British Tinnitus Association

In this article, Lucy Handscomb, Hearing Therapist, explains more about Sound Therapy and how it can help people with tinnitus.

When people first come to see me about their tinnitus, one of the questions I always ask is what kind of strategies they are using already to help them cope. More often than not, people tell me that listening to other sounds gives them some relief. They put the TV on, listen to music, go for a walk in the street or open the window to let the outside in. Using sound as a coping strategy is such a very natural thing to do that people with tinnitus have probably been doing it for centuries. Indeed, the first record of sound therapy comes from the French writer Jean-Marie Itard who, in his medical textbook of 1821, recommends a number of DIY sound-making devices for tinnitus patients such as damp, crackling wood on the fire and gently trickling water¹.

But what is it about sound therapy that helps people with tinnitus, and which sounds are most effective? The answers are far from obvious, and have been a hot topic of discussion within the tinnitus community for many years.

Readers of Quiet who had contact with tinnitus services, such as they were, in the 1970’s and 80’s will probably have been advised to use masking. The principle of masking is simple; one sound drowns out another. Many types of tinnitus can be masked by white noise (the sound a radio makes when off-station), so both ear-worn and under-the-pillow white noise makers were developed. These were easy to use and provided welcome relief to many, but there were a few problems. Not all types of tinnitus can be masked by white noise, and the relief provided by masking was only ever temporary. Switch the masking off and the tinnitus is, if anything, more intrusive than before.

The development of tinnitus retraining therapy in the early 1990’s saw a move away from masking towards sound enrichment. Turning the volume down to a level that is just below the tinnitus may not provide such an immediate sense of relief, but it does allow the all important process of habituation to occur. Most types of modern tinnitus therapy have habituation as their aim; the brain becomes so accustomed to and so uninterested in the tinnitus that it stops bothering to pay it much attention. Clearly, you cannot habituate to tinnitus if you cannot hear it, in the same way that you cannot habituate to the cars passing in the street outside if you spend your life behind sealed double glazing.

Sound therapy is a crucial component of Tinnitus Retraining Therapy (TRT), and the instructions for its use are quite specific. The sound used should be easy to hear but below the tinnitus and free from emotional associations, either positive or negative². This makes white noise a good choice but music, whether liked or disliked by the listener, a bad one. Music can still be listened to for pleasure, but the idea of sound enrichment is that habitual use of neutral background sound reduces the stark contrast between tinnitus and silence, and gradually makes the tinnitus signal weaker and less intrusive². According to the neurophysiological model, this process happens largely at a subconscious level, without involving much thought on the part of the patient.

However, some researchers have argued that in fact it is the emotional content of sound that is most helpful to people with tinnitus. We know that relaxation tends to help people manage their tinnitus better, so when people listen to soothing sounds like seashores or singing birds, it may be partly because of the relaxed feeling they induce that the tinnitus becomes less distressing, rather than simply because of the direct effect of the sound on the brain’s ability to pick up tinnitus. We know that imagining seashores and other calming scenes seems to help people feel less upset with their tinnitus just as much as listening to seashores and other nature sounds³ and that, given the option, people tend to choose sounds which make them feel relaxed or are associated with pleasant memories, rather than neutral ones, to help them sleep at night⁴. Bedside sound generators (portable machines which offer a choice of several different nature sounds) do appear to help people with tinnitus sleep, but at the moment it is unclear whether it is the presence of the sound that makes the difference, or the relaxed feeling it induces, or a bit of both⁴.

If you have visited a tinnitus clinic, you may have been fitted with sound generators, either in or behind your ears. These replaced the old maskers. They generate low-level white noise and are a good way of keeping a neutral background sound permanently with you. Some people, perhaps particularly those with hyperacusis, find them very helpful. Others do not get on with them so well, and some find white noise quite unpleasant⁴. The important thing to remember is that, although sound generators are designed as specialised tinnitus devices, they are just one of many ways to use sound enrichment, and there may be another way that appeals to you more. Many people enjoy using nature sounds both at night and when doing quiet activities such as reading. Interestingly, partners who don’t have tinnitus themselves often find the presence of calming sound at night beneficial to their sleep, too. Those who are au fait with computers can create their own personal sound file, while the less technologically minded can buy or borrow CDs. The sounds of running water and birdsong seem to be particularly popular, at least at night⁴, but preferences vary and it is worth experimenting to find something that suits you. You might find that sounds which demand your attention, such as TV or radio, are less helpful than environmental sounds when trying to concentrate on other things, or sleep. The rather glib advice many people get from doctors: ‘put the radio on’ is not always the best option.

For those who have hearing loss as well as tinnitus, hearing aids are an excellent from of sound therapy. By bringing more sounds from the environment into the ears, they help shift attention away from the tinnitus onto more interesting things. Some people with tinnitus prefer a little less ‘noise reduction’ programmed into their digital aids than people with hearing loss only, and it is worth discussing this with your audiologist. Having a hearing aid in each ear, and thus picking up sounds from all around, is probably more helpful for tinnitus than using just one, so do ask about this if you are using one aid but have hearing loss in both ears.

Although Itard’s patients didn’t have access to hearing aids, his recommendations for sound therapy tie in pretty well with what we know today. Nature sounds, whether created by a digital machine or a real log fire, do seem to help people manage their tinnitus better. It is not yet fully understood exactly how this works, but it does seem that drowning out the tinnitus with loud sound is less effective in the long term than listening to soothing sounds at a lower level. So, make a note of sounds that you find pleasant, relaxing and easy to listen to, and have fun experimenting!

References:

1. Itard JM. Traite des Maladies de l’oreille. 1821.

2. Jastreboff P, Hazell J. Tinnitus Retraining Therapy: Implementing the neurophysiological model. Cambridge: Cambridge University Press; 2004.

3. Eysel-Gospath K, Gerhards F, Schickertanz KH, Teichman K, Benthien M. Aufmerksamkeitslenkung in der Tinnitustherapie. HNO. 2004; 52: 431-438.

4. Handscomb, L. Use of bedside sound generators by patients with tinnitus-related sleeping difficulty: which sounds are preferred and why? Acta oto-laryngologica, 2006; 126: 59-63.

Spring Quiet 2007