Editorial: Translating Tinnitus Research Findings Into Clinical Practice
Year: 2019
Type: editorial
Abstract: You have accessAmerican Journal of AudiologyIntroduction22 Apr 2019Editorial: Translating Tinnitus Research Findings Into Clinical Practice Sarah M. Theodoroff, and Gabrielle H. Saunders Sarah M. Theodoroff VA Rehabilitation Research and Development Service, National Center for Rehabilitative Auditory Research, VA Portland Health Care System, Portland, OR Department of Otolaryngology—Head & Neck Surgery, Oregon Health & Science University, Portland, OR Google Scholar and Gabrielle H. Saunders VA Rehabilitation Research and Development Service, National Center for Rehabilitative Auditory Research, VA Portland Health Care System, Portland, OR Eriksholm Research Centre, Snekkersten, Denmark Google Scholar https://doi.org/10.1044/2019_AJA-TTR17-19-0015 SectionsAboutAbstractPDF ToolsAdd to favoritesDownload CitationTrack Citations ShareFacebookTwitterLinked In For over a decade, tinnitus has remained the most prevalent service-connected disability for Veterans receiving compensation (Veterans Benefits Administration, 2018). However, the high prevalence of tinnitus is not just limited to Veterans. In the general population of the United States, approximately 25% (~50 million adults) are estimated to have tinnitus (Shargorodsky, Curhan, & Farwell, 2010). People with tinnitus try a variety of management strategies to varying degrees of success. Currently, there is no cure for tinnitus, and its management is complicated by the fact that physiological, psychological, and psychosocial factors influence its presence, severity, and the extent to which it is bothersome and disabling. Negative consequences of tinnitus manifest as sleep disorders, anxiety, depression, and even suicidal ideation (Cima, Crombez, & Vlaeyen, 2011; Erlandsson & Hallberg, 2000; Han et al., 2018; Liu, Streelman, & Guthrie, 2015). It is critical to understand the underlying mechanisms that give rise to tinnitus so that treatments can be developed targeting the neural generator(s) and modulatory pathways. In the fall of 2017, the Veterans Administration (VA) Rehabilitation Research and Development Service National Center for Rehabilitative Auditory Research (NCRAR) hosted its eighth biennial conference, titled “Translating Tinnitus Research Findings Into Clinical Practice.” The primary objective of the conference, as suggested by its title, was to bring together experts in the field and provide a forum to discuss how tinnitus research findings can be integrated into evidence-based clinical practice. During this 3-day conference, scientists and clinicians discussed a range of topics on tinnitus, including its epidemiology, neurophysiological models to explain its underlying causes, techniques and challenges for developing pharmacological cures, assessment and measurement procedures, and current approaches to tinnitus management. The articles in this special issue are based on seven of the conference presentations. Approaches to Assessment and Management In the first article by Henry and Manning (2019), we learn that clinical services for tinnitus are unstandardized across clinics and among clinicians, leading to inconsistent outcomes and inequalities in patient care. Henry and Manning recommend using an evidence-based clinical protocol known as progressive tinnitus management (PTM), which is endorsed by the VA Central Office. PTM takes a hierarchical approach to evaluating and best meeting the tinnitus patient's needs. PTM focuses on promoting self-efficacy to manage reactions to tinnitus (Henry et al., 2017). Their article brings to light the need for audiologists to have appropriate clinical tools and guidelines to be successful in providing tinnitus management services for their patients. The recommendations they make are informed by years of research combined with existing tinnitus clinical practice guidelines (Tunkel et al., 2014). A tinnitus “decision-tree” is provided to aid clinicians in their decision making for what services to offer their tinnitus patients. In the second article, Beck, Zaugg, Egge, Lima, and Thielman (2019) describe the clinical implementation and outcomes of PTM in two VA clinics. The PTM framework was modified from the standard protocol and tailored to suit the individual VA medical centers. Their work provides added evidence for the effectiveness of PTM as a tinnitus management approach while also noting that clinician-directed modification to the overarching PTM protocol still results in positive outcomes. The research note by Manning, Thielman, Grush, and Henry (2019) reports on a study looking to understand the relationship, in a general sense, between the functional effects of tinnitus (i.e., reactions) and psychoacoustic measures of tinnitus loudness and pitch (i.e., perceptions). The rationale for this work was that while tinnitus psychoacoustic measures are commonly used to assess intervention outcome, there is little evidence to suggest characteristics of the tinnitus perception relate to patient reactions associated with tinnitus distress. Manning et al. reveal that overall, only weak relationships exist between perceptual measures of tinnitus and the reactionary impact of the condition, but they note that in some instances, it may be appropriate to evaluate both domains. The authors go on to explain the value in assessing both perceptual and functional effects of tinnitus; the former can help patients feel emotionally validated, while the latter can be beneficial for tracking changes in reactions to tinnitus over time. These findings demonstrate that to select appropriate metrics, one must account for various considerations specific to the research and/or clinical setting. Comorbid Mental Health Conditions The work of Carlson et al. (2019) examined health care use and mental health diagnoses among Veterans with and without tinnitus using retrospective data obtained from electronic medical records (i.e., VA Corporate Data Warehouse). The rationale for this work stems from the fact that service-connected disabilities and associated compensation are calculated based on multiple variables, and although tinnitus has remained the top service-connected disability for Veterans receiving compensation since 2007, Carlson et al. note the proportion of Veterans seeking health care services for tinnitus, either inside or outside the VA, is unknown. Carlson et al. (2019) determined that while almost all Veterans in their sample had received care in a primary care clinic sometime during a 5-year period, Veterans with tinnitus had a higher percentage of using VA health care services and were more likely to have comorbid mental health disorders compared to Veterans without tinnitus. Their work highlights the need for coordinated tinnitus and mental health care services for Veterans in the VA system of care. Tinnitus Mechanisms Tinnitus can only be measured indirectly, and due to its complex and subjective nature, exacting a “true” measure is beyond challenging. Although no objective measure of tinnitus exists, brain imaging techniques show promise to elucidate the underlying neural mechanisms giving rise to the percept and neural network changes associated with tinnitus distress. Functional magnetic resonance imaging (fMRI) is used to detect changes in neural activity and/or neural networks during different tasks or subject states (e.g., at rest). Data collected in “resting-state” are spontaneous fluctuations in the blood oxygenation level–dependent signal and provides insight into the underlying nature of how the brain functions (perceptual and cognitive processes). The article by Husain et al. (2019) explores the replicability of resting-state fMRI in individuals with tinnitus. Specifically, Husain et al. examined the reliability and correlations between different resting-state neural networks (default mode network, dorsal attention network) to establish the replicability of these measures in tinnitus patients. Their findings demonstrate resting-state functional connectivity measures are reliable and replicable within individuals with tinnitus over time. Establishing this fact is an important first step before attempting to understand the relationship between these neural network measures and tinnitus distress. Conducting future studies comparing resting-state functional connectivity measures in individuals with and without tinnitus are necessary to determine if resting-state fMRI measures could be considered objective biomarkers of tinnitus. The next article in this special issue is by Campbell, LaBrec, Bean, Nielsen, and So (2019). They examined the relationship between behavioral audiometric thresholds and physiological measures of central inhibitory function obtained via a sensory gating paradigm, in individuals with and without tinnitus. Sensory gating is a pre-attentive neurological process that functions to filter or “gate” out nonpertinent stimuli. Campbell et al. theorized that compared to controls, tinnitus patients would show reduced sensory gating function associated with elevated behavioral high-frequency (> 8 kHz) audiometric thresholds. Their findings did not support their hypothesis and suggest perhaps there is a tinnitus severity “threshold” that needs to be reached before central inhibitory processes become affected (an interesting theory to be explored in future studies). Additionally, their study investigated the variability in sensory gating performance within the tinnitus group. Examining correlations between extended high-frequency hearing ability and gating performance in tinnitus individuals not distressed by their tinnitus based on their Tinnitus Handicap Inventory (THI; Newman, Jacobson, & Spitzer, 1996) scores showed that as gating function decreased, THI scores increased. This finding suggests an interaction between decreased sensory gating and heightened auditory awareness. Follow-up studies are needed to fully understand the role sensory gating processes play in contributing to the perception of and reactions to tinnitus. There is widespread acceptance that tinnitus is associated with alterations in cortical activity, but this view is overly simplistic because it does not account for the brainstem's role. Theodoroff and Kaltenbach (2019) discuss a new perspective regarding the brainstem's involvement in generating and modulating tinnitus and associations with nonauditory comorbid conditions. Understanding the involvement of both cortical and subcortical contributions to tinnitus perception, distress, and comorbidities can help guide health care professionals in their treatment approach. For example, somatic manipulations can directly influence the tinnitus perception for many patients (Shore, 2011), which suggests somatosensory tinnitus is an indicator of an underlying musculoskeletal deficit of the head or neck. Clinicians do not routinely perform an in-depth tinnitus assessment, and no standard guidelines exist recommending questions or screening procedures to identify tinnitus fluctuations, triggers, and comorbid conditions. It is critical to consider all the facets of tinnitus patients' needs and keep in mind that successful tinnitus management may involve a multidisciplinary approach to treating/managing auditory and nonauditory comorbid conditions simultaneously. We hope you enjoy reading these articles and that, as a result, you gain a broader perspective on tinnitus etiology, the nuances of tinnitus assessment and management, and knowing when a multidisciplinary approach is warranted. The next NCRAR conference is scheduled for September 2019. It will address the impact of ototoxicity and noise damage on audiological management. We hope to see you there. Sarah M. Theodoroff and Gabrielle H. Saunders, Guest Editors Acknowledgments This research was supported by Department of Veterans Affairs, Rehabilitation Research & Development Service, National Center for Rehabilitative Auditory Research (Center of Excellence Award #C9230C, M. P. Feeney [PI] and G. H. Saunders [co-PI]) at the VA Portland Health Care System in Portland, OR, and National Institute of Health's National Institute on Deafness and other Communication Disorders (1 R13 DC016549-01, G. H. Saunders [PI]). The content does not represent the views of the U.S. Department of Veterans Affairs, Department of Defense, or the U.S. Government. References Beck, J. E., Zaugg, T. L., Egge, J. L., Lima, E. N., & Thielman, E. J. (2019). Progressive tinnitus management at two Veterans Affairs medical centers: Clinical implementation with modified protocols.American Journal of Audiology, 28(1S), 162–173. https://doi.org/10.1044/2018_AJA-TTR17-18-0040 ASHAWireGoogle Scholar Campbell, J., LaBrec, A., Bean, C., Nielsen, M., & So, W. (2019). Auditory gating and extended high-frequency thresholds in normal-hearing adults with minimal tinnitus.American Journal of Audiology, 28(1S), 209–224. https://doi.org/10.1044/2019_AJA-TTR17-18-0036 ASHAWireGoogle Scholar Carlson, K. F., Gilbert, T. A., O'Neil, M. E., Zaugg, T. L., Manning, C. A., Kaelin, C., … Henry, J. A. (2019). Health care utilization and mental health diagnoses among Veterans with tinnitus.American Journal of Audiology, 28(1S), 181–190. https://doi.org/10.1044/2018_AJA-TTR17-18-0042 ASHAWireGoogle Scholar Cima, R. F., Crombez, G., & Vlaeyen, J. W. (2011). Catastrophizing and fear of tinnitus predict quality of life in patients with chronic tinnitus.Ear and Hearing, 32(5), 634–641. CrossrefMedlineGoogle Scholar Erlandsson, S. I., & Hallberg, L. R. M. (2000). Prediction of quality of life in patients with tinnitus.British Journal of Audiology, 34, 11–20. CrossrefMedlineGoogle Scholar Han, K. M., Ko, Y. H., Shin, C., Lee, J. H., Choi, J., Kwon, D. Y., … Kim, Y. K. (2018). Tinnitus, depression, and suicidal ideation in adults: A nationally representative general population sample.Journal of Psychiatric Research, 98, 124–132. CrossrefMedlineGoogle Scholar Henry, J. A., & Manning, C. (2019). Clinical protocol to promote standardization of basic tinnitus services by audiologists.American Journal of Audiology, 28(1S), 152–161. https://doi.org/10.1044/2018_AJA-TTR17-18-0038 ASHAWireGoogle Scholar Henry, J. A., Thielman, E. J., Zaugg, T. L., Kaelin, C., Schmidt, C. J., Griest, S., … Carlson, K. (2017). Randomized controlled trial in clinical settings to evaluate effectiveness of coping skills education used with progressive tinnitus management.Journal of Speech, Language, and Hearing Research, 60(5), 1378–1397. ASHAWireGoogle Scholar Husain, F. T., Schmidt, S. A., Tai, Y., Granato, E. C., Ramos, P., Sherman, P., & Esquivel, C. (2019). Replicability of neural and behavioral measures of tinnitus handicap in civilian and military populations: Preliminary results.American Journal of Audiology, 28(1S), 191–208. https://doi.org/10.1044/2019_AJA-TTR17-18-0039 ASHAWireGoogle Scholar Liu, Y. F., Hu, J., Streelman, M., & Guthrie, O. W. (2015). The Epworth Sleepiness Scale in the assessment of sleep disturbance in Veterans with tinnitus.International Journal of Otolaryngology, Article 429469. https://doi.org/10.1155/2015/429469 MedlineGoogle Scholar Manning, C., Thielman, E. J., Grush, L., & Henry, J. A. (2019). Perception versus reaction: comparison of tinnitus psychoacoustic measures and Tinnitus Functional Index scores.American Journal of Audiology, 28(1S), 174–180. https://doi.org/10.1044/2018_AJA-TTR17-18-0041 ASHAWireGoogle Scholar Newman, C. W., Jacobson, G. P., & Spitzer, J. B. (1996). Development of the tinnitus handicap inventory.Archives of Otolaryngology—Head & Neck Surgery, 122(2), 143–148. CrossrefMedlineGoogle Scholar Shargorodsky, J., Curhan, G. C., & Farwell, W. R. (2010). Prevalence and characteristics of tinnitus among US adults.The American Journal of Medicine, 123, 711–718. CrossrefMedlineGoogle Scholar Shore, S. E. (2011). Plasticity of somatosensory inputs to the cochlear nucleus—Implications for tinnitus.Hearing Research, 281(1–2), 38–46. CrossrefMedlineGoogle Scholar Theodoroff, S. M., & Kaltenbach, J. A. (2019). The role of the brainstem in generating and modulating tinnitus.American Journal of Audiology, 28(1S), 225–238. https://doi.org/10.1044/2018_AJA-TTR17-18-0035 ASHAWireGoogle Scholar Tunkel, D. E., Bauer, C. A., Sun, G. H., Rosenfeld, R. M., Chandrasekhar, S. S., Cunningham, E. R., … Whamond, E. J. (2014). Clinical practice guidelines: Tinnitus.Otolaryngology—Head and Neck Surgery, 151(Suppl. 2), S1–S40. CrossrefMedlineGoogle Scholar Veterans Benefits Administration. (2018). Annual benefits report for fiscal year 2017. Washington, DC: U.S. Department of Veterans Affairs. Retrieved from https://benefits.va.gov/REPORTS/abr/ Google Scholar Author Notes Disclosure: The authors have declared that no competing interests existed at the time of publication. Correspondence to Sarah M. Theodoroff: [email protected] Publisher Note: This article is part of the Special Issue: Select Papers From the National Center for Rehabilitative Auditory Research Conference. Editor-in-Chief: Sumitrajit Dhar Additional Resources FiguresReferencesRelatedDetails Volume 28Issue 1SApril 2019Pages: 149-151 HistoryReceived: Feb 2, 2019Accepted: Feb 4, 2019 Published online: Apr 25, 2019 Published in issue: Apr 25, 2019PubMed ID: 31022359 Get Permissions Add to your Mendeley library Metrics Topicsasha-topicsasha-article-typesCopyright & PermissionsCopyright © 2019 American Speech-Language-Hearing AssociationPDF downloadLoading ...
Source: American Journal of Audiology
Language: English
Subfield: Sensory Systems
Field: Neuroscience
Domain: Life Sciences
Open Access status: green
OpenAlex ID: W2941790770