Tinnitus Retraining Therapy: Merits and Flaws

As a tinnitus specialist, I'm frequently asked about the merits of Tinnitus Retraining Therapy (TRT). Here, I offer a critical review where you'll learn answers to these questions:

• What is TRT?
• How much does TRT cost?
• Does TRT work?
• What is the #1 flaw with TRT?

What is Tinnitus Retraining Therapy?

Tinnitus Retraining Therapy (TRT) is a method of treating tinnitus and hyperacusis that combines educational counseling with sound therapy. The method was developed by audiologist Pawel Jastreboff, PhD, in the 1990s. TRT is based on the “Neurophysiological Model of Tinnitus”, a model introduced by Jastreboff himself. 

This tinnitus treatment method has helped many people achieve lasting relief from tinnitus. However, when put head-to-head in randomized controlled studies, it does no better than standard therapy.

So what’s going on?

Here are some candid thoughts on TRT from the point of view of a tinnitus specialist, starting with what is missing in the TRT approach.

What is the #1 Flaw with TRT?

The #1 critical error in TRT is that it presents an incomplete picture of what causes tinnitus. The TRT model is nearly 35 years old and fails to incorporate the latest scientific findings on what drives tinnitus loudness:

• Current research shows that tinnitus is driven by a migraine-associated hypersensitivity of the hearing nerves and related brain structures.

Over the past 5 years, we’ve published scores of academic papers that outline the role of migraine in tinnitus. It's important to understand that migraine is not just about headaches.

We now understand that migraine is a sensory processing disorder driven by nerve inflammation and can affect many different nerves, including the balance nerve (vestibular migraine) and the hearing nerve (cochlear migraine, or, loud tinnitus).

Here is what happens in summary format:

Stage in Tinnitus Development	Description
Tinnitus Initiation	Inner ear damage (noise damage, infection, ototoxic medications, aging, COVID, etc) leads to hearing loss. The auditory nerves become hyperactive. This is registered in the brain as a phantom sound.
Neurogenic Inflammation	Nerve inflammation, triggered by environmental or internal stressors, enhances sensory signaling, intensifying the perceived loudness of tinnitus. This is also known as the migraine reaction.
Fear Activation	The fear center of the brain (the limbic system) is activated, registering the ringing as a threat. This drives our negative reactions to the tinnitus sound and triggers the attention centers of the brain. Tinnitus annoyance increases.
Increased Attention	Loud ringing increases brain attention (its “salience”). The salience network includes brain regions that determine how much attention we pay to sensory signals. It now becomes hard to ignore.
Neural Network Formation	Stable neural networks establish, making the ringing a permanent fixture.
Persistent Perception	Even after migraine resolution, the tinnitus signal persists, although it is less intense.
Neural Network Strengthening	Continued focus and worry strengthen neural networks, potentially triggering migraines and creating a vicious cycle.
Clinical Significance	Clinically significant tinnitus emerges, impacting quality of life and emotional health.

In the end, sound-centric tinnitus management strategies like TRT will often fall short. Without treating the root cause of tinnitus loudness, patients are left managing symptoms rather than addressing the source of their tinnitus. For this, you need targeted medical interventions that go beyond sound-based approaches.

What happens in TRT?

TRT basically gives patients a graduate-level course on tinnitus and the auditory system, delivers a masking device and sound therapy education, and then provides emotional support over a period of time. 

In traditional TRT, the first visit is REALLY long, sometimes lasting up to 6 hours. In fact, it's usually broken up into several days. There are four things on the initial visit agenda:

• Initial Interview and Testing: This is where you explain in detail what your tinnitus is like, followed by extensive testing of middle ear problems, hearing loss in one or both ears, and specifics about your tinnitus frequency.
• Medical History: This step makes sure that treatable medical conditions related to tinnitus are ruled out. This part is sometimes performed by an ENT doctor. Special attention is given to screen for hyperacusis, a condition where loud noises cause pain and discomfort.
• Tinnitus Counseling: This is where you get your degree in tinnitus science. Basically, you are taught the basic principles of the neurophysiological model of tinnitus.
• Sound Therapy: The final step in the initial TRT is how to use sound therapy. Here you’re offered various sound therapy options, instructed to avoid silence, and encouraged not to completely cover their tinnitus. It usually includes the sale of either hearing aids for tinnitus or ear-level masking devices (looks like a hearing aid).

Next you have a series of followup visits where your audiologist reinforces the model and discusses your progress. The typical cadence of treatment is to follow up at 1, 3, 6, 12, and sometimes 18 months. Some packages include more frequent visits, but in general, the minimum length of the program is 6-12 months. 

What is “Tinnitus Counseling” in TRT?

The primary goal of tinnitus counseling in TRT is to demystify tinnitus. When people know what’s going on with their tinnitus, it gives them a sense of empowerment. They are taught the Neurophysiological Model of Tinnitus (see Addendum below). 

Here is a list of key concepts taught in the first TRT session. This is modified from a handout from a well known TRT protocol that’s given to patients after the first visit [1].

TRT Concept	Concept Explanation
The goal of TRT is to change your mind.	TRT helps your brain to reclassify the tinnitus signal from “dangerous” to “unimportant”. This is not a conscious process; you can't force your mind to do it. However, if you understand the goal and use sound therapy properly, it will stop tinnitus from activating your fear center.
Tinnitus is not the same thing as hearing loss.	While the two usually go together, tinnitus does not mean you are actively losing hearing. Tinnitus is not a warning sign that you’re losing hearing. Basically, don’t freak out about your hearing.
The brain makes tinnitus loud and annoying, not your ear.	Loudness and annoyance are related to the strength of negative feelings you have regarding the tinnitus signal. The emotional part of your brain and your autonomic nervous system are what makes tinnitus annoying, not your ear.
Don’t focus on what you can’t fix.	The hearing is gone and the tinnitus is here to stay. What you can do is change the way your brain reacts to it. Don’t focus on the features of the tinnitus sound, it doesn’t determine your outcome.
The tinnitus signal is weak and neutral.	It doesn’t change from good days to bad days. So if you could measure the auditory system activity on a good day or a bad day, the signal is the EXACT SAME. What changes are the other parts of your brain (the fear center).
Tinnitus is a phantom auditory perception.	The hearing center recognizes the hyperactive nerve signal coming from the cochlea and recognizes it as a sound. The problem is that we can’t control it. When we lose control, the fear center freaks out.
The brain has the ability to rewire and change.	We can rewire the brain to filter out the tinnitus sound and reclassify it from “threat” to “not important”. This is habituation, or ‘passive extinction’. All we can do is understand the goal and use sound therapy religiously.

Here are four additional concepts taught in the first session and reinforced in later TRT sessions [1]:

Selective Perception in Tinnitus

This describes the subconscious filtering of sound signals enhances different or important information while filtering out neutral details. Routine activities are often ignored once deemed nonsignificant, illustrating habituation.

• Imagine the feeling of your socks on your feet. They’ve been on your feet all day. The sensory signals coming from your feet to your brain have not stopped or changed. When you pay attention to it, you feel the socks, but in one paragraph, your brain will have forgotten about it again. Many people have tinnitus and for them, it’s like socks on their feet; they don’t notice it until asked to pay attention to it. 

Sensory Contrast in Tinnitus

Perception of a signal is influenced not only by its physical intensity but also by its strength relative to the surrounding activity. Tinnitus loudness is heightened in quiet settings due to sensory contrast. Sensory contrast explains why background noise is so important.

• Imagine a candle in a pitch dark room. In the darkness, the candle is super bright. However, if you open the blinds and turn on the light, the candle seems not bright at all. The number of photons reaching your eye from the candle light has not changed. It’s the same with tinnitus when its quiet. With nothing else going on, the tinnitus signal seems louder, even though the auditory nerve signally rate hasn’t changed. With background noise, the tinnitus sound becomes insignificant.

Prioritization in Tinnitus

Subconscious processes can override conscious decisions, prioritizing important or threatening signals. This phenomenon is evident in situations where seemingly insignificant sounds can evoke strong reactions, highlighting the influence of subconscious meaning on attention and response.

• Imagine you are alone at night and you hear the creaking of a floorboard down the hall. Is someone breaking in? Your fear center kicks in and now you're listening intently for any tiny hint of another sound. This hypervigilance happens with tinnitus. Once the sound is perceived as a threat, it gets “prioritized” so now your mind finds the tinnitus sound subconsciously, often even searching for it to see if it's still there. 

Habituation in Tinnitus

Habituation in TRT is when your brain simply stops paying attention to the tinnitus signal. Per above, it’s not something that you do actively. It’s something that happens passively when you use sound therapy properly. Essentially, the sound of your tinnitus becomes like the feeling of your socks on your feet. You can hear the tinnitus sound if you listen, but most of the day, your brain ignores it.

My Opinion of TRT Psychoeducation

This is actually awesome information and I agree with most of it. However, new key concepts are missing in the model, including what we’re discovering about the connection between tinnitus and migraine. In TRT, they only understand HALF of the problem.

What is sound therapy in TRT?

For the brain to habituate, it has to still hear the sound signal. This is a key difference between TRT sound therapy and tinnitus masking. Here are some key principles on TRT's sound therapy component:

Sound Therapy Component	Explanation
The Mixing Point	Sound therapy files should be set to the point at which you can just barely hear your tinnitus. This is called the “mixing point”. TRT participants are counseled not to mask tinnitus above this point.
Noise-enriched Environment	TRT is also big on silence avoidance and always practicing environmental sound enrichment. This helps reduce tinnitus perception.
Sound Files	Most TRT programs use simple white noise as the type of masking sound. Masking is designed to effectively suppress the tinnitus sound, but in TRT, you want people to hear their tinnitus sound so they can habituate to it.
Daily Duration	Most programs call for using sound therapy for a minimum of 4 hours a day, daily. Clinical data supports this. In a trial comparing 1,3, and 5 hours mixing point masking, the 5 hour group had statistically significant improvements in tinnitus symptoms over the other groups [2].

Tinnitus Maskers and Hearing Aids in TRT

There is no standard for tinnitus masking or sound stimulation in TRT. Here are the most common options:

Device Option	Description
Tinnitus Masking Devices	Most of the time, people are offered ear-level white noise generators that look like a hearing aid. This may be appropriate for someone with normal hearing or only mild hearing loss. They can go behind the ear or in the ear canal.
Hearing Aids	These are dispensed to people who have tinnitus and moderate to severe hearing loss. However, in these cases, those with hearing loss are still instructed to use some other source of external sounds.
Combination Hearing Aids	Many hearing aids can be programmed to generate white noise at the mixing point. This way you get both amplification and masking while wearing hearing aids. Using a hearing aid allows you to accurately produce mixing point matching.
External Sound Machines	This is the use of conventional sound generators. Most options these days include settings where you can choose the color of noise (ie pink noise or brown noise) or select from nature sounds (rain, ocean, etc.). Here the masking noise is coming from external sound, rather than an ear-level device.

One criticism of most TRT programs is that they'll try to sell you an expensive hearing aid-type device. Theoretically, there is no reason why the sound generated for TRT can't be from external noise generators, headphones, earbuds, or other sources of background sounds.

How much does Tinnitus Retraining Therapy cost?

TRT costs anywhere from $3,000-$7,000. The cost depends on several factors, such as the inclusion of an ear-level sound generator and the number of sessions included in the program. 

Even online TRT can be expensive. For instance, one popular online TRT clinic offers a 6-month program for $5000. The high price is nearly always related to the embedded sale of an overpriced ear-level device.

Does Tinnitus Retraining Therapy work?

Does TRT work? Yes and no. According to a systematic review [3], TRT consistently shows positive results for treating moderate to severe tinnitus. The question is, does it work better than other treatments for tinnitus? 

To answer this, we turn to the Tinnitus Retraining Therapy Trial, one of the largest and well designed controlled clinical trials on TRT to date. Here, TRT was testing against standard tinnitus masking programs [4]. 

The results of the study showed that there was no significant difference in improvement between the two groups. In other words, TRT worked, but no better than standard therapy. 

What is the difference between TRT and CBT for tinnitus?

There are similarities between TRT and Cognitive Behavioral Therapy (CBT). The American Tinnitus Association characterizes TRT as “A treatment regimen that combines the use of traditional CBT counseling with supplemental sound masking to habituate patients to tinnitus”.

I think this is inaccurate. The Tinnitus Counseling of TRT is very technical, like a graduate level class. The focus is very narrow and does not come close to the full spectrum of psychological tools available in CBT for tinnitus.

CBT tools may be more effective than the ones used in TRT. In one clinical trial, CBT was compared to TRT. At 6 months, tinnitus severity (measured by the Tinnitus Handicap Inventory) resulted in better improvements in the CBT group than the TRT group (reduction 54.5% vs. 20%). This illustrates both the power of CBT techniques or deficiencies in TRT tinnitus counseling.

What is online Tinnitus Retraining Therapy?

Modified Tinnitus Retraining Therapy (MTRT) is a modern adaptation of TRT, designed to retain its most effective components while making the process shorter, more affordable, and accessible. Online TRT is one form of MTRT, offering the same counseling benefits in a convenient virtual format. Similarly, app-based TRT programs have demonstrated comparable success to conventional methods, providing a flexible, user-friendly option for patients [5].

Another approach to MTRT involves intensive programs where patients complete all tinnitus counseling over a focused 7-day period. These programs often include multidisciplinary care, allowing patients to work closely with a team of healthcare professionals. By streamlining the process and leveraging modern technology, MTRT expands access to effective tinnitus management. 

Tinnitus Rehabilitation at NeuroMed

At NeuroMed, we integrate tinnitus education and sound therapy, just like TRT. However, this tinnitus intervention is nested in a much more comprehensive program, that includes:

• App-based CBT
• Medication therapy
• Nutraceuticals
• Dietary interventions
• Sleep optimization
• Mindfulness therapy
• Motivational interviewing
• Lifestyle medicine

Results from our multimodal rehabilitation program are showing success rates in the 85-90% range. This is because we address both the cause and the symptoms of loud tinnitus.

Conclusion: Treating Tinnitus with TRT Falls Short

All tinnitus specialists owe a debt of gratitude to Jastreboff for his pioneering work on managing tinnitus. The clinical protocol that emerged from his research shows positive outcomes. However, there are three critical questions that illustrate where TRT falls short:

• Does TRT work better than other forms of tinnitus therapy? No.
• If it yields the same outcomes, but is more expensive and time consuming, is it worth it? No.
• Are expensive hearing aids or masking devices necessary to treat tinnitus? No.

Ultimately, the key flaw with TRT is that it does not include the most important discoveries about what drives tinnitus perception, namely migraine-associated sensory hypersensitivity. Without addressing the fundamental causes of tinnitus, results will always fail to reach the kind of high success rates we are seeing at NeuroMed.  

The Neurophysiological Model of Tinnitus

TRT References

[1] Gold SL, Formby C, Scherer RW. The TRT Counseling Protocol as Implemented in the TRT Trial. Am J Audiol. 2021 Mar 10;30(1):1-15. doi: 10.1044/2020_AJA-20-00024.

[2] Jin IK, Choi SJ, Ku M, Sim Y, Lee T. The Impact of Daily Hours of Sound Therapy on Tinnitus Relief for People With Chronic Tinnitus: A Randomized Controlled Study. J Speech Lang Hear Res. 2022 Aug 17;65(8):3079-3099. 

[3] Han M, Yang X, Lv J. Efficacy of TRT in the treatment of tinnitus: A meta-analysis and systematic review. Am J Otolaryngol. 2021 Nov-Dec;42(6):103151.

[4] Suh MW, Park MK, Kim Y, Kim YH. The Treatment Outcome of Smart Device-Based TRT: Prospective Cohort Study. JMIR Mhealth Uhealth. 2023 Jan 12;11:e38986.

[5] TRT Trial Research Group; Scherer RW, Formby C. Effect of TRT vs Standard of Care on Tinnitus-Related Quality of Life: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg. 2019 Jul 1;145(7):597-608.