Effectiveness Of Tinnitus Retraining Therapy Research Articles

Sound therapy in patients with tinnitus: traditional sound generators vs. mobile apps.

Tinnitus Retraining Therapy (TRT) is a rehabilitation approach for tinnitus that is currently considered an effective treatment with an elevated response rate. TRT is usually delivered through sound generators; however, they are often difficult to find and expensive. Recently, mobile apps have been proposed for TRT. This study aims to verify the effectiveness of TRT performed using mobile apps in reducing the adverse effects of tinnitus on the quality of life. A total of 80 patients affected by tinnitus in category 0 (mild tinnitus) and category 1 (moderate tinnitus), according to the Jastreboff classification, were included in the study. Patients of both classes were subsequently differentiated into two homogeneous groups; the first (Group A) was treated with a traditional sound generator, and the second (Group B) using a mobile app. The Tinnitus Handicap Inventory - the Italian version of the questionnaire - was used to investigate the impact of tinnitus on the quality of life in enrolled patients and evaluate their response to TRT. A significant improvement was found in THI scores in category 0 patients for both sound generator and mobile app groups; no difference was found between the two-treatment delivery technology (-1.186, p=0.783); conversely, tinnitus improvements in category 1 patients were only reported for subjects treated using a sound generator (-14.529, p<0.001), while no significant improvement was found in patients treated using the mobile app. This study confirms the value of TRT, which in patients with mild tinnitus (category 0), can also be delivered through mobile apps with results comparable to traditional sound generators. Further studies are necessary to confirm the effects of the different tinnitus treatments available and improve the knowledge on this topic.

Effectiveness of Tinnitus Retraining Therapy Based on Mobile Devices for Tinnitus Patients

Background and Objectives Tinnitus retraining therapy (TRT) is a well-known effective method for tinnitus management by retraining the brain to achieve habituation of tinnitus. The mobile device based TRT can let both clinicians and patients be free from time and space limitations and secure cost-effectiveness. The study aimed to investigate whether the mobile-based TRT is inferior or not to the conventional TRT in treatment outcomes for chronic subjective tinnitus.Subjects and Method A prospective randomized controlled trial was conducted in a single tertiary hospital. Adult patients with chronic subjective tinnitus were enrolled. Pure tone audiometry, State-Trait Anxiety Inventory [(STAI), axis1 and axis2], Beck Depression Inventory, Pittsburgh Sleep Quality Index, and a survey for TRT were evaluated. Tinnitus Handicap Inventory (THI), Visual Analog Scale (VAS) of tinnitus, and Tnnitogram were compared at the start, then at one month and three months of the treatment. The mobile group was subdivided into the treatment effective group and the refractory group. Demographics, baseline tinnitus severity, and therapy compliance were comparatively analyzed.Results A total of 19 patients for the mobile-based TRT and 21 patients for the conventional TRT were enrolled. THI scores and Tinnitus scores using VAS were significantly reduced in the mobile group after the treatment. Furthermore, THI and STAI were significantly more improved in the conventional group than in the mobile-based TRT at one and three months of the treatment. Also, the effective group of the mobile device based TRT was statistically younger than the refractory group and had a higher understanding of the treatment method.Conclusion The mobile-based TRT could improve THI and VAS scores of tinnitus at one and three months of treatment. However, the conventional TRT showed better outcome than the Mobile-based TRT with respect to THI scores. The mobile-based TRT can be one of different potential options that clinicians can apply to tinnitus patients who cannot follow the conventional TRT or limited candidate. Further improvement of the mobile device based TRT would be needed.

Effect of Tinnitus Retraining Therapy in Normal Hearing Individual with Subjective Tinnitus: An Observational Study.

This study was done to study the effect of Tinnitus Retraining Therapy (TRT) in Bilateral Normal Hearing Individual with subjective tinnitus and to evaluate the success of simplified TRT with relation to duration of tinnitus, the patient's age and state of mind. As on date there is no definite cure available for tinnitus, so current TRT focuses on reducing the impact of tinnitus on the patient's quality of life. This study included total fifty (50) participants with bilateral normal hearing sensitivity, who had reported to the department of ENT with a complaint of tinnitus in one or both ears. All the participants are active serving military personnel and their dependents of Indian Armed Forces. All the participants had undergone basic audiological test batteries to assess the hearing acuity followed by TRT and its components (TRT counselling and sound therapy) in randomized manner. Audiological test batteries include pure tone audiometry to make sure that the participants have normal hearing acuity in both the ears and then tinnitus matching i.e. pitch and loudness match and measurement of Uncomfortable Level (UCL) followed by sound therapy and counselling. There was significant improvement reported in impact of tinnitus after completion of six (06) months of TRT schedule. Amongst the participants, 40% reported with complete relief from tinnitus, 30% reported with remarkable benefit but they can still perceive the tinnitus, 20% reported with no benefit with TRT and rest of the 10% were not able to tell whether they have got any benefit or not. Normal hearing individual with tinnitus can be benefitted with TRT accompanied with counselling and the improvement in impact of tinnitus severity that ensued over six months of TRT appear to be vigorous with significant clinical outcomes.

Long-Term Results of Tinnitus Retraining Therapy in Patients Who Failed to Complete the Program.

Purpose: We aimed to evaluate the results of Tinnitus Retraining Therapy (TRT) in patients who did not complete the program. Methods: We divided 90 patients who failed to complete the TRT program were into 3 groups: 36 patients who only completed the first phase of the TRT program (Missing group; M), 34 patients who attended counselling for less than 6 months (Noncompliant group; NC) and 20 patients who attended counselling for more than 6 months but did not complete the TRT program (Compliant group; C). The Tinnitus Handicap Inventory (THI), tinnitus Visual Analogue Scales (VAS) and a questionnaire regarding the reasons for dropout were obtained through a telephone survey. Results: Telephonic THI and VAS scores were significantly lower than the initial scores in the M and C groups but not in the NC group. Patients who were unsure about the effectiveness of TRT were prevalent in the NC group, and the poorest long-term THI results were registered in those patients. Conclusions: A fundamental cause of very poor TRT results was when patients were unsure about TRT. On the other hand, a single counselling session could be effective in reducing tinnitus annoyance in patients who accepted the TRT approach and trusted its efficacy.

The effect of tinnitus retraining therapy on chronic tinnitus: A controlled trial.

ObjectivesThe goal of this study was to compare treatment outcomes for chronic bothersome tinnitus after Tinnitus Retraining Therapy (TRT) versus standard of care treatment (SC) and to determine the longevity of the effect over an 18‐month period.Study DesignA randomized controlled trial comparing TRT to SC for chronic tinnitus.MethodsAdults with subjective, stable, bothersome chronic tinnitus associated with hearing loss amenable to aural rehabilitation with hearing aids were recruited. The Tinnitus Handicap Inventory (THI) was the primary outcome measure and the Tinnitus Functional Index (TFI) the secondary outcome measure of tinnitus severity and impact. Data were collected at screening, entry (0 months), and 6, 12, and 18 months after the beginning of treatment, using an integrated digitized suite of evaluation modules. TRT consisted of directive counseling and acoustic enrichment using combination hearing aids and sound generators; SC consisted of general aural rehabilitation counseling and hearing aids.ResultsSignificant improvement in tinnitus impact occurred after both TRT and SC therapy, with a larger treatment effect obtained in the TRT group. Lasting therapeutic benefit was evident at 18 months in both groups. THI initial scores were unstable in 10% of enrolled participants, showing moderate bidirectional fluctuation between screening and baseline (0 month) assessment.ConclusionAdults with moderate to severe tinnitus and hearing loss amenable to amplification, benefit from either TRT or SC treatment when combined with hearing aid use. TRT benefit may exceed that of SC. The global improvement in tinnitus severity that accrued over an 18‐month period appeared to be robust and clinically significant.Level of EvidenceI

Subjective tinnitus assessment and treatment in clinical practice: the necessity of personalized medicine.

Subjective tinnitus can be triggered by a variety of causes, and therefore tinnitus patients constitute a very heterogeneous population difficult to manage. In this article, we reviewed the current literature to present our conceptual model of the conscious auditory percept and tinnitus - based on experimental research - in order to explain the clinical approach to the individual tinnitus patient. Fundamental research has provided evidence to support the neurophysiological model of tinnitus developed by Jastreboff. By manipulating the limbic, autonomic and auditory systems, tinnitus retraining therapy (TRT) aims to reduce the response to the abnormal stimulus. Evidence has confirmed the effectiveness of TRT and cognitive behavioral therapy in reducing the negative impact of subjective tinnitus on the patients' quality of life. Every patient with subjective tinnitus has its unique 'tinnitus profile' which provides a guide to the necessary combination of therapeutic actions. Evidence suggests the multidisciplinary approach combining etiological therapy as well as TRT, and cognitive behavioral therapy in specialized clinics is not only effective in reducing the patient's quality of life but also cost-effective from a healthcare and societal point of view.

Clinical trials supported by the Tinnitus Research Consortium: Lessons learned, the Southern Illinois University experience

The Tinnitus Research Consortium funded three clinical trials investigating treatments for chronic bothersome tinnitus at Southern Illinois University School of Medicine. The trials were designed to measure the subjective changes in tinnitus distress using standardized questionnaires and objective changes in tinnitus loudness using psychophysical matching procedures. The results of the first two trials have been published and are summarized here. The first trial investigated the effect of gabapentin on the loudness and annoyance of tinnitus in adults with chronic bothersome tinnitus with and without a history of acoustic trauma. A small but significant number of subjects reported decreased tinnitus annoyance that corresponded with a decrease in objective measures of tinnitus loudness during active drug treatment with a washout effect during placebo treatment. The second trial compared the effect of tinnitus retraining therapy (TRT) on adults with normal to near-normal hearing and chronic bothersome tinnitus to treatment with general counseling without acoustic enrichment. Significant improvements in tinnitus severity, but not in objective psychometric measures of tinnitus loudness, occurred in both treatment groups, however a greater effect was observed in the TRT group compared with the control group. The third trial is nearing completion and investigates the long-term results of tinnitus retraining therapy on chronic bothersome tinnitus in adults with hearing loss. Significant lessons and observations on conducting tinnitus clinical trials were learned from these three trials. The challenges of recruiting and retaining study participants is discussed. More importantly, the reliability and stability of the Tinnitus Handicap Inventory (THI) over long intervals is presented. The implications of this variability for the design and interpretation of future tinnitus studies is discussed.This article is part of a Special Issue entitled <Tinnitus>.

25 years of tinnitus retraining therapy.

This year marks 25 years of tinnitus retraining therapy (TRT), the approach that aims to eliminate tinnitus as a problem by extinguishing functional connections between the auditory and the limbic and autonomic nervous systems to achieve habituation of tinnitus-evoked reactions and subsequently habituation of perception. TRT addresses directly decreased sound tolerance (DST) as well as tinnitus. TRT consists of counseling and sound therapy, both based on the neurophysiological model of tinnitus. The main goal of retraining counseling is to reclassify tinnitus into the category of a neutral stimulus, while the main goal of sound therapy is to decrease the strength of tinnitus-related neuronal activity. A unique aspect of TRT is that because treatment is aimed to work above the tinnitus source, and at connections linking the auditory and other systems in the brain, the etiology of tinnitus is irrelevant. Any type of tinnitus, as well as somatosounds, can be successfully treated by TRT. Over 100 publications can be found on Medline when using "tinnitus retraining therapy" as a search term. The majority of these publications indicate TRT offers significant help for about 80 % of patients. A randomized clinical trial showing the effectiveness of TRT has been published and another large study is in progress. The principles of the neurophysiological model of tinnitus, and consequently TRT, have not changed in over 25 years of use, but a number of changes have been introduced in TRT implementation. These changes include the recognition of the importance of conditioned reflexes and the dominant role of the subconscious pathways; the introduction of the concept of misophonia (i.e., negative reactions to specific patterns of sound) and the implementation of specific protocols for its treatment; greater emphasis on the concurrent treatment of tinnitus, hyperacusis, misophonia, and hearing loss; extensive modification of counseling; and refinements in sound therapy. The effectiveness of TRT has increased significantly during the past 25 years, presumably due to changes incorporated in its implementation. The main improvement has been to shorten the average time until seeing clear improvement from 1 year to 1 month, with a statistically significant improvement seen at, and after, 3 months. Furthermore, there is a higher effectiveness and a shorter treatment time for DST and an increased extent of help for hearing loss.

Open ear hearing aids in tinnitus therapy: An efficacy comparison with sound generators

Objective: This study aimed to compare the effectiveness of tinnitus retraining therapy (TRT) with sound generators or with open ear hearing aids in the rehabilitation of tinnitus for a group of subjects who, according to Jastreboff categories, can be treated with both approaches to sound therapy (borderline of Category 1 and 2). Design: This study was a prospective data collection with a parallel-group design which entailed that each subject was randomly assigned to one of the two treatments group: half of the subjects were fitted binaurally with sound generators, and the other half with open ear hearing aids. Both groups received the same educational counselling sessions. Study sample: Ninety-one subjects passed the screening criteria and were enrolled into the study. Structured interviews, with a variety of measures evaluated through the use of visual-analog scales and the tinnitus handicap inventory self-administered questionnaire, were performed before the therapy and at 3, 6, and 12 months during the therapy. Results: Data showed a highly significant improvement in both tinnitus treatments starting from the first three months and up to one year of therapy, with a progressive and statistically significant decrease in the disability every three months. Conclusions: TRT was equally effective with sound generator or open ear hearing aids: they gave basically identical, statistically indistinguishable results.SumarioObjetivo: El objetivo de este estudio es comparar la efectividad de la terapia de re-entrenamiento del acúfeno (TRT), con generadores del sonido o con auxiliares auditivos con molde abierto en la rehabilitación del acúfeno, para un grupo de sujetos que, de acuerdo con las categorías de Jastreboff, pueden ser tratados con ambos enfoques hacia la terapia del sonido (límite entre la categoría 1 y la 2). Diseño: Este estudio fue una colección prospectiva de datos con un diseño de grupos paralelos en el que cada sujeto fue asignado al azar en uno de los dos grupos de tratamiento: la mitad de los sujetos fueron adaptados binauralmente con generadores de sonido y la otra mitad con auxiliares auditivos con molde abierto. Ambos grupos recibieron las mismas sesiones de asesoría. Muestra: 91 sujetos aprobaron el tamiz de criterios y fueron incluidos en el estudio. Se realizó una entrevista estructurada con una variedad de mediciones evaluadas en la Escala Visual Análoga y el Inventario del Impedimento por el Acúfeno, un cuestionario auto-administrado, antes de la terapia y a los 3, 6 y 12 meses durante la terapia. Resultados: Los datos mostraron una mejoría altamente significativa en ambos tratamientos desde los primeros tres meses y hasta el primer año de terapia con una significancia estadística progresiva y un descenso trimestral significativo en la discapacidad. Conclusiones: La TRT fue igualmente efectiva con generadores de sonido que con auxiliares auditivos de molde abierto: básicamente dieron resultados idénticos, estadísticamente indistinguibles.

Effect of Tinnitus Retraining Therapy on the Loudness and Annoyance of Tinnitus: A Controlled Trial

Subjective tinnitus is the sensation of hearing a sound in the absence of an external stimulus. Although an estimated 30 million Americans experience chronic tinnitus, only a small percentage are significantly bothered by the sensation. However, this population is currently in need of effective therapy that reduces the impact of tinnitus. Tinnitus retraining therapy has been promoted as an effective intervention for treating chronic bothersome tinnitus from any etiology. The aim of this study was to compare the effect of tinnitus retraining therapy on the loudness and annoyance of tinnitus with a control group. Subjects with subjective, stable, bothersome, chronic tinnitus, and normal to near-normal hearing in the speech frequencies (average pure-tone thresholds for 0.5, 1, 2, and 4 kHz ≤ 30 dB HL) were recruited to participate in a study for the effect of tinnitus retraining therapy (TRT) on the loudness and annoyance of their tinnitus. Participants were assigned to either the TRT arm or a control arm, with assignment balanced between groups by tinnitus severity. After baseline evaluation, participants received acoustic stimulation devices and 3 mos of individual counseling. An integrated computerized test battery of questionnaires and psychophysical procedures were used to evaluate participants at 6, 12, and 18 mos after enrollment. The primary outcome measure was the change in total score on the tinnitus handicap inventory. Secondary outcome measures were change in global tinnitus impact on a tinnitus experience questionnaire, subjective tinnitus loudness rating, and tinnitus loudness objectively measured using a psychophysical matching procedure. Both TRT and general counseling without additional sound therapy are effective in reducing the annoyance and impact of tinnitus. The largest effect on overall tinnitus handicap was observed in the TRT participants, with an effect size of 1.13. However, a clinically significant effect was also observed in the control group, with an effect size of 0.78. Individuals with moderate to severe tinnitus, without hearing loss in the speech frequency range, benefit from treatment with either TRT or general counseling. The global improvement in tinnitus handicap with TRT accrues over an 18-mo period and seems to be a robust and clinically significant effect.

Short Term Effect of Mixed Tinnitus Retraining Therapy

Background and ObjectivesZZThe long-term effect of tinnitus retraining therapy (TRT) is excellent while its short-term effect is known to be inferior to tinnitus making (TM). In this regard, we mixed TRT (mTRT) by combining TRT and TM to improve the short-term effect of TRT. This study evaluated the short-term effect of the mTRT and also compared the clinical efficacy between mTRT and TM. Subjects and MethodZZTwenty patients who underwent mTRT due to chronic subjective tinnitus were included in this study. Sound therapy of the mTRT was performed with mixed noise of broadband noise and narrow band noise. The broadband noise was used for TRT and the narrow band noise was used for TM. During the first month of mTRT, sound therapy was mainly composed of narrow band noise. During the second month, the proportion of broadband noise was gradually increased to 2/3. After 3 months, only the broadband noise was applied. Tinnitus Handicap Inventory (THI), Visual Analog Scale (VAS) on annoyance and the tinnitus awareness duration (hr/day) was checked as the outcome measures. The outcome was also compared between mTRT and TM. ResultsZZThe THI score decreased significantly from 41.8 ±24.3 to 27.3±25.6 after mTRT. The VAS (from 5.9±1.4 to 4.7±1.8) and the tinnitus awareness duration (from 18.5±8.2 to 12.6±10.7) also showed a significant improvement after treatment. When the treatment out come was compared between mTRT and TM, there was no significant difference. ConclusionZZmTRT seems to be effective in relieving the discomfort of tinnitus. Similar shortterm outcomes can be expected from mTRT as they did in TM. � Korean J Otorhinolaryngol-Head Neck Surg 2011;54:693-8 Key WordsZZTinnitus ㆍTinnitus retraining therapy ㆍTinnitus masking ㆍSound therapy.

Personal experience with tinnitus retraining therapy

We present the results of tinnitus retraining therapy (TRT) in a group of patients suffering from tinnitus and/or hyperacusia. Based on the scores from a specific questionnaire and the Tinnitus Handicap Inventory (THI), the patients were classified into five categories and began therapy according to Jastreboff's criteria. Depending on the individual case, therapy envisaged counselling sessions, ambient sound enrichment, sound generators and hearing aids. At the end of the 18-month period, therapeutic success was observed in 79% of the patients. The initial numerical values of the scale of the symptoms and the THI seem predictive of treatment outcome. The use of instruments (sound generators) increases the success rate, but the study also demonstrates the effectiveness of counselling and ambient sound enrichment. Failures mainly involved patients with hypacusia who refused to wear hearing aids, as this influenced the effectiveness of ambient sound enrichment and counselling. Paralleling the data in the literature, the results demonstrate the effectiveness of TRT, which cannot be attributed to a placebo effect given the extended duration of treatment.

Estimation of factors influencing the results of tinnitus retraining therapy

Conclusion: The factors of tinnitus loudness and Tinnitus Handicap Inventory (THI) score in tinnitus patients have the potential to relate to therapeutic results of tinnitus retraining therapy (TRT). Objectives: To confirm what factors in tinnitus influence the results of TRT. Patients and methods: Twelve factors were investigated in 53 patients with tinnitus, examining the relationship between these factors and the results of TRT. A THI score was determined before and 6 months after TRT introduction (pre- and post-TRT). Moreover, the change of THI score from pre- to post-TRT (ΔTHI) was referred to as the therapeutic effect of TRT. Based on the 12 factors, subjects were respectively divided into two groups, comparing Δ THI between groups. Results: Two groups of greater tinnitus loudness and higher THI score showed significant increases in ΔTHI, indicating that two factors of tinnitus loudness and THI score were related to the therapeutic effect of TRT.

Pros and cons of tinnitus retraining therapy

Conclusions. A significant reduction in the Tinnitus Handicap Inventory (THI) was obtained as early as 1 month after implementation of tinnitus retraining therapy (TRT). Over half of our patients either could not tolerate the tinnitus control instrument (TCI) or obtained a poor result in the TRT trial. Candidates for TRT should thus be restricted to patients who can use the TCI. Objectives. TRT has been regarded as a promising therapy for tinnitus, although there have been very few studies to determine which patients are most likely to benefit from TRT. The aim of the present study was to demonstrate TRT's pros and cons based on our experience. Subjects and methods. The subjects were 217 patients with intractable tinnitus. Of those, 84 tolerated TRT and 79 were followed for 6 months. The remaining subjects did not undergo TRT. Japanese translations of the THI and visual analogue scale of annoyance caused by tinnitus (VAS) were administered to evaluate the effect of TRT. Results. The average THI score at the beginning of the treatment was 48.8, but it was 36.3 (p<0.01) 1 month after starting the treatment and 28.3 (p<0.005) after 6 months.

Tinnitus retraining therapy: prognosis factors

Introduction Tinnitus retraining therapy (TRT) is, nowadays, one of the most extended treatments for tinnitus control. The goal is the habituation to a nonsignificative signal, that is, tinnitus, first, eliminating its reaction and, second, minimizing its perception. Purpose The objective of this study is to identify the factors that could improve or reduce the efficacy of TRT. Materials and methods A prospective nonrandomized clinical assay (n = 137) was conducted. Three parameters were considered for tinnitus evaluation at 1-year follow-up: patient self-evaluation, visual analogue scale for intensity, and Tinnitus Handicap Inventory. Results Tinnitus retraining therapy group improved at 1-year follow-up, considering the 3 parameters. The most important factor of failure to TRT efficacy has been the refuse to instrumentation when it was required, according to TRT recommendations. Tinnitus Handicap Inventory score in this group did not show any improvement ( P = .009). Highest scores of tinnitus intensity (visual analogue scale) and handicap (Tinnitus Handicap Inventory) before treatment as well as the most disabled diagnosis (sudden deafness and Meniere's disease) had better response to TRT. Jastreboff's treatment categories, longer presence of tinnitus, existence of hyperacusis or hearing loss, type of prosthesis used, duration of the treatment, and index of assistance to our follow-up program were not related to the effectiveness of TRT. Conclusions Tinnitus retraining therapy has demonstrated to be an effective treatment of tinnitus. More severe tinnitus are susceptible to get better response with this approach. Instrumentation, when recommended, is mandatory to obtain a higher relief of this symptom (EMB rating: B-2).

Retraining therapy for chronic tinnitus. A critical analysis of its status.

Tinnitus retraining therapy (TRT), as conceived of mainly by PJ Jastreboff, has recently received increasing attention in the media, as well as in seminars and congresses on treatment methods for chronic tinnitus. It is often claimed, though not explicitly in scientific publications, that TRT is currently the most efficacious therapy for tinnitus, obtaining improvement rates exceeding 80%. This assertion is highly significant in light of the most likely increasing prevalence of chronic tinnitus and ensuing urgent demand for effective therapies. Before examining the evidence regarding the effectiveness of TRT, Jastreboff's theoretical idea of tinnitus as a neurophysiological disorder is examined and evaluated. This idea is plausible and is supported by some evidence. The interaction between neuroacoustic and emotional processes emphasized by Jastreboff is, however, neither new nor sufficiently elaborated with respect to the underlying psychological factors. The TRT intervention technique and its main components 'directive counselling' and use of 'noise generators' are found to be theoretically well grounded. The lack of detailed information concerning TRT implementation and the potential consequence that differing interventions may be labelled TRT are criticized. Jastreboff's obvious opposition to psychologists' participation in TRT, despite the increase in efficacy they could affect through utilization of cognitive restructuring techniques and behaviour modification interventions, is also criticized. Finally, studies regarding the efficacy of TRT are reviewed and severe methodological shortcomings (e.g. lack of controlled randomized group studies) in TRT research are noted. Taking the current state of evidence into account, we conclude that there is no convincing empirical support for the assumption that TRT is superior to other treatments, since no comparative studies have been conducted. It is contended that there is more substantial empirical support for the efficacy of cognitive-behavioural interventions in reducing tinnitus annoyance and tinnitus-related suffering. The necessity for methodologically well-designed studies to pinpoint effect sizes of TRT and compare them with other techniques, especially cognitive-behavioural ones, is emphasized.