Progressive Tinnitus Management

Clinical Handbook for Audiologists

Progressive Tinnitus Management

Clinical Handbook for Audiologists

James A. Henry 

Tara L. Zaugg 

Paula J. Myers 

Caroline J. Kendall
Published by:

VA Employee Education System

Long Beach, CA 90822

(562) 826-5505

This volume was prepared for educational use by the Veterans Health Administration. The 

focus of the information is to provide guidelines for VA audiologists to conduct the method 

of Progressive Tinnitus Management (PTM) with Veteran patients. In general, VA endorses 

the method of PTM. 

Use of trade or brand names in this publication is for illustrative purposes only and does 

not imply endorsement by the Veterans Health Administration.

Certain parts of this publication pertain to copyright restrictions.

All rights reserved.

No copyrighted parts of this publication may be reproduced or transmitted in any form or 

by any means, electronic or mechanical (including photocopy, recording, or any 

information storage and retrieval system), without permission in writing from the 

publisher or copyright owner.

Printed in the United States of America
Contents

Foreword	 vii

Introduction	 ix

Acknowledgments	 xii

Authors and Contributors	 xiii

1 Definitions and Background 1

2 Research Leading to PTM 11

3 Overview of PTM 21

4 Level 1 Triage 35

5 Level 2 Audiologic Evaluation 39

6 Sound Tolerance Evaluation and Management (STEM) 51

7 Level 3 Group Education 57

8 Level 4 Interdisciplinary Evaluation 67

9 Level 5 Individualized Support 77

References	 85

Appendixes	

A	 PTM Flowchart	 95

B	 Tinnitus Triage Guidelines	 97

C	 Overview of Objectives and Procedures of the Level 2 Audiologic Evaluation	 99

D	 Tinnitus and Hearing Survey	 101

E	 What to DoWhen Everyday Sounds Are Too Loud	 103

F	 Tinnitus Handicap Inventory	 105

G	 Hearing Handicap Inventory—ScreeningVersion	 109

H	 Tinnitus Problem Checklist	 111

I	 Flowchart for Assessment and Fitting of Ear-Level Instruments	 113

J	 Level 2 Audiologic Evaluation: Special Considerations for Hearing Aids	 115

K	 Sound Tolerance Interview	 117

L	 Sound ToleranceWorksheet	 121

M	 Loudness Discomfort Levels—Clinical Guide	 123

N	 Sound PlanWorksheet	 125

O	 Relief Scale	 127

P	 Attention Scale	 129
	 vi	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

Q	 Tinnitus Contrast Activity	 131

R	 Level 4 Interdisciplinary Evaluation: Tinnitus Interview	 133

S	 Hospital Anxiety and Depression Scale (HADS)	 137

T	 The Primary Care PTSD Screening Tool (PC-PTSD)	 139

U	 Epworth Sleepiness Scale (ESS) 141

V	 Level 4 Interdisciplinary Evaluation: Guide to Trial Use of Ear-Level Instruments	 143

W	 Level 4 Interdisciplinary Evaluation: In-Clinic Trial Use of Hearing Aids	 145

X	 Level 4 Interdisciplinary Evaluation: In-Clinic Trial Use of Combination Instruments	 147

Y	 Level 4 Interdisciplinary Evaluation: In-Clinic Trial Use of Noise Generators	 149

DVD and CD information	 151

Index	 153

Also Included:

DVD: “ManagingYour Tinnitus” (for Level 3 group viewing)

CD: PowerPoint files (for Level 3 live presentations)
Foreword

Tinnitus can dramatically compromise quality of 

life, rendering some persons unable to function 

as happy, healthy, and productive human beings. 

Tinnitus is one of the most common health concerns among combat-injured military personnel 

and veterans, and a major health care problem 

within the VA system. Tinnitus is also a significant health issue in the general population. Each 

year debilitating tinnitus prompts millions of 

persons to seek help from health care providers. 

Unfortunately, the person with tinnitus often does 

not benefit from prompt and appropriate care 

from physicians and other health care providers. 

Although effective tinnitus management techniques do exist, and all persons with bothersome 

tinnitus can be helped, a systematic, logical, and 

efficient approach to this large-scale health care 

problem is desperately needed. The progressive 

tinnitus management (PTM) method described 

in the new three-book Plural bundle offers such 

a solution.

The information within the three PTM books is 

evidence-based and clinically-proven. The strategy 

for assessment and management of tinnitus contained within the three books is consistent with the 

accumulated clinical experiences of audiologists 

who provide services to persons with bothersome 

tinnitus. In the words of the authors, PTM “utilizes 

a hierarchical structure for providing clinical services. That is, patients receive services that ‘progress’ to higher levels only as needed.” For many 

(perhaps most) prospective patients, timely and 

accurate information about tinnitus coupled with 

rather generic counseling will allay their concerns 

and prevent the need for more extensive (and 

expensive) intervention. At the other end of the tinnitus seriousness spectrum are patients with disabling tinnitus and, often, complex health and 

audiologic histories including significant management challenges such as posttraumatic stress disorder (PTSD). This relatively small proportion of 

patients will require highly specialized and individualized support and management.

The authors of the three books—three audiologists and one psychologist—draw on years 

of research and clinical experience with tinnitus assessment and management in the development of the PTM approach. Readers are probably 

already familiar with the authors’ peer-reviewed 

publications on tinnitus. James Henry, PhD is a VA 

Research Career Scientist at the National Center 

for Rehabilitative Auditory Research (NCRAR). 

Tara Zaugg, AuD is a research audiologist at the 

NCRAR. Paula Myers, PhD is Chief of the Audiology Section and Cochlear Implant Coordinator at 

the James A. Haley VA Hospital in Tampa, Florida. 

Caroline Kendall, PhD is a research psychologist 

at the VA Connecticut Healthcare System in West 

Haven Connecticut.

Multiple unique features of the three PTM 

books contribute importantly to their clinical usefulness. The first book of the bundle is a clinical 

handbook on PTM written for audiologists. The 

components of the progressive tinnitus management approach are thoroughly explained in nine 

chapters. Clinical implementation of PTM is facilitated with 25 appendices containing a variety of 

practical materials such as patient handouts, questionnaires, and procedural guides. The handbook 

also includes a clinically valuable CD with informational PowerPoint presentations plus a DVD 

containing videos for patients containing, for example, demonstrations of different relaxation techniques. The second book is a guide for one-on-one 

counseling of patients with tinnitus. In the management of bothersome tinnitus and hyperacusis 
	 viii	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

(reduced sound tolerance), patient counseling is an 

essential and very effective component of intervention. The 300-page counseling guidebook is 

designed and formatted to be used directly in the 

counseling process, literally interfacing the audiologist with the patient. The counseling book also 

includes a 75-minute audio CD with a variety of 

sound tracks to demonstrate different types of 

sounds that can be used for managing reactions 

to tinnitus.

Consistent with the clinically proven adage 

that “knowledge is power,” the third book is a selfhelp workbook written for the person with tinnitus. 

The workbook provides step-by-step instructions 

to facilitate learning how to self-manage reactions 

to tinnitus. It also includes information on hearing 

protection, relaxation exercises, cognitive behavioral therapy (CBT) and 10 appendices chock full 

of additional practical information prepared for the 

patient. The self-help workbook will be very useful 

to augment the services provided by audiologists, 

and also will be invaluable for patients who, for 

various reasons, cannot directly access the services 

of an audiologist.

The three PTM books, with varied accompanying educational materials, provide a remarkably 

creative and comprehensive solution for the health 

care problem of tinnitus in both the VA and nonVA patient populations. Most audiologists regularly encounter patients who require a compassionate and evidence-based approach for diagnosis and intervention for bothersome tinnitus. 

Within the PTM book series is all the information and materials an audiologist needs to 

provide effective clinical services to this traditionally underserved patient population.

James W. Hall III, PhD

University of Florida
Introduction

Tinnitus is the perception of sound in the ears or 

head that does not have a source outside the body. 

The perceived sound is generated within the body 

and thus has been referred to as a “phantom” 

sound. Most typically, people who experience tinnitus have been exposed to loud noise that caused 

damage to the auditory system, resulting in both 

tinnitus and hearing loss. There are numerous other 

causes of tinnitus, as reviewed in Chapter 1. 

Tinnitus is a vexing and intractable problem 

for millions of people. It can cause sleep problems, 

difficulty concentrating, and can be the cause of 

mental health problems—most commonly anxiety 

and depression. People who already suffer from 

mental health conditions may be particularly vulnerable to tinnitus becoming problematic. Interestingly, of all the people who experience tinnitus, 

many more are not bothered by it than those who 

are. This is just one of many aspects of tinnitus that 

make it difficult to provide a clinical program that 

addresses the needs of all patients who report tinnitus to a health care provider.

We have conducted tinnitus clinical research 

at the Portland VA Medical Center continuously 

since 1995 (under the auspices of the VA National 

Center for Rehabilitative Auditory Research since 

1997). Our initial studies evaluated psychoacoustic aspects of tinnitus. In 1999 we started the first 

of a series of controlled clinical studies to evaluate different methods of tinnitus intervention (as 

described in Chapter 2). These clinical studies provided important efficacy data with respect to the 

different methods studied, but more importantly 

we learned a great deal about how best to meet the 

needs of patients who suffer from tinnitus.

We determined that a “progressive” approach 

to tinnitus management was essential to most 

efficiently address the range of services needed 

by patients. In 2006 we received a research grant 

from VA Rehabilitation, Research and Development (RR&D) Service to develop and test a new 

method that was progressive in its approach. The 

method was designed to be conducted entirely 

by audiologists, provided patients were referred 

appropriately to other disciplines as needed. Five 

hierarchical levels of clinical services were defined, 

and patients “progressed” only to the level of care 

necessary to meet their needs. The intervention 

mainly was educational and was intended to promote self-efficacy for managing reactions to tinnitus. The overall intent was to meet the needs of 

patients on an individualized basis, and to provide 

them with the self-management skills that they 

would likely need for a lifetime.

Following development of our progressive 

approach, it became clear that psychological effects 

due to tinnitus needed to be addressed. This resulted 

in the incorporation of cognitive-behavioral therapy (CBT) into the intervention protocol. CBT has 

been used for many years as effective intervention 

for pain, depression, and anxiety. CBT was adapted 

to the management of tinnitus and was shown to 

be effective with many people for that purpose. We 

now have incorporated key components of CBT 

into the PTM program, resulting in an interdisciplinary approach to providing tinnitus clinical services.

The result of these efforts is the development 

of progressive tinnitus management (PTM). The 

method continues to evolve, especially with the 

addition of CBT. However, the method has reached 

a level of development at which it now can be specifically defined with respect to the procedures 

required for its clinical implementation. This book 

provides a description of the clinical procedures 

necessary for audiologists to conduct PTM. A separate book is in preparation that will focus primarily 
	 	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

on CBT procedures used by mental health specialists to combine with the audiologic components 

of PTM.

It is acknowledged that numerous methods 

of tinnitus management are in use and that clinicians often disagree regarding the most effective 

approach. A number of controlled clinical studies 

have been completed that demonstrate benefit to 

the majority of participants enrolled in these studies. However, these studies are not definitive; thus, 

clinicians have the latitude to use any method that 

has research support. It is important to recognize 

that evidence-based tinnitus interventions use some 

combination of three broad components: education, relaxation techniques, and therapeutic sound. 

Addressing some or all of these three components 

in general provides reasonable benefit such that 

many patients notice a significant improvement in 

their quality of life. Of course, there is no cure for 

tinnitus; thus, patients must realize that no matter 

which method is applied, their tinnitus perception 

will most likely remain unchanged and that clinical management focuses on reducing any negative 

reactions associated with the tinnitus.

Although many practitioners already are conducting some form of tinnitus therapy, others have 

little to no experience providing tinnitus services. 

Experienced clinicians generally have definite ideas 

about how to go about providing tinnitus services 

to their patients. These clinicians can adopt PTM 

as described in this book, or they can use the different levels of PTM as a framework within which 

to conduct their preferred form of therapy. For clinicians with little to no experience, it is suggested 

they start by implementing the first three levels 

of PTM. With sufficient experience implementing 

these lower levels, they can start practicing the 

higher levels (Levels 4 and 5).

The interdisciplinary aspect of PTM requires 

some further explanation. Level 1 Triage is directed 

to all clinicians (except audiologists or other ear 

specialists) who encounter patients complaining of 

bothersome tinnitus. Nonaudiologist clinicians are 

provided with guidelines to assist them in properly 

referring these patients for appropriate clinical services. Level 2 Audiologic Evaluation is performed 

solely by audiologists who: (a) conduct an auditory assessment; (b) facilitate management of any 

hearing disorders; (c) conduct a brief assessment 

of tinnitus impact; and (d) (optional) provide educational materials to the patient to facilitate selfmanagement. Level 3 Group Education involves 

two interactive workshops conducted by an audiologist, which focus on teaching patients how to 

use therapeutic sound. In addition, a psychologist 

(or other qualified mental health professional) conducts three workshops that teach key principles of 

CBT. The CBT sessions are designed to facilitate 

specific coping skills to augment the use of therapeutic sound.

Although it is optimal that a mental health 

provider be part of the PTM clinical team, we recognize that this will not always be possible. At a 

minimum, appropriate mental health providers 

should be identified and then used to refer patients 

when mental health services are needed. Audiologists should take the lead in implementing PTM, 

and adapt the program as necessary to be flexible 

in how it is implemented to make the most of the 

resources available at any one clinic.

Patients whose needs are not met through 

Level 3 are advised to undergo Level 4 Interdisciplinary Evaluation. The evaluation should be conducted by both an audiologist and a mental health 

professional (typically a psychologist, as they are 

specifically trained to evaluate and diagnose mental 

health disorders). The audiologist and psychologist 

work as a team for Levels 4 and 5 collaboratively 

to determine the best therapeutic approach for the 

patient. Level 5 Individualized Support thus can 

involve multiple appointments with the audiologist, the psychologist, or both. Level 5 normally 

involves up to 6 months of individualized support. 

Throughout each level, the goal of intervention is 

for the patient to learn the skills necessary to selfmanage any situation in which his or her tinnitus 

is problematic.

This handbook provides minimal background 

information about tinnitus and focuses on describing the practical information that is necessary to 

learn how to implement PTM in the clinic. Chapter 1 establishes common ground with respect to 

terminology and definitions pertaining to tinnitus 

management. Chapter 2 describes how our controlled clinical studies (and other influences) led 

to the development of PTM. Chapter 3 provides an 
Introduction xi

overview of PTM. The remaining chapters detail 

the clinical procedures that are used for each of the 

five levels of PTM. These details include numerous forms, questionnaires, clinical “cheat-sheets,” 

and patient handouts—all of which are provided 

as appendices.

The goal of intervention with PTM is for 

patients to learn how to develop and implement 

individualized plans to manage their reactions to 

tinnitus. These plans involve the use of therapeutic 

sound and coping techniques. Success in achieving this goal depends largely on patients acquiring 

confidence in applying the self-management strategies. Breaking the process of learning into small 

achievable tasks helps to ensure that patients experience initial success. This approach is consistent 

with the self-efficacy theory. Research has demonstrated that self-efficacy is a good predictor of motivation and behavior. In general, the experience of 

success increases self-efficacy whereas experiencing failure reduces self-efficacy. This is a basic tenet 

of intervention with PTM.

Clinical implementation of PTM by audiologists should involve the use of two additional books 

that were prepared to facilitate educating patients 

in the self-management techniques. The first is a 

self-help workbook (How to Manage Your Tinnitus: 

A Step-by-Step Guide) for patients that provides 

step-by-step procedures to learn how to develop 

individualized plans for managing their reactions 

to tinnitus—one using therapeutic sound and the 

other using selected coping techniques from CBT. 

The workbook includes videos that model much of 

what is taught during Level 3 Group Education, as 

well as a CD that describes and demonstrates the 

various uses of therapeutic sound.

The second book (Progressive Tinnitus Management: Counseling Guide) is a patient counseling 

guide that is used by audiologists during Level 5 

Individualized Support. The book lays flat between 

the clinician and patient, and is used like a flip 

chart—each time a page is turned, the page facing 

the clinician provides talking points while the 

opposite page faces the patient and provides short 

bullet points plus graphics that illustrate the main 

points. A second counseling guide is being developed for psychologists to implement the CBT components of PTM during Level 5. 

PTM has been developed to a high degree of 

specificity, but it is important to realize that the 

methodology is considered a “work in progress.” 

We are learning continually, from both patients and 

clinicians, and the methodology is revised to be 

appropriately responsive to this feedback. Audiologists are encouraged to modify the materials and 

procedures as necessary to meet the needs of their 

patients and their clinics.

It is our sincere hope that this handbook will 

provide you with information that ultimately will 

result in improved outcomes for your patients who 

need help learning how to manage their reactions 

to tinnitus. We always welcome your comments 

and suggestions to continually improve on these 

methods.
Acknowledgments

Development and publication of this book was 

supported by the VA Rehabilitation Research and 

Development (RR&D) Service, the NCRAR, and 

VA Employee Education System. Numerous individuals have contributed in various and significant 

ways toward this effort, including:

n Daniel C. Garcia (Graphic Designer, Long 

Beach Employee Education Resource 

Center, Long Beach, California)

n Katie J. Fick, MS (Research Assistant, 

James A. Haley Veterans’ Hospital, 

Tampa, Florida)

n Christine Kaelin, MBA (Clinical Research 

Coordinator, NCRAR, Portland, Oregon)

n Robert Kerns, PhD (National Program 

Director for Pain Management, Veterans 

Health Administration, VA Connecticut 

Healthcare System, West Haven, Connecticut)

n David Lehman (Executive Producer, Salt 

Lake City Employee Education Resource 

Center, Salt Lake City, Utah)

n Marcia Legro, PhD (Research 

Psychologist, Seattle, Washington)

n Will Murphy (Audiovisual Production 

Specialist, Portland VA Medical Center)

n Kimberly Owens, MPH (Clinical 

Research Coordinator, Saint Thomas 

Research Institute, Nashville, Tennessee)

n Martin Schechter, PhD (Audiologist, 

Portland VA Medical Center)

n Emily Thielman, MS (Research Assistant, 

NCRAR, Portland, Oregon)

n Dwayne Washington (Audiovisual 

Production Specialist, Portland VA 

Medical Center)

n John C. Whatley, PhD (Project Manager, 

Birmingham Employee Education 

Resource Center, Birmingham, Alabama)

Also, thanks to Stephen Fausti, PhD and Sara Ruth 

Oliver, AuD for their continued support of tinnitus 

research and clinical activities at the Portland VA 

Medical Center. Illustrations were done by Lynn 

Kitagawa, MFA, Medical Media Service, VA Medical Center, Portland, Oregon.
Authors and Contributors

James A. Henry, PhD

VA RR&D National Center for Rehabilitative 

Auditory Research (NCRAR) at the Portland 

VA Medical Center,

Portland, Oregon; 

and Department of Otolaryngology, 

Oregon Health and Science University, 

Portland, Oregon

Caroline J. Kendall, PhD 

VA Connecticut Healthcare System, 

West Haven, Connecticut;

and Department of Psychiatry, Yale University, 

New Haven, Connecticut

Paula J. Myers, PhD

VA Audiology Clinic, James A. Haley Veterans’ 

Hospital, 

Tampa, Florida

Tara L. Zaugg, AuD

VA RR&D National Center for Rehabilitative 

Auditory Research at the Portland VA Medical 

Center, 

Portland, Oregon

Special Contributions by:

Marcia Legro, PhD (Chapter 2)

Kyle Dennis, PhD (Chapter 3)

Dennis Trune, PhD (Chapter 4)

Elias Michaelides, MD (Chapter 5)

Kathryn Sanders, PhD (Chapter 5)

Lynn Kitagawa, MFA (Illustrations)

This book is dedicated to our nation’s military veterans. We thank you for serving our country. 

You are the reason we enjoy freedom.