Retraining therapy (TRT) is based on research by Jastreboff and is based on finding that tinnitus causes hyperacusis. Hyperacusis is due to an alteration in the central processing of sound in the auditory pathways where there is an abnormally strong reaction from exposure to moderate sound levels. The success of TRT is based on working with a trained tinnitus therapist. It involves the following:-
1. Sound enrichment – which is the introduction of sound so that the individual is never in a quiet situation where the tinnitus is more annoying. Masking devices were once used but recent research suggests that natural sound should not be excluded. See section on Masking Devices.
2. Retraining tactics – these involve relaxation.
The following is a more detailed description of these techniques. Remember that their success is based on working closing with a therapist.
Sound enrichment.
Sound enrichment is an essential part of all retraining therapy. It is not easy to choose the appropriate sound or sounds which should be present in the background throughout 24 hours of the day. The important message is to avoid silence. This is something which is not particularly easy to do for some patients. There are many ways of enriching the sound environment, but it must be with a sound that is not irritating or intrusive itself. The best sounds are those that are like nature. In summer it may be possible to have the window open. Otherwise sounds coming from a a large slow moving domestic fan or radio tuned just of the station may be suitable. It is essential that the sounds do not mask or block out the tinnitus when present, as it is not possible to habituated to a sound that you cannot hear. Many people with hyperacusis spend a lot of time in silence because of the dislike for external environmental noise. Some resort to ear plugs*. This is the worst thing to do, because it results in an increase of sensitivity in the central auditory system ( increase of gain) which makes external sounds louder still. In hyperacusis it is usually essential to be fitted with binaural white noise generators by someone who has been trained in TRT. They are frequently also necessary in treating significant tinnitus. It should be realized to that the wrong kind of sound therapy, for instance, listening to distorted music tapes, or using devices to mask tinnitus completely, can actually be harmful in certain cases. Commercial devices which produce sounds like the sea or rain can be very useful, but everyone has an individual preference. Just leaving the television or radio on all the time is not really the answer, as this tends to be stimulating or intrusive at times, or to mask any tinnitus that may be present. Where there is a significant hearing loss causing a problem in hearing speech, patients will require amplification with appropriate hearing aids. These must be a properly fitted by ‘ best practice’ only and the two ears must be as evenly balanced as is possible.
Retraining tactics
1) Examine your reaction to tinnitus or unpleasant external sounds (in hyperacusis) for some (short) periods each day. 10 seconds is long enough
2) Practice relaxation techniques to reduce the body (autonomic activity) part and try to reduce you annoyance / irritation / fear (limbic part) by an ‘act of diplomacy’. Don’t worry if you can’t reduce these things by much, every little counts, and each time the exercise will be easier.
3) Reduce the impact by sound enrichment or use of instruments according to TRT principles.
4) Try and identify your emotional and body reaction to the sound, and reduce this by a small amount each time. This is an aversive conditioned reflex response. It takes a long time to retrain conditioned reflexes (like hand writing, or your golf swing!). Be patient.
Do all these exercises for only such time as you experience no unpleasant reaction (may be 10 seconds to start with). Do this perhaps 10 times a day only. The rest of the time you maybe reacting as before, with distress, that’s OK in the initial stages.
This is an exercise in facing the object of your disaffection / dislike without reacting to it so strongly, an ‘exercise in diplomacy’. The principle works with everything in your life that annoys you or upsets you! It is important not to do too much to start with. Flooding yourself with unpleasant tinnitus experiences, or too much environmental sound to which you are aversive, can make things worse. As with desensitiation to an allergy, progress must be very slow and deliberate. An average period for retraining might be 18 months, or more in severe cases.
5) Think positively about the REAL meaning of tinnitus or external sound during this time, as described in the Jastreboff model.
6) Increase the period of these exercises gradually, by seconds, then maybe minutes. Slow progress, little and often, works best! If you try to rush it, you can go backwards.
RESULT: Experience decreased periods of reaction to, or awareness of tinnitus / external sounds and WITHOUT annoyance = progress (Habituation). If you notice any improvement, then you must be on the right track