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

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 Agency June 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. “Medically Ready Force…Ready Medical Force” UNCLASSIFIED 2

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 UNCLASSIFIED “Medically Ready Force…Ready Medical Force” 3

Definitions Service member Veteran ∎ A member of the "uniformed ∎ A person who served in services", including the armed the active military, naval, or air forces (Army, Navy, Air Force, service, and who was Marine Corps, and Coast discharged or released under Guard), the Commissioned conditions other than Corps of the National Oceanic dishonorable. and Atmospheric 38 U.S. Code § 101 Administration, and the Commissioned Corps of the Public Health Services. https://www.va.gov/opa/persona/active_duty.asp “Medically Ready Force…Ready Medical Force” UNCLASSIFIED 4

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 injury focused on: “ 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)” UNCLASSIFIED “Medically Ready Force…Ready Medical Force” 5

Goals Develop, disseminate, and facilitate implementation of Goal 1: Best Practices best practices. Coordinate, encourage, and facilitate conduct of Goal 2: Research research. Help coordinate VA rehabilitation benefits and services Goal 3: Delivery to former Service members. “Medically Ready Force…Ready Medical Force” 6 UNCLASSIFIED

HCE: A Platform to Facilitate Collaboration International Partners Department of Health Industry and Human Services HCE Department Academia of Defense Department of Veterans Affairs UNCLASSIFIED “Medically Ready Force…Ready Medical Force” 7

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 Veterans Fiscal Year https://www.benefits.va.gov/REPORTS/abr/archive.asp UNCLASSIFIED “Medically Ready Force…Ready Medical Force” 8

DoD Hearing Conservation Program (HCP) Noise Measurement and Analysis Program Noise Performance Abatement Evaluation DoD HCP Noise Hazard Audiometric Signs and Testing Labels Personal Education Hearing Protectors DoD Instruction 6055.12 (2019) “Medically Ready Force…Ready Medical Force” UNCLASSIFIED 9

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.nidcd.nih.gov/health/tinnitus https://www.ata.org/understanding-facts “Medically Ready Force…Ready Medical Force” UNCLASSIFIED 10

Tinnitus Pyramid Dobie, R. A. (2004). Overview: Suffering from tinnitus. In J. B. Snow (Ed.), Tinnitus: Theory and management . Lewiston, NY: BC Decker. “Medically Ready Force…Ready Medical Force” UNCLASSIFIED 11

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 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 “Medically Ready Force…Ready Medical Force” UNCLASSIFIED 12

Impact of Tinnitus: IOM (2006) HCE slide adapted from IOM (2006), www.hearing.health.mil “Medically Ready Force…Ready Medical Force” UNCLASSIFIED 13

Tinnitus: Potential Impact on Service Members and Veterans Veterans Service members ∎ Medical readiness ∎ Quality of life ∎ Operational performance, ∎ Occupational performance mission accomplishment ∎ Safety ∎ Individual and unit safety ∎ Quality of life WWII POW/Veteran, J.H. Wilson. Photo used with https://www.defense.gov/observe/photo-gallery/ permission from J.H. Wilson family. “Medically Ready Force…Ready Medical Force” UNCLASSIFIED 14

Tinnitus in a High-risk Population ∎ Exposure to hazardous noise levels q Steady-state noise q Impulse noise q Blast exposure ∎ Tinnitus association with: q Traumatic brain injury (TBI) q Posttraumatic stress disorder (PTSD) DoD Blast Injury Research Program (2011) https://blastinjuryresearch.amedd.army.mil/assets/docs/sos/mee ting_proceedings/2011_SoS_Meeting_Proceedings.pdf “Medically Ready Force…Ready Medical Force” UNCLASSIFIED 15

Progressive Tinnitus Management (PTM) ∎ Developed by Dr. James Henry, VA ∎ Evidence-based best practice – National Center for Rehabilitative randomized controlled trials Auditory Research (NCRAR), conducted Portland VA Medical Center, ∎ Interdisciplinary approach Portland, OR, his research team, (audiologists, otolaryngologists, and other VA collaborators and mental health providers) q NCRAR Research Career Scientist ∎ Five stepped-levels of tinnitus q Research Professor, Department of management care – patients only Otolaryngology/Head and Neck receive levels they need Surgery, Oregon Health & Science ∎ Currently implemented by VA and University q Adjunct Professor, Department of DoD Audiology, Portland State University 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 “Medically Ready Force…Ready Medical Force” UNCLASSIFIED 16

Managing Reactions to Tinnitus ∎ Chronic tinnitus is usually permanent ∎ Tinnitus cannot be quieted, but patients can learn to manage their reactions to it q May 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 “Medically Ready Force…Ready Medical Force” UNCLASSIFIED 17

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. “Medically Ready Force…Ready Medical Force” UNCLASSIFIED 18

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. “Medically Ready Force…Ready Medical Force” UNCLASSIFIED 19

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. “Medically Ready Force…Ready Medical Force” UNCLASSIFIED 20