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Tinnitus: What can occupational offer?

Article in Occupational Therapy Now · November 2018

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Chelsea Jones Leiden University Medical Centre

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Tinnitus: What can occupational therapy offer?

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What is tinnitus? frequent occurrence among the CAF population. Many CAF innitus is widely defined as auditory perceptions of members referred to occupational therapy reported that they Tsound in the absence of external acoustic stimulation were informed by colleagues and care practitioners (Mayo Clinic, 2018). Tinnitus is not a condition of itself; it is that tinnitus is common in the military and there is nothing a symptom of an underlying condition, such as , that can be done about it. While it is true that effective ear injury, or a systemic disorder (Mayo Clinic, 2018). Those treatments to reduce or eliminate the sensation of tinnitus are experiencing tinnitus may describe this symptom as “ringing in limited, I recognized there might be something I could do to the ears” or “white noise”; however, each individual’s experience enable CAF members to manage the effects of tinnitus on with tinnitus is unique—the sensation and sound can vary occupational performance and engagement. from person to person. Consistent with findings from studies During the process of conducting a literature review, of military members in other developed countries, there is a I learned that tinnitus is a widespread auditory disorder higher prevalence of tinnitus among Canadian Armed Forces affecting approximately 10 to 15% of the civilian population, (CAF) members in comparison to the general Canadian making it a barrier to occupational engagement that is relevant population (Abel, 2004; Department of National Defence, not only to practitioners working with military members and 2016). This could be attributed to increased exposure to often Veterans but also to practitioners employed in civilian health unpredictable and repeated high decibel noise during military care (Leaver, Seydell-Greenwald, & Rauschecker, 2015; Mayo duties (Humes, Joellenbeck, & Durch, 2006). In a study Clinic, 2018). In 2016, I consulted with audiologists conducting of 1,057 CAF members in the Army, Navy, and Air Force, research with the Department of National Defence and 52% of those surveyed reported experiencing some tinnitus inquired into the current state of protocols and research in (Abel, 2004). Among these, 11% reported moderate to much the area of tinnitus. Research regarding tinnitus management, interference in their ability to hear (Abel, 2004). Tinnitus therapy, prevention, and rehabilitation with the CAF was may be caused or exacerbated by mental health conditions limited. I began researching tinnitus management strategies. (e.g., depression and anxiety), noise-related trauma, stress, Systematic reviews and evidence-based protocols for tinnitus and other conditions; such issues are experienced by service management interventions and programs are available from members at a higher rate than by their civilian counterparts around the world. These protocols typically involve multiple (Abel, 2004; Department of National Defence, 2016; Fagelson practitioners from interdisciplinary teams, such as primary & Smith, 2016). Tinnitus can have a profound effect on a care physicians, psychologists, social workers, and speech- person’s functioning, impacting, for example, sleep, cognition, language pathologists; however, I was unable to find any and affect. In addition to affecting overall daily functioning, literature specific to tinnitus and occupational therapy. The tinnitus can be exacerbated in noisy and busy environments, more I learned about tinnitus, the more I recognized a role for resulting in an affected CAF service member avoiding such occupational therapists in its management. situations. Aversion to noisy or busy environments can lead to decreased occupational performance and engagement in all What can occupational therapists offer? areas of life, including military work, leisure pursuits, and social Occupational therapists are unique in that our profession relationships (Fagelson & Smith, 2016). acknowledges—through our holistic, inclusive, and recovery- based models, frameworks, perspectives, and functional Addressing a need approaches to assessment and treatment—the intertwining As a CAF , I receive occasional referrals of biopsychosocial factors that may contribute to barriers for CAF members with tinnitus that ranges in severity from to occupational performance. One frequently used model mild to catastrophic as defined by the Tinnitus Handicap is the Canadian Model of Occupational Performance and Inventory (Newman, Jacobson, & Spitzer, 1996). Referring Engagement (CMOP-E), which highlights the person, primary care practitioners are typically unsure of where occupation, environment, and spirituality as essential else to send their patients to address tinnitus, despite its components that interweave to affect an individual’s

12 OCCUPATIONAL THERAPY NOW VOLUME 20.6 strengths, engagement with the world, and experience of indicate their tinnitus is having a severe or higher impact on barriers (Polatajko, Townsend, & Craik, 2007). Focus on psychosocial domains may also benefit from additional mental daily functioning, with the client taking an active role in the health screens to inform the rehabilitation plan and targeted care path, is integral to the success of any intervention. The intervention involving a multidisciplinary team. perspective informed by this and other holistic models is what makes occupational therapists so successful at working Management strategies with a variety of clients and addressing a variety of specific Tinnitus can affect occupational performance in activities of conditions, many of which are chronic in nature. daily living related to self-care, productivity, and leisure, which Chronic pain and tinnitus are similar in that they are can lead to distress and potentially affect mental health. A sensory–perceptual symptoms associated with negative affect person with tinnitus may worry about whether this symptom and significant impact on well-being and behaviour (Leaver is a precursor or adjunct to a disease, a predictor of future et al., 2015). Both chronic pain and tinnitus involve higher- hearing loss, or evidence of a mental illness (Fagelson & Smith, level cognitive and affective brain systems, even though 2016; Martinez-Devesa, Perera, Theodoulou, & Waddell, the resulting sensations are experienced in different areas 2010). Managing tinnitus involves minimizing the resulting of the body (Leaver et al., 2015). Addressing chronic pain psychological stress it can cause and maintaining or increasing management is a common practice for occupational therapists, day-to-day functioning despite its presence (Fagelson & as we have the skillset to effectively unite physical, mental, Smith, 2016; Humes et al., 2006). Management of tinnitus may and cognitive health with evidence-based assessment and include cognitive-behavioural therapy (CBT), mindfulness, intervention. With this in mind, it was not surprising to me that psychoeducation, and sound therapy to reduce fear and the evidence-based literature around tinnitus management anxiety surrounding symptoms (Fagelson & Smith, 2016; interventions showed that they have similarities to chronic pain Martinez-Devesa et al., 2010). Psychoeducation may provide management interventions. reassurance to clients, which could be integral to reducing psychological barriers to engagement in daily occupations. Assessments Cognitive rehabilitation strategies to assist with listening There is research indicating which outcome measures most skills, attention, and concentration could also be provided by effectively quantify the effects of tinnitus on performance occupational therapists. As well, occupational therapists can and functioning in activities of daily living. These outcome play a role in providing education about hearing protection, measures, such as the Tinnitus Handicap Inventory (Newman safe noise thresholds, and auditory health to prevent et al., 1996), Tinnitus Function Index (Fackrell, Hall, Barry, & exacerbation of tinnitus and/or hearing loss. The use of all the Hoare, 2016), and Tinnitus Reaction Questionnaire (Wilson, aforementioned interventions in combination is consistent Henry, Bowen, & Haralambous, 1991) have been validated with evidence-based recommendations for the management in multiple languages, including French and English. These of tinnitus by interdisciplinary teams in different outcome measures address perception of functioning, settings. (Zenner et al., 2016) Many occupational therapists are , and distress attributed to tinnitus, and they fit within educated and trained in CBT, mindfulness, psychoeducation, the frameworks, models, and perspectives of occupational and cognitive rehabilitation and apply these interventions to a therapy. These measures also address the severity of an multitude of chronic conditions and incidences of dysfunction. individual’s tinnitus. As multiple domains are addressed within Through the application of psychoeducation and optimal the Tinnitus Function Index in particular, practitioners can use of self-management techniques, stress and dysfunction use it to acquire some indication of how tinnitus is impeding related to tinnitus may be reduced. Following occupational a person’s participation and engagement in daily activities therapist-led instruction on mindfulness and meditation from a psychological (sense of control, emotional distress, practices, some CAF members reported these were effective intrusiveness, relaxation interference), functional (cognitive for providing relief from the tinnitus as well as in managing interference, quality of life), and physiological (auditory, sleep stress. Some members reported that they continued to disturbance) perspective. These outcome measures can be practice mindfulness independently and that the severity and utilized to measure change over time. volume of their tinnitus were reduced after the intervention. Additionally, subjective interviewing can also help practitioners to find valuable information about the history Looking forward and onset of the tinnitus as well as what strategies or Occupational therapists could have an integral role in the treatments the client has used or engaged in previously. The management of tinnitus and other hearing-related disorders in Canadian Occupational Performance Measure (COPM) both civilian and military health care. I encourage occupational is an outcome measure developed and widely used by therapists to look to the evidence base if they encounter occupational therapists for a myriad of different clients clients with tinnitus. Members of our profession have a unique with varying conditions (Law, Baptiste, Opzoomer, McColl, skill set that can allow us to provide effective interventions Polatajko, & Pollock, 1990). This measure could be helpful in that enable clients to manage this symptom and its associated assessing a client’s perspective and prioritization of functional occupational barriers. Yet, more research would be beneficial issues caused by tinnitus, in a similar way to how it is often to validate the effectiveness of occupational therapy utilized with clients with other chronic conditions. Clients who interventions for clients with dysfunction due to tinnitus.

OCCUPATIONAL THERAPY NOW VOLUME 20.6 13 Overall, evidence related to the involvement of occupational Humes, L., Joellenbeck, L., & Durch, J., (2006). Noise and military service: therapists with clients with tinnitus is limited; however, this Implications for hearing loss and tinnitus. Washington, DC: National Academies Press. doi:10.17226/11443 identified gap in services could be an emerging area of practice, the expansion of which could result in increased Martinez-Devesa, P., Perera, R., Theodoulou, M., & Waddell, A. (2010). Cognitive Behavioral therapy for tinnitus. Cochrane Database of Systematic functioning and quality of life for many clients with this Reviews, 2010(9). doi:10.1002/14651858.CD005233.pub3 potentially devastating symptom. Law, M., Baptiste, S., McColl, M., Opzoomer, A., Polatajko, H. & Pollock, N. (1990). The Canadian Occupational Performance Measure: An outcome measure for occupational therapy. Canadian Journal of Occupational Disclosure: I certify that I have affiliation with the organization Therapy, 57, 82-87. doi:10.1177/000841749005700207 discussed in the manuscript in the form of civilian employment Leaver, A., Seydell-Greenwald, A., & Rauschecker, J. (2015). Auditory-limbic as an occupational therapist with the Department of National interactions in chronic tinnitus: Challenges for neuroimaging research. Hearing Defence/Canadian Armed Forces. The opinions stated are Research, 334, 49-57. doi:10.1016/j.heares.2015.08.005 those of the author and not those of the organization. Mayo Clinic. (2018). Tinnitus. Retrieved from https://www.mayoclinic.org/ diseases-conditions/tinnitus/symptoms-causes/syc-20350156 Newman, C., Jacobson, G., & Spitzer, J. (1996). Development of the Tinnitus Handicap Inventory. Archives of Otolaryngology – Head and Neck Surgery, References 122, 143-148. doi:10.1001/archotol.1996.01890140029007 Abel, S. M. (2004). Risk factors for the development of noise-induced hearing Polatajko, H. J., Townsend, E. A., & Craik, J. 2007. Canadian Model of loss in Canadian Forces personnel. Retrieved from http://www.veterans. Occupational Performance and Engagement (CMOP-E). In Enabling gc.ca/pdf/about-us/research-directorate/risk-factors-hearing-loss-cdn- occupation II: Advancing an occupational therapy vision of health, well-being, forces.pdf & justice through occupation. In E. A. Townsend & H. J. Polatajko, Eds. (2nd ed., p. 23) Ottawa, ON: CAOT Publications ACE. Department of National Defence. (2016). Health and lifestyle information survey 2013/14 of Canadian Forces personnel – Regular Force report. Ottawa, Wilson, P., Henry, J., Bowen, M., & Haralambous, G. (1991). Tinnitus Reaction ON: Author. Questionnaire: Psychometric properties of a measure of distress associated with tinnitus. Journal of Speech and Hearing Research, 34, 197-201. Fackrell, K., Hall, D., Barry, J., & Hoare, D. (2016) Psychometric properties of doi:10.1044/jshr.3401.197 the Tinnitus Functional Index (TFI): Assessment in a UK research volunteer program. Hearing Research, 335, 220-235. doi:10.1016/j.heares.2015.09.009 Zenner, H., Delb, W., Kroner-Herwig, B., Jager, B., Peroz, I., Hesse, G., Mazurek, B., Goebel, G., Gerloff, C., Trollmann, R., Biesiger, E., Seidler, Fagelson, M., & Smith, S. (2016). Tinnitus self-efficacy and other tinnitus H., & Langguth, B. (2016). A multidisciplinary systematic review of self-report variables in patients with and without post-traumatic the treatment for chronic idiopathic tinnitus. European Archives of stress disorder. Journal of Ear and Hearing, 37, 541-546. doi:10.1097/ Otorhinolaryngology, 274, 2079-2091. AUD.0000000000000290

About the author Chelsea Jones, MScOT, OT, has been an occupational therapist for the Canadian Armed Forces for six years. She graduated from the Master of Science in Occupational Therapy program at the University of Alberta in 2010. She is employed at Canadian Forces Base Edmonton and is also currently employed by the Faculty of Rehabilitation at the Universirty of Alberta as the Heroes in Mind, Advocacy and Research Consortium (HiMARC) Coordiantor. She can be reached at: [email protected]

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