miércoles, 30 de marzo de 2011

Acúfenos: Sección etiología: Hipertensión arterial

La temible hipertensión



CARMEN REIJA

Las enfermedades cardiovasculares se han convertido en la primera causa de muerte en países del primer mundo, incluso por delante de los accidentes de circulación o el cáncer.
Se han establecido una serie de "factores de riesgo cardiovascular" coadyuvantes en la aparición de ciertas enfermedades graves como la angina de pecho, el infarto de miocardio, la insuficiencia cardiaca o la hemorragia cerebral.

Tres factores de alto riesgo se hallan presentes en casi todos los casos: el tabaquismo, la hipercolesterolemia (exceso de grasas en sangre) y la hipertensión arterial. De ellos, la hipertensión arterial resulta un factor clave y primera causa de insuficiencia cardiaca y renal en nuestro país.

La tensión arterial deseable oscila entre 130/85, en función de la raza, el sexo, la edad, etc. y la mayor parte de la población no se adapta a estas cifras. La Organización Mundial de la Salud considera que existe hipertensión cuando tres medidas distintas realizadas en reposo y en condiciones adecuadas superan los valores 140/90. Según los valores determinados en el paciente, hablamos de tres grados: ligera, moderada y grave.

Inicialmente no se manifiesta a través de síntomas, lo que provoca un problema añadido. Los enfermos no notan nada, salvo en casos graves (mareos, dolor de cabeza y pecho, pérdida de visión, inestabilidad, acúfenos, etc.), lo que complica que se adapten a nuevas actitudes vitales o a un tratamiento farmacológico que creen no necesitar.

La hipertensión no tratada produce, a largo plazo, lesiones irreversibles en el sistema vascular, pero fundamentalmente en los denominados órganos diana: corazón, cerebro y riñón, que deben ser protegidos para evitar complicaciones como el accidente cerebro-vascular, la insuficiencia renal o el infarto de miocardio.

El tratamiento puede dividirse en dos partes interrelacionadas. Una se refiere al tratamiento farmacológico y la otra a la adopción de un nuevo estilo de vida, una serie de normas dietéticas e higiénicas que pueden minimizar e incluso evitar el farmacológico.

Debe actuarse siempre bajo supervisión médica, estando la automedicación absolutamente prohibida. Los fármacos son muy eficaces y específicos para cada caso, pudiendo utilizarse en monoterapia, aunque lo más frecuente es que se administren asociados.
Será el médico el que prescriba el más adecuado. Puede ocurrir que al principio recete uno y al cabo de un tiempo (tras comprobar la evolución del enfermo) lo cambie.

Modificar el estilo de vida parece sencillo, pero a los hipertensos les cuesta adaptarse a su nueva situación, aunque las normas son fácilmente aplicables y reducirían los riesgos de accidente vascular:

-Dejar de fumar

-Evitar el alcohol

-Vivir sin estrés con mecanismos de relajación o con fármacos bajo control médico.

-Realizar ejercicio físico diario.

-Adelgazar, a través de una dieta prescrita por un especialista. Aumenta el consumo de verdura, fruta y legumbres y reduce el de alimentos ricos en grasa y precocinados.

A nivel dietético:

-Reduce la sal; los especialistas coinciden en eliminar de la dieta embutidos, conservas, alimentos precocinados, quesos, etc., cuyo contenido en sal es muy elevado.

-Utiliza ajos, aunque sin abusar, porque el exceso provoca diarreas y trastornos estomacales, además del conocido y denostado mal olor.

-Aumenta el consumo de alimentos ricos en potasio: frutos secos, legumbres, chocolate, pescado, carne, cereales, etc.

-Incorpora alimentos ricos en calcio como espinacas, cebolla, judías, brócoli, garbanzos, nueces, etc.

-Aumenta la cantidad de agua ingerida para favorecer la diuresis y reducir la sobrecarga en el riñón. Elige agua mineral con bajo contenido en sodio.

El pronóstico de los hipertensos correctamente tratados es bueno. Su calidad de vida es comparable con la de las personas que no padecen esta patología, pero deben concienciarse y cuidarse desde el momento en que son diagnosticados, siguiendo siempre las pautas establecidas por el especialista.

fuente: La Opinion Coruña, España
http://www.laopinioncoruna.es/sociedad/2011/02/28/temible-hipertension/471997.html
fuente de la imagen: bbc.co.uk

Acúfenos: Sección Videos. Acufenos en la TV Española

Acúfenos: Sección Etiologia, causas potencialmente curables

Hear It 28 de febrero de 2011

El tinnitus es común en Nigeria

El tinnitus en Nigeria se asocia principalmente a condiciones de salud que se pueden curar.

En Nigeria, entre un 10% y un 33% de la población padece tinnitus. El tinnitus es común entre los nigerianos de más edad y se relaciona principalmente con condiciones de salud que se pueden tratar, como la otitis media, la sinusitis, traumatismos de cabeza e hipertensión, según un estudio publicado en la revista científica Otolaryngoly.

En el estudio se realizaron entrevistas personales a 1.302 personas de 65 años en adelante; la edad, el sexo, la situación económica o el lugar de residencia no estaban relacionados con la presencia de tinnitus. Los investigadores descubrieron una diferencia significativa entre la incidencia de tinnitus entre los sujetos de la tercera edad más jóvenes, de 65 a 69 años (6,5%) y el grupo de más de 80 años (41,9%).

“Nuestros resultados tienen una importancia potencial teniendo en cuenta las consecuencias generales en la salud por envejecimiento en este entorno, especialmente si se consideran los pronósticos del rápido aumento del porcentaje de ancianos en los países en vías de desarrollo”, dice Akeem Olawale Lasisi, autor del estudio.
Escaso interés científico
A pesar de la importancia que tiene para la salud pública, existe un escaso interés en estudiar el tinnitus entre las personas mayores en los países del África subsahariana, dónde las dificultades para acceder a los servicios de salud hace que las causas de enfermedades importantes, que podrían de otro modo tratarse fácilmente, se conviertan en crónicas y aumenten la vulnerabilidad de padecer tinnitus.

En el estudio, los autores se centraron en el tinnitus subjetivo; para seleccionar los factores de riesgo en el estudio, supusieron que la presencia de sinusitis recurrente crónica podía provocar una disfunción de la Trompa de Eustaquio, y como consecuencia causar un desequilibrio en la presión del oído medio y tinnitus. Asimismo, consideraron que las afecciones crónicas que predisponen a la arterioesclerosis guardan correlación porque cuando no se tratan o se complican (suele ser frecuente en esta zona), pueden provocar hipoperfusión en la cóclea o desequilibrio de los fluidos dinámicos del oído interno, lo que puede a su vez causar tinnitus.

Fuente: Otolaryngology - Head and Neck Surgery, American Academy of Otolaryngology, número de Octubre de 2010 y www.news-medical.net

Hiperacusia: Sección acúfenos en el arte: Chris Singleton


El músico británico Chris Singleton padece hiperacusia.
Daily Mail

Chris Singleton empezó a desarrollar su enfermedad en 2004



Un músico de rock alérgico al sonido

Abrir un grifo o tirar de la cadena de un inodoro le resulta insoportable

Periodista Digital, 08 de marzo de 2011 
 
El británico Chris Singleton (33) padece hiperacusia, una sensibilidad aguda al sonido.
Cuando se lo diagnosticaron pensó que era un chiste malo: es músico de rock.
Abrir un grifo o tirar de la cadena del inodoro puede volverse insoportable para una persona que padece esta enfermedad.
El Daily Mail, en el artículo Allergic to sound: The debilitating condition, suffered by thousands of Britons, that makes everyday noise excruciatingly loud, habla de esta dolencia que provoca que ruidos percibidos generalmente como normales resulten dolorosos para los que la sufren porque captan una frecuencia aguda del sonido.
Singleton empezó a cambiar sus hábitos diarios a raíz de la enfermedad:
Esto empezó a tener un efecto sutil en mi comportamiento. Al coger el tren, buscaba los altavoces que anuncian los nombres de las paradas para sentarme tan lejos de ellos como pudiera; en los cafés, tenía que evitar estar acercarme a la máquina de expresos.
Cuando la enfermedad avanzó, las discotecas se convirtieron en lugares prohibidos, no podía soportar ni su propia voz y con su novia se sucedían las discusiones... susurradas.

Un problema fundamental es la falta de conocimiento de esta enfermedad entre el público en general e incluso entre los profesionales.

Chris Singleton tardó 4 meses en descubrir cuál era su dolencia. Lo único que puede hacer para combatir la hiperacusia es llevar tapones para los oídos.
La hiperacusia puede desencadenarse por causas físicas como un daño en la cabeza o sobreexposición a ruidos altos. Pero también la ansiedad juega un gran papel.

Fuente: http://www.periodistadigital.com/salud/medicina/2011/03/08/un-musico-de-rock-alergico-al-sonido-hiperacusia.shtml

Acúfenos: Sección mecanismos, traumatismos cefálicos

Tinnitus grave tras traumatismos en la cabeza

Las lesiones en el cuello o en la cabeza pueden ser el comienzo de una vida con tinnitus. Para más de una persona de cada diez con tinnitus crónico, el problema se originó tras un traumatismo en la cabeza o el cuello. Estas lesiones suelen estar asociadas a un tipo particularmente grave de tinnitus, que tiene síntomas más desagradables.

En una investigación, realizada por el Servicio de Sanidad de Oregón y la Clínica Universitaria del Tinnitus, se estudió a 2.400 pacientes que sufrían tinnitus crónico. Se les preguntó sobre las causas del tinnitus. Más del 12 por ciento informaba que el origen de su problema estaba relacionado con un accidente en la cabeza o cuello. En este grupo, un tercio había sufrido únicamente una lesión en el cuello o traumatismo cervical. Los dos tercios restantes habían tenido lesiones en la cabeza o una combinación de traumatismo en cabeza y cuello.

Al compararlos con otros pacientes de tinnitus, el grupo con lesiones de cabeza o cuello solía sufrir más problemas diariamente por culpa del tinnitus. Tenían problemas para dormir, relajarse, pensar con claridad y recordar. También consideraban que su tinnitus era tres veces más alto que el de los demás convalecientes. En el llamado Índice de Severidad del Tinnitus, daban una puntuación media de 41,9 puntos, los cuales, según los autores del estudio, son significativamente superiores a los 38,1 puntos de media del resto de los pacientes.

Los pacientes cuyo tinnitus estaba asociado a lesiones de cabeza o cuello acudían al médico antes que los demás pacientes. Por término medio, buscaban tratamiento 2,3 años después del comienzo de su tinnitus, mientras que los demás pacientes lo hacían con una media de 6,9 años. Una posible explicación es que el tinnitus causado por un accidente o traumatismo en la cabeza es tan severo que el paciente no es capaz de hacerle frente. Mientras que si el tinnitus va aumentando gradualmente a través de los años, los pacientes están más capacitados para desarrollar estrategias de ayuda, según los investigadores.

Fuente: Chronic Tinnitus Resulting From Head or Neck Injuries, The Laryngoscope, no. 5 de mayo de 2003.

Acúfenos: Sección tratamiento farmacológico: Acido Folico

2 de febrero de 2011:

El ácido fólico puede reducir o retrasar el riesgo de padecer pérdida de audición

Al menos tres estudios indican que el ácido fólico es beneficioso para la audición.

Tener un nivel bajo de ácido fólico en sangre se asocia a un aumento del riesgo de padecer pérdida de audición en un 34 %, según un estudio australiano. El ácido fólico, o vitamina B9, es un compuesto natural de los alimentos. Este estudio consolida la idea de que existe una relación entre las vitaminas B y la capacidad auditiva.

Investigadores de la Universidad de Sydney analizaron los niveles en sangre de ácido fólico, vitamina B12 y homocisteína, en relación con el riesgo de padecer pérdida de audición por envejecimiento.

Los datos indicaban que los niveles de ácido fólico por debajo de los 11 nanomoles por litro se asociaban a un aumento del riesgo de padecer pérdida de audición por envejecimiento del 34%. Asimismo, los niveles de homocisteína por encima de los 20 micromoles por litro se relacionaban con un aumento del riesgo del 64%. El estudio se basó en una población de 2.956 personas de 50 años en adelante.
Otros estudios
Esta no es la primera vez que la vitamina B se ha relacionado con la prevención de la pérdida auditiva.
En 2009, en el congreso anual de la Academia Americana de Otolaringología y la Fundación de Cirugía de Cabeza y Cuello en San Diego, los investigadores con sede en Boston habían descubierto que los hombres mayores de 60 años con alta ingesta de ácido fólico de alimentos y suplementos alimenticios tenían una reducción del riesgo de desarrollar una pérdida auditiva del 20%. Este estudio mostraba además que el aumento del consumo de vitaminas antioxidantes no tenía relación con desarrollar o no una pérdida auditiva.
En 2007, científicos de la Universidad de Wageningen ponían de manifiesto que los suplementos de ácido fólico retrasaban la aparición de la pérdida de audición por envejecimiento en bajas frecuencias, en un estudio en el que participaron 728 hombres y mujeres de 50 a 70 años.

Mientras que los datos de Australia muestran que realmente existe una correlación, no se demuestra que tener altos niveles de ácido fólico pueda reducir el riesgo de padecer pérdida de audición por envejecimiento. De hecho, los investigadores afirman que: “es necesario realizar más estudios en el futuro para confirmar estas asociaciones”.
En la mayoría de las verduras
Los alimentos con alto contenido en ácido fólico se encuentran en las hojas de las verduras como las espinacas, los espárragos, los grelos, la lechuga, además de los guisantes, las judías verdes o legumbres, los cereales enriquecidos, las pipas de girasol y muchas otras clases de verduras y frutas. La levadura, el hígado y los productos derivados del hígado también son ricos en ácido fólico. Por tanto es posible aumentar los niveles de ácido fólico a través de la alimentación.

El ácido fólico es especialmente importante durante los periodos de división y crecimiento celular rápido. Tanto los niños como los adultos necesitan ácido fólico para producir glóbulos rojos sanos y prevenir la anemia. El nombre ácido fólico o folato procede del latín “folium” que significa hoja.

Fuente: Journal of Nutrition (revista de nutrición), www.nutraingredients.com, y Eurekalert

Acúfenos: Sección etiología. mutaciones geneticas

23 de marzo de 2011

Dos genes, dos clases de proteínas y dos tipos de pérdida de audición

Un estudio demuestra que la pérdida de audición varía dependiendo del tipo de proteína que falta.

Investigadores de la Escuela Universitaria de Medicina de Minnesota acaban de descubrir cómo se producen distintos tipos de pérdida de audición relacionada con la edad en los seres humanos.

Los investigadores estudiaron el modo en el que dos genes estrechamente relacionados contribuían en la función auditiva en ratones. La mutación en estos genes se asocia también a la sordera en los seres humanos. En sus experimentos descubrieron dos procesos clave de las células ciliadas que son necesarios para mantener la función auditiva.

Los genes codifican dos proteínas llamadas beta-actina e gamma-actina. En los seres humanos, las mutaciones que causan la sordera se han vinculado a ambas proteínas. La beta-actina y la gamma-actina constituyen los principales elementos estructurales de las células ciliadas del oído interno, encargadas de convertir las ondas del sonido en señales nerviosas que permiten oír a los seres humanos.

Aunque las dos proteínas son idénticas en un 99 por ciento, sus leves diferencias se han conservado intactas a lo largo de la evolución, desde las aves hasta los mamíferos, lo que sugiere que cada proteína puede tener funciones fundamentales y diferentes. Los investigadores y doctorandos, James Ervasti y Ben Perrin, pusieron a prueba la teoría de que estas dos proteínas tan similares tienen funciones separadas, pero cruciales, para la capacidad auditiva, dejando inactivo cada gen en células ciliadas del oído en ratones.
Dos tipos distintos de pérdida de audición
Los investigadores descubrieron que la beta-actina y la gamma-actina tienen distintas funciones que en conjunto mantienen sanos los filamentos de las células ciliadas permitiendo a los ratones oír. En ambos grupos de ratones con uno de los genes inactivo tenían una capacidad auditiva normal en edades jóvenes, pero desarrollaron tipos específicos de pérdida de audición progresiva y patologías en las células ciliadas que variaban dependiendo de la proteína que faltaba.

“Estos dos mecanismos de conservación por separado pueden ser fundamentales para mantener la función auditiva durante el envejecimiento, lo que podría contribuir a que comprendamos en un futuro las formas más comunes de la pérdida de audición relacionada con la edad en los seres humanos”, explica Ben Perrin, uno de los investigadores del estudio.

En definitiva, este descubrimiento podría llegar a servir para que los facultativos desarrollen fármacos para combatir la pérdida de audición progresiva en el futuro.

Fuentes: www.sciencedaily.com y PLoS Genetics.

Sección acúfenos en el arte: Musicos Will.i.am de Black Eyed Peas

10 de marzo de 2011

El cantante de Black Eyed Peas tiene tinnitus

Will.i.am, el cantante del famoso grupo norteamericano Black Eyed Peas, tiene pitidos en los oídos.

El cantante de Black Eyed Peas, de 35 años, ha declarado que a pesar de que su tinnitus lo ha provocado la música a todo volumen, ahora es lo único que lo hace soportable. El tinnitus no le deja otra opción más que hacer música, porque solo puede ignorar el molesto sonido cuando está rodeado de ruido.

Will.i.am, cuyo nombre de nacimiento es William Adams, comenta: “Ya no sé cómo suena el silencio. La música es lo único que alivia mi dolencia”.

“No puedo estar tranquilo. El trabajo me relaja. No puedo estar en silencio porque es cuando noto el pitido de los oídos. Está ahí siempre, todo el día, como ahora. No sé exactamente desde cuando lo tengo pero poco a poco ha ido empeorando”.
Centrarse en el tinnitus
En una declaración, David Stockdale, presidente ejecutivo de la asociación británica del tinnitus, British Tinnitus Association, comenta: “ El reciente comunicado de que Will.i.am de los Black Eyed Peas padece tinnitus pone de relieve un asunto tremendamente importante, esta afección prolifera entre los músicos y no se está haciendo lo suficiente para prevenirla y evitar los daños auditivos permanentes entre la comunidad de músicos y el público en general”.

Fuentes: www.thesun.co.uk y www.webmd.com

martes, 29 de marzo de 2011

Acúfenos: Sección técnicas de diagnostico: Magnetoencefalografía


Magnetoencefalografía (MEG)
para Detectar imágenes de acúfenos

por Keate Barry

Por décadas, los científicos han intentado comprender la complejidad de los acúfenos.  

Una de las principales herramientas para la investigación básica ha sido el uso de escáneres cerebrales en un intento de localizar la parte exacta del cerebro que causa el acúfeno. 

 Las reuniones del Foro Internacional de acúfenos están repletas de miles de escáneres cerebrales muestran áreas destacadas del cerebro que se cree responsable por el sonido fantasma.

Hasta hace poco, el escaneo cerebral  no ha demostrado un alto grado de precisión.  

Todo el hemisferio de la corteza auditiva mostraba  una mayor actividad neuronal.
Esto no es útil para localizar áreas exactas para la terapia de intervención.

Las terapias potenciales incluyen intervenciones eléctricas, químicas, farmacéuticas y nutricionales.

Un método mucho más preciso es necesario para facilitar la comprensión y orientación en la terapia de los acúfenos 
Ahora, una técnica de imágenes relativamente nueva, la Magnetoencefalografía (MEG) se ha convertido en un procedimiento que aporta imágenes de tinnitus con un enfoque mucho más agudo.

MEG mide los campos magnéticos diminutos que se generan por la actividad eléctrica del cerebro.
Es completamente no invasivo y no requiere el uso de radiaciones ionizantes ni se inyectan contrastes radiactivos utilizados en las tecnologías de diagnóstico por imágenes.

También es silenciosa, a diferencia de la RM, que requiere de tapones para los oídos.
Y, lo mejor de todo es que es capaz de identificar las áreas de actividad neuronal excesiva tan pequeñas como de 2 Mm (menos de 1 / 10 pulgadas) de diámetro.

 Una breve revisión de otras técnicas de imágenes cerebrales revela dos formas básicas de los escáneres cerebrales, estructurales y funcionales.

Las Técnicas de imagen estructural buscan estructuras y formas en el cerebro, tales como inflamación, tumores o coágulos sanguíneos que conducen al accidente cerebrovascular.

Las Técnicas de imagen funcional se ven para determinar qué áreas del cerebro están más activas durante un estímulo particular.

Las áreas del cerebro se activan más brillantes en la exploración y se conocen como áreas "de encendido."

Imágenes estructurales:



Tomografía computarizada (TC o TAC) utilizan una serie de radiografías de la cabeza. Estas exploraciones se utilizan principalmente para evaluar el grado de inflamación de daño tisular.

Imagen por Resonancia Magnética (MRI) utiliza campos magnéticos y ondas de radio para producir imágenes de alta calidad de las estructuras del cerebro sin la radiación ionizante de los rayos X. Las desventajas son la caja pequeña y tipo claustrofóbica en la que debe colocarse al paciente y el ruido excesivo, requiriendo tapones para los oídos.




Imágenes funcionales
 
Tomografía por Emisión de Positrones (PET) y la tomografía computarizada por emisión de fotón único (SPECT) son similares en que utilizan material radioactivo para rastrear las zonas metabolitamente activas del cerebro.
La materia radiactiva se adhiere al oxígeno y la glucosa, que se acumulan en las áreas que son metabólicamente activas y se muestran como más brillante en el escaneo.

La resonancia magnética funcional (fMRI) combina la tecnología de resonancia magnética con la capacidad de ver imágenes de los cambios del flujo sanguíneo en el cerebro asociados con la actividad neuronal.  

Puede ser utilizada para revelar las estructuras cerebrales y los procesos asociados con la percepción, el pensamiento y la acción. La fMRI ha sustituido en gran medida al  PET para el estudio de los patrones de activación cerebral.

Electroencefalografía (EEG) mide de los campos eléctricos en el cerebro mediante electrodos colocados en el cuero cabelludo.  

No utiliza materiales radiactivos y es más silenciosa que la RM y RMf. Una limitación es que las señales eléctricas son distorsionadas por el tejido circundante, en particular el cráneo y el cuero cabelludo.








Magnetoencefalografía (MEG)

Como se mencionó anteriormente, la MEG mide los campos magnéticos diminutos que se generan por la actividad eléctrica del cerebro.
Una gran ventaja de MEG es que ofrece grabación en tiempo real de la actividad cerebral durante un período de hasta 10 minutos.

Esto se logra por medio de dispositivos muy sensibles llamados dispositivos superconductores cuánticos de interfaz (SQUIDS). Debido a que son imanes superconductores, que requieren temperaturas criogénicas para su operación.  
Un conjunto de 300 SQUIDS está contenido en un casco que también contiene helio líquido.
El paciente lleva puesto el casco en una posición sentada, eliminando las cajas tipo claustrofobia de otras técnicas de imagen.

Los escáneres MEG son extremadamente caros y sólo hay cerca de 20 unidades en funcionamiento en los Estados Unidos. 
Se utilizan actualmente para la marcación del cerebro antes de la cirugía en los pacientes sometidos a cirugía para la eliminación de tumores cerebrales o tratamiento de la epilepsia.

Afortunadamente, un escáner MEG esta en el Henry Ford Health System en Michigan y el Dr. Michael Seidman ha llevado a cabo los estudios iniciales con MEG para la localización de los acúfenos.

 Él dice: "Con el PET y resonancia magnética funcional, la mayor parte de la corteza auditiva del cerebro se enciende durante la exploración. 

El MEG, sin embargo, es una máquina mucho más sofisticada y se puede identificar un tono específico o un punto especial, por lo que sólo una pequeña área en el cerebro se enciende.
Es como tener las luces encendidas sólo en la ciudad de Detroit, en comparación con tener las luces encendidas en todo el estado de Michigan”.
 
Los pacientes sin tinnitus tenido múltiples áreas activas pequeñas en el cerebro, pero no se encontraron áreas específicas a ser muy coherente en el MEG, de 10 minutos de exploración.

El Dr. Seidman ha utilizado el MEG de exploración para encontrar la ubicación exacta del tinnitus.

Él usa esta información para neuronavegar y para guiar la inserción de manojos de electrodos en el cerebro para la estimulación eléctrica directa de la corteza auditiva.

Esta estimulación, si se coloca correctamente, debe interrumpir el tinnitus y reducir los niveles de sonido del acúfeno para en los pacientes2

En una revolucionaria serie de cirugías experimentales, el Dr. Seidman y su equipo han demostrado que con un conjunto de electrodos implantados directamente en la corteza auditiva se puede controlar los niveles de tinnitus..
Sería imposible colocar correctamente los electrodos sin la tecnología MEG.



Esta investigación es muy nueva y el Dr. Seidman la compara con el desarrollo   los implantes cocleares para personas con sordera profunda.

Cuando se implantaron los primeros, el paciente sólo se escuchaba una serie de clics.
Tomó muchos años de ingeniería biomédica para proporcionar la percepción de sonido de alta calidad y reconocimiento de voz de quienes reciben un implante coclear actualmente

Referencias

   
1. http://www.diagnosticimaging.com/display/article/113619/1482978.
   
2. Seidman MD, et al. Directo Estimulación Eléctrica del giro de Heschl para el tratamiento de tinnitus. Laringoscopio. 2008 Mar; 118 (3) :491-500.

FUENTE:  http://www.tinnitusformula.com/qtimes/2011/03/MEG-for-pinpoint-tinnitus-imaging.aspx

Acúfenos: Sección Causas y desencadenantes: el estress

Stress, Tinnitus and Hearing Loss Linked

 According to the World Health Organization, hearing loss will become one of the most common disabilities in the near future. 
To find out why hearing loss is on the rise, researchers have begun studying what factors contribute to deteriorating hearing abilities. 
What they found might surprise you.

Hearing Health around the World

In many industrialized countries, cases of hearing loss are alarmingly on the rise.  With so many different ways to access health care in developed nations, it is shocking to see something as simple as the ability to hear affected so negatively. 
In some countries, hearing difficulties are reported in over 30% of its citizens. 
The most common complaints that citizens report are ringing in the ears and loss of hearing.

Connecting Stress and Hearing Loss

stress and hearing lossHaving seen that there was such a large number of people reporting hearing loss and tinnitus, researchers began looking for reasons why this trend was occurring.  One scientific idea was that since stress is also reported more often in developed countries, perhaps hearing loss could be correlated with this finding. 
To find a link between the two, scientists set out to explore the possibility that stress can lead to hearing loss and ringing in the ears.


Studying Hearing Health
Finding a proven link between hearing and stress required thousands of surveys to be distributed to patients.  The research was conducted in Sweden by the Karolinska Institute in Stockholm. 

Researchers developed a questionnaire asking survey participants 120 questions about how they would report certain stressors.  These stressors included the following life situations:
  • Psychosocial Work Environment
  • Physical Work Environment
  • Lifestyle
  • Physical Health
  • Mental Health
In addition to questions about work and home lifestyle stressors, respondents were also asked three questions regarding their hearing health. 

These three questions focused on tinnitus (ringing in the ears) and the ability to hear normal conversations.
Hearing Loss Study Results

A linear relationship exists between certain stressors and hearing health. 

What this means is that those respondents that reported more stress, especially in the areas of poor sleep and ill health, also had more complaints of tinnitus and hearing loss

Men and women both showed similar results, and when considering health status, both men and women reported that hearing loss seemed worse when they perceived their health status to be low.

Workplace stress was also correlated with hearing health. 

The more stressed respondents reported that they feel from work, the more they also complained of hearing loss and tinnitus. 
It is well known that stress leads to health problems, such as a decreased ability to fight off infections and increases in the chance of developing heart conditions, but it was not until this study was published that there was a clear association with hearing and stress.

hearing lossIs Stress Affecting my Hearing Ability?
After reading this report, you may be wondering if your own lifestyle is affecting the quality of your hearing health. 

The best way to assess your hearing ability is to visit a licensed audiologist or hearing aid specialist for a hearing exam. 

Once there, you should let your provider know of your hearing concerns and discuss ways to decrease stress in your daily life. 

You may find that steps taken to improve your lifestyle may also improve your hearing.

fuente: http://www.healthyhearing.com
Tuesday, March 8th 2011

Acúfenos: Sección Acufenos en los medios

Lo que hay que oír.



Aunque muchas veces es pasado por alto, controlar la salud auditiva es tan importante como cualquier otro chequeo médico.

Los expertos advierten que la pérdida de la audición trae consigo consecuencias que deterioran de forma significativa la calidad de vida y sus alcances llegan más lejos que lo pensado.  





Por Agustina Sucri 

¿Le molestan los ruidos de la calle? ¿Escucha pero no comprende lo que dicen en la radio o la televisión? ¿Le cuesta comprender las conversaciones? ¿Le cuesta mantener una conversación telefónica? ¿Escucha música a muy alto volumen? ¿Está expuesto muchas horas a trabajos ruidosos? Si la respuesta a alguna de estas preguntas es sí, es un buen momento para consultar a un especialista en audición.

Si bien la progresiva pérdida de la capacidad auditiva es un proceso fisiológico que acompaña el envejecimiento a partir de los 30 años, existen diversos factores que pueden adelantar o acelerar esa pérdida.
Algunas de las causas de deterioro auditivo más frecuentes son la exposición prolongada a ruidos intensos en la calle, el hogar o el trabajo; el uso de aparatos de reproducción de música a volúmenes muy altos; y pararse al lado de los parlantes en los boliches.

Los acúfenos (sensación de zumbido o ruidos en los oídos) son los primeros síntomas que suelen aparecer por exposición al ruido, seguidos por la no comprensión del mensaje.

Se trata de dos signos de alerta a los que debe prestarse atención para realizar una consulta médica oportuna. Así lo explicó en una entrevista con La Prensa la licenciada Silvia Caponetto, jefa de Fonoaudiología del Hospital de Clínicas José de San Martín y docente de la Universidad de Buenos Aires (UBA).

"Dado que vivimos en una ciudad muy ruidosa, donde hay demasiados sonidos altos todo el tiempo, creemos estar acostumbrados y que es normal, pero sin embargo estos ruidos fuertes provocan problemas a nivel de la comprensión, causan zumbidos o ruidos -acúfenos- y cierta irritabilidad" , remarcó la especialista.

La gravedad de estar expuestos a estos ruidos de forma cotidiana reside en que pueden generar trastornos  no sólo transitorios sino también permanentes y esto se debe a que ciertos ruidos lesionan las células cilíadas, delicadas estructuras del oído interno encargadas de recepcionar los sonidos y enviar el mensaje al cerebro.

- ¿Hay en la sociedad una progresiva pérdida de la audición?

- A partir de los 30 años uno pierde aproximadamente un decibel por año, hay un deterioro degenerativo fisiológico que se da de manera natural. Sin embargo, muchos de los nuevos hábitos de vida y la contaminación auditiva contribuyen a que se haya adelantado el momento de inicio de esta pérdida natural de la audición.

Hace muchos años los controles auditivos a gente joven de entre 18 y 25 años demostraban que no tenían pérdida de la audición; pero los últimos controles que hicimos muestran que los jóvenes en ese mismo rango etario ya presentan pequeñas pérdidas de la audición.

- ¿A partir de qué edad se comienza a advertir la pérdida de la audición?

- Se empieza a notar a partir de los 45 a 50 años. De todas formas, depende mucho de cada persona. Hay adultos mayores que tienen una audición fantástica. Hay muchos factores que entran en juego, además de la exposición a los ruidos hay un componente genético.

DIAGNOSTICO NECESARIO

- ¿Qué estudios deben realizarse para detectar una pérdida de la audición?

- Hacemos audiometría tonal, logoaudiometría, impedanciometría y timpanometría. Son las cuatro pruebas básicas. A partir de ahí se hacen otros. En la campaña vamos a hacer un "screening auditivo", que nos permite detectar qué trastornos de audición hay, sobre todo en las frecuencias agudas. 

- ¿Cuáles son las consecuencias de no oír bien y no consultar a un profesional?

- Las consecuencias son que no llega la información al sistema nervioso central (cerebro) y las personas se empiezan a aislar porque no escuchan lo que sucede a su alrededor... van a un restaurante y no escuchan la mitad de la conversación. Pero muchos de los adultos mayores no se quieren poner audífono porque dicen que los demás hablan mal.

En realidad son ellos, que no comprenden que el audífono es igual de necesario que un par de anteojos a partir de una determinada edad. Esto es muy importante para la interacción neuronal, para estar conectados, para estar despiertos y enganchados con el medio, sino se pierden la televisión, la radio y un montón de cosas.

- ¿Por lo tanto mantener una buena audición también ayuda a prevenir o retrasar ciertas enfermedades neurodegenerativas?

- Exactamente. Por eso realizamos en el Hospital de Clínicas la campaña de controles auditivos para personas de entre 14 y 40 años, porque salvo que tengan algo muy evidente, no vienen a consultar. Y la detección precoz es fundamental.

- ¿Existen otras alternativas además de los audífonos para contrarrestar los efectos de la pérdida de la audición?

- Sí, hay entrenamiento auditivo. Esto brinda al paciente pistas para llegar a comprender mejor el mensaje. Esto se hace en gente grande para darle un mayor confort y comunicación.

COMO PROTEGERSE

- ¿Cómo nos podemos proteger de los ruidos urbanos?

- Para eso habría que hacer una campaña contra la contaminación auditiva. Hace algunos años se hizo un estudio en Santa Fe y Juan B. Justo, donde se tomó con un decibelímetro la intensidad del ruido, y arrojó que alcanzaba los 110 decibeles. 

Es una exposición al ruido muy alta porque entre 80 y 85 decibeles ya es lesionante. Esta misma situación se repite en muchas otras esquinas porteñas, por lo que son necesarias medidas tendientes a disminuir el ruido urbano.

- ¿Cuál es el volumen indicado para escuchar música o ver la televisión?

- Algunos dispositivos, como los MP3s, MP4 y ciertos teléfonos celulares traen incorporado un aviso cuando se supera el volumen máximo que puede soportar el oído sin sufrir lesiones. 

De modo que es conveniente prestar atención a ese tipo de avisos y no traspasar esos límites.

Ciencia y Salud Lo que hay que oír 27.03.2011 |
Fuente: Diario La Prensa. Buenos Aires. Argentina.

viernes, 25 de marzo de 2011

Acúfenos: Sección tratamientos Alternativos: Acupuntura y efecto placebo.

La acupuntura placebo como una forma de curación de contacto ritual: Un modelo neuro-fenomenológico



Catherine E. Kerra, Jessica R. Shawa, Lisa A. Conboya, John M. Kelleyb, c, Jacobsona Eric y Ted J. Kaptchuka

aCentro de Investigación Osher, de la Harvard Medical School, Boston, MA, Estados Unidos

b Endicott College en Beverly, MA, Estados Unidos

c Hospital General de Massachusetts, Harvard Medical School, Boston, MA, Estados Unidos

11 de marzo de 2011.

Resumen

La evidencia de que la acupuntura placebo es un tratamiento efectivo para el dolor crónico representa un rompecabezas: ¿cómo es que las agujas placebo que a los pacientes les parecen penetrar en el cuerpo, y que sin embargo solo tocan la superficie de la piel en forma de un estímulo táctil, provoca una respuesta de curación?

 Las experiencias descriptas previamente de curación ritual por tocar, en las que los pacientes a menudo describen las sensaciones mayor contacto (incluyendo calor, hormigueo o sensaciones que fluye) sugieren la existencia de un mecanismo de curación consagrada.

En este estudio cualitativo, que pidió a un subgrupo de pacientes con  síndrome de colon irritable, en un ensayo aleatorizado de tipo ciego simple,  describir sus experiencias en el tratamiento mientras se someten a un tratamiento placebo.

El análisis se centró en las descripciones espontáneas de los pacientes de cualquier sensación táctil mejorada (por ejemplo, calor, hormigueo) y a toda importancia asignada  por el paciente a tales sensaciones.

Hemos encontrado en 5 / 6 casos, los pacientes sensaciones como "calor" y "hormigueo" asociadas con la eficacia del tratamiento.

La conclusión ofrece una base "neuro-fenomenológica" para tomar en cuenta en el efecto placebo, al considerar los efectos dinámicos de la atención de filtrado en la corteza sensorial, posiblemente como base de la fenomenología de la acupuntura placebo.

Palabras claves: la acupuntura placebo; Ritual; táctil; curación; filtrado atencional, procesamiento sensorial, el efecto placebo; Fenomenología; cualitativa; neurofenomenología
Consciousness and Cognition
doi:10.1016/j.concog.2010.12.009 
fuente de la imagen: http://www.creemetafisica.com/imagenes/acupuntura_

Acúfenos: seccion tratamiento, La autilizacion del Counseling en acúfenos

Principles and application of educational counseling used in progressive audiologic tinnitus management


1 VA RR and D National Center for Rehabilitative Auditory Research, VA Medical Center, Portland, Oregon; Department of Otolaryngology/Head and Neck Surgery, Oregon Health and Science University (OHSU), Portland, Oregon, USA
2 VA RR and D National Center for Rehabilitative Auditory Research, VA Medical Center, Portland, Oregon, USA
3 James A. Haley, VA Medical Center, Tampa, FL, USA
4 Yale University, Department of Psychiatry, New Haven, CT; VA Connecticut Healthcare System, West Haven, CT, USA

Abstract
Exposure to loud sounds is a common cause and exacerbater of tinnitus - a troubling auditory symptom that affects millions of people worldwide. Clinical research at the National Center for Rehabilitative Auditory Research has resulted in a clinical model of tinnitus management referred to as Progressive Audiologic Tinnitus Management (PATM). The model involves five hierarchical levels of management: Triage, Audiologic Evaluation, Group Education, Tinnitus Evaluation, and Individualized Management. Counseling by audiologists and, as needed, mental health providers, is a key component of PATM. This style of counseling focuses less on didactic informational counseling; instead, counseling is used for facilitating patients' learning to adjust to the disturbing auditory symptom by successfully employing tools from two powerful skillsets for self-management of chronic tinnitus - the therapeutic uses of sound and techniques from cognitive-behavioral psychology. This article provides an overview of the methods of counseling used with PATM and provides details concerning the overarching principles of collaborative adult learning that are believed to be most important in facilitating self-management by patients who complain of tinnitus.

Keywords: Auditory, counseling, education, health literacy, hearing disorders, intervention, psychology, rehabilitation


How to cite this URL:
Henry JA, Zaugg TL, Myers PJ, Kendall CJ, Turbin MB. Principles and application of educational counseling used in progressive audiologic tinnitus management. Noise Health [serial online] 2009 [cited 2011 Mar 26];11:33-48. Available from: http://www.noiseandhealth.org/text.asp?2009/11/42/33/45311

  Introduction Top


Approximately 10-15% of all adults experience tinnitus, i.e ., noise in their ears or head generated internally generated. [1] Tinnitus also occurs often in children. [2],[3] A common cause of tinnitus is exposure to loud sound, [4] including loud music. [5],[6],[7] Of those people who experience tinnitus, approximately 20% experience it as a 'clinically significant' problem. For the purposes of this article, clinical significance is defined as a problem for which, based on the patient's perception, some degree of clinical intervention would be appropriate.

A further concern sometimes overlooked is that exposure to loud sounds can exacerbate existing tinnitus, [8],[9] i.e ., the person may notice an increase in the perceived loudness of the tinnitus sensation. When this occurs, a nonbothersome tinnitus may become clinically significant, or an already clinically significant tinnitus may be escalated to a higher degree of severity. Tinnitus usually is associated with some degree of hearing loss. [10],[11] When exposed to loud sounds, people thus could face the risk of both further reduced hearing acuity and an enhanced tinnitus percept - deleterious changes that often are permanent. The problem of tinnitus and noise exposure has been described previously, [4] so we focus here on interventions to help people who experience clinically significant tinnitus.

Intervention for tinnitus is provided by practitioners in many healthcare disciplines, including alternative and complementary medicine. Most commonly, otolaryngologists, psychologists, and audiologists are directly involved in various interventions for tinnitus. Otolaryngologists (and otologists) conduct medical examinations and prescribe medications or perform surgery as indicated for tinnitus. Ongoing management of tinnitus is facilitated by psychologists and audiologists. Psychologists may use cognitive-behavioral therapy (CBT). [12] Audiologists use a variety of sound-based methods, including tinnitus masking (TM), [13] tinnitus retraining therapy (TRT), [14] neuromonics tinnitus treatment (NTT), [15] and progressive audiologic tinnitus management (PATM). [16]

Although a plethora of methods are offered as 'treatment' for tinnitus, research evidence does not support any method as unequivocally providing benefit. Indeed, many treatments for tinnitus offer nothing more than nonspecific effects resulting mainly from expectations for a treatment's effectiveness. [17],[18] It is typical for patients to expect healthcare professionals to provide medical treatment that will give them lasting relief. This expectation is consistent with the 'biomedical model' of medicine, which is how the developed world typically views clinical treatments. The biomedical model is based on the efforts of science, technology, and research to find cures for disease. In its strictest sense, the model is reductionist and ignores the role of psychological and social factors. Although the model is effective in diagnosing and treating many diseases, it is not an appropriate model for helping people learn how to manage chronic health conditions, including tinnitus, long-term. Tinnitus is a symptom that is almost wholly defined by subjective auditory perceptions and their potential to cause psychological disturbances. The tinnitus intervention model we present here is, by contrast, 'biopsychosocial' as detailed by the World Health Organization [19] in its international classification of function, disability, and health. Such a model thus fosters health, instead of only fighting disease, by attention to psychological, social, environmental, and biological factors that impede individuals' full participation in their chosen life activities.

We have described a clinical method of tinnitus management referred to as PATM. [16],[20] The method is 'progressive' in that a hierarchical approach is used to provide clinical services only to the degree needed by the patient. Patients requiring clinical intervention for tinnitus vary widely with respect to the symptom's impact on their daily functioning. These patients have a broad spectrum of clinical needs, ranging from basic education about tinnitus to long-term individualized therapy. PATM is structured to efficiently address this range of needs.

There are five levels of management with PATM. Level 1 is the Triage that provides guidelines to properly refer patients who present with the complaint of tinnitus. The majority of patients have their needs met by receiving the Level 2 Audiologic Evaluation (including hearing aids if necessary) and Level 3 Group Education. Often, management of hearing problems at Level 2 addresses any problems that were attributed to the tinnitus. If tinnitus-specific intervention is needed, then the Level 3 Group Education provides patients with key self-management strategies. Relatively few patients require the Level 4 Tinnitus Evaluation, which relies mainly on an in-depth interview to determine if individualized management is needed. If so, then a plan for Level 5 Individualized Management is formulated and implemented.

PATM involves specific assessment procedures as well as a unique intervention strategy. The assessment procedures have been described in detail. [20],[21] The purpose of the present article is to describe the intervention protocol. The unique aspects of intervention with PATM are: (a) its emphasis on collaborative management by patient and clinician, leading to self-management by the patient; (b) development and use of sound-based therapy that is customized to address patients' individual needs; (c) application of evidence-based principles of patient education and health literacy; and (d) use of multiple modalities to provide education within different stages of PATM. In addition, components of CBT currently are being added to the intervention protocol. Each of these unique aspects of PATM will now be described.


  Collaborative-management and Self-management Top


Chronic tinnitus usually is a permanent condition. In most cases, tinnitus cannot be quietened, but it can be managed. Depending on how tinnitus affects a person, it may need to be managed for a lifetime. When referring to intervention for chronic tinnitus, we do not use the word 'treatment', which might imply that a finite 'course of treatment' will quiet a patient's tinnitus. Instead we use the word 'management' to more correctly reflect the need for ongoing attention to tinnitus. Different strategies often are needed to manage tinnitus in different situations. Patients need to learn these strategies so that they can self-manage their tinnitus in any life experience disrupted by the symptom. This learning should take place with a compassionate and knowledgeable clinician.

The PATM approach to self-management is modeled closely after clinical methodologies that currently are used to manage chronic pain. [22] It increasingly is recognized that patients' ability to manage their chronic pain depends much more on their own efforts and expectations than upon any treatment received. In the past, treatment for urgent pain relief was the sole emphasis, often through the use of opioid drugs or invasive surgeries. Recognizing that chronic pain requires an approach quite different from treating acute pain, these biomedical solutions increasingly are supplanted by educational approaches that focus on supporting long-term rehabilitation. Patients are more closely involved in the decision-making process and consequently they are more committed to participating in the collaborative management process. There is thus 'a shift of responsibility from the healthcare professional to the individual for the day-to-day management of their condition' [23] . This shift is accomplished by working with patients to help them: (a) understand their condition; (b) actively participate in decision making; (c) develop and follow a management plan; (d) self-manage the impact of the condition on daily functioning; and (e) monitor success of management efforts and revise the management plan as needed. In that the clinician and patient maintain a therapeutic relationship, with contacts occurring either on an 'as needed' or periodic basis ( i.e. , regular follow-ups), we may usefully term the approach 'collaborative self-management'.


  PATM Educational Counseling Protocol Top


Educating patients to use therapeutic sound

The use of therapeutic sound for tinnitus management is well supported by research. [16] Clinical evidence for sound-based methods of tinnitus management has been reported for TM, [24],[25],[26],[27] TRT, [28],[29],[30],[31] and NTT. [15] Importantly, in some cases, simply using hearing aids to manage a hearing problem can simultaneously result in sufficient amelioration of a tinnitus problem. [27],[32],[33],[34],[35],[36] We have completed two prospective clinical trials that involved the use of hearing aids, ear-level noise generators, or combination instruments (hearing aid plus noise generator) for most of the subjects. [37],[38] All cohorts, regardless of the specific intervention involved, showed significant improvement (to varying degrees). Folmer and Carroll [27] evaluated long-term outcomes in patients who attended a comprehensive tinnitus management clinic. Three groups of 50 patients each were evaluated who: (a) used ear-level noise generators; (b) used hearing aids; and (c) did not use ear-level noise generators or hearing aids. Significant improvement was observed for all patients. However, patients who used ear-level devices (hearing aids or noise generators) experienced significantly better outcomes than patients who did not use devices.

Many studies, including those cited above, provide strong support for the use of therapeutic sound to manage tinnitus. These studies have not, however, revealed the superiority of any one method. With PATM, the focus of patient education is to provide patients with the knowledge and skills to use sound in adaptive ways to manage their tinnitus in any life situation disrupted by tinnitus. This is accomplished by supporting patients in learning about the different ways that sound can be used for tinnitus management and developing and implementing custom sound-based management plans that address patients' unique needs.

The PATM educational counseling is provided during Level 3 Group Education and Level 5 Individualized Management. Patients first are taught the three uses of sound for tinnitus management [16] : (1) 'Soothing sound' is used to provide an immediate sense of relief from the stress or tension that is caused by tinnitus. (2) 'Background sound' is used to reduce contrast between tinnitus and the acoustic environment (thereby making it easier for the tinnitus to go unnoticed). (3) 'Interesting sound' is used to actively divert attention away from the tinnitus. As shown by the tinnitus-management sound grid [Figure 1], for each of these three uses of sound, three types of sound can be used (resulting in nine possible combinations): (1) 'Environmental sound' includes any nature sound (sounds of animals, weather, moving water, etc.) or man-made sound ( e.g. , electric fans and appliances, broad-band masking noise, synthesized sounds). (2) 'Music' of all styles can be used, including music with and without lyrics. (3) Speech of all varieties is appropriate, including lectures, sermons, talk radio, guided imagery, crowd noise, one-on-one conversation, etc.

Patients need to understand the different uses and types of sound to manage tinnitus so that they can use the sound plan worksheet (Appendix A) to develop an action plan to manage their 'most bothersome tinnitus situation'. The objective is for patients to develop a plan using the worksheet , carry out the plan for about one to two weeks, evaluate the effectiveness of the plan, and then modify the plan to improve its effectiveness. It is critical to maximize the likelihood that the initial plan will be implemented. Patients therefore are instructed to identify (using the tinnitus problem checklist - appendix B) the situation in which their tinnitus bothers them the most and to create a sound plan to manage just that particular situation using sounds and sound devices that are easily accessible. In this way, patients are empowered to create a sound plan that can be implemented with minimal effort, ideally using sound-producing devices they already own (radios, fans, etc.) to address their most bothersome tinnitus situation. After patients have gained experience and confidence with the process and the concepts, additional bothersome tinnitus situations can be addressed and more complicated and sophisticated technology can be incorporated. Patients are encouraged to use the worksheet on a regular basis to refine and improve their sound plans.

The development of a specific plan to address one problem situation involves four small, manageable tasks that are likely to be done successfully (1-4 on the sound plan worksheet - Appendix A): (1) identify a situation in which the tinnitus is particularly bothersome; (2) determine which general strategy (or strategies) for using sound will be tried to help that situation; (3) determine a specific sound that will be used for each strategy; and (4) determine a specific device for presenting each sound. The plan is implemented for one week and then evaluated for its effectiveness (5 on the w orksheet).

A case example demonstrates how patients use the worksheet . Mr. Roberts' most bothersome situation was 'being annoyed by his tinnitus while working in his quiet office' (1). As a general strategy (2), he thought that using background sound might be helpful. The type of sound he would try would be constant fan noise (3) from a small fan in his office (4). He tried this plan for one week and determined that the plan was 'a little' helpful (5). He then revised his plan by adding soothing sound (2). He liked sounds of nature and decided to listen to beach sounds (3) using a CD and CD player that he already owned (4). After trying a combination of fan noise and sounds of nature for one week, he indicated that the plan helped him 'a lot' (5). Mr. Roberts' initial sound plan demonstrated limited success. Based on that experience, he revised his plan and the new plan worked well for him. He experienced success using the worksheet to address one particular problem situation, and he now uses the worksheet as needed to develop plans to address other problem situations.

Self-management workbook

The PATM Level 2 Audiologic Evaluation involves primarily the assessment of auditory function and self-perceived hearing and tinnitus handicap. Hearing aids may be ordered if the patient is a hearing-aid candidate. Education about hearing loss and tinnitus is provided as warranted. A self-management workbook is discussed and provided to patients with problematic tinnitus ( How to Manage Your Tinnitus: A Step-by-Step Workbook). [39] The sound plan worksheet (Appendix A) and tinnitus problem checklist (Appendix B) described previously are located in the workbook along with instructions on how to use sound to manage tinnitus. Patients are invited to attend the group education classes (Level 3) if further tinnitus-specific intervention is needed.

Level 3 Group Education

Level 3 Group Education normally involves two sessions that are separated by about two weeks. A powerpoint presentation ( Managing Your Tinnitus: What to Do and How to Do it ) is given during each session. A separate presentation is used for each workshop. An audiologist makes the presentations, facilitates discussion, and addresses any questions or concerns. Additional workshops are scheduled if needed.

During the first session the principles of using sound to manage tinnitus are explained, and group participants use the sound plan worksheet (Appendix A) to develop individualized 'sound plans' to use to manage their most bothersome tinnitus situation. Completing the worksheet is the goal for each participant. Participants are asked to return for a follow-up session approximately two weeks later. Their 'homework' is to implement the sound plan that they developed during the first session. They should bring their worksheet developed at the first session to the second session.

The objectives of the second session are to: (1) discuss participants' experiences using the sound plan and sound plan worksheet from the first session; (2) engage in collaborative problem solving; and (3) develop an improved sound plan for each participant. In addition, some new information is covered that was not presented at the first session, including: (1) Various devices capable of producing sound that might be unfamiliar to the participants are explained. (2) Ideas for using sound at night are presented. (3) Different sound-based methods of tinnitus management are explained. (4) Participants are told about various lifestyle factors that can affect tinnitus and hearing. The second session is a continuation of the first, and it is important for participants to attend both sessions. Any participant who does not attend the second session should have the opportunity to receive follow-up by telephone.

Level 5 Individualized Management

Relatively few patients who complete Level 3 Group Education require further intervention. Those who do can schedule an appointment to receive the Level 4 Tinnitus Evaluation, during which a comprehensive assessment is made to evaluate the patient's potential need for further clinical services. If further help for tinnitus is required, then the patient can receive Level 5 Individualized Management, which normally requires up to 6 months of repeated appointments.

Counseling that is provided during Level 5 involves essentially the same educational protocol that is presented during Level 3 Group Education. The main difference at Level 5 is the one-on-one setting that facilitates direct interaction between patient and clinician. Some patients do better by receiving ongoing individualized attention from a caring and knowledgeable clinician. Some patients also need the opportunity to resolve any questions or concerns about their tinnitus in a one-on-one setting where they can express feelings and concerns that they might not have been comfortable discussing in a group setting.

A patient counseling guide ( Progressive Audiologic Tinnitus Management: Counseling Guide ) is used during the Level 5 appointments. The counseling guide is used like a flip chart, but laid flat on a table between clinician and patient. When the book is open, one side faces the clinician and the other side faces the patient. The clinician's pages contain bulleted talking points, and the patient's pages show simplified bulleted points and illustrative graphics. The counseling guide corresponds with the Level 3 powerpoint presentations ( Managing Your Tinnitus: What to Do and How to Do it ).

Incorporation of cognitive-behavioral therapy to PATM protocol

Intervention with PATM focuses on assisting patients in learning how to self-manage their tinnitus using therapeutic sound in adaptive ways. Some patients, however, require psychological intervention to alter maladaptive reactions to tinnitus and to aid in coping with tinnitus. Psychological intervention is particularly important for tinnitus patients who also experience posttraumatic stress disorder (PTSD), depression, anxiety, or other mental health problems. Psychological intervention can be an important component of an overall approach to managing tinnitus for all patients.

CBT has been used successfully to manage pain, depression, anxiety, and sleep disorders and has previously been applied to the management of tinnitus. [40] Numerous studies have been conducted to evaluate the effectiveness of CBT as intervention for tinnitus, and a meta-analysis of psychological interventions for tinnitus revealed that CBT had greater efficacy in reducing annoyance relative to the other psychological methods that were evaluated. [41] For these reasons, CBT (which is also sometimes called 'cognitive therapy') is the psychological method of choice for use with PATM.

Beck [42] has described 10 basic principles of CBT. One principle particularly relevant to PATM is "cognitive therapy is educative, aims to teach the patient to be her/his own therapist, and emphasizes relapse preventions" . Although PATM was not originally designed to incorporate this mode of psychotherapy, [16] the flexible, multidisciplinary approach of PATM lends itself well to ongoing evolution. Specifically, CBT is a mode of psychotherapy that fits well within PATM because CBT is inherently flexible and educates patients factually as well as psychologically. Therefore, CBT within the PATM framework will be focused to target specific thoughts and core beliefs that are unconstructive and negative appraisals of situations while providing tools for implementing more adaptive behavioral modifications. [42] The main goal when offering CBT for tinnitus patients is to help patients develop ways to modify behaviors and cognitions in reaction to tinnitus, which then lead to more positive emotional outcomes. [12] Furthermore, patients learn adaptive coping skills that facilitate tinnitus self-management.

The psychological intervention, CBT is an adjunct to the sound-based PATM counseling that addresses emotional difficulties by teaching patients to attend to their core beliefs and habitual thoughts or 'self-talk'. [12] Upon adding CBT to PATM counseling, special attention will be paid to identifying, evaluating, and responding to thoughts that precede irritability, anger, tension, anxiety, depressed mood, or feelings of helplessness. Patients will learn healthy attitudes and constructive approaches to stress since negative attitudes and appraisals of situations often lead to negative emotions, which are immediately applied to individuals' unique problems and concerns. Patients will learn the 12 basic types of negative appraisals: (1) overgeneralization, (2) all-or-none thinking, (3) filtering or selective abstraction, (4) mind-reading, (5) magnification or catastrophization, (6) minimization, (7) personalization, (8) jumping to conclusions or arbitrary inference, (9) emotional reasoning, (10) 'should' statements, (11) labeling, and (12) blaming. Patients will be taught to systematically examine their thoughts and behaviors and modify them so as to create a different, more desirable emotional reaction. Worksheets will be assigned as 'homework' to enable patients to apply their new skills to personal experiences.

Teaching relaxation techniques is another method of addressing patients' emotional response to stress. When patients learn to control behavior in reaction to tinnitus, they learn that their emotional response to tinnitus also may be altered. Furthermore, stress is known to exacerbate tinnitus, thus coping with stress may reduce the severity of tinnitus. Techniques such as progressive muscle relaxation (PMR), [43] controlled breathing, and imagery are basic relaxation techniques patients may use to reduce tension. Patients learn to attend to muscle groups during PMR, diverting their attention from tinnitus to other areas of the body. Controlled breathing encourages attention to the mechanisms of the lungs and sounds of breathing, which releases tension and diverts attention from tinnitus. Imagery is useful in identifying sensory experiences of our minds and as a way to recall past emotions and cognitions. [42] Imagery also is useful as a relaxation technique when a pleasant or neutral image is envisioned during distress. [12] These techniques also will require practice assigned as 'homework' between sessions.

Handouts about healthy attitudes, stress management, and basic instructions for learning controlled breathing will be developed to provide to patients during the Level 2 Audiologic Evaluation. This information also will be added to the workbook that is provided to patients at Level 2. [39] Later, if the patient progresses to Level 3 Group Education, then group CBT will be offered. Group CBT, as opposed to individual CBT sessions, is efficient and allows patients to apply skills to a variety of situations and to develop social support for which to model or from which to imitate positive behaviors. Although the administration of CBT for tinnitus management may optimally be performed by a psychologist or other mental health provider, relatively few mental health professionals have expertise in providing CBT for tinnitus. [40] Fortunately, it is acceptable for audiologists or clinicians from other disciplines to administer CBT, provided they receive the proper training from a CBT expert. [12],[40],[44]
While six to ten sessions of CBT are typical in many clinical settings, the actual number of CBT sessions is flexible and depends on the purpose of the therapy. One controlled study has shown that a condensed version of CBT can be conducted in two sessions with no differences in disability reduction relative to a group that attended 11 sessions. [45] For cost-effectiveness considerations, and since tinnitus education and distraction skills already are provided during the existing PATM counseling, we plan to develop a two-session CBT for tinnitus protocol to include in the Level 3 Group Education. The current two-session group education therefore will be expanded to four sessions to incorporate CBT. The first two sessions will continue to focus on sound therapy, although some CBT will be added to these sessions. The two new sessions will focus on CBT, with a secondary emphasis on using sound. Following development, the abbreviated CBT protocol will be evaluated to determine its effectiveness. Changes will be made to the protocol as necessary to optimize overall outcomes.

If patients continue to have difficulties managing their tinnitus and progress to Level 5 Individualized Management, then individual sessions of CBT can provide more in-depth therapy to reinforce and apply the skills of CBT for tinnitus. The PATM patient counseling guide that is used during Level 5 will include a section to facilitate CBT intervention in a one-on-one setting.


  Using Principles of Patient Education with PATM Counseling Top


PATM relies on a structured program of patient education. Some definitions are in order prior to our discussion of this important topic. Lorig, [46] who has years of experience developing successful patient education interventions for persons with chronic illnesses, defines 'patients' as "people who have defined health problems" and who are "receiving medical care for a condition". She states "patient education is any set of planned, educational activities designed to improve patients' health behaviors, health status, or both." Lorig notes the difference between patient education and patient teaching. In some cases it is necessary to increase knowledge (patient teaching) in order to change a behavior. [46] However, increasing knowledge does not necessarily result in changed behavior. For example, smokers know that smoking is dangerous to their health but they continue to smoke. There are many of these kinds of examples, and it often is a challenge for clinicians to support their patients in a way that will result in the patient changing behaviors that create undue health risks. [47] On the other hand, patients can have good health behaviors with minimal knowledge. Patient education is designed to give patients the support they need to initiate behaviors that result in improved health and thus improved quality of life.

Lorig [46] further states, "the purposes of patient education are to maintain and improve health and, in some cases, to slow deterioration. These purposes are met through changes in behaviors, mental attitudes, or both.". As we discussed earlier, the current trend in medical care is for patients to self-manage their health and ongoing healthcare. Patient education therefore must focus on building the patient's self-management skills. This includes building his or her confidence in applying those skills on a daily basis. The primary purpose of patient education in PATM is to support patients in developing effective self-management skills.

The audiologist's role as patient educator

A patient can progress through up to five hierarchical levels of PATM. At the lower levels (2 and 3) many patients learn how to self-manage their tinnitus and do not need or want to progress to the higher levels (4 and 5). Beginning at Level 2 and continuing through Level 5, patient education is the most important aspect of PATM. Thus, one of the audiologist's primary roles in this program is that of patient educator. Training received by audiologists generally does not include theories and concepts of patient education for achieving changes in behavior. The information in this article will help audiologists to better understand their role as patient educator and maximize their effectiveness in implementing the educational components of PATM.

The mental health provider's role as patient educator

Mental health providers who work on a PATM team should have been specifically trained in CBT by experienced CBT practitioners. Similar to audiologists, mental health providers serve to educate patients about tinnitus, although their focus will be more on psychological responses to tinnitus. However, the mental health provider's face-to-face role as PATM educator will not begin until Level 3 of PATM. Therefore, the mental health provider should work closely with his/her audiologist teammate to learn anything about an individual patient that might be helpful in addressing the patient's concerns during the group CBT sessions. The mental health provider can assist in reinforcing skills being taught by the audiologists and help patients by using terminology and facts consistent with those provided by the audiologists. The mental health provider also will have his/her own set of CBT concepts and skills to impart to patients, and will conduct in-class exercises, assign out-of-class homework, and debrief with patients about how homework played out in their daily life. As already noted, audiologists and other healthcare professionals can perform CBT if they receive proper training.


  Theories of Patient Education Relevant to PATM Top


Some theories related to facilitating changes in health behavior are particularly relevant to PATM. These theories provide support for the educational tools and activities that are used with PATM. Theories relevant to PATM include:

  • Adult learning theory - Andragogy
  • Health belief model
  • Self-efficacy theory
  • Locus of control theory


We will now discuss each of these theories and how they apply to PATM counseling.

Adult learning theory - Andragogy

Adults learn differently than children. Knowles [48] named his adult learning theory andragogy, a word used in Europe before he brought it to the United States, to mean the art and science of helping adults learn. He noted many of the assumptions of teaching methods used on adults were borrowed from pedagogy - the teaching of children. Knowles popularized a different set of assumptions that form the foundation of his adult learning theory:

  • As the adult matures, his or her self concept moves from that of a dependent to a self-directed learner.
  • Adults accumulate vast experience that becomes an increasing resource for learning.
  • Adults' readiness to learn becomes oriented increasingly to the developmental tasks of their social roles.
  • Adults' time perspective shifts from one of postponed application of knowledge to immediacy of application.
  • Adults' orientation toward learning shifts from subject centeredness to problem centeredness.


Andragogy applied to PATM

  • With PATM, the education is designed to teach patients how to independently develop plans to manage their unique tinnitus-problem situations.
  • PATM patient education materials provide suggestions for immediate application of management strategies.
  • PATM incorporates patient education materials for self-directed learning and management. At the Level 2 Audiologic Evaluation, patients receive the workbook. [39] With the addition of CBT, patients also will receive basic information about health attitudes and instructions on how to use controlled breathing for relaxation to take home and use on their own. It is up to them to read the materials, complete worksheets, and self-administer a management plan.
  • At PATM Level 3 Group Education, patients are in a supportive environment where the goal is 'immediacy of application' (an individualized plan is written out during the workshop).
  • At Level 3, the group's focus primarily is 'problem centered' rather than 'topic centered' ( i.e. , patients complete forms that identify when their tinnitus is most bothersome, and a plan is developed to address the described problem, rather than discussing topics that pertain generally to tinnitus but may not have direct application).


Health belief model

The health belief model helps to explain why patients may or may not accept preventive health practices (such as hearing conservation) or the adoption of new health behaviors (such as self-managing problematic tinnitus). This theory proposes that patients will respond best to messages about health promotion or disease prevention when they believe that:

  • They are at risk of developing (or worsening of) a specific condition.
  • The risk is serious and the consequences of developing the condition are unwanted.
  • The risk will be reduced by a specific behavior change.
  • Barriers to the behavior change can be overcome and managed. [49]


This model is based on six key concepts: [50] (1) perceived susceptibility; (2) perceived severity; (3) perceived benefits; (4) perceived barriers; (5) cues to action; and (6) self-efficacy. These key concepts influence how the patient will respond to health advice. The concepts were developed with respect to managing and/or preventing diseases. Although tinnitus is a symptom and not a disease, most of the key concepts of the model pertain to tinnitus management. One of the concepts (perceived susceptibility) has only partial relevance to tinnitus management, and another concept (perceived severity) does not relate at all. We now will discuss each of these two concepts for clarification. The remaining four concepts are summarized in [Table 1] that shows how each concept relates to the PATM sound-based counseling protocol.

Perceived susceptibility: Patients must believe they are susceptible to a disease (perceived susceptibility) before they will engage in an advised action to prevent developing or worsening of the disease. When asking patients to use sound to manage tinnitus (which is the primary focus of PATM), perceived susceptibility is irrelevant because using sound to manage tinnitus has no impact on susceptibility. Perceived susceptibility is relevant to PATM only with respect to preventing exacerbation of tinnitus through the use of ear protection or avoiding loud sound.

Perceived severity: The key concept of 'perceived severity' refers to beliefs about the seriousness of a disease and its consequences. Normally, awareness of the seriousness of a disease is a factor in motivating patients to comply with healthcare recommendations. It therefore is appropriate to inform patients that their disease is serious. With tinnitus, however, this kind of reasoning is inappropriate. Tinnitus is a symptom, not a disease. Tinnitus is 'serious' only when patients believe it to be serious. And, in fact, the belief that tinnitus is serious can contribute to the tinnitus remaining a problem for the patient. Patients therefore should not receive information that would increase their perception of the severity of their tinnitus, unlike what normally would be appropriate when addressing diseases.

Knowing what aspects of the health behavior model concepts the patient accepts or rejects can help guide interactions with the patient. For example, if the patient is aware of the risk (continued stress/anxiety of unmanaged tinnitus and/or hearing loss), but feels that the behavior change is overwhelming or unachievable, teaching efforts can focus on helping the patient overcome the perceived barriers ( e.g. , ensuring that a patient who expresses difficulty understanding the educational material provided at Level 2 comes to Level 3 Group Education where the material will be described in detail, and there will be a provider available to answer questions).

Self-efficacy theory

Self-efficacy and locus of control are among the many personal control constructs that have received enormous attention from psychologists over the years. [51] Much of the research on personal control has focused on the relationship between control beliefs (perceived control) and health outcomes. While other control constructs have shown a positive relationship with successful management of tinnitus, [52] self-efficacy and locus of control have received the most interest from audiologists and we focus here on those two schools of thought and clinical practice.

Self-efficacy refers to how confident the patient is about his or her abilities based on feelings of self-confidence and control. [53] Tendencies to perform a given behavior are influenced by:

  • Expectation of outcome (Is it worth it?)
  • Expectation of self-efficacy (Can I do it?)


The self-efficacy theory is important to consider in administering PATM because research has demonstrated that self-efficacy is a good predictor of motivation and behavior. Motivation is highest when the patient is dissatisfied with the current conditions, but motivation alone is seldom enough to promote changes in behavior. It is important that the patient believes that he or she can do what the management plan requires, and that the effort will be worth it. The clinician can enhance self-efficacy by using teaching techniques such as skills mastery and modeling. [54]

Skills mastery : Self-efficacy is enhanced most effectively through the mastering of skills. [55] In general, the experience of success increases self-efficacy while experiencing failure reduces self-efficacy. Repeatedly experiencing failure during an initial course of events can be particularly detrimental to the development of self-efficacy. Repeated successes, on the other hand, result in a strong sense of self-efficacy, and subsequent failures are unlikely to diminish the ensuing self-confidence. Gonzales, Goeppinger, and Lorig [56] stated,
"Skills mastery is generally achieved first by breaking skills into very small, manageable tasks and then by ascertaining that each small task is successfully completed… One of the best ways to foster mastery is to have clients set goals for themselves in a particular area or for a specific behavior; this can be written in the form of a contract with oneself. These goals provide direction and incentive for action or change. To increase its effectiveness, the goal setting or contract should be client driven. The goal should be clear and specific, describing the behavior as well as the amount of effort needed to accomplish it successfully."

In addition, regular feedback concerning progress should be provided to patients. For example, patients are not judged or scolded when they do not complete their 'homework' for the week. Rather, efforts to understand barriers to completing the homework are explored and future behaviors are emphasized. Successful completion of homework is rewarded by reflections and observations of behavioral change as a result of homework and positive verbal feedback from the provider.

Self-efficacy theory applied to PATM : Self-efficacy theory has particular relevance to PATM. The goal of PATM is for patients to develop and implement individualized plans for using sound (and, in the future, cognitive restructuring) to manage their tinnitus. Success in achieving this goal depends largely upon patients acquiring confidence in applying the self-management strategies.

Use of the sound plan worksheet (Appendix A) addresses the need for developing skills mastery. The worksheet facilitates development of individualized plans for tinnitus management. Development of each sound plan involves four small, manageable tasks that are likely to be done successfully: (1) identify a situation in which the tinnitus is particularly bothersome; (2) determine which general strategy for using sound will help that situation; (3) determine a specific sound that will be used; (4) determine a specific device for presenting the sound. Initial use of the worksheet facilitates skills mastery by focusing on assisting patients in developing a sound plan that can be implemented with minimal effort and usually at no cost to address a situation in which the tinnitus is particularly bothersome.

Modeling is another technique for increasing self-efficacy that is incorporated into PATM. At Level 3 Group Education, patients develop plans for using sound to manage their tinnitus in a group setting with others who are developing their own plans (thereby modeling the behavior to each other). Group members can brainstorm and share ideas for managing tinnitus using sound. Modeling also is incorporated into PATM through the use of examples of people using sound to manage tinnitus.

To build self-esteem that is the basis of self-efficacy, patients should be recognized and rewarded for successfully accomplishing tasks. For example, patients can be told "Great job! You came up with a great plan for managing your tinnitus at night."

Use of the PATM restructuring thoughts worksheet (Appendix C) will address the need for developing skills mastery by facilitating development of individualized plans of restructuring thoughts for tinnitus management. Development of thought restructuring includes examining one situation at a time systematically: (1) identify a situation in which the tinnitus is particularly bothersome; (2) identify the emotion associated with this situation; (3) recall the automatic thought associated with this situation; (4) examine evidence to support this automatic thought; (5) examine evidence against this automatic thought; and (6) create a new thought that is positive and facilitates coping. [12]

Locus of control theory

The locus of control theory describes generalized beliefs by people regarding how much they have control over their life (internal locus of control) as compared to control coming from outside persons or forces (external locus of control). [57] This theory received further development and was specifically applied to health outcomes. [58] Research [59],[60] has shown that people who believe they are in charge of their own health status and lives (Internal Health Locus of Control) are more likely to make necessary changes than those who believe their health is in the doctor's hands (Powerful Others Health Locus of Control). A somewhat weaker relationship has been shown to exist between beliefs in doctors' ability to provide solutions for disease and short-term adherence to treatment plans. Beliefs in the power of fate, luck, or chance (Chance Health Locus of Control) has the weakest relationship with positive health behaviors and outcomes.

Locus of control theory applied to PATM: According to research on health locus of control, patients who believe they are in charge of their own health status are more likely to make the necessary changes to manage a health condition than people who believe their health is primarily in their provider's hands or is a function of fate, luck, or chance. But multidimensional locus of control scales, including those for health locus of control, are not either/or instruments. Thus, when, as in PATM, the provider and patient work collaboratively, there will be experiential elements of both internal health locus of control and powerful other health locus of control that can potentiate positive treatment effects. The initial level of intervention with PATM is the collaborative process of enabling patients to use the sound plan worksheet (Appendix A) to develop their own management plans. (The restructuring thoughts worksheet - Appendix C - also will be used in conjunction with CBT.) Supporting patients in their efforts to develop and implement a tinnitus management plan ultimately puts the patient in charge of managing the condition, not the provider, and not fate.

PATM was designed to help develop an internal locus of control at every level of management. Most patients do not, at the outset of their tinnitus management process, feel that they have control over their tinnitus. Clinicians' awareness of the locus of control theory can shape interactions with patients in ways that shift power for change from the clinician to the person who is going to live with tinnitus for possibly the rest of his or her life. A considerable body of evidence [59] confirms that patients' beliefs about control for health can be modified. Some ways that can help patients to gain a sense of control include: [54]

  • Reminding them of the abilities they already possess to take control over their tinnitus ("You already know how to operate numerous devices that produce sound. Each of these can be used for tinnitus management.")
  • Helping them improve their decision-making skills (assist them with the sound plan worksheet , e.g. , what type of device to use and when to use it)
  • Encouraging them to use social support systems ( e.g. , support groups, referral to mental health counseling when appropriate, and/or providing them with information where to obtain more information such as www.ata.org)
It is reasonable for patients to feel they have no control because they cannot control either the presence or the loudness of tinnitus. Distressed patients may think that the only kind of control that matters is control over the loudness. The clinician's job is to introduce the idea of a different kind of control - control of acoustic environment and control of thoughts about tinnitus. Controlling the environment and changing thoughts can lead to feeling better even if the tinnitus does not become quieter.

Following these steps can make it easier for the patient to initiate tinnitus self-management behaviors:

  • Make sure the education you provide is understandable and well-matched with individual patient abilities and expectations.
  • Use teaching strategies that are interactive ( e.g. , patient and clinician, patient and family member; encourage your patients to ask questions).
  • Demonstrate interest in how patients fit self-management needs into their daily life.


If the patient hasn't taken steps to self-manage problematic tinnitus after following the steps above:

  • Ask the patient to explain. His or her view of why self-management is a problem is the one that counts.
  • Don't propose an immediate solution; rather, help the patient learn problem-solving skills.
  • Determine if the patient believes that self-management using the principles and methods that you have taught will help solve the problem. If not, assess his or her beliefs about the problem, and about PATM.
  • Make sure the patient knows how to follow instructions and has a sufficient level of health literacy to comprehend the information.
  • If the new health behavior is too complex for the patient, then simplify tasks and break them down into simpler steps as needed. Use the analogy that marathon runners start running only a few miles daily and work slowly to increase their distance.


Goal of PATM: Self-management

We have discussed relevant theories and models for enhancing patient education. It is hoped that these theoretical underpinnings will guide the clinician to be an effective patient educator to meet the educational needs of patients to effectively self-manage their tinnitus, which is the goal of PATM. PATM provides the tools for audiologists to help their patients self-manage their tinnitus, [Table 2].

Barriers to self-management

There are several potential barriers to effective self-management, including:

  • Poor literacy standards
  • Disability
  • Low income
  • Low confidence or low self-efficacy
  • Stigma about receiving service from a mental health provider
  • Nonsupportive family and friends
  • Cognitive state and ability to learn
  • Healthcare provider knowledge and confidence in delivery of information
  • Low confidence in the intervention offered


The first stage within PATM that patients might experience barriers to self-management is after the Level 2 Audiologic Evaluation. During the evaluation, the clinician helps the patient determine if the tinnitus is a problem that requires management. If management is indicated, then the recommended protocol is for the patient to receive the take-home education workbook [39] and to enroll in the Level 3 Group Education workshops. If the patient agrees to attend the workshops, but does not show up, then it is important to contact the patient to determine why he or she did not come and if further assistance is needed. This kind of follow-up is essential at all levels of PATM to ensure that patients are not left on their own when they still need to be supported.

Planning and record keeping for patient self-management: Symptom action plans and monitoring diaries

Symptom action plans (SAPs) and monitoring diaries are recommended in international guidelines for chronic disease management. SAPs normally are developed to assist patients in monitoring and responding appropriately to symptoms associated with a chronic disease. An action plan is created for each symptom and depending on the characteristics of the symptom (which are monitored by the patient), the patient produces behaviors according to the action plan. As an example, a randomized controlled study with patients who have chronic obstructive pulmonary disease (usual care control vs intervention group receiving a self-management booklet and written action plan) revealed that provision of an action plan and self-management booklet increased the utilization of self-management skills. [63]

Planning and record keeping for PATM: Sound plan worksheet and patient workbook

PATM employs the use of a SAP/monitoring diary concept via the sound plan worksheet (Appendix A) that is provided in the patient take-home education workbook. [39] With tinnitus, we normally do not want patients to monitor the symptom because the intent is to reduce the amount of time thinking about it. However, we do want them to identify when their tinnitus is problematic and to develop action plans to deal with those situations. The sound plan worksheet serves two purposes. First, it provides patients with the structure to develop specific action plans to use sound to manage their tinnitus. Second, it provides the means to monitor the efficacy of each action plan that is implemented.


  Teaching Tools for Patient Education Top


People have different preferred learning styles (visual, auditory, kinesthetic), and different teaching methods are available to address the different styles. PATM does not depend on a single teaching method, but uses a variety of teaching methods, including:

  • One-to-one verbal instruction
  • Group education
  • Demonstrations and other interactive educational activities
  • Handouts and workbook
  • Videos/DVDs


Teaching tools used with PATM

Specific teaching tools that are used with PATM include:

  • Patient education handout on tinnitus (available on the internet at http://vaww1.va.gov/audiospeech/)
  • Patient educational video on basic tinnitus management ( Ringing in the Ears: What Can I do About it? ) available for computer download, or on DVD and VHS (www.ncrar.research.va.gov)
  • Patient take-home education workbook ( How to Manage Your Tinnitus: A Step-by-Step Workbook ) written at the sixth grade reading level [39]
  • Two PATM powerpoint presentations ( Managing Your Tinnitus: What to Do and How to Do It [sessions one and two]) for use at Level 3 Group Education (available from authors)
  • Flipchart-style patient counseling book ( Progressive Audiologic Tinnitus Management: Counseling Guide ) for use during the Level 5 appointments (to be made available as a commercial publication)
  • (under development) Handout listing the 12 negative appraisals of situations with examples, the restructuring thoughts worksheet , and instructions for a relaxation technique (controlled breathing)



  Addressing the Problem of Low Health Literacy Top


Nearly one-third of English-speaking adults in the US have low health literacy. [64],[65],[66] Those with low health literacy have an incomplete understanding of their health problems, and are more likely to report poor health, have more hospitalizations and higher healthcare costs, as well as suffer worse health outcomes overall. [67],[68],[69],[70] Tinnitus disproportionately affects the populations most likely to have low health literacy: older adults and low-income individuals. [1],[71],[72],[73],[74]

Even literate persons may have difficulty understanding health information, so training clinicians to communicate in ways that reach low-literate patients is good for all patients. [75] There is general consensus among health literacy and communication experts that the seven strategies described in Appendix D can help to improve provider-patient communication. [71],[76] These strategies are incorporated into the PATM educational and counseling materials and should be adopted during all interactions with patients.


  Conclusion Top


Because exposure to loud sounds is a common yet preventable cause of tinnitus, [4] hearing conservation efforts should always stress that loud sound not only contributes to hearing loss, but also can cause tinnitus. As noise continues to be an increasing concern in our society, so does tinnitus. Effective hearing conservation programs thus are essential to reduce the incidence of tinnitus. The current reality, however, is that tinnitus is increasing as a problem on a worldwide basis. Basic research is underway in the attempt to find the 'cure' for tinnitus. In the meantime, effective methods exist to manage tinnitus. We have presented three key components to effective tinnitus management: counseling, stress reduction, and the use of therapeutic sound.

The effectiveness of intervention with PATM depends on the effectiveness of the counseling. It is essential that evidence-based methods of patient counseling are utilized. We have reviewed a variety of learning theories that have particular relevance to PATM. This review shows that PATM adheres to a number of principles that have been demonstrated to optimize effective patient learning of skills for self management of health.

We recognize that counseling for facilitating health behavior change presents challenges that can result in frustration for patients and clinicians alike. [47] Behavioral changes do not come easily, especially when the target behaviors and their underlying cognitions are longstanding, sometimes even lifelong habits. However, counseling with PATM is a patient-centered method that addresses the uniqueness of each patient and his or her particular tinnitus-problem profile. This patient-centered approach has been shown to greatly enhance individual motivation for making adaptive changes for improving health. [77] In PATM, patients participate in the process of defining the problem and identifying specific behavior changes for managing the problem. Each patient becomes an active participant in making decisions and ultimately is in charge of making lifestyle adjustments to mitigate his or her own tinnitus problem. Understanding that the PATM patient is an expert in his or her own life circumstances, problems, resources and abilities is the key that enables this collaborative tinnitus self-management approach to succeed.[81]


  Acknowledgments Top


Funding for this work provided by Veterans Health Administration, and Veterans Affairs Rehabilitation Research and Development (RR&D) Service. Special thanks to Martin Schechter, PhD, for his significant contributions to our research. All figures were created by Lynn Kitagawa, MFA, Medical Media Service, Portland VA Medical Center.

 
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Correspondence Address:
James A Henry
VA RR and D National Center for Rehabilitative Auditory Research, VA Medical Center, Portland, Oregon; Department of Otolaryngology/Head and Neck Surgery, Oregon Health and Science University (OHSU), Portland, Oregon
USA
Login to access the Email id DOI: 10.4103/1463-1741.45311
PMID: 19265252
Fuente: Noise Health 2009;11:33-48