART, MI, NVAM and NVA on patients' state anxiety, pain perception, and perceived self-efficacy in healing were determined. METHODS: A randomized clinical trial (RCT) involving 105 same day surgery (SDS) patients, who were assigned to an ART (n = 25), MI (n = 25), NVAM (n = 15), NVA (n = 16), or a control group (n = 24) were assessed for state anxiety, self-reported pain, and self-efficacy four days prior to surgery, immediately prior and following a surgical intervention, and day five post-operative. RESULTS: ANOVA found no statistically significant differences in anxiety scores; pain, or perceived self-efficacy between the five groups. Matched pairs t-Test revealed all participants had an increase in anxiety from pre-op to day 10 follow-up; a significant change in pain levels from pre-op to day 10 follow-up; and all participants had a significant increase in general self-efficacy from pre-op to day 10 follow-up. Mean pain level scores from day 1 to pre-op showed a significant decrease in pain for the ART group and NVAM group. Matched pairs t-Test for self-efficacy scores indicated the MI group and the NVA group had significant increases in self-efficacy. A significant decrease in anxiety from pre-op to day 10 for participants reporting a prior history of anxiety and for those reporting prior history of taking anti-anxiety medications. CONCLUSIONS: Despite the non-significant findings between the five groups, at any measurement point, there were valuable trends toward significance and confirmed feasibility in a clinical setting. Among the groups there were statistically significant findings for all interventions on anxiety, pain, and self-efficacy. The feasability of the implementation of novel interventions of NVAM and NVAM adds to clinical practice and the CT literature. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02236455 (September 4, 2014).