Tinnitus Retraining Therapy and Current Practice

Before the advent of Pavel Jastreboff's Neurophysiological model of Tinnitus it could be said that the treatment of Tinnitus was in quite a poor state. Patients routinely received negative counselling from GP's and ENT Surgeons, e.g. 'There's nothing we can do, you just have to learn to live with it'. Not infrequently any interventions that were tried proved to be unhelpful or even harmful. For example maskers were used in residual inhibitition in an attempt to blast the cochlear (inner ear) with sufficient sound energy to fatigue the system, with the hope that the patient would experience temporary relief, usually in an attempt to get to sleep. Even more dramatic surgeons sometimes agreed to sever the eighth nerve (nerve of hearing) in the mistaken belief that this would stop aberrant firing of damaged hair cells in the cochlear from reaching the brain. What this actually achieved in most cases was highly intractable Tinnitus no longer susceptible to sound enrichment.

Following the publication of Jastreboff's Neurophysiological model and the development of Tinnitus Retraining Therapy by Johnathan Hazel and Jaqui Sheldrake there was a marked shift in attitudes and focus within the Audiological world. Previously Tinnitus patients had been characterised in a lot of departments very negatively and largely dismissed as hopeless causes (sadly this is still the case amongst some reactionary and retrograde Audiologists). Now it appeared that there was something which could be done for these patients and the proponents of TRT were very confident of success. Perhaps it could be argued that there was a tendency to overconfidence which manifested itself in an initial reluctance to heed ‘calls for robust evidence of efficacy’ (Andersson G. et al 2005) and an ongoing insistence that only those trained by its originators are qualified to undertake true TRT. The publication of Hazell and Jastreboff’s TRT – Implementing the Neurophysiological Model and Henry and Jastreboff’s TRT Clinical Guidelines/Patient Counselling Guide in 2004/2007 may represent a softening of this stance.
Currently what takes place in most hospitals is a blending of TRT, the Neurophysiological model, traditional Audiology and sleep/relaxation training. This has been called the Audiological model, however defining what here is actually effective and what is filler can be hard to tell. It appears that a patient centered approach which adjusts the intervention to the patient is considered to be most effective but is this 'holism' the best use of time and resources for both patients and the NHS?
(J Eval Clin Pract. 2010 Nov 19. doi: 10.1111/j.1365-2753.2010.01566.x. [Epub ahead of print]
Management of tinnitus in English NHS audiology departments: an evaluation of current practice.
Hoare DJ, Gander PE, Collins L, Smith S, Hall DA.)
An attempt has been made to simplify the treatment pathway and protocol, but as this relies on naive patients successfully interpreting a poster guiding them to the correct intervention some concerns have been raised about the approach.
Simplified form of tinnitus retraining therapy in adults: a retrospective study.
Aazh H, Moore BC, Glasberg BR.
BMC Ear Nose Throat Disord. 2008 Nov 3;8:7.

As I recently said at a talk to the RNID in Northern Ireland any service offering positive and accurate advice is better than no service at all. It has been suggested many times that the greatest benefit inherent in TRT was the 'counselling', or educative component rather than the attempt to subconsciously de-condition a response which has been criticized as a mis-reading of conditioning theory.

http://www2.cochrane.org/reviews/en/ab007330.html
There is a good deal of work remaining to be done on the Audiological model. One of the greatest challenges will be attempting to bring some order to the range of approaches on offer so that it becomes more amenable to research and meta-analysis. What I would offer up is that practitioners of alternative treatments are content that they have an answer to the problem that is correct without testing. Science based practitioners on the other hand take more take more care to test, develop and refine their treatments to ensure they are achieving the best outcomes possible based on the latest evidence.
Sadly this can make the scientific approach appear less certain and unwilling to guarantee specific outcomes – the CAM person knows, the clinician advocates the most compelling lines of evidence. At my recent RNID talk I was dismayed to see patient information leaflets produced by them advocating and signposting access to CAM treatments instead of evidence based ones. There remains a job of work to be done to educate the public that the distinction is vital.

Bad Tinnitus Forum

You may or may not have noticed that the forum is gone. This is mainly because I have no time to administer it, but also because it was mostly populated by spam, despite frequent weeding.

I'm pleased to say that I've heard the British Tinnitus Association will shortly be launching a forum of its own with expert moderation. I've been moaning to the RNID for a while now that there discussion board is quite an unhealthy place for new people with Tinnitus, but they have seemed unwilling to address it. Hopefully this will become a joint venture and the RNID can let their current message board go.

Apologies then to anyone who was actually using the forum but I think it time to let the big boys try to get it right.

Tim