level 3: pain in moving the lumbar spine and legs. ⢠level 4: surgery, accidents, medication and other specialisms. Item frequency: ⥠45% is a clinical marker for ...
Cervicogenic Tinnitus Incidence, characteristics and treatment in patients with tinnitus Iem C.P. Bakker, MSc, PT, MPT* Prof. Rob A.B. Oostendorp, PhD, PT, MPT** * Practice for Physiotherapy, Arnhem, The Netherlands ** Radboud University, Nijmegen, The Netherlands
Earlier presentations on ITS ITS2008: Pilot RCT (N=40): significant difference in favour of treatment group (Manual Therapy Utrecht [MTU]) ITS2011: Observational study (N=400): MTU leads to 52,8% less tinnitus volume ( 5% decrease) Follow up (N=104): Treatment in low frequency is more effective on long term Conclusion: MTU is an effective treatment in patients with tinnitus
Aim and Background The objective of this study is to develop an intake for patients with cervicogenic tinnitus (CT) and to prove the effectiveness of Manual Therapy Utrecht (MTU). It is assumed that gently movements of the cervical motion segments C0/C4 decrease tinnitus, based on the neuronal connections of NV, NVII and cervical spinal nerves at the trigeminocervical nucleus.
Neuronal connections of NV, NVII and cervical spinal nerves .
NVII Cervical spinal nerves
Hypothesis 1. The middle ear is mainly innervated by branches of trigeminal nerve (NV) that has convergence with spinal nerves C2-C3. Hypervelocity movements during whiplash lead to a sensitisational unbalance in cervicogenic area. Grieve GP, Common vertebral joint problems, 1981
2. Central sensitization (CS) can be minimised by gentle mobilisation of the cervical spine in patients with lower tinnitus volume in the middle ear. Woolf CJ, Central sensitization: Implications for the diagnosis and treatment op pain, PAIN (2011), Mar;152(3 Suppl):S2-15
Material and Methods - 1 Patient population • Advertising in local papers during 4 years • Inclusion: patients with tinnitus (n=528) • Exclusion: patients 82 yrs, use of psychopharmaca, (n=22) • Informed Consent • 3 papers with information about treatment strategy • Patient’s diary
Material and Methods - 2 Patient characteristics Intake in five levels: • level 0: tinnitus localization, gender, hearingimpairment, kind of noise and duration, blood pressure • level 1: problems in the head, neck and eyes • level 2: pain by moving arms and shoulders • level 3: pain in moving the lumbar spine and legs • level 4: surgery, accidents, medication and other specialisms Item frequency:
45% is a clinical marker for Cervicogenic Tinnitus (CT)
Intervention Manual Therapy Utrecht (MTU) Characteristics: • Very gentle treatment method, no (sudden) force • An eggshell should not break during therapy • Moving in sagittal (median), frontal (coronal) and transversal/horizontal plane together in 3 dimensions (3D) De Waal H, De Waal K, Development digital MT-system software and analysis, CD-rom version 1.0 © 2006 School of Manual Therapy, Nieuwegein, The Netherlands (www.manueletherapie.nl)
Primary clinical outcome Primary Outcome • Visual Analoque Scale Tinnitis (VAS-tin)* • 0 = no tinnitus, 100 = unbearable tinnitus • VAS-tin: good reliability and validity** Minimal Clinically Important Change • MCIC: VAS pain = 15 • MCIC: VAS-tin = 10*** Statistics student T-Test ( =0,05) * Oostendorp, 1976; Bakker, 1992 ** Adamchic, 2012; Figueiredo, 2009 *** Adamchic, 2012; Bakker, 2013)
Results - 1 Population N=506 • Man: 69,4% • Deaf: 50,6% • Age: mean 55 yr, range 15-82 yr, median 56 yr • Tinnitus duration: 1-10 yr (79,3%)
Results - 2 Patient characteristics • Level 0: Noise in two ears or centre scalp, blood pressure >85 mm Hg • Level 1: Cervical crepitation, impossibility to localize sound, nose unilateral nostril, stress leads to a higher tinnitus volume • Level 2: No markers • Level 3: Pain in lumbar spine • Level 4: Whiplash trauma in history, use of anti-blood pressure drugs Based on the criteria for clinical markers ( 45%) 307 of the 506 patients (60,8%) belong to the CT-group
Results - 2 Clinical Outcome • The pre-to post-test differences VAS-tin statistically (SS) and clinically significant (CS) • Relevant improvement: CT MTU 52,8% (SS) and 45,8% (CS)
Conclusions A systematic intake of patients with tinnitus is a valuable instrument to identify a subgroup of patients with CT. Treatment according to Manual Therapy Utrecht (MTU) leads to statistically and clinically significant decrease of tinnitus volume in CT patients.
Discussion How can we out sort tinnitus? Cervicogenic Tinnitus (CT) 61% What to find in 39%: • • • • • • • • • •
Noise related Tinnitus (25-30%) Neural Tinnitus (1-2%) Juvenile Tinnitus (1-2%) Acoustic Tinnitus (1-2%) Pulsatile/typewriter Tinnitus 2.5% Inherited Tinnitus 0.75% Drugs related Tinnitus, f.i. cisplatin (1-2%) Infections related Tinnitus (1-2%) Temporomandibular joint related Tinnitus (
