Research Leading to PTM

In 2005, audiologic tinnitus management (ATM) 

was published as a comprehensive protocol for the 

management of tinnitus by audiologists (J. A. Henry, 

Zaugg, & Schechter, 2005a, 2005b). ATM was modified and expanded upon to create five hierarchical 

levels of clinical management, at which point the 

name was changed to “progressive” ATM (PATM) 

(J. A. Henry, Zaugg, Myers, & Schechter, 2008a, 

2008b). PATM now is under revision to incorporate 

components of cognitive-behavioral therapy (CBT) 

to address psychological aspects of tinnitus (J. A. 

Henry, Zaugg, Myers, Kendall, & Turbin, 2009). As 

PATM is evolving to become inherently interdisciplinary, use of the word “audiologic” to describe 

the protocol no longer is appropriate. For that reason, the name was shortened to progressive tinnitus management (PTM).

The need for a progressive approach to tinnitus management became apparent as a result of 

conducting our series of controlled clinical studies. 

The PTM methodology evolved largely as a result 

of these experiences. Additional influences for 

PTM came from clinical experiences with patients 

and from consultation with experts from different 

disciplines whose insights in particular shaped 

the PTM patient education. PTM is designed to 

address the needs of all patients who complain 

about tinnitus while having minimal impact on 

clinical resources.

Prospective, controlled clinical studies are 

essential to evaluate and document the efficacy of 

tinnitus interventions. We have completed three 

studies and two are underway—both of which 

involve PTM. Conducting these studies required 

the development of highly specified protocols to 

ensure consistent performance of the various interventions. In addition, procedures were developed 

to efficiently screen and evaluate candidates to 

determine if they met study inclusion criteria, 

which differed for each study. Conducting these 

studies not only provided efficacy data, but also 

identified procedures that were most efficient for 

clinical application. Each of these studies and the 

insights gained from them are described below.

2
	 12	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

First Study

Our first study evaluated the relative efficacies 

of tinnitus masking (TM) and tinnitus retraining 

therapy (TRT) (J. A. Henry, Schechter, et al., 2006a, 

2006b). For the study protocol, each of these methods involved the use of ear-level devices (hearing 

aids, noise generators, combination instruments) 

and intervention appointments at 0, 3, 6, 12, and 18 

months. Only persons with very problematic tinnitus would warrant such rigorous, long-term clinical 

procedures. Therefore, it was necessary to carefully 

evaluate study candidates to determine their eligibility for receiving one of the interventions.

Advertising resulted in about 800 callers who 

expressed interest in participating. This level of 

response greatly exceeded our capacity to conduct 

a full clinical evaluation of each candidate. We 

therefore devised a three-stage screening protocol. 

For stage 1, a brief series of questions were administered to callers to establish that they experienced 

chronic tinnitus and that the tinnitus was so problematic that 18 months of intervention seemed 

justified. If so, they were invited for a hearing and 

tinnitus assessment (stage 2). Of the 800 callers, 171 

(21%) received the stage 2 assessment. Following 

the assessment, those who qualified met with one 

of the tinnitus specialists (stage 3) to discuss results 

and to ensure a full understanding of all study 

requirements. Of the 171 who received the stage 3 

assessment, 123 qualified and agreed to participate

—representing only 15% of the original 800 callers.

Study outcomes were based on the Tinnitus 

Handicap Inventory (THI) (C. W. Newman, Jacobson, & Spitzer, 1996; C. W. Newman, Sandridge, & 

Jacobson, 1998). Overall, both TM and TRT cohorts 

showed significant improvement on the THI, with 

TRT providing greater benefit at 12 and 18 months 

(J. A. Henry, Schechter, et al., 2006a, 2006b).

Lessons Learned from First Study

The first study showed that both TM and TRT, 

when conducted in a tightly controlled manner, 

could provide significant benefit to a large majority 

of individuals with severely bothersome tinnitus. 

Both methods utilize broadband noise as therapeutic sound, but the application and purpose of the 

sound differ substantially between methods (J. A. 

Henry, Schechter, Nagler, & Fausti, 2002). With TM, 

sound is used to achieve an immediate sense of 

relief. “Immediate relief” is irrelevant with TRT 

because the objective of TRT is to create contrast 

reduction between tinnitus and the acoustic environment to promote habituation (P. J. Jastreboff, 

2004). Our study provided evidence that these different clinical objectives largely were achieved for 

the two methods. Thus, a major lesson learned 

from this study was that sound can be used in different ways to accomplish different therapeutic 

objectives. The use of therapeutic sound with PTM 

expands on this concept to provide patients with 

an understanding of many different ways that 

sound can be used for tinnitus management. By 

understanding these different strategies for using 

sound, patients learn to use sound in a targeted 

manner to address any situation in which tinnitus 

is problematic.

With PTM, the basic strategies of using 

therapeutic sound with TM and TRT have been 

retained. However, the terminology and descriptions used with patients have been changed. These 

changes were designed to simplify the concepts for 

patients—to avoid misconceptions (such as thinking that the purpose of “masking” is to make the 

tinnitus inaudible) and to reduce confusion (such 

as trying to understand how specifically to achieve 

the “mixing point” with TRT). With PTM, use of 

sound to provide “immediate relief” is referred to 

as “soothing sound.” Soothing sound can be used 

whenever patients wish to reduce stress or tension 

associated with tinnitus. Using sound to create 

“contrast reduction” is referred to as “background 

sound.” Patients are advised to use background at 

all times as a passive-listening strategy to pay less 

attention to their tinnitus. Patients receiving PTM 

education learn to distinguish between the different applications of sound and to select different 

applications to accomplish different purposes.

For any clinical trial, it is necessary to determine 

if a candidate’s condition warrants the intervention 

being offered. Our unexpectedly high volume of 
Research Leading to PTM	 13

callers made it immediately evident that methodology was needed to provide efficient screening 

of individuals who claim to have a problem with 

tinnitus. In Chapter 3 we discuss how the large 

majority of people who experience tinnitus are not 

bothered by it. Many individuals with nonbothersome tinnitus, however, respond to announcements 

about tinnitus trials—even if the announcement 

states clearly that the study is for persons who are 

bothered by tinnitus. We needed methodology to 

query these callers to quickly assess the nature and 

severity of their tinnitus. It was particularly important to determine if a caller’s complaint was due 

more to a hearing problem than to the tinnitus itself 

(J. A. Henry, Zaugg, et al., 2005a; Zaugg, Schechter, 

Fausti, & J. A. Henry, 2002). We have since developed and refined screening techniques to differentiate hearing problems from tinnitus problems. 

Most importantly, we developed the Tinnitus and 

Hearing Survey that now is the essential tool used 

with PTM for this purpose (see Chapter 5).

Second Study

The purpose of our second study was to determine the potential benefit of group education as 

intervention for bothersome tinnitus (J. A. Henry, 

Loovis, et al., 2007). The educational curriculum 

was an adaptation of the structured TRT counseling protocol. Participants attended four weekly 

1.5-hour classes. Two control groups consisted of 

a “tinnitus support group” and a no-intervention 

group. The support group, also involving four 

weekly 1.5-hour meetings, was led by a facilitator 

who encouraged positive discussion about tinnitus 

but did not provide education. Veterans with bothersome tinnitus (n = 269) were randomized into 

one of the three groups. Outcomes were assessed at 

baseline and at 1, 6, and 12 months. Overall results 

revealed that group education provided significant 

improvement on the Tinnitus Severity Index (R. M. 

Johnson, 1998) from baseline through 12 months 

(p <.001). Neither of the control groups showed significant improvement from baseline to any of the 

follow-up time points.

Lessons Learned from Second Study

This study tested the effectiveness of a unique 

protocol of group education for tinnitus. Importantly, although participants did not receive an 

audiologic evaluation, 93% of the participants 

responded “sometimes,” “usually,” or “always” in 

response to the questionnaire item “Do you experience hearing difficulty?” In response to another 

item (“Does your tinnitus make it more difficult 

for you to hear?”), 83% responded “sometimes,” 

“usually,” or “always” (an additional 8% were 

“unsure”). In Chapters 3 and 5 we discuss the concern that many patients who complain about tinnitus mostly are bothered by hearing difficulties. 

Thus, when patients seek services for their tinnitus they may really need a hearing assessment and 

possibly hearing aids. Not addressing these participants’ audiologic needs undoubtedly reduced the 

effectiveness of the group education. This insight 

confirmed the need to conduct a hearing evaluation and fit hearing aids if necessary as the first 

stage of management for tinnitus. For this reason, 

the Level 2 Audiologic Evaluation is the first stage 

of management with PTM, and includes a hearing 

evaluation and questionnaires to differentiate hearing problems from tinnitus-specific problems.

The benefit observed for the education group 

was sustained for 12 months, contrasting with 

results from a similar trial (J. L. Henry & P. H. Wilson, 1996). In that trial, significant improvement 

was observed on the Tinnitus Reaction Questionnaire for the education group immediately following the intervention, but which dissipated by 

12 months. A major difference between the two 

education groups was that in our study the education group received focused instruction on using 

constant low-level background sound to facilitate 

habituation to tinnitus. It may be conjectured that 

the participants applied this information, thus 

facilitating the sustained benefit. Using constant 

background sound is a major instructional point 

with the PTM education and counseling.

Of the approximately 750 callers who were 

screened, 269 (36%) were enrolled. Thus, although 

all participants were offered the four education 

classes (those in the control groups could attend 
	 14	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

the classes after completing the study), 64% of the 

callers declined the opportunity to receive the education. Most callers indicated that their tinnitus 

was not enough of a problem to warrant attending 

the classes. This again speaks to the need to provide a hierarchy of clinical services so as to tailor 

services to the individual and to avoid providing 

more services than are necessary.

Additional insights gained from this study 

include: (a) a typical noneducational tinnitus support group does not seem to benefit the participants 

(thus, any group meetings for patients should 

include an appropriate educational component); 

and (b) individuals who are bothered by tinnitus 

but do not receive clinical services seem to stay at 

the same level with regard to how they are affected 

by their tinnitus (the fact that they don’t seem to 

improve over a period of a year suggests that these 

individuals should receive clinical services). Most 

importantly, this study showed clear benefit of providing education in a group setting, which led to 

the development of PTM Level 3 Group Education 

(J. A. Henry, Zaugg, Myers, Kendall, et al., 2009).

Third Study

The first study evaluated the methods of TM and 

TRT to determine their efficacy for veterans who 

are severely bothered by tinnitus. Benefit was evident, but each method was conducted by an expert 

in the respective intervention. This third study was 

designed to determine if audiologists who are not 

tinnitus experts can provide effective intervention 

with TM and TRT. The study was conducted at four 

VA hospitals (Bay Pines, Florida; Portland, Oregon; 

San Diego, California; and Seattle, Washington). At 

each site, 36–38 veterans with clinically significant 

tinnitus (total n = 148) were recruited and randomized to TRT, TM, or a control group that received generic tinnitus counseling (i.e., nothing specific to TM or TRT) and hearing aids (if needed). 

Participants in all three groups received an initial 

evaluation and attended counseling appointments 

at 0, 3, 6, 12, and 18 months. Analyses revealed that 

each of the three groups showed significant improvement (based on mean index scores from the Tinnitus 

Handicap Inventory), with no significant differences 

between groups (publication in preparation).

Lessons Learned from Third Study

It was unexpected that the control group had 

outcomes comparable to TM and TRT. Although 

intended as a nonspecific-therapy control group, 

the counseling developed for this group was effective and subsequently published as part of the 

method referred to as audiologic tinnitus management (ATM) (J. A. Henry, Zaugg, et al., 2005b). The 

ATM counseling focused on how to use sound and 

sound-delivery devices to reduce the impact of tinnitus, which was the precursor to the counseling 

we have since developed for PTM. For PTM, these 

basic concepts have been refined and organized 

into a systematic description of the different ways 

that sound can be used to manage tinnitus. Thus, 

an insight from the third study was that a single 

approach to using sound may be too restrictive for 

addressing all of the different situations when tinnitus is problematic for patients. With PTM, patients 

are instructed in depth about the different uses of 

therapeutic sound to empower them to determine 

on their own how to use sound in a specific manner 

whenever their tinnitus is bothersome (J. A. Henry, 

Zaugg, Myers, Kendall, et al., 2009).

As a result of developing the “generic” counseling for the control group, we devised a third 

strategy for using therapeutic sound (in addition to using “soothing sound” and “background 

sound” as described under “Lessons Learned from 

First Study” above). The third strategy was to use 

sound for attention diversion, by listening to anything that would engage the mind for a sustained 

period. For PTM, this third strategy is referred to 

as using “interesting sound” with the purpose of 

focusing conscious attention away from the tinnitus and onto the target sound. Furthermore, the 

counseling created for the control group led to our 

development of numerous concepts, techniques, 

and tools for using therapeutic sound that now are 

described in the PTM self-help workbook and as 

part of the PTM educational counseling.
Research Leading to PTM	 15

As for the first study, this third study required 

participants who were so bothered by their tinnitus that rigorous, long-term intervention was warranted. Screening methods that we developed as a 

result of the first and second studies were used with 

the third study to ensure that only qualified veterans were enrolled from the 505 candidates. Prior to 

completing all of the appointments, however, many 

participants realized that the intervention they had 

received was sufficient and that no further services 

were needed (30% of the participants dropped out 

of the study—most for this reason). Although it 

was gratifying to observe early therapeutic success, 

it was clear that a progressive approach was needed 

to provide services only to the degree necessary to 

meet individual needs. This progressive approach 

is a hallmark concept for PTM—patients undergo a 

series of short-term clinical interventions that can, 

if necessary, lead to Level 5 Individualized Support.

A comprehensive tinnitus assessment protocol 

was developed for use with all participants in this 

study. The protocol was published as one of the two 

ATM companion articles (J. A. Henry, Zaugg, et al., 

2005a), and included: (a) a structured interview to 

identify problematic aspects of tinnitus; (b) a tinnitus psychoacoustic assessment; and (c) in-clinic 

trials to determine the potential benefit of ear-level 

noise generators and combination instruments. The 

protocol has since been refined for the PTM Level 

4 Interdisciplinary Evaluation, and some components have been adapted for use during the Level 2 

Audiologic Evaluation (J. A. Henry et al., 2008b).

Conducting this study required training 12 

audiologists at four VA hospitals. The training was 

provided via the VA videoconferencing (V-Tel) 

system. Each study audiologist received about six 

hours of V-Tel training supplemented by a procedures manual. This training likely was inadequate 

for audiologists to perform methodology that normally requires much more training and considerable experience to attain a high level of proficiency. 

It was evident that any future tinnitus trials would 

require much more intensive training. For our 

pilot PTM study (described immediately below), 

we developed an extensive online training course 

as well as numerous clinical tools to facilitate all 

aspects of implementing the protocol.

Fourth Study

The fourth study currently is nearing completion 

at the James A. Haley Veterans’ Hospital in Tampa, 

Florida. This study was designed to develop PTM 

and to evaluate its clinical efficacy in a pilot study to 

compare it to “usual care.” Usual care (UC) involves 

services that are typical of what is provided at VA 

audiology clinics, that is, an audiologic examination, hearing aids if needed, and some minimal 

counseling specific to tinnitus. For this study, UC 

participants can receive ear-level noise generators 

or combination instruments if deemed necessary 

by the audiologist.

Development of the PTM implementation 

materials was a substantial undertaking requiring two years of continuous effort. Insights gained 

from our previous trials were applied to the PTM 

protocol. Five hierarchical levels of PTM were 

defined and detailed clinical procedures were 

developed for each level. A new counseling protocol was developed that incorporated principles of 

patient education and health literacy to ensure that 

the materials were accessible to as many patients as 

possible (J. A. Henry, Zaugg, Myers, Kendall, et al., 

2009). An online, 18-module training course was 

developed for audiologists and numerous materials were developed for audiologists and patients. 

Major educational materials were developed to 

implement the protocol at the different levels.

As of November 2009, 221 clinical patients 

were enrolled by telephone in this study—109 

were randomized to UC and 112 to PTM. Of these 

221 patients, 21 who were randomized to UC, and 

26 randomized to PTM, were excluded from study 

participation because they did not show up, called 

to be removed, or had a diagnosed psychotic disorder, dementia, or serious health concern. After 

excluding these 47 patients, 86 PTM patients and 

88 UC patients attended an initial appointment 

and completed questionnaires. Of the 86 PTM 

patients, 23 attended at least one of the Level 3 

Group Education sessions. Following Level 3, four 

patients attended a Level 4 evaluation. Only one 

PTM patient felt it was necessary to receive Level 

5 Individualized Support. Of the 88 UC patients, 
	 16	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

36 attended only the evaluation appointment and 

52 attended a second appointment to receive hearing aids. As the study is still in progress, analyses 

of outcomes are not yet possible to determine how 

well patients do at the different levels of PTM.

Lessons Learned from Fourth Study

A major goal of this project was to learn about the 

process of putting the PTM protocol into clinical 

practice. To do so we conducted several formative 

evaluations. (A formative evaluation is “a rigorous 

assessment process designed to identify potential 

and actual influences on the progress and effectiveness of implementation efforts” [Stetler et al., 

2006].) The results have been applied to our current 

research with PTM.

Online Course for Clinicians

An early, central element of implementing the PTM 

protocol is clinician education via an online course. 

The Chief of Audiology at the Tampa VA hospital 

made time available for each clinician to complete 

the 18-module course. All study audiologists completed the course and responded to embedded 

questions. These responses were compiled and 

analyzed to identify how to improve the course.

The online course currently is being revised 

and updated, and we are working with VA Employee 

Education System to make the course available 

via the VA Learning Management System (LMS). 

This course should become available for use by VA 

audiologists shortly after the publication of this 

handbook. We also will attempt to make the course 

available to non-VA audiologists.

When the online course becomes functional, an 

additional need will be to develop a program that 

simulates a clinical practicum for audiologists who 

have received the PTM training. To address this 

need, future plans include development of a “virtual clinic” to computer-simulate patients receiving 

clinical services with PTM. The program will depict 

patients with a variety of clinical presentations and 

clinicians will be challenged to make appropriate 

decisions to provide optimal care.

Conference Calls Held with PTM Audiologists

During these calls with clinicians and the study 

team, semistructured discussions addressed the 

acceptance and general satisfaction with the protocol as well as any difficulties performing each level 

of PTM care. Notes from these calls were compiled 

and reviewed to identify any barriers or facilitators 

to the management of tinnitus using PTM. We are 

adapting the program to be responsive to the feedback received from these calls.

Clinical Implementation of PTM

By collecting formative data during the implementation of PTM in the Tampa VA Audiology Clinic, 

we learned that preplanning for some of the activities could improve the implementation process. For 

example, prior to starting the program, administrators should know that (a) the PTM audiologists 

will require release time to complete the Webcourse; (b) the audiologists will be working with 

psychologists, which will require preplanning with 

the psychology section of the hospital; (c) patients 

being seen for tinnitus will need hearing evaluations and may need ear-level devices; and (d) the 

PTM protocol necessitates access by audiologists to 

a meeting room for the Level 3 workshops. We also 

recommend holding regular calls or meetings with 

audiologists who are beginning to use the protocol 

to address barriers that may arise as they put PTM 

into practice. Valuable information can be identified and acted on to improve fidelity to protocol.

Patients in this pilot study were all veterans 

at the Tampa VA hospital who complained of bothersome tinnitus. As all of the patients in the PTM 

cohort were offered tinnitus services beyond Level 

2 Audiologic Evaluation, it is clear that the majority 

of these patients either chose not to receive higherlevel services or it was too difficult for them to 

attend the additional visits that were required to 

participate in the Level 3 workshops. We will look 

carefully at the data to determine if patients’ perceptions of adequate care following Level 2 are accurate. We now are more strongly advising patients to 

attend Level 3 Group Education to ensure that each 

patient who is bothered by tinnitus receives the edu-
Research Leading to PTM	 17

cation that is essential to learn basic self-management skills. We also provided patients in the PTM 

cohort the self-help workbook at the end of Level 2. 

We now are recommending that the workbook not 

be provided to patients until they attend their first 

Level 3 workshop (see Chapters 3 and 5).

Finally, only a few patients in the PTM cohort 

required services beyond Level 3. With the addition 

of CBT to the Level 3 protocol, the effectiveness of 

the Level 3 workshops is expected to be substantially improved, which should ensure that very few 

patients will require Level 4 and 5 services.

Fifth Study

This is an observational pilot study currently being 

conducted to assess an adaptation of the PTM 

methodology for use with veterans and active military who have experienced traumatic brain injury 

(TBI) and also have bothersome tinnitus. As these 

individuals are located all over the country, we 

developed a home-based telehealth method. The 

procedures are conducted over the telephone, and 

intervention materials and questionnaires are delivered via the mail/FedEx. The study includes three 

cohorts (all with bothersome tinnitus): (a) probable 

mild TBI history; (b) moderate or severe TBI; and 

(c) no TBI.

Interested callers are screened for tinnitus 

severity and probable TBI history. Callers who pass 

screening are sent the self-help workbook (2nd 

edition prepared specifically for this study) along 

with baseline questionnaires and the informed consent form. The research coordinator then conducts 

informed consent, assesses “capacity” (cognitive 

ability) for candidates to provide informed consent, 

and enrolls eligible candidates. Participants attend 

a telephone appointment with the study psychologist who conducts brief cognitive screening and 

teaches coping techniques for managing reactions 

to tinnitus based on CBT (J. L. Henry & P. H. Wilson, 2001). The next appointment is with the study 

audiologist who provides the PTM audiologic/

sound-based counseling that normally is provided 

at Level 3 Group Education, but in a one-on-one 

format similar to Level 5 Individualized Support 

(J. A. Henry, Zaugg, Myers, Kendall, et al., 2009). 

Telephone appointments alternate between the 

psychologist and audiologist for 6 months (total of 

seven appointments).

As of November 2009, 172 individuals called 

about the study. Of these, 36 participants were 

enrolled, including 15 in the probable-mild TBI 

group, 10 in the moderate/severe TBI group, and 11 

in the no-TBI group. Twelve-week outcome data are 

available for 23 participants, and 24-week outcome 

data are available for 16 participants. Preliminary 

results of the primary outcomes can be summarized 

as follows. On average, participants lowered their 

Baseline THI scores by 13.6 points at the 12-week 

evaluation, and by 21.7 points at 24 weeks. Because 

outcome data are incomplete, and because of the 

small numbers of participants, these data cannot 

yet be subjected to statistical comparisons.

Lessons Learned from Fifth Study

This project responds to the need to provide special 

clinical services for veterans and military personnel who have experienced TBI and also suffer from 

bothersome tinnitus. Because of the complications 

of TBI, it was necessary to include a neuropsychologist with expertise in TBI and a clinical psychologist 

with expertise in tinnitus management to assist in 

the design and implementation of the trial. These 

collaborators have made the necessary revisions 

to the PTM protocol so that it is appropriate for 

telephone-based administration to TBI patients. 

For example, the participants undergo a cognitive 

screen to determine their abilities to comprehend 

the counseling information and to follow through 

with the management recommendations.

Prior to the design and development of this 

study, it was obvious that psychological concerns 

were not adequately addressed by the PTM counseling. This was a shortcoming that is being addressed 

for the first time using the PTM protocol in this 

pilot study. The PTM protocol thus is evolving to 

include counseling that covers all aspects of using 

therapeutic sound as well as addressing psychological components of tinnitus. Several researchers 
	 18	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

have conducted clinical trials that support CBT as 

an effective psychological method for managing 

tinnitus (Martinez Devesa, Waddell, Perera, & Theodoulou, 2007). Thus, CBT was incorporated into 

the PTM method. The components of CBT that are 

being used include training in behavioral modification (stress management via relaxation techniques 

and scheduling pleasant activities), as well as cognitive restructuring (step-by-step examination of 

changing thoughts to acquire a more positive attitude about tinnitus). Thus, abbreviated telephonebased CBT was developed to incorporate essential 

features of this psychotherapy.

The addition of CBT to the PTM protocol 

required expansion of the self-help workbook to 

include the new information. We developed a second edition of the workbook that is mailed to all 

participants in this pilot study (J. A. Henry, Zaugg, 

Myers, & Kendall, 2009). This new workbook also 

contains two DVDs that supplement the written 

material: (a) interactive video that guides patients 

through the material normally presented in PTM 

Level 3 Group Education; and (b) demonstrations of 

relaxation training exercises including deep breathing and imagery. We recently completed the third 

edition of the workbook based on feedback from 

subjects using it during this pilot study, which is 

being distributed to all VA audiologists and also is 

in publication for non-VA use (J. A. Henry, Zaugg, 

Myers, & Kendall, 2010a). The workbook contains 

a DVD and CD that were developed through VA 

Employee Education System.

Additional Evidence

Supporting PTM

Numerous studies have supported the use of therapeutic sound for tinnitus management. Evidence 

has been provided by these studies supporting the 

beneficial use of: (a) hearing aids (Del Bo & Ambrosetti, 2007; Folmer & Carroll, 2006; Saltzman & 

Ersner, 1947; Surr, Kolb, Cord, & Garrus, 1999; Surr, 

Montgomery, & Mueller, 1985; Trotter & Donaldson, 

2008); (b) ear-level masking devices (Folmer & Carroll, 2006; Hazell et al., 1985; Schleuning, Johnson, & 

Vernon, 1980; Stephens & Corcoran, 1985); (c) TRT 

(Bartnik, Fabijanska, & Rogowski, 2001; Berry, Gold, 

Frederick, Gray, & Staecker, 2002; Herraiz, Hernandez, Plaza, & de los Santos, 2005; Herraiz, Hernandez, 

Toledano, & Aparicio, 2007); and (d) neuromonics 

tinnitus treatment (P. B. Davis, Paki, & Hanley, 

2007). Our first clinical study (see First Study above) 

demonstrated that all types of ear-level devices 

(hearing aids, sound generators, and combination 

instruments) could be used effectively with both 

TM and TRT (J. A. Henry, Schechter, et al., 2006a, 

2006b). Our third clinical study (see Third Study 

above) extended the first clinical trial and showed 

that TM, TRT, and a nonspecific control group all 

provide significant benefit to subjects. Folmer and 

Carroll (2006) evaluated 150 patients who attended 

a comprehensive tinnitus management clinic, including patients who (a) used hearing aids (n = 50); 

(b) used ear-level noise generators (n = 50); and (c) 

did not use ear-level devices (n = 50). Significant improvement was experienced by all three groups. 

Notably, the patients who used hearing aids and noise 

generators experienced significantly greater benefit 

than did the patients who did not receive devices.

As a whole, these many studies comprise a 

strong body of support for the efficacy of using 

therapeutic sound to manage tinnitus. It should be 

noted, however, that the evidence does not demonstrate that any one of these methods is superior to 

any other. Rather, it appears that any judicious use 

of sound seems to be helpful for managing tinnitus, 

and it may be that some methods are more helpful 

in certain situations and for certain patients. Clearly, 

research is needed that systematically evaluates the 

different parameters of sound to determine which 

parameters provide the greatest benefit and under 

what conditions. With PTM, the overriding philosophy is that therapeutic sound provides the greatest benefit when patients are informed about the 

different uses of sound for tinnitus management, 

and when patients learn how to develop, on their 

own, sound-management plans to address specific situations when their tinnitus is problematic. 

PTM utilizes procedures that encourage patients to 

incorporate good self-management practices.

CBT is an evidence-based and appropriate 

addition to PTM to address the psychological components of tinnitus distress that are so common 

with these patients. CBT is a type of psychother-
Research Leading to PTM	 19

apy that targets specific thoughts, core beliefs, and 

negative appraisals of situations that are unconstructive (and may cause distress) while providing 

tools for implementing more adaptive behavioral 

and cognitive modifications (Beck, 1995; Sweetow, 

2000). Martinez Devesa et al. (2007) conducted a 

meta-analysis of six randomized, controlled studies 

(285 participants) of CBT for tinnitus. They found 

significant improvement in quality of life (decrease 

of global tinnitus severity) for those receiving CBT 

compared to those who did not receive CBT.

Summary

The five levels of PTM provide a logical, sequential 

means of working collaboratively with a patient to 

best determine the patient’s needs and to provide 

only the services that are needed. PTM patients 

receive only basic audiology services and tinnitus 

education (from an audiologist and a psychologist) 

through Level 3, which do not require a major commitment on the part of either the clinician or the 

patient. Included in the education are thorough 

explanations of the different ways that therapeutic sound and coping skills can be used to manage 

reactions to tinnitus. Patients are then taught how 

other sound-based methods use therapeutic sound. 

Patients should have this understanding before 

committing to an expensive and time-consuming 

clinical protocol. This also is the reason that fitting 

ear-level noise generators or combination instruments is not normally advocated until Level 4. 

Patients need to be fully informed before making 

such consequential decisions.

Tinnitus research has been conducted at the 

Portland VA Medical Center since 1995 (under the 

auspices of the NCRAR since 1997). In 1999 we 

began a series of clinical trials to evaluate different 

methods of tinnitus management, which provided 

the experience and data that led to development 

of the PTM model of care. The basic content of 

the PTM protocol (i.e., the levels of care) has been 

defined from the results of our years of research. 

The addition of CBT techniques to the PTM protocol addresses psychological aspects of tinnitus and 

thereby is expected to improve the effectiveness of 

PTM. The basic PTM protocol continues to provide 

a framework for “progressive” management for 

clinical expediency, but the clinical services provided now are of a more interdisciplinary nature.