Transcript

Spotlight on Pain Management Series

2-7-2012

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Good morning everybody. This is Bob Kerns, National Program Director for pain management and it is my great pleasure to welcome you to this webinar series called Spotlight on Pain Management. Today we are going to hear from colleagues that I know well and their presentation on similarities between chronic pain management and progressive tinnitus management. 

First I would like to welcome Dr. James Henry. He is a research career scientist at the VA National Center for Rehabilitative Auditory Research located at the Portland Oregon VA Medical Center. He is a research professor in the Department of otolaryngology, Head and Neck surgery, at Oregon Health and Science University. He has conducted research focusing on clinical management of tinnitus for 20 years. 

Dr. Paula Myers is chief of the audiology section and the cochlear implant coordinator at the Tampa VA hospital in Tampa, Florida. And is assistant professor at the University of South Florida. She has been at the in Tampa VA for 23 years. Her expertise in research focuses on development of audiology educational materials, tinnitus management, traumatic brain injury and audiology research.

Dr. Samantha Boris-Karpel is here in VA Connecticut where she is a researcher psychologist at our pain research informatics medical comorbidity and education or PRIME Center. She is co-investigator with the VHA National Center for Rehabilitative Auditory Research at Portland and staff affiliate in the department of psychiatry here at the Yale University School of Medicine. 

Dr. Tara Zaugg, AuD, is a licensed certified clinical privileged audiologist. She is a research audiologist that the national Center for rehabilitative auditory research in Portland. She is involved in Tinnitus clinical trials and she has been doing this for the last 11 years at the national Center where she has developed expertise in tinnitus assessment and management and the training of audiologist to perform tinnitus management. 

And last but not least is my colleague, Dr. Caroline Schmidt, PhD, formerly Caroline Kendall. She is a licensed research psychologist here at VA Connecticut and the PRIME Center and a associate research scientist at Yale University in the Department of Psychiatry. She received her doctorate at Gallaudet University in Washington DC and has worked at the VA since then. Her interests are in behavioral interventions for tinnitus as well as understanding psychiatric and medical comorbidities among Veterans with tinnitus It is with great pleasure now I turn the presentation over to Dr. Schmidt. 

Think you very much, Dr. Kerns and thank you for inviting us to present. First of all, we don't have any disclosures to report. We are all VA employees. We are supported by the VA Rehabilitation Research and Development Service as well as the VA Connecticut Healthcare System in West Haven, Connecticut, the VA Portland, National Center for Rehabilitative Auditory Research, and the James A. Haley Veterans Hospital in Tampa, Florida. 

Today our presentation will include five program objectives. We will provide an overview of tinnitus; describe the similarities between chronic tinnitus and chronic pain; briefly explain what progressive tinnitus management or PTM is. We will compare chronic pain management to PTM. And describe the roles of various health providers in PTM. 

We would like to thank these folks and many others not listed for their support of PTM over the years. They have contributed to the developed of PTM or have been involved in research now or in the past. 

Before we get started, we would like to ask a poll question. We understand there are a lot of listeners registered for today's presentation and we were curious to know who was on the call. So if you could please respond to the poll question that will be coming up in just a moment. 

We would like to know your profession or discipline.

We are at 60% right now so we are just waiting for those responses. 

So if you could just let us know if you are a physician in primary care, or a physician in specialty services, or a mental health provider. Or work in audiology, or another discipline that we have not listed. 

This will really be helpful for us in terms of knowing who is on the call. And hopefully we can cater our descriptions and responses accordingly. 

So it looks like so far, I am going to go ahead and end the poll. Just in order to get moving. So right now it looks like about 48% are in other disciplines not listed. And about 30% of you are mental health providers. And about 10% are in audiology. 7% in primary care physicians. And about 5% are specialty services physicians. 

So thank you so much for responding. 

So we are going to start the presentation with Dr. Henry. We are going to switch speakers often throughout the presentation. We are going to start with Dr. Jim Henry. 

Hello everybody. We are in to start out with a very brief overview of tinnitus. What is tinnitus and why is a problem? 

Let's first talk about transient ear noise, which is experienced by just about everyone. Transient ear noise is a transient whistle type sound that comes on suddenly in one ear and then decays in less than about a minute. The sound of accompanied by a sense of ear fullness and what seems like hearing loss. After about a minute everything recovers. Transient ear noise is a normal occurrence and is not tinnitus. The textbook definition of tinnitus is ear or head noise lasting at least five minutes and that occurs at least twice a week. This definition distinguishes tinnitus from transient ear noise but it is irrelevant to a great majority of our patients who experience chronic tinnitus. Chronic tinnitus is always present even if it is not noticed or is masked by environmental sound. If chronic tinnitus is suspected, a good question to ask your patients is “do you usually hear your tinnitus if you listen for it in a quiet room.” 

So now you know the definition of tinnitus, how many of you have tinnitus? We will do little survey to determine the prevalence if tinnitus for those of you listening. So go ahead and respond -- yes, no or not sure. 

Okay that poll is up. We are at about 64% right now but we will wait a couple more seconds for people to respond here. 

It looks like things are starting to slow down. 

And I am going to close that and share the results here. 

There we go. 

Isn't that interesting? Usually it is surprising how many of our colleagues have tinnitus. And it looks like right there -- 32% of you have tinnitus according to the definition we just provided. 

So let's quickly run through a few more definitions. The two big categories of tinnitus are near a neurophysiologic tinnitus and somatic tinnitus. Somatic tinnitus is real sound that is generated in the head or neck. It is a mechanical event and we hear the noise through our normal hearing mechanism. 

The most common example of somatic tinnitus is pulsatile -- where we actually hear the pulsing of blood in a vessel close to the ear. Somatic tinnitus is relatively uncommon and always indicates the need for an examination by an otolaryngologist or otologist

In some cases somatic tinnitus is correctable. 

The most common form of tinnitus is neurophysiologic tinnitus meaning that the tinnitus originates somewhere in the brain. 

There is no acoustic signal causing the sound. It is a phantom sound. This is a type of tinnitus we deal with everyday with our patients. It cannot be cured and no drug has been approved for the treatment of tinnitus. 

Our patients often ask us will I listen to the sound of the rest of my life? If the patient has had have tinnitus for about a year or more, then it is very likely to be a permanent condition. Our answer to the question should be that the tinnitus may be permanent, but it also could resolve on its own. 

It is thus particularly important for them to protect their ears from loud noise to optimize any chance that the tinnitus will spontaneously resolve. 

Many people experience tinnitus who are not bothered by it. So experiencing tinnitus is not necessarily a problem but tinnitus becomes a problem when people react to it. And by react, I mean that they pay undue attention to it, and it affects their life in some significant way. 

These reactions are the problem and what patients need to learn is how to manage their reactions. 

How can patients learn to manage their reactions to tinnitus? There are certain bottom-line strategies that they need to learn to regulate the stress and emotions that result from tinnitus. 

They need to learn how to use therapeutic sound. They need to learn relaxation techniques and distraction strategies. They also need to learn how to thank less negatively about their tinnitus. 

All of this learning requires that they are educated in a way that leads them to acquire and use these skills on their own to manage their reactions to tinnitus. 

Many methods are used to treat tinnitus. Just Google tinnitus and you will be amazed at how many treatments there are. Most of these treatments have no scientific basis, and many of them are simply scams. People with tinnitus are at a real disadvantage in seeking help because of the massive amount of misleading information. 

However, many of these unscientific methods work because of non-specific effects, i.e., the placebo effect. Tinnitus is a subjective condition with highly alterable positive outcomes due to high expectation. 

This is not necessarily bad, if the patient is getting quality care from an ethical provider. But it is, of course, far too easy to convince the unsuspecting person that some unproven treatment will help them or even cure their tinnitus. 

There are really only a handful of methods that have an evidence basis. Here is a list of methods that have some reasonable degree of research support. Hearing aids have long been known to help people who have tinnitus. Hearing aids can relieve stress and the implied sounds and help patients pay less attention to their tinnitus. 

Tinnitus masking has been around since the 1970s. This masking -- [ Interference on phone line.  Dropped call. ] 

So we will wait for Jim to get back on the call. But I will take it from here so we are going to continue talking about tinnitus masking. And masking has been around since the 1970s. With masking, the purpose is not to cover up or mask the patient with tinnitus, the patient is to achieve a sense of relief from the stress or tension caused by tinnitus. This is done by the use of the ear sound generators often called maskers that generate broadband sound. 

The word masking has created confusion. The method should be thought of as a sound-based relief. 

Tinnitus retraining therapy, or TRT, has been around since the 1990s. Sound is also used with this method but for a completely different purpose than for masking. With TRT sound is not intended to induce a sense of relief, but rather to create a background noise to make tinnitus less noticeable. 

TRT often involves a fairly expensive counseling, which is based on the neurophysiology model. 

[Dropped caller returns. Organizational discussion]

So this model is used to help patients understand that tinnitus is a meaningless signal. That the combination of therapy and counseling with TRT is designed to lead to habituation, meaning that the patient does not normally pay attention to the tinnitus, does not react to it when it does come into the consciousness.

Okay. Sorry everybody but I got spontaneously disconnected. I do not know what happened. Anyway. Neuromonics is unique because this is a company and any treatment is controlled by the company usually through audiologists. With Neuromonics the patient receives a proprietary MP3 device which essentially plays relaxing music combined with wideband noise. They use this device for two or more hours per day, and the purpose is to desensitize the person with tinnitus by gradually reducing the sound output of the device and exposing more and more of the tinnitus. In the private sector, this treatment costs about $5000 or more. 

We mention this method because it is in the literature, even though all studies have been conducted by people affiliated with a company. We do not advocate use of this method unless all other viable methods have not worked for a patient. 

Cognitive behavioral therapy, or CBT is a method that probably most of you are aware of. CBT has been used for decades to treat depression, anxiety and pain, and others and has also been adapted to tinnitus. We highlight CBT, because components of CBT have been utilized in the method of progressive tinnitus management -- or PTM. 

PTM is the method we are focusing on today. It is the result of our years of research and clinical experience. It utilizes elements of hearing aids, masking, TRT and CBT. The key features of PTM are that it is a step care approach. It is based on education leading to self efficacy. And it creates a framework for management that is flexible to accommodate differing requirements of clinicians and patients. 

You might be wondering, which of these methods is the most effective. Simply put the literature is equivocal. Each of these methods has been shown to work in a certain number of people. They are all reasonable techniques. This points to the need for more research, although such research will take many years. In the meantime, patients can generally get good help from any approach that utilizes education leading to self management, the appropriate use of therapeutic sound, and a program of behavioral and cognitive modification. 

That is the end of my part and Dr. Myers will take over from here. 

Tinnitus is estimated to affect 10% to 15% of the overall population and 30% of our polled audience today. Of those persons with tinnitus, 20 percent are bothered by it enough to seek some form of medical help and a smaller percent are debilitated by it. These patients with bothersome and debilitating tinnitus and/or **hyperacusis,** which is an abnormal sensitivity to sound, have a number of characteristics that are similar to chronic pain. For example, anxiety, depression, sleep disturbance and withdrawal from social activities can be found in both patient groups. Emotional and psychosocial factors as well as coping abilities impact the level of distress, and disruption caused by tinnitus and chronic pain. 

This tinnitus pyramid that you are going to see pop-up on the screen will be a way for you to visualize how people who experience chronic tinnitus are affected differently. The base of the pyramid reveals that most persons who experience tinnitus are not bothered by it or only require some rudimentary information about tinnitus. 

Epidemiological studies generally reveal that about 80% of people who experience tinnitus are not particularly bothered by it. The remaining 20% are bothered but to different degrees, as depicted by the people with progressively more severe tinnitus problems towards the top of the pyramid. 

The tip of the pyramid contains those relatively few patients who have the most severe tinnitus conditions. That is, those who are debilitated by it. This pyramid shows that people who have tinnitus have very different needs, ranging from the simple information to longtime individualized support. And this range of needs is what necessitates the progressive management approach. 

So what do we see in our audiology clinics? Here at Tampa, especially in VISN 8, we see an influx of claims for tinnitus and hearing loss disability. 

Tinnitus is the most common individual disability for all veterans receiving disability, as well as the most common disability with all new disabilities. Aside from the huge economic impact of tinnitus disability, more important is the emotional impact of tinnitus. Many of our veterans with blast or other combat injuries result in chronic tinnitus and pain which serves as a constant reminder to the traumatic event. These patients will likely require psychological intervention to alter these negative reactions and associations to tinnitus and pain and to aid in coping with it. 

Dr. Samantha Boris-Karpel will take over from here.

Thank you, Paula. I am now going to speak about similarities between this and pain management in chronic non-cancer pain. 

So this slide is based on a chart that Paula Myers created to just oppose the similarities between chronic tinnitus and chronic non-cancer-related pain. 

I will address each comparison on this chart in the next four slides: Type of patient report, variety of causes, mechanisms of perception, and focus on management. 

The first comparison is how the symptoms or condition is reported. So with tinnitus we have subjective report versus objective report. And with pain, we have subjective perception of pain versus observable stimulus causing the nocioception. 

Now while we conceptualize pain as a fifth vital sign, we measure it through self report. It is an invisible symptom. The same is true with most chronic tinnitus. Except for exquisitely rare occurrences of an objective tinnitus from an internal source, chronic tinnitus cannot be heard by others. Relying on subjective reporting changes the whole dynamic of how diagnoses are made and treatment is handled. 

Patients may fear that they are not being trusted, or that their providers are pathologizing them as hysterical. Likewise the term of the success for the intervention relies on the patient's self-report. With tinnitus there is not an observable stimulus causing the sensation of bothersome sound, likewise with many types of non-cancer chronic pain, there may or may not be any confirmed stimuli causing the bothersome sensation

Causes: With tinnitus, there are many known causes including acoustic trauma. Although some causes cannot be known. With pain the cause may be due to injury, disease or also unknown. 

Some patients have an explanatory narrative as to why they have tinnitus. It may be from riding a motorcycle, playing in a rock band or becoming injured in a blast. Other tinnitus patients may be unsure or still seeking to claim the causes of their tinnitus. They may seek assistance from the healthcare providers as to whether or not we think exposure to a plane engine or working in an artillery factory or so on. 

To those of you treat chronic pain patients, this may sound familiar that some patients have a story as to why they are in pain while others struggle to seek to explain why. 

So we have several mechanisms of neurological input for both tinnitus and pain. In tinnitus it is the ear and/or brain. And with pain it is a peripheral and/or central nervous system. In chronic tinnitus there are likely a number of possible mechanisms of neurological dysfunctions that can cause tinnitus. In some cases it may seem more likely that injury to neurological structures of the year are involved. Especially if there is hearing loss. 

Regardless, certainly the central nervous system, that is the brain, is involved in enabling if not creating the tinnitus. 

Likewise with pain, phantom limb pain and reflex sympathetic dystrophy always seems to point us in the direction of major central nervous system involvement and Melzack and Wall’s 1965 gate control theory of pain has outlined a more dynamic involvement of the role of the peripheral and central nervous system in creating and modulating the sensations of pain. 

It is interesting to note that with both tinnitus and pain, we often use the term phantom sensation when we are explicating the role of the central nervous system to the perception of bothersome stimuli. 

For both tinnitus and pain, management is key. Tinnitus and chronic non-cancer pain often have no cure. 

Management targets the patients’ reactions to the stimulus. Note -- reactions are the patient's behaviors -- as to say movement, nutrition, pharmacological compliance, thoughts and feelings. 

Finally, both chronic tinnitus and chronic non-cancer pain often have no cure -- this is even truer for chronic tinnitus than it is for chronic pain. For those pain management providers who can think of a number of patients who they consider cured of chronic pain, that is wonderful. And that is what everyone wants. However, this is less likely with chronic tinnitus. So we really need to manage the expectations of tinnitus patients. And explain that tinnitus management is about multiple strategies for coping with this condition and that this condition is likely to be lifelong. 

I would therefore invite the pain management providers on this call, to reference in your mind, cases of seemingly intractable chronic non-cancer pain, when thinking about the clinical picture of chronic bothersome tinnitus. 

Next, Dr. Tara Zaugg is going to give an overview of PTM -- progressive tinnitus management. 

As Dr. Boris-Karpel explained, I will give you a overview of PTM but let's start with a review of completed clinical controlled study. We don't have time for me to get into the nitty-gritty details of each study, so I would just give you a quick overview. 

A little over a decade ago we completed a study with 126 subjects comparing a method of tinnitus management know as tinnitus V therapy to a different method of tinnitus management known as tinnitus masking. And the results of that study showed significant improvement for subjects in both groups. Over the course of the study we became very familiar with each method and noted what we liked and did not like with each method and then the components of each of those methods that we like, remains in PTM today. And of course we did not include problematic components of either method in PTM. 

We also completed a group education study with 269 subjects comparing group education based on concepts from tinnitus retraining therapy or TRT. Two groups focused on tinnitus with no educational agenda. And the results of that study show statistically significant improvement for the group provided with the group education based on TRT. 

With that particular study we brought people directly into groups for education based on TRT provided without first assessing or addressing hearing problems which he learned was a mistake. It’s very important to deal with hearing problems before moving on to a tinnitus problem and this concept continues to be an important component of PTM. 

With this study we also learned that group education can be an effective method of providing intervention.

Next we completed a study comparing masking, TRT and a form of tinnitus education, which is actually very early version of PTM. The results from the study showed that TRT, masking and this form of tinnitus education are all helpful interventions for Veterans with tinnitus. 

After that study we dedicated an entire study to the development of progressive tinnitus management. [indesc] that study allowed us to clearly define the methodology and develop all of the material needed to perform PTM. 

After that study was completed, we dedicated a study to adapting the method of PTM to be delivered over the telephone and at that point with the help of Dr. Schmidt who is on the call today, we began incorporating concepts of cognitive behavioral therapy into the method. 

And the results of this pilot study showed that the provision of PTM over the telephone is a viable method of intervention for people with tinnitus.

And the most recent study we completed was a pilot study of CBT for tinnitus. The pilot CBT for tinnitus study compared CBT provided to 11 subjects by psychologists, to education provided to 9 subjects by an audiologist using a mixed methods approach. Quantitative and qualitative methods were utilized. And the results found that both groups benefited on the intervention. 

We currently have two studies related to PTM underway. One is a multisite controlled study of PTM being carried out at 2 sites -- and we are comparing subjects who are receiving PTM to subjects on a wait list. And the other study is a follow-up to the telephone-based study that I mentioned just a moment ago. And the follow-up study compares subjects receiving PTM over the telephone to subjects on the waiting list. 

Research data supporting PTM come primarily from these trials, but also from numerous studies that have documented the effectiveness of using therapeutic sound in different ways and cognitive behavioral therapy for tinnitus management. 

Now that we have very briefly reviewed the evidence for PTM, let's move on to the nuts and bolts of PTM. 

As Dr. Meyer explained earlier, this pyramid represents the entire population of adults with tinnitus. And down here at the bottom of the pyramid are the approximately 80% of people with tinnitus that isn’t problematic.... I am having some problems with my computer here. 

So at the bottom of the pyramid are people that are not particularly bothered by their tinnitus and do not require any intervention for it. And as you move up the pyramid, people are more progressively bothered by their tinnitus and need progressively more services to help them. At the top of the pyramid represent a very small percentage of people who are extremely the bothered by tinnitus and required one on one assistance in managing reactions to tinnitus. 

Now that you have the big picture, I will quickly describe what happens at each level of PTM. 

The first level is triage. Triage is the initial point of contact where patients report to provider -- any provider -- that they have tinnitus. We developed specific guidelines for non-audiologists to use to decide what to do when a patient complaints of tinnitus. 

I am not going to take the time to go through each of these but I will run through one example with you. You can see here at the top that if a patient complaints of physical trauma, facial palsy, sudden and explained hearing loss or any other urgent medical condition then the patient should be referred for emergency care to otolaryngology-- and at the bottom of the guidelines you can see the conditions that must be met for simple non-urgent referral to audiology. This is really designed as just to simplify the process of helping people who are not necessarily familiar with patients who have tinnitus what to do with their patient complain about it. So you know that the referral process sometimes start out with otolaryngology or somewhere other than audiology but the eventually all patients should filter through audiology. Once a patient goes through triage and ends up in the hands of the audiologist, then he or she goes through level II of audiologic evaluation. That primarily consists of a hearing test, a hearing evaluation if needed, screening for sound tolerance problems, and a brief assessment of tinnitus impact to determine if tinnitus-specific intervention is warranted. 

A couple of quick notes -- if a patient is need of hearing aids or other assisted-listening devices, then that should be fitted before the patient moves on to level three. And very occasionally when screening for a sound tolerance problems, a sound tolerance problem so severe that it would prevent a patient from being able to participate in a group setting is discovered. 

In these cases, the patient then goes through our sound tolerance evaluation and management – referred to as STEM -- once the sound tolerance is better under control, then the patient can go to level three group education if needed. It is pretty rare for a person to need to go through STEM. In most cases the patient goes through level II -- and if it is determined that intervention specific to tinnitus is warranted, they go to level III. 

The level III group education consists of a series of five workshops. Two of the five workshops are led by an audiologist. And the audiology workshops focus on learning to use sound to manage reactions to tinnitus. So participants identify their most bothers and that his situation and they learn how to use sounds that are soothing, interesting and neutral background sounds to help them feel better during those times without changing the sound of the tinnitus itself. 

And Dr. Myers will go more into detail on this later.

Three of the five workshops are led by a mental health professional these sessions are based on cognitive behavioral therapy. And Dr. Schmidt will talk in more detail about what pieces of cognitive behavioral therapy are included. 

Experience tells us that most patients don't need help beyond the group education sessions. But we don't have any way of knowing that without checking in on them. So six weeks after participants have complete the entire workshop series, they are contacted by telephone to see how they are doing. And if it is determined that a patient may need more than is available through level III, then the patient goes on to level IV. And level IV consists of an in depth evaluation by both an audiologist and a mental health professional to determine if one-on-one services by an audiologist, a mental health provider or both are warranted. 

If at level IV it is determined that the patient is a good candidate for level V individualized support, then that patient would be one on one with the audiologist and or the mental health provider. The content of the Level V sessions is an individualized and somewhat expanded version of the same material that is covered in the level III workshop. 

So that covers the bare-bones of progressive tinnitus management. And I will head over to Dr. Myers now who will talk about PTM books and the PTM online training. 

Thank you. 

The clinician guideline handbook which includes the PowerPoint files and the DVDs of the groups session, the PTM counseling guide and an online training course, have been developed to provide detailed clinical education, guides and tools to conduct PTM. These materials were developed in conjunction with the randomized clinical trial funded by the VA R&D service that Dr. Zaugg just discussed. The clinical handbook for audiologists, counseling guide, and hundreds of the patients step-by-step workbooks, which includes DVDs of using sound and relaxation techniques to manage reactions to tinnitus, were distributed to all VA audiology clinics last year. The patient step-by-step workbook and the tinnitus question and answer brochure are available for free via the TMS catalog. 

The VA online tinnitus management training course is currently being edited and the first 12 modules will be online via TMS -- TMS this spring. This course was developed in conjunction with employee education systems so all clinicians who work with patients with bothersome tinnitus are encouraged to take this training course. Stay tuned.

And back to you Dr. Boris-Karpel. 

So now let’s talk about chronic pain management versus PTM, Progressive Tinnitus Management. 

On this slide this comparison chart is based on one that Paula Myers designed. I will be covering these topics in the next four slides. Care models, the inclusion of different disciplines, the focus on management and individualized plan of care. 

With tinnitus we have a hierarchical or progressive model of care. With pain we have a stepped care model of pain management. So these are both new or trending VA gold standard health service models. We content that PTM is best-practices. And they are not yet fully implemented by all sites. Because the nature of interventions with chronic tinnitus and chronic non-cancer pain will vary from patient to patient and because there are different levels of symptoms of severity, and different physiological, psychological and social landscapes for each patient, and because for some patients the interdisciplinary approach is best, there cannot be a one size fits all health care protocol. So how do we organize health services for these patients? 

Both the fields of pain management and the field of tinnitus management have identified a best practice model that is hierarchal and progressive. Those of you in pain management are likely familiar with a stepped care pain management that has three levels of care. The first level is intervention within the patient centered medical home which may be the primary care provider. The second level is a specialty consultation. And the third level is a tertiary interdisciplinary pain clinic. So the actual structures of PTM and pain management stepped care model are distinct. But the idea of moving up and progressing up the steps, or up the pyramid based on need, is the same. 

There is some background noise going on -- anyway. 

A final similarity with PTM -- with pain management stepped care model -- is that both models of care are empirically supportive. 

So next slide. It takes a village for both tinnitus management and pain management. I was unable to fit all the disciplines I wanted to on the slide and my apologies if yours is not included. But that very fact, in and of itself is telling. In tinnitus management this may include primary care, audiology, mental health, ENT but it may also include psychiatry, dentistry, neurology, occupational therapy and others. 

Pain management includes primary care, nursing, mental health, physical therapy, occupational therapy, anesthesiology, neurology, orthopedics and others. 

[ Indiscernible - background noise ] 

As mentioned before tinnitus management is akin to learning to manage intractable chronic non-cancer pain. Patients learn coping skills to manage the reactions. 

Finally, both tinnitus and pain call for an individualized plan of care. Tinnitus develops a customized management plan to account for individual differences. And pain management develops a treatment plan to account for individual differences. 

Next, Dr. Caroline Schmidt will present on the roles of various health providers in PTM. 

Thank you Dr. Boris-Karpel. 

We are going to discuss the various roles of healthcare providers in PTM. As was mentioned back on slide 32, during level one of PTM which is called triage, any of these providers can refer patients who claim tinnitus to make sure that their needs are met efficiently and to the correct provider based on the urgency of their needs. So because in the past many patients have been told just go home and live with their tinnitus, patients who learned to not even talk about their tinnitus and don't even realize that there are services available. Some of the departments who are going to see patients with tinnitus but haven’t received the services yet are some of these listed on the screen.

You can see here on slide 50, that not all patients are referred in the same way. And we have detailed various problems that tinnitus patients commonly report and where you as a provider can refer patients based on these problems. 

There are four referral options and your patient may need one or more referrals to meet their immediate needs. 

Providers are often unsure about what to do and where to refer patients. And whether or not to refer to an audiologist for an exam or an ENT doctor, ear nose or throat doctor for an ENT exam. And by the way, a ENT doctor is sometimes called an otolaryngologist, a neurotologist or a otologist based on the special training. 

The specific symptoms would warrant a referral to and ENT doctor for an ENT exam because the condition such as tinnitus would be treatable or possible dangerous. These would include pulsatile tinnitus or somatic sounds described earlier on slide 10, ear pain, drainage an malodor, dizziness or vertigo, asymmetric hearing loss where one ear is worse than the other, conductive hearing loss as it’s known, or rapid change in symptoms. 

Now Dr. Myers is going to play the role of audiologists in PTM. 

So the role of the audiologist in conducting PTM at level I is to provide all healthcare provider referral sources with a tinnitus triage guidelines. And a copy of the triage guideline article located in the reference section at the conclusion of this presentation. 

At level II, the audiologist performs the standard audiologic evaluations and administers brief written questionnaires to assess relative impact of hearing problems, sound tolerance problems, tinnitus problems; provide appropriate intervention and referrals as needed. 

At level III, the audiologist provides group education on tinnitus management which I will describe more on the upcoming slide. 

And most -- most patients can satisfactorily self manage their tinnitus after participating in level III group education. 

Patients who need more support and education than was available at level III can progress to the level 4 tinnitus evaluation to determine their needs if further intervention is required. The tinnitus evaluation includes an intake interview and an optional tinnitus psychoacoustic assessment to determine whether one-on-one individualized support or referrals or needed. And if so, the audiologist and patient begin to formulate an individualized management plan. 

Level V individual support is needed by relatively few patients. This level uses the standardized individualized counseling flow chart to provide directed counseling as well as discussion of sound management and relaxation strategies. If individualized support is not effective after about 6 months then different forms of intervention are considered.

The level III group education normally consists of two sessions separated by about two weeks. During the first session the principles of using sound to manage tinnitus are explained. And each tinnitus participant uses a worksheet that is in the workbook to develop an individualized sound plan to manage their most bothersome tinnitus situations.

Patients are instructed to use the sound plan that they developed during this first meeting, until the next meeting, at which time they discuss their experience using the plant and its effectiveness. The audiologist facilitates the discussion and addresses any questions or concerns. Further information about managing tinnitus is then presented. And the participants revise their sound plan based on the discussion and the new information. 

At session 1, the patient first identifies their most bothersome tinnitus situation using the tinnitus problem checklist that is located in their workbook. 

Here you can see the tinnitus problem checklist. And then this bothersome tinnitus situation is written at the top of the individual sound plan. The patients are then taught the three types of sound that can be used to manage the reactions to tinnitus and they listen to examples of each. Soothing sound is used to provide an immediate sense of relief from the stress caused by tinnitus. Background sound is used to reduce contrast between tinnitus and the acoustic environment but which thereby makes it easier for the tinnitus to go unnoticed. And interesting sound is used to actively divert attention away from the tinnitus on to something else. 

After the group education session, most patients don't request any further intervention to manage the reactions to tinnitus. A small majority will require further intervention progressing to level IV tinnitus evaluation whereby special procedures are used to select devices for tinnitus management including customized devices such as ear level found generators and combination hearing aid sound generator instruments. 

And on the next slide we see that there are non customized personal listening devices which are also very popular options for sound therapy consideration. 

And these augmentative devices are demonstrated in the audiology clinic -- the patients know what they are and how they work. These devices can be very effective in helping veterans manage their reactions to tinnitus. 

Sleep disturbances are frequently reported by patients with tinnitus and pain. Tinnitus patients who report sleep problems often tend to have the most severe tinnitus. 

PTM provides sound based strategies and that can help patients improve their sleep, as well as sleep hygiene education. If these strategies are unsuccessful, then sleep problems may be mitigated by proper treatment from a physician or mental health professional. And Dr. Schmidt will take over from here. 

Thank you Dr. Myers. I will quickly go through this because I want to leave enough time for the question and answer period. 

The role of the mental health providers in PTM is available during each of the five levels. During level I, if you have a patient who has tinnitus, you would want to refer appropriately and respond to urgent referrals if the patient is in distress. In level II you would respond to urgent referrals, probably from an audiologist but possibly other referrals. 

Level III there is the group education -- providing coping techniques based on CBT. Level four would be assessing psychological symptoms, if the patient does not respond to the group education. And in level V, providing coping techniques based on CBT with individuals. So the level III is group care. Five would be individualized care. 

These are the typical coping techniques taught at level III and these are the ones that are typically used and that patients respond to. Not all patients respond to every one of these, but they are very helpful for a lot of patients. So stress reduction, attention diversion and cognitive restructuring. 

So basically PTM is collaborative self-management. And it is not a treatment but intervention. 

At Level III we help develop strategies for managing tinnitus. We use the changing thoughts and feelings workshop to do this. And patients can devise this plan along with the sound plan worksheets that Dr. Myers just presented and they are used very similarly. You can see the changing thoughts and feelings worksheet targets the problem and uses each of the skills to help patients develop a plan for managing their tinnitus. 

In conclusion, tinnitus and pain management share many similarities. Like chronic pain management, PTM is progressive, individualized and interdisciplinary. It’s a flexible framework. And the similarities and impact on symptoms and ways that they can be managed with transferable lessons that -- and these conditions are not fixed. 

You can learn more about PTM at this website. And there is a general description about it. 

And also some resources for you as a provider and for patients can be found at the NCRAR website. 

This is how to contact us is if you have any questions after our presentation. And the next few slides will just give references and resources but I will quickly run through them and come back to the slide and you can contact Heidi Schlueter for the Q&A session. 

I love hearing how people pronounce my last name -- it's totally fine. I understand completely. We do have a few questions and we have got some time but so we will start going through those if you guys are ready for that. 

The first question that we received here: it was not clear how a hearing aid can help. 

Dr. Henry -- would you like to address how hearing aids can help with tinnitus? 

I talked about it a little earlier -- hearing aids overall reduce stress in general for patients when they have trouble communicating, talking, listening. Hearing aids just reduce the overall stress level associated with the communication difficulties. 

And then with regard to tinnitus, the hearing aids raise the level of environmental sound, just like using background sound. So it makes everything a little bit louder. And just by doing that, you are sort of enhancing the acoustic environment. And by doing that, you automatically make the tinnitus less noticeable. Kind of a passive listening thing. That if you just raise the level of sound, you are going to make the tinnitus less noticeable. 

Great. Thank you. The next question that I have here -- how do you address transient hearing noise versus tinnitus when a veteran claiming tinnitus for CNP but really has transient ear noise?

A good question -- would Dr. Myers answer the question? 

The VBA -- the Veteran Benefit Administration has kind of a different definition for disability purposes than the audiologic definition that Dr. Henry had described. For the VA disability purposes, tinnitus merely has to be subjectively reported and recurrent. That is the definition. So we are not permitted to use our audiologic definition for disability purposes. But it is kind of a separate presentation in itself. 

Okay. Thank you. The next question we have here: from the description, I have somatic tinnitus although most of the time just regular very loud tinnitus. My physician leads me to believe that this is no big deal but can you expound on the possible causes of somatic tinnitus.

Dr. Zaugg would you like to respond to that one? 

Well let's see. Actually I am curious what leads to this person to believe that they have somatic tinnitus. There can be some vascular abnormalities that can cause tinnitus. Occasionally there is something referred to as a glomos tumor that can cause pulsatile tinnitus. To be perfectly honest, I am not entirely sure how physicians go about determining if that is the case but I just note that happens and it is important for a person to be seen by a physician. Preferably by a otolaryngologist.

Those are a few causes of somatic tinnitus -- there is usually a vascular or muscular thing going on. And occasionally can be a glomos tumor which I believe causes vascular abnormalities.

Does either Paul or Dr. Myers have any other comments on somatic tinnitus.

I would reference that audience member to look at the triage guidelines that Dr. Elias Michaelides had helped write. In the physician manual, I know he highlights more details from a medical perspective. And so I think they would find that reference helpful. And I think Caroline has it up on the screen right now. In the Journal of Family Practice 

But you are right -- vascular and muscular are the most common. 

And I like the idea of looking at the triage guidelines. If you see anything in there that concerns you, it is fine to ask for referrals to otolaryngology because you're concerned about it. I think a lot of times primary care physicians have very basic information and are less familiar with somatic tinnitus because it is so unusual so if you see anything in the guidelines that concern do it would be appropriate to ask for a referral to ENT.

Great. Thank you. The next question -- how do we get the patient workbook again. 

Do want to me to answer this 

In TMS, when you go into the homepage, there is a toolbar called catalog. And when you go under the catalog, you can type in tinnitus. And you will see the PTM workbook pop-up. As well as the brochure on tinnitus questions and answers that describes a wreath overview of tinnitus management. And lets the patient know that help is available. And it is free and you would just type in the address of your clinic and how many that you wish to order. And they will ship it to you. I just ordered some recently, and it was in two weeks I received my shipment. 

I just want to add -- you can stop in your audiology clinic -- if you are not an audiologist and ask if they have some that they might be able to give you. And also the workbooks are available to people who are not VA clinicians or patients through Plural publishing. You can find them online. 

Great. Thank you. The next question we received -- is there a relationship between obsessive compulsive disorder and tinnitus. 

I can answer that. This is Dr. Schmidt. We don't know of any specific relationship between OCD and tinnitus but it is a very good question but in something that definitely needs to be researched further. We do see that patients who have tinnitus sometimes have comorbid anxiety symptoms and depressive symptoms. But we are still investigating the incidence and rates of coexisting mental health providers. That is a very good question. 

Thank you. The next question we received – any of the presenters have experience with the use of cranial electrical stimulation such as a alpha stem to address tinnitus? 

-- Anyone? 

Probably not. 

The closest we have is an investigator here in our center is doing a study on transcranial magnetic stimulation to treat tinnitus. And he's got the latest and greatest equipment to do that. He has got a sham coil and he is conducting a randomized clinical study. And he is probably about halfway into the study right now. So there is some promising results from other studies, but nothing definitive yet. But that study is being conducted by Robert Palmer so that should be coming out in the literature in the next year or two. 

Great. Thank you The next question we received -- is there a known cause of low tolerance to sound such as can be encountered in daily life. 

That is a difficult question to answer. I think that whenever you damage the auditory system, one of the possible co-occurrences is that you affect the gain system of the auditory system. And so sometimes people who have tinnitus also have what is called hyperacusis which is basically a reduced sound tolerance and I think that is what this question is getting at -- is what causes that? And I would say any damage to the auditory system that can cause hearing loss and tinnitus can also cause hyperacusis. 

With hyperacusis people are bothered by sounds that other people are not bothered by. So sounds that everyone else can seem to tolerate just fine come of the person with hyperacusis has trouble dealing with that. It is actual pain that is caused by sound. 

There is also a related condition called misophonia -- which is an emotional response. Is a sound that is just annoying or bothersome and has nothing to do with any physical response or physical discomfort, it is simply an emotional discomfort caused by certain sounds. 

I hope that answers your question. 

Great. Thank you. And I know we are just past the top of the hour. We have three or four pending questions left. I'm hoping presenters are able to stay on the line for a couple minutes so we are able to capture these on the recording. 

And I want to add something -- the comments about hyperacusis. We just had a patient -- with one or studies recently who is diagnosed with hyperacusis -- and actually his VA healthcare provider are treating it very much like pain -- and he prescribed Vicodin for it. So that is another link between pain management and management of auditory disorders. 

Thank you but we did a couple -- perfect. We did get a couple more comments in from the questioner -- about the somatic tinnitus. She could hear pulsing in her ear. And she is questioning what kind of tumor. 

Not sure if anyone -- 

I can comment on that usually this is the case -- but usually glomos tumor can be associated with pulsing tinnitus -- glomos tumor is a benign tumor. That sometimes... rarely actually occurs in the middle ear.

Thank you. 

The next question we have here -- most OEF/OIF/OND combat veterans returning home complain of tinnitus. Most are referred to audiology. Would be appropriate to suggest some of things on the slide to help manage Many use a fan when sleeping . Our audiology department is very busy.

I would say that it is certainly useful to provide a workbook. But you do want to make sure that they know that they can see an audiologist and if desired a mental health provider for their condition. We were hoping through this call that we can educate some more mental health providers about the tinnitus services. Perhaps if you are offering services to patients with pain that you would be willing to learn a little bit about tinnitus and offer those services to. So we know that audiology clinics are extremely busy. And we certainly hope that you make that referral. For making sure that the patients know that the workbook is available and providing that for them is certainly a good step. 

One thing that we found from the research studies is sometimes when you give patients the workbook and they don't come back to get help for their tinnitus and managing their problem so we do like to provide that at level three after they have been assessed. Patients often get confused about what is the hearing loss. And what is tinnitus. So educating them in the first step is often important. 

And if I might add to that -- any patient who report tinnitus really just needs to have their hearing evaluated. And along with that hearing evaluation, you do a brief tinnitus assessment -- that is the level two audiologic assessment. So the hearing evaluation is what an audiologist would normally do. The brief tinnitus assessment is two or three tinnitus questionnaires that they can even fill out in the waiting area. So it really adds very little time to the assessment. The most important thing is to use the tinnitus and hearing survey which we developed.

It is 10 items and they would help you to determine if they really have a tinnitus problem or not. And if they don't really have a problem with their tinnitus, then nothing needs to be done. If you have evaluated their hearing, and they don't have a problem as per the tinnitus and hearing survey, then you have done everything you need to do but they don't need the workbook. They don't need intervention. It is certainly available to them if they need it in the future. But then, based on the data that you collect during the audio evaluation and brief tinnitus assessment, you will do -- know whether they need tinnitus services or not. 

Would you please comment on why PTM with mental health participation would be a better alternative to developing a Veterans support group for persons with tinnitus. 

We have done support groups and we have nothing against support groups. However we think it is more important that patients learn how to self manage their tinnitus because they are going to have a tinnitus most likely for the rest of their lives. 

So they learn -- need to learn tools. And that's what the workshops are all about. Teaching them tools. The audiologist teaches them certain tools for using sound and the mental health provider teaches them coping skills. 

So we think it is the in their best interest of patients to provide them with the help -- self-help tools but rather than just bringing them together into a support type environment, where -- which is not necessarily constructive. But they do seem to like support groups they like the -- to meet a group. That's why the group education works so well. It is efficient. You bring people together. They like the collegial nature. They like being in a room with their fellow veterans who have a common problem. We have nothing against a support group. We just think their time our time and their time is better spent in a structured environment teaching them self-help skills. 

Great. Thank you. Last question -- can tinnitus be situational? I noticed in the past two months a low grade sound I suspect to be tinnitus. I just went on a 10 day vacation and I do not recall hearing the sound. Now that I am back, I notice it again. 

That is a common report from a lot of patients. And a lot of patients report that they don't notice tinnitus when they are busy, when they are happy or when they are relaxed. Likely what is happening is it is moved to a less conscious place. And it is possible that the tinnitus is reducing when you are a less stressful situation, but not likely. Likely it is you are noticing it more under stress. And when you're not as busy. It varies from person to person. And we do hear a lot of reports that people say when they are very stressed out, that their tinnitus is worse. And that’s likely because of what they are perceiving. 

Thank you that does conclude our questions. Do any of the presenters have any closing remarks if they would like to make? 

This is Bob. Bob Kerns. I would like to specifically thank our team of presenters for a great job today in informing our pain community in practice and others about this important problem and its similarities and differences with chronic pain and pain management. Thank you very much. 

Thank you. 

Great. And I want to thank all of our presenters. We really appreciate the time that you put into the presentation. I want to thank our attendees for sticking with us. We appreciate that you stuck with us and we were able to get through all of our questions today. 

If nobody else has any other closing remarks, I am going to formally conclude today's spotlight on pain management server seminar. Thank you everyone. 

[Event concluded]