tinnitus in a high-risk population (veterans and service

Tinnitus in a High-risk Population (Veterans and Service Members)

Lynn W. Henselman, PhD (LTC, U.S. Army, Retired)DoD Hearing Center of Excellence

Defense Health AgencyJune 2020

This briefing is UNCLASSIFIED

Disclosure

The views expressed in this presentation are those of the authors and do not necessarily reflect the official policy of the Hearing Center of Excellence, Defense Health Agency, Department of Defense, or United States Government.

2UNCLASSIFIED “Medically Ready Force…Ready Medical Force”

Agenda

∎ Introduction∎ Overview of Department of Defense (DoD) Hearing Center of

Excellence (HCE)∎ Impact of tinnitus on Service members and Veterans∎ DoD and Department of Veterans Affairs (VA) clinical and

research efforts and best practices∎ Conclusion

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Definitions

Service member∎ A member of the "uniformed

services", including the armed forces (Army, Navy, Air Force, Marine Corps, and Coast Guard), the Commissioned Corps of the National Oceanic and Atmospheric Administration, and the Commissioned Corps of the Public Health Services.

https://www.va.gov/opa/persona/active_duty.asp

Veteran∎ A person who served in

the active military, naval, or air service, and who was discharged or released under conditions other than dishonorable.

38 U.S. Code§ 101

4“Medically Ready Force…Ready Medical Force”UNCLASSIFIED

https://www.va.gov/opa/persona/active_duty.asp

https://www.law.cornell.edu/definitions/uscode.php%3Fwidth=840&height=800&iframe=true&def_id=38-USC-1994457193-746307971&term_occur=999&term_src=title:38:part:I:chapter:1:section:101

Department of Defense Hearing Center of Excellence (HCE)

Congressional Mandate Duncan Hunter National Defense Authorization Act for Fiscal Year 2009 (Public Law 110-417, Section 721): Directed Secretary of Defense to establish a Center of Excellence for hearing loss and auditory system injuryfocused on:

UNCLASSIFIED “Medically Ready Force…Ready Medical Force”

“ensure that the center collaborates to the maximum extent practicable with the Secretary of Veterans Affairs, institutions of higher education, and other appropriate public and private entities (including international entities)”

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Goals

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Coordinate, encourage, and facilitate conduct of research.

Goal 2: Research

Help coordinate VA rehabilitation benefits and services to former Service members.Goal 3: Delivery

Goal 1: Best Practices Develop, disseminate, and facilitate implementation of best practices.

UNCLASSIFIED

HCE: A Platform to Facilitate Collaboration

HCE

International Partners

Department of Health

and Human Services

Department of Defense

Department of Veterans

Affairs

Academia

Industry


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Veterans: FY18 Prevalence of Hearing Loss and Tinnitus

Department of Veterans Affairs Disability Awards –Tinnitus and Hearing Loss are the Top Two Service-connected Disabilities in Veterans

# of

Vet

eran

s

Fiscal Year


https://www.benefits.va.gov/REPORTS/abr/archive.asp


DoD Hearing Conservation Program (HCP)

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DoD HCP

Noise Measurement and Analysis

Noise Abatement

Noise Hazard Signs and

Labels

Personal Hearing

ProtectorsEducation

Audiometric Testing

Program Performance

Evaluation

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DoD Instruction 6055.12 (2019)

Tinnitus

∎ Tinnitus is the perception of sound (often referred to as ringing) in the ears or head that does not have a source outside the body.

∎ It is not a disease – it is a symptom that something is wrong in the auditory system.

∎ It is typically associated with exposure to loud noise that can cause hearing loss; however, there are several non noise-related causes (medications, ear and sinus infections, diseases of heart or blood vessels, etc.).

∎ Can be classified into two categories: objective and subjective. q Objective tinnitus can be heard in close proximity to your ear by an examiner. This kind of

tinnitus is rare.q Subjective tinnitus is tinnitus only you can hear. Most people who experience tinnitus

have subjective tinnitus.

∎ About 10 – 15% of adults in the general population experience tinnitus; about one in five describe their tinnitus as “bothersome.”


https://www.ata.org/understanding-facts https://www.nidcd.nih.gov/health/tinnitus

https://www.ata.org/understanding-facts

https://www.nidcd.nih.gov/health/tinnitus

Tinnitus Pyramid


Dobie, R. A. (2004). Overview: Suffering from tinnitus. In J. B. Snow (Ed.), Tinnitus: Theory and management. Lewiston, NY: BC Decker.

Institute of Medicine Report (IOM, 2006)

∎ Public Law 107-330 (December 6, 2002), Section 104, Assessment of Acoustic Trauma Associated with Military Service from WWII to Present.

∎ Concerns about the noise hazards associated with military service and questions about the relationship between noise exposure and hearing loss or tinnitus

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Institute of Medicine (2006). Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. https://doi.org/10.17226/11443


https://doi.org/10.17226/11443

Impact of Tinnitus: IOM (2006)

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HCE slide adapted from IOM (2006), www.hearing.health.mil


http://www.hearing.health.mil/

Tinnitus: Potential Impact onService Members and Veterans

Service members∎ Medical readiness ∎ Operational performance,

mission accomplishment∎ Individual and unit safety∎ Quality of life

Veterans∎ Quality of life ∎ Occupational performance∎ Safety


https://www.defense.gov/observe/photo-gallery/WWII POW/Veteran, J.H. Wilson. Photo used with permission from J.H. Wilson family.

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Tinnitus in a High-risk Population

∎ Exposure to hazardous noise levelsq Steady-state noiseq Impulse noiseq Blast exposure

∎ Tinnitus association with:q Traumatic brain injury (TBI)q Posttraumatic stress disorder

(PTSD)


https://blastinjuryresearch.amedd.army.mil/assets/docs/sos/meeting_proceedings/2011_SoS_Meeting_Proceedings.pdf

DoD Blast Injury Research Program (2011)


Progressive Tinnitus Management (PTM)

∎ Developed by Dr. James Henry, VA National Center for Rehabilitative Auditory Research (NCRAR), Portland VA Medical Center, Portland, OR, his research team, and other VA collaboratorsq NCRAR Research Career Scientistq Research Professor, Department of

Otolaryngology/Head and Neck Surgery, Oregon Health & Science University

q Adjunct Professor, Department of Audiology, Portland State University

∎ Evidence-based best practice –randomized controlled trials conducted

∎ Interdisciplinary approach (audiologists, otolaryngologists, and mental health providers)

∎ Five stepped-levels of tinnitus management care – patients only receive levels they need

∎ Currently implemented by VA and DoD


Henry, J. A. et al. (2015). Adult tinnitus management clinical practice recommendation. Department of Veterans Affairs National Center for Rehabilitative Auditory Research. https://www.ncrar.research.va.gov/Education/Documents/TinnitusDocuments/TinnitusPracticeGuidelines.pdf

https://www.ncrar.research.va.gov/Education/Documents/TinnitusDocuments/TinnitusPracticeGuidelines.pdf

Managing Reactions to Tinnitus

∎ Chronic tinnitus is usually permanent∎ Tinnitus cannot be quieted, but patients can learn to

manage their reactions to itqMay need to be managed for a lifetime

∎ PTM counseling focuses on educating patients to become self-sufficient in managing their reactions to tinnitus


Henry, J. A. et al. (2010). Progressive tinnitus management: Clinical handbook for audiologists. San Diego, CA: Plural Publishing Inc.https://hearing.health.mil/For-Providers/Progressive-Tinnitus-Management/PTM-Provider-Resources/PTM-Guides-and-Handbooks

https://hearing.health.mil/For-Providers/Progressive-Tinnitus-Management/PTM-Provider-Resources/PTM-Guides-and-Handbooks

Collaborative Self-Management

∎ Intervention is not “treatment”∎ Intervention should primarily involve educating

the patient about their managing reactions to tinnitus

∎Different strategies may be needed to manage reactions that occur in different situations


Henry, J. A. et al. (2010). Progressive tinnitus management: Clinical handbook for audiologists. San Diego, CA: Plural Publishing Inc.

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Five Hierarchical Levels of Clinical Services with PTM

∎ Level 1: Referral∎ Level 2: Audiologic Evaluation∎ Level 3: Skills Education∎ Level 4: Interdisciplinary Evaluation∎ Level 5: Individualized Support


Henry, J. A. et al. (2010). Progressive tinnitus management: Clinical handbook for audiologists. San Diego, CA: Plural Publishing Inc.

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VA: Adult Tinnitus Management Clinical Practice Recommendation

∎ Takes into account the Clinical Practice Guideline published by the American Academy of Otolaryngology – Head and Neck Surgery Foundation (Tunkel et al., 2014)

∎ VA recommendation is based on the PTM clinical protocol used by VA and DoD


Henry, J. A. et al. (2015). Adult tinnitus management clinical practice recommendation. Department of Veterans Affairs National Center for Rehabilitative Auditory Research.

Tinnitus Assessment and Treatment Gaps

∎ DoD/HCE (2014) and VA/NCRAR (2015) conducted studies that included assessments of DoD and VA hearing healthcare providers to identify gaps in tinnitus care, including PTM

∎ VA/NCRAR study identified gaps/barriers/challenges to PTM implementation

∎ DoD/HCE study found that more provider support and education was needed to implement PTM in VA and more so in DoD


Findings from the two studies led to a collaboration facilitated by HCE to improve DoD and VA tinnitus services, including better access, for Service members and Veterans.

Schmidt et al. (2017). Need for mental health providers in Progressive Tinnitus Management: a gap in clinical care. Federal Practitioner; 34(5): 6–9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6370437/

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6370437/

VA-DoD Tinnitus Working Group –Founding Organizations


VA-DoD Tinnitus Working Group


Noise Outcomes in Servicemembers Epidemiology Study (NOISE)

∎ Studying short- and long-term effects of military and nonmilitary noise exposures on auditory functioning among Veterans and Service members (Principal Investigator: Dr. James Henry, NCRAR)q NCRAR, 644 participantsq Wilford Hall Ambulatory Surgical Center and Brooke Army Medical

Center, Joint Base San Antonio, TX, 372 participants∎ Investigate the impact of tinnitus on Service members. Analyze data

from the NOISE study that addresses for example, how tinnitus impacts job performance, emotional well-being, etc. (Henry et al., 2019)q Study examines impact of tinnitus in 246 Veterans, 182 Service

members


Impact of Tinnitus on Military Service Members (Henry et al., 2019)


∎ Tinnitus Group:q Job performance: 27% “had difficulty performing work or other activities”q Concentration: 21% reported as a moderate to very big problem that tinnitus

“kept me from concentrating on reading”q Sleep: 59% were “very sleepy, should seek medical advice” (vs. 39% of Service

members without tinnitus)q Anxiety: 52% reported mild to moderate anxiety (vs. 18% Service members

without tinnitus)q Depression: 22% reported mild to moderate depression (vs. 6% of Service

members without tinnitus)

NOISE Study Highlights: Impact of Tinnitus


Service members: “Presence of tinnitus can have effects on job performance, which may be directly or indirectly caused by effects of tinnitus on concentration, anxiety, depression, and sleep.” (Henry et al., 2019)

Henry, J. A. et al. (2019). Impact of tinnitus on military service members. Military Medicine, Volume 184 (Suppl 1), 3/4:604-614. https://doi: 10.1093/milmed/usy328

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https://doi:0/milmed/usy328

∎ Combines clinical episodes of care from both DoD and VA audiograms, demographic, deployment, and theatre trauma and non-trauma data

∎ All information is digitized∎ Identifies and tracks personnel with hearing loss and auditory/vestibular

injury via clinical diagnosis (ICD9/ICD10 codes in a watch list)∎ Supports readiness through monitoring∎ Provides outcomes data∎ Supports clinical providers with longitudinal

data∎ Provides bidirectional data sharing

capability between DoD and VA∎ Outlines, monitors, and reports on critical

measures of program effectiveness∎ Enables research for the development of best practices

Joint Hearing Loss and Auditory System Injury Registry (JHASIR)


HCE (2019)

Summary

∎ Service members and Veterans are at high risk to develop tinnitus.

∎ Tinnitus has the potential to impact Service members’ medical readiness and operational performance and Veterans’ quality of life.

∎ The HCE, DoD, VA, and collaborators are working to close research and clinical care gaps that impact Service members and Veterans.


Thank You

29

Questions


References

Clifford, R. E., Baker, D., Risbrough, V. B., Huang, M., & Yurgil, K.A. (2019). Impact of TBI, PTSD, and hearing loss on tinnitus progression in a U.S. Marine cohort. Military Medicine, 184, 11/12: 839-846. https://academic.oup.com/milmed/article/184/11-12/839/5357468

Dobie, R. A. (2004). Overview: Suffering from tinnitus. In J. B. Snow (Ed.), Tinnitus: Theory and management . Lewiston, NY: BC Decker.

DoD Blast Injury Research Program Coordinating Office (2011). International state-of-the-science meeting on blast-induced tinnitus. https://blastinjuryresearch.amedd.army.mil/assets/docs/sos/meeting_proceedings/2011_SoS_Meeting_Proceedings.pdf

DoD Instruction 6055.12, “Hearing Conservation Program,” August 14, 2019. https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/605512p.pdf?ver=2019-08-14-073309-537

Edmonds, C. M., Ribbe,C., Thielman, E. J., & Henry, J. A. (2017). Progressive tinnitus management level 3 skills education: A 5-year clinical retrospective. American Journal of Audiology, Sep 18;26(3):242-250.

Henry, J. A., Zaugg, T. L., Myers, P. J., & Kendall, C. J. (2010). Progressive tinnitus management: Clinical handbook for audiologists. San Diego, CA: Plural Publishing Inc.https://hearing.health.mil/For-Providers/Progressive-Tinnitus-Management/PTM-Provider-Resources/PTM-Guides-and-Handbooks

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https://academic.oup.com/milmed/article/184/11-12/839/5357468


https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/605512p.pdf%3Fver=2019-08-14-073309-537


References

Henry, J. A., Zaugg, T. L., Myers, P. J., & Kendall, C. J. (2010). How to manage your tinnitus: A step-by-step workbook, Third Edition. San Diego, CA: Plural Publishing Inc. http://www.ncrar.research.va.gov/Education/Documents/TinnitusDocuments/HowToMan ageYourTinnitus.pdf

Henry, J. A., Zaugg, T. L., Myers, P. J., & Kendall, C. J. (2010). Progressive tinnitus management: Counseling guide. San Diego, CA: Plural Publishing Inc. https://hearing.health.mil/For-Providers/Progressive-Tinnitus-Management/PTM-Provider-Resources/PTM-Guides-and-Handbooks

Henry, J. A., Zaugg, T. L., Myers, P. J., Schmidt, C., Edmonds, K., Forbes, S., & Thielman, E. (2015). Adult tinnitus management clinical practice recommendation. Department of Veterans Affairs National Center for Rehabilitative Auditory Research. https://www.ncrar.research.va.gov/Education/Documents/TinnitusDocuments/TinnitusPracticeGuidelines.pdf

Henry, J. A., Griest, S. E., Blankenship, C., Thielman, E. J., Theodoroff, S. M., Hammill, T., & Carlson, K. F. (2019). Impact of tinnitus on military service members. Military Medicine, Volume 184 (Suppl 1), 3/4:604-614. https://doi: 10.1093/milmed/usy328

Institute of Medicine (2006). Noise and military service: Implications for hearing loss and tinnitus. Washington, DC: The National Academies Press. https://doi.org/10.17226/11443

Lew, H. L., Jerger, J. F., Guillory, S. B., & Henry, J. A. (2007). Auditory dysfunction in traumatic brain injury. J Rehabil Res Dev; 44(7): 921-928. https://www.rehab.research.va.gov/jour/07/44/7/page921.html


http://www.ncrar.research.va.gov/Education/Documents/TinnitusDocuments/HowToMan%2520ageYourTinnitus.pdf


https://www.ncrar.research.va.gov/Education/Documents/TinnitusDocuments/TinnitusPracticeGuidelines.pdf


https://doi.org/10.17226/11443

https://www.rehab.research.va.gov/jour/07/44/7/page921.html

References

Moring, J.C., Peterson, A.L. & Kanzler, K.E. (2018). Tinnitus, traumatic brain injury, and posttraumatic stress disorder in the Military. Int.J. Behav. Med. 25, 312–321. https://doi.org/10.1007/s12529-017-9702-z

Myers, P. J., Griest, S., Kaelin, C., Legro, M. W., Schmidt, C. J. , Zaugg ,T. L., & Henry, J. A. (2014). Development of a progressive audiologic tinnitus management program for Veterans with tinnitus. J Rehabil Res Dev; 51(4):609–622.http://dx.doi.org/10.1682/JRRD.2013.08.0189

Schmidt, C. J., Kaelin, C., Henselman, L., & Henry, J. A (2017): Need for mental health providers in Progressive Tinnitus Management: a gap in clinical care. Federal Practitioner; 34(5): 6–9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6370437/

Tunkel, T. E., Bauer, C. A,. Gordon, H. S., Rosenfeld, R. M., Chandrasekhar, S.S., Cunningham Jr, E. R., Archer, S.M., Blakley, B. W., Carter, J. M., Granieri E. C., Henry, J. A., Hollingsworth, D., Khan, F. A., Mitchell, S., Monfared, A., Newman, C. W., Omole, F.,S., Phillips, C. D. , Robinson, S. K., Taw, M. B., Tyler, R. S., Waguespack, R., & Whamond, E. J., Clinical practice guideline: Tinnitus. Otolaryngology— Head & Neck Surgery, 151(Suppl. 2), S1–S40, 2014. https://journals.sagepub.com/doi/pdf/10.1177/0194599814545325

Veterans Benefits Administration. Annual Benefits Report fiscal year 1999-2017. Retrieved from https://www.benefits.va.gov/REPORTS/abr/archive.asp

Veterans Benefits Administration. Annual Benefits Report Fiscal Year 2018. https://www.benefits.va.gov/REPORTS/abr/docs/2018-compensation.pdf, https://www.benefits.va.gov/REPORTS/abr/docs/2018-abr.pdf


https://doi.org/10.1007/s12529-017-9702-z

http://dx.doi.org/10.1682/JRRD.2013.08.0189

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6370437/

https://journals.sagepub.com/doi/pdf/10.1177/0194599814545325



https://www.benefits.va.gov/REPORTS/abr/docs/2018-compensation.pdf

https://www.benefits.va.gov/REPORTS/abr/docs/2018-abr.pdf

Backup Slides


HCE-facilitated Research

Protocol Title Collaborators Research PurposeClinical Investigation of Hearing Injuries, Noise Exposures, and Cost Burden in Active Duty US Military Service Members

N/A Aims to examine the incidence and prevalence of hearing impairment and auditory injuries (including tinnitus) among active duty Service members between January 1, 1998 and January 1, 2013.

Identifying Subgroups of Tinnitus Using Novel Resting fMRI Biomarkers and Cluster Analysis

University of Illinois at Urbana-Champaign

Aims to better understand neural correlates of tinnitus severity, such as those involving attention, auditory, and emotion processing neural networks, and thereby identify subgroups that differ in a systematic fashion within the larger heterogeneous population.

Alternate Tinnitus Management Techniques Developed Using Blood-Oxygen-Level Dependent MRI with Neurofeedback

Wright State University Indiana University

Aims to develop a simple and portable training regimen to teach military personnel neuroplastic brain control techniques that can be used during and after deployment to minimize the symptoms of tinnitus.


HCE-facilitated Research

Protocol Title Collaborators Research PurposeEffects of Military Noise Exposure on Auditory Function in Service Members and Recently Discharged Veterans (“NOISE Study”)

NCRAR Aims to gather information from active duty Service members and recently separated Veterans about their military and non-military noise exposures, other relevant military and non-military exposures, and potential outcomes of these exposures including tinnitus, hearing loss, and other hearing-related health concerns.

Battlefield Acupuncture (BFA) as a Treatment Option for Chronic Tinnitus

Wilford Hall Ambulatory Surgical Center (WHASC), Joint Base San Antonio

Aims to determine if BFA can provide significant decrease/improvement in perception/coping of chronic tinnitus.

Clinical Trial of Etanercept (TNF-a blocker) for treatment of blast-induced tinnitus

Wayne State UniversityNaval Medical Center San DiegoNCRAR/Portland VA

Aims to conduct a clinical trial to test Etanercept (Enbrel) as a new treatment for blast- and noise-induced tinnitus.

Investigating the Neurobiology of Tinnitus

Washington University in St. Louis

Aims to determine if warfighters who develop tinnitus have differences in their brain networks before exposure to loud noise and other trauma. Also examining if changes in their brain networks are associated with tinnitus.


VA and DoD Tinnitus Research and Research Roadmapping

∎ HCE-facilitated Collaborative Auditory Vestibular Research Network (CAVRN) includes over 225 federal auditory and vestibular researchers; research and roadmapping

∎ Defense Medical Research and Development – Defense Health Agency and U.S. Army Medical Research and Development Commandq Congressionally Directed Medical Research Programsq Joint Program Committee 8 - Clinical & Rehabilitative Medicine Research Programq Joint Program Committee 5 – Military Operational Medicine Research Program

(Injury Prevention and Reduction)

∎ VAq NCRAR; research and roadmappingq Rehabilitation Research and Development Services, Office of Research and

Development


PTM Books

1. Progressive Tinnitus Management: Clinical Guide for Audiologists

2. How to Manage Your Tinnitus: A Step-by-Step Workbook3. Progressive Tinnitus Management: Counseling Guide


JHASIR Data Sources

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Data Source Acronym

Definition

DOEHRS-HC Defense Occupational & Environmental Health Readiness System-Hearing Conservation

ECAA Enterprise Clinical Audiology Application

DMDC Defense Manpower Data Center

DoDTR Department of Defense Trauma Registry

TMDS Theater Medical Data Store

VA CDW Veteran Affairs Corporate Data Warehouse*

VA NAR Veteran Affairs National Audiometric Registry**VA data sources are incorporated through DoD & VA Infrastructure for Clinical Intelligence (DAVINCI)

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