Nov 14 2012
There are several features of a symptom or illness that make it a convenient target for proponents of unconventional therapies. Subjective symptoms are more likely to be targeted than objective conditions – you don’t see many so-called “alternative” birth control treatments. Symptoms for which placebo effects alone are likely to produce the illusion of effectiveness are good targets for ineffective treatments. Symptoms that vary naturally over time also are good targets – patients are likely to seek treatment when their symptoms are maximal, which means spontaneous regression to the mean will provide an effective illusion of efficacy for any intervention. Illnesses with a substantial psychological component (such as those that are worsened by emotional stress or that are emotional, such as anxiety) are likely to benefit from non-specific effects of the therapeutic interaction, rendering the treatment itself irrelevant.
Finally, any condition or symptom for which there is currently no effective treatment provides a market ripe for exploitation.
Tinnitus has many of these features. Tinnitus describes the subjective experience of spontaneous noise perceived in one or both ears, which can be a buzzing, hiss, tone, or ringing sound. The severity of the tinnitus, its loudness, can vary over time, but perhaps more importantly the degree to which the tinnitus is bothersome can vary considerably. The sound is distracting and can have a significant impact on quality of life. Those with tinnitus can ignore the sound at times (depending on its severity), can be distracted from the sound, and may even learn through cognitive therapy to become accustomed to it. Therefore we might expect that tinnitus is amenable to placebo effects.
Finally, there is no proven effective treatment for tinnitus, which means that those who suffer from tinnitus may be desperate for a treatment. Desperation is a commodity highly prized by snake-oil salesmen.
Not surprisingly, there are a few “alternative” treatments that claim to be effective for tinnitus. There are also some experimental but scientifically legitimate treatments. Neuroscientists are still uncertain about the cause – the pathophysiology – of tinnitus. One theory, however, is that it is caused by insufficient tonic inhibition (the nervous system generally functions by inhibiting the firing of neurons at baseline, until they are activated). GABA is the most common inhibitory neurotransmitter in the brain, so it is possible that decreased GABA activity in the auditory system is one component of tinnitus. Drugs that increase GABA activity in the brain, therefore, would be a plausible treatment for tinnitus.
One GABA agonist drug, vigabatrin, has been tested on an animal model of tinnitus and has shown some effectiveness. We do not yet know, however, how predictive or useful the animal model is, and the drug has not been tested in humans. This is, therefore, extremely preliminary information and not an adequate basis for treatment decisions. Another GABA drug, gabapentin, has been tested in humans. A recent review found only two studies worth considering, both of which concluded that gabapentin was no more effective than placebo. The studies were insufficient, however, to definitively rule out an effect.
There is also preliminary evidence that the drug clonazepam may be effective for tinnitus. This drug, however, also has anti-anxiety effects and the study was open-label, so it is too soon to make any definitive conclusions.
That’s about it for science-based pharmacological therapy for tinnitus. There are other treatments, such as tinnitus retraining therapy (TRT) and tinnitus masking (TM). There is one study showing efficacy of TRT compared to TM (not blinded and not placebo-controlled), with significant effects for severe tinnitus and modest effects for mild to moderate tinnitus. TM involves using earphones (essentially hearing aids) that produce a masking noise meant to cancel out the tinnitus. At present these two interventions appear to be the most effective treatments for tinnitus, but their effectiveness is modest.
I have found three “alternative” treatments recommended for tinnitus. The most common is the herb Ginkgo biloba. Ginkgo is more commonly recommended for dementia or memory difficulty, although the best evidence to date shows that it is completely ineffective for this condition. Ginkgo is also offered as a treatment for tinnitus, with the same hand-waving justification as for memory symptoms. Dr. Weil recommends it for tinnitus and claims:
Ginkgo may help by increasing blood circulation in the head and neck. Give it at least a two months trial.
The evidence, however, is not with Weil – the best study to date shows no effect from Ginkgo:
There were no significant differences in primary or secondary outcome measures between the groups. 34 of 360 participants receiving active treatment reported that their tinnitus was less troublesome after 12 weeks of treatment compared with 35 of 360 participants who took placebo.
50 mg Ginkgo biloba extract LI 1370 given 3 times daily for 12 weeks is no more effective than placebo in treating tinnitus.
A Cochrane systematic review concurs that Gingko is ineffective.
Dr. Weil also recommends craniosacral therapy (CST) from a naturopath for tinnitus. This is a completely unscientific therapy. Mark Crislip does an excellent job of explaining why CST is nonsensical and unscientific – it has something to do with the fact that the bones of the skull are fused and cannot be manipulated in the manner claimed by CST. Just to be thorough, I did a PubMed search for craniosacral therapy and tinnitus and came up with zero results. A recent systematic review of CST for any condition concluded:
This review revealed the paucity of CST research in patients with different clinical pathologies. CST assessment is feasible in RCTs and has the potential of providing valuable outcomes to further support clinical decision making. However, due to the current moderate methodological quality of the included studies, further research is needed.
In other words, there is no evidence that CST works for anything. The ubiquitous conclusion that “further research is needed” is an excellent example of the difference between evidence-based medicine and science-based medicine. The SBM conclusion would be quite different – Considering the extreme scientific implausibility of CST, not one penny or scientific resource should be expended further studying this fanciful notion.
There is also a homeopathic treatment for tinnitus that has been widely marketed recently. The product is known as Quietus (not to be confused with the suicide drug from the excellent movie, Children of Men). The Quietus website proclaims:
Quietus® homeopathic tablets are formulated to homeopathically help support the body’s own healing mechanism that cancels out symptoms such as roaring, buzzing & whizzing, and supports healthy functioning in the inner ear… safely & naturally.
The site does not list the homeopathic “ingredients” of this product. It doesn’t matter, of course, because most homeopathic preparations are diluted to the point that there are no active ingredients left. I say “most” because some products may be only slightly diluted and still contain active ingredients, which is worse because then direct toxicity becomes a possibility.
There is no evidence that Quietus or any homeopathic preparation is effective for tinnitus (or for any indication, for that matter). The marketers of Quietus offer only testimonials, which are worse than useless given that they are cherry picked to give a certain impression. The website does contain the usual CAM disclaimer:
**These results not typical. Individual results will vary. These real testimonials do not represent the typical or ordinary experience of users. Each person’s experience with Quietus® is different, which cannot be determined from these testimonials. These statements have not been evaluated by the Food and Drug Administration. Claims are based on traditional homeopathic principles, which are different than modern scientific testing. For more information on homeopathy, please visit http://nccam.nih.gov/health/homeopathy
If any visitor bothers to follow the link to the NCCAM website they will find this statement about homeopathy:
There is little evidence to support homeopathy as an effective treatment for any specific condition.
Several key concepts of homeopathy are inconsistent with fundamental concepts of chemistry and physics.
Tinnitus is a difficult symptom at present with no clearly effective treatment. Scientific research is increasing our understanding of the cause(s) of tinnitus and there are some plausible treatments being researched.
So called “alternative” therapies, however, have nothing to offer. Herbs are simply drugs that are not purified and are difficult to standardize. If an herb contains an active ingredient that might be effective in treating tinnitus (or any condition) it should be identified, purified, and studied. In any case, the herb Ginkgo which is claimed to be effective for tinnitus is ineffective according to the best available evidence.
Craniosacral therapy and homeopathy are both rank pseudosciences that have no plausibility as treatments and for which there is no evidence of efficacy for anything, including tinnitus.
For now we have to accept the fact that there are no proven therapies that are highly effective for tinnitus. The best chance for developing solutions comes from science-based assessments of plausible treatments, and from not wasting time and resources on fanciful nonsense.
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