Hanyang Med Rev.  2016 May;36(2):120-124. 10.7599/hmr.2016.36.2.120.

Tinnitus Retraining Therapy

• Shin JW
• Lee HK

• KMID: 2164670
• DOI: http://doi.org/10.7599/hmr.2016.36.2.120

Abstract

According to the Jastreboff's neurophysiological model of tinnitus, if negative associations are attached to the tinnitus signal, tinnitus is perceived to be a threat or a danger and it activates the autonomic nervous and limbic systems. Consequently patient's awareness of tinnitus is heightened and so patient perceives it to be louder and more persistent. Jastreboff and Hazell started tinnitus retraining therapy (TRT) based on the neurophysiological model of tinnitus. The purpose of TRT is blocking tinnitus from activating the sympathetic nervous and limbic systems (habituation of reaction) and from reaching the cerebral cortex (habituation of perception). TRT is composed of two components directive counseling that tries to reclassify tinnitus into the meaningless stimuli and sound therapy that decreases the relative strength of the tinnitus signal. Physicians try to put patient's tinnitus into the territory of meaningless stimuli through retraining the brain (habituation of reaction). Because the brain habituates all unimportant stimuli, if habituation of reaction is fully achieved, habituation of perception will follow automatically. In most clinical results, clinical success rates of TRT approach or exceed 80% improvement. Early improvement can be achieved during the first few months, followed by additional progressive improvement. It should be recommended that the patient continue treatment at least 18 months.

Keyword

Tinnitus Retraining Therapy; Tinnitus; Sound Therapy

MeSH Terms

Brain
Cerebral Cortex
Directive Counseling
Humans
Limbic System
Tinnitus*

Figure

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  Fig. 1 The Jastreboff's neurophysiological model of tinnitus. Initially, the tinnitus related neuronal activity is generated at the peripheral auditory system. The subconscious level of the brain may detect this signal. After then, the auditory cortical levels perceive and evaluate this signal. Tinnitus is evaluated and compared with information stored in memory. If the person's tinnitus does not have negative associations, tinnitus signal is subsequently interrupted from contacting conscious perception. But, if tinnitus gets some negative associations, it is classified in the category of unpleasant or dangerous stimuli and consequently activates the autonomic nervous and limbic systems, so results in anxiety, stress, panic attacks and loss of wellbeing. This in turn enhances detection of tinnitus, and further enhances the activation of autonomic nervous and limbic systems.

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  Fig. 2 Ultimate goal of TRT is to retrain the brain to be habituated to tinnitus. Habituation of reaction is preventing tinnitus from activating the sympathetic nervous and limbic systems. If habituation of reaction is fully achieved, patients do not experience negative reactions and habituation of perception will follow automatically, because the brain habituates all unimportant stimuli. If habituation of perception is achieved, tinnitus is blocked before it reaches the consciousness level, and patients do not hear tinnitus. HP, habituation of perception; HLR, habituation of limbic reaction; HAR, habituation of autonomic reaction.

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  Fig. 3 The relationship between sound generator volume and the effectiveness of habituation. When the sound generator is used, we usually adjust sound generator volume close to the mixing point, in category 1 patients. Mixing point is the volume of sound generator at which the noise just starts to mix with the tinnitus. The effectiveness of habituation increases as volume proceeds to the mixing point. But, after the sound generator volume is louder than mixing point, masking begins and efficacy quickly decreases. Tinnitus should never be masked in TRT, because patients cannot be habituated to tinnitus that they cannot hear.

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