1. Hearing Loss, Tinnitus, Hyperacusis & PTSD Dr. David Lyon Dr. David Lyon RCMP and VETERANS AFFAIRS CANADA May 31 st, 2016

2. DISABILITY APPLICATIONS TO VAC Made to VAC under the Canadian Forces Members and Veteran Re- establishment and Compensation Act.

3. TOP REASONS FOR DISABILITY PENSION CLAIMS BY CURRENT/FORMER MOUNTIES TO VETERANS AFFAIRS CANADA Men 1. Tinnitus1. Tinnitus 2. Hearing Loss2. Hearing Loss 3. PTSD3. PTSDWomen 1. PTSD1. PTSD 2. Depressive Disorder2. Depressive Disorder 3. Chronic Lower Back Pain3. Chronic Lower Back Pain

4. VAC CRITERIA CLAIMS FOR DISABILITY MUST MEET THREE SPECIFIC CRITERIA SET OUT BY VAC FOR THE DISABILITY CLAIMED. CLAIMS FOR DISABILITY MUST MEET THREE SPECIFIC CRITERIA SET OUT BY VAC FOR THE DISABILITY CLAIMED. 1.CRITERIA FOR THE CONDITION/DISABILITY 2.CRITERIA FOR SERVICE RELATED CAUSE OR PARTIAL CAUSE OF THE DISABILITY 3.CRITERIA FOR THE EFFECT OF THE DISABILITY ON QUALITY OF LIFE

5. TABLE OF DISABILITIES The VETERANS AFFAIRS CANADA TABLE OF DISABILITIES lists these criteria for each disabilityThe VETERANS AFFAIRS CANADA TABLE OF DISABILITIES lists these criteria for each disability Can be found on the Veterans Affairs website.Can be found on the Veterans Affairs website. –PLUS Step by step guide to the application process.Step by step guide to the application process.

6. OVERVIEW –Hearing Loss measurement and effects –Noise induced hearing loss (NIHL) _ Tinnitus –Hyperacusis –The application process

7. SensorineuralSensorineural ConductiveConductive MixedMixed

8. TYPES OF HEARING LOSS Hearing loss can result when there is a problem in any part of the auditory pathwayHearing loss can result when there is a problem in any part of the auditory pathway Conductive loss is a problem in the outer or middle ear (e.g. infection, wax, pressure, injury).Conductive loss is a problem in the outer or middle ear (e.g. infection, wax, pressure, injury). Sensorineural hearing loss results from damage to the inner ear ( the cochlea hair cells or nerves of hearing) (e.g. aging, noise exposure or disease).Sensorineural hearing loss results from damage to the inner ear ( the cochlea hair cells or nerves of hearing) (e.g. aging, noise exposure or disease). Treatment of hearing lossTreatment of hearing loss

9. SENSORINEURAL LOSS The most common type of hearing loss -NIHLThe most common type of hearing loss -NIHL Hair cells transform sound vibration into a neural (nerve) impulse that is sent along the auditory nerve to the brain along the which interprets it.Hair cells transform sound vibration into a neural (nerve) impulse that is sent along the auditory nerve to the brain along the which interprets it. Hair cell loss can be due to aging (presbycusis), noise exposure, ototoxic medication, toxins, disease and genes.Hair cell loss can be due to aging (presbycusis), noise exposure, ototoxic medication, toxins, disease and genes.

11. HEARING LOSS Hearing loss is measured using an audiometer which assesses the threshold (quietest Decibel level) at which an individual can detect each of the frequencies from 250Hz-8,000Hz.Hearing loss is measured using an audiometer which assesses the threshold (quietest Decibel level) at which an individual can detect each of the frequencies from 250Hz-8,000Hz. Results are plotted on an audiogram ( slide 13 )Results are plotted on an audiogram ( slide 13 ) Normal hearing < =25 B across the frequenciesNormal hearing < =25 B across the frequencies Mild, moderate, severe, profound hearing lossMild, moderate, severe, profound hearing loss

12. Audiogram Frequency is measured in Hertz (Hz) Intensity is measured in Decibels (dB)

13. Pure Tone Audiometry

14. VAC CRITERIA FOR HEARING LOSS DISABILITY VAC criteria for eligibility for hearing loss are based and defined on levels of hearing on the DISCHARGE AUDIOGRAM VAC criteria for eligibility for hearing loss are based and defined on levels of hearing on the DISCHARGE AUDIOGRAM A certain amount of loss must be present on discharge for VAC to recognize that the disability is related to service. A certain amount of loss must be present on discharge for VAC to recognize that the disability is related to service.

15. VAC HEARING LOSS DISABILITY Hearing loss disability exists when the discharge audiogram showsHearing loss disability exists when the discharge audiogram shows –Decibel Sum Hearing Loss (DSHL) 100dB or greater across the frequency range 500, 1000, 2000 and 3000Hz in either ear – OR –50dB or more in both ears at 4000Hz –AND –A hearing loss of 100dB is present on application

16. NON DISABLING HEARING LOSS VAC also defines a non-disabling hearing loss or lesser degree of hearing as a decibel loss >=30dB at any frequency from 250Hz-8000Hz i.e. there is slight loss but the loss is not sufficient to meet VAC’s definition of a hearing loss disabilityVAC also defines a non-disabling hearing loss or lesser degree of hearing as a decibel loss >=30dB at any frequency from 250Hz-8000Hz i.e. there is slight loss but the loss is not sufficient to meet VAC’s definition of a hearing loss disability VAC will consider a hearing disability to be to be partially caused by service when the service discharge audiogram shows non-disabling hearing loss AND a disabling hearing loss is established after dischargeVAC will consider a hearing disability to be to be partially caused by service when the service discharge audiogram shows non-disabling hearing loss AND a disabling hearing loss is established after discharge

17. NOISE INDUCED HEARING LOSS Noise normally first damages the frequencies 3,000Hz -6,000Hz.Noise normally first damages the frequencies 3,000Hz -6,000Hz. The typical NIHL audiogram shows a clear notch at these frequencies in early stages.The typical NIHL audiogram shows a clear notch at these frequencies in early stages. The loss spreads to other frequencies over time.The loss spreads to other frequencies over time. Hearing loss disability is measured at frequencies from 500Hz-3,000Hz on the basis that these are the most important frequencies for understanding speech.Hearing loss disability is measured at frequencies from 500Hz-3,000Hz on the basis that these are the most important frequencies for understanding speech.

18. NIHL

19. RCMP NOISE-INDUCED HEARING LOSS (NIHL) Factors that contribute to NIHL:Factors that contribute to NIHL: –High levels of continuous and impulse noise –Traffic noise, sirens, radios, headsets, planes, boats helicopters, snowmobiles –Firearms use and training –Inappropriate hearing protection or inability to use it in some duties.

20. ACOUSTICAL FEATURES OF POLICE & MILITARY NOISE IMPULSE NOISE: rapid changes of pressure from the atmospheric level. Can reach as high as 160-190 dB in a very short time (1ms). Cannons,, hand and stun grenades, shotgun, Smith & Wesson, sirens etc. Acoustic trauma.IMPULSE NOISE: rapid changes of pressure from the atmospheric level. Can reach as high as 160-190 dB in a very short time (1ms). Cannons,, hand and stun grenades, shotgun, Smith & Wesson, sirens etc. Acoustic trauma. CONTINUOUS NOISE: a continual battering of auditory system by high and low frequency noise. Headsets, traffic noise, sirens, aircraft engines, engine rooms, galleys, sonar, helicopters, vehicles, snowmobiles etc.CONTINUOUS NOISE: a continual battering of auditory system by high and low frequency noise. Headsets, traffic noise, sirens, aircraft engines, engine rooms, galleys, sonar, helicopters, vehicles, snowmobiles etc.

21. NOISE INDUCED HEARING LOSS Impact: People with NIHL can generally understand conversational speech in quiet environments as long as they are within several meters from their conversational partner.Impact: People with NIHL can generally understand conversational speech in quiet environments as long as they are within several meters from their conversational partner. In noisy conditions, or when the person speaking is further away, understanding speech is far more challenging. High frequency speech sounds (ex. f, s, t) are not heard so many words can be unclear and misunderstoodIn noisy conditions, or when the person speaking is further away, understanding speech is far more challenging. High frequency speech sounds (ex. f, s, t) are not heard so many words can be unclear and misunderstood

22. CONSEQUENCES OF HEARING LOSS Impact: Patients complain that people “mumble”, while their significant others and/or co-workers complain that “he’s (she’s) not listening”, or “ignores me” or “has selective hearing”.Patients complain that people “mumble”, while their significant others and/or co-workers complain that “he’s (she’s) not listening”, or “ignores me” or “has selective hearing”. Those with hearing loss are more fatigued at the end of the day as they have to strain to understand what is said a lot of the timeThose with hearing loss are more fatigued at the end of the day as they have to strain to understand what is said a lot of the time Misunderstandings often resultMisunderstandings often result Affects different people differentlyAffects different people differently

23. CONSEQUENCES OF HEARING LOSS Compared to age-matched peers with normal hearing, those with hearing loss showCompared to age-matched peers with normal hearing, those with hearing loss show – Increased worry and anxiety in social situations – Decreased social activity (may withdraw from certain situations) – Increased feelings of depression, paranoia & isolation – Poorer overall health – Poorer Quality of Life ratings – Increased frustration among family members & friends

24. TINNITUS DISABILITY Tinnitus is the perception of sound in one or both ears or in the head in the absence of external sound.Tinnitus is the perception of sound in one or both ears or in the head in the absence of external sound. Common causes: noise damage, aging, disease.Common causes: noise damage, aging, disease. Must be diagnosed by medical practitioner or certified audiologistMust be diagnosed by medical practitioner or certified audiologist Must be present for at least 6 monthsMust be present for at least 6 months

25. TINNITUS Perceived differently by different people normally ringing or buzzing or hissing soundPerceived differently by different people normally ringing or buzzing or hissing sound Steady or intermittentSteady or intermittent Fluctuate in loudness or pitchFluctuate in loudness or pitch May consist of more than one soundMay consist of more than one sound Pulsatile vs. Non-PulsatilePulsatile vs. Non-Pulsatile

26. EFFECTS OF TINNITUS ConcentrationConcentration Emotional stabilityEmotional stability FocusFocus Ability to understand and follow conversationAbility to understand and follow conversation Sleep irritation and maintenanceSleep irritation and maintenance AnxietyAnxiety DepressionDepression Overall quality of lifeOverall quality of life

27. TINNITUS Problem: Inaccurate advice “There’s nothing wrong” “You have normal hearing” “There’s nothing else we can do” “Avoid being around noise” “You’ll just have to live with it”Problem: Inaccurate advice “There’s nothing wrong” “You have normal hearing” “There’s nothing else we can do” “Avoid being around noise” “You’ll just have to live with it” “Knowledge is Power” is the most effective intervention“Knowledge is Power” is the most effective intervention

28. VAC CRITERIA for TINNITUS Exposure to at least one episode of acoustic trauma just prior or prior to onsetExposure to at least one episode of acoustic trauma just prior or prior to onset Exposure to noise of sufficient intensity and duration to cause hearing loss of 25dB or more at 3000, 4000 or 6000Hz in the ear(s) with tinnitus prior to onset.Exposure to noise of sufficient intensity and duration to cause hearing loss of 25dB or more at 3000, 4000 or 6000Hz in the ear(s) with tinnitus prior to onset. This loss must be present on a service audiogram –not necessarily the discharge audiogram.This loss must be present on a service audiogram –not necessarily the discharge audiogram.

29. VAC CRITERIA FOR TINNITUS Other criteria related to injury, head trauma, barotrauma, middle ear disease and malfunction a number of medications and illnesses.Other criteria related to injury, head trauma, barotrauma, middle ear disease and malfunction a number of medications and illnesses. If applicable these must be detailed in the applicant statement for Tinnitus.If applicable these must be detailed in the applicant statement for Tinnitus. Hopefully these factors are mentioned in the medical records.Hopefully these factors are mentioned in the medical records. 20% of tinnitus patients do not demonstrate hearing loss from 250Hz-8000Hz.20% of tinnitus patients do not demonstrate hearing loss from 250Hz-8000Hz.

30. HYPERACUSIS Decreased tolerance to loud sounds; loud sound causes startle response, stress, discomfort even painDecreased tolerance to loud sounds; loud sound causes startle response, stress, discomfort even pain Very narrow range between threshold ( quietest sound heard) and tolerance levelVery narrow range between threshold ( quietest sound heard) and tolerance level (loudest sound can tolerate) (loudest sound can tolerate) Usually triggered by sudden high-pitched noises like alarms, bus brakes, silverware and dishes, children’s crying, and clapping.Usually triggered by sudden high-pitched noises like alarms, bus brakes, silverware and dishes, children’s crying, and clapping.

31. HYPERACUSIS Those reporting hyperacusis often, but not always also have tinnitus and vice-versaThose reporting hyperacusis often, but not always also have tinnitus and vice-versa VAC eligibility criteria consider the two disabilities together (that hyperacusis is subsidiary symptom of tinnitus) but symptoms are different.VAC eligibility criteria consider the two disabilities together (that hyperacusis is subsidiary symptom of tinnitus) but symptoms are different. Rely on 25dB on a service audiogram 3,000Hz-6,000Hz.Rely on 25dB on a service audiogram 3,000Hz-6,000Hz.

32. EFFECTS OF HYPERACUSIS Fear of going to places that may be noisyFear of going to places that may be noisy Avoidance of social situations, restaurants, movie theatres, concerts etc.Avoidance of social situations, restaurants, movie theatres, concerts etc. Difficulty listening to speaker announcements e.g. in airports, planesDifficulty listening to speaker announcements e.g. in airports, planes Difficulty concentrating in noiseDifficulty concentrating in noise Feel emotionally drained and tired after being in soundFeel emotionally drained and tired after being in sound

33. APPLICATION FORMS Formally request VAC to send Form 923APe (2011-09) Application for Disability BenefitsFormally request VAC to send Form 923APe (2011-09) Application for Disability Benefits IT IS VERY IMPORTANT TO SPEND TIME TO FILL IN THESE FORMS COMPLETELY WITH AS MUCH DETAIL AS POSSIBLEIT IS VERY IMPORTANT TO SPEND TIME TO FILL IN THESE FORMS COMPLETELY WITH AS MUCH DETAIL AS POSSIBLE

34. VAC CRITERIA CLAIMS FOR DISABILITY MUST MEET THREE SPECIFIC CRITERIA SET OUT BY VAC FOR THE DISABILITY CLAIMED. CLAIMS FOR DISABILITY MUST MEET THREE SPECIFIC CRITERIA SET OUT BY VAC FOR THE DISABILITY CLAIMED. 1.CRITERIA FOR THE CONDITION/DISABILITY 2.CRITERIA FOR SERVICE RELATED CAUSE OR PARTIAL CAUSE OF THE DISABILITY 3.CRITERIA FOR THE EFFECT OF THE DISABILITY ON QUALITY OF LIFE

35. PEN 923 APe First section A (p1-2) requires personal details of service, family etc.First section A (p1-2) requires personal details of service, family etc. Second section B. (p.3) requires you to “Clearly state how you relate each claimed condition to your service or to a specific service period “Second section B. (p.3) requires you to “Clearly state how you relate each claimed condition to your service or to a specific service period “ For hearing loss, tinnitus and hyperacusis you need to provide details of the specific types of noise exposure you experienced in service.For hearing loss, tinnitus and hyperacusis you need to provide details of the specific types of noise exposure you experienced in service.

36. APPLICANTS STATEMENT Section B. P.3. You must fill in a separate section B each disability claimed.Section B. P.3. You must fill in a separate section B each disability claimed. Hearing Loss, Tinnitus and Hyperacusis applications requires three completed section B statements.Hearing Loss, Tinnitus and Hyperacusis applications requires three completed section B statements. The information in each may be the same, as all three are a result of noise exposure and related to service in the same way but repeat it.The information in each may be the same, as all three are a result of noise exposure and related to service in the same way but repeat it.

37. PEN 923 APe Section C ( P 4… ) is the Quality of Life QuestionnaireSection C ( P 4… ) is the Quality of Life Questionnaire Requires you to indicate how the claimed condition affects your everyday lifeRequires you to indicate how the claimed condition affects your everyday life E.g. “ I can shop and do errands”E.g. “ I can shop and do errands” Check: Yes; yes with assistance/adaptations; no.Check: Yes; yes with assistance/adaptations; no. Comments for each one and section for additional comments.Comments for each one and section for additional comments.

38. PEN (23 APe) Fill in a section C QOL for each condition claimedFill in a section C QOL for each condition claimed For most of the questions the answer will be “yes with assistance or adaptations”For most of the questions the answer will be “yes with assistance or adaptations” Can be anything that is different than it would be without the claimed condition e.g. asking people to repeat themselves, turning up the volume, avoiding noisy places, needing help to sleep etc.Can be anything that is different than it would be without the claimed condition e.g. asking people to repeat themselves, turning up the volume, avoiding noisy places, needing help to sleep etc.

39. PEN 923 APe & VAC 928 Section D is more personal informationSection D is more personal information VAC 928 is Consent for VAC to collect personal information from Third Parties –this should be completes with the information for whoever did the assessments of the conditions.VAC 928 is Consent for VAC to collect personal information from Third Parties –this should be completes with the information for whoever did the assessments of the conditions.

40. CLINICIAN’S RESPONSIBILITIES The doctor or health professional has a responsibility to ensure that the report contains as much information as possible to support your application.The doctor or health professional has a responsibility to ensure that the report contains as much information as possible to support your application.

41. QUESTIONS??

42. TINNITUS, PTSD & HYPERACUSIS PTSD and tinnitus share a number of symptomsPTSD and tinnitus share a number of symptoms –Sleep problems –Irritability/anger –Difficulty concentrating –Hyper vigilance –Exaggerated startle response –Difficulty tolerating loud sounds - hyperacusis

43. EXPLANATIONS? Both affect the same neural mechanism in the brain especially those connected to the limbic system that controls arousal and emotional behavior.Both affect the same neural mechanism in the brain especially those connected to the limbic system that controls arousal and emotional behavior. Mutual negative effects of one on the other i.e. tinnitus is exacerbated by stress and in turn stress is exacerbated by tinnitusMutual negative effects of one on the other i.e. tinnitus is exacerbated by stress and in turn stress is exacerbated by tinnitus

44. EXPLANATIONS? Tinnitus maybe triggered by cochlear damage – damage to the hearing mechanism but it is disorder of the brain -in a sense the network of the brain gets rewired and interacts with other brain networks-including the one controlling stress.Tinnitus maybe triggered by cochlear damage – damage to the hearing mechanism but it is disorder of the brain -in a sense the network of the brain gets rewired and interacts with other brain networks-including the one controlling stress. Increasing evidence that the damage to the ear that triggers tinnitus may be subtle and not seen on a conventional audiogram.Increasing evidence that the damage to the ear that triggers tinnitus may be subtle and not seen on a conventional audiogram.

45. QUESTIONS