Similarities Between Chronic Pain 

Management 

and 

Progressive Tinnitus Management (PTM)
Presentation for the

HSR&D Pain Cyberseminar Program

Spotlight on Pain Management

Caroline Schmidt, PhD

James Henry, PhD

Paula Myers, PhD

Tara Zaugg, AuD

Samantha Boris-Karpel, PhD

Tuesday, February 7, 2012

2
Disclosures of 

Conflict of Interest: 

None

3
Support provided by:

VA Rehabilitation Research & Development Service

VA Connecticut Healthcare System, West Haven, CT

VA Portland, National Center for Rehabilitative Auditory 

Research

James A. Haley Veterans’ Hospital, Tampa, Florida

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Program Objectives

1. Overview of tinnitus

2. Similarities between chronic tinnitus and 

chronic pain

3. Overview of Progressive Tinnitus 

Management (PTM)

4. Chronic pain management vs. PTM

5. Roles of various health providers in PTM

5
Acknowledgments

• Robert Kerns, PhD

• Susan Griest, MPH

• Christine Kaelin, MBA

• Lynn Kitagawa, MFA

• Marcia Legro, PhD

• Johnna Gonzalez, MS

• Emily Thielman, MS

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1. Overview of Tinnitus

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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

• Chronic tinnitus = continuous ear/head noise 

that is extended in duration, and persistent 

over time

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Do You Have Tinnitus?

• Everyone has ear noises—not everyone has 

tinnitus

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More Definitions

• Neurophysiologic vs. somatic tinnitus

• Subjective vs. objective tinnitus

• Permanent tinnitus

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What Can be 

Done About Tinnitus?

• Tinnitus itself is not the problem— reactions

to tinnitus are the problem

• Patients can be helped if they learn to manage 

their reactions to tinnitus

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How Can Patients Learn to Manage Their 

Reactions to Tinnitus?

 Bottom line: They need to learn how to 

regulate their stress and emotions by:

 Using sound

 Using relaxation techniques

 Using distraction strategies

 Changing negative thoughts

 All of this requires education leading to skill 

building

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Which Methods Are Effective?

• Dozens of methods are used to treat tinnitus

• If the patient benefits, then the method is 

effective

• Only a handful of methods have an evidencebasis

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Methods That Have an Evidence-basis

• Hearing aids

• Tinnitus Masking

• Tinnitus Retraining Therapy (TRT)

• Neuromonics Tinnitus Treatment

• Cognitive-Behavioral Therapy (CBT)

• Progressive Tinnitus Management (PTM)

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Which Method is the 

Most Effective?

• No evidence proving any one method is more 

effective than any other

• Much more research is needed to determine 

which specific components of intervention are 

most effective

• In the meantime, use a method that involves 

education, therapeutic sound, and behavioral 

and cognitive modification

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Prevalence of Tinnitus

• 10-15% of adults

• Estimates for U.S.: 40-50 million

– 10-12 million seek some form 

of medical help

• 2.5 million “debilitated” by tinnitus

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The Tinnitus Pyramid

From: Dobie RA. Overview: suffering from tinnitus. In: Snow JB, editor. 

Tinnitus: Theory and Management. Lewiston, NY: BC Decker Inc.; 2004. p. 1-7. 

Population of adults who 

experience chronic 

tinnitus 

(10-15% of all adults)

Non-bothersome tinnitus

(~80% of all those who experience tinnitus)

Bothersome tinnitus

seek clinical intervention

(~20% of all those 

who experience tinnitus)

Debilitating tinnitus

Mild

Moderate

Severe

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What Do We See in VA Audiology Clinics? 

Increased Claims for Tinnitus & 

Hearing Loss Disability

American Tinnitus Association Help us PREVENT it!

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Tinnitus is #1 – unfortunately

• Most common individual disability (744,871 

Veterans) for all Veterans receiving disability 

payments in FY 2010

• Also, most common disability among Veterans 

who began receiving benefits during FY 2010 

(92,260 Veterans – 10.7% of all new disability 

awards)

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2. Similarities Between 

Tinnitus and Pain

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Chronic Tinnitus Chronic Pain

Tinnitus symptom is 

subjective report (rare cases 

of objective tinnitus)

Pain perceptions can be 

measured subjectively 

(subjective condition)

Variety of causes Variety of causes 

Not just one mechanism 

behind tinnitus perception

Not just one mechanism 

behind pain perception

Often unable to cure 

underlying cause of tinnitus, 

but can often manage 

resulting problems (primary 

suffering of symptom itself 

and secondary suffering of 

way one reacts to symptom) 

to minimize impact

Often unable to cure 

underlying cause of pain, but 

can often manage resulting 

problems (primary suffering 

of symptom itself and 

secondary suffering of way 

one reacts to symptom) to 

minimize impact 21
Subjective

• Tinnitus

–Subjective report vs. objective

• Pain

–Perception of pain vs. observable 

stimulus causing nocioception

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Causes

• Tinnitus

–Many known causes including 

acoustic trauma

–Some causes cannot be known

• Pain

–May be due to injury, disease, or 

unknown

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Several Mechanisms

The neurological input comes 

from....

• Tinnitus

–Ear and/or brain

• Pain 

–Peripheral and/or central source

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No Cure –

Management is Key

• Tinnitus and Chronic Non-Cancer Pain 

often have no cure

–Management targets reactions to 

the stimulus

–Note: Reactions are the patients’ 

behaviors (i.e. movement, nutrition, 

rx compliance); cognitions 

(thoughts) and feelings

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3. Overview of PTM

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Controlled Clinical Studies

1. Comparison of masking and TRT (n=126)

2. Group education using TRT counseling (n=269)

3. Multi-site study to compare masking, TRT, and 

“tinnitus education” (n=149)

4. Development of PTM (n=221)

5. Adaptation of PTM for telephone-based 

counseling of TBI patients (n=36)

6. Pilot Study of CBT for Tinnitus (n=20)

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New Studies Underway

1. Multi-site controlled study of PTM

– Memphis VAMC

– VA Connecticut Healthcare System (West Haven, 

CT)

2. Telephone tinnitus education for patients 

with TBI – nationwide study

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Development of PTM

• Research data supporting PTM come primarily 

from these trials, but also from numerous 

studies (e.g., Cochrane Review 2010) that 

have documented the effectiveness of using 

therapeutic sound in different ways & 

cognitive-behavioral therapy for tinnitus 

management

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Five Hierarchical Levels 

of Clinical Services with 

PTM

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Level 1 Triage

• Guidelines for referring patients at the initial 

clinic point-of-contact

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Tinnitus Triage Guidelines

(My Patient Complains About Tinnitus—What Should I Do?)

If the patient: Refer to:

1. Has physical trauma, facial palsy, or unexplained 

sudden hearing loss

 Has any other urgent medical condition

Emergency Care or Otolaryngology 

(If unexplained sudden hearing loss—

Audiology referral prior to Otolaryngology 

visit same day) 

(emergency referral)

2. Has suicidal/homicidal ideations

 Manifests obvious mental health problems

Emergency Care or Mental Health—report 

suicidal ideation 

(may be emergency—if so escort patient to 

Emergency Care or Mental Health) 

3. Has ANY of the following:

 Symptoms suggest somatic origin of tinnitus (example: 

tinnitus that pulses with heartbeat)

 Ear pain, drainage, or malodor

 Vestibular symptoms (example: dizziness/vertigo)

Otolaryngology

(urgency determined by clinician; refer to 

audiologist for follow-up management)

Can refer to Primary Care if ear pain, 

drainage, or malodor

4. Has ALL of the following:

 Symptoms suggest neural origin of tinnitus (example: 

tinnitus does not pulse with heartbeat)

 No ear pain, drainage, or malodor

 No vestibular symptoms (example: no dizziness/vertigo)

 No unexplained sudden hearing loss or facial palsy

Audiology

(not urgent) 

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Level 2 Audiologic Evaluation

• Standard audiologic evaluation, plus brief 

assessment of tinnitus impact

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Sound Tolerance Evaluation and 

Management (STEM)

• Adjunct procedures to evaluate and treat a 

severe sound tolerance problem

STEM

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Level 3 Group Education

• Workshops for patients who require tinnitusspecific intervention

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Level 3 Workshops

• Series of 5 workshops

• Two are lead by an audiologist

– Focus on learning to use sound to manage 

reactions to tinnitus

• Three are lead by a mental health professional

– Based on CBT

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Level 4 Interdisciplinary Evaluation

• In-depth evaluation of patients who require 

services beyond Level 3

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Level 5 Individualized Support

• One-on-one support for patients who require 

longer-term intervention from an audiologist 

and/or a mental health provider

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PTM Books—Clinical Tools

• Progressive Tinnitus Management: 

Clinical Handbook for Audiologists

• How to Manage Your Tinnitus: A 

Step-by-Step Workbook

• Progressive Tinnitus Management: 

Counseling Guide

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VA Online Tinnitus 

Training Course

• First 12 modules completed and coming 

online ~ April

– Module 12 is a “virtual clinical practicum”

• Additional modules (13-19)

– Should be online by end of year

• Training modules in development for 

psychologists

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4. Chronic Pain Management Versus 

PTM

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Chronic Pain Management Progressive Tinnitus 

Management

Stepped Care Model is the 

trending model in the VA

Hierarchical Care Model is the 

trending model in the VA

Multi- or Interdisciplinary Interdisciplinary

Most often concerned with 

management versus cure

Concerned with management 

versus cure

Individualized plan of care Individualized plan of care 

(facilitated by sound plan and 

changing thoughts and feeling 

worksheets)

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Stepped versus Progressive

• Tinnitus

–Hierarchical (Progressive)

• Pain 

–Stepped Care

Note: These are new or trending VA gold- standard health service models and are 

not yet fully-implemented by all sites.

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Interdisciplinary

• Tinnitus

– Includes primary care, audiology, mental 

health, ENT, otology

– May also include psychiatry, dentistry, 

neurology, occupational therapy, and 

others

• Pain

– Includes primary care, nursing, mental 

health, physical therapy, occupational 

therapy, anesthesiology, neurology, 

orthopedics, and others

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Symptom Management

• Tinnitus and Pain

–Patients learn coping skills to 

manage their reactions

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Individualized Plan of Care

• Tinnitus

–Develops a customized management 

plan to account for individual 

differences

• Pain 

–Develops a treatment plan to 

account for individual differences

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5. Roles of Various Health Providers in 

PTM

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Tinnitus Management Triage 

Guidelines Are For All Providers 

• Patients report tinnitus to healthcare providers in 

many different clinics – besides Audiology

– Otolaryngology

– Primary Care

– Psychology

– Psychiatry

– Neurology

– Oncology

• The triage level applies to all clinicians who 

encounter patients who complain 

about tinnitus

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• Any of the following: 

– Pulsatile tinnitus / somatosounds

– Ear pain, drainage, or malodor

– Dizziness or vertigo

– Asymmetric hearing loss

– Conductive hearing loss

– Rapid change in symptoms

• These could indicate a treatable and/or 

dangerous medical condition

When is an ENT Exam Required? 

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Role of Audiologists in PTM

• Level 1: Provide referral sources with triage 

guidelines

• Level 2: Audiologic evaluation and brief 

assessment of tinnitus (determine need for 

hearing, tinnitus, or sound tolerance 

intervention, and referrals PRN)

• Level 3: Group education 

• Level 4: In-depth evaluation

• Level 5: Individual support and counseling

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Level 3 with Audiologist

• Explain principles of using sound to manage 

tinnitus

• Sound Plan Worksheet used to develop 

individualized “sound plan” to manage most 

bothersome tinnitus situation

• “Homework” is to implement sound plan developed 

during first session

• Pts asked to return for follow-up session 2 weeks 

later

– Try to improve on sound plan

– Learn new information

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3

types 

of

sound

Three types of sound can be used to 

manage tinnitus

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Customized Tinnitus Management Devices

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Non-Customized Tinnitus Management Devices

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Demonstrating Personal Listening Devices, 

Stationary Devices, and Apps

• Augmentative sound can be very effective for 

helping to manage reactions to tinnitus 

• Should be demonstrated in clinic so patients 

know what they are and how they work

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Sleep Problems with Tinnitus (and Pain)

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Role of Mental Health Providers 

in PTM

• Level 1: Refer appropriately

• Level 2: Respond to urgent referrals

• Level 3: Provide coping techniques (based on 

CBT) via groups

• Level 4: Assess psychological symptoms

• Level 5: Provide coping techniques (based on 

CBT) with individuals

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Essential Coping Techniques (for 

Tinnitus)

Three coping techniques are 

taught:

1. Stress reduction 

(“relaxation”)

2. Attention diversion 

(“planning pleasant 

activities”)

3. Cognitive restructuring 

(“changing thoughts”)

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Collaborative Self-Management

• Intervention is not “treatment”

• Intervention should involve primarily 

educating the patient about managing 

reactions to tinnitus

• Different strategies needed to manage 

reactions that occur in different situations

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Level 3 with the MH Provider

• Work with patients to help them:

– Understand their condition

– Participate in decisions regarding their 

management plan

– Develop and follow a management plan

– Monitor success of their self-management efforts 

and revise the plan as needed

• Overall approach is “collaborative 

self-management”

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Changing Thoughts and Feelings 

Worksheet

• Modeled after and used simultaneously with 

Sound Plan Worksheet used by the audiologist

• Helps patients track their use of three coping 

skills taught during Levels 3 and 5

• Used throughout sessions with objective for 

participants to develop personalized plans for 

managing their reactions to tinnitus in specific 

problem-situations

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Conclusions

• Tinnitus and pain management share 

many similarities

• Like Chronic Pain Management, PTM is 

progressive, individualized, and 

interdisciplinary

–Flexible framework

– Similarities in impact of symptoms and ways they 

can be managed with transferable lessons that 

these conditions are not fixed

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To Learn More about the PTM Protocol Created for VA

http://www.va.gov/health/NewsFeatures/20110524a.asp

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http://www.ncrar.research.va.gov/Education/Do

cuments/TinnitusDocuments/Index.asp

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Contact us:

caroline.schmidt@va.gov 

james.henry@va.gov

paula.myers@va.gov

tara.zaugg@va.gov

samantha.boris@va.gov

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References and Resources:

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Otolaryngology and Allied Sciences, 19(5), 37-80.

Cima, R., & Anteunis, L. (2009). Tinnitus hurts! A Cognitive-Behavioural Analysis of Tinnitus-related 

Pain. Health San Francisco, 6200-6200.

DeRidder, D., Elgoyhen, A. B., Romo, R., & Langguth, B. (2011). Phantom percepts: tinnitus and pain as 

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act

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The Journal of Family Practice, 59(7), 389-393. 

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References and Resources 

(continued)

Henry, J.A., Zaugg, T.L., Myers, P.J., & Kendall, C.J. (2010). Progressive Tinnitus Management: 

Counseling Guide. Long Beach, CA: VA Employee Education System. 

Henry, J.A., Zaugg, T.L., Myers, P.J., & Kendall, C.J. (2010). Progressive Tinnitus Management: How to 

Manage Your Tinnitus: A Step-by-Step Workbook. Long Beach, CA: VA Employee Education System. 

Henry, J.A., Zaugg, T.L., Myers, P.J., & Kendall, C.J. (2010). Progressive Tinnitus Management: Clinical 

Handbook for Audiologists. Long Beach, CA: VA Employee Education System. 

Henry J.A., Zaugg T.L., Myers P.J., Kendall C.J., & Turbin, M.B. (2009). Principles and application of 

educational counseling used in progressive audiologic tinnitus management. Noise and Health, 11(42), 

33-48. 

Henry, J.A., Zaugg, T.L., Myers, P.J., & Schechter, M.A. (2008). Using therapeutic sound with Progressive 

Audiologic Tinnitus Management. Trends in Amplification. 12(3): 188-209. 

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References and Resources 

(continued)

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References and Resources 

(continued)

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