The Pros and Cons of Telehealth for Tinnitus Care
By Marc Fagelson, PhD
It may be that the first human ever bothered by tinnitus was simultaneously bothered by the lack of help they received from family, friends, and if such things existed, the opinions of local healthcare providers. From that moment until the present, the prevalence of tinnitus has outpaced the availability of care providers. Add psychological distress and mental health considerations that often complicate the tinnitus experience, and the ability to access effective care becomes a challenge that some patients would rather forgo than pursue.
About 20 years ago, Gerhard Andersson, a Swedish professor of clinical psychology, coauthored two groundbreaking papers that investigated the utility of cognitive behavioral therapy (CBT) programs tailored for delivery through the internet. The first focused on headache; the second, on tinnitus.1,2 Both studies demonstrated, as compared to face-to-face contact, the efficacy of CBT was maintained when offered on an internet platform. This accomplishment is even more impressive when we consider that the 2002 study provided, remotely, a psychological intervention for distressing sensory events whose severity relied in part upon mental health status. It is a credit to the authors that these publications remain relevant today with regard to their methodology as well as the opportunities they represent for patients experiencing healthcare challenges.
Remote service provision may be provided synchronously — essentially face-to-face but from remote locations — or asynchronously, using prerecorded materials or modules scripted a priori that patients access at their own pace.
Synchronous Intervention
In the synchronous setting, a clinician and patient conduct a telephone or video meeting in which they may engage in dialogue regarding everything from case history to recommendations. Patients can complete intake forms and tinnitus, hyperacusis, and mental health questionnaires, and receive counseling in real time. Screen sharing allows the clinician to support counseling with images pertaining to the patient’s test results, anatomy, tinnitus mechanisms, and demographics.
Here, the patient must commit to a specific appointment time, but they attend the session from a site more convenient to them than the audiology clinic or hospital. Some patients report experiencing anxiety in medical settings3 and express a preference for accessing services from home. Patients could also attend sessions synchronously in a group (similar to a Zoom call). One advantage to such groups is that they tend to produce higher retention rates among patients, perhaps due to peer support or good-natured peer pressure.
In addition to requiring specific appointment times, limitations of synchronous counseling appointments include impediments to the exchange of information, such as low-quality images on the patient’s phone or computer. In our experience, the majority of veteran patients in a rural setting (i.e., one of the populations, it could be said, that remote health-care targets) expect to conduct a synchronous tinnitus counseling session on their phone. In such cases, the reduced image quality of shared slides may degrade the patient’s experience. Further, when the clinician is masked, for example, as during a session at a clinic requiring masks, patients may experience greater difficulty understanding the clinician than they would encounter during face-to-face contact.
The experience of conducting tinnitus counseling remotely in real time resembles that of video phone call with friends or family: not as good as being together, but at least problems can be discussed, information shared, and plans devised with mutual contribution and understanding.
Patients may access several interventions for tinnitus through telemedicine or telehealth platforms that offer synchronous contact. For example, Progressive Tinnitus Management (PTM) was offered via telephone and internet for veterans.4,5 Several clinics in countries around the world offer versions of tinnitus retraining therapy (TRT) through interactions using telephones and telemedicine platforms.6 Results from such approaches to tinnitus management appear to maintain the fidelity and success rates of in-person interactions.
Asynchronous Interaction
Asynchronous programs, such as those discussed by Andersson et al.,2 employ counseling and educational materials in sets of modules through which patients matriculate at their own pace. Asynchronous platforms may employ materials associated with, among others, CBT,2,3 mindfulness meditation,7 and acceptance therapy8 (see, additionally, Beukes et al. [2019] for review).9
Many interventions offer specific sets of “required” modules, while other studies include optional modules.3 In truth, all modules offered asynchronously are optional, and participants know it. In comparison to synchronous group meetings, patients who agree to complete a set of online modules appear less likely to do so without any peer support or peer pressure to maintain attendance.2
Unlike a synchronous consult, the modularized offerings lack the flexibility and spontaneity of a live discussion. However, the modules never forget to mention something that might be important to the patient. Most online programs consist of modules focused on specific elements of management, including, for example, masker use, hearing aid use (if appropriate), sleep hygiene, muscle relaxation, and hearing protection use. Other modules focus on anatomy and physiology, thereby offering reasonable, albeit bare-bones information regarding tinnitus mechanisms.
Although online tinnitus management strategies are accessible to patients, their utility and the durability of their effects remain to be thoroughly researched. One major drawback related to research focused on internet interventions is that low participant retention and completion rates may hinder generalizing results to a wider patient population. These statements are not intended to dissuade potential participation but rather to reinforce the need for realistic expectations prior to embarking upon any intervention course.
Andersson and colleagues identified a number of study limitations that would influence research conducted using the internet platform.2 Of primary importance, the authors caution that engagement of the participants requires monitoring, and they suggest consideration of participant motivation to complete the intervention prior to enrollment. To maximize intervention efficacy, participants would likely need to review study materials carefully, albeit without oversight from providers. Some participants might agree to the program, with good intentions, but withdraw without completing as a result of time limitations.
Additional Considerations
We may be at an important intersection: If time bears out the current state of affairs, in which remote tinnitus service provision approximates the success of in-person contact, then tinnitus clinicians will need to either improve the success of face-to-face interactions or devote substantially more time than at present to their use of internet platforms. This writer’s opinion is that the face-to-face appointment is the standard for our profession; however, the emergence of a viable alternative to the in-person appointment compels a thoughtful pause even as it produces an irrational gnashing of teeth.
By definition, the use of an internet platform requires that the clinician abdicate control over the intervention. In asynchronous interventions, the materials are intended as a self-guided experience for the patient. It is probably counterintuitive for a well-practiced audiologist to willingly step back from administering direct care in favor of a self-paced psychological intervention. Hence the aforementioned gnashing of teeth.
Indeed, face-to-face audiologic interventions outnumber those relying on internet delivery with regard to patient load and services rendered, suggesting: (1) audiologists value, and likely believe, patients receive more benefit from in-person contact; (2) self-efficacy for clinicians is higher in the clinic than it is when providing remote services; (3) most patients do not experience undue difficulty accessing in-person services, and anyway, they would rather travel to a clinic to seek in-person contact than complete a self-guided intervention; (4) audiologists hesitate to take up new technology, and anyway, the internet didn’t change much since 2002. It is probable that many patients would deny number 3, and a majority of audiologists would deny number 4. But it is clear by now that enhancing provider self-efficacy in the context of remote interactions will increase in importance with time.
There is no need to reemphasize lessons learned from the pandemic; it is likely that other circumstances will emerge in the future that limit the movement and opportunities of at least the most vulnerable members of a population. Like it or not, if audiologists are to manage tinnitus in a manner that has the potential to be successful and sustainable, we will increasingly rely upon remote contact between patients and providers.
“Like it or not” is the key statement in the sentence above because there is much to like and dislike about remote interactions between patients and clinicians. Along with the examples above, Table 1 summarizes some advantages and disadvantages.
Such considerations were taken into account nearly 20 years ago when Gerhard Andersson and colleagues presented an early attempt to employ psychological intervention for tinnitus using a telemedicine platform.2 Although they reported high dropout rates — characteristic as well of internet-based interventions for other health problems — the authors concluded that the platform provided patients care and information that they would not have otherwise been able to access. They suggested that online delivery of services for tinnitus would be most appropriate as an ancillary element to support clinical intervention rather than as the primary intervention. In this regard, investigators could not anticipate that the clinical endeavor of tinnitus management would be affected not only by pandemics but also by chronic challenges associated with a dearth of clinicians and an overabundance of patients.
Tinnitus challenges both patients and providers. Perhaps we can paraphrase the old Catskills joke: One patient with tinnitus says to another: “Nobody has been able to help me cope with my tinnitus,” to which the other replies, “Yes, and there are so few clinicians willing to try.”
Marc Fagelson, PhD, is a professor of audiology in the Department of Audiology and Speech-Language Pathology at East Tennessee State University. He earned undergraduate and master’s degrees at Columbia University in New York City and his PhD at the University of Texas at Austin. His clinical and academic teaching includes hearing science, audiological evaluation, pathologies of the auditory system, and tinnitus management. He coedited Tinnitus: Clinical and Research Perspectives and a companion text, Disorders of Sound Tolerance, with Dr. David Baguley; both books were published by Plural. Dr. Fagelson has more than 40 publications and has presented more than 100 times at conferences and workshops. He opened the James H. Quillen Mountain Home VA Medical Center Tinnitus Clinic in 2001; the clinic has enrolled more than 1,000 patients. Dr. Fagelson provides extensive and collaborative counseling for patients, as well as a variety of sound therapy strategies, to support their ability to manage tinnitus. A substantial proportion of the veterans seen in the clinic experience tinnitus that is complicated by the influence of co-occurring psychological conditions, and in particular post-traumatic stress disorder. This challenging and underserved population is the focus of Dr. Fagelson’s research. He is also a member of the ATA’s Scientific Advisory Committee.
1 L. Ström, R. Pettersson, & G. Andersson. (2000). A controlled trial of self-help treatment of recurrent headache conducted via the internet. Journal of Consulting and Clinical Psychology, 68, 722–727.
2 G. Andersson, T. Strömgren, L. Ström, & L. Lyttkens. (2002). Randomized controlled trial of internet based cognitive behavior therapy for distress associated with tinnitus. Psychosomatic Medicine, 64, 810–816.
3 E. W. Beukes, V. Manchaiah, A. S. A. Davies, P. M. Allen, D. M. Baguley & G Andersson (2018) Participants’ experiences of an Internet-based cognitive behavioural therapy intervention for tinnitus, International Journal of Audiology, 57:12, 947-954, DOI: 10.1080/14992027.2018.1514538
4 J. A. Henry, E. J. Thielman, T. L. Zaugg, et al. (2019). Telephone-based Progressive Tinnitus Management for persons with and without traumatic brain injury: A randomized controlled trial. Ear and Hearing, 40(2), 227–242.
5 J. A. Henry, E. J. Thielman, C. Kaelin, C. M. Quinn, & M.-C. Goodworth. (2020). Telehealth-based Progressive Tinnitus Management. Hearing Journal, 73(5), 32–35. doi:10.1097/01. HJ.0000666428.38843.10
6 P. J. Jastreboff & J. W. Hazell. (2004). Tinnitus Retraining Therapy: Implementing the Neurophysiological Model. Cambridge: Cambridge University Press
7 B. P. Fitzgerald, C. Stocking, M. Ralli & A. Sheppard. (2021). At-home meditation for tinnitus management. Hearing, Balance and Communication, 1–9. doi:10.1080/21695717.2020.18 70825
8 H. Hesser, T. Gustafsson, C. Lunden, et al. (2012). A randomized controlled trial of internet-delivered cognitive behavior therapy and acceptance and commitment therapy in the treatment of tinnitus. Journal of Consulting and Clinical Psychology, 80, 649–661.
9 E. W. Beukes, V. Manchaiah, P. M. Allen, D. M. Baguley, & G. Andersson. Internet-Based Interventions for Adults With Hearing Loss, Tinnitus, and Vestibular Disorders: A Systematic Review and Meta-Analysis. Trends in Hearing. January 2019. doi:10.1177/2331216519851749