Current Approaches to Helping the Tinnitus Patient UIHC

my plan here is just to talk about tinnitus in a very general way the kinds of things that are done to help people with tinnitus and the kinds of things some things that are not there and possibly some things that could be done in the future so first of all this is a definition so this you have to hear it it's involuntary not something you're producing intentionally and that's something in your head it's not something that you're super sensitive area they're pumping up so there's a list of the boys hearing loss so typically in a healthcare system you often hear about objective versus subjective notice I like to talk about cannabis to wait and we talk about hearing loss so it's either a middle ear tinnitus version the Hillyer behind your eardrum or it's a sensory neural notice but as it starts in the sensory neural system in your body how many people here have done so okay so that's how we think about hearing loss so it's either a bitly er to us or a sensory business most of people here I'm guessing not all of you have a sensory chances are you don't have any abnormal blood flow in the middle tears behind your eardrum but you don't have any muscles twitching there's something going on that's not supposed to do in a sensory girl system okay so it turns out to the both three of the people as unilateral tinnitus raise your hand we have a unilateral tennyson one year so about half the people have it in two years raise your hand okay above there's number of people here in there hit anybody's further okay and I've only seen one patient that says they're somewhere out there so I didn't count exactly but I think we're pretty close to the numbers that we did in this survey many many years ago so this is a survey done showing house the age affects the prevalence of tinnitus in males and sort of bars and this is the percentage of the population now this is actually kind of tricky question because it really depends on how you how you ask the question you can get quite different results but the bottom line is that the as we get older were more likely to get tennis and that's true especially over the age of about 50 and as I always say especially it's a professional audiences these days everybody in this room is going to get so most of us are going to be hearing it and chances are you guys must be you top dentists but even if you didn't because of a wine for people generally end up giving up it's either the person on your left to your right or sitting on you it's actually incredibly common anybody know what the most common cause hearing loss is related to it the most common causes noise exposure exposure caused by a long shot so these are people this is a survey population at large and these are people that have tennis charts of 13% of these people have drink is almost half of them say they have a hearing loss but they don't have hearing aids yet and almost half of them say they have normal uragan don't have any problem hearing now this is actually not true these people do have trouble if they do having hearing loss but it's either a very small mild hearing loss or their tinnitus is so prominent it's so important for them that they have not yet noticed or taking them taking charge of the fact that they also have big hearing loss so to notice almost always occurs with a hearing loss the airlock was not great but almost always occurs with the hearing loss so they backed up their site what kind of problems has to this creative freedom what kind of challenges really focusing your attention okay concentration anybody anxiety anxiety project anxiety depression anything else it's aggravation aggregation concern it's gonna get worse concern it's gonna get worse okay so let's see how he's not stopped here with the survey so interestingly forty five percent of the people say it really doesn't have any effect on them that's not true I said this I said this to people today I actually did a cause of all grant a few years ago from the University of Iowa they had an alumni newsletter and in the alumni newsletter they had a paragraph of this grant that I have antennas and of I paid a long time and well then the next two or three weeks I have a hundred emails from people and they all said pretty much the same thing they said I have 10 of us I've had for 10 years it doesn't bother but if you make it go away does anybody think their tinnitus interferes with their hearing ability over and above their hearing loss that some people tell me they have to listen through there so they have to hear over in communities sometimes they confuse the sounds with their hearing loss as well confused so sleep is one of the most common ones concentrating and getting upset I call these other things leisure activities social life's work personal relationships secondary effects so now they'll talk about the mechanisms and there are probably several mechanisms so it has to be related to recall spontaneous activity in the nervous system as there's activity going on spontaneously without any sound coming in those nerve fibers that are active and have waited they shouldn't be and of course there's nerves throughout the whole body and all over the brain and nerves going from our ear all the way up to the brain and all these nerve fibers are passed to each other connected the connected of these neural junctions we call synapses here and there's one neuron one they're on cell bodies and there's these synapses all the way these synapses and the inner fibers carry the information from one to the other so these nerve fibers are transmitted it's like transmitting out what I call electrical impulse like a flashlight going on top and they're translating from one mirror fibers or the other of these impulses and they're regulated by some chemicals at the junction between the two nerve fibers and that's true the cochlea where we have hair cells and had junctions all the way up to the brain and there's different kinds of chemicals at each of those junctions some of them make the nerve fibers more likely to be active and some of them some of the chemicals make it more difficult to communicate from one nerve logger to the next well it's quite a sophisticated that of course there's hundreds of thousands of these all the way up to the brain so it was noted a long time ago that some people had tended us in their left ear and they were really upset by this and they would go to a surgeon the surgeon would actually cut the ear and cut the nerve fiber going up to that to the brain from that ear that's how bad this was so they gave up cheering in that one ear and it turns out that they were only successful at about 30% of the people so they stopped doing that but it gives you an idea of how desperate some people it also tells you how much we really don't know sorry absolutely ground it also gives you an idea how little we know about dentists for example some other indications were that people have compared to this and their left ear and we did some experiments early on and put a noise in that here to try and they could go away and I remember the patient said oh that's wonderful I can't hear my tinnitus anymore in my left ear but now I hear my right ear so it was probably there all the time in both ears but it was louder and wonderful together and they lateralized the long side we also discovered much to our surprise that even though somebody their tennis and her left ear for some patients we just put it noise in the right ear at a very low level and make their to this goal and the notion was that even though they hear it in one here that still might be mediated and controlled by something going on up in the brain that created how does activity from both ears opposite so that was something we discovered early on that the central nervous system has to be really active so there's three different at least the way I think about this there's three broad areas three broad categories of what causes kids what the mechanism is for this and keep in mind there's a spontaneous activity going on and the auditory system all the time so one theory is that it's simply increased spontaneous activity so for example here the hearing nerve and that hearing nerve even without any sound has a little info electric electrical activity that goes hearing them that's even without any sound at all when we say a word like table and some of the dirt bikers get really active and of course there's 20 or 30 of you sir 20 or 30,000 of these nerve fibers in there with a bunch of them get activated all at the same time in the similar fashion the brains up there are saying oh somebody just said the words table basically how we here understand speech well they may very well be that some of these nerve fibers are hyperactive even without sound and the brains doing what it's supposed to do that's interpreting that activity on those nerves as the sound so as I tell patients your brains doing what it's supposed to do it's interpreting all the hyperactivity I spy here of us a year ago I hear a noise so it depends on that activity so that's one clear theory the other theory is that there's lots of nerve fibers as I said and usually those nerve fibers are independent so there's a we call these action potentials activity on this nerve powder but not on this one activity on this motor protein darkness but what happens if they were all firing at the same time the brains going to say whoa there's something really different going on here something special and that might happen because of something like this and actually here's the nerve fiber here the nerve fiber is covered with it sheep sort of like a rubber sheath around an electrical wire activity now mr.

White was separate from this one well the sheath is damaged that may be an electrical signal traveling down this nerve fiber it's picked up by another one when it's not supposed to fire at the same time actually that was proposed first by heavy polar area so the other way of thinking about just the third category of mechanisms responsible for tennis has to do with the brain reorganizing itself and the way that I think about this is the ya be hearing loss at 4,000 Hertz or four thousand cycles per second and what happens that you lose hair cells in the cochlea everybody hears have their hearing tested right I'm sure also hope so you would then explain the audiogram would have been explained to you and how it relies on the cochlea heart and the hair cells in the cochlea would disappear at four thousand carats if you have a 4000 X hearing loss what happens is that the nerve fibers attach to that part of the cochlea the end organ of hearing start to disappear but the part of the brain in response to 4000 Harris buzzing disappear it's still there now part of the brain at 4,000 carats is now not getting any input and what happens is that that part of the brain starts to respond to 3000 hours instead of four though it's going to sit there doing nothing so now there are two parts of the brain that are responding to 3000 Hertz so just too much spontaneous activity 3000 parrots and the brain says hey there's the 3000 signal over here I hear at home at 3000m and that's one the third wage that we think of mechanisms of tennis and the analogy from that comes from this neural plasticity so for example if you lose a finger the part of your brain that used to respond to the finger doesn't get that representation anymore what happens is that part of the brain starts to respond to other parts there can be a full representation area so it's also important to think about tinnitus in terms of two parts of it so you have to know that's a signal going on on your brain that's not supposed to be there but you also have your reactions at each end so you have to notice you know if your reaction to the tennis so your tennis might be low pitch or high pitch might sound like a roaring like a buzz it's often different different people and people the annoyance people get from that the reaction that they have can be quite different as well and of course all of us have stress in our bikes we all have challenges from here there some of those are quite good at dealing with stressful this don't make it easy to see spiders we get upset by that we're all different about it a little bit differently and of course the more upset we are in general the more anxious we are generally whether we have noticed or not more upset we're going to have be by the hood I hear some people say that the loudness of tinnitus here's some researchers say that now I think that's wrong if anybody here would prefer to have a louder to displace regimen but within an individual it matters of love what your tenderness sounds like and how poverty we do correlations across lots of different people than the correlations between estimates of broadness of annoyance are not as high but that's because different people so I've been doing this for a long time and eventually I grew the primary reactions of tinnitus and of these four areas so – this can have an effect on your thoughts and emotions and have an effect on your concentration have an effect on your hearing and having an effect on their sleep now it turns out everybody's different so a lot of patients are not bothered at all by their sleep and other patients that's the worst – sleep is the most common complaint this patients anybody anybody here not bother at all when they try to sleep because differences okay so that's important to keep in mind the annoyance of influence by they do this itself by the patient and it's more annoying generally of its logarithm it's a narrower spectrum or focus and frequency if you're under stress if you don't have enough sleep your reactions to that are going to be magnified so now I want to talk about measuring tinnitus because we don't always appreciate that it can be measured does anybody here have their ten this measure would you like to share how was it different hearing tests okay okay so you Thomas is one way anybody else how did you help your to notice Thanks pitch matching okay stain okay so when I think about you this is it it's a signal in here in your head somewhere and that we should be able to make the same basic measurements on to this that we can of some physical tone and so the basic properties are of a tone of its pitches and its loudness quality in them so we can also do things like mask it I'm going to just talk about those those three things that and then so we have the tent up we're going to try and measure the tinnitus itself with those pitch and masking and loud and then we have the reaction to tinnitus and we can try and measure that by different questionnaires for example and then sometimes people study this also into their psychological tests ago upset you are anxious you are there's lots of different ways of trying to get at what's going on here it's over the pitch what I say is I'm going to let you hear it's my tone and I want you to adjust the frequency of my tone so it has the same pitch as the most prominent pitch of your tennis now it shows my words carefully your tennis might not sound like a tone it might not even have one pitch but most people not everybody most people can adjust my tongue so it has the same pitch that's the most prominent pitch of your toes not everybody and it's quite difficult it's quite variable even do it I want you to adjust the intensity of my tone so it has the same loudness as your tinnitus okay very straightforward I want you to adjust the level of my noise until it just covers up your tinnitus and we call that the minimum asking level some people they can't master to this for somebody's a bit different it's not like a pure tone and a normal list or we can always manage it but for some reason for some people we can skip the maximum tinnitus so there are some difference it's not like a really good talk so now we'll mention the reactions the people so these are some of the things that that are often comes the way I like to have control over everything in my life unfortunately it doesn't work out that way very often but I really do like control and so what happens if you have a sound in your head you don't have any control over it's not supposed to be in her is it going to be there forever is it going to get worse does it mean I have some illness these are common reactions that people have common reactions everybody has usually for this first begin it turns out the biggest problems people experience you can occur in the first 3 to 6 months after they first started and after about 9 or 10 months or a year or so that sometimes they sort of the reaction anyway so we say people that seem to adapt because a lot of people have tennis like I said that build up to call me after they'd rather be a lot not newsletter they sit doesn't seem to be a big factor in that way so the onset their concern they have they ask questions they might try some coping strategies and then eventually they realize it's there it's not that are bad it's throw lots of people have trouble they focus on other parts of their life they're still aware of it occasionally but they seem to have a awaited to it as we say this takes time to adjust to unpleasant experiences and we're stressed out in our life that might take more time but in time these people seem to be able to managers everybody's different those patients who do not get out they have the same initial reaction this is terrible it's not fair I'm upset by this they interpret their tinnitus as being significant they start asking questions that try different strategies their attention does not decline in the long term they become even more aware they become anxious they're compressed volume we sometimes talk about being a vicious cycle the more you're upset by it the more you think about think about sex you get and it could become a real problem secondary things about becoming depressed anxious and again you can control your reactions you have your tinnitus if I know have any control over that you can control your reactions so there are some things that you can't do to change how you your reaction and these fears and worries can be helped and others can have done this and made it less important in their life so sometimes as audiologists I'm an audiologist sometimes we think we know the answer we have a plan we're going to provide you with hearing aids we'll hear better we know that you can just do this we have an idea of what's going on and if that doesn't always work out for tinnitus because everybody's different than everybody comes from a different background and it's really important especially with tennis to try and understand what's going on not just with a ton of us but with the individual patient that we're trying to talk does anybody experience loud sounds as being really loud at one hand so we tend to call that Piper occlusive and I refer to this as four different kinds of mic the loudness hyperacusis annoyance high producing the fear I purchase a pain hypothesis so for example some people get so annoyed and for some people it's just some sounds and not other sounds some people get so annoyed by it some sounds and that the Sun sounds are so loud they decide not to go to church or not to go to football game or not to go to the restaurant because of their Hyperloop it seems like a lot of people who have tinnitus also have iceberg losses so it's fairly common for these things to occur together it must be some profit relationship at least somebody ok so there's work done on a loss of control and how important that is so I also think about this I have a friend from Denmark nf Moore who's clinical psychology actually there might be at the end and I'll get a book and she wrote a book on she wrote chapter on us it has to do with accepting so as she would say the tinnitus isn't good or bad as the Sun and so some of her patients are just mixed up accepting this this is my style and that's different from being overwhelmed by it I can't stand that this is terrible it's awful I don't like it overwhelmed by your tinnitus what we typically try and do is we try and help patients control them to make it less important and a lot of patients actually benefit from wearing comfort sound therapies and wearing comfortable sounds that help them adjust to this and increase the prominence and we're going to talk more about that I also tell patients that because a lot of people come in has anybody looked on the internet about what surprised them so the more you're thinking about your tinnitus the more you're thinking about your tendons so a lot of patients come in with a long list of things with lots of questions and that's okay but keep in mind we're certainly you know you're trying to control this and that's okay three different reactions to be overwhelmed by it controlling it that can be a helpful thing and accepting to separate the tennis from your reaction to it and you can control your reaction my job is here to help you okay so medications and dietary supplements for tennis is anybody tried the dietary supplement for they're telling us what if you try a long list okay anybody else vitamin B buddy else the most late night anybody else they can do they're not actually something perhaps but you have a point so one of the interesting things about I'm going to I'm going to say that that I grab that it's helped yet that's wonderful thing so one of the amazing things is that every now and again we see a patient who says I take this supplement and might say this is really caused by now there has been no study that has been done and replicated by this has been carefully done it showed that any dietary supplement or medication now it doesn't mean that it can't helpin some individual people because there's different mechanisms were all different the interest thing about saying that the patient's do that I have a group session once a month this dangerous thing about saying that is that a lot of people spend a lot of money they total a lot of places and they're constantly looking for that cure and it might not be there as long as you're thinking about your tinnitus you're thinking about your sanity so this slide right here and a group session I will say that there's no medication or dietary supplement that has been shown that the effectiveness controls to reduce or eliminate tempers and I pause for about five seconds and I say in my professional opinion there has been no study that's been replicated with the right kind of controls with the right kind of metrics that has shown that anybody can offer you a drug or medication to help you with the counters so I say that what now there are drugs that will help you with anxiety and depression and there are drugs that will help you get to sleep those are all good things that's okay I think wrong with them you know but there right now there is no drug or medication that has been shown to be effective in treating that they have attained 50 milligrams of niacin we will get the flash that hearing I've been taking here behind occasion for circulation in the room okay well the game I'm glad that works for you I'm gonna emphasize once again that that has not gone through any controlled investigation that has been published in any favor of their journal or anybody can say this help of some patients that is adopted I'm glad it helps you that's wonderful yes it's just so my experiences so I'll talk about this oh yeah this is a generic question you said no particular drug has been shown to be effective in studies how does one if one comes up with the drug begin to test in one of these studies you know in other words the researchers can't possibly have researched every possible combination so how would you know somebody says hey this worked for me and they want to have a study who would conduct that spam right well there's the most common way that this occurs is that somebody comes up with an idea and maybe from personal experience and they connect with a dietary supplement company or a drug company and they actually try to call it open in Prague so we get 250 people and we'll give them given the drug supplement and see if it works make some measurements before we give them the drug for two months make some measurements up again see how many people would report about it the problem of doing that is what's called a besito is that a lot of people now that they're engaged well good this is a wonderful thing this is kind of home so that kind of trial is not sufficient to convince the FDA or the healthcare community that this drug is effective but if there's enough people in the open trial that benefit then somebody's going to say wow this actually might work now we'll do a controlled trial and the best kind of controlled trial is called a crossover design so we got 50 people to get them and running and 50 people that get a placebo pill they take it for a month and then the 50 people switch and they don't them people don't know whether they're getting the placebo or the drug and I deal with the people that are doing experiment on my leaders so that's how yes so number three says there are promising medications under study are they being tested in this way they are yet in both ways yes and interesting my head somebody called me last week that is has a company that does a dietary supplement workers don't say what it is but he has really bad to it and he wants to do a try and he's I don't know how this is going to work out but he's prepared to give a thousand people just run just whatever it is I can't even take one and then to make some measurements a month later two months later if I see an open trial and this actually works because he really wants this to happen so but there are lots of because there are so many people in the world with tinnitus and because there is no cure there are a lot of people interested in making a lot of money from finding the right pill and that's okay we just have a powder yet so the same thing is true for alternative medicines alternative medicine alternative to treatment interestingly I didn't know this that phrase that the FDA doesn't regulate dietary supplements okay so the idea is that they're not prescribed by a physician therefore they don't have to be regulated and as long as they don't hurt anybody and some of them do it's okay if they start making claims and some of them do then yeah it usually doesn't get involved but somebody might sue and that's how they change how they present their labels and this is this is actually a few years old now but it's incredible how come how common thinking complementary medicines are throughout the United States for all kinds of things and options so I raised your hand that you tried a dietary supplement for your attendance not that many all right how many people here have hearing aids all right great so it turns out that I think that hearing aids are an incredible bargain I've heard a lot of people say how expensive hearing aids are hearing aids are not expensive hearing is one of the most important things that we do it enables us to communicate with the people and to interact with other people and socialize and think about the future and look toward that tomorrow caring is really really important so when you buy your hearing aids that we're all going to need them eventually make sure you get excellent hearing aids that are wealthy this hearing is really really important it turns out fortunately the hearing aids often help tinnitus so they help to notice probably because they improve communications and therefore reduce stress some hearing aids amplify background noise and not come back to be a good thing for tinnitus patients and provides some distraction and partial masking so this is a survey where we asked people who use hearing aids you know that actually and help them with their status or not and above half of them said knock and helitack whatsoever and so that's okay it's not over here and and four percent of them here said it actually made their tinnitus worse so keep in mind now actually the hearing aids can be adjusted so that doesn't happen so it's possible to turn the maximum upward of the hearing aid down for a while gradually increases slowly but most of the people are half of the people here also said that using their hearing aids help them with their time okay so hearing aids our mother both they improve communication that reduce stress because you don't have to listen his heart the amplified background sounds and for a lot of people actually when they their hearing aids up at the end of the day because their auditory system has been activated for a long time their tennis is actually gone for a while even even when they're not using their hearing aids those of you that have hearings that have hearing aids does it help you with your tennis though so here's a yes one one though so in addition to hearing aids there are wearable sound therapy devices or to notice that produce a variety of different sounds these days and these are often very very helpful for lots of people and of course these days does anybody have a little cell phone well of course the people this was paired here from the beginning these are actually computers and we all have computers now and some of them almost all the computers we took talked with and take pictures of it and some of the small computers are all part are also used as one of the options of telephones so they're all doing the same thing a lot of these computers including our cell phones also Fergus town and you can search for apps that'll help produce sounds for tinnitus a lot of people listen to these fountains are a lot of people benefit so it turns out that a lot of the hearing aid companies mouth and some not hearing aid companies actually produce wearable devices often like hearing aids therefore do some and the reason they do this is because people buy them because it helps them with their tennis so ten years ago there were three or four companies doing this and now there are 15 because they're making money because people are buying them because they're done so they're actually very helpful and this is an example from a friend of mine from New Zealand so often people will say that their tennis not like a cricket sound so there is your preference or the visual analogy and some of the sounds that go on are like these waterfalls broadband comfortable noise okay so some of you may not have realized you still have your tennis so that's the visual analogy of taking away the promise of that sound the different sounds therapies that have been tried over the years different mostly in the level that's used and in the quality of the fight so Jack Vernon from Portland first proposed us and he suggested a total masking where the noise background noise the comfort sound covers up the tinnitus completely and the person listens to this sound noiseless way for example at a waterfall sound and they listen to that instead of their tinnitus like the whistling screeching and for a lot of people that's wonderful and a lot of people enjoy and benefit from this total masking approach it's easier of us however for some people that's too loud and they don't like it and so a lot of people would prefer a lower level of sound and we call that partial masking where you hear the tinnitus and you hear this background sound but your tennis is no longer as prominent as it was and actually you could reduce the loudness of your tinnitus by having a low level sound in the background we called out a martial master so now there's lots of options 10 years ago there was only one or two options now there's many options to listen to it shoots broadband noise like this you can modify and amplify the high frequencies or low frequencies you can change the envelope you can have tones process music modulate the tones like you're going to spa you can adjust the noise depending upon your individual audiogram you can actually do some devices now as they spawn some theoretical issues where you can watch out certain parts of the sound so that you hear some regions of your our crisis activation and other price bump get on today so lots of different options now because usually the kind of therapy that we do with this and we recommend the counseling with all of our cell therapies we refer to as tinnitus activities counseling and this is one of the slides that end that war from Denmark suggested to me so this is all a bunch of pictures and we actually go through and sit down the patients with this started with a study that did many years ago memoir they control it so I want all the counseling to follow the same protocol it actually helped me because I sometimes I realized that a patient left and I forgot to say something really clever that I said to the patient yesterday so this helps me keep organized myself and one of the things that I met more help me with what she said to her patients where do you want to start because we're all different and some patients after a lot of different problems and others and sometimes it's not necessarily related to their kids she's a psychologist what do you think caused your tinnitus we talked about spontaneous activity these are just some of the slides that we show door bell goes off door bell goes off there's a player next door the next day the door bell goes dominant in a car accident the next day the door bell goes off and your tree is falling on a neighbor's walk the next door the next day the doorbell goes up and you're thinking oh no now two weeks go by the door bell goes off the summons and your flowers the next day the door bell goes off as a friend the next day the doorbell goes up essentially some accentuate rise the next thing the door bill goes off you're thinking wow this is cool now it's good it's the same sound that's the same door but people have quite different experiences and that has an impact on the kind of reactions that we yeah this is true for all of us and this is part of what they call cognitive behavioral therapy and when we designed this treatment many years ago we use some of the principles of cognitive behaviour therapy to help people understand how how they think about things to have an emotional consequence well I'm going to I'll leave up here afterwards these are two books that are self-help books that we give up to our patients this one is hard to get these days but this is from two psychologists from it's very structured it's chapter one he did this stuff to do you do die Chuck writes people through one step at a time this is the other book that I edited and I should confess that I think about for every question so but this is based on different chapters of addiction I invited people all around the world that I thought they do a good job is it chapter on hearing aids the chapter on medications of the chapter on medical workup the chapter on sound therapy a chapter on mechanisms in song okay I'm going to finish off by talking about some aspects where I think that the future might need us and I think there is a couple of options here and one is that there will be a cochlear implant for ten something so there are a lot of patients who get booked with anybody heard of a cochlear implant anybody know anybody in the cochlear implant so cochlear implant is electrode that goes into the cochlea behind your ear drum the inner ear where the hair cells and the nerve fibers are usually for people that are totally done that's what we started initially over the years people live or water in current lofts are now giving him tax actually my first job was in England and I came back to work in Iowa to help start the cochlear implant program and I thought my job was to show that program plants did not work and I was wrong again fortunately so this is in terms of the accommodations get cochlear implants and they say well I can hear so much better now thank you but even better than that my cannabis was gone for my tinnitus is reduced so now there's lots of interest I've been trying to get interest on this for a number of years now there's lots of interest in using a cochlear implant so these this is a single patient this is over a month these are different days and we have them rate their ten as well so zero is gone and 100 is the worst lot mistaken imagine this person had a urinated one here and a coconut went in the other year and we have to raise the loudness of their tinnitus every day during the year we shouldn't change very much and in the other year they had their cochlear implant the cochlear implants have different electrodes and this one had 20 and on electrode 1 and 3 and 5 and 7 so they have their signal from the environment their microphone from the speech the environmental noise of all presented on those electrodes to help them hear better and on the other electrode it's 2 for 6 tonight we presented the signal that we thought might suppress their tenants and they alternated every single day between those two different cities but the good news is that their tennis was produced by both of these signals and it turns out it was better on one than the other so I think that there will be something in the future but it's taken a long time the other approach and it turns out this approach is being done with big motor stimulation which has been shown to be effective to her a couple of see I recall the first time I saw this at a meeting in Washington DC and legal methods uses usually in the neck and ears it make sure that I saw somebody showed me a videotape of somebody but that's less he go on like this and then we put the switch so I was overwhelmed like this now Gladys I have involvement study as is sites in Buffalo Detroit Dallas City so there's work now going on carrying the stimulation of the vagal nerve which has the potential to change while your brain is reacting and coding the chain of signal as a treatment for tennis so the trial is underway right now all right so I want to finish here so here's the screen it turns out that I was in a coffee shop but a month ago and this is the wall of the coffee room here this is a this is a window in the coffee shop and sure enough here's the screen well it turns out that I was wrong once again here's the coffee shop there's a table opposite in that painting on the wall so here I thought all these years this guy had tinnitus build us a coffee okay we also been propagating in Iowa City every year we have the 23rd annual conference and actually we invite patients as well as professionals so we usually get anywhere from and you're all welcome ok there any questions you

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