Interprofessional Practice and Education Supports Tinnitus Management Tinnitus has the potential to influence a wide range of routine and important activities in a person's life. It can impair sleep, communication, concentration, and in severe cases can be affected by depression, anxiety, and other mental health issues. Perhaps more important, tinnitus may influence the patient's psychological state; its ... Article
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Article  |   October 26, 2016
Interprofessional Practice and Education Supports Tinnitus Management
Author Affiliations & Notes
  • Marc Fagelson
    Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City, TN
    James H. Quillen Mountain Home Veteran’s Affairs Medical Center, Mountain Home, TN
  • Disclosures
    Disclosures ×
  • Financial: Marc Fagelson is Director of Audiology, Assistant Chair, and Professor in the Department of Audiology and Speech Language Pathology at East Tennessee State University, and a Consultant at the James H. Quillen Mountain Home VAMC.
    Financial: Marc Fagelson is Director of Audiology, Assistant Chair, and Professor in the Department of Audiology and Speech Language Pathology at East Tennessee State University, and a Consultant at the James H. Quillen Mountain Home VAMC.×
  • Nonfinancial: Marc Fagelson has previously published in this subject area. Some of these works are referenced in this piece.
    Nonfinancial: Marc Fagelson has previously published in this subject area. Some of these works are referenced in this piece.×
Article Information
Hearing Disorders / Part 1
Article   |   October 26, 2016
Interprofessional Practice and Education Supports Tinnitus Management
Perspectives of the ASHA Special Interest Groups, October 2016, Vol. 1, 5-12. doi:10.1044/persp1.SIG7.5
History: Received May 4, 2016 , Revised July 29, 2016 , Accepted July 30, 2016
Perspectives of the ASHA Special Interest Groups, October 2016, Vol. 1, 5-12. doi:10.1044/persp1.SIG7.5
History: Received May 4, 2016; Revised July 29, 2016; Accepted July 30, 2016

Tinnitus has the potential to influence a wide range of routine and important activities in a person's life. It can impair sleep, communication, concentration, and in severe cases can be affected by depression, anxiety, and other mental health issues. Perhaps more important, tinnitus may influence the patient's psychological state; its bidirectional effects, although well established, often challenge patients and providers across a variety of clinical settings. Management of tinnitus requires audiologists to be adept at communicating and supporting coping strategies that may include, but should not be limited to, patient-centered counseling and delivery of sound therapy or hearing aids. In the short term, patient care may benefit from interprofessional collaborations and effective referral networks. In the long term, the inclusion of tinnitus clinic rotations, classes, and interprofessional opportunities for students in Audiology programs should provide AuD students the experiences and competencies to provide for patients with tinnitus.

Introduction
Although a patient's tinnitus experience is consistent with that of an audible sensation, the response to tinnitus, the way that it makes the patient feel physically and emotionally, contributes substantially to the severity of the perception, regardless of the psychoacoustic qualities of the tinnitus sound. In addition to its effect on emotional and psychological state, tinnitus may influence the most fundamental routines and elements of a person's life as it impairs sleep, concentration, and communication. Further, patients with co-occurring psychological conditions, such as depression or anxiety (Landgrebe & Langguth, 2011; Langguth and Landgrebe, 2011), or psychological injury, such as posttraumatic stress disorder (PTSD) (Fagelson, 2007), often endure tinnitus effects that exceed those reported by patients without such injuries (Erlandsson, 2000).
Tinnitus distress may be multi-faceted and, as a result, difficult to manage. The myriad sound therapy approaches available suggest that no single method adequately meets the needs of patients and clinicians (Fagelson, 2014). A review summarizing several investigations indicates that efficacy of sound therapy increases when offered with counseling and patient education, and that sound therapy without counseling offers a less effective intervention than counseling without sound therapy (McKenna & Irwin, 2008). Therefore, practitioners whose skills are tested by tinnitus should acknowledge that the most reasonable interventions incorporate practice components from audiology and psychology. In this report, elements contributing to tinnitus severity will be discussed with respect to the influence of tinnitus on physical and psychological health. Interventions addressing patient responses to the tinnitus sound and response will be contrasted. Finally, the experience of providing student rotations through tinnitus clinics, as well as interprofessional practice objectives, will be summarized in order to offer an example of elements that students report as helpful in their preparation to provide appropriate services for patients with tinnitus.
Patient Beliefs: Physical Effects of Tinnitus
In many ways, tinnitus disruption displays the hallmarks of a psychosomatic disorder, specifically the effects of a physical malady amplified by a negative psychological response to the disruption. Several indices available to assess tinnitus effects are well validated, and the physical intrusions associated with tinnitus can reasonably be drawn from their questions. Several questionnaires are used throughout the world, and a sampling from two, the Tinnitus Functional Index (TFI; Meikle et al., 2012) and the Tinnitus Handicap Inventory (THI; Newman, Sandridge, & Jacobson, 1998) illustrates the physical challenges produced by tinnitus. Patients are queried regarding the effects of tinnitus on basic life activities such as sleep, ability to relax, concentration, communication, relationships with family and friends, reading, working, and completing routine household activities. Of course, the questionnaires also address issues such as depression, anxiety, frustration, and other emotional responses to tinnitus. Such questions underscore the multifaceted nature of tinnitus annoyance; routine activities taken for granted by most people are disrupted by a tinnitus signal that produces powerful negative emotional responses. When linked to studies that indicate tinnitus is assessed as more severe by patients who experience co-occurring psychological injury (i.e., PTSD) or condition (i.e., depression), the effect of psychological state on tinnitus effects cannot be ignored. Unfortunately, hypochondriacs have given psychosomatic illness a bad name; labeling tinnitus “psychosomatic” may be unacceptable to many patients and providers.
Another issue relates to quantifying the patient's tinnitus experience. Quantifying tinnitus effects relies upon patient self-assessments, as well as psychophysical characterization of tinnitus. The former strategies are employed most often and are considered the more accurate measures of tinnitus severity. The latter are notoriously difficult to obtain and interpret because of variability, and hence many practitioners consider them to be of questionable value. For example, when measured in the tinnitus pitch region, the loudness of tinnitus is often matched to a signal of less than 10 dB SL with regard to the patient's puretone threshold at that frequency. The same tinnitus sound, when compared to an external signal centered in a different frequency region, would more likely be matched at greater than 20 dB SL with regard to the puretone threshold at the non-tinnitus frequency (Oregon Health and Science University Tinnitus Archive, 2001; Tyler, 2000). Further, nearly 50% of patients with bothersome tinnitus report a sound experience that changes several times per day, thereby influencing potential benefit from sound therapy approaches that require specific tinnitus attributes for their programming and implementation. Such measures are difficult for patients as well and should be conducted only when the clinician has a strong rationale for doing so.
If a patient believes that tinnitus imposes physical limitations and reduces quality of life because of its effects on daily activities, then those beliefs must be examined and ultimately challenged by the clinician. Problems with hearing and communication often are reported by patients with tinnitus, and it is not unusual for patients to report that tinnitus affects their hearing, is responsible for their hearing loss, or impairs communication. Clinic practice guidelines (Tunkel et al., 2014) state that the first priority for clinicians providing for patients with tinnitus and hearing loss is to manage the hearing loss. Such intervention may be medical (i.e., surgery for otosclerosis) or audiologic (i.e., hearing aids). Clinicians must on occasion walk a fine line; we must challenge patients' beliefs that tinnitus causes hearing loss and communication difficulties while acknowledging that tinnitus is an intrusive experience. Patients benefit from clear definitions of tinnitus and accurate descriptions of auditory system function. Such counseling can foster in the patient an understanding of the difference between hearing loss and tinnitus, and can facilitate their ability to divide and conquer, so to speak, the two conditions. Considerations for counseling such patients can include the following:
  • The relation between hearing loss and tinnitus is not strong; there are some patients with normal hearing and debilitating tinnitus just as there are some patients with profound deafness and no tinnitus. Conversely, there are patients with profound deafness and debilitating tinnitus as there are patients with normal hearing and no tinnitus. Therefore, any severity of tinnitus may accompany any audiometric configuration.

  • A corollary to the previous point is that any patient with tinnitus may review their audiogram and recognize the likelihood that a person with the same thresholds but without tinnitus would experience similar communication problems. In this way, the patient who blames tinnitus for communication problems can appreciate the potential value of hearing aids or assistive devices. Perhaps more important, they can readily accept the possibility that their frustration directed at the tinnitus sound because of communication problems may be misplaced.

  • Fitting patients with hearing aids may result in improved communication, but no change in tinnitus. Although this outcome is not ideal, it affords the clinician another opportunity to facilitate appreciation of the difference between hearing loss and tinnitus. If hearing aids improve communication, but not tinnitus, then the patient may recognize that their communication difficulties should more reasonably be attributed to hearing loss than tinnitus; if communication can improve without the tinnitus changing, then tinnitus could not have been the culprit in the first place.

Sleep disorder is another problem associated by many patients with their tinnitus experience (Tyler & Baker, 1983). Tinnitus severity is strongly correlated with severity of insomnia (Meikle, Vernon, & Johnson, 1984), and insomnia may persist for years following tinnitus intervention (Crönlein, Geisler, & Hajak, 2011). Patients report difficulty getting to sleep, as well as frustration getting back to sleep, particularly if they believe that tinnitus awakens them. Some patients also indicate fatigue during the day from disrupted sleep. More problematic for other patients is the knowledge they carry throughout the day that they cannot look forward to a good night's sleep, with the result that patients report anxiety and depression related to their sleep problem (Breslau, Roth, Rosenthal, & Adreski, 1996). The stress imposed by poor sleep and the patient's anticipation of difficulty sleeping may be addressed through counseling that focuses on sleep hygiene and may be supported by the use of bedside masking devices (McKenna, 2000). As indicated above with regard to consideration of hearing status, it is essential for disorders affecting sleep, such as sleep apnea or restless leg syndrome, to be addressed prior to initiating tinnitus intervention targeting sleep improvement.
Although some patients report tinnitus waking them up in the middle of the night, these complaints are less common than those related to difficulty getting to sleep (Crönlein et al., 2011). When patients express concern that tinnitus does wake them up, it is reasonable to counsel regarding sleep cycles and the effect that aging exerts on sleep quality. Polysomnographic data indicate that tinnitus patients display sleep cycle activity similar to patients without tinnitus who experience insomnia (Crönlein, Langguth, Geisler, & Hajak, 2007). Therefore, the possibility that tinnitus exerts measurable changes on a person's sleep patterns cannot be discounted. Patients often benefit from strategies to improve sleep, as well as the counseling that can augment their understanding of sleep patterns and disorders. Some patients benefit from elements of cognitive behavioral therapy focused on sleep improvements (Cima et al., 2012) and report that quality of life is substantially influenced by the quality of sleep (McKenna, 2000).
Patient Beliefs: Psychological Effects of Tinnitus
Tinnitus onset may be associated with events that involve damaging noise exposures, however other injuries such as whiplash and traumatic brain injury may produce tinnitus regardless of auditory damage resulting from the traumatic event (Kreuzer, Landgrebe, Schecklmann, Staudinger, & Langguth, 2012). As a consequence, many patients experience a tinnitus perception that may be influenced by a variety of factors that are not amenable to auditory-only interventions, or that lack a clear auditory system target. Coles (1995)  indicated that barely one quarter of 100 patients seeking services for tinnitus identified an auditory event related to their complaint. Patients were more likely to indicate “bereavement,” “negative counselling,” or stress-related to domestic or employment situations than an auditory dysfunction. Clinical interventions for tinnitus must therefore consider patients' experiences and psychological state in addition to any otologic history or audiologic insult.
The relation between tinnitus and mental health is discussed in literature from both fields and affirms the value of interprofessional management. Hinton, Chhean, Pich, Hofmann, & Barlow (2006)  report that patients with PTSD and tinnitus rate their PTSD as more severe than those patients without tinnitus. Similarly, Fagelson (2007)  reports that patients with PTSD and tinnitus rate their tinnitus as more severe than patients without PTSD. Both authors discuss the potential for mutual reinforcement of symptons. Reviewing tinnitus management approaches, McKenna (2004)  provides a comprehensive comparison of interventions that employ psychological approaches to tinnitus retraining therapy and other audiologic strategies.
The upshot of such comparisons is clear: tinnitus distress is complex, arises from a variety of sources both physical and psychological, and in severe cases will be most reasonably addressed through the collaboration of audiologists and otolaryngologists with psychologists and other mental health providers. The need for such care also provides the basis for the effective triage program that forms the first stage of progressive tinnitus management (Henry, Zaugg, & Schechter, 2005; Henry, Zaugg, Myers, & Schechter, 2008). Referral options should include interdisciplinary or polytrauma teams designed to offer patients with multiple injuries and related symptoms the comprehensive resources their care requires. Such teams may be accessed by patients on their own, through effective referral networks, in tinnitus group settings attended by providers from diverse backgrounds (Newman, Sandridge, Meit, & Cherian, 2008), or in collaborative interprofessional practice.
The influence of traumatic experiences may take many forms in the tinnitus clinic and may appear without warning during an evaluation or intervention session. Some patients may ask for students to be excluded from the test suite, for doors to be left open, and they may startle often and palpably when sounds from outside the test room (voices, doors closing) occur unexpectedly. Audiologists, as other health care professionals, strive to ensure that patients feel safe in the test and intervention environments; this priority is most acute when working with patients distressed by chronic hyperarousal, re-experiencing of negative memories in addition to tinnitus-related anxiety and depression. Imagine, then, the effect of testing acoustic reflexes? Or attempting to deliver a rigorous series of loudness discomfort level stimuli? For some patients, even the sound of a bedside masking device, for example, when producing the sound of brook or thunderstorm, can provoke recollections of threatening environments, heighten a patient's state of arousal and, by doing so, trigger insecurity or, still worse, fear or anger.
In addition to the effects of depression and anxiety, the most powerful tinnitus exacerbators relate in some way to traumatic memories that are associated by some patients with tinnitus onset and related distress. Environmental stressors or environmental conditions that resemble those from a traumatic episode may exacerbate tinnitus severity as they provoke physical or psychological stress. Patients with trauma histories are three times more likely than those without such experiences to report tinnitus that increases in loudness or annoyance in response to external sounds (Fagelson, 2007); so-called “reactive” tinnitus. Veterans of combat deployments, for example, complain most frequently that unexpected impulse or explosive sounds intensify the tinnitus sensation. Additionally, tinnitus may also react to the sound of sirens, dishes being stacked, dogs barking, or grandchildren yelling, particularly when such sounds are unexpected. Such complicating factors often emerge during patient interviews and must be considered when working with patients as well as when overseeing students' clinical contacts.
Preparing For the Future
Audiologists will continue to work with patients who experience negative consequences from tinnitus for as long as the profession exists, therefore preparation of doctoral students must include classwork and clinic experiences related to tinnitus and the patients affected by tinnitus. The expertise of other professionals will be called upon as the myriad mechanisms underlying tinnitus, as well as its ability to provoke powerful psychological responses, ensures the durable value of such professional collaborations. As providers, we work with patients who express tinnitus distress that can be as severe as it is multi-faceted. Additionally, it is well established that negative counseling and ineffective interactions with patients and their families can exacerbate a patient's tinnitus experience.
Managing patients with tinnitus is supported by a clinician's understanding of mechanisms, the relation between different etiologies and tinnitus, patients' psychological and emotional reactions, as well as the sound-based and psychologically-based interventions available for clinical use. Management should also be supported through collaboration with health care providers from other disciplines. Addressing the importance of accurate counseling, Cavanaugh and Konrad (2012)  emphasize that counseling has a substantial impact on the patient, with the ability to “hurt as well as heal (p. 294).” The accuracy and relevance of counseling clearly benefits from the broader perspective provided by interprofessional teams. Indeed, one of the four core competencies associated with interprofessional care centers on communication with patients and their families, and between the providers in whose care the patient is placed (Schmitt, Blue, Ashenbrener, & Viggiano, 2011).
The feasibility of preparing students to meet clinical challenges associated with tinnitus must be critically examined, and can benefit from consideration of the interprofessional collaboration core competencies. Because it is well known that no simple cure exists for the tinnitus sensation, audiology students must be provided sufficient information and experience to realize that they can affect change in a patient's life, even when that patient is distressed first and foremost by tinnitus. Perhaps more than other patient groups, the heterogeneity of tinnitus patients will require students to retain and employ a combination of basic hearing science, theories of tinnitus mechanisms, and an understanding of practice outcomes; essential competencies for audiology students are clearly entwined with these concepts. An introduction to tinnitus via clinical observation provides students the additional benefit of witnessing the effects of counseling on patients' progress. In most cases acoustic therapy (i.e., hearing aids, maskers, or other sound therapy) is an element of the intervention, but never the only element. Therefore, the tinnitus clinic provides students an important lesson; audiologic intervention helps, but must be augmented in all cases by an informed dialogue with the patient that focuses on interpreting tinnitus accurately and responding to it rationally. This lesson may be generalized over time to other etiologies and audiologic interventions. The tinnitus clinic also lays bare the value of interprofessional care.
Group sessions for patients with tinnitus provide examples of collaborative interventions and patient-centered counseling consistent with the objectives of interprofessional health care. Implementation of such groups can include elements of otolaryngology, physical therapy, psychology, neurology, and social work that are provided to the group participants by professionals in those respective fields. Examples from current practice can highlight differences between interprofessional practice as defined by Cavanaugh and Konrad (2012)  and multidisciplinary care opportunities. For example, Newman and Sandridge (2005), while not employing the core competencies of interprofessional practice, report on patient outcomes that follow enrollment in tinnitus groups including providers from the backgrounds listed above. Prior to tinnitus management, patients receive medical and audiologic assessments, and complete a variety of intake forms that identify presence and severity of co-occurring depression, anxiety, or other psychological condition. The group event identifies those patients for whom additional, individual sessions would be appropriate; Newman and Sandridge (2005)  indicate the subsequent audiologic management options that would be implemented on an individual basis.
In order to extend this approach to fit with the objectives of interprofessional practice, providers should take additional time to consult and strategize regarding the needs of individual patients prior to formal counseling sessions. Indeed, collaboration between the providers is a primary difference between interprofessional practice and the aforementioned group session with professionals from different disciplines (Schmitt, Gilbert, Brandt, & Weinstein, 2013; World Health Organization, 2010). In the former, the process of collaboration provides problem-solving and counseling opportunities beyond those provided in the group setting that may not consider the core competencies of interprofessional collaboration. Patient interactions with providers in the formal interprofessional context include communication and information exchange that profits from provider collaboration both prior to and during the counseling session. The result is a form of shared learning in which the providers benefit from each other's expertise as the patient receives a plan containing comprehensive and multifaceted information from a team of clinicians (Cavanaugh & Konrad, 2012).
In addition to interprofessional communication, core competencies of interprofessional practice include consideration of values and ethics associated with other professions, the roles and responsibilities of team members, and the use of team dynamics to establish appropriate roles for team members. The core competencies apply both to the training of team members, as well as the delivery of services. Because of the complex and sweeping effects of the tinnitus experience, the implementation of an interprofessional practice program should in many cases provide the wide-ranging counseling elements required by patients. Such intervention will be most critical for patients whose injuries influence multiple sensory and motor systems. Strasser, Uomoto, and Smits (2008)  reiterate the value of interprofessional care in polytrauma team settings as providing “optimal outcomes” that rely upon “integration of medical, psychosocial, financial, ecducational, and vocational resources,” (p. 180). Although the role of audiologists on polytrauma teams is beyond the scope of this report, such opportunities are likely to increase over time; students and clinicians should be encouraged to participate on such teams when possible.
Although it is often acknowledged that patients with severe tinnitus cannot easily secure the clinical attention they require, it is possible that audiology students are similarly underserved when it comes to educational and practical opportunities to work with this large and challenging patient group. Until the administrative bodies governing audiologic practice specify clear requirements for tinnitus providers, it is not reasonable to expect substantial improvement over current practice; therefore, it is incumbent upon programs to provide both didactic instruction regarding tinnitus, clinical exposure to patients with tinnitus, and opportunities for interprofessional collaboration in the management of patients. Failing to do so ensures that another generation of patients will lack access to basic information that should be the purview of every practicing audiologist, whether working in a standalone clinic, or as part of an interprofessional care team. Because tinnitus often exacerbates and/or is exacerbated by co-occurring mental health injury or condition, or is influenced as a result of negative or inaccurate counseling, the preparation of audiologists who are confident counseling and collaborating with other providers should remain a priority of our professional training programs and clinical partners. Tinnitus represents an area of audiologic practice that has not received the priority it deserves in academic and clinic training programs, and for the benefit of millions of patients, the situation must be improved.
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