The Analysis Of The Primary Efficacy Of The Group Tinnitus Retraining Therapy And Its Related Factors And Prognostic Factors

Background:Tinnitus is a common clinical symptom instead of an independent disease. According to the relevant epidemiological data, the proportion of tinnitus among the population is about 10% to 15%. There are two kinds of tinnitus including subjective and objective tinnitus. The former means a virtual sensation of sound without external sound or vibration, which can only be perceived by the patients and not measured and evaluated.Vascular source, breathing source, temporomandibular joint dysfunction and so on, account for objective tinnitus. Except for 80% of tinnitus patients who get natural habituation, tinnitus causes severe interference to the rest 20% patients, including anxiety, panic, inattention, sleep disorders, irritability, lower productivity, depression and even suicide, raising the attention of otolaryngology doctors and psychiatrists. Common causes of tinnitus include various kinds of diseases such as sensorineural deafness, acoustic neuroma, Meniere’s disease, depression, noise and so on, but the specific pathogenesis of tinnitus is still in research. Through persistent efforts, Scholars put forward the theory of edge, inconsistent damage principle, cross theory and other relevant theories. The treatment of tinnitus includes drugs, hypnosis, acupuncture, transcranial magnetic stimulation, tinnitus masking therapy, cognitive behavior therapy, tinnitus retraining therapy and so on. Because effective methods have not been found, clinicians start to take the elimination of tinnitus’bad adverse effect as the treatment target, and have achieved certain results. Among them, the tinnitus retraining therapy is one of the most widely used therapies, especially for long-term persistent tinnitus patients.Directive counseling and sound therapy are two cornerstones of tinnitus retraining therapy. Directive counseling is performed by skilled clinicians to the patients with detailed explanation and education including the pathway of voice, the mechanism of tinnitus,how tinnitus annoys patients and other relevant theoretical knowledge, so that the patients may get rid of anxiety or even fear brought by the ignorance of the tinnitus or other reasons. Sound therapy provides another sound through rich background sounds or carrying sound generator, hearing aids, to reduce the difference between background neural activities and tinnitus so as to accelerate the habituation of tinnitus. As for psychological therapy, it’s believed to be established on the basis of the guidance and treatment. The theoretical basis of tinnitus retraining therapy is neural physiological model, which explains how tinnitus annoys patients. Except for the auditory system, the limbic system and the autonomic nervous system also play an important role in it.It has been more than 25 years since Jastreboff and Hazell firstly put forward tinnitus retraining therapy, which is widely applicated in the United States, Japan, Korea, Malaysia and other countries. Most of the clinical trials showed that 80% tinnitus patients got relieved after a year’s treatment of tinnitus retraining therapy without obvious complications. Many experts from different countries performed modified tinnitus retraining therapy combining clinical characteristics and the patients’ characteristics, without changing the basic principles. In addition, tinnitus retraining therapy has been performed in China in 2000, however, it is still not widely used in clinical practice except for some hospitals or hearing centers. Standard tinnitus counseling needs doctors and tinnitus patients one to one and face to face for a long time treatment, consuming a large amount of labour and time,. At the same time, the traditional directive counseling takes a few hours and several times, which is completely unable to perform in view of the current domestic clinical load. So far, some international centers try to arrange doctors and patients in groups instead of individuals, releasing the burden of doctors.To some extent, tinnitus patients of China are in the embarrassed state of "no cure". In view of the above matter, we try to use group therapy, and optimize the contents of counseling, apply pictures and visualized content to finish the work of directive counseling, evaluate the effect, so as to establish a counseling project that accords with the situations in China.Objective:There were 79 subjective tinnitus outpatients whose duration were more than six months in this study. Before and after the treatment, the patients finished the basic data of tinnitus handicap inventory, self-rating anxiety scale and self-rating depression scale and so on. To study on the primary efficacy of a simplified version of the group directive counseling with pictures for subjective tinnitus patients. To explore the correlation between tinnitus severity and anxiety and depression before the treatment. And to analyze the related prognostic factors of the efficacy of the therapy to provide new ideas for future clinical diagnosis and treatment.Methods:According to the inclusion criteria and exclusion criteria strictly, the subjective tinnitus outpatients suffered more than 6 months were screened from August 2014 to August 2015 in Guangdong Province People’s Hospital of otolaryngological clinics. Before the treatment, patients completed the primary questionnaire, tinnitus handicap inventory, self-rating anxiety scale and self-rating depression scale with a doctor’s help. Then they were divided into groups of 3-5 people. Each group accepted directive counseling for about 40 minutes explained by powerpoints, including 10 minutes of free discussion in the end. Six months after the treatment, a skilled physician followed up the paients by telephone, filled in the scales of tinnitus handicap inventory and visual analog scale,and enhanced the effect according to the patients individually. The contents of directive counseling consist of tinnitus general characteristics, sound conductive pathway, the relation of tinnitus and hearing loss, principle and objective of directive counseling and sound therapy, the final goal of tinnitus retraining therapy, the brain plasticity, the limited attention and so on.Analysis of the primary efficacy of the simplified version of the group tinnitus retraining therapy:Wilcoxon rank test was performed to compare 6 months’efficacy after the treatment, including THI, VAS (loudness, degree of distress, time of consciousness, time of distress). Effect size was often used to evaluate the therapeutic effect, as the difference between before and after treatment with the standard deviation.To study on the correlation between the patients’tinnitus severity and anxiety, depression before the treatment, so as to provide clinical evidence for the more attention of the physicians in the process of diagnosis and treatment about the patients’degree of anxiety and depression:the tinnitus handicap inventory and its three subscales, SAS, SDS is equal interval variables applied to Pearson correlation analysis. According to the grading standards of guideline provided by Mccombe in the 2001,in order to study the correlation of the mild and severe tinnitus severity and anxiety and depression, the patients were divided into two groups to be analyzed by Pearson correlation analysis with SAS,SDS taking THI points<38 points (mild) and THI>38 (severe) as the standard.To explore prognostic factors of the simplified version of the group tinnitus retraining therapy:the patients were divided into the effective group and ineffective group, with Wilcoxon rank test comparing age, sex, course of disease, sleep, anxiety, depression, loudness and distress degree of the basic data between the two groups,with binary logistic regression analysis of the significant index of whether treatment is effective.Results:1.The efficacy of treatment of the 79 subjective tinnitus patients after six months:Wilcoxon rank test was performed to compare THI and its subscales, the VAS (loudness, degree of distress, time of consciousness, time of distress) before and after the treatment, which turned out to be significant(p≤0.001). According to the evaluation criteria of efficacy promoted by Wang, after six months,21 patients (26.6%) were totally habituated,28 patients (35.4%) were almost habituated,16 patients (20.3%) were partially habituated,14 patients (17.7%) were not habituated. The effect size of THI and its subscales, the VAS (loudness, degree of distress, time of consciousness, time of distress) were evaluated. The outcomes showed that all iterms were>0.80 (THI:1.156, THIC:0.797, THIE:0.894, THIF:1.029.AN: 1.471,AW:0.998,AT:0.865) with significant efficacy, except for the loudness with mild efficacy(LD:0.387).2.The relation between THI and SAS,SDS:Pearson correlation analysis was applied to analyze THI and SAS, THI and SDS, both showing moderate positive correlation(THI&SAS:r= 0.556, P< 0.001; THI&SDS:r= 0.480, P< 0.001). The three subscales and SAS, SDS were analyzed with Pearson correlation analysis respectively. The results turned out mild positive correlation between THIC and SAS, no correlation between THIC and SDS (r=0.210,P=0.063), and moderate positive correlation for the rest (THIE&SAS:r= 0.506, P< 0.001; THIF&SAS:r= 0.627, P< 0.001; THIE&SDS:r= 0.438, P< 0.001; THIF&SDS:r= 0.499, P< 0.001).The comparison of the mild tinnitus patients and moderate to severe tinnitus patients was evaluated by Mann-Whitney U analysis,both demonstating statistics significance (SAS:Z=-3.362, P=0.001;SDS:Z=-2.884, P=0.004).3.The patients were divided into effective and ineffective groups to compare the basic data with Mann-Whitney U analysis or the Wilcoxon rank test(grade variables):the results showed that the duration, THI score, loudness, the degree of distress, time of distress and SAS score were positively significant to the efficacy. Age, sex, the onset of tinnitus, tinnitus types, ear sides, average threshold, tinnitus consciousness daily and SDS score had no statistical significance. Binary Logistic regression analysis was applied according to the efficacy with treatment outcome as the dependent variable, and the duration, THI score, loudness, the degree of distress, time of distress and SAS score as independent variables. It turned out only THI score was statistically significant(p<0.001, Exp(P)=1.161).Conclusions:This study established specific scheme of the simplified version of the group tinnitus retraining therapy, which had not been reported before in China.79 patients with subjective tinnitus were treated and followed up for 6 months, with the treatment efficacy of 74.68%,and the rate of habituation of 82.3% according to the evaluation standard of efficacy. The scheme has the advantages of simplified content, vivid and easy to understand and time-saving.For subjective tinnitus patients with duration more than 6 months, the level of anxiety and depression showed moderate positive correlation to the tinnitus severity. Moderate to severe tinnitus patients suffered more anxiety and depression than themild tinnitus patients. Clinical resources should be allocated to more moderate to severe tinnitus patients. As for the simplified version of the group tinnitus retraining therapy, the favourable factors of the short term efficacy were longer duration, higher THI score before treatment, higher loudness rating before treatment, higher distress of degree rating before treatment, higher distress of time, higher SAS score. Among them, THI score is the protective prognostic factor of the treatment.