ASMR: A Therapy for Tinnitus?

Copy of A Review of Tinnitus Treatments

If you have access to the internet, chances are you’ve come across ASMR during your surfing.  An online phenomenon that has become something of a craze these last few years, ASMR has become hugely popular with hundreds of channels on YouTube specialising in different themes.  What’s it all about?  Ultimately, regardless of what type or theme you like, ASMR is all about relaxation and “tingles”, the pleasurable “fizzy”, “static-like” sensations that are felt over the head and often down the spine in response to certain visual or auditory “triggers”.

What is ASMR?

ASMR stands for Autonomous Sensory Meridian Response, which is described as the subjective experience of a tingling sensation on the skin and positive feelings in response to certain visual or auditory stimuli.  These stimuli are more commonly known as “triggers” and can be anything from sounds, such as brushing, tapping and whispering, to personal attention and role-play.  Even if you’ve never heard of ASMR, chances are you’ve still experienced the “tingles” – most of us are familiar with that pleasant and relaxing tingly sensation down the back during a head or back massage, a hair cut or in response to certain “nice” sounds.  Most people would agree that sounds such as striking a match, popping bubble wrap and rain drops elicit positive, relaxed feelings at the very least, even if they haven’t experienced “tingles”.  However, it is usually the new experience of “tingles” that prompts someone to experiment with ASMR to find their own personal “tingle triggers”.

ASMR and Tinnitus

Tinnitus is most commonly described as “ringing in the ears” and, although a high-pitched ringing is perhaps the most common type of tinnitus described, tinnitus can present itself with different sounds, including low-pitched “rushing” and even musical sounds.  There is currently no known “cure” for tinnitus, however, commonly used management strategies include “sound enrichment” (e.g. use of white noise generators to reduce the obviousness of the tinnitus sound and make it easier to ignore) and relaxation techniques combined with some form of counselling and education (e.g. talking therapy or Cognitive-Behavioural Therapy) (Hobson et al., 2012).  I have written another blog post that summarises the main tinnitus treatments here.

Stress and anxiety commonly occur at the same time as tinnitus (whether a person who has anxiety is less able to cope with their tinnitus, or the experience of tinnitus causes anxiety) – whichever comes first, it is generally agreed that some form of combination therapy will work best.  In combination with sound-enrichment, reducing stress and encouraging relaxation can make it easier to manage tinnitus and achieve a better quality of sleep (Baguley et al., 2013).

While there is little in the way of scientific research into the real physiological and emotional effects of ASMR, its increased popularity certainly supports its positive benefits, which are known to include relaxation, reduced stress and anxiety and better sleep.  However, one recent study by Poerio et al. (2018) suggests ASMR can have notable positive therapeutic benefits, including regulating emotions and reducing heart rate.

So we know tinnitus and anxiety often occur at the same time, and, there is increasing anecdotal and scientific evidence emerging on the stress-reducing benefits of ASMR.  Based on the fact that one of the most popular categories of ASMR “trigger” is auditory, could ASMR be an effective tinnitus therapy? Not only can ASMR sounds provide sound enrichment and/or partial masking of the tinnitus signal, but, much like commonly used nature sounds (e.g. ocean waves or rain), ASMR sounds often initiate positive feelings of relaxation, calmness, safety and even euphoria.

Check out my new YouTube channel, Harmoniss ASMR, which has an increasing selection of ASMR videos, all of which are listed with options of background binaural beats and pink noise for tinnitus.  The aim of the videos is to provide highly relaxing sound-enrichment to help habituate to tinnitus and help reduce tinnitus-related anxiety to promote restful sleep.  Any feedback, comments, or requests, do get in touch!

References

Baguley, D., Andersson, G., McFerran, D. & McKenna, L. 2013. Tinnitus: A Multidisciplinary Approach. Wiley-Blackwell, UK.

Hobson, J., Chisholm, E. & El Refaie, A. 2012. Sound therapy (masking) in the management of tinnitus in adults (Review). The Cochrane Database of Systematic Reviews. Issue 11. Art. No.: CD006371. DOI: 10.1002/14651858.CD006371.pub3.

Poerio GL, Blakey E, Hostler TJ, and Veltri T.  More than a feeling: Autonomous sensory meridian response (ASMR) is characterized by reliable changes in affect and physiology. Aspell JE, ed. PLoS ONE. 2018;13(6):e0196645. doi:10.1371/journal.pone.0196645.

Disclaimer

The information provided and topics discussed in this blog are not intended as a medical treatment for tinnitus or alternative advice to that provided by a medical doctor.  Always use tinnitus sound-enrichment and tinnitus maskers with caution. Never aim to completely mask tinnitus and always maintain volume at a safe level that provides only partial masking. Always seek advice from a doctor for tinnitus that is only in one ear, pulsatile (beating) or particularly distressing.

Question: Why are private hearing aids so expensive?

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When I worked as an Audiologist in the UK’s National Health Service (NHS), I was often asked by my patients questions such as “Are private hearing aids any better than what you get free from the NHS?”, “Might I hear any better with a private hearing aid?”, and “Why are private hearing aids so expensive?”  I always found such questions difficult to answer because I didn’t know for sure if private hearing aids were indeed any better, I didn’t know if the private technology at the time could help a person with hearing loss hear any better and I certainly had no idea as to why NHS hearing aids are free and a pair of private devices can set you back anything up to £6,000.  Of course, I always opted for the “politician’s answer”!

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I was, however, very proud of my NHS – often working in the local hospitals, I witnessed first-hand the enormous amount of hard graft, team-work, tax-payers’ money and impressive amount of training and education that goes into running this mammoth and precious system.  A system that, despite being gargantuan in size, is actually quite fragile and teetering on collapse due to increasing demands and not enough money.  As an NHS Audiologist, I felt proud of the fact we were able to offer good digital hearing aids completely free of charge and always made sure my patients did not assume NHS hearing aids were inferior in quality just because they were free (some UK NHS patients don’t know how lucky they are!).  However, I also advised the patients who asked about private hearing aids to, by all means, see a private hearing aid audiologist, but to make sure they trial private hearing aids before they decide to buy and still stand by this advice.

I no longer work in the NHS and now work for a major hearing aid manufacturer that supplies both the public and private sectors.  I now know a lot more about the technology that goes into hearing aids and train both NHS and private Audiologists and Hearing Aid Dispensers on our latest products and software.  I am also now in a better position to answer those tricky questions posed by many an NHS patient all those years ago!

“Are private hearing aids any better than what you get free from the NHS?”

In some ways yes, but for some people it isn’t something that matters.  Private hearing aids will most often offer more advanced technology, such as direct streaming via an iPhone (“Made For Apple”), several intelligent automated features, custom In-The-Ear styles and a multi-functional app, but you might not have any need for all these things.  So, really, a private hearing aid with all the associated modern technology is only “better” if you can and will use all the extra options you are buying.  Even just 10 years ago, there was a notable difference between NHS and private hearing aids, but today this gap is closing.  Hearing aid manufacturers are now offering very similar spec in their NHS product as they do in their private product.  That said, most NHS Audiology departments do not offer the more expensive custom-made In-The-Ear or Receiver-In-The-Ear devices.

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“Might I hear any better with a private hearing aid?”

As previously mentioned, private hearing aids often come with extra smart technology, however much of this is more about convenience than actually hearing better.  For example, being able to adjust your hearing aids’ volume or noise cancellation via a smartphone app, streaming music directly to your hearing aids via an iPhone or having a tiny custom-made Invisible-In-Canal device will not necessarily contribute to hearing better, but will certainly make hearing more convenient.  How well you hear with a hearing aid is as much about its programming as it is about its technology.  The NHS routinely fit hearing aids with a Real-Ear Measurement (REM), an objective test used to fine-tune the sound of the aid to your individual ear canal and verify the aid is amplifying accurately according to your prescription.  REMs are carried out by many private hearing aid dispensers, but not routinely.

“Why are private hearing aids so expensive?”

And finally, just why are private hearing aids so incredibly expensive?!  There is one element of better technology costing more.  However, NHS hearing aids usually have a basic cost of about £50-£60 each for a standard Behind-The-Ear device, whereas private dispensers might purchase a top-spec Receiver-In-The-Ear aid for about £1500-£2000 (depending on spec, etc.).  The difference in price at this point is not just about technology, but also about the number of units purchased.  Most NHS Audiology departments in the UK fit hundreds of hearing aids every week and spend hundreds of thousands of pounds on hearing aids each year.  Compare this to an individual private hearing aid dispenser and the number of hearing aid fittings can drop to just one or two per week.  So private dispensers pay a higher cost price for premium hearing aids, so have to charge their customers more, but they also need to charge according to demand and capacity.  A private hearing aid dispenser has far less demand than an NHS department and far less capacity to see many patients.

The other misconception about private hearing aids is that the entire cost is for the devices alone.  The cost you pay for private hearing aids may also include your consultation, hearing test, ear wax removal, ear impressions, custom-made devices, hearing aid fitting, follow-up appointment, batteries, replacement parts, reassessment, etc.  When you actually cost all of these other included products, services and clinic time, the cost of the actual hearing aids comes down significantly.  Buying a hearing aid is not the same as buying a sofa – you won’t walk out of the store with your new hearing aids and never need to visit again.  Hearing and hearing aids require on-going observation and maintenance.

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So, yes, you can get more advanced technology privately and, if you plan to use all of what’s available then it may well be worth the expenditure.  The other main difference between hearing aids from the NHS and privately is the service.  While NHS Audiologists are highly trained and well-educated, they are pressured to see as many people as possible in a very short space of time and appointment waiting lists are usually long.  Even if you don’t have to wait for an appointment for a repair, you still may have the inconvenience of having to wait at a walk-in repair clinic.  Like most other private health care, by seeing a private Audiologist you will most likely never have to wait to be seen and, when you are, you will have much more time with your clinician.

So, if you are weighing up whether to stick with NHS hearing aids or purchase privately, my advice, having worked on both sides, would be to ask yourself: do you want and will you use the latest technology, do you want a very discreet device, do you want to be seen quickly?  If these are all important to you, and of course you can afford it, then private aids may be the right option for you.  However, if your listening needs are not complex (i.e. mostly 1-2-1 conversation in quiet or watching TV), you have no desire for modern technology and don’t mind NHS waiting times and busy clinics, then stick with the fantastic UK NHS!

Question: How loud does a sound have to be before it damages your hearing?

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Answer

A sound needs to be over 80 dB before it can potentially cause permanent hearing damage.  However, it is not as simple as just the loudness of the sound.  The duration of exposure and how the sound enters the ears are equally important.

The louder the sound, the less time it takes before damage can occur.  For example, it is safe to listen to sounds under 80dB indefinitely.  Sounds at 85dB can start to cause damage after 8 hours of exposure.  This time drops by half to 4 hours just by increasing the sound level to 90dB.  Increasing the sound level to 95dB reduces this safe listening time to just 2 hours.  The average preferred volume of portable media players is about 94dB.  Sounds over 100dB may cause hearing damage within 15 minutes of exposure and sounds louder than 130dB damage hearing instantly.

As well as the sound level and the duration of exposure, how the sound enters the ear also plays a part in how likely the sound will cause hearing damage.  Supra-aural headphones (the larger headphones that completely cover the entire ear) are safest.  Tests show in-ear earphones are more than three times more likely to cause hearing damage than supra-aural earphones.

What Will Hearing Aids Sound Like?

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If you have, or suspect you have, a hearing loss, you might be considering trying hearing aids.  Many people are reluctant to take the first step because of concerns, reservations or even fear of what using hearing aids might involve.  Many people have concerns about how the hearing aid might look, some worry they might not manage with today’s modern technology, while others assume they won’t like the sound of hearing aids.  The latter barrier to hearing aids is most often a misconception – most people who believe they won’t like the sound of hearing aids wrongly assume that they will sound loud and some even believe a hearing aid will make them talk louder.

While these are all normal, human concerns, today’s digital hearing aids provide a more natural sound than ever before.  Modern technology has become so intelligent that hearing aids process and amplify sound using very clever electronic systems, which can carry out several automated changes at once without the hearing aid wearer having to adjust any manual controls or even being aware of the hearing aid’s sound processing changes.

The most common type of hearing loss is high-frequency (or high-pitch) – this means that the person can hear lower frequency sounds easily, even if they are very quiet.  However, as the frequency of a sound increases, the louder the sound has to be before the person can hear it.  At some frequency, which will vary from person-to-person, the sound cannot be heard at all, no matter how loud it is and no matter how much it is amplified.  The speech frequencies span from about 250Hz to 6,000Hz.  A standard hearing test will test across 250Hz-8,000Hz.  Hearing aids tend to amplify sound across 100Hz-10,000Hz, however this does vary, depending on the spec of the device and how it is fitted in the ear canal.

Most people with a high-frequency hearing loss tend to make similar complaints – speech sounds unclear or “mumbled”, even minor background noise makes it extremely difficult to understand speech, the need for people to repeat becomes more frequent, and increased volume is required to hear speech on television, usually much to the annoyance of better-hearing family members!  So if that is what a high-frequency hearing loss sounds like, what do hearing aids sounds like?

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I’m lucky to have normal hearing myself, so can’t speak from personal experience, but I have fitted hundreds, if not thousands, of hearing aids, so I can tell you about how my patients report their experiences of wearing hearing aids.  Many people report the hearing aids’ sound to be “tinny” – some patients do not take to this quality initially and prefer less volume in the high frequencies that causes this effect.  However, many patients understand that this is normal – if s/he has had a high-frequency hearing loss for many many years, the brain is inevitably going to sense a “tinny” sound when the hearing aids are amplifying high-pitch sounds so that they can be perceived by the brain.  Patients also report speech as sounding “sharp”, “crisp” or “clear” and they become more aware of quieter surrounding sounds, such as rustling paper, air conditioning or a ticking clock.  Many patients note they can hear their own voice more (which people may or may not like!), however, sometimes this can be remedied by trying a different fitting in the ear canal.  Because new hearing aid users can hear their own voice louder, they worry that they are talking louder – reassuringly, it is actually the opposite.  Hearing loss can cause a person to talk louder because they cannot hear their own voice properly.  However, because hearing aids amplify sound, the hearing aid wearer can hear his/her own voice more clearly and at a normal level.  Most people with hearing loss who routinely raised their voice when talking prior to using hearing aids notably lower their voice as soon as their hearing aids are in their ears.  Some patients perceive the new sound as being loud – such patients have usually put off getting hearing aids until their hearing loss has become more severe.  As the brain becomes accustomed to being deprived of sound, adapting to amplification can be more of a challenge.

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Overall, and most commonly, new hearing aid users report that the sound of their hearing aids is just different.  Often people find it difficult to explain how the sound is different, but once they become aware of how much clearer speech is, how much easier it is to communicate with people, how their aids may allow them to bring previously lost pleasures back into their life, such as music, and how general listening requires less effort, they stop worrying about the sound of their aids and instead start anticipating how hearing aids may positively impact their quality of life.

How To Get The Most From Your Hearing Assessment and Hearing Aid Fitting.

How to get the most from your hearing assessment-2Whether you’ve raced straight to your audiologist at the first signs of hearing loss, or you’ve put off the inevitable for decades, your hearing assessment and hearing aid fitting appointments often lay the foundations of your entire hearing aid experience.  The information you provide to your audiologist guides the selection of hearing aid manufacturer, style, model, amplification strategy, programmes, controls, wireless accessory options, etc., so it is important to use your appointment time wisely and provide the concise and highly relevant information your audiologist needs to provide you with a hearing aid that is perfectly tuned to your individual needs.  Read on for a guide on how to get the most from your hearing aid assessment and fitting.

1.  Answer consultation questions with concise and highly relevant answers

Every good audiologist will conduct an initial consultation, which should involve a medical history questionnaire and further questions about your lifestyle and problem listening situations.  The purpose of the medical history questionnaire is to screen for any symptoms that may need onward referral, for example to an ENT specialist, and also to guide further diagnostic tests.  Avoid giving too much detail on less relevant information, such as unrelated or historic illness or other people’s experiences.  Instead, try to answer questions with concise responses that answer the question directly.  This allows your audiologist to cover all the questions they need to ask and get a clear understanding of your hearing needs.

2.  Be honest

Most audiologists want to help people with hearing loss.  While there are of course some hearing aid dispensers who are just out to make money, the vast majority of audiologists have a good understanding of the negative impact hearing loss can have on someone’s life and a strong belief in the potential benefits of today’s hearing technology.  It is not at all uncommon for people with hearing loss to be in denial, and this is very human, but playing down your hearing difficulties or blaming other factors only serves to prolong your struggle and prevent your audiologist from providing help.

3.  Give specific examples of typical difficult listening situations

When it comes to your hearing aid fitting, your audiologist will programme your hearing aids in a way that best compensates for your individual lifestyle and challenging listening situations.  Today’s hearing aid technology is highly advanced and, in most cases, devices can be programmed to work automatically, including volume changes, noise reduction and how the aids focus their microphones forwards in noisy environments.  Think about your lifestyle day-to-day.  Is most conversation 1-2-1 or in groups?  Are you most often in quiet or sometimes in noisy environments?  Do you spend much time outdoors?  Do you listen to music or play a musical instrument?  Do you struggle to hear speech when watching television or talking on the telephone?  Do you particularly struggle to hear speech clearly in background noise?  If you can provide a clear and concise description of your daily lifestyle and difficult listening situations, your audiologist can prescribe your hearing aid fitting more accurately and finely tuned to your individual needs.

4.  Further fine-tuning – try to provide clear descriptions of problems and give specific examples

Most audiologists will invite clients back to the clinic a few weeks later for a follow-up appointment, especially if after an initial trial period.  If you are having a few problems and want some further fine-tuning of the sound or some changes made, try to provide clear descriptions of your experiences.  Your audiologist cannot experience your hearing first-hand, but instead has to make adjustments in the fitting software purely based on your feedback.  Vague comments such as “it sounds a bit strange” or “sometimes I can’t hear” give the audiologist nothing to go on.  Instead, use logical descriptive words such as “traffic is too loud”, “speech sounds very tinny or harsh” or “speech on TV is not clear”.  Specific examples are always helpful, for example, “I went to a restaurant on Saturday and, while using the Restaurant programme, I could not hear conversation clearly because of the background noise of all the other people talking” is more informative than “I can’t hear in noise”.

5.  Embrace modern technology!

Hearing aid technology is advancing at a faster pace than ever before.  While this can be daunting to some, newer technology in hearing aids often makes using a hearing aid easier, not more difficult.  Historically, a hearing aid wearer would face the challenge of having to press a button to change programmes or volume, whereas today, not only are hearing aids much more intelligent and change settings automatically, most manufacturers now offer smartphone apps, which allow end-users to abandon the need to feel around their ear to fiddle with ear-level controls and instead adjust simple-to-see controls on a smartphone or tablet.  Most hearing aid manufacturers also offer other wireless streaming devices to connect to your television and many now offer tele-audiology technology, which allows you to request hearing aid sound adjustments through your app.

We never lose Grandad anymore, now

The key to a successful and productive hearing assessment and hearing aid fitting appointment is good communication.  If you can provide clear, concise and relevant information to your audiologist, he or she will be more equipped to conduct a thorough assessment and provide a finely tuned hearing aid that is personalised to your individual needs.