Tinnitus retraining therapy versus sound therapy alone: what the evidence shows

Tinnitus is the perception of sound or noise when no external sound is present [1, 3]. Over 50 million people in the United States alone have reported experiencing tinnitus [3]. While there is no outright cure for tinnitus, various strategies have been developed to help reduce its impact [1, 3]. For a broader look at different approaches, you can refer to our broader review of tinnitus management evidence.

This article focuses specifically on Tinnitus Retraining Therapy (TRT). TRT is a defined protocol that combines directive counselling with sound therapy within a strict framework [1]. It is important to understand that TRT is not simply a synonym for general sound therapy. Many studies may refer to TRT when they are actually implementing a modified version of the therapy [1].

What is Tinnitus Retraining Therapy (TRT)?

Tinnitus Retraining Therapy (TRT) is a structured approach to managing tinnitus. It was developed following the publication of a neurophysiological model of tinnitus [1]. The core of TRT involves two main components: * Directive counselling: This involves education specific to tinnitus. The goal is to help patients understand tinnitus and how their brain processes it [2]. * Sound therapy: This uses sound generators to provide external sound [1, 2].

The aim of TRT is to reduce a patient's negative reaction to tinnitus and their awareness of it [2]. It is designed to be a strict protocol, meaning it follows a specific set of guidelines for both the counselling and the use of sound therapy [1]. This structured framework is what distinguishes TRT from more general applications of sound therapy, where sound might be used without the accompanying directive counselling or within a different therapeutic context [1].

Evidence for TRT: The Cochrane Review

In 2010, a Cochrane review was published with the objective of assessing how effective TRT is in treating tinnitus [1]. Cochrane reviews are systematic reviews of research in health care, known for their rigorous methods.

How the Review Was Conducted

The researchers searched several databases, including the Cochrane ENT Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and EMBASE. They looked for randomised controlled trials (RCTs) that compared TRT with either no treatment or other forms of treatment in adults with tinnitus [1].

Key Findings and Limitations

The review found that only one trial met its strict criteria for inclusion [1]. This single trial involved 123 participants [1]. Many other studies were excluded because they did not follow the strict protocol for TRT, instead evaluating modified forms of the therapy [1].

The included trial compared TRT with a tinnitus masking (TM) approach [1]. Tinnitus masking involves using external sounds to cover up or "mask" the perception of tinnitus. The study measured outcomes using three different instruments: * The Tinnitus Handicap Inventory (THI) * The Tinnitus Handicap Questionnaire (THQ) * The Tinnitus Severity Index (TSI) [1]

Participants in the study were categorised based on how much of a problem their tinnitus was: 'moderate problem', 'big problem', or 'very big problem' [1].

At 18 months, the trial reported improvements in scores for TRT compared to the tinnitus masking approach across all three categories and all three measurement tools [1]: * For participants with a 'moderate problem': * THI: TRT showed an 18.2-point improvement versus 4.6 points for TM. * THQ: TRT showed a 489-point improvement versus 178 points for TM. * TSI: TRT showed a 7.5-point improvement versus 1.6 points for TM [1]. * For participants with a 'big problem': * THI: TRT showed a 29.2-point improvement versus 16.7 points for TM. * THQ: TRT showed a 799-point improvement versus 256 points for TM. * TSI: TRT showed a 12.1-point improvement versus 6.7 points for TM [1]. * For participants with a 'very big problem': * THI: TRT showed a 50.4-point improvement versus 10.3 points for TM. * THQ: TRT showed an 1118-point improvement versus 300 points for TM. * TSI: TRT showed a 19.7-point improvement versus 4.8 points for TM [1].

The authors of the Cochrane review concluded that this "single, low-quality randomised controlled trial suggests that TRT is much more effective as a treatment for patients with tinnitus than tinnitus masking" [1]. This conclusion highlights the limited amount of high-quality evidence available at the time the review was conducted.

The Tinnitus Retraining Therapy Trial (TRTT): A Larger Study

Several years after the Cochrane review, a larger, multicenter phase 3 trial, known as the Tinnitus Retraining Therapy Trial (TRTT), was conducted in the United States [2]. This trial aimed to provide more robust evidence regarding the efficacy of TRT. The researchers noted that TRT is an internationally recognised, but controversial, protocol with uncertain efficacy [2].

Study Objectives and Design

The main objective of the TRTT was to compare the effectiveness of TRT and its individual components (tinnitus-specific educational counselling and sound therapy) with the standard of care (SoC) [2]. The goal was to see which approach was best at reducing the negative effect of tinnitus on a person's quality of life [2].

The study was designed as a randomised, placebo-controlled, multicenter trial [2]. It took place between August 2011 and June 2017 across six US military hospitals [2].

Participants

The trial included 151 active-duty and retired military personnel and their dependents [2]. All participants had functionally adequate hearing sensitivity and experienced moderate to severe subjective tinnitus [2]. The group consisted of 44 women and 107 men, with an average age of 50.6 years [2].

Interventions

Participants were randomly assigned to one of three groups [2]: 1. TRT Group: Received tinnitus-specific educational counselling (TC) and sound therapy (ST) using conventional sound generators [2]. This group represented the full TRT protocol. 2. Partial TRT Group: Received tinnitus-specific educational counselling (TC) but with placebo sound generators [2]. This group aimed to isolate the effect of counselling. 3. Standard of Care (SoC) Group: Received the usual care provided for tinnitus [2].

Outcomes Measured

The primary outcome measured was the average change in scores on the Tinnitus Questionnaire (TQ), assessed over 18 months from the start of therapy [2]. Secondary outcomes included changes in subscales of the TQ, as well as scores from the Tinnitus Functional Index (TFI), the Tinnitus Handicap Inventory (THI) (total and subscales), and a 10-point visual analog scale (VAS) [2].

Results of the TRTT

The 151 participants were distributed among the groups as follows: 51 to TRT, 51 to partial TRT, and 49 to standard of care [2].

The main finding of the TRTT was that longitudinal analyses showed no difference between partial TRT or TRT compared with standard of care on the primary outcome (TQ scores), or on the TFI or THI total scores [2]. There was also no difference found when comparing partial TRT with full TRT [2]. When looking at changes in mean scores from baseline to the 18-month visit, there was still no difference between any of the treatment groups [2].

However, the study did observe that all treatment groups showed significant improvement in TQ scores at 18 months compared to their baseline scores [2]: * TRT group: effect size of -1.32 (95% CI, -1.78 to -0.85) [2]. * Partial TRT group: effect size of -1.16 (95% CI, -1.56 to -0.76) [2]. * Standard of Care group: effect size of -1.01 (95% CI, -1.41 to -0.61) [2].

This means that while all groups improved, the specific TRT protocol did not show a greater improvement than counselling with placebo sound or standard of care [2].

The study also reported the percentage of participants who showed clinically meaningful reductions in the effect of their tinnitus at 18 months, compared to baseline [2]: * Tinnitus Questionnaire (TQ): 77.55% (86 of 111 participants) showed a reduction of 7 points or more [2]. * Tinnitus Functional Index (TFI): 46.8% (52 of 111 participants) showed a reduction of 13 points or more [2]. * Tinnitus Handicap Inventory (THI): 56.8% (63 of 111 participants) showed a reduction of 7 points or more [2]. * Visual Analog Scale (VAS): 48.4% (45 of 93 participants) showed a reduction of 2 points or more [2].

The authors of the TRTT concluded that "there were few differences between treatment groups" and that "about half of participants showed clinically meaningful reductions in the effect of tinnitus" [2].

Professional Guidelines on Tinnitus Management

In 2014, the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) published a Clinical Practice Guideline on Tinnitus [3]. This guideline provides evidence-based recommendations for clinicians managing adult patients (18 years and older) with persistent, bothersome tinnitus (lasting 6 months or longer) [3].

The guideline makes several recommendations relevant to tinnitus management strategies: * Strong Recommendations: * Clinicians should distinguish between bothersome and non-bothersome tinnitus [3]. * A targeted history and physical examination should be performed to identify conditions that might relieve tinnitus if promptly managed [3]. * A comprehensive audiologic examination should be obtained for patients with unilateral, persistent tinnitus, or tinnitus associated with hearing difficulties [3]. * Patients with persistent, bothersome tinnitus should be educated about management strategies [3]. * A hearing aid evaluation should be recommended for patients with persistent, bothersome tinnitus and documented hearing loss [3]. * Cognitive behavioural therapy (CBT) should be recommended to patients with persistent, bothersome tinnitus [3]. * Recommendations Against: * The routine use of antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for persistent, bothersome tinnitus [3]. * The use of Ginkgo biloba, melatonin, zinc, or other dietary supplements for treating persistent, bothersome tinnitus [3]. * Transcranial magnetic stimulation for the routine treatment of persistent, bothersome tinnitus [3]. * Options (Clinicians May Consider): * Clinicians may obtain an initial comprehensive audiologic examination for any patient presenting with tinnitus [3]. * Clinicians may recommend sound therapy to patients with persistent, bothersome tinnitus [3].

It is important to note that while the guideline recommends cognitive behavioural therapy and suggests sound therapy as an option, it does not specifically recommend Tinnitus Retraining Therapy (TRT) as a distinct intervention [3].

What this means for you

Tinnitus is the perception of sound without an external source, and it can significantly affect quality of life for many individuals [1, 3]. While there isn't a cure, various management strategies aim to lessen its impact [1, 3].

Tinnitus Retraining Therapy (TRT) is a specific approach that combines directive counselling with sound therapy [1]. Early evidence from a single, low-quality trial suggested that TRT might be more effective than tinnitus masking [1]. However, a larger, more recent randomised trial (the TRTT) found no significant difference in improvements in tinnitus-related quality of life between full TRT, partial TRT (counselling with placebo sound), and standard of care [2]. This trial showed that while all groups experienced improvements over 18 months, TRT did not offer greater benefits than the other approaches [2]. About half of the participants in that study experienced clinically meaningful reductions in the effect of their tinnitus, regardless of the treatment group [2].

Professional guidelines recommend educating patients about management strategies for persistent, bothersome tinnitus [3]. They also recommend cognitive behavioural therapy (CBT) and state that clinicians may consider recommending sound therapy [3].

If you are experiencing persistent, bothersome tinnitus, a regulated hearing professional can assess your specific situation and discuss suitable management strategies [3]. This might include exploring options like sound therapy, counselling, or other approaches. An audiologist or a hearing aid practitioner can provide an evaluation and help you understand the available options.

You can verify the registration of audiologists through the Alberta College of Speech-Language Pathologists and Audiologists (ACSLPA) [4], and hearing aid practitioners through the College of Hearing Aid Practitioners of Alberta (CHAPA) [5]. To find a professional, you can search for audiologists in Calgary.