What Is TRT and When Should It Be Started?

What is TRT and when should it be started?

I have talked about TRT in many of my posts. One tinnitus talk member recently told me that I have mentioned it no less than twenty five times. He went on to ask, am I an Audiologist promoting my practice in this forum purely for business purposes? Another member was quite disgruntled and told me to stop mentioning it because where he lives the treatment is expensive and can’t afford it. It just goes to show one never knows what is going on behind the scenes when you think no one is watching.

I understand and empathise with people that are unable to afford this treatment or any other to help one’s health but don’t feel this is a good enough reason for me to stop mention it when I believe it can help, having had TRT twice in the 20 years that I’ve had tinnitus. I am not an Audiologist. I just consider myself like many others at tinnitus talk, who want to help people that are having a difficult time coping with this condition, as I was once helped many years go when I first got tinnitus.

Some people have been sending me private messages asking if TRT cures tinnitus? A member mentioned having two sessions with their Audiologist and was shown some slides, and told that anxiety can make tinnitus louder. Understandably this person wasn’t sure if this was TRT, and then asked if it’s something they could do on their own? As I have mentioned I have had TRT twice and I also have the Tinnitus Retraining Therapy book, written by Professor Pawel Jasterboff and Jonathon Hazell. It is available at Amazon should anyone wish to purchase it.

It is the reference book that Hearing Therapists and Audiologists follow when practicing TRT with their tinnitus patients. There are two parts to the treatment. Counselling and sound therapy. Sound therapy is supplied by wearing two white noise generators and then using a “sound machine “ at night by the bedside for sound enrichment. If hyperacusis is present the sound therapy will also treat it. Throughout the TRT book there is no mention that this treatment cures tinnitus. TRT or Tinnitus Retraining Therapy, is what it implies: Through regular counselling sessions there is a gradual retraining of the way a person thinks about tinnitus and to treat it as non life threatening.

At first the therapist discusses with the patient how the tinnitus makes them feel and how it has impacted on their life. Often people say they have lost interest in the things they once liked doing, which is perfectly understandable. The main goal here is to gradually help them look at life differently and with a more positive outlook. Over time the negative thinking that is often associated with tinnitus and hyperacusis is gradually dispelled and demystified.

The Hearing Therapist does this in a controlled and precise manner so that the patient feels relaxed and not pressured. In many instances the tinnitus is gradually pushed further into the background making it less prominent. Therefore, it must be stressed and understood, this treatment takes time. To complete a course of TRT takes approximately twelve to twenty four months and in some cases longer. The duration of each counselling session is left to the discretion of the Hearing Therapist. Typically, these can last up to one hour or more. The amount of appointments required will be different for each patient, but it is quality rather than the quantity of the counselling that really matters.

There are a few misconceptions about this treatment and the way it is administered that some people misunderstand which I want to address. If a patient is given one white noise generator to wear this is not TRT. When two wngs are issued and no tinnitus counselling is offered on a regular basis, it is not TRT. I am not saying that a patient will not gain any benefit from the above treatments; I only want to state they do not follow the proper Tinnitus retraining therapy protocol.

When should TRT be implemented or started?

The following is based on my own opinion and therefore is not professional medical advice. The onset of tinnitus can be quite an emotional roller coaster for a lot of people, and I believe a person needs time for this to settle. Many people habituate within the first 6 months to one year of the onset of tinnitus without any treatment. If a person just has tinnitus without any additional symptoms, such as dizziness, deafness or balance problelems. I think a period of six months should elapse before starting a long-term treatment such as TRT.

Michael

 

Hi Michael, do you have any comment on this study?

Effect of Tinnitus Retraining Therapy vs Standard of Care on Tinnitus-Related Quality of Life: A Randomized Clinical Trial | Otolaryngology | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network

I was disheartened to find the study as TRT was probably my best hope. Saying that, it is only one study so I've not ruled TRT out. I would be grateful for any constructive feedback from anyone.

 

Hi @HopefulG.

Tinnitus is a very common condition that comes in many forms and intensities and no two people will experience it the same. A lot of people learn to habituate to tinnitus within 6 to 12 months from onset, without the need to be referred to ENT and Audiology for treatment.

Unfortunately, there is a dark and sinister side to tinnitus that the study you have highlighted conveniently brushes aside but I will address. Some people have a lot of difficulty coping with tinnitus to the point that their mental and emotional wellbeing are greatly affected. It can prevent one from working. In more severe circumstances it can make a person have suicidal thoughts and want to cause their early demise. It might require them to be admitted into a psychiatric hospital to prevent this from happening.

Until the medical field has alternative treatments for tinnitus and hyperacusis, the best currently available are: counselling, sound therapy, medication, hearing aids, relaxation therapy. These treatments can be incorporated into CBT and TRT.

Michael

 

This is my assessment of TRT and Jastreboff:

"The Proponents of TRT,
When Faced With The Likes Of Just Me,
Were Oh So Contentious,
And Wrongly Sententious,
To Such An Ignoble Degree."

@Michael Leigh as usual trots out an empirically disprovable, painfully transparent alibi about TRT not working because the recipients were apparently in such a dark place that they firmly believed that it would not.

What particularly incenses me is the cruelty and cowardice implied in such an alibi when any such failure is solely and automatically blamed on the client's inability (or defective mindset) in adapting a "positive" outlook.

This is a classic technique of "thought reform" straight out of Kim-Jong Il's mental manipulation Playbook.

Did it ever occur to @Michael Leigh that these subjects of this Clinical Trial might have initially been brimful of hope and enthusiastic anticipation about trying something new? Why would they have even gone into this unless they had at least a modicum of positive anticipation?

You may want to solicit @Michael Leigh's opinion on this. He has placed me on Ignore (which is reminiscent of the "Memory Hole" in Orwell's "1984", and thoroughly in keeping with a mentality that he would share with Big Brother).

 

Thank you Michael. On further consideration the study is comparing TRT to ASHA-preferred practice recommendations which from what I understand include a lot of the points you cover in your last paragraph. So we could say both of these methods have benefits. I live in the UK and have had zero treatment beyond physical checks so I'm still hopeful that I can get some benefit from TRT or alternatives. My local Trust is supposedly a tinnitus specialist but doesn't offer anything beyond hearing checks.

Unfortunately I've had loud tinnitus for 2 years now and haven't habituated and I'm in that dark place you mention (I had mild tinnitus prior for maybe 5 years which was annoying but liveable).

Do you by chance know of any Trusts in the UK that offer TRT? I live in the North-East but willing to travel anywhere.

 

Dave, I kind of get the anger from one tinnitus sufferer to another and there are so many ****'s trying to make money out of tinnitus that I could happily punch but @Michael Leigh isn't trying to sell anything or get me to join his cult. He's just sharing his opinion and I expect many like me are really glad he takes the tie to share. I genuinely hope you find some peace.

 

Since your local Trust specialises in tinnitus, I am surprised that you haven't been offered additional treatment other than hearing checks. Treatments can include: white noise generators, counselling, hearing aids, medication which can be incorporated into CBT or TRT.

Talk to your ENT consultant and ask, if it's possible to have some additional treatment since you are having difficulty managing your tinnitus. If such treatment is available, your consultant should refer you to Audiology. There, you will see either a hearing therapist or audiologist. ENTs treat underlying medical problems within the auditory system that cause tinnitus but they don't normally specialise in tinnitus treatment and management. When you talk to your ENT doctor, my advice is not to mention CBT or TRT. You are simply asking if it's possible to get some further help.

If your Trust is unable to provide additional treatment for tinnitus, you have the right to attend any NHS Hospital in the UK for tinnitus treatment, as long as they are willing to accept you. Talk this over with your GP. If you wish, you can mention CBT and TRT, but try not to come across as making any demands or telling your doctor what to do, as this may not go down well. The softly approach and showing some humility, I have always found beneficial when dealing with healthcare professionals. I have been an NHS out-patient for 26 years and had very good treatment and aftercare for my tinnitus.

There are many NHS hospitals that will provide some form of tinnitus treatment. It is best to discus this with your GP, who will hopefully make enquires.

Best of luck,
Michael

 

It should never be started.

 

Some time ago I was minding my own business and @Michael Leigh in typical schoolyard bullying fashion tore into me (as he has done with so many others).

I don't know how it is with you, but us Chicagoans have zero tolerance for such insufferable, bullying behavior.

What distresses me is that you chose to ignore the very content and point of my commentary. Do you actually endorse his bullying, cowardly fallback alibi that anyone who "fails" at TRT is solely to be blamed for his / her lack of "positivity"? What thoroughly obnoxious victim - blaming.

The sad reality is that the fawning subservience to @Michael Leigh exhibited by numerous posters is indeed indicative of many of the classically observable characteristics of cult adherents.

 

@Michael Leigh, do you think gradually increasing the volume with TRT WNGs and sound therapy approaches is key, or do you believe in keeping things at the same level until it's comfortably tolerated, and then from there louder volumes in the real world should be tolerated and hyperacusis can be 'resolved'? I hope that makes sense.

I want to share my own audiologist's TRT approach and see what your opinions are on it.

 

Thank you for your question @Shizune. I have been asked this many times by people having some difficulty using white noise generators as part of TRT.

My audiologist was born with tinnitus and advised me to always set the level of the WNGs slightly below the tinnitus and keep it there. This way irritation to the auditory system is kept to a minimum and the risks of the tinnitus and hyperacusis spiking is reduced. Some audiologists advise tinnitus patients to gradually increase the volume of the WNGs to treat the hyperacusis first. However, this approach often causes irritation making the tinnitus and hyperacusis spike.

I have used white noise generators for many years and hope to be writing a piece soon, on the best way I believe to use them as part of TRT and for long term sound enrichment.

All the best,
Michael

 

The thing with TRT is this: You have to be patient and follow it in a strict manner.

You have to be dedicated: I had to wear my ear pieces for hours per day.

Friends wanted to hang out, I'd say no. It was a process, that took time and lots of it.

I worked closely with my audiologist (he understood tinnitus).

All I cared about: doing the treatment (I was positive) and finishing it.

 

I hope you guys do realize that blasting your ears with noise generators doesn't reduce tinnitus, right?

 

I don't get it either. He mentions how he still suffers quite a bit. Personally I would feel ripped off. I have written many posts on how it failed me. Is being positive not wanting to off oneself? Then I'm a ray of sunshine!

 

Thank you.

I see, my audiologist agrees with that. I wasn't sure because as you mentioned, some advise to gradually increase volume, not just with WNGs but in general. Particularly the University of Iowa slides. So I wasn't sure.

So far when I used the WNGs at first, at the lowest possible volume programmed, I had my hyperacusis spike. Note that I have severe loudness hyperacusis just with occasional pain, which is why I'm holding out for hope. My tinnitus isn't too much of an issue but I'd reckon the WNGs are louder than it, not possible to go lower. This was before I began to ease off hearing protection though. I can tolerate sound a bit better now, so I'm considering trying again, but have hesitancy due to my first try with them.

I listen to music throughout the day but I've mostly stayed at the same level tolerance wise, haven't had any big improvements yet other than one that I got a major setback after and wiped my progress. I've been asking my audiologist if I should try the WNGs again but they aren't sure if it irritates me. White noise is rather harsh to me, I have no pink noise setting. I will occasionally try to listen to green noise on YouTube but I have some trouble with that too.

Additionally, my audiologist isn't a registered counselor, but my current therapist is very unclear about how they should go about CBT. They had zero knowledge about hyperacusis prior to seeing me. They seem impossible to come by.

 

I would be careful too. I did MCBT with the wrong therapist.

 

The key is not to give up, this doesn't mean you should endure prolonged discomfort or pain. Approximately 18 months ago, @Eleanor89 was having a lot of difficulty wearing white noise generators because her hyperacusis was very severe. She followed my advice to introduce the WNGs slowly. Wearing them for just 10 or 15 minutes at a time and then take them off for the same duration.

Gradually over many weeks and months her oversensitivity to sound decreased, to the point she was able to wear the WNGs for long periods of time. Eleanor has made very good improvement because she stayed with the programme, even when things got tough she carried on regardless taking things slow. I will give my suggestions on the way to use white noise generators in a future post.

Take care,
Michael

 

Noise generators do not cure hyperacusis. Time does. Correlation does not imply causation.

 

@AnthonyMcDonald, why?

 

Because TRT doesn't lower tinnitus. It helps lower anxiety for some mild cases and helps habituate. Time and being careful can cause remission. In many cases using sound generators can make tinnitus worse.

 

I couldn't have said it any better:

TRT is nothing more than the last-ditch effort on the part of psychotherapy to claim some degree of relevance.

It never occurs to the proponents of TRT to ask the following questions:

1) Since it is virtually unavailable in the third largest city in the USA, does this argue for its lack of effectiveness? Why is this the case if it has worked so well?

2) Even if I wanted to, where would I go to get this? Should I actually move to London for two years so I can find this (according to @Michael Leigh) in the only hospital there that might still offer it? (And, given England's rapidly deteriorating State of Financial Emergency, perhaps even this will soon be no longer possible).

3) The cost (up to $6,000.00) and the time commitment (perhaps even longer than 2 years) makes it a wholly unreasonable burden for nearly everyone.

4) Like so much of outdated psychotherapy, it is constructed of the most transparently contentless and substanceless rhetoric; just what, for example, does "demystifying tinnitus", or "placing it in the background", really mean?

5) Given the above, I guess I'm just a sadly broken misfit who can't get with the program.

But one thing I am goddamnably sure of is that I will never accept an obnoxious, outsized charlatan like @Michael Leigh condescending to me for not having internalized (in, I suppose, a way that would transform me into a cavorting Ronald McDonald) the "Positivity" required to allegedly succeed at this.

 

But I will go insane if I just listen to my tinnitus all day long... If I keep the volume low, how could it make things worse?

 

For most it won't, but for some it will - and it's very difficult to know in advance.

If you can handle day to day sounds relatively well, such as TV, radio, outdoor sounds etc, and can manage low level white noise without spiking, you MAY be in the majority.

If though your tinnitus is very sound reactive, your baseline increases easily and often and new tones are added easily too, this may be a warning sign.

Reality is only you will know whether you feel your ears could handle low level white noise in the way TRT advocates.

Have you tried playing low level white noise during the night as sound enrichment? And if so, how did you find it?

 

I manage just fine. Given enough time. If your tinnitus is unstable/reactive, then sound "therapy" isn't a good idea.

 

I play crickets pretty much all day/night long unless I'm having a really good day. I use my iPhone mainly (Spotify) and I usually only turn the iPhone volume up three clicks from silent, so it shouldn't be loud at all. I haven't measured it though, maybe I will. I would love to get to a point where I didn't need to try and set some noise just below my tinnitus. I do, however, make sure not to try and mask over it.

 

I'm having a hard time determining if my tinnitus is reactive. Sometimes I think yes, sometimes I think no. But to be safe I usually don't try to cover it at all. I only go up three clicks from silent on my iPhone, two clicks if it is not that bad in the moment. I feel like I have 4 bad days, 1 good day. I'm hoping that I start having more good days.

So I guess what I am doing is called "sound therapy", correct?

 

There is no one-size-fits-all to tinnitus and its possible treatments. What works for one person, may not work for another person. We are all different. How we feel and react to things are different.

If your tinnitus does annoy you, having sound therapy (hearing other noises besides your tinnitus) could possibly be helpful (it all depends on the person).

There is no golden rule to this and everyone is different. It's all about adjustments and trying to see what can possibly help our situation.

 

Most people who have reactive tinnitus kind of know they have reactive tinnitus. The volume increase for moderate and particularly severe cases are usually easily noticed.

If it is possible for you to mask, and your tinnitus is relatively stable, it sounds perhaps a moderate case (subjectively speaking).

If this is true, this will likely work with you than against you with TRT.

Personally speaking, I think TRT can be of benefit for mild-moderate stable cases to help them settle in to the emotional aspect of having tinnitus.

For those with severe tinnitus, but loudness hyperacusis, there may be a benefit here too.

I have often wondered though whether the loudness enhancement is a body defense reflex encouraging the body to introduce less sounds whilst trauma is being managed.

In any case, from your position it 'sounds' like you're a more stable case than some on here to try it.

It at least helps introduce a more pleasant sound for a while whilst you introduce back in to life - which help some of the mild and moderate sufferers.

I think TRT can help many, especially those with high anxiety with low to medium tinnitus, especially when following a strict set of protocols.

I just don't happen to like the guy that created it.

 

Hi @ThorOdinson, you are very new to tinnitus and I note from your profile it is caused by Labyrinthitis. If this is the case, then I don't recommend TRT for you at this early stage, as mentioned in my introductory post to this thread. If one is contemplating having TRT, ideally it should be started at least 6 months after the onset of tinnitus.

I will assume that you have been thoroughly examined by your ENT doctor and advised of the type of Labyrinthitis you have, since there are several different types and treatments may vary. In addition to your tinnitus, if you have been experiencing any of the following: nausea, loss of balance, dizziness, vertigo, hearing impairment or vision problems which can accompany Labyrinthitis, these can be treated.

Using sound enrichment is fine to help with tinnitus management. Try using a dedicated table-top sound machine by your beside at night, instead of your iPhone which isn't the best source, unless it's Bluetooth to an external speaker or plugged into a docking station that has speakers. It is recommend to use nature sounds and not music at night, because music draws attention to itself. More about this is explained in my thread: New to Tinnitus, What to Do?

You will probably find the tinnitus improves with time, as it usually does within the first 6 months to a year of onset. However, if you are experiencing any of the symptoms mentioned above, it's important treatment is sought, as they could have some bearing on the tinnitus and habituation.

All the best,
Michael

New to Tinnitus, What to Do? | Tinnitus Talk Support Forum

 

Hi Michael,

Thanks for your response. I had the other symptoms originally in early-mid December 2022 and the tinnitus started December 30th. The only symptoms that I currently have are tinnitus, off and on again ear fullness, and clicking sounds when I swallow or yawn (which may not be related to Labyrinthitis at all). The ENT office and Neuro office said that this is likely what happened but seeing as though nobody can see inside your inner ear, I guess I won't ever know for sure, but it seems very likely. I'm having an MRI in March to rule out other things and I have a follow-up appointment with an audiologist February 21st so hopefully my hearing is stable. I hope I can recover as I know some people do over time.

I do also have some mild high frequency hearing loss from 6 kHz - 8 kHz in my right ear, which is either from the Labyrinthitis or that is what I had prior to it (I never knew my baseline before so it is possible that I recovered my hearing from the virus).

I have been using my iPhone to listen to crickets as sound therapy throughout the day and night at a low level. I will look into getting a small speaker to use with my phone. I don't want to listen to my tinnitus all day long so that is my only option right now. I haven't been listening to music or using earbuds, headphones, etc., since I've had tinnitus. I probably won't ever again at this point.

Do you recommend in-ear maskers for sound therapy or potentially hearing aids that come with sounds that you can play?