The Use of Virtual Reality for Managing Chronic Tinnitus

Abstract

Tinnitus is the sensation of hearing a “ringing” or “buzzing” in the ears without any external stimuli. Possible causes of tinnitus include hyperactivity in central auditory nuclei, 1 tonotopic reorganization in the auditory cortex, 2 noise exposure, 3 underlying conditions, 4 and use of certain medications. 5 Between 5% and 30% of adults suffer from tinnitus, 6 with about 50% having idiopathic tinnitus. 7www.Shutterstock.com, virtual reality, artificial intelligence, tinnitus.Patients’ emotional well-being is affected by tinnitus, 8 including increased anxiety levels. 9 The amygdala and other nonauditory structures in the brain may be involved in tinnitus maintenance by mediating the emotional response in tinnitus patients. 10,11 Novel techniques like the use of vagus nerve implants have been explored for tinnitus mitigation. 12 Although there is no cure for tinnitus yet, effective management techniques include relaxation/mindfulness training, 13 amplification, 14 and sound therapy for both hearing aid users 15 as well as cochlear implant recipients. 16 Sweetow and Sabes 17 evaluated the effects of combining amplification and sound therapy for tinnitus management. The sound therapy included white noise and fractal tones from Widex Zen Therapy. 18 Participants reported a significant reduction in tinnitus annoyance after listening to both sounds but reported feeling more relaxed when hearing the fractal tones. Stress reduction is a significant component in managing chronic health conditions. Distressed patients may turn to social media or mobile applications to explore solutions. 19–22 Techniques for reducing stress can decrease the impact of tinnitus. 23 A randomized controlled trial (RCT) discovered that 16 hours of therapy over two months led to significant reductions in tinnitus measures and reactions to tinnitus. 13 Therapy techniques using virtual reality (VR) have been shown to reduce anxiety in patients with chronic conditions. 24 VR uses specialized equipment that presents visual and auditory information to create specific simulated environments. The use of VR has proven to aid in acute pain management of patients receiving routine and invasive medical procedures. 25 VR also has proven to have significant effects on all affective domains mediated by the limbic system, 26 which is also involved in the perpetuation of tinnitus. 27 Therefore, VR therapy may lessen the engagement of the limbic system in tinnitus perception by delivering relaxation and sound therapy components. The aim of the present study 28 was to explore whether the use of VR combined with conventional sound therapy helped in mitigating tinnitus and reactions to tinnitus as compared to conventional sound therapy alone. STUDY PARTICIPANTS Adults with continuous, chronic, subjective tinnitus were sought as study participants. Adults with hearing aids were recruited if they did not have tinnitus management features programmed into their hearing aids. Twenty adults with both unilateral and bilateral tinnitus (11 males, nine females) between the ages of 18 and 76 years were enrolled in the study. PROCEDURES This study was an RCT with a crossover design. Each participant received two sessions, one week apart. The control intervention provided sound therapy alone, while the experimental intervention provided sound therapy with VR. The sound therapy component used the Zen Aqua program from Widex. The sounds were played for 15 minutes through a computer loudspeaker at a comfortable volume level. The experimental intervention included 15-minute viewings of natural scenes, including flowing streams, lakes, and gorges, presented via VR goggles, while listening to the Zen sounds. Ten participants received the control intervention followed by the experimental intervention and 10 received the experimental intervention followed by the control intervention. Participants’ tinnitus loudness, tinnitus functional index (TFI), 29 and minimum masking level (MML) scores were recorded before and after each intervention. RESULTS A multilevel mixed-effects linear regression model accounting for confounding variables revealed that the mean tinnitus loudness and TFI scores reduced significantly (p=0.015 and p=0.043, respectively) after the experimental intervention compared to the control intervention. The MML differences were not statistically significant, but mean values were reduced after the experimental intervention than after the control intervention (p=0.090). DISCUSSION Tinnitus loudness, MMLs, and TFI scores have been used to portray the effectiveness of tinnitus management strategies. 30–32 In the present study, since tinnitus loudness levels and TFI scores improved significantly after receiving the experimental intervention, it can be concluded that these factors are positively affected by combining VR with sound therapy in a controlled setting. While there was no significant improvement in MMLs after the experimental intervention, this could be due to the study procedures causing participants’ attention to be focused on their tinnitus. Many tinnitus therapy techniques recommend having an active lifestyle to redirect attention from tinnitus. 33 Previous research has demonstrated that sound therapy, especially fractal tones, can be used to induce relaxation and manage tinnitus. 34,35 In the Sweetow and Sabes study, 17 86% of participants reported feeling relaxed after listening to the wind-chime-like fractal tones. Simonetti et al. 36 discovered a significant reduction in tinnitus handicap inventory (THI) 37 scores after studying the effects of fractal tones on patients with chronic tinnitus. In the present study, participants listened to fractal tones either standalone or with a VR video. Following these interventions, reductions in tinnitus loudness, MMLs, and TFI were present. The emotional and auditory effects of sound therapy can partially explain this trend. For more than two decades, VR has been used to treat conditions such as phobias, 38 anxiety disorders, 24 eating disorders, 39 and intractable pain. 40 A systematic review of 20 studies found VR to be an effective treatment for decreasing acute pain. In 2010, a theoretical framework for the use of VR to manage chronic subjective tinnitus was proposed. 41 Malinvaud et al.42 applied this framework to assess the differences in tinnitus attributes between those receiving VR and those receiving cognitive behavioral therapy (CBT). Without significant differences found between interventions, both interventions showed improvement on THI scores, subjective tinnitus severity scale, and the hospital anxiety and depression scale. 43 The Malinvaud 44 study concluded that VR can be at least as effective as CBT when managing tinnitus. The present study showed significant reductions in tinnitus loudness and TFI for the experimental intervention as compared to the control intervention, supporting these results. LIMITATIONS AND FUTURE DIRECTIONS The present study was conducted in a laboratory setting. Future studies could explore the effects of VR on tinnitus in more natural settings, such as at home. Stimuli can also be presented for a longer duration with more sessions. A longitudinal study would be able to analyze the long-term effects of VR on tinnitus. Future studies could also use a larger participant group. Genetic risk modeling can be used to investigate the biological mechanisms underlying tinnitus. In the present study, participants benefitted from using VR combined with sound therapy for 15 minutes in a laboratory setting. After this intervention, tinnitus loudness levels, MMLs, and TFI scores were reduced when compared to receiving sound therapy alone. Therefore, VR combined with sound therapy is a promising potential technique for managing tinnitus. Future studies could alter the stimuli, mode of delivery, number of sessions, total therapy duration, and number of participants. More trials will be needed before confirming the use of VR and sound therapy to manage tinnitus in a clinical setting.