A systematic review of techniques and effects of self-help interventions for tinnitus: Application of taxonomies from health psychology

How people with tinnitus-related insomnia experience group CBT-for-insomnia (CBTi): a thematic analysis

Objective: Although insomnia often compounds tinnitus, sleeping problems in people experiencing tinnitus are rarely treated. This study investigates the experiences of participants receiving Cognitive Behavioural Therapy for insomnia (CBTi) as part of a randomised controlled trial for managing tinnitus-related insomnia. The aim of this study is to gain detailed insight into participants' perceptions and experiences of this treatment.Design: Semi-structured interviews were conducted via phone or in-person by one of the two clinical psychologists who facilitated the CBTi sessions. Reflexive thematic analysis with semantic inductive approach was used for analysis to keep the research question theoretically flexible.Study samples: Eight participants (three females, age range 32-69 years) were interviewed six months after CBTi completion.Results: Three superordinate themes were identified: "Common humanity and transcending individual distress," "Changing the things I can" and "Accepting the things I cannot change." The group environment helped participants to normalise their experiences. Reliable tinnitus/sleep information and robust behavioural change techniques helped participants to respond and relate to their condition differently.Conclusion: Generally, participants reported long-term benefits from CBTi to treat tinnitus-related insomnia, particularly increased confidence, and getting on with life. CBTi is multi-component, so clinicians need to respond to individual preferences and lifestyles.

[Apps for tinnitus? A systematic review on quality, intervention components, and behavior change techniques]

BACKGROUND

Various smartphone applications (apps) for people with tinnitus are available and promise tinnitus relief. Yet, it is difficult for people suffering from tinnitus and healthcare professionals to estimate their quality, potential, or risks. The current study aims to generate an overview of available tinnitus apps in the German language and to offer orientation for research and healthcare providers.

METHOD

The most prominent stores were searched systematically (November 2020-April 2021; Google Play Store and Apple App Store). Apps specifically developed for tinnitus were evaluated by two independent raters using multiple approaches: a) a quality screening was performed using the German version of the Mobile App Rating Scale (MARS-G), b) intervention components were assessed using a newly developed list of categories, and c) implemented strategies for active tinnitus management were analyzed using behavior change techniques (BCTs).

RESULTS

The search yielded 1073 apps, of which 21 apps were analyzed. The apps' overall quality as assessed by MARS‑G was average (M = 3.37, SD = 039). A lot of apps offered sounds (n = 18) and information (n = 9) or assessed tinnitus characteristics (n = 13). Out of 93 BCTs, 24 were identified at least once. Only one app was evaluated in non-randomized trials.

CONCLUSION

Although a variety of apps are available, most of them focus on a few intervention components (e.g., sounds or information). Therefore, apps do not exploit their potential to impart important evidence-based content for tinnitus management. The app evaluation using multiple approaches points out potential for improvement.

Tinnitus Guidelines and Their Evidence Base

Evidence-based medicine (EBM) is generally accepted as the gold standard for high-quality medicine and, thus, for managing patients with tinnitus. EBM integrates the best available scientific information with clinical experience and patient values to guide decision-making about clinical management. To help health care providers and clinicians, the available evidence is commonly translated into medical or clinical guidelines based on a consensus. These involve a systematic review of the literature and meta-analytic aggregation of research findings followed by the formulation of clinical recommendations. However, this approach also has limitations, which include a lack of consideration of individual patient characteristics, the susceptibility of guideline recommendations to material and immaterial conflicts of interest of guideline authors and long latencies till new knowledge is implemented in guidelines. A further important aspect in interpreting the existing literature is that the absence of evidence is not evidence of absence. These circumstances could result in the decoupling of recommendations and their supporting evidence, which becomes evident when guidelines from different countries differ in their recommendations. This opinion paper will discuss how these weaknesses can be addressed in tinnitus.

Chronic Tinnitus and the Positive Effects of Sound Treatment via a Smartphone App: Mixed-Design Study

Background

Tinnitus is a phantom auditory sensation in the absence of an external stimulus. It is accompanied by a broad range of negative emotional symptoms and a significantly lower quality of life. So far, there is no cure for tinnitus, although various treatment options have been tried. One of them is mobile technology employing dedicated apps based on sound therapy. The apps can be managed by the patient and tailored according to their needs.

Objective

The study aims to assess the effect of a mobile app that generates background sounds on the severity of tinnitus.

Methods

The study involved 68 adults who had chronic tinnitus. Participants were divided into a study group (44 patients) and a control group (24 patients). For 6 months those in the study group used a free mobile app that enriched the sound environment with a background sound. Participants were instructed to use the app for at least 30 minutes a day using their preferred sound. The participants in the control group did not use the app. Subjective changes in the day-to-day functioning of both groups were evaluated using the Tinnitus Handicap Inventory (THI) questionnaire, a visual analog scale, and a user survey.

Results

After 3 months of using the app, the THI global score significantly decreased (P<.001) in the study group, decreasing again at 6 months (P<.001). The largest improvements were observed in the emotional and catastrophic reactions subscales. A clinically important change in the THI was reported by 39% of the study group (17/44). Almost 90% of the study participants (39/44) chose environmental sounds to listen to, the most popular being rain and ocean waves. In the control group, tinnitus severity did not change over 3 or 6 months.

Conclusions

Although the participants still experienced limitations caused by tinnitus, the advantage of the app was that it led to lower negative emotions and thus reduced overall tinnitus severity. It is worth considering whether a mobile app might be incorporated into the management of tinnitus in a professional setting.

Auricular Acupressure Combined with Self-Help Intervention for Treating Chronic Tinnitus: A Longitudinal Observational Study

Tinnitus is a phantom sound perception in the ears or head and can arise from many different medical disorders. Currently, there is no standard treatment for tinnitus that reliably reduces tinnitus. Individual patients reported that acupressure at various points around the ear can help to reduce tinnitus, which was investigated here. With this longitudinal observational study, we report a systematic evaluation of auricular acupressure on 39 tinnitus sufferers, combined with a self-help smartphone app. The participants were asked to report on tinnitus, stress, mood, neck, and jaw muscle tensions twice a day using an ecological momentary assessment study design for six weeks. On average, 123.6 questionnaires per person were provided and used for statistical analysis. The treatment responses of the participants were heterogeneous. On average, we observed significant negative trends for tinnitus loudness (Cohen’s d effect size: −0.861), tinnitus distress (d = −0.478), stress (d = −0.675), and tensions in the neck muscles (d = −0.356). Comparison with a matched control group revealed significant improvements for tinnitus loudness (p = 0.027) and self-reported stress level (p = 0.003). The positive results of the observational study motivate further research including a randomized clinical trial and long-term assessment of the clinical improvement.

Self-help interventions chosen by subjects with chronic tinnitus - a retrospective study of clinical patients

OBJECTIVE

Self-help (without specialist support) can play an important role in tinnitus therapy. The purpose of this study was to investigate what fraction of subjects with tinnitus use self-help, what techniques are most commonly used to reduce tinnitus severity, and what distinguishes patients that use self-help from others.

DESIGN

retrospective, observational study.

STUDY SAMPLE

Adult patients admitted to our hospital clinic (460 participants) aged 19-83 years and reporting chronic tinnitus. The survey concerned therapy attempts prior to the clinic visit as well as self-help techniques chosen freely by the patient to reduce tinnitus severity.

RESULTS

Data showed that 40.9% of the respondents chose some action themselves to reduce their tinnitus severity. Among the reported self-help techniques, acoustic stimulation was the most popular. In addition, patients chose distraction attention, relaxation, meditation, yoga, and physical activity. The likelihood of undertaking self-help increases with better education and higher tinnitus severity.

CONCLUSIONS

Knowledge about patients' preferences of forms of self-help may help the health practitioner suggest a more suitable form of therapy. Due to the great interest in using sound therapy in tinnitus, it would be worthwhile looking at new forms of this therapy, for example increasingly popular mobile applications.

Intervention Planning for the Tinnitus E-Programme 2.0, an Internet-Based Cognitive Behavioral Intervention for Tinnitus

Purpose The purpose of this study is to comprehensively describe the intervention planning process for the Tinnitus E-Programme 2.0, an Internet-based cognitive behavioral intervention for tinnitus. Method Theory-, evidence-, and person-based approaches to intervention development were used. In Phase 1, quantitative systematic reviews were used to identify potentially effective intervention techniques and design features. Primary mixed-methods research involving adults with tinnitus explored the acceptability of the first version of the intervention. In Phase 2, person-based guiding principles highlighted key intervention design objectives and features to address needs of the intervention's target group (identified in Phase 1) to maximize its acceptability, feasibility of delivery, and effectiveness. Theory-based "behavioral analysis" and "logic modeling" comprehensively described intervention content and potential mechanisms of action. From this planning work, a prototype intervention was developed. Results The intervention design objectives outlined in the guiding principles were to (a) normalize tinnitus, (b) support users to maintain a regular relaxation practice, (c) minimize the worsening of users' tinnitus sensation, and (d) ensure the intervention is accessible to those with hearing loss. Behavioral analysis and logic modeling identified intervention processes (e.g., illness perceptions, beliefs about consequences, skills, goals) and purported mediators (acceptance of tinnitus, negative thinking, use of the cognitive skills tools for managing negative thoughts, and practicing regular relaxation) hypothesized to facilitate reductions in tinnitus symptom severity. Conclusions The guiding principles highlight key design objectives and features to consider when developing interventions for tinnitus. The logic model offers hypothesized mechanisms of action that can be tested in future process analyses.

Effectiveness of tinnitus therapy using a mobile application

Background

The World Health Organization reports that the number of tinnitus sufferers is increasing year on year. Given the common use of mobile devices and the availability of applications designed to support patients in tinnitus therapy and reduce tinnitus severity, patients seeking help are likely to try this form of support. The aim of this study was to evaluate the effectiveness of a mobile application in tinnitus sound therapy, in this case ReSound Tinnitus Relief™.

Methods

The study involved 52 patients hospitalized for tinnitus. All participants used the free ReSound Tinnitus Relief application for 6 months. The application is based on sound therapy. Patients were advised to use the application for at least 30 min per day, the sounds should not completely mask the tinnitus, and they should be listened to via a loudspeaker. The effects of the therapy were evaluated by means of standardized questionnaires for tinnitus severity: the Tinnitus Handicap Inventory and the Tinnitus Functional Index.

Results

The study showed a reduction in tinnitus severity as measured by both questionnaires. The general severity decreased after the first 3 months and again in the following 3 months of using the application. In both questionnaires the biggest changes were observed in the subscales of emotions.

Conclusions

Results obtained here from standardized questionnaires indicate that the tested application may contribute to tinnitus reduction. However, it is advisable to conduct further research on the applicability of such technology in medical practice.

A process for prioritising systematic reviews in tinnitus

Objective: To develop an innovative prioritisation process to identify topics for new or updated systematic reviews of tinnitus research.Design: A two-stage prioritisation process was devised. First, a scoping review assessed the amount of randomized controlled trial-level evidence available. This enabled development of selection criteria for future reviews, aided the design of template protocol and suggested the scale of work that would be required to conduct these reviews. Second, using the pre-defined primary and secondary criteria, interventions were prioritised for systematic review.Study sample: Searches identified 1080 records. After removal of duplicates and out of scope works, 437 records remained for full data charting.Results: The process was tested, using subjective tinnitus as the clinical condition and using Cochrane as the systematic review platform. The criteria produced by this process identified three high priority reviews: (1) Sound therapy using amplification devices and/or sound generators; (2) Betahistine and (3) Cognitive behaviour therapy. Further secondary priorities were: (4) Gingko biloba, (5) Anxiolytics, (6) Hypnotics, (7) Antiepileptics and (8) Neuromodulation.Conclusions: A process was developed which successfully identified priority areas for Cochrane systematic reviews of interventions for subjective tinnitus. This technique could easily be transferred to other conditions and other types of systematic reviews.

Tinnitus groups: A model of social support and social connectedness from peer interaction

Tinnitus is a chronic condition for which there is no medical treatment. Tinnitus groups are a widely available resource for people with tinnitus.

OBJECTIVES

Our objectives were to explore the active ingredients of tinnitus support groups in terms of their mechanisms for providing support, the contextual factors that elicit such mechanisms, and the outcomes in terms of coping enhancement.

DESIGN

We adopted a pluralist and iterative approach informed by the realist evaluation method.

METHODS

We conducted ethnographic data generation at tinnitus support groups involving observations (n = 160), focus groups (n = 130), and individual interviews (n = 20). Inductive analyses were conducted following the constant comparison method of grounded theory. We then interrogated the inductive themes to identify evidence of Contexts, Mechanisms, and Outcomes. We then produced a model which was tested in a survey of tinnitus group members (n = 65) in effect providing large-scale respondent validation of the data-driven model created through our inductive analysis.

RESULTS

We identified that tinnitus groups can facilitate social connectedness between group members. This experience appeared to build resilience among those experiencing tinnitus-related distress. Groups also played a role in building a sense of control related to knowledge and information sharing. Additionally, we identified risks associated with not accessing social support in a group environment.

CONCLUSIONS

Our findings contribute to the growing understanding of the power of social connectedness as building shared social identity when living with tinnitus. Statement of contribution What is already known on this subject? Tinnitus is a prevalent condition with approximately 10-15% of the population experiencing a spontaneous sound without obvious source. Tinnitus is an invisible health and chronic condition. People with tinnitus experience high levels of distress, anxiety, and depression. Group support is beneficial to people with many health problems. What does this study add? This study describes the mechanisms by which tinnitus support groups can support coping in tinnitus. This is the first study to comprehensively explore the views of those who attend tinnitus groups. The study identifies the key features of support groups that facilitate social connectedness among group members. The most valued features of groups are the knowledge and information provided, the sense of belonging communicated to group members, and the creation and maintenance of a sense of hope towards the tinnitus. This study contributes new insights to both the tinnitus field and adds to the literature on support groups in health.

Understanding User Reactions and Interactions With an Internet-Based Intervention for Tinnitus Self-Management: Mixed-Methods Evaluation

Purpose Internet-based interventions have the potential to reduce the disparity in access to psychological therapy that people with tinnitus currently experience. One example is the Tinnitus E-Programme, which, although freely available online, has not yet been formally evaluated. The purpose of this study was to evaluate past, current, and new users' reactions and interactions with the Tinnitus E-Programme. Method Study 1 used an online survey to gather past and current users' reactions to, and interactions with, the intervention (n = 27). Study 2 used interviews and a relaxation log to assess how new users implemented the skills they learned into their everyday lives (n = 13). Results Generally, users expressed positive views on the intervention content and design features. Users particularly valued the education about tinnitus and its management and the relaxation skills training, and use of these components was high. In contrast, user reactions to self-monitoring tools, an online support forum, and therapist support were mixed, and use was lower. Implementation was limited by instances of poor usability and accessibility, user engagement, and adherence to relaxation goals. Users' perceptions of the intervention's credibility and relevance and beliefs regarding a negative impact on their tinnitus influenced engagement. Users in both studies identified several benefits gained, including functional and emotional management, self-efficacy for managing and coping with tinnitus, understanding tinnitus and its management, social support, and acceptance of tinnitus. Conclusion Findings suggest that the intervention was acceptable to its target group but also highlighted some areas for improvement. These findings will be used to inform further optimization work.

Findings and Ethical Considerations From a Thematic Analysis of Threads Within Tinnitus Online Support Groups

PURPOSE

Tinnitus is the perception of noise without a corresponding external stimulus. Current management typically aims to moderate associated psychosocial stressors and allow sufferers to retain an adequate quality of life. With the increasing recognition of the Internet as a repository for health advice, information, and support, the online support group has become a popular coping strategy for those living with chronic conditions such as tinnitus. Patients find that communicating with each other, providing encouragement, and sharing information in the absence of physical and temporal boundaries are invaluable ways of managing their condition. The purpose of this study was to explore the potential positive and negative consequences of participating in online support groups for tinnitus.

METHOD

Discussion forum threads were collated from across 4 public online support group websites. All threads were initiated between February and April 2016. Texts from these threads were coded by 3 separate analysts using both inductive and deductive thematic analysis, until data saturation was reached.

RESULTS

Analysis of 75 threads (641 individual posts) found 9 independent themes pertaining to aspects of participation in tinnitus online support groups. The results revealed that using the forums allowed users to exchange knowledge and experiences, express complex emotions, profit from a network of support, and engage in everyday conversation away from the burden of their tinnitus. However, some experiences appeared to be compromised by negative messages, limited communication, and informational issues such as conflicting advice or information overload.

CONCLUSIONS

This study represents the 1st research into discussion forums in tinnitus online support groups. A nonintrusive (passive) analysis method was used, whereby messages comprising the dataset were retrieved without direct interaction with the discussion forum. Individuals and the community of tinnitus online support groups are deemed to be at low risk from potential harm in this study. Most tinnitus patients likely benefit from accessing online support groups, for example, they discover they are not alone, and they find new coping strategies. However, for those who are particularly vulnerable or prone to psychological stress, accessing these groups could be detrimental.

Review of Smart Services for Tinnitus Self-Help, Diagnostics and Treatments

In the recent years, there has been an increasing interest in the potential of internet- and smartphone-based technologies for the support of tinnitus patients. A broad spectrum of relevant approaches, some in the form of studies, others in the form of market products, have been mentioned in literature. They include auditory treatments, internet-based Cognitive Behavioral Therapy (iCBT), serious games, and questionnaires for tinnitus monitoring. The goal of this study is to highlight the role of existing internet-based and smart technologies for the advancement of tinnitus clinical practice: we consider contributions that refer to treatments and diagnostics, and we include contributions refering to self-help measures. We elaborate on the potential and challenges of such solutions and identify constraints associated to their deployment, such as the demand for familiarity with internet-based services and the need to re-design interactive services so that they fit on the small surface of a smartwatch.

The effectiveness of various computer-based interventions for patients with chronic pain or functional somatic syndromes: A systematic review and meta-analysis

Computer-based interventions target improvement of physical and emotional functioning in patients with chronic pain and functional somatic syndromes. However, it is unclear to what extent which interventions work and for whom. This systematic review and meta-analysis (registered at PROSPERO, 2016: CRD42016050839) assesses efficacy relative to passive and active control conditions, and explores patient and intervention factors. Controlled studies were identified from MEDLINE, EMBASE, PsychInfo, Web of Science, and Cochrane Library. Pooled standardized mean differences by comparison type, and somatic symptom, health-related quality of life, functional interference, catastrophizing, and depression outcomes were calculated at post-treatment and at 6 or more months follow-up. Risk of bias was assessed. Sub-group analyses were performed by patient and intervention characteristics when heterogeneous outcomes were observed. Maximally, 30 out of 46 eligible studies and 3,387 participants were included per meta-analysis. Mostly, internet-based cognitive behavioral therapies were identified. Significantly higher patient reported outcomes were found in comparisons with passive control groups (standardized mean differences ranged between -.41 and -.18), but not in comparisons with active control groups (SMD = -.26 - -.14). For some outcomes, significant heterogeneity related to patient and intervention characteristics. To conclude, there is a minority of good quality evidence for small positive average effects of computer-based (cognitive) behavior change interventions, similar to traditional modes. These effects may be sustainable. Indications were found as of which interventions work better or more consistently across outcomes for which patients. Future process analyses are recommended in the aim of better understanding individual chances of clinically relevant outcomes.

Use and Mediating Effect of Interactive Design Features in Audiology Rehabilitation and Self-Management Internet-Based Interventions

PURPOSE

The purpose of this study is to explore the presence of key interactive design features across Internet-based audiology rehabilitation and self-management interventions, and whether there is evidence of them mediating effects of the intervention.

METHOD

Adult audiology interventions relevant to this review were identified through a literature search in Google Scholar and a hand search of key journals. Four key interactive design features that have been proposed to mediate the effects of Internet-based health interventions were reported for each intervention: social context and support, contacts with the intervention, tailoring, and self-management.

RESULTS

Five interventions were identified as representative examples of work in the field. Social context and support and contacts with the intervention were provided in most interventions, mainly through clinician guidance. Only 1 intervention utilized tailoring to personalize intervention content to individual users, but use was minimal. Self-management features were also used in all interventions but the precise nature of these features was poorly reported.

CONCLUSION

Future studies should assess the optimal dose and combinations of intervention features for maximizing efficacy in audiology intervention. To be specific, the role of tailoring should be explored, which has been identified as a potential mediator of intervention outcome in the wider e-health literature.

Understanding User Reactions and Interactions With an Internet-Based Intervention for Tinnitus Self-Management: Mixed-Methods Process Evaluation Protocol

Background

Tinnitus is a common medical symptom that can affect an individual’s emotional and functional quality of life. Psychological therapies are acknowledged as beneficial to people with tinnitus; however, such therapies are not always readily accessible. With their global reach, automated Internet-based interventions have the potential to reduce the disparity in access to psychological support that people with tinnitus currently experience. However, the evidence on the acceptability and efficacy of these interventions is lacking. Process evaluations that develop an in-depth understanding of how users experience these interventions provide an essential first step when evaluating complex psychological interventions.

Objective

To describe the protocol for a study that will explore past, current, and new users’ reactions to and interactions with the Tinnitus E-Programme, an Internet-based intervention for the self-management of tinnitus.

Methods

Two parallel mixed-methods studies will be carried out with 2 different populations. Study 1 will use an online survey to gather past and current users’ views of the program. Study 2 will recruit new program users to take part in an interview and complete a relaxation log to explore how well they were able to implement the skills they learned during the program in their everyday lives. The findings from both studies will be triangulated to develop an in-depth understanding of the program’s mechanisms of impact and identify any implementation or contextual factors that strengthen or impede its delivery and functioning.

Results

Study 1 is open for recruitment with a projected completion in June 2016 and Study 2 was completed November 2015. At the time of submission, 36 participants have been recruited to Study 1 and 12 participants have taken part in Study 2.

Conclusions

Findings will inform the optimization of the Tinnitus E-Programme and guide future evaluation work to assess the program’s effectiveness as a therapy for people with tinnitus.