Tinnitus Retraining Therapy

1. Tinnitus Retraining Therapy (TRT) is strictly based on the neurophysiological model of tinnitus. 2. Tinnitus is a phantom auditory perception, i.e. perception of tinnitus is not linked to any vibratory activity within the cochlea. 3. The model postulates that it is necessary to include interconnections within a network of systems in the brain in the study and treatment of tinnitus. 4. The auditory system, while needed for perception of tinnitus, is secondary for clinically relevant tinnitus (i.e. tinnitus which is bothersome to the extent of requiring treatment). 5. The limbic and autonomic nervous systems are the main systems responsible for negative tinnitus-evoked reactions. 6. Tinnitus is frequently accompanied by a decreased sound tolerance, consisting of hyperacusis and misophonia. 7. Hyperacusis results from an increased gain within the auditory pathways and is determined solely by physical characteristics of sound (i.e. its intensity and spectrum). 8. Misophonia results from enhanced functional connections between the auditory and the limbic and autonomic nervous systems, and reactions occur to specific patterns of sound, with the total spectral energy being secondary or irrelevant. 9. In misophonia, the meaning of sound and an ­individual’s past history of encountering it is crucial, with the auditory characteristics of the sound playing a secondary role. 10. There are two loops in network processing tinnitus signal: a. High loop, which involves cognitive processing of the signal and which is dominant at the initial stages of tinnitus. b. Low, subconscious loop, which appears to become dominant in chronic tinnitus. Connections within the neural networks that are involved in the adverse effects of tinnitus are governed by the principles of conditioned reflexes. 11. The primary goal of TRT is habituation of reactions evoked by tinnitus. 12. Habituation is initiated and further facilitated using the method of modified passive extinction of the conditioned reflexes and involves: a. Teaching/counseling aimed at reclassification of the tinnitus signal to the category of neutral stimuli. b. Sound therapy, which decreases the strength of the tinnitus signal by increasing the level of background neuronal activity in the auditory system achieved by providing an enhanced sound background. 13. Habituation of perception happens automatically once sufficient level of habituation of reactions is achieved. 14. Decreased sound tolerance must be treated concurrently with tinnitus. 15. Different protocols must be used for hyperacusis than for misophonia. 16. A specific variant of treatment, related to ­classifying a patient to one of 5 categories, is determined by the following factors: a. Impact of tinnitus on patients’ lives and/or duration of clinically significant tinnitus. b. The presence of hyperacusis. c. The presence and significance of hearing loss. d. Prolonged exacerbation of tinnitus/hyperacusis by sound. 17. Misophonia is treated independently by specific protocols concurrently with tinnitus, hyperacusis, and hearing loss. 18. Results from many centers have confirmed the effectiveness of the tinnitus retraining therapy (TRT) for tinnitus, reporting a success rate of more than 80%. 19. Specific studies performed to assess the stability of improvement after 3 and 5 years revealed that impro-vement continues to be present with patients over time. These studies show a trend of ­continuing improvement, even after ending the treatment. 20. Prevention of clinically significant tinnitus or potential worsening of already existing tinnitus could be achieved by: a. Avoidance of silence and providing enriched sound environment. b. Avoidance of negative counseling and ­providing proper information in advance. 21. Certain populations are at high risk of developing clinically significant tinnitus, such as military ­personnel, police officers and firefighters, and patients who are going to have ear-related surgery. Providing them with a proper short informational session about tinnitus would significantly decrease the risk of developing bothersome tinnitus. People will still hear tinnitus, but it will not be a problem for them.