Progressive Tinnitus Management: 

An Interdisciplinary Approach

James Henry, PhD

VA RR&D 

National Center for Rehabilitative Auditory Research (NCRAR)

Portland VA Medical Center

Caroline Schmidt, PhD

VA Connecticut Healthcare System

West Haven, CT
Co-Developers of PTM

Tara Zaugg, AuD

Paula Myers, PhD
Acknowledgments

• Robert Baldwin, PhD

• Steve Benton, AuD

• Samantha Boris-Karpel, PhD

• Stephen Fausti, PhD

• Johnna Gonzalez, MS

• Susan Griest, MPH

• Allison Jones, AuD

• Christine Kaelin, MBA

• Lynn Kitagawa, MFA

• Marcia Legro, PhD

• Jackie McCarroll, MSN, RN

• Dan McDermott, MS

• Michael Moody

• Sara Ruth Odell, AuD

• Martin Schechter, PhD

• Barbara Stewart, PhD

• Emily Thielman, MS

• Janet Wood, BPS

• and many others....
Poll Question #1

What is your primary role in VA? 

A. A physician in Primary care

B. A Physician in Specialty services such as 

Otolaryngology, Psychiatry, or 

Anesthesiology 

C. A Mental health provider

D. Work in Audiology

E. Another discipline not listed?
What is Tinnitus?

• Transient ear noise = unilateral sudden tone

with other auditory sensations that decay

within about 1 min

– NOT TINNITUS

• Tinnitus = ear/head noise lasting >5 min that

occurs >once/wk (textbook)

• Chronic tinnitus = continuous ear/head noise

that is extended in duration, and persistent

over time
Poll Question #2

• Do you have tinnitus?

A. Yes

B. No
For Veterans, Tinnitus is #1 

(unfortunately)

• Most prevalent service-connected (SC)

disability for Veterans receiving compensation

at the end of FY 2012 (971,990 Veterans SC for

tinnitus)

• Also the most prevalent SC disability for

Veterans who began receiving compensation

during FY12 (115,638 Veterans)
0 

100

200

300

400

500

600

700

800

900

1994 1996 1998 2000 2002 2004 2006 2008 2010 2012

Number of Veterans (thousands)

Year

1,000

Veterans service-connected for tinnitus FY1994 – 2012
Risk Factors for Tinnitus

• Age

• Cardiovascular/cerebrovascular disease

• Drugs/medications

• Ear infections/inflammation

• Head/neck trauma and injury

• Hyper- and hypothyroidism

• Loud noise exposure

• Meniere’s disease
Risk Factors (cont.)

• Otosclerosis

• Presbycusis

• Sudden deafness

• Acoustic neuroma

• Anything that can cause hearing loss can also

cause tinnitus

– Exact mechanisms for how these factors interact

or cause tinnitus is not understood
Mechanism(s) of Tinnitus—

Contemporary View

• Although tinnitus may be triggered by ear

injury, neural generators are most likely in

central auditory pathways

• Plasticity is main component, with reduced

auditory nerve input triggering a shift in

balance of central excitation and inhibition

• Onset and maintenance of tinnitus may

involve different mechanisms
TBI and Tinnitus

• Clinical & epidemiologic studies confirm TBI is

strongly associated with tinnitus

• Tinnitus can occur not only as a direct

consequence of the event causing TBI, but

also as a side effect of medications commonly

used to treat cognitive, emotional, and pain

problems associated with TBI
Poll Question #3

Are you involved in direct care of Veterans with 

TBIs? 

– Yes

– No
Blast-Related TBI and Tinnitus

• When TBI is blast induced, the onset of

tinnitus is even more likely (but typically

under-reported)

• Studies:

– 49% of blast injured patients at Walter Reed Army

Medical Center reported tinnitus (Cave et al,

2007) 

– 38% of inpatients with blast injury at Palo Alto VA

Polytrauma Rehabilitation Center complained of

tinnitus (Lew et al., 2007)
International State-of-the-Science 

Meeting on Blast-Induced Tinnitus

• November 15-17, 2011

• Collaboration between:

– DoD Blast Injury Research Program Coordinating

Office

– DoD Hearing Center of Excellence

– Department of Veterans Affairs

• 107 participants from 8 countries

– Representing DoD, VA, NIH, academia, medicine,

and industry
International State-of-the-Science 

Meeting on Blast-Induced Tinnitus

• Objectives:

– Assess current knowledge regarding cause,

diagnosis, and treatment of tinnitus

– Identify research gaps for further investigation

– Foster collaboration among researchers and

inform DoD research investment strategies

• Proceedings published

– Major findings

– Priority recommendations for research
Key Questions on 

Blast-Induced Tinnitus

• What are the clinical characteristics and comorbidities of blast-induced tinnitus?

– Are there different subforms of blast-induced

tinnitus?

– How is blast-induced tinnitus associated with

hyperacusis, headache, depression, anxiety, and

somatic modulation of tinnitus?

– How is blast-induced tinnitus related to other

blast-induced symptoms (e.g., migraines, memory

impairment, or PTSD)?
Key Questions on Blast-Induced 

Tinnitus (not all listed)

• What are the effects of blast alone, blast plus

concussion, and concussion alone on the

development of tinnitus?

• Are there other factors or conditions that

induce or potentiate tinnitus in combination

with blast or noise?

– While limited data exist, need to determine why

nonauditory areas of the brain are involved such

as those related to attention and emotional

processing
Conclusion of Meeting

• “Continued research and development are

needed to resolve key barriers in the ability to

effectively diagnose and treat tinnitus, and

thereby reduce the impact of tinnitus on the

DoD and VA”

• Proceedings available – contact:

james.henry@va.gov
There is No Cure for Tinnitus

• No method has been shown to consistently

and safely reduce or eliminate the sound of

tinnitus

• Any claim to reduce or eliminate tinnitus is

not credible
There is No Drug for Tinnitus

• No drug has received FDA approval for

treating tinnitus

• All drugs used for tinnitus are approved to

treat other conditions – typically depression,

anxiety, insomnia, & epilepsy
What Can be Done 

About Tinnitus?

• Tinnitus = perception/sensation

– Not the problem

• Reactions = functional effects, suffering,

distress, disturbance, etc.

– The problem

• Patients can be helped if they learn to manage

their reactions to tinnitus
Three Essential Components to 

Manage Reactions to Tinnitus

1. Education

– Ideally teaching self-management skills

2. Therapeutic sound

– Any combination of soothing sound, interesting

sound, and background sound

3. Stress reduction

– Relaxation exercises, lifestyle modifications
Which Methods Are Effective?

• Dozens of methods are used to treat tinnitus

• Only a handful of methods have an evidencebasis from controlled clinical studies
Methods That Have 

an Evidence-basis

• Hearing aids

• Tinnitus Masking

• Tinnitus Retraining Therapy (TRT)

• Cognitive-Behavioral Therapy (CBT)

• Progressive Tinnitus Management (PTM)

• Neuromonics Tinnitus Treatment*

• others?
Which Method is 

the Most Effective?

• Cochrane Reviews:

– CBT has the strongest research evidence

– Sound therapy is effective when provided along

with counseling

• No evidence proving any one method is more

effective than any other
Poll Question #4

Challenges to applying tinnitus interventions at your VA 

include (select all that apply): 

– Lack of support by administration (staff allocation)

– No available audiology staff

– No available mental health staff

– Not enough patients would be interested

– The interventions are too difficult to implement

– I want to see more research before implementing PTM at

my site
Research 

Leading to PTM
Controlled Clinical 

Studies (Completed) 

• Comparison of Masking and TRT (n=126)

• Group education using TRT counseling (n=269)

• Multi-site study to compare masking, TRT, and

“tinnitus education” (n=149)

• Development and piloting of PTM (n=221)

• Adaptation of PTM for telephone-based

counseling of TBI patients (n=36)

• Pilot study of CBT for tinnitus (n=25)
Controlled Clinical 

Studies (Current) 

• Multi-Site Evaluation of Progressive Tinnitus

Management

• Telehealth Tinnitus Intervention for Patients

with TBI

• Comparison of combination instruments to

hearing aids for tinnitus management

• Transcranial Magnetic Stimulation (PI: Bob

Folmer, PhD)
PTM is based on 

13 principles learned 

from our research and 

clinical experience 
1. Clinical services for tinnitus

should be progressive

Mild 

Moderate 

Severe 
2. Use an interdisciplinary approach

3. Clinicians need training in tinnitus

management

4. All patients reporting tinnitus need an

audiologic evaluation

5. Determine if the tinnitus problem is “clinically

significant”

6. Questionnaires are the best way to determine

tinnitus severity

7. Make sure the tinnitus problem is not a

hearing problem
8. Intervention should start with patient

education

9. Address the problem of low health literacy

10.Patients are best served if they learn selfefficacy skills

11.Patients should learn different methods of

using therapeutic sound

12.Patients should learn psychological coping

techniques

13.Patient education can be provided effectively

by telephone
Overview of PTM
Five Hierarchical Levels 

of Clinical Services with 

PTM

Level 1 Triage

• Referring patients at initial point-of-contact
Level 2 Audiologic Evaluation

• Includes brief assessment of tinnitus impact
Level 2 also includes screening for 

a sound tolerance (hyperacusis) 

problem
Sound Tolerance Evaluation and 

Management (STEM)

• Procedures to evaluate and treat a severe

sound tolerance problem

STEM 
Level 3 Group Education

• Workshops for patients who require tinnitusspecific intervention
Level 4 Interdisciplinary Evaluation

• In-depth tinnitus evaluation by audiologist

and psychologist
Level 5 Individualized Support

• One-on-one support from audiologist and/or

psychologist
PTM Books

1. Progressive Tinnitus Management: Clinical

Guide for Audiologists

2. How to Manage Your Tinnitus: A Step-by-Step

Workbook

3. Progressive Tinnitus Management:

Counseling Guide
Additional Materials 

Supporting PTM

• Tinnitus brochure

• 17-minute patient video

• 2-DVD set (7 videos: 5 PTM Level 3 workshops

+ 2 relaxation training)

• CD (70-minute sound therapy tutorial)

• Online training course for VA clinicians (19

modules)
Multi-Site Evaluation of 

Progressive Tinnitus Management 

– Memphis and West Haven (CT) VAMCs (n=300) 

– PTM vs. 6-mo Wait-List Control (WLC)

– Interim quantitative analysis (n=228) 

– PTM group showed statistically significant improvement (3 

outcome measures)

– PTM improved significantly more than WLC

– Interim qualitative analysis

• Most pts using some to all methods learned in workshops

• Only 2 patients continued to complain about tinnitus
Telehealth Tinnitus Intervention 

for Patients with TBI

– Subjects recruited nationwide, primarily from

VA & military hospitals

– Callers passing screening consented &

scheduled with Study Psychologist to

determine TBI status & screen for anxiety,

depression, PTSD, & sleep disorder

– Qualified candidates randomized to either

“TelePTM” or 6-mo WLC
Modifying PTM for 

Patients with TBIs

• Delivery via telephone into homes

• Frequent and brief appts to address:

1. Memory impairments

2. Limited concentration

3. Other cognitive limitations (organization)

• Appointment log for participants

• Reminder calls for appointments

• “Homework” catered to individual

• Support system utilized
Telehealth Tinnitus Intervention 

for Patients with TBI (cont.)

– Seven telephone appointments

• Study Psychologist or Study Audiologist

• 1, 2, 3, 4, and 5 weeks, and 3 and 6 months

– To date, 133 participants enrolled

– Interim quantitative analyses (3 measures)

– TelePTM group showed statistically significant 

improvement

– TelePTM improved significantly more than WLC

– Interim qualitative analyses

• Patients’ comments overwhelmingly positive

• Central database needs improvement
Current Status of PTM

• Shown in controlled studies to reduce

symptoms and improve life satisfaction for

tinnitus sufferers

• Endorsed by VA Central Office as effective

intervention for tinnitus and recommended

for use at VAMCs

– But, not routinely offered to Veterans suffering

from tinnitus
Next Step:

Pre-Implementation Study

• Prepare for implementation study

– Assess barriers, facilitators, and readiness to 

conduct PTM across VA clinics

– Proposal submitted “Implementation of 

Progressive Tinnitus Management: An Assessment 

of Readiness”
Long-Term Goals

• Evaluate implementation of PTM within VA,

involving (1) In-Clinic Care, (2) Clinical Video

Telehealth, and (3) Home Telehealth

• Implement PTM nationally in a way that will

increase & ensure patient access & ultimately

reduce the burden of tinnitus among Veterans

and other patients
Case Example #1 - Sam

• 65 yo Veteran served in Army

(combat/Vietnam)

• TBI #1: Exposed to blast (grenade) 40 yr ago

– Lost consciousness for 5-20 min

– Woke up on a truck – tinnitus began

– Treated for lacerations to arms but no specific TBI

treatment

– Service connected for PTSD, tinnitus, HL, diabetes

(exposed to agent orange)
Case Example #1 – Sam (cont.)

• TBI #2 - Bicycle accident 15 yr ago

– Lost consciousness for ~10 min

– Headaches and sensitive to bright light persist

– Fractured several vertebrae – pain persists

– Tinnitus worsened

• Enrolled at local VA

• Recent treatment for alcohol dependence

• Strong support system and no recent SI
Case Example #1 – Sam (cont.)

• Response to PTM “self-management” plan:

– Sound: Fan at night (hypervigilant)

– Stress: Deep breathing at social gatherings

– Distraction: Books on CD in the evening

– Cognitions:

• Negative thought before “This tinnitus will eventually

drive me crazy”

• Positive thought after – “I’ve dealt with so many hard

times in life, I can deal with tinnitus even if it gets

louder”
Case Example #2 - Steve

• 33 yo Veteran served in Navy (combat—

OEF/OIF)

• TBI: At least 5 times head was “banged

around” in vehicles – lost count

• Lost consciousness at least once for unknown

time (less than 5 min)

– Many times dazed and confused after

– Never assessed after head traumas

– Noticed tinnitus but didn’t report it
Case Example #2 (cont.)

• Enrolled at local VA – rarely visits

• Mentioned tinnitus to PCP who referred him

to Audiology

• Mild unilateral HL – not hearing aid candidate

(ENT workup – no significant findings)

• Works 2 jobs and enrolled in college

• Tinnitus affects sleep, mood, “ability to hear

teachers,” and concentration when reading
Case Example #2 (cont.)

• Self-management plan:

– Education: Learned tinnitus vs. hearing problems

– Sound: Waterfall on iPod and Jazz when reading

– Stress: Imagery when trying to sleep

– Distraction: Frequent breaks from studying (walks 

for 5 min around the block)

– Cognitions: Negative thought before “No one 

cares what I’m going through.” Positive thought 

after “People forget I have tinnitus.”
What Veterans Say...

1. “Noticing a difference started slowly,

but the more I practiced the activities 

that were recommended to me, the 

more rapidly I experienced comfort and 

control. I have found that using the 

tools provided are the keys to success.”
What Veterans Say...

2. “Once I accepted that the program

might work, it did. I had problems 

thinking that anything would help my 

tinnitus. Your program worked for me! 

Thanx much!”
What Veterans Say...

3. “I have included listening to soft music and

nature sounds to my daily activities to help

me to relax more. And the breathing

techniques help a lot as well. Thanks for

helping me with these things.”
What Veterans Say...

4. “As soon as my tinnitus becomes an issue in

my life now, I know how to react to it and

continue on with a quality day.”
Questions?

www.ncrar.research.va.gov

james.henry@va.gov

caroline.schmidt@va.gov