Review of somatosensory tinnitus Sanchez TG and Rocha CB The treatment was based on 10 sessions of real MTP deactivation and 10 sessions of placebo MTP deactivation in tinnitus patients. The placebo part of the control-group session related to a fake treatment, that is, pressure applied to points adjacent to each real MTP and not to the real MTP. The real treatment used pressure release in each MTP of eight possible muscles (infraspinatus, levator scapulae, superior trapezius, splenius capitis, splenius cervicis, sternocleidomastoid, masseter and temporalis) along with home orientations (muscle stretching, postural guidance and hot pack). Thirty-seven patients from the experimental group and 34 patients from the control group were analyzed blind by a researcher before treatment began and again after 10 weeks of treatment. Ultimately, three patients with unilateral tinnitus benefitted from complete relief, two patients with bilateral tinnitus felt complete relief in one of the ears, and one patient reported an improvement in the number of perceived sounds (a decrease from seven to three). All of these patients maintained their relief following the two-month revaluation. Patients with normal pure tone audiograms were the ones with the best results after treatment, regardless of whether the tinnitus was constant or intermittent, unilateral or bilateral. Another remarkable finding was that patients in whom tinnitus intensity had diminished during modulation had better results during treatment when compared with those in whom tinnitus intensity had increased. Many techniques dealing with MTP relief have been published, but few have been supported by scientific evidence. The most commonly used treatment procedures for myofascial pain syndrome were reviewed by Vernon and Schneider,44 showing that they were supported by evidence. Laser therapy, pressure release, transcutaneous electrical nerve stimulation, acupuncture and magnet therapy for MTP and myofascial pain syndrome are treatments that are scientifically supported to varying degrees. The duration of relief fluctuates across the therapies. Evidence is weak, however, for ultrasound therapy, as it is also for electrical muscle stimulation, high-voltage galvanic stimulation, interferential current and frequency modulated neural stimulation. Training exercises repeating movements that evoke tinnitus modulation Exercise in general may be beneficial because it increases brain-derived neurotrophic factor.45 Training with repetitive movements generates specific neurophysiological changes through the activation of neural plasticity. Activation of neural plasticity has been proved to have therapeutic effects on many disorders, such as vestibular diseases, where the repetition of specific maneuvers can decrease vestibular disturbances. Sanchez et al.46 showed that muscle contrac- tions may change the pattern of tinnitus, from temporary worsening to temporary improvement, with repetition of the maneuvers that modulate tinnitus. A similar strategy was able to cure one of our patients, who had gaze-evoked tinnitus, at the Tinnitus Research Group of the University of Sa˜o Paulo School of Medicine, by repeating all the eye maneuvers that evoked her tinnitus.26,47 The central element of vestibular rehabilitation is the repetition of a set of exercises, which compensates for the central nervous system abnormalities using eye movements, as well as cervical and body maneuvers. In this case, the disappearance of gaze-evoked tinnitus occurred with the repetition of eye 1092 CLINICS 2011;66(6):1089-1094 movements that used to evoke it. The vertical component of the patient’s gaze-evoked tinnitus responded sooner to treatment than the horizontal component, which indicates that more than one neural network or process is involved in this process. Thus, individuals with somatosensory tinnitus or tinnitus that can be modulated may experience relief through coordinated exercise of the muscles that can modulate tinnitus. Future studies may add further information. Transcutaneous nerve stimulation The effect of transcutaneous nerve stimulation is based on its ability to induce widespread, non-segmental and prolonged increased microcirculation due to simpatico- inhibition in vascular beds.48 Kaada et al.48 treated 29 tinnitus patients by using transcutaneous nerve stimulation: nine patients reported reduction in their tinnitus. The improvement was more common with low-frequency (125–500 Hz) tinnitus. Seven patients also reported improve- ments in hearing, mostly in the low-frequency band. In 1997, Rahko and Kotti49 treated 26 tinnitus patients with transcutaneous nerve stimulation. Except for three patients with normal hearing, all had cochlear hearing losses. Tinnitus disappeared in none of them, but was diminished in 7 cases, as opposed to 3 out of 24 non-treated control subjects. Among the controls there was no relief in low- frequency tinnitus cases. In the Aydemir et al.50 study, the efficacy of transcutaneous nerve stimulation for the man- agement of tinnitus symptoms was evaluated in 22 patients. The authors concluded that it is a useful method for improving the quality of life of patients with tinnitus. Hypnosis Attias et al.51 compared self-hypnosis, masking and ‘‘attentiveness to the patient’s complaints’’ in the treatment of tinnitus. Self-hypnosis reduced tinnitus significantly, attentiveness reduced it partly, and masking did not have any significant effect. Marks et al.52 tried hypnotherapy for chronic tinnitus. One out of 14 patients showed a highly significant response to the latter treatment, as judged by visual analogue scales. Five out of 14 patients (36%) found the induction of a hypnotic state to be worthwhile. It seemed to help them tolerate their tinnitus better, although its loudness and quality were unaltered. On the other hand, Coles and Hallam53 tried hypnosis and relaxation with two tinnitus patients. One of them was given a post-hypnotic suggestion that whenever he was aware of tinnitus it changed to pleasant music. Tinnitus was relieved in both patients. In another experiment the combination of relaxa- tion and hypnotherapy was used to change tinnitus to a more pleasant sound. Both patients were also taught to ‘‘turn tinnitus down’’ with an imaginary control knob. After treatment, tinnitus was better accepted by the patients than before it. Botulinum toxin type A Botulinum toxin type A (Bot-A) is a neurotoxin that can inhibit the release of acetylcholine at the neuromuscular junction.54 Because of its known paralytic effect, it is administered locally to control muscle hyperactivity in many different disorders, as well as in cosmetic procedures. Besides the paralytic effect, Bot-A might have direct antinociceptive action through blockage of the autonomic nervous system in addition to neuromuscular action.55–59