British Tinnitus Association

The British Tinnitus Association - registered charity no: 1011145

Tinnitus: Where Are We Now, and Where Are We Going?

The need for effective intervention for tinnitus is obvious. 25% (15 million) of the UK population have experienced tinnitus at some stage in their lives, and 6% of the UK population (3.6 million) suffer moderate to severe tinnitus. 8% consult their GP and 2 – 4% of individuals will proceed to a hospital visit. However fewer than 20% of those referred to a specialist have been offered access to treatment. Even if offered treatment, the quality of services is variable, with only a few clinics offering clearly defined intervention via a multi-disciplinary team.

Where are we now?

Just 20 years ago, tinnitus was a footnote in many medical journals. However there have been tremendous changes both in our understanding of tinnitus mechanisms, and in approaches to tinnitus management during this time. There have been several milestones during the last two decades. The most significant being the development of the neurophysiological model by Dr. Pawel Jastreboff, and the habituation models of tinnitus developed by Jastreboff and separately by Dr. Richard Hallam and his co-workers.

Tinnitus management has developed from Jack Vernon’s pioneering work on tinnitus masking, and the early forms of psychological management published in the 1970s. Members of the psychology community in Europe and Australia have developed and researched Cognitive Behavioural methods of tinnitus management with great success. At the same time Jastreboff and his colleagues, Jonathan Hazell and Jacqueline Sheldrake, have developed Tinnitus Retraining Therapy. Both therapies have the clear aim of bringing about habituation to tinnitus.

The evolution of tinnitus management was encapsulated during the 21^st European Instructional Course on Tinnitus and its Management held in Nottingham last month. This course is now organised by David Baguley (Head of Audiology at Addenbrookes Hospital, Cambridge) and Dr. Laurence McKenna (Head of Psychology at The Royal National Throat, Nose and Ear Hospital, London). This provided a forum for (amongst others) presentations on auditory anatomy and neurophysiology from Dr. Carole Hackney and a summary of the neurophysiological model from Dr. Pawel Jastreboff (International guest of honour). From a clinical point of view the TRT approach was outlined, and for the first time in the history of the course an entire session was devoted to the psychology of tinnitus. This session included a presentation of Multi-Component Treatment of Tinnitus using Cognitive Behavioural Therapy and Relaxation Management from Dr. Gerhard Andersson of the University of Uppsala, Sweden.

Where are we going?

At The British Tinnitus Association AGM held in Cambridge last September (2000), the latest trends and results of tinnitus research were outlined. Of particular interest were scanning techniques to image areas involved in tinnitus perception, and the possibility of a pharmacological intervention for tinnitus.

Dr. Debbie Hall of the Institute of hearing Research at Nottingham described the progress being made with imaging areas of the brain involved in tinnitus perception. She indicated that fMRI and PET scanning were increasingly being used to determine which areas of the brain were involved. Much work in this area is being done in the UK, USA and Australia with promising results.

Dr. Ewart Davies, of the Department of Pharmacology at Birmingham University Medical School, suggested that it might now be possible to find a pharmacological solution to tinnitus. Tinnitus as a consequence of hearing loss may be due to re-organisation, growth and re-connections of nerve cells. He suggested that these re-connections involve the generation of new axons, new receptors, and possibly new transmitters. If these could be identified, then they would be classical targets for drug influence.

Collaboration between basic scientists, psychologists, medical specialists and audiologists will almost certainly prove to be key to future tinnitus findings. This collaboration has already provided a better understanding of the neurophysiological processes underlying tinnitus perception, and how clinical interventions may work. More importantly, these models can be used to show how clinical interventions might be better targeted or implemented and may include a combination of pharmacological and behavioural interventions.

Neurophysiological models show that developments in the areas of cognitive and behavioural therapy for tinnitus are long overdue. The paucity of psychologists working in this field makes it difficult to implement psychological strategies such as Cognitive Behavioural Therapy. However it may be possible that these techniques can be adapted for use by Medical Specialists and Audiologists as an adjunct to other tinnitus counselling strategies.

A glance at the tinnitus literature during the past twenty years will reveal a multitude of eclectic approaches to management, often with differing methodology and outcome measures. The advent of Cognitive Behavioural Therapy and Tinnitus Retraining Therapy are at least going some way towards standardising interventions. Evidence based medicine guidelines and greater attention to research design and implementation have improved the standard of tinnitus research in general. At present randomised controlled trials of tinnitus interventions are few and far between (and may be impossible to obtain in some studies), however there are a growing number of robust experimental studies in this area. Advances in the field of behavioural tinnitus research are being made.

Of particular interest is an outcomes study to prospectively evaluate the effectiveness of Tinnitus Retraining Therapy and Tinnitus Masking conducted by Dr. James Henry, Research Investigator for the Veterans Affairs National Center for Rehabilitative Auditory Research. This study is now at its mid-point at the Veterans Affairs Medical Center in Portland, Oregon, USA.

British Tinnitus Association Lobbies Parliament

Following the presentations made at the BTA's Annual General Meeting, a proposal was made for a Tinnitus Research Centre to develop and co-ordinate multi-disciplinary tinnitus research. To lay the basis for this an Early Day Motion (426) was launched in the House of Commons:

“That this House notes that Tinnitus affects around one in ten of the population, including an even higher proportion of older people and that following advances in various therapies to counter the effects of Tinnitus, a pharmacological solution is now a real possibility, urges the Government to encourage appropriate research to this end by all means at its disposal.”

Over 300 MPs signed or supported this, the highest number of signatures for an Early Day Motion ever known in the House of Commons. The result was a delegation led by the Rt. Hon. The Lord Ashley of Stoke CH to meet the Minister for Health, Mr. John Hutton. The delegation consisted of The Rt. Hon. Robert MacLennan, Mr. Tom Levitt MP, Mr. Roger Berry MP, Mr. Terry Buffin, Dr. Ewart Davies, Mr. Jonathan Hazell, and the Chairman of the BTA, Mr. Jack Shapiro. The Minister stated that whilst research was filtered through the Medical Research Council, there “were other funds available to further the project of a Tinnitus Research Centre”.

A follow up meeting was arranged in Portcullis House, to which members of both Houses were invited. The Rt. Hon. The Lord Ashley of Stoke CH chaired a meeting in which Dr. Ewart Davies, Ms. Catherene McKinney, Dr. Peter Tungland and Mr. Jack Shapiro presented a summary of tinnitus mechanisms, research to date, and the need for further resources and research. Despite the pressures of the recent rail crash, Foot and Mouth, Europe and forthcoming elections members of the House of Lords and the House of Commons attended the meeting. Although it is of course far too early to gauge the outcome, feedback from the meeting was extremely favourable.

At the same time the BTA held its first Regional Tinnitus Conference in Scotland. Following this the BTA briefed MSP Margaret Jamieson who led a 30 minute debate on Tinnitus in the Scottish Parliament in which The Deputy Minister for Health and Community Care answered. This was the first time that Tinnitus was debated in Parliament anywhere in the world.

Summary

This is an exciting and challenging time in the field of tinnitus research and management. The clinical need is pressing, and the content of courses is changing to reflect increasing knowledge both in the fields of neurophysiology and clinical intervention. Although funding for future research and clinics is far from certain, there is growing pressure to find these resources in order to fund high-quality multi-disciplinary research. Those of you who thought you knew everything may still have something new to learn about tinnitus!

This article was written by Catherene McKinney, Head of Audiology at Guy's and St Thomas' Hospital Trust, London and Jack Shapiro - former BTA Chairman.