Therapeutic Sound for Tinnitus Management: Subjective

Helpfulness Ratings

Steven Benton, Au.D.

VA M e d i c a l C e n t e r

D e c a t u r, G A 3 0 0 3 3

The Neurophysiological Model

According to Jastreboff and Hazell (2004):

The subconscious auditory filter allows us to ignore most incoming sounds to

which we are constantly exposed and to focus on those that “suggest something

bad might happen. (p. 44).”

After repeated exposure to a sound that is not expected and not understood,

negative cortical evaluation and negative limbic and autonomic nervous system reactions can result.

Specifically, tinnitus patients may develop negative thoughts regarding the cause, potential danger and

medical significance of this unexpected and misunderstood sound which in turn can result in negative

limbic and autonomic nervous system reactions.

A reflex (vicious cycle) is created in which merely perceiving the tinnitus immediately results in fear,

anxiety, muscle tension and sleeplessness.

Simplified Neurophysiological Model

Simplified Neurophysiological Model

A Reflex (Vicious Cycle)

is Created

Awareness

Progressive Tinnitus Management

PTM (Henry, Zaugg, Myers, Kendall & Turbin, 2009) emphasizes patient education and the use of therapeutic

sound to manage tinnitus disturbance.

The goals of PTM are to help the patient:

Optimal therapeutic sounds address the negative limbic and autonomic nervous system activity described by

the Neurophysiological Model.

The most suitable specific use of sound depends on the situation in which the tinnitus is disturbing the patient.

Sound Plans facilitate the identification of optimal sounds.

• Feel less stressed about tinnitus;

• Have fewer emotional reactions to tinnitus;

• Almost never think about tinnitus;

• Feel like tinnitus has little effect on daily activities

• Feel like tinnitus is not much of a problem; and

• Feel like there is no need for further tinnitus help.

Soothing Sound

Soothing Sound provides relief from the anxiety, tension and stress that is caused by, or that exacerbates,

tinnitus by creating the relaxation response.

The fight or flight response is a state of extreme physiological alertness and arousal. The relaxation response is

the counterpart of "fight or flight" and returns the body's status to normal.

Inducing the relaxation response through Soothing Sound actively fights negative limbic and autonomic

nervous system activity created by the tinnitus signal. The body transitions from a state of physiological arousal

and alertness to a state of physiological relaxation.

Improving the patient’s emotional and physiological status reduces the significance of tinnitus.

Reducing the significance of tinnitus reduces frustration and improves quality of life.

Perhaps most importantly, Soothing Sound allows relaxation which improves sleep, resulting in improved

concentration while reducing mood swings and irritability.

Soothing Sound: Relaxation

Two specific types of Soothing Sound which counteract stress and tension are Guided Relaxation and Guided

Imagery.

Guided Relaxation: a soothing recorded voice directs the patient through relaxation (deep breathing) exercises.

Guided Imagery: the recorded voice assists the patient in creating a vivid mental image of a safe, relaxing place.

Two well-known benefits of relaxation are specific to tinnitus management:

Reduced negative limbic system activity (e.g., anger, frustration, anxiety)

Reduced negative autonomic nervous system activity (e.g., muscle tension, stress)

By addressing negative limbic and autonomic nervous system activity, sleep is improved and patients

experience greater calmness, happiness and energy.

Background Sound

Background Sound reduces auditory contrast and is the very definition of environmental sound enrichment.

Background Sound decreases the perceived loud ness of the tinnitus signal, thereby reducing its strength as it

travels from the ear to the brain.

We judge the loudness of a sound in relation to the loudness of other sounds in the environment.

Tinnitus in a silent environment is perceived as being louder than tinnitus in a sound-enriched environment.

Because the tinnitus signal is weaker when embedded in Background Sound, activation of the limbic and

autonomic nervous systems also is weaker.

Background Sound restores lateral inhibition and reduces abnormal internal auditory gain.

Reduced limbic and autonomic system activity reduces tinnitus-related distress which, in turn, improves quality

of life.

Interesting Sound

Interesting Sound redirects attention away from tinnitus by addressing selective perception, the process

whereby the most attention is paid to sounds that are most important.

Because the tinnitus signal already has been classified as significant, tinnitus is attended to and is frequently

monitored.

Frequent monitoring increases negative emotional and physiological reactions, resulting in frustration, inability

to concentrate, greater sleeplessness and reduced quality of life.

Interesting Sound impacts tinnitus by reducing the subconscious importance of tinnitus, thereby reducing the

negative consequences of constant tinnitus monitoring.

Reduced monitoring behavior improves concentration which, in turn, reduces frustration and improves quality

of life.

Current Study

We examined outcome questionnaires returned

by mail from 39 consecutive patients who

completed PTM Level 3, Tinnitus Group

Education.

The questionnaires asked subjects to use a 0-10

scale to rate the helpfulness of specific

strategies and skills taught in PTM Level 3,

Group Education.

Arbitrary Interpretation of 0-10 Scale

0 = 0% relief

1 = 10% relief

2 = 20% relief

3 = 30% relief

4 = 40% relief

5 = 50% relief

6 = 60% relief

7 = 70% relief

8 = 80% relief

9 = 90% relief

10 = 100% relief

Inadequate Helpfulness

Adequate Helpfulness

Helpfulness Ratings

0%

5%

10%

15%

20%

25%

30%

0 1 2 3 4 5 6 7 8 9 10

Soothing Sound: n=30

0%

5%

10%

15%

20%

25%

30%

0 1 2 3 4 5 6 7 8 9 10

Background Sound: n=36

0%

5%

10%

15%

20%

25%

30%

0 1 2 3 4 5 6 7 8 9 10

Interesting Sound: n=32

47% 53% 53% 47% 41% 59%

The percentage of subjects reporting different 0-10 ratings is shown for each tinnitus management strategy

and skill. The RED LINE denotes the arbitrary limit of ADEQUATE vs. INADEQUATE helpfulness. The red and

green values indicate the percentage of subjects reporting adequate(green) or inadequate (red) helpfulness.

Helpfulness Ratings

0%

5%

10%

15%

20%

25%

30%

0 1 2 3 4 5 6 7 8 9 10

Deep Breathing: n=32

0%

5%

10%

15%

20%

25%

30%

0 1 2 3 4 5 6 7 8 9 10

Guided Imagery: n=30

50% 50% 53% 47%

The percentage of subjects reporting different 0-10 ratings is shown for each tinnitus management strategy

and skill. The RED LINE denotes the arbitrary limit of ADEQUATE vs. INADEQUATE helpfulness. The red and

green values indicate the percentage of subjects reporting adequate(green) or inadequate (red) helpfulness.

Helpfulness Ratings

0%

5%

10%

15%

20%

25%

30%

0 1 2 3 4 5 6 7 8 9 10

Changing Thoughts: n=17

0%

5%

10%

15%

20%

25%

30%

0 1 2 3 4 5 6 7 8 9 10

Pleasant Activities: n=18

41% 59% 22% 78%

The percentage of subjects reporting different 0-10 ratings is shown for each tinnitus management strategy

and skill. The RED LINE denotes the arbitrary limit of ADEQUATE vs. INADEQUATE helpfulness. The red and

green values indicate the percentage of subjects reporting adequate(green) or inadequate (red) helpfulness.

0

1

2

3

4

5

6

7

8

9

10

Soothing Sound

Background Sound

Interesting Sound

Deep Breathing

Guided Imagery

Changing Thoughts

Pleasant Activities

Mea

n H

elp

fuln

ess

Rat

ing

(SD

)

Average Helpfulness Ratings

A Kruskal-Wallis One Way ANOVA on Ranks revealed that no single strategy

or skill was significantly more helpful than any other (H = 7.12, df = 6, p = .302).

Average Helpfulness Ratings

0

1

2

3

4

5

6

7

8

9

10

Average Sound Help Average Relaxation Help

Changing Thoughts Help

Pleasant Activities Help

Mea

n H

elp

fuln

ess

Rat

ing

(SD

)

A Kruskal-Wallis One Way ANOVA on Ranks revealed that no single strategy or skill

category was significantly more helpful than any other (H = 6.05, df = 3, p = .109).

Adequate vs. Inadequate Helpfulness

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Soothing n=30

Background n=36

Interesting n=32

Thoughts n=17

Activities n=18

Breathing n=32

Imagery n=30

% o

f Su

bje

cts

Rating 0-4

Rating 5- 10

Conclusions and Discussion