Sound Therapy & Counseling

Evidence of Effectiveness
Sound Therapy
Alternative Sound Therapy


It is common for hyperacusis symptoms to worsen as a result of sound exposure leading many to make the logical decision to isolate themselves from sound. However, studies by those who provide sound therapy show that, on average, individuals who undergo treatments that encourage the gradual reintroduction of sound see improvement in sound tolerance. In contrast, the “no treatment” groups of two sound therapy studies saw no improvement on average (group sizes of 30 patients and 6 patients). Counseling is generally included as a critical part of therapy to address pain, setbacks, and emotions that may arise from sound exposure. In these studies, sound therapy and counseling showed roughly 9-12 dB improvement on average after treatment:

Table 1: TRT & CBT Summary
Table 1: Sound Therapy and Counseling Summary

It should be noted that there have been no proper sound therapy studies that include a placebo group, meaningful sample size, and random sampling of hyperacusis patients.

Sound therapy should be viewed as a rehabilitation strategy rather than a cure-all. It is slow, not effective on all patients, and will not necessarily lead to a complete recovery. Those who have recovered are at risk for redeveloping hyperacusis as a result of loud but not necessarily uncommon sound exposure. Continued research into other treatments is needed.

Evidence of Effectiveness

Sound therapy with counseling has several forms but the most marketed and studied is Tinnitus Retraining Therapy (TRT). The following reviews results of two studies on TRT. When referencing Table 1 above, you can see that alternative sound therapies and counseling types performed better than their respective categories in the TRT clinical trial. As a result, it is possible that the improvement reflected in the TRT data below could be enhanced by an alternative counseling strategy and/or sound therapy type.

A proper large scale study has yet to be carried out however there have been many smaller studies without placebo groups. Additionally, there are two studies that include a control group. The first is a CBT study that used a waitlist as a control group. The second is an unusually small TRT study (7 in control group, 10 in treatment group) that only includes those with hearing loss. Table 1 (above) shows several studies where an average LDL increase of 12 dB was observed after therapy while those without therapy showed no improvement on average. The plot below breaks down results from the small clinical trial of TRT (Formby 2013).


Data interpreted from Figure 1 of Formby et al. 2013

The breakdown above helps show that significant improvement is possible for some even with low initial LDL values. The results also show that those without treatment can improve, but sound therapy with counseling may accelerate recovery. 80% of those treated with TRT showed 5dB or more improvement in LDL while 43% of those without treatment showed such improvement. 50% of those treated with TRT showed greater than 20 dB of LDL improvement while none of those without treatment showed improvement above 15 dB. These results taken with the perspective from Table 1 provide support that TRT may be a useful treatment tool.

The graph above does show some bias in group assignments. 57% of the placebo group started with LDLs above 90 DB while all participants in the TRT group started with LDLs below 90 dB. Sound therapy clinicians report greater potential for improvement for those who start with lower LDLs, as can be seen in the next graph. As a result of this narrowed scope, small sample size, and bias in initial LDLs, conclusions of this study cannot be applied to the hyperacusis population as a whole.

In another study without a placebo group, Craig Formby led an analysis of clinical data of 68 patients who had enrolled in TRT and whose primary complaint was decreased sound tolerance. Patients who did not go to at least one follow-up visit with LDL testing were excluded. By the end of treatment, 80% of these patients showed measurable improvement in LDLs (at least 5 dB). The average LDL improvement among the 68 patients was 10-15 dB across frequency. An enlightening breakdown of patients with less than 40 dB hearing loss (HL) at the worst LDL frequency is shown below. Note that LDL change is for the frequency that was lowest at the start of treatment:


Data interpreted from Figure 14 of Formby et al. 2007

The low number of individuals with LDLs below 70dB in this study makes it difficult to draw conclusions on the most severe hyperacusis patients. However, of those with LDLs below 70dB, all but one who had follow-up testing showed significant improvement. For the group as a whole, it appears three individuals who had a setback were willing to have their LDLs tested at a follow-up visit. Without a placebo group and without knowledge of those who dropped out due to setbacks, it is difficult to judge whether this rate for setbacks is normal or higher than would be expected for those who do not undergo therapy.

Effectiveness with Pain Hyperacusis

Studies so far do not include a clear breakdown of results between patients with and without pain. Craig Formby’s 2007 statistical analysis of TRT treatment attempts to address this by analyzing the impact of self-reported pain and physical discomfort on TRT success. The data showed no statistical difference between those that reported pain or physical discomfort symptoms from those that reported no pain or physical discomfort. A majority of hyperacusis patients who seek treatment are expected to include pain as a symptom (Anari 1999). The success stories summarized on this site show several individuals with pain hyperacusis who recovered while using sound therapy. This is not proof, but this evidence suggests that sound therapy and counseling can help those with pain symptoms.

Bias in LDL studies

There is some inherent bias in the studies above as they require complete LDL testing at follow-up visits. If a person sustained severe and long-lasting setbacks during therapy, this person will be less likely to participate in LDL testing. This patient is more likely to be concerned that LDL testing will increase the risk of another setback. A requirement for follow-up LDL testing and completion of treatment separates those with weak tolerances from those with strong tolerances and inherently biases results. The degree that omission of dropouts biases results is unknown. In the end, a treatment cannot be deemed successful if patient retention is low.

A conflict of interest that is likely unavoidable is that sound therapy studies are generally performed by the treatment providers themselves.

Click to Show: Dropout Omission Bias and Risk Disclosure

In the CBT clinical trial (see counseling section), just 5 of 61 patients dropped out. The reasons for two were unrelated to sound tolerance issues. Reasons for the other three were not reported.

An independent 2010 study of TRT for tinnitus patients by Ariizumi et al showed that 38% of patients found sound generators intolerable or ineffective after one month of use. In a 2002 study by TRT cofounder Hazell et al, 27% of patients did not return for a follow up visit.

TRT studies would do well to provide this type of disclosure. The results of the TRT studies presented above show those with low LDLs improve as much or more than those with higher LDLs. However a statement from the Tinnitus Retraining Therapy literature suggests one group may be underrepresented:

“Category 4 consists of patients who have tinnitus and/or hyperacusis and exhibit prolonged worsening of their symptoms as a result of sound exposure. This is the most difficult category of patients to treat, and the success rate is lower than in the other four categories”

-Tinnitus Retraining Therapy (2007) by Pawel Jastreboff and Jonathan Hazell

Hyperacusis questionnaires provide a painless way to track patient setbacks and could be done by email if the individual was unable or unwilling to return. Studies could then report results of those who completed treatment (as is currently done) along with results of those who did not. Setbacks could then be compared with a placebo group. An analysis comparing the differences between those who drop out with those who complete treatment would also be valuable.

As there are risks with surgery, there are similarly risks with gradually increasing sound exposure. If these risks are low, presenting this evidence to those starting sound therapy would be reassuring. If these risks are not low, presenting this evidence is the responsible thing to do in order to allow patients to make their own risk assessment.

Comments on Effectiveness

Sound therapy is not a miracle cure. For most patients, progress is slow and it can take months or years to improve. Without long-term follow up studies, it is unknown how many who do see improvement suffer major setbacks years after treatment. Not all of those that improve show a significant increase in loudness tolerance (> 20dB). There are also a number of individuals (20% in the studies above) who do not respond to treatment. This percentage is likely larger when including those who do not finish treatment or refuse follow-up LDL testing. Unfortunately, there is a tendency for some to blame lack of success on the will power of the patient rather than the counseling, treatment methods, or severity of hyperacusis. If results can vary significantly depending on the counseling as some claim, remote access to the more successful counselors would likely benefit these individuals. In the end, treatment providers ought to investigate why some improve and some do not and adapt the treatment strategy accordingly.

While TRT presents its own model of auditory gain and the role of the limbic system to encourage sound exposure, benefit from sound therapy does not prove these potential mechanisms. For example, the fear-avoidance model used in treating chronic back pain could similarly be applied to sound therapy and counseling. Blood flow, electrical, chemical, and cellular changes in the cochlea are also known to take place as a result of increasing average sound exposure. Thus, while auditory gain and fear of sound are expected to play a part, the only thing that can be proven by positive sound therapy results is that gradually confronting sound can be a helpful treatment tool.


Although hyperacusis is not at its root a psychological issue, living with hyperacusis can have profound psychological effects that can hinder both recovery and quality of life. There are differences among counseling types but the consistent themes are to encourage gradual sound exposure and to minimize fear of sound or re-injury. This behavior adjustment puts patients in a position that is more susceptible to setbacks and thus requires an explanation and encouragement. The following are common topics covered in hyperacusis counseling.

Topic Example
Potential Mechanisms Counseling, especially with TRT, often presents the Jastreboff model of decreased sound tolerance to encourage sound exposure and reduce stress and anxiety.
Managing environmental sounds Identify specific activities that have ceased due to environmental sounds. Discuss when to use earplugs and ways to find alternative environments
Managing sound therapy What to use, when to use it, when to adjust exposure
Identifying activities limited by fear rather than physical discomfort Questions regarding specific activities, gradual reintroduction of offending sounds with discussions of physical and emotional reaction.
Recognizing improvement Identifying improvement over time and discussions on adjustment of protection tendencies.
Managing hyperacusis impact on family and social life Managing emotions that arise when family and friends generate uncomfortable sounds. Discuss how to manage lack of understanding from others.

The style of counseling can vary. With directive counseling, the counselor will play an active role in shaping the decision-making process. Other therapies instead use shared decision-making to give the patient inputs greater weight in determining the treatment path. Different people will prefer different styles.

“[It is the patient] who has to make these efforts on a daily and continuous basis. One implication of this increased onus on the patient is that it is even more important that the patient ‘‘buys in’’ to the treatment decision, and hence provides even greater rationale for the need for shared treatment decision-making”

-Shared decision-making in primary care by Murray et al.

In-Depth: Activities Treatment, TRT, CBT, Presenting Evidence

Hyperacusis Activities Treatment (HAT)
Tinnitus Retraining Therapy (TRT)
Cognitive Behavioral Therapy (CBT)
Presenting Evidence with Counseling

Hyperacusis Activities Treatment (HAT)

Hyperacusis activities treatment is a modification of tinnitus activities treatment. The counseling seeks to help the patient recognize the relationship between the loudness of a sound and his or her reaction to it. The style of counseling is more along the lines of shared decision making rather than directive counseling. The counseling components include:

  • Thoughts and emotions
  • Hearing and communication
  • Sleep
  • Concentration

The sound-therapy components include:

  • Continuous low-level broadband noise
  • Successive approximations to high levels of noise
  • Successive approximations to troublesome sounds
  • Partial masking with a variety of sounds (including music)
  • For those with hearing loss: Gradual increase of the maximum output of hearing aids.

More information can be found in Tinnitus and Hyperacusis by Dr. Richard Tyler of the University of Iowa (2009). The University of Iowa provides remote counseling for hyperacusis.

Tinnitus Retraining Therapy (TRT)

TRT was initially developed to treat tinnitus. When tinnitus patients started showing improved loudness discomfort levels (LDLs) after treatment, the model was adjusted so that TRT could be used to treat hyperacusis patients as well. TRT uses a combination of broadband noise and counseling to treat hyperacusis. The counseling presumes that central auditory gain is the primary mechanism of hyperacusis and presents a mechanism for fear and annoyance from sound. It then provides strategies for managing these conditions under those assumptions. TRT counseling leans more toward the style of directive counseling.

Counseling is said to play an important role in TRT. The clinician for TRT acts as both educator and occupational therapist. The first priority of counseling is to convince the patient that gradual reintroduction of sound is necessary for healing and will not cause damage. This is done by presenting the central gain theory and concepts such as auditory toughening. The concept of auditory toughening comes from studies that show pre-exposure to safe sound levels reduces cochlear damage from subsequent loud sounds. Some clinicians will also present the idea that damage will not occur at sound levels below 85 dB. The second priority of counseling is to directly address the role of fear and emotion in decreasing sound tolerance (misophonia), a mechanism said to be very different from hyperacusis. To treat misophonia, the clinician will guide the patient through specific protocols that attempt to link currently offensive sounds to something positive. As these treatments for hyperacusis and misophonia are easier said than done, the third role of the clinician is to track the patient’s progress and to help navigate the patient around specific issues that may come up during treatment (e.g. fear, pain, setbacks, isolation).

Some details of the treatment protocol can be found in “Treatments for Decreased Sound Tolerance (Hyperacusis and Misophonia)” by Pawel and Margaret Jastreboff. There is more detailed information included in the Tinnitus Retraining Therapy book by Jastreboff and Hazell. Independent research into the underlying mechanisms of hyperacusis can be found in the Potential Mechanisms section of this website.

Tips for finding TRT treatment can be found on

Click to Show: Comments on TRT

Comments on TRT

To help encourage sound exposure, tinnitus retraining therapy educates patients on potential mechanisms of hyperacusis that have not been proven. Pawel and Margaret Jastreboff comment on this in their 2014 paper on decreased sound tolerance,

“The mechanism associated with the emergence of DST, and how negative reactions to sound develop, are hypothetical and none of the proposed mechanisms have been proven”

Treatments for Decreased Sound Tolerance (Hyperacusis and Misophonia),Jastreboff P, Jastreboff M

Craig Formby comments on this before his 2007 follow-up experiment on gain plasticity,

“The idea of an adaptive auditory gain mechanism is a fundamental concept in the treatment of both tinnitus and hyperacusis with tinnitus retraining therapy (TRT). This notion, however, has gone virtually untested.”

Adaptive Recalibration of Chronic Auditory Gain,Formby et. al 2007

While presenting a potential mechanism is necessary for changing protection behavior, some may have trouble buying into a therapy supported by unproven mechanisms. Gathering and presenting evidence on setbacks may alleviate these concerns.

There is also a very strong emphasis on the impact of the limbic system. While the limbic system is expected to play a role in delaying recovery, TRT instruction suggests the limbic system is the primary reason recovery takes more than weeks. In the 2007 edition of Tinnitus Retraining Therapy written by Pawel Jastreboff and Jonathan Hazell, the authors claim that “The improvement of pure hyperacusis occurs fast, within weeks.” Later, however, the authors do note that recovery for those who experience setbacks lasting days or weeks “takes a long and unpredictable time.”

TRT is not always accessible. Counseling is said to be a critical part of treatment however many do not have access to experienced TRT clinicians. TRT counseling training materials are not in the public domain which further limits those without access visibility to a key component of therapy. There is also the very real barrier of tolerating office visits for those with severe hyperacusis. If providers are serious about helping the most severe hyperacusis patients and patients without access to a clinician then a system of remote treatment ought to be established. Remote hyperacusis treatment is already being practiced at the University of Iowa and has been shown to be effective in other fields as well(Carlbrin 2006).

Cognitive BehavioralTherapy (CBT)

While TRT is generally conducted by audiologists, CBT is often conducted by a psychologist and can be an effective supplemental treatment. Cognitive behavioral therapy (CBT) when applied to hyperacusis is somewhat similar to the counseling that accompanies Tinnitus Retraining Therapy. Cognitive behavioral therapy is used to treat a variety of disorders such as depression, anxiety, and insomnia. The common theme in these treatments is that an attempt is made to change maladaptive thought patterns in order to change behavior patterns. In the application of CBT to hyperacusis, there is a strong emphasis on sound enrichment (confronting sound rather than avoiding sound). Patients are taught that sound is necessary for healing and they are given exercises in therapy sessions and as homework. A study in applying this form of CBT to hyperacusis patients showed an average of 6dB-9dB LDL improvement by the end of treatment (2 months) while LDLs of patients on the wait list (6 months) actually worsened by 2 dB on average.

Click to Show: Treatment Methods

The CBT procedure used for the clinical trial by Juris et al consisted of six sessions. The first session lasted 90 minutes and the others lasted 45 minutes. The full treatment lasted 2 months. An overview of the treatment is shown in the table below:


Figure from Hyperacusis: Clinical Studies and Effect of Cognitive Behavioral Therapy, Juris L

CBT Example with Fictitious Hyperacusis Patient

To help explain the CBT treatment plan, Juris provides a treatment example using the fictitious patient Elisabeth. An overview is given below:

“Elisabeth experienced pain in her ears at work. Her experience led to a respondent conditioning, pairing sounds at her workplace with pain in her ears and fear of hearing loss. To reduce the pain and fear, she used earplugs and avoided many situations with a perceived risk of exposure to uncomfortable sounds, leading to negative reinforcement of her avoidance behaviour. The frequency of occurring avoidance behaviour therefore increased. Instantly, the pain or the risk of experiencing pain decreased, but in the long run Elisabeth will be more afraid of sounds and this will also affect her auditory gain, and her auditory system will become more sensitive to sound.

In treatment, it is essential for the patient to understand these principles in order to be able to work together with the therapist to reverse the adverse effects of avoiding normally loud sounds. A tentative CBT treatment approach for Elisabeth would be to start with an introduction to the CBT model for hyperacusis. Together with her therapist, she would then set her treatment goals, and plan for exposure therapy by exploring and arranging situations she avoids, in order to prepare for controlled and stepwise exposure. There would also be a plan for sound enrichment. The exposure therapy would take place in the sessions but also in between sessions, both at her workplace and at home. In addition, Elisabeth would learn applied relaxation, and later to restart the activities she had quit due to hyperacusis. Finally, there would be a recapitulation, and a relapse prevention plan would be constructed.”

-Hyperacusis: Clinical Studies and Effect of Cognitive Behavioral Therapy by Linda Juris

The sound exposure therapy would consist of rating offending sounds from 0 to 100 in difficulty to endure and then gradually reintroducing these sounds, starting with those rated near 30-40.

“Elisabeth practiced dropping cutlery on plates. She started out in a session by dropping small teaspoons from a height of only a few centimetres, to gradually increasing the size and number of utensils and the height from which she dropped them.

Another part of this work was for her to listen to her favourite choir music at home, starting with a very low volume the first week but for a more extended period of time, around one hour per session. The volume was then gradually increased every week until Elisabeth reached a level that was considered normal by members of her family.”

-Hyperacusis: Clinical Studies and Effect of Cognitive Behavioral Therapy by Linda Juris

More information on the CBT treatment procedure can be found by reading Hyperacusis: Clinical Studies and Effect of Cognitive Behavioral Therapy by Linda Juris.

Comments on CBT

The CBT methods just described were shown to be effective when compared to patients on the wait list with 57% of those treated showing over 6dB of LDL improvement. The concepts presented in CBT address the challenges that arise when sound is paired with pain for a sufficient amount of time. This conditioning eventually results in strong, self-sustaining psychological barriers to increasing sound exposure even if pain has been reduced. Although somewhat similar to the Jastreboff model, the CBT model’s primary focus on psychological factors may deter some hyperacusis patients from buying into this treatment. Hyperacusis at its root is not a psychological issue although there are very real psychological (and physiological) hurdles to overcome when increasing sound exposure.

It is interesting to compare the results of this study with the “Counseling only” group from the Formby TRT clinical trial. While the counseling only group in the TRT trail showed minimal gain in loudness tolerance after treatment, CBT patients showed 6-9dB improvement. It is possible the sound therapy exercises and homework given during CBT treatment played an important role in increasing its relative effectiveness.

Presenting Evidence with Counseling

It is not common for counseling to provide direct evidence to patients as people often will take a medical professional at their word. However, some may have trouble taking a counselor’s word that sound exposure is the right thing to do when the mechanisms of hyperacusis have not been proven. Studies geared toward building proper, all-inclusive evidence on sound therapy, setbacks, and potential mechanisms may provide stronger encouragement.

This can be done in a few ways. First, an investigation into setbacks and their impact on long-term recovery could provide data that would be encouraging to patients if setbacks from “safe” sound levels are shown to have little long-term impact. Second, success rates for hyperacusis patients with pain symptoms should be separated from success rates for hyperacusis patients without pain symptoms (ignoring loudness discomfort reports). If success rates are still high, this would provide encouragement that this therapy is effective in reducing pain, as well as loudness. Third, a more detailed model that explains the subtle sensations of hyperacusis (e.g. sudden/lingering setbacks, delayed pain, or burning sensations from low volume broadband noise) may keep more people on the sound therapy treatment path. The model is primarily a tool to encourage gradual sound exposure and additional detail could make it more convincing.

Sound Therapy

Increasing Environmental Sounds

Environmental sounds are the primary source of sound and anxiety for someone with hyperacusis. Increasing environmental sound exposure is thus a critical component of counseling and sound therapy. Finding environments with fewer unexpected painful sounds is important for reducing protection and reducing stress. Reducing earplug use is another common way that environmental sounds are gradually increased. The key, especially for those with severe hyperacusis, is a controlled and gradual increase in sound exposure. Counseling plays an active role with this aspect of sound therapy.

Low-level Broadband Noise

Broadband noise is the most common sound enrichment tool used. It is used for TRT, pink noise therapy, and DIY therapy. Wearable noise generators are encouraged by TRT providers as this therapy encourages at least 8 hours per day of exposure to low-level broadband noise. Wearable noise generators look like a hearing aid and can be worn throughout the day more practically than headphones. An example of a wearable noise generator used for both tinnitus and hyperacusis patients is shown below:


General Hearing Tranquil II Wearable Sound Generator

The intention of regular exposure to low-level, broadband noise is to stimulate all frequency paths of the auditory system with the hope that hyperactivity of the system will reduce as a whole. There have been several studies that show loudness tolerances and acoustic reflex thresholds increase from such treatment in normal hearing individuals. Pink noise (noise that has reduced intensity as frequencies increase) is generally preferred by hyperacusis patients as it can be less irritating yet still simulates the sound spectrum expected from day-to-day sounds. Below is the frequency profile of the Tranquil II noise generator,


Introducing noise generators to severe hyperacusis patients can be challenging and is generally done gradually over weeks or months depending on hyperacusis severity. Sensations of irritation or burning can occur even with the lowest volume settings for severe hyperacusis patients. Counseling may help provide guidance in these scenarios.

A high quality Pink Noise mp3 or CD can be used as a much less expensive alternative to wearable noise generators. offers a pink noise CD that can be used with a music player and open headphones.

A discussion covering pink noise vs white noise along with consequences of “low quality” sources can be found here.

Short Duration Sound Therapy Sessions

Some therapies recommend sound exposure sessions of a few hours or less. Sound types include pink noise, nature sounds, and music. These shorter sessions might allow for slightly higher volumes than would be expected for sound therapies that last throughout the day. Dynamic sound in the case of nature sounds and music may provide additional benefit.

“White noise is not very effective compared with modulated dynamic sounds”

-Dr. Fan-Gang Zeng of UC Irvine in “Help For Hyperacusis: Treatments Turn Down Discomfort

Typically a volume is fixed to allow for listening throughout the allocated time slot. Gradually over weeks or months the volume is increased. See the alternative therapies below for variations on this technique.

In-Depth: Alternative Sound Therapies

Other sound therapies have been developed for hyperacusis although their use is uncommon.

Hearing Loss Adjusted, Frequency Hopping Sound Therapy
Hearing Loss Adjusted Music (Neurmonics)
S-Tone Tinnitus Therapy (Soundcure)
Nature Sounds through Speakers

Hearing Loss Adjusted, Frequency Hopping Sound Therapy

Arnaud Norena and Sylviane Chery-Croze from the University of Provence in France tailored sound therapy for hyperacusis patients according to their hearing sensitivity tests (minimum detectable sound level). The study included 8 individuals with hyperacusis. The sound therapy consisted of a tone that switched to a random frequency every 100ms. The frequencies covered started from the visually determined normal hearing cutoff frequency (where hearing loss starts to increase vs frequency) to the maximum frequency that could be heard. Tone amplitude is scaled according to the hearing loss that had been measured for that patient at that particular frequency. In the end, 64 frequencies per octave over the range of hearing loss were stimulated in random order with hearing loss adjusted signal strength. The participants listened for 1-3 hours a day “at just an audible level.” A sample of this therapy customized for a patient with hearing loss starting around 2kHz is below:


Example of Frequency (y-axis) vs Time (x-axis). Color changes show higher frequency tones are also at a higher intensity.

WARNING: START WITH VOLUME LOW, THEN TURN UP SLOWLY TO AUDIBLE LEVEL. VERY HIGH FREQUENCY TONES. Please contact your doctor first if you have any question about your capacity to listen to unknown audio files.

After 3 months of treatment, loudness tolerances increased 9-13dB on average with statistically significant increases in all frequency bands despite the fact that sound therapy only stimulated frequency regions that showed hearing loss. Similar observations of sound covering a small frequency range impacting tolerances over a broad frequency range have been found in other studies. One example is the Formby 2003 gain plasticity experiment described in Earplug Use: Overprotection. By providing sound therapy that targets hearing loss only, the authors believe they have addressed a suspected mechanism of central inhibition more precisely than broadband noise therapy.

The full paper can viewed (with purchase or subscription) here.

Click to Show: Comments

Comments on this therapy
This treatment has a few interesting differences from broadband noise therapy. First, there is an emphasis on stimulating only regions with hearing loss rather than the full frequency spectrum. According to the authors, it is possible that those who developed hyperacusis due to hearing loss may benefit from this therapy more than broadband noise. This aspect of the therapy, however, would not be easily applied to those that don’t have hearing loss. If hidden hearing loss is the culprit for some cases, there would be no way to customize the scaling of tones as detection of such loss is not a simple hearing test. Second, while pink noise decreases in signal strength as frequency increases, this sound therapy actually will increase signal strength as frequency increases for those with typical hearing loss profiles. Third, this therapy gives a rest period to each frequency band while pink noise is constantly stimulating all frequency regions. More specifically, this treatment stimulates each frequency for only 100ms and then moves on to another frequency and won’t return for 10s of seconds. It would be interesting to see if such a treatment could reduce irritation sometimes found from white or pink noise while showing similar effectiveness in increasing sound tolerance. Lastly, the duration of this treatment is 1-3 hours per day rather than nearly non-stop noise exposure recommended in TRT. Shorter sound therapy sessions may reduce irritation and pain that can be caused by sound therapy although intuitively shorter sound exposure periods would be expected to result in reduced LDL improvement.

Hearing Loss Adjusted Noise (Neuromonics)

Neuromonics has a patented therapy that uses devices that emit music along with broadband noise which has been equalized according to hearing loss in each ear. This was developed as tinnitus treatment but showed an average of 10 dB LDL improvement after 6 months. Patients listened to the devices for an average of 1.5-2 hours per day. This was a study run by neuromonics and some have suspicion of bias in testing methods (link).


S-Tone Tinnitus Therapy (SoundCure)

A tinnitus therapy that uses amplitude modulated tones (S-tones) was found to be more effective than broadband noise at reducing tinnitus loudness. In this therapy, the tone is first set to match in loudness and frequency to the tinnitus tone. The tone is then amplitude modulated at 40Hz to provide “synchronized, robust neural activity in the auditory cortex.” Evaluation of applying this treatment to hyperacusis is being considered.

SoundCure Release:

Nature Sounds through Speakers

A 2008 paper led by Fernando Peiro of Dia Quiron Hospital in Zaragoza, Spain presents a simple nature sound protocol that is claimed to provide unexpectedly large increases in loudness tolerances. 34 patients with hyperacusis ranging from mild to severe were included in this study. The sound therapy consisted of nature sounds said to be “balanced in symmetry and frequency” and included sounds of ocean waves and water flowing. Patients were asked to sit 3-5 feet away from the speakers (not headphones) for 30 minutes daily while performing a simple activity such reading, knitting, or doing simple puzzles. The CD player given to play the sounds had incremental volume changes that adjusted the sound level by 5 dB. Patients were asked to note the volume of the minimum level that caused discomfort (for example setting 12) and then asked to start treatment 4 settings lower (for example setting 8) which effectively reduces the sound level by 20dB. After the first week, the patients were then asked to increase to volume by one digit (for example setting 9). The complete instruction is shown in the table below

Week 1 Volume 8 -20 dB
Week 2 Volume 9 -15dB
Week 3 Volume 10 -10 dB
Week 4 Volume 9 -15 dB
Week 5 Volume 10 -10 dB
Week 6 Volume 11 -5 dB
Week 7 Volume 10 -10 dB
Week 8 Volume 11 -5 dB
Week 9 Volume 12 0 dB

The authors state that the previous week’s level should be repeated if there is discomfort during treatment. In this study, none of the 34 patients reported such discomfort.

The paper states that after just over 2 months of this 30 minute a day treatment, 97% of patients showed dramatic improvement with an LDL increase of 30 dB on average. This is unexpected to say the least as this is essentially a claim of a cure for hyperacusis using methods that are very similar to other sound therapies. An independent study of this treatment protocol would be necessary to verify its effectiveness.

The full paper can be found here.

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Ariizumi Y, Hatanaka A, Kitamura K. Clinical prognostic factors for tinnitus retraining therapy with a sound generator in tinnitus patients.J Med Dent Sci 2010:57:45-53.

Carlbrin P, Boham S, Brunt S, Buhrman M, Westling BE, Ekselius L, Andersson G. Remote treatment of panic disorder: a randomized trial of internet-based cognitive behavioral therapy supplemented with telephone calls.Am J Psychiatry 2006:163(12):2119-2125.

Dauman R, Bouscau-Faure F. Assessment and amelioration of hyperacusis in tinnitus patients. Acta Oto-Laryngologica 2005:125:503-509.

Formby C, Gold S, Keaser M, Block K, Hawley M. Secondary Benefits from Tinnitus Retraining Therapy: Clinically Significant Increases in Loudness Discomfort Level and Expansion of the Auditory Dynamic Range. Seminars in Hearing 2007:28(4):227-260.

Formby C, Hawley M, Sherlock L, Gold S, Parton J, Brooks R, Payne J. Intervention for restricted dynamic range and reduced sound tolerance: Clinical trial using Tinnitus Retraining Therapy protocol for hyperacusis. Acoustical Society of America 2013:19:1-5.

Formby C, Hawley M, Sherlock L, Gold S, Payne J, Brooks R, Parton J, Juneau R, Deporte E, Siegle G. A Sound Therapy-Based Intervention to Expand the Auditory Dynamic Range for Loudness among Persons with Sensorineural Hearing Losses: A Randomized Placebo-Controlled Clinical Trial. Seminars in Hearing 2015:36(2):77-109.

Hazell JWP, Sheldrake JB, Graham RL. Decreased sound tolerance: predisposing factors, triggers, and outcomes after TRT. Proceedings of the Seventh International Tinnitus Seminar 2002:255-261.

Jastreboff P, Hazell J. Tinnitus Retraining Therapy. Cambridge University Press. 2007.

Jastreboff P, Jastreboff M. Treatments for Decreased Sound Tolerance (Hyperacusis and Misophonia). Seminars in Hearing 2014:35(2):105-120.

Juris L. Hyperacusis: Clinical Studies and Effect of Cognitive Behavioral Therapy. Uppsala Dissertations from the Faculty of Medicine 2013:934:1-64.

Juris L, Andersson G, Larsen H, Ekselius L. Cognitive Behavioral Therapy for hyperacusis: A randomized controlled trial. Behavioral Research and Therapy 2014:54:30-37.

Moller A. Similarities between Severe Tinnitus and Chronic Pain. J Am. Acad. Audiol 2000:11:115-124.

Murray E, Charles C, Gafni A. Shared decisian-making in primary care: Tailoring the Charles et al. model to fir the context of general practice. Patient Education and Counseling 2006:62:205-211.

Neuromonics, Davis P, Paki B, Hanley P. Neurmonics Tinnitus Treatment: Third Clinical Trial. Ear & Hearing 2007:28(2):242-259.

Norena A, Eggermont J. Enriched acoustic environment after noise trauma abolishes neural signs of tinnitus. NeuroReport 2006:17(6):559-563.

Norena A, Chery-Croze S. Enriched acoustic environment rescales auditory sensitivity. NeuroReport 2007:18:1251-1255.

Peiro F, Gonzalez M, Garcia J, Pueyo J, Ortega F. Open-field treatment of hyperacusis. Acta Otorrinolaringol Esp. 1990:60(1):38-42.

Tyler R. S., Noble W., Coelho C., Haskell G., Bardia A. Tinnitus and Hyperacusis In Katz J, Burkard R, Medwetsky L, Hood L (Eds.) 2009 ( p 726-742 ) Handbook of Clinical Audiology, Sixth Edition. Baltimore: Lippincott Williams & Wilkins.

Tyler R, Stocking C, Secor C, Slattery W. Amplitude Modulated S-Tones Can Be Superior to Noise for Tinnitus Reduction. American Journal of Audiology 2014:23:303-308.