J Am Acad Audiol 25:335-342 (2014)
Music Therapy for Chronic Tinnitus: Variability of Tinnitus Pitch in the Course of Therapy DOI: 10.3766/jaaa.25.4.5 Elisabeth Hutter* Miriam Grapp* Heike Argstatter* Hans Volker Bolayf
Abstract Background: In general, tinnitus pitch has been observed to be variable across time for most patients experiencing tinnitus. Some tinnitus therapies relate to the dominant tinnitus pitch in order to adjust ther apeutic interventions. As studies focusing on tinnitus pitch rarely conduct consecutive pitch matching in therapeutic settings, little is known about the course and variability of tinnitus pitch during therapeutic interventions. Purpose: The purpose of this study was to investigate the variability and development of tinnitus pitch in the course of therapeutic interventions. Tinnitus pitch was suspected to be highly variable. Research design: The researchers conducted a descriptive, retrospective analysis of data. Study Sample: A total of 175 adult patients experiencing chronic tinnitus served as participants. All patients had received a neuro-music therapy according to the “Heidelberg Model of Music Therapy for Chronic Tinnitus.” Data Collection and Analysis: During therapeutic interventions lasting for 5 consecutive days, the indi vidual tinnitus frequency was assessed daily by means of a tinnitus pitch-matching procedure. The extent of variability in tinnitus pitch was calculated by mean ratios of frequencies between subsequent tinnitus measurements. Analysis of variance of repeated measures and post hoc paired samples f-tests were used for comparison of means in tinnitus frequencies, and the test-retest reliability of measurements was obtained by the Pearson product-moment correlation coefficient. Results: Tinnitus pitch displayed a variability of approximately 3/5 to 4/5 octaves per day. Overall, the mean frequency declined in the course of the therapy. Detailed analysis revealed three groups of patients with diverging tinnitus progression. The test-retest reliability between assessments turned out to be robust (r = 0.74 or higher). Conclusions: Considerable variation in tinnitus pitch was found. Consequently, a frequent rechecking of tinnitus frequency is suggested during frequency-specific acoustic stimulation in order to train appropriate frequency bands. Key Words: tinnitus, tinnitus pitch, tinnitus variability, music therapy Abbreviations: ANOVA = analysis of variance
innitus, described as the perception of a ringing, hissing, or buzzing sound in the absence of an external acoustic source, is one of the most prev
alent auditory disorders in industrialized countries (Lockwood et al, 2002; Heller, 2003). Although the exact causes for generation of tinnitus are not completely under stood, structural and functional alterations of neuronal networks seem to play a crucial role. Electrophysiologic
‘ German Center for Music Therapy Research (Deutsches Zentrum fur Musiktherapieforschung (Viktor Dulger Institut) DZM e V V fMusic Theraov Tinnitus Outpatient Department, Heidelberg, Germany ' " Elisabeth Hutter, German Center for Music Therapy Research (Deutsches Zentrum fur Musiktherapieforschung (Viktor Dulger Institut) DZM e.V.) MaaBstraBe 32/1, 69123 Heidelberg, Germany; E-mail: [email protected]
Journal o f the American Academy of Audiology/Volume 25, Number 4, 2014
and neuroimaging studies with patients experiencing chronic tinnitus give increasing evidence of tinnitusrelated functional and structural changes both within the central auditory system and in nonauditory brain areas (Landgrebe et al, 2009; Lanting et al, 2009; Vanneste and De Ridder, 2012). Regarding the auditory pathway and the central auditory system, tinnitus-related brain changes appear to be the result of an increased neuronal plasticity leading to a reorganization of the cortical tonotopic map and a hyperactivity of neurons (Eggermont, 2006; Mpller, 2006; Norena, 2011). The quality of the perceived sounds varies strongly among people experiencing tinnitus, ranging from tone-like ringing characterized by m ainly one specific frequency, to rather noise-like sensations, where a band of varying width with diverse frequencies contribute to the perceived sound (Kodama and Kitahara, 1990; Lockwood et al, 2002; Pan et al, 2009). In recent years, novel therapeutic approaches have been developed based on neurophysiologic findings con cerning tinnitus mechanisms (e.g., Miihlnickel et al, 1998; Eggermont, 2006; Saunders, 2007). Common to these interventions is the stimulation of the auditory pathways and brain regions involved in the processing of acoustic stimuli by external sounds in order to affect neural plasticity (Hoare et al, 2010). A treatm ent by means of “Neuromonics” uses a broad frequency stimu lus, customized for each patient, in order to reverse the effects of auditory deprivation (Hanley and Davis, 2008). Sound therapies such as the “Neuromonic Tinnitus Treatment” or general sound generators combined with counseling have been shown to promote tinnitus relief, especially when patients were highly distressed by the symptom (Newman and Sandridge, 2012). Auditory dis crimination tasks were conceived to train the perceptual abilities of patients with tinnitus within specific fre quency bands close to the tinnitus frequency or within the region of hearing loss (Flor et al, 2004; Herraiz et al, 2010; Hoare et al, 2012). There are several out standing questions concerning acoustic discrimination trainings, their underlying mechanisms of neural reor ganization, and therefore the target frequency of the con ceived trainings. Studies investigating these questions often show methodological limitations. A recent work about two controlled trials suggests rather nonspecific underlying mechanisms instead of frequency-depending training effects (Hoare et al, 2012). In other treatm ent approaches, patients are told to listen to individually filtered music, which is supposed to target the auditory cor tical areas processing the tinnitus frequency, called “tailormade notched music” (Okamoto et al, 2010; Teismann et al, 2011; Pantev et al, 2012) or required to listen to a broadband noise containing a filter surrounding the indi vidual tinnitus frequency (Lugli et al, 2009) or to a sound modified by phase shifting (Choy et al, 2010; Heijneman et al, 2012).
In the neuro-music therapy according to the “Heidelberg Model of Music Therapy for Chronic Tinnitus” (Argstatter, 2009), auditory training by means of tone sequences in tar geted frequency bands is one part of the intervention. Besides the auditory training, further therapeutic mod ules based on the individual tinnitus frequency contri bute to the final outcome of therapy, which was revealed to be an effective treatment of tinnitus (Argstatter, 2009; Argstatter et al, 2010; Argstatter et al, 2012). Generally, the conception of this multimodal neuro-music therapy approach is based on the assumption that tinnitus is experienced as an auditory perception, just as musical stimuli are experienced as auditory perceptions. In con trast to many other therapies, the patients are supposed to actively discriminate specific acoustic stimuli and to exert active control over auditory processes. Thus, dur ing relaxation training, patients have to filter out irrel evant and aversive information such as the individual tinnitus sound, which is intermittently integrated into the background music. Auditory discrimination training is accomplished in frequency bands surrounding the actual tinnitus frequency or the tinnitus frequency transposed by 1 or more octaves. Before each intervention, the indivi dual tinnitus frequency is assessed by a pitch-matching pro cedure in order to train the appropriate neural regions by the tone sequences. This procedure of individualized and continuously adapted training is unique in comparison to other treatm ents aiming at directed stimulation of the auditory system (e.g., Flor et al, 2004; Teismann et al, 2011). To verify the individual course of tinnitus pitch seems all the more important because specific acoustic training supposed to cause cortical reorganization may provoke variations in tinnitus frequency. Even in the absence of therapeutic interventions, tinnitus pitch seems to be a rather unstable characteristic that is difficult to assess reliably (Penner, 1983; Burns, 1984; Penner and Saran, 1994; Tyler, 2000). However, some studies point to a better reliability, especially when tinnitus frequency is assessed repeatedly and after training sessions (Tyler and Conrad-Armes, 1983; Norena et al, 2002; Moore et al, 2010; Nageris et al, 2010) or when tinnitus measures are performed by a computer-automated procedure (Henry et al, 2004; Henry et al, 2006). The results of Henry et al (2001) even indicate a certain amount of consistency in tin nitus frequency across time at least for a part of the patients, possibly because of more reliable and reproduc ible tinnitus pitch measurements. Studies m onitoring tinnitus characteristics rarely investigate frequency by means of tinnitus pitch match ing during therapeutic interventions (e.g., Hirschfelder et al, 2004). Besides, most approaches aiming at stimu lating specific frequencies or training discriminative abilities of patients usually do not assess tinnitus char acteristics in the course of training period and thus do not adapt the training to possible changes in tinnitus characteristics (Flor et al, 2004; Herraiz et al, 2010;
V ariability o f Tinnitus P itch in the Course o f Therapy/Hutter et al
Hoare et al, 2012; Teism ann et al, 2011). The question rem ains if unique tinnitus frequency assessm ent before treatm ent is sufficient or if assessm ent should rather be conducted regularly throughout the therapy process. Therefore, we analyzed tinnitus frequency in patients who received a neuro-m usic th era p y according to the “Heidelberg Model.” The objective of this study was to obtain inform ation about th e variability and course of tinnitus frequency characteristics during therapeutic interven tion. As tin n itu s frequency seemed to be variable in p re vious studies even without therapeutic interventions, we suspected tinnitus frequency being highly variable during treatm ent, suggesting the use of auditory trainings th at are not only targeted but also frequently adjusted in order to optimize therapeutic outcome.
METHODS P atients We conducted a retrospective analysis of d ata from 175 p atients w ith tin n itu s who had received neuro music therapy according to the “Heidelberg Model of Music Therapy for Chronic Tinnitus” from 2008-2011. The procedures of th e study followed th e principles in th e Declaration o f H elsinki (World Medical Association, 2013). Neuro-music therapy was eligible for adult patients without any psychiatric disorder and having a h e a rin g loss not exceeding 50 dB HL. Additionally, the therapy was only suitable for patients whose tinnitus could be matched by a pure sinusoidal tone or by a broadband noise with a center frequency. Most of the patients in our sample were men (n = 124), and there were 51 women. The m ean age was 51.47 yr (SD = 12.02; age range, 22-84 yr. A total of 73% of the patients experienced tone-like tinnitus, whereas 27% described their sensations as noise-like. The mean duration of tinnitus at time of therapy was 7.55 yr (SD = 7.42; range, 1-36 yr).
Neuro-m usic Therapy Neuro-m usic th erap y for chronic tin n itu s is a m anualized short-term m usic th erapeutic tre a tm e n t last ing for 9 consecutive 50 min sessions of individualized therapy. Therapy took place in the Center of Music Ther apy Research in Heidelberg for 5 days (from Monday through Friday). The music therapeutic interventions are structured into modules. At first, a counseling session informing about the neuroscientific principles of music therapy was given to the patients. A vocal exercise called “resonance training” was offered to stimulate the cranio cervical resonating cavities. The module “tinnitus recon ditioning” offered coping mechanisms related to stress control by a relaxation exercise. D ining relaxation, the individual tinnitus sound was integrated interm ittently
into the background music, and subsequently, situations intensifying the tinnitus were imagined in order to decou ple tinnitus and aversive associations. For the last mod ule, “neuroauditive cortex training,” a targeted auditory training, was accomplished in frequency bands surround ing the actual tinnitus frequency or the tinnitus frequency transposed by 1 or several octaves. It was performed by the therapist playing a piano in which the atonal tone sequences had to be vocally im itated by the patient. F u r ther details concerning the components of the modules are explained by A rgstatter et al (2012).
A ssessm ent o f Tinnitus Frequency In order to adapt the auditory training, on day 1 to day 4 the individual tinnitus frequency was assessed proceed ing any intervention. Because pitch m atching can be exhausting for some patients, it was obtained only once a day for each patient. The matching procedure was conducted by the same experimenter each day. On day 5, tinnitus frequency was not estim ated because the audi tory training was term inated on day 4 of therapy. All patients had obtained a training session to get used to the m easurem ent procedure at a prelim inary checkup before therapy started. For patients who described th eir tinnitus as tonal, tin nitus pitch was m atched by a tone generator, which pro duced pure sinusoidal tones in the range of 1-20.000 Hz and allowed the frequency to be shifted in steps of 1 Hz (Mair and Rohner OEG: A rbitrary Waveform Generator WG 810). After m atching the external tone to a volume where both sounds - the external tone and the internal tinnitus — could be heard and compared, the experi m enter shifted the external tone in pitch by m eans of a continuously adjusting knob. The patients were asked if their subjective tinnitus was equal, higher in pitch, or lower in pitch. For patients unable to m ake such deter m inations, the experim enter asked if the external tone approached to the tinnitus pitch or was ra th e r departed while changing the frequency of the stimulus. After the patients could not differentiate between the external and the subjective tone anymore, the procedure was repeated to confirm the m easured frequency. For patients with noise-like tinnitus, the program “noise estimator” (designed by Dr.rer.med. Christoph M. Krick, Neurocenter of the Saarland University Clinic) was used to m atch the subjective tinnitus. This program generates a passband filtered broadband noise with the center fre quency and the bandwidth as characteristics. The mea surem ent procedure was similar to the assessment of tonal tinnitus, except th at the external sound was charac terized not only by a predominant tone but also by adjacent frequencies. So, in addition to the loudness and pitch, the experimenter varied frequency bandwidth on a scale from 1-10,000 Hz. Except for the analysis of bandwidth, for patients with noise-like tinnitus solely the measured
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center frequency was taken into account in further anal ysis, combined with the assessed frequencies of patients with tone-like tinnitus. C a lcu la tio n s
As a measure of the extent of variability in tinnitus frequency, the m ean ratios of frequencies in H ertz between subsequent tinnitus measurements were calcu lated according to the formula
w ith f ax = the higher frequency and f bx = the lower frequency of person x. By means of this calculation, a value of 1 would indicate an average change in tinnitus pitch on subsequent days of 1 octave. Ratios were used because differences in frequencies are not meaningful, as the perceived tone pitch is not varying proportionally with changing frequency measured in Hertz. To account for unequal weighting of ascending or descend ing tinnitus pitch, we always used the higher frequency as fax and the lower frequency as f bx, regardless of whether the frequency was ascending or descending at subsequent assessments. Thus, the mean ratios of the dif ferences reflect the magnitude of each difference, ignor ing positive or negative changes in frequency. As a global measure of variability within the 4 d of tinnitus assess ment, the mean of these ratios was calculated. We performed statistical analysis using IBM SPSS S tatistics 19. The comparison of m eans a t different assessment times was conducted by an analysis of var iance (ANOVA) of repeated measures using a level of significance of p value < 0.05. Post hoc paired samples f-tests were used. The test-retest reliability of measure ments was calculated by the Pearson product-moment correlation coefficient.
of tinnitus frequency at the different assessment points for all patients. As Table 1 indicates, tinnitus frequency descended on average from day to day during the 4 days of measurement and training. This change was significant (ANOVA: F = 22.74; p < 0.01). Post hoc f-tests revealed significant changes from day 1 to day 2 and from day 2 to day 3 (paired-samples f-tests; p < 0.05). The product moment correlations between tinnitus frequencies of each patient at two successive days were calculated as a measure of test-retest reliability of tin nitus frequency assessment (Table 1). All correlations were statistically significant and achieved values of approximately r = 0.74 or higher. T in n itu s F req u en cy V ariab ility
As a measure of variability of tinnitus frequency, the mean ratios of tinnitus frequencies at successive days were calculated, as can be seen in Table 2. The mean val ues on successive days indicate that the average variation in tinnitus pitch within 1 day was approximately 3/5 to 4/5 octaves, revealing no difference between ascending or descending tinnitus pitch. The standard deviation indi cates that the patients did not have identical tinnitus var iations but that there existed patients with strongly fluctuating tinnitus, and others having only small fluc tuations day by day during the course of the therapy. The m ean variability from day 1 to day 4 even shows a variation in tinnitus pitch of approximately 1 3/4 octaves.
RESULTS M ean T in n itu s F req u en cy
The change in tin n itu s frequency in the course of therapy was investigated regarding the m ean values
T in n itu s F req u en cy C hange
To analyze the variability of tinnitus frequency in detail, we divided the patients into groups with dif ferent progression in tinnitus frequency (Table 3). In more than half of the cases, tinnitus frequency changed in a ra th e r unsystem atic m anner (“zigzag shape”), which means th at a t least once in the course of the week, the gradient (ascending or descending) changed. With many patients, tinnitus frequency monotonically decreased, and in only few cases the tinnitus frequency monotonically ascended. Figure 1 illu stra te s the
Table 1. Means of Tinnitus Frequency at Different Assessment Times: Comparison of Means between Assessment Times and Test-Retest Reliability of Tinnitus Frequency Assessment * Tinnitus Frequency (Hz) [mean(SD)] ANOVA (Repeated Measures) Paired-Samples f-tests Test-Retest Reliability
F = 22.74
df = 3
p < .001 Day 3 to Day 4
Day 1 to Day 2
Day 2 to Day 3
p < 0.001
p = 0.017
p = 0.247
p < 0.001
p < 0.001
p < 0.001
Variability of Tinnitus Pitch in the Course of Therapy/Hutter et al Table 2. Variability of Tinnitus Pitch in the Course of Therapy Calculated by Mean Ratios Mean Ratio (SD)
Day 1 to Day 2
Day 2 to Day 3
Day 3 to Day 4
Day 1 to Day 4
average course of tinnitus frequency for the different groups of patients.
Tinnitus Bandwidth The measurements of the bandwidth of tinnitus in patients experiencing noise-like tinnitus indicate that the width of the frequency band surrounding the pre dominant frequency did not change significantly in suc cessive days during the week (Table 4).
DISCUSSION n this retrospective analysis of data of patients ex periencing chronic tinnitus, assessments of tinnitus frequency on successive days were examined. All patients underw ent neuro-m usic th erap y according to the “Heidelberg Model of Music Therapy for Chronic Tinnitus” lasting for 5 days. Results indicate th at tinnitus fre quency seems to be a rath er changeable characteristic of tinnitus. The mean tinnitus frequency in all patients displayed a considerable, statistically significant decline day by day during the therapeutic setting. In further analysis, two main patterns of frequency progression could be identified. First, in more than half of the patients, tinnitus frequency revealed an unsystematic variability in the manner that it increased and descended both in the course of the week. Second, a large group of patients experienced a continuous descent in frequency from day to day. Only a m arginal pro portion of patients reported ascending tinnitus frequency. Noticeably, Stauffer and Tyler (1990) report in one of the few studies concerned with tinnitus frequency assess ments across time that tinnitus pitch is ascending in some patients, contradictory to our findings of descent in tinni tus frequency. Unlike our study, patients had not received a therapeutic intervention during the time of tinnitus fre quency assessments. Results revealed a considerable general variability of tinnitus pitch with a mean fluctuation of up to 4/5 octaves in pitch per day. The comparison of tinnitus m easurem ent on day 1 and on day 4 even showed a mean change in pitch of nearly 2 octaves. Other studies as well indicate th at tinnitus ranged within a broad frequency band: Henry et al (2004) observed in 14 assessments th at pitch matches covered a range of 2 1/3 octaves in approximately half of the participants, Henry et al (2001) found th a t 70% of the participants revealed variations within 1 octave, and Tyler and Conrad-Armes (1983) concluded th at pitch matches
of a large group of patients were located in a range of 1 octave. There are several possible reasons for the variability and descent in tinnitus frequency found in this study. At least part of the variability can probably be explained by general fluctuation in tinnitus frequency across time, as it was found in studies monitoring tinnitus frequency without therapeutic interventions (Penner, 1983; Burns, 1984; Penner and Saran, 1994; Tyler, 2000; Henry et al, 2001). However, the descent in tinnitus frequency can hardly be explained by general tinnitus variability. This trend might be an effect of the neuro-music therapeutic intervention and the specific attention and discrimina tion training in the vicinity of the actual tinnitus fre quency. In a study evaluating perceptual training in tinnitus, Norena et al (2002) measured the contribution of different frequencies to subjective tinnitus sound and found a reduction in high-frequency components after the training. This result is an analogy to our findings despite different ways of tinnitus assessment: Possibly more fre quency components contribute to the actual tinnitus per ception, which was measured in our study by only one main center frequency. If the higher-frequency bands are reduced, the general perception of pitch declines, leading to a descent in frequency assessment. A further investigation focusing on passive stimulation with hear ing aids, however, found a reduction of low frequencies contributing to the tinnitus sound in a group of patients (Moffat et al, 2009). Hoare et al (2012) reported variation in tinnitus frequency in assessments before and after fre quency discrimination training of 1800 Hz in one study group, although the variation was not statistically signif icant. This result certainly represents a smaller extent of variation in pitch than found in our data, as the starting frequency amounted to 8000 Hz. Remarkably, in patients experiencing noise-like tinnitus, no specific direction in variation of frequency bandwidth (i.e., variation in the quality of the noise component) could be revealed in our study. As the therapeutic treatment focuses exclusively on the predominant tinnitus frequency and does not take into account the bandwidth of tinnitus, this outcome could strengthen the assumption that therapeutic treatment is one cause of tinnitus variation and descent in frequency.
Table 3. Progression of Tinnitus Frequency during Therapy Week (n = 175) Continuously Decreasing Tinnitus Frequency Continuously Ascending Tinnitus Frequency Zigzag Shape of Frequency Course
67 (38.3%) 7 (4.0%) 101 (57.7%)
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— ■— Descending • - ♦ - - Ascending - - A — Zig-zag
Figure 1. Change of the mean tinnitus frequency in the course of therapy, subdivided into three groups with diverging progressions.
In conclusion, the results argue for a frequent rechecking of tinnitus frequency during therapeutic interventions dealing with the individual tinnitus pitch in order to avoid training or stimulation at deviating frequencies. Usually, approaches aiming at stimulating specific frequencies, or training discriminative abilities of patients, assess tinnitus characteristics only before the beginning of the intervention and do not adapt the interventions in the course of the training period (Flor et al, 2004; Herraiz et al, 2010; Hoare et al, 2012; Teismann et al, 2011), except Okamoto et al (2010), who continue pitch matching during the course of their study. Our findings suggest that it would be more effective to monitor the progression of tinnitus characteristics frequently in order to optimize thera peutic outcome, as significant changes occur within only 1 day. The “Heidelberg Model of Music Therapy for Chronic Tinnitus” is able to take fluctuations in tinnitus
frequency into account in order to adjust therapeutic training. Such variations in tinnitus might be the rea son for some of the inconsistent findings about the rele vance of choice of target frequency (Hoare et al, 2010). For instance, Teismann et al (2011) concluded in their study that tinnitus frequency probably influences ther apy outcome, whereas Flor et al (2004) did not find a difference in therapy outcome depending on trained fre quency band. Herraiz et al (2010) showed that training 1 octave below the originally measured tinnitus fre quency was most effective, and Hoare et al (2012) reported severe doubt on specific frequency-depending therapy effects regarding the results of their studies. Generally, the assessment of tinnitus characteristics, especially tinnitus pitch matching, is considered diffi cult and not as reliable as loudness matching (Tyler, 2000; Henry et al, 2001). Patients differ in their ability to match an external stimulus to the internal sound,
Table 4. Means of Tinnitus Bandwidth at Different Assessment Times for Patients with Noise-like Tinnitus and Comparison of Means Day 3
df = 3
p = 0.634
Tinnitus Bandw idth [mean (SD)]
ANOVA (Repeated Measures)
F = 0.57
Paired-sam ples f-tests
Day 3 to Day 4
Day 1 to Day 2
Day 2 to Day 3
- 0 .3 0
p = 0.495
p = 0.763
p = 0.440
V a ria b ility o f T in n itu s P itc h in th e C ou rse o f Therapy/H utter et al
trainings effects are frequent (Tyler, 2000), and even the procedure itself can alter the symptom (Tyler and Conrad-Armes, 1983). In this data analysis, the testretest reliability at intervals of 1 day turned out to be robust and similar to or higher than the reliability found in other studies (Mitchell et al, 1993; Henry et al, 2001; Zenner and De Maddalena, 2005). Specifically, computerautomated procedures seemed to yield reliable tinnitus assessments, a very differing method to the one we used in our study (Henry et al, 2001; Henry et al, 2004; Henry et al, 2006). Perhaps the interaction between the therapist and the patients and the possibility of adjusting the pro cedure to the patient can play an important role for exact measurements. A possible advantage over automated pro cedures could also be the continuous adjustability of the external tone in pitch. Besides, the training session be fore the beginning of treatment and the repetitions under taken during assessment in order to verify the tinnitus pitch might lead to a trustworthy tinnitus frequency as sessment. However, an explicit retesting several times per day would allow for a more exact determination of the retest reliability of our measurements. An important limitation of this study surely was the missing data on subjective tinnitus loudness. Unfortu nately, as the therapy concept is based on the predom inant frequency of tinnitus, the loudness was adapted during assessment but was not recorded systematically. In future research, it would be of interest to additionally investigate the variation in tinnitus loudness in the course of therapeutic interventions. Furthermore, as we conducted a retrospective analysis of data origi nating from patients who all received the treatm ent, no certain conclusion about the reason for the variability in tinnitus frequency can be drawn without comparison to an adequate group of patients not receiving the treatment. A further interest of research is whether the revealed variation in tinnitus frequency plays a role in therapy out come, in the manner that fluctuation may correlate with success in treatment and that the effects of therapy may depend on the course of tinnitus change during therapy. Such results could indicate that variability in tinnitus fre quency dining the period of interventions, and possibly underlying neurophysiologic changes in the auditory path ways and cortices involved in such variations of tinnitus frequency, might be crucial in tinnitus therapy.
REFERENCES A rgstatter H. (2009) HeidelbergerMusiktherapiemanual: Chronischtonaler Tinnitus. Berlin, Germany: Uni-Edition. A rg statter H, Krick C, P linkert P, Bolay HV. (2010) [Music th e r apy for noisiform tinnitus. Concept development and evaluation]. H N O 58(11): 1085-1093. A rg statter H, G rapp M, H u tte r E, P lin k ert P, Bolay HV. (2012) Long-term effects of the “Heidelberg Model of Music T herapy” in patien ts w ith chronic tinnitus. In t J Clin Exp Med 5(4):273-288.
B um s EM. (1984) A comparison of variability among measurements of subjective tinnitus and objective stimuli. Audiology 23(4):426-440. Choy DS, Lipm an RA, Tassi GP. (2010) Worldwide experience w ith sequential phase-shift sound cancellation tre a tm e n t of pre dom inant tone tin n itu s. J Laryngol Otol 124(4):366-369. Eggerm ont J J . (2006) Cortical tonotopic m ap reorganization and its im plications for tre a tm e n t of tin n itu s. Acta Otolaryngol Suppl 126(s556):9-12. Flor H, Hoffmann D, Struve M, Diesch E. (2004) A uditory discrim ination train in g for th e tre a tm e n t of tinnitus. A ppl Psychophysiol Biofeedback 29(2):113-120. H anley P J, Davis PB. (2008) T reatm ent of tin n itu s w ith a custom ized, dynamic acoustic n eu ral stim ulus: underlying principles and clinical efficacy. Trends A m p lif 12(3):210-222. Heijneman KM, de Kleine E, van Dijk P. (2012) A randomized double blind crossover study of phase-shift sound th erap y for tinnitus. Otolaryngol H ead Neck S u rg 147(2):308-315. H eller AJ. (2003) Classification and epidemiology of tinnitus. Oto laryngol Clin N orth A m 36(2):239-248. H enry JA, Flick CL, G ilbert A, Ellingson RM, F au sti SA. (2001) Comparison of two com puter-autom ated procedures for tin n itus pitch m atching. J Rehabil Res Dev 38(5):557-566. H enry JA, Flick CL, G ilbert A, Ellingson RM, F au sti SA. (2004) Comparison of m an u al and com puter-autom ated procedures for tin n itu s pitch-m atching. J Rehabil Res Dev 41(2):121-138. H enry JA, R heinsburg B, Owens KK, Ellingson RM. (2006) New in strum entation for autom ated tin n itu s psychoacoustic assess m ent. A cta Otolaryngol S u p p l 126(s556):34-38. Herraiz C, Diges I, Cobo P, Aparicio JM, Toledano A. (2010) Auditory discrimination training for tinnitus treatm ent: the effect of different paradigm s. E u r A rch Otorhinolaryngol 267(7):1067-1074. H irschfelder A, Caffier P, Scherer H, M azurek B. (2004) Audiom etrische Veranderungen unter am bulanter Tinnitus-RetrainingTherapie. 7. DGA Jahrestagung. Retrieved Ju ly 30, 2012 from www.uzh.ch/orl/dga2004/program m/wissprogramm /Hirschfelder. pdf. Hoare DJ, Stacey PC, Hall DA. (2010) The efficacy of auditory per ceptual train in g for tinnitus: a system atic review. A n n Behav Med 40(3):313-324. H oare D J, Kowalkowski VL, H all DA. (2012) Effects of frequency discrim ination train in g on tinnitus: resu lts from two random ised controlled trials. J Assoc Res Otolaryngol 13(41:543-559. Kodama A, K itah ara M. (1990) Clinical and audiological charac teristics of tonal and noise tin n itu s. ORL J Otorhinolaryngol Relat Spec 52(3):156-163. Landgrebe M, L angguth B, R osengarth K, et al. (2009) S tru ctural b rain changes in tinnitus: grey m a tte r decrease in auditory and non-auditory brain areas. Neuroimage 46(1):213-218. L anting CP, de Kleine E, van Dijk P. (2009) N eural activity u n d er lying tin n itu s generation: resu lts from PET and fMRI. H ear Res 255(1-21:1-13. Lockwood AH, Salvi RJ, B urkard RF. (2002) T innitus. N E ngl J M ed 347(12):904^910. Lugli M, R om ani R, Ponzi S, B acciu S, P arm ig ian i S. (2009) The w indow ed so und th e ra p y : a new em p irical ap p ro ach for an
Journal of the American Academy of Audiology A7olume 25, Number 4, 2014
effectiv personalized trea tm e n t of tinn itu s. In t T innitus J 15 (1):51—61. Mitchell CR, Vernon JA, Creedon TA. (1993) Measuring tinnitus parameters: loudness, pitch, and maskability. J Am Acad Audiol 4 (3):139—151. Moffat G, Adjout K, Gallego S, Thai-Van H, Collet L, Norena AJ. (2009) Effects of hearing aid fitting on the perceptual character istics of tinnitus. Hear Res 254(l-2):82-91. Mpller AR. (2006) Neural plasticity in tinnitus. Prog Brain Res 157:365-372. Moore BC, Vinay, Sandhya. (2010) The relationship between tinnitus pitch and the edge frequency of the audiogram in individuals with hearing impairment and tonal tinnitus. Hear Res 261(l-2):51—56. Miihlnickel W, Elbert T, Taub E, Flor H. (1998) Reorganization of auditory cortex in tinnitus. Proc Natl Acad Sci USA 95(17): 10340-10343. Nageris BI, Attias J, Raveh E. (2010) Test-retest tinnitus charac teristics in patients with noise-induced hearing loss. A m J Otolar yngol 31(3):181-184. Newman CW, Sandridge SA. (2012) A comparison of benefit and economic value between two sound therapy tinnitus management options. J A m Acad Audiol 23(2):126-138. Norena AJ. (2011) An integrative model of tinnitus based on a cen tral gain controlling neural sensitivity. Neurosci Biobehav Rev 35(5):1089-1109. Norena AJ, Micheyl C, Chery-Croze S, Collet L. (2002) Psycho acoustic characterization of the tinnitus spectrum: implications for the underlying mechanisms of tinnitus. Audiol Neurootol 7 (6):358-369. Okamoto H, Stracke H, Stoll W, Pantev C. (2010) Listening to tai lor-made notched music reduces tinnitus loudness and tinnitusrelated auditory cortex activity. Proc Natl Acad Sci USA 107(3): 1207-1210.
Pan T, Tyler RS, Ji H, Coelho C, Gehringer AK, Gogel SA. (2009) The relationship between tinnitus pitch and the audiogram. In t J Audiol 48(5):277-294. Pantev C, Okamoto H, Teismann H. (2012) Music-induced cor tical plasticity and lateral inhibition in the hum an auditory cor tex as foundations for tonal tinnitus treatm ent. Front Syst Neurosci 6:50. Penner MJ. (1983) Variability in matches to subjective tinnitus. J Speech Hear Res 26(2):263-267. Penner MJ, Saran A. (1994) Simultaneous measurement of tinni tus pitch and loudness. Ear Hear 15(6):416-421. Saunders JC. (2007) The role of central nervous system plasticity in tinnitus. J Commun Disord 40(4):313-334. Stouffer JL, Tyler RS. (1990) Characterization of tinnitus by tin nitus patients. J Speech Hear Disord 55(3):439-453. Teismann H, Okamoto H, Pantev C. (2011) Short and intense tailormade notched music training against tinnitus: the tinnitus fre quency matters. PLoS ONE 6(9):e24685. Tyler RS. (2000) The psychoacoustic measurement of tinnitus. In: Tyler RS, ed. Tinnitus Handbook. San Diego: Singular Publishing Group, 149-179. Tyler RS, Conrad-Armes D. (1983) Tinnitus pitch: a comparison of three measurement methods. Br J Audiol 17(2):101-107. Vanneste S, De Ridder D. (2012) The auditory and non-auditory brain areas involved in tinnitus. An emergent property of multiple parallel overlapping subnetworks. Front Syst Neurosci 6:31. World Medical Association. (2013) WMA Declaration o f Helsinki Ethical Principles for Medical Research Involving Human Sub jects. www.wma.net/en/30publications/10policies/b3/. Zenner HP, De Maddalena H. (2005) Validity and reliability study of three tinnitus self-assessment scales: loudness, annoyance and change. Acta Otolaryngol 125(11):1184-1188.
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