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Squeeze the ringing out!

Assessment and management of benign tinnitus by CRAFTA® specialized therapists


Tinnitus or “ringing in the ears” is a conscious perception of an auditory sensation in the absence of a corresponding external stimulus (Baguley et al., 2013; Hoekstra, 2013). The term tinnitus is derived from the Latin word “tinnire,” meaning “to ring.” For those affected, this has a considerable influence on the activity and participation level. In 0,5 % of this group life quality is extremely restricted by symptoms such as concentration and sleeping disturbances, reactive depression and fear (Cho et al., 2013; Malakouti et al., 2011).

Classification of tinnitus

Various types and causes of tinnitus have been described. Tinnitus is in most cases sub-jective which means that the patient hears a sound with different kind of tones and intensities without any auditory stimulus. In some cases, an internal, measurable, stimulus can cause the tinnitus, for instance turbulences of the blood flow; this can be considered as an objective tinnitus. (Baguley et al., 2013; Park et al., 2013; Swain et al., 2016).

Prevalence and etiology

Tinnitus affects 10-19% of the adults, mostly affecting the elderly population (Cima, 2019; McCormack et al., 2016). 6% have debilitating symptoms (Heller, 2003), and an equal 6% prevalence has also been found in children (Coelho et al., 2007; Savastano, 2007). There are twice as much male affected as female (Oostendorp et al., 2015).

Although the etiology of tinnitus is often unknown, several risk factors for subjective tinni-tus have been described. Among these are a hearing deficit, head injuries, middle ear pathology and depression (Martines et al., 2010; McKenna et al., 1991; Trevis et al., 2016). Also dysfunctions of the cervical spine and temporomandibular joint are mentioned (Saldanha et al., 2012; Teachey et al., 2012).

Tinnitus elicited by the somatosensory system of the cervical spine and/or temporomandibular region is called somatic tinnitus. (Langguth et al., 2006; Levine et al., 2003; Sanchez and Rocha, 2011; Zhan et al., 2006).


Different models can be used to explain benign ear dysfunction expressed in tinnitus such as an anatomic/structural model, a neurophysiological model and the cognitive/affective model.

Anatomic/structural model:

  • As we speak about the anatomic/structural model the sensory input can come from the craniofacial region, the outer and middle ear, the craniocervical region and from the temporomandibular joint (TMJ) (Hilgenberg et al., 2012; Bernhardt et al., 2011).

Neurophysiological model:

  • Belonging to this model the tinnitus has a strong input character, with means that nociception of healthy tissue from capsule, muscle, and peripheral nervous tissue is directly related to the tinnitus. This leads to a disinhibition of the dorsal cochlear nucleus (DCN) and therefore an increased output of the DCN. Also tinnitus with processing mechanisms has been described, particularly about the brainstem. (Levine et al., 2007; Jastreboff and Jastreboff, 2006; Abel&Levine, 2004; Kaltenbach et al., 2004; Cima et al., 2019). Stage 1 involves generation of the auditory stimulus in the auditory periphery. Stage 2 involves detection of the tinnitus related signal. Stage 3 involves the perception evaluation of tinnitus.

Neurophysiological model of tinnitus. Adapted from Jastreboff and Jastreboff, 2006 & from Cima et al., 2019.

Cognitive/Affective model:

  • In the last decade, central mechanisms have been recognized as causes of tinnitus alongside the traditional medical models. It has been shown that emotional and cognitive concepts can cause functional impairments that are related to tinnitus (Goebel, 1997; Hazell, 2001; McKenna et al., 2014; Robson, 2002). The intensity of unpleasant sensation is dependent on the strength of emotional influences (limbic system) and the body’s autonomic reaction (Jastreboff, 1990).

Actual state treatment tinnitus

In general patients are screened by an Ear Nose and Throat (ENT) specialist, an audiological center and/or mental health care when they are qualified for treatment, but according to the guideline tinnitus (2016) (Guideline tinnitus, 2016) there is currently no consensus on the treatment of the first choice of tinnitus. For instance, the diversity of therapeutic options leads in different countries, like the Netherlands and in Great Britain to referrals to different care providers in an unstructured and non-standardized way (Cima et al., 2009; Hoare, 2012).

It’s good to realize that chronic pain and also tinnitus can give a sensitization of the peripheral and central nervous system with a reinforcement of sound at the awareness in the brain (Levine et al., 2000). This sensitization and enhanced awareness sensitivity can ensure that sound continues without an external sound stimulus. (Oostendorp, 2017). Based on this premise a specialized physiotherapist like a CRAFTA® certified Physical therapist might be able to influence tinnitus driven by the models as described above.

Management of benign Tinnitus by a CRAFTA® certified Physical therapist

In the literature there are apart from medication therapy two main management strategies, i.e. sound based therapies and cognitive behavioral therapy (Cima et al., 2019; Oostendorp et al., 2015). Additionally to that manual therapy interventions have been described (Langguth et al., 2007; Oostendorp et al., 2016). A CRAFTA® therapist is able to do an extensive assessment of the patient with tinnitus. The assessment will be directed to the structures which are part of the anatomical/structural and neurophysiological model (i.e. cervical spine, TMJ, cranial nerves).

Besides there will be attention for the cognitive/affective model by asking the patient about beliefs, knowing and thoughts about the tinnitus. Also other contributing factors might be needed to take into account.

Questionnaires like the Tinnitus Handicap Inventory (THI) and the Tinnitus Questionnaire (TQ) can be used for assessing the level of severity of tinnitus complaints. The THI was developed to measure the impact on daily life. The TQ has six domains; emotional distress, cognitive distress, intrusiveness, auditory and perceptual difficulties, sleep disturbances and somatic complaints because of the tinnitus.The TQ and THI are widely used in clinical practice and clinical trials (Cima et al., 2019).

Management of benign tinnitus can exist of appropriate neuromusculoskeletal therapy of the contributing areas and/or by education about tinnitus and life style coaching.

What can you expect of a CRAFTA® certified Physical therapist

  • Acts according actual Tinnitus guidelines (2016), integrates neurophysiological, cognitive/affective models. Offers systematic tinnitus education and adapts lifestyle.

  • It is strongly individually based driven by modern clinical reasoning strategies based on a biopsychosocial framework.

  • Integrating craniofacial-mandibular-cervical techniques with systematic training, coaching and education.

  • Has consensus of qualified healthcare professionals like ENT doctors, speech therapists and orthodontists.


  • Benign (subjective) tinnitus has a considerable influence on the activity, participation level and therefore quality of life.

  • Specialized neuromusculoskelal therapy, like CRAFTA therapy could be considered for managing benign tinnitus on individual level.

  • CRAFTA® therapists treat according actual guidelines of Tinnitus (2016), integrate neurophysiological models during manual therapy and use cognitive/affective models during systematic tinnitus education and adapting of lifestyle.

Miranda Hanskamp & Daan Bredewout


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