Thoughts on TRT ...

@Steve recently asked me to write a piece about TRT for the Hub. I am still tweaking it, but I thought I'd post it below in draft form because it contains information that some here might find helpful.

Dr. Stephen Nagler

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TRT (Tinnitus Retraining Therapy) is a treatment protocol devised by Dr. Pawel Jastreboff and based upon Dr. Jastreboff's Neurophysiological Model of Tinnitus, which he first described in 1990. The details of the model are not crucial to this discussion, but it is of value to understand its fundamental principle: In clinically relevant bothersome tinnitus neurological systems other than the auditory system are dominant (PJJ, 2012). The most important of these systems are the limbic system (emotion) and the autonomic nervous system ("fight-or-flight").

Where did the name "Tinnitus Retraining Therapy" come from? Consider for a moment the chair you are likely sitting in right now. You have been sitting in it for quite a while, but until I mentioned it to you, you have been unaware of the pressure of the chair against your buttocks. You might have been aware of it just as you sat down, and you are aware of it now that I am pointing it out to you, but other than that you have been unaware of it. And within a few moments I can pretty much guarantee that you will be unaware of it again – unless I draw your attention to it. One might say that the reason you are unaware of it is that you do not react to it. And the reason you do not react to it is that your brain classifies it as a neutral stimulus. The brain, even the brain at rest, is a very complex and busy organ. As such the brain must prioritize. The brain simply cannot attend to everything at once – so it places neutral stimuli way down on its priority list. What does all that have to do with tinnitus? Well, like the pressure of the chair against your buttocks, tinnitus is a stimulus. Of course, it is an internally-generated stimulus instead of an externally-generated one. And of course, there are a number of aspects of your tinnitus that make it far different from the pressure of that chair. But in the final analysis, it is indeed a stimulus, and if your brain can somehow be retrained to classify your tinnitus as a neutral stimulus, then you should largely cease reacting to it, and it should largely fade from your awareness unless you purposely seek it. Just like the chair. And that is where the name Tinnitus Retraining Therapy came from.

There are a number of independent TRT studies published in the literature. Even if you throw out Dr. Jastreboff's own studies on the grounds of potential bias, the others all pretty-much conclude the same thing – a success rate in the neighborhood of 85% with success defined as a significant decrease in reaction to tinnitus (Hr) and a consequent decrease in perception of tinnitus (Hp). TRT does not claim to make tinnitus less loud. It does, however, make it less bothersome regardless of how loud it might be (i.e., you react to it less.) The implication cannot be overstated, because – due to prioritization within the brain – a decrease in awareness is an inescapable consequence of a decrease in reaction. And if you are not aware of your tinnitus (see the chair example in the above paragraph), then what does it matter how loud it is?

One frequently hears that if 85% of people with tinnitus tend to do rather well on their own over the first year after onset, how can it be said that TRT is any more effective than just giving it time. The answer is that if a person starts TRT shortly after the onset of tinnitus, he or she will likely improve considerably over the next year or so but will not know for sure how much of that improvement is due directly to TRT. On the other hand, try telling somebody who had been truly suffering for five, ten, fifteen, or twenty years prior to starting TRT and then a year or so later was doing fine ... that it was all just a matter of giving it time! So relatively recent onset of tinnitus is not a contra-indication to TRT unless that person is so compulsive that he or she absolutely needs to know. And thus, the real decision comes down to how much the tinnitus sufferer is suffering rather than how long the tinnitus sufferer has been suffering!

TRT is a very specific protocol. It starts with an evaluation during which a person's "TRT category" is identified by his or her TRT clinician. There are five distinct TRT categories, which are inconveniently numbered 0 through 4. The numbering does not reflect severity; rather it is based on the presence or absence of hyperacusis, hearing loss, and a variety of other auditory factors. Sound therapy and TRT counseling (which used to be called "directive counseling") are the two essential elements in TRT. The particular form of sound therapy as well as the specific TRT counseling strategies are dictated by the TRT category. Thus, for instance, a Category 2 patient would receive completely different sound therapy and counseling recommendations from a Category 3 patient. Regardless of TRT category, the counseling is consistent with the Neurophysiological Model of Tinnitus and involves an in-depth description of the rationale behind habituation as well as how and why the brain classifies stimuli. TRT counseling involves an initial session and two to four "follow-up" sessions throughout the course of treatment – generally six to twelve months. The sound therapy in TRT might involve environmental sound, hearing aids, wearable broadband sound generators, or some combination thereof as determined by the patient's TRT category. The sound generators emit a soft "shhhhh" sound, the volume of which can be adjusted by the wearer, who is carefully instructed in how to set them each morning. The end result of the instructions is that (1) the sound does not suppress the tinnitus in any way, (2) the sound is not annoying, (3) the sound does not interfere with communication, (4) the sound does not elicit the stochastic resonance phenomenon (which can actually aggravate tinnitus), and (5) within the aforementioned constraints the sound maximally facilitates habituation. The specific details of how sound therapy is employed in each TRT category and how devices are set (for the categories requiring devices) for each is well-described in a number of publications and is beyond the scope of this review. Suffice it to say that when wearable devices are used in TRT (a) they are inconspicuous, (b) they are comfortable, (c) the sound they emit is not annoying, (d) the sound they emit does not interfere with communication, and (e) within a few minutes the wearer becomes oblivious to them. The devices are worn as much as possible but for at least eight hours a day – but since the wearer quickly becomes oblivious to the devices and to the sound they emit, that is largely irrelevant. At the conclusion of TRT the devices are no longer needed.

One of the problems with TRT is that the name is not trademarked – so with many clinicians claiming to offer TRT, what you see is not necessarily what you get. And to my way of thinking, that represents an enormous challenge for the tinnitus community. Anybody can call himself or herself a "TRT clinician." Moreover, since there is no credentialing or standardization in TRT, even if a clinician has read Dr. Jastreboff's book and taken his course, there is no assurance that he or she has retained the material or even understood it in the first place. It should be noted that there is a "TRT Association" with members listed on Dr. Jastreboff's website, but Dr. Jastreboff makes a point of stating that it should not be treated as a referral list and that being a member of the TRT Association is not equivalent to certification. As I see it, at best the list should be viewed as a starting point. Moreover, I would be concerned about going to any clinician claiming to be "certified" in TRT. Such certification simply does not exist.

If I were considering TRT, I would want to know where and when the clinician actually took a TRT course. I would also want to know if he or she were using the original TRT protocol or some sort of "variation" of TRT. (Variations of TRT might or might not have merit, but they are not TRT and should not necessarily be expected to yield the same results.)

Here are some important questions that I would pose to any tinnitus clinician regardless of the treatment approach he or she is offering to you:
· What is the approach the clinician is recommending and why?
· What type of training has the clinician undergone in the use of that approach?
· How long has the clinician been using the approach?
· How many tinnitus sufferers has the clinician treated with the approach?
· What is the clinician's success rate using the approach?
· How does the clinician define and measure success?

What if you have decided on TRT, but after carefully researching the matter and making a number of phone calls, you have concluded that there are no truly knowledgeable and experienced TRT clinicians in your geographical vicinity? Well, those who do a lot of TRT are often set up to do the follow-up counseling sessions by telephone or Skype. Only the initial evaluation-fitting-counseling session need be done in person. Beyond that visit there is generally no need to contemplate any traveling.

Stephen M. Nagler, M.D.