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Music Therapy Today Vol. IV (4) Nov. 2003

Auditive Stimulation Therapy AST® as an intervention in subacute and chronic tinnitus.

Martin Kusatz *, Thomas Ostermann **, David Aldridge***

* Tinnitus Therapy Center (TTZ), Krefeld & Dusseldorf, Germany

** Department of Medical Theory and Complementary Medicine, Fac- ulty of Medicine, University of Witten Herdecke

*** Chair of Qualitative Research in Medicine, Faculty of Medicine, University of Witten Herdecke

Abstract:

Background: Tinnitus is a noise, ringing, or roaring sound in the affected ear becoming a more and more serious problem for the health care systems. Integrative therapy concepts are regarded as a promising therapeutic concepts for managing tinnitus. The aim of this study is to present the results of the Auditive Stimulation Therapy AST®, a com- pact programme of music therapy originally employed in the treatment of chronic pain and developed specifically for tinnitus treatment. Material

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Kusatz, M. ,Ostermann, Th., Aldridge, D. (2003) Auditive Stimulation Therapy AST as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, 5, available at http://musictherapyworld.net

and Methods: Data on out-patient-treatment results for 154 Tinnitus patients were collected and evaluated in a prospective observational study with three defined defined times of measurement (start, end and 6 months after the end of treatment). Apart from anamnestic data and sub- jective evaluation of treatment, the major outcome-parameter was the score of the Tinnitus questionnaire (German: TF). To evaluate effective- ness of the therapy effect-sizes according to Cohen were calculated.

Results: 51% of the patients were male. The mean value of patients age was 48,8 years (95% CI:[46,6;51,0]). 137 patients (89%) were capable of gainful employment which means they were in the age between 18 and 65 years. The duration of tinnitus was over 6 months for 80 % of patients.

43,3% had been suffering from tinnitus for more than three years. In gen- eral, all subscales of the TF showed highly significant changes (t-test, p<0,01) between the measurement points “start of therapy” and “end of therapy”, while no significant differences were found between the mea- surement points “end of therapy” and “follow-up”. At follow-up, the val- ues of the subscales are stabilized at a level recorded at the end of the therapy; a reduction to the level prior to treatment was not observed. The values for the effect sizes mostly ranged between medium (>0.5) and high sizes (>0.8). Closer investigations indicated that a combination of Music therapy and psychological training rendered the best effect-sizes.

Conclusion: This study demonstrates that music therapy is an effective treatment approach and offers a way to make progress in tinnitus treat- ment. Music has an aesthetic aspect, it is part of our cultural heritage.

How we integrate sounds into our daily life, and how they become per- ceived as noise or music, is a complex activity involving the physiologi- cal, the psychological and the social. A therapeutic intervention that incorporates these understandings appears to offer considerable benefits,

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Kusatz, M. ,Ostermann, Th., Aldridge, D. (2003) Auditive Stimulation Therapy AST as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, 5, available at http://musictherapyworld.net

Introduction

Tinnitus is derived from the Latin tinnire (ringing) and is defined as the perception of sound in the absence of any appropriate external stimula- tion There is a basic difference between objective and subjective tinnitus.

The term objective tinnitus is used for ear sounds based on genuine phys- ical vibrations/ oscillations that may be perceived by others or even mea- sured (Feldmann 1992). This type of tinnitus is rather rare. Subjective tinnitus is far more frequent. In these cases, only the person afflicted per- ceives the sounds. These may occur as rustling, whistling, whirring, ring- ing, or droning sounds. High frequency sounds are perceived far more often than low frequency sounds (Pilgramm et al.1999), and a hearing impairment is detectable in over 50 % of all cases.

The incidence of patients suffering on tinnitus in Germany and the west- ern world is about 10%. About 1-2% of the population are severely dis- turbed by tinnitus and it may disrupt everyday activities and sleep (Rosanowski et al. 2001). If the symptoms continue for 6 months, then we consider the condition to be chronic, the degree of which differs con- siderably from person to person and afflicts patients in different ways (Kröner –Herwig 1997, Wilhelm et al 1995). A decompensated tinnitus is accompanied in most cases by other complaints, e.g. depression, anxiety, impaired sleep and concentration, sensitiveness to noises etc (Goebel et al 1992; Goebel 1992); consequently, intervention is required. Several treatments of chronic tinnitus have been proposed and implemented (Kröner –Herwig 1997). Homeopathy and acupuncture are amongst the complementary therapies that are proposed (Park, White and Ernst 2000;

Simpson, Donaldson and Davies 1998; Weihmayr 1998). Although there are several case-studies reporting efficiency of these treatments, the empirical support for therapeutic approaches like acupuncture in well- controlled studies is still weak (Biesinger 1999, Ernst 2000).

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Kusatz, M. ,Ostermann, Th., Aldridge, D. (2003) Auditive Stimulation Therapy AST as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, 5, available at http://musictherapyworld.net

Today, integrative therapy concepts like cognitive-behavioural treatment compiled of counselling, relaxation therapy, music therapy and pharma- cological preparations (lidocaine, neurotransmitters) are regarded as a promising therapeutic concepts for managing tinnitus. In particular, music therapy offers the chance of a global treatment approach for tinni- tus patients (Neugebauer 1999). Harmony, for instance, as a connecting link between rhythm and melody has a social function. Rhythm may also influence biological parameters via tempo accentuation and metre (Mosonyi 1975). This is the theoretical background for Auditive Stimula- tion Therapy AST®, the music therapy programme evaluated in this paper (Kusatz 1991).

Therapy

Auditive Stimulation Therapy AST® is a compact programme of music therapy originally employed in the treatment of chronic pain and devel- oped specifically for tinnitus treatment. It comprises a total of 10 therapy sessions and consists in specifically developed receptive music pro- grammes in combination with an education programme. Musical Self Control (MSC) training is a music programme designed on the basis of music psychology and music therapy, the effectiveness of which was demonstrated in a clinical study (Kusatz 1991). The objective of MSC training ®, as a form of musical self control, is to improve patients’ con- trol of ear sounds and to relieve their feelings of helplessness. Ringing in the ear, or strange sounds bring about alterations in perception. If we encourage the ability of selective hearing then we can promote some sounds in the hierarchy of perception, and to ignore other sounds or regu- late them such that they are hardly perceptible. MW training ® improves, that is, lowers, the level of sensitivity to sounds.

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Kusatz, M. ,Ostermann, Th., Aldridge, D. (2003) Auditive Stimulation Therapy AST as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, 5, available at http://musictherapyworld.net

In conclusion, the objective Auditive Stimulation Therapy is to improve a patient's emotional state and also to induce relaxation, to reduce anxiety and to stimulate changes in behaviour patterns that are unfavourable from the therapist's perspective. A particular focus is on perception of ear ring- ing which has to be controlled and influenced via music therapy interven- tion. The education programme is aimed at alterations on a cognitive level.

Material and Methods

At the Tinnitus Therapie Zentrum Krefeld (Germany), a research study was performed on a multimodal treatment concept (Krefelder Modell) in out-patient treatment of subacute and chronic tinnitus over a projected period of two years. Data on treatment results for 154 Tinnitus patients were collected and evaluated in a prospective observational study.

The out-patient therapy (duration: 2 weeks) comprised a total of 38 hours of therapy (20 h psychological training; 10 h music therapy – AST® ; 8 h kinesitherapy) and also included counselling by ENT experts, orthopae- dists and dentists. Data were collected with questionnaires immediately prior to and after therapy, with a follow-up after 6 months.

Apart from anamnestic data, the questionnaires also asked for a subjec- tive evaluation of treatment. Especially, the Tinnitus questionnaire designed by Goebel & Hiller (2000), now the recommended standard tool throughout Germany, was employed at all times of measurement.

Only those questionnaires were included, where more than 90% of the questions were filled out properly.

The main purpose of a follow-up interview of patients after six months was to indicate the degree of sustained therapy success. In addition, these

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Kusatz, M. ,Ostermann, Th., Aldridge, D. (2003) Auditive Stimulation Therapy AST as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, 5, available at http://musictherapyworld.net

interviews provide important feedback for therapists and suggest longer- term positive treatment results, specifically in the areas of well-being and re-integration of patients in their family environment. Such a follow-up is of particular relevance in tinnitus treatment as the temporal dimension of the therapy success plays a major role here. We hear frequently that ther- apy success in most cases becomes evident over time. If a re-orientation in terms of perception takes place, then the consequences of this re-orien- tation, as therapeutic effects, are best seen in follow up assessments. For an evaluation of the efficiency and sustained success of the therapy, t-test was applied to show significant differences of tinnitus-questionnaire scales after therapy. To evaluate effectiveness of the therapy and to ren- der the results comparable with each other and also with other treatment facilities in the health care sector, effect-sizes were calculated according to Cohen(1988) and corrected according to McGaw & Glass(1980).

Results

A total of N=155 patients were included in this evaluation. Sufficient fol- low-up documentation for assessment was available for n=111 patients (71,6%). Table 1 presents the basic socio-demographic and anamnestic data of patients.

TABLE 1. Socio-demographic and anamnestic data

Male Female Total

Gender 51,0% 49,0%

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Kusatz, M. ,Ostermann, Th., Aldridge, D. (2003) Auditive Stimulation Therapy AST as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, 5, available at http://musictherapyworld.net

Age

ß Mean [95% Conf-Int.]

ß Std.-Dev.

ß Median

48,9 [46,2;51,6]

12,1 52

48,7 [45,2;52,2]

15,5 50

48,8 [46,6;51,0]

13,9 51,5 Marital status

ß single

ß Married/fixed partner ß Divorced/living separated ß Widowed

15,8%

73,7%

10,5%

-

17,4%

64,0%

9,3%

9,3%

16,6%

68,8%

10,0%

4,6%

Graduation

ß Secondary School

ß Secondary Modern School ß High-School/A-Levels ß University/College

55,3%

25,0%

6,6%

13,2%

43,4%

28,9%

18,4%

9,2%

49,3%

27,0%

12,5%

11,2%

Profession

ß Work-men ß clerk

ß Self-employed ß Not employed

32,9%

39,5%

3,9%

23,7%

12,6%

47,9%

2,8%

36,6%

23,1%

43,5%

3,4%

29,9%

Duration of tinnitus ß < 6 month ß 6-12 month ß 1-3 years ß 3-5 years ß > 5 years

19,7%

15,8%

19,7%

14,5%

30,3%

20,3%

16,2%

21,6%

9,5%

32,4%

20,0%

16,0%

20,7%

12,0%

31,3%

Loudness of ear-ringing (from 0=

„not at all“ to 10 = “maximum”) ß Mean [95% Conf-Int.]

ß Std.-Dev.

ß Median

6,5 [6,0;7,0]

2,2 6

5,5 [4,9;6,1]

2,8 5,5

6,1 [5,7;6,5]

2,5 6 TABLE 1. Socio-demographic and anamnestic data

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Kusatz, M. ,Ostermann, Th., Aldridge, D. (2003) Auditive Stimulation Therapy AST as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, 5, available at http://musictherapyworld.net

137 patients (89%) were of wage-earning age, i.e. between 18 and 65 years. Table 1 shows that the duration of tinnitus was over 6 months for 80 % of patients. 43,3% had been suffering from tinnitus for more than three years. 33,5% of those interviewed reported that tinnitus develops gradually. Every second patient (50,3%) said tinnitus sets in suddenly.

16,1% did not answer this question. 76,8% said tinnitus occurs continu- ously, and 21,3% reported that tinnitus occurs with interruptions. 3 patients (1,9%) had no comments. Almost all patients (94,8%) reported that there are times when tinnitus is particularly intense. In contrast, only 75,5% said that there are times when tinnitus makes itself barely percep- tible.

FIGURE 1. TF total score at the different measurement points, according to a) total sample (start: N=146, post: N=146, b) follow Disruption due to of ear-ringing

(from 0= „not at all“ to 10 =

“maximum”)

ß Mean [95% Conf-Int.]

ß Std.-Dev.

ß Median

7,0 [6,4;7,6]

2,6 7

6,4 [5,7;7,1]

3,0 6

6,7 [6,3;7,1]

2,8 7 Restrictions due to ear-ringing

(from 0= „not at all“ to 10 =

“maximum”)

ß Mean [95% Conf-Int.]

ß Std.-Dev.

ß Median

5,8 [5,1;6,5]

3,0 6

4,5 [3,8;5,2]

3,2 4

5,2 [4,7;5,7]

3,2 5 TABLE 1. Socio-demographic and anamnestic data

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Kusatz, M. ,Ostermann, Th., Aldridge, D. (2003) Auditive Stimulation Therapy AST as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, 5, available at http://musictherapyworld.net

up: N=106)follow-up sample (start: N=106, post: N=106, follow up: N=106)

Patients were also asked how often they resorted to facilities of the health care system over six months prior to treatment, and they had the option of several possible answers. 74 of patients answering this question reported 111 individual consultations (Main consultation: ENT-Specialists:

44,6%), which means an average of 1,5 consultations per patient approx- imately. Prior to treatment, patients were also asked about previous treat- ment. 137 patients reported a total of 304 instances, i.e. an average of 2,2 treatments per patient. The major treatments were infusions with 78,8%.

The total score of the TF at the different measurement points is shown in Figure 1.

The total sample as well as the sample reduced to follow-up participants were presented graphically in order to test the sample coherence. The fol-

20,0 25,0 30,0 35,0 40,0 45,0

pre post at follow-up

total sample follow-up sample

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Kusatz, M. ,Ostermann, Th., Aldridge, D. (2003) Auditive Stimulation Therapy AST as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, 5, available at http://musictherapyworld.net

low-up sample with regard to tinnitus does not differ significantly from the general population.

Figure 2 shows the mean scale values of the tinnitus questionnaire prior to and after the outpatient tinnitus therapy (N=146), and also at follow-up after 6 months (N=106).

FIGURE 2. Scale values prior to and after outpatient tinnitus therapy (Npre=146, Npost=146, Nfollow-up=106). E: Emotional stress; C: cognitive stress; E+C: mental stress; I: Intensity of ear- ringing; A: auditive problems; SI: Sleep intensity; SO: somatic complaints.

In general, all subscales showed highly significant changes (t-test, p<0,01) between the measurement points “start of therapy” and “end of therapy”, while no significant differences were found between the mea- surement points “end of therapy” and “follow-up”. At follow-up, the val-

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Kusatz, M. ,Ostermann, Th., Aldridge, D. (2003) Auditive Stimulation Therapy AST as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, 5, available at http://musictherapyworld.net

therapy; a reduction to the level prior to treatment was not observed. The scale items “emotional stress (E)” and “cognitive stress (C)”, and the combined subscale “mental stress” (E)+(C), indicated positive changes compared to values determined at the end of treatment. These differ- ences, however, are not significant.

The values of effect sizes were determined for individual subscales, and the total score. The values for the effect sizes are all in the range of medium (>0.5) to high sizes (>0.8) – with the exception of the scale

“somatic disorders” and are illustrated in Figure 3.

FIGURE 3. Changes of scale values in effect sizes

As the treatment concept presented in this study (Krefelder Modell) is a multimodal concept, the different elements of treatment have to be com- pared in order to achieve more detailed results on the efficiency of the

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Kusatz, M. ,Ostermann, Th., Aldridge, D. (2003) Auditive Stimulation Therapy AST as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, 5, available at http://musictherapyworld.net

music therapy training programme (AST®). Kinesitherapy having received a distinctly lower rating by patients, only the two treatment ele- ments rated as most successful were compared (psychological training PT – music therapy MT). The findings gained in this way were then used to draw conclusions on the significance of individual therapies for the entire therapy concept.

Comparing the individual therapies, music therapy training (AST®) was responsible for a surprisingly high percentage of the positive total result and clearly preferred by patients despite the fact that psychological train- ing was twice as long (20 therapy sessions hours compared to 10 for music therapy). For further analysis of these findings, effect sizes at mea- surement times were calculated and related to the patients' subjective evaluation. The following graph illustrates the calculation of effect sizes.

The most expressive results in this context certainly are those of the fol- low-up, since the data of these particular patients are available for all measurement times. In retrospective they were able to come to a conclu- sive evaluation for themselves.

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Kusatz, M. ,Ostermann, Th., Aldridge, D. (2003) Auditive Stimulation Therapy AST as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, 5, available at http://musictherapyworld.net

FIGURE 4. Changes in effect sizes (N total=143; N fu=105) depending on patients preferred therapy

Figure 4 indicates that a combination of MT and PT renders the best effects. MT alone is in second place, and PT third. The combination of MT=PT comprises the partial therapies MT and PT, and this suggests that the share of MT in this result is higher than that of PT. In addition, MT shows excellent effect sizes over longer periods as well; a clear indica- tion of the quality of the concept of AST® as to contents and didactic implementation. The results appear to confirm in particular the intention to enable patients to continue independently with music therapy and to make autonomous use of receptive music programmes.

In answer to the question whether the therapy helped them to cope better with ringing in the ear, 40 % of patients described the success as "excel- lent", 29 % as good and 16,8 % as satisfactory. At a follow-up six months after the end of the therapy, the question was whether any ear ringing was still perceivable; 3,2 % of patients said none at all; 30.8% had a tempo-

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Kusatz, M. ,Ostermann, Th., Aldridge, D. (2003) Auditive Stimulation Therapy AST as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, 5, available at http://musictherapyworld.net

rary absence of ear ringing; about two thirds of patients continued to per- ceive noises during the six months after the therapy ended; however, these had been clearly reduced. In summary, 52,3 % indicated further positive changes after the therapy was concluded.

Conclusion

We were able to demonstrate that the multimodal concept evaluated (Krefelder Modell see Kusatz 2003) achieves highly significant changes.

The calculation of effect size, according to the tinnitus questionnaires, illustrated that the most significant effect sizes occurred in the area of psychological stress and total score changes.

In comparison with studies into other therapies with hospitalized patients and out-patients, the advantages of a multimodal treatment concept has been amply demonstrated. The fact that the Krefelder Modell is the only concept to use the music therapy training programme, combined with the significance of this programme for the entire treatment concept, indicates that the advantage compared to other treatment forms is principally the consequence of the music therapy intervention (Kusatz 2003).

An analysis of the tinnitus problem, particularly from a traditional per- spective, suggests a general confusion among most experts, although many scientists have explored the problem. A great variety of models and treatment approaches are available, the effectiveness of which are still inconclusive. The standard therapies in Germany include medication, to improve blood circulation or, with increasing frequency, infusions as part of a period in hospital, with disproportionate side effects compared to the severity of the complaints (Bork 2000). The question remains, “Why this helplessness in medical treatment of tinnitus”?

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Kusatz, M. ,Ostermann, Th., Aldridge, D. (2003) Auditive Stimulation Therapy AST as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, 5, available at http://musictherapyworld.net

If we assume that tinnitus is not a disease but a symptom of an underly- ing process, then singular symptom orientated approaches will fail 2. 61

% of patients state that professional medical help was of not much use – a shockingly high figure in view of the numerous medical interventions.

There is much to suggest a holistic treatment approach and to see ringing in the ear as a sign of particularly high stress. The question whether the symptom is of a somatic, or a psychosomatic, nature seems to be of no importance in the treatment of subacute and chronic tinnitus. An analysis not only of the biological but also the psychological and social needs of patients provides a more comprehensive insight into and understanding of their situation Aldridge 1998). Music therapy AST® is seen as salient to their problems among patients, and highly effective, perhaps because we are not directly making a singularly psychological intervention but an intervention in the same modus as the symptom is experienced. by accommodating sound control within an ecology of other sounds, itself within a stress reduction context, then we are offering a form of self con- trol that is adapted to a personal environment (Aldridge 1996/1999). On this extended basis of our knowledge about hearing, it should be possible to develop coping strategies for patients that address the causes of the problem directly and thus render the symptom superfluous.

The subjective symptom of tinnitus is a phenomenon which persons not afflicted cannot easily understand, as it is difficult to define a cause in most cases. Hearing, or the auditory sense, normally directed to the out- side, is suddenly directed internally and therefore hard to imagine for others. The sufferer suffers from a personal noise problem that is inaudi- ble to others. Consequently, there is a lack of understanding on their part.

For musicians, however, this is a concept that is easily understood (Neu- gebauer 2001). "Only inner anticipatory hearing makes musical interpre- tation possible. This phenomenon is most obvious in Ludwig van

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Kusatz, M. ,Ostermann, Th., Aldridge, D. (2003) Auditive Stimulation Therapy AST as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, 5, available at http://musictherapyworld.net

Beethoven who composed without being able to hear. Accordingly, lis- tening must also be seen as an internal process of perception”. Neuge- bauer (1999) reminds us that a sensory stimulation must not necessarily result in a conscious perception, nor must a sensory experience necessar- ily be caused by a physical stimulus. The specific way in which music therapists or musicians hear may indeed be helpful or suitable to under- stand tinnitus patients and also to explain – taking a composer as an example – how such experiences of internal hearing may also be observed in different settings where they are absolutely normal and by no means pathological. Aldridge (1996) suggests that the purpose of music therapy is that patients are enabled to generate expressive potentials, which reveal new possibilities for becoming healthy. In the context of ear ringing, music therapy might help to create a context of meanings which integrates the sounds or noises into the music and thus removes them from conscious perception, which would clearly promote recovery.

Sounds, no longer perceived as disturbing, once brought under control, are perceived as musical.

This study demonstrates that music therapy is an effective treatment approach and offers a way to make progress in tinnitus treatment. Music has an aesthetic aspect, it is part of our cultural heritage. How we inte- grate sounds into our daily life, and how they become perceived as noise or music, is a complex activity involving the physiological, the psycho- logical and the social. A therapeutic intervention that incorporates these understandings appears to offer considerable benefits, not as a cure but as a healthy adaptation.

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Kusatz, M. ,Ostermann, Th., Aldridge, D. (2003) Auditive Stimulation Therapy AST as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, 5, available at http://musictherapyworld.net

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Kusatz, M. ,Ostermann, Th., Aldridge, D. (2003) Auditive Stimulation Therapy AST as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, 5, available at http://musictherapyworld.net

tische Möglichkeiten beim komplexen chronischen Tinnitus. Psy- chother Psychosom med Psychol 1991; 41:123-133

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Kusatz, M. ,Ostermann, Th., Aldridge, D. (2003) Auditive Stimulation Therapy AST as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, 5, available at http://musictherapyworld.net

Neugebauer L. (1999) Schöpferische Musiktherapie bei Patienten mit chronischem tinnitus, in: Aldridge D. (Ed), Kairos III, Beiträge zur Musiktherapie in der Medizin, Verlag Hans Huber, Bern, Göttin- gen, Toronto, Seattle.

Park J., White AR. and Ernst E. (2000) Efficacy of acupuncture as a treat- ment for tinnitus: a systematic review. Arch Otolaryngol Head Neck Surg 2000;126(4):489-92

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This article can be cited as: Kusatz, M. ,Ostermann, Th., Aldridge, D.

(2003) Auditive Stimulation Therapy AST® as an intervention in sub- acute and chronic tinnitus. Music Therapy Today (online) Vol IV, Issue 5, available at http://musictherapyworld.net

References

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from radish seeds elicited anti-proliferative effects in A549 cells, and the reduced cell viabilities.. were maintained after

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