TRT

[Jerry K]

Doctor Nagler, I developed a sudden onset of very severe tinnitus in October, 2013. At that time, I had my bite adjusted by a dentist via occlusal equilibration (a big mistake), which caused my jaw and cervical muscles to go into incredible spasms, triggering intense clenching. I was prescribed flexeril, to which I had a severe reaction, including tinnitus and severe agitation, insomnia, muscle twitching, spasms, etc . My stress level at this time was off the charts. A neurologlist opined that the flexeril "triggered" these symptoms, all of which subsided after approximately 2 months, but the tinnitus remains, and it is of the somatic type - it modulates when I tense my jaw of move my neck.
I am wearing bte sound generators, which are providing relief. I have 2 questions regarding TRT. First, how do these devices facilitate habituation? I understand the concept of decreasing contrast, but when I remove them in the evening, the contrast returns and I "hear" the tinnitus. Why would this be different after the 18 month treatment period? The only explanation I found was from an article by Jonathan Hazell, which states that the devices "very gently stimulate all the nerve cells in the subconscious networks, allowing them to be more easily programmed or reset, so that tinnitus signals are no longer detected." And Dr. Jastreboff himself implies that habituation may occur more quickly without the devices: "Partially suppressed tinnitus can still be habituated, but the effectiveness of habituation will decrease because retraining will occur not to the original but to the modified signal."
My second question is regarding the therapy. What does it mean to "reclassify" the signal as meaningless or neutral? I have the sound of a jet engine in my head 24/7 which is annoying and debilitating - I am not classifying or attributing any "meaning" to it.
I thank you in advance for your time. Regards, Jerry

 

[Dr. Nagler]

@Jerry K wrote [in part]:

I have 2 questions regarding TRT. First, how do these devices facilitate habituation? I understand the concept of decreasing contrast, but when I remove them in the evening, the contrast returns and I "hear" the tinnitus. Why would this be different after the 18 month treatment period? The only explanation I found was from an article by Jonathan Hazell, which states that the devices "very gently stimulate all the nerve cells in the subconscious networks, allowing them to be more easily programmed or reset, so that tinnitus signals are no longer detected." And Dr. Jastreboff himself implies that habituation may occur more quickly without the devices: "Partially suppressed tinnitus can still be habituated, but the effectiveness of habituation will decrease because retraining will occur not to the original but to the modified signal."

My second question is regarding the therapy. What does it mean to "reclassify" the signal as meaningless or neutral? I have the sound of a jet engine in my head 24/7 which is annoying and debilitating - I am not classifying or attributing any "meaning" to it.

.............

Jerry, I am in the process of putting together a rather detailed discussion of Neuromonics and TRT for this board. I should be posting it within a week or so.

But very briefly ....

There are a variety of ways that the use of broadband sound facilitates habituation. One is through decreasing contrast, an effect that shows overall results over the long haul rather than at the end of any given day or days. Another is through associative conditioning whereby over time the brain begins to confuse your tinnitus with the very benign and not-at-all-unpleasant sound that you introduce to your auditory system through the use of wearable devices. A third is by gently stimulating all of the networks involved as Mr. Hazell suggests, but I strongly reject his idea that at some point you will be unable to detect your tinnitus, which is poorly worded on his website and is incredibly misleading. There are other ways that wearable devices are helpful; I have given you but three. I only wish to add that at the end of TRT, the devices are no longer needed. It's not like you wear them forever.

In terms of your reference to Dr. Jastreboff's suggesting that habituation may occur more quickly without devices, I believe you are misinterpreting what he wrote. Masking suppresses tinnitus. Partial masking partially suppresses tinnitus. The range of settings where devices (along with proper counseling) are more effective in facilitating habituation are those settings that are loud enough to decrease contrast, but not loud enough to partially or totally mask. The process of how to find the best setting for any given individual is a bit complex and best explained by his or her TRT clinician. Suffice it to say that when set properly the volume of the devices (1) is not in any way annoying, (2) does not interfere with communication, and (3) maximally decreases contrast while not partially or totally masking one's tinnitus.

Regarding your last question, the fact that your 24/7 jet engine tinnitus is annoying and debilitating is an indication that your brain is not classifying it as a neutral stimulus. The goal of TRT is to retrain your brain to classify your 24/7 jet engine tinnitus as a neutral stimulus so that it will no longer be annoying or debilitating in spite of its remaining like a jet engine in your head 24/7.

Hope this helps more than confuses.

Dr. Stephen Nagler