METHODS
published: 15 December 2016
doi: 10.3389/fnagi.2016.00294
Measuring the Moment-to-Moment
Variability of Tinnitus: The
TrackYourTinnitus Smart Phone App
Winfried Schlee 1 *, Rüdiger C. Pryss 2 , Thomas Probst 3,4 , Johannes Schobel 2 ,
Alexander Bachmeier 2 , Manfred Reichert 2 and Berthold Langguth 1
1
Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany, 2 Institute of Databases and
Information Systems, Ulm University, Ulm, Germany, 3 Department of Psychology, University of Regensburg, Regensburg,
Germany, 4 Department of Psychology and Psychotherapy, University of Witten/Herdecke, Witten, Germany
Edited by:
Rilana F. F. Cima,
Maastricht University, Netherlands
Reviewed by:
Angelos P. Kassianos,
University College London, UK
Umesh Gangishetti,
Emory University, USA
Silvana Mareva,
University of Cambridge, UK
*Correspondence:
Winfried Schlee
winfried.schlee@gmail.com
Received: 18 April 2016
Accepted: 21 November 2016
Published: 15 December 2016
Citation:
Schlee W, Pryss RC, Probst T,
Schobel J, Bachmeier A, Reichert M
and Langguth B (2016) Measuring
the Moment-to-Moment Variability of
Tinnitus: The TrackYourTinnitus Smart
Phone App.
Front. Aging Neurosci. 8:294.
doi: 10.3389/fnagi.2016.00294
Tinnitus, the phantom perception of sound without a corresponding external sound,
is a frequent disorder which causes significant morbidity. So far there is no treatment
available that reliably reduces the tinnitus perception. The research is hampered by the
large heterogeneity of tinnitus and the fact that the tinnitus perception fluctuates over
time. It is therefore necessary to develop tools for measuring fluctuations of tinnitus
perception over time and for analyzing data on single subject basis. However, this type
of longitudinal measurement is difficult to perform using the traditional research methods
such as paper-and-pencil questionnaires or clinical interviews. Ecological momentary
assessment (EMA) represents a research concept that allows the assessment of
subjective measurements under real-life conditions using portable electronic devices
and thereby enables the researcher to collect longitudinal data under real-life conditions
and high cost efficiency. Here we present a new method for recording the longitudinal
development of tinnitus perception using a modern smartphone application available for
iOS and Android devices with no costs for the users. The TrackYourTinnitus (TYT) app is
available and maintained since April 2014. A number of 857 volunteers with an average
age of 44.1 years participated in the data collection between April 2014 and February
2016. The mean tinnitus distress at the initial measurement was rated on average
13.9 points on the Mini-Tinnitus Questionnaire (Mini-TQ; max. 24 points). Importantly,
we could demonstrate that the regular use of the TYT app has no significant negative
influence on the perception of the tinnitus loudness nor on the tinnitus distress. The TYT
app can therefore be proposed as a safe instrument for the longitudinal assessment of
tinnitus perception in the everyday life of the patient.
Keywords: chronic tinnitus, smartphone application, ecological momentary assessment, moment-to-moment
analysis, crowd sourcing, ecological validity
INTRODUCTION
Tinnitus is the perception of a sound when no corresponding external sound is present.
The severity of tinnitus varies largely between tinnitus sufferers. While a large percentage
of cases is only minimally impaired during their daily routing, the severe cases of
tinnitus are affected by anxiety, depression, insomnia and concentration problems all of
which can impair their quality of life (Dobie, 2003; Heller, 2003; Kreuzer et al., 2013).
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neurobiological mechanisms of tinnitus changes over time;
(3) knowledge of tinnitus fluctuations over time is important
for patient management (e.g., for tinnitus counselling); and
(4) information of tinnitus fluctuations is highly relevant
for clinical studies, e.g., when effects of specific therapeutic
interventions are assessed.
In this article, we want to present a conceptual and technical
framework for an ecologically momentary assessment (EMA;
Stone and Shiffman, 1994), which allows to systematically
assess the moments of different tinnitus symptom severity. The
method of EMA (also called Experience sampling method, e.g.,
Csikszentmihalyi and Larson, 2014) was originally developed for
the collection of self-reports of behavior, cognition or emotions
in the daily lives of the participants. In the context of tinnitus,
we extend this framework to also collect self-reports about
the perception of the phantom tinnitus sound and objective
measurements of contextual variables (here: sound pressure
of the environmental sounds to discover tinnitus masking).
The EMA method offers several benefits for the assessment of
tinnitus.
First, the EMA approach minimizes the retrospective bias.
Several studies from multiple disciplines have demonstrated that
multiple biases may jeopardize the retrospective data collection,
e.g., in pain reports (Erskine et al., 1990) or for coping strategies
(Todd et al., 2004). The retrospective recall is based on a
process of mental reconstruction rather than a correct retrieval
whereby the current circumstances and the peak of symptoms are
emphasized (for a review see e.g., Fredrickson, 2000 on this peakand-end rule). EMA approaches with momentary assessments
of the tinnitus symptoms allow the measurements with exact
time stamps in real life and should thereby be well suited for
minimizing this retrospective bias.
Second, longitudinal assessment can reveal dynamic processes
and temporal relationships. Even though it has been shown
that tinnitus symptoms fluctuate from one moment to the
other (Henry et al., 2012; Wilson et al., 2015), many questions
about this dynamic process are still open: how much varies
the extent of fluctuations from one person to the other?
How strong are the fluctuations within and between days?
Is there a temporal pattern (e.g., tinnitus symptoms are
higher/lower in the morning compared to the evening)? Is
there a temporal relationship with other factors like stress,
emotion, concentration, sleep etc. which can suggest a causal
relationship (e.g., emotional arousal increases lead to an
increase of tinnitus or vice versa)? Are there context-specific
factors for tinnitus improvement or worsening? All these
questions can be systematically addressed by the EMA approach
at the level of individual subjects (for a review see e.g.,
Wichers, 2013 about EMA assessment in mental disorders).
With this manuscript, we want to introduce the technical
platform of the TrackYourTinnitus (TYT) app that will be
able to answer a large number of these questions. Some
work using TYT has already been published investigating the
relationships between tinnitus and emotional states (Probst
et al., 2016a) as well as between tinnitus and emotion dynamics
(Probst et al., 2016b). Further analyses are currently under
preparation.
Epidemiological studies of tinnitus indicate a prevalence between
6%–26% with 1.2%–1.6% reporting severely annoying tinnitus
(Davis and Rafaie, 2000; Hasson et al., 2010; Gallus et al., 2015).
There is currently little evidence for an effective treatment of
tinnitus loudness and no pharmacological treatment approved by
the US Food and Drug Administration (FDA) or the European
Medicines Evaluation Agency (EMEA; Langguth and Elgoyhen,
2012). Among other factors the large heterogeneity of the
tinnitus patient population represents a major barrier for the
development of effective tinnitus treatments (for a review see
e.g., Elgoyhen et al., 2015). A recent review of tinnitus identified
at least 13 different types of causal factors for tinnitus (Baguley
et al., 2013) that can be described on various dimensions such
as its etiology, perceptual characteristics of the sound (i.e., pitch
and loudness), time since onset, continuous or intermittent,
levels of conscious awareness and perceived distress and
comorbidities.
As tinnitus is a purely subjective phenomenon, its assessment
is not trivial (Langguth et al., 2007). For the assessment
of tinnitus severity standardized questionnaires have been
developed, whereas tinnitus loudness can be assessed either
by visual analog scale (VAS; Adamchic et al., 2012) or by
psychoacoustic measurements. All these measurements are
based on the assumption that tinnitus is a rather static
phenomenon. However recent data demonstrates that tinnitus
loudness and annoyance fluctuate significantly from moment
to moment (Henry et al., 2012; Wilson et al., 2015). Henry
et al. (2012) conducted a pilot study in which tinnitus
symptoms were measured in 24 participants over 2-weeks at
four random time points per day using a personal digital
assistant (PDA) device. They presented results, which suggest
a large between-days variability of tinnitus distress for some
study participants. Notably, the frequent measurement of
tinnitus over the 2 weeks period had no negative impact on
the perceived tinnitus distress as measured by the tinnitus
handicap inventory (THI, Newman et al., 1996) indicating
that directing the attention on tinnitus several times per
day does not worsen the tinnitus (Henry et al., 2012).
Using a similar study design (4 assessments per day for
2 weeks), Wilson et al. (2015) also investigated the intraindividual variability of tinnitus distress using smart phone
notifications. Likewise, to the study by Henry et al. (2012)
they showed that tinnitus fluctuations vary strongly across
individuals. Some individuals report strong fluctuations of
their tinnitus distress while others report relatively low
fluctuations. A coefficient of variation (CV) calculated over
the tinnitus self-reports of each participant ranged between
11.5% and 109.9% with a median of 48.4% (Wilson et al.,
2015). So far it is not understood why tinnitus fluctuates
in some cases and what are the underlying mechanisms for
the fluctuations of tinnitus from one moment to the other.
Better assessment of the fluctuations of tinnitus is of highest
importance for many different reasons: (1) exact assessment
of tinnitus fluctuations are of diagnostic importance as intraindividual fluctuations may be an important characteristic
feature of an individual’s tinnitus; (2) exact measurement of
perceptual fluctuations is a precondition for investigating the
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Third, assessment in real-life situations is characterized
by large ecological validity. There are multiple examples in
clinical research where a large discrepancy can be observed
between the measurements in the clinic (or laboratory) and
the measurements in everyday life. For instance, blood pressure
readings made by a physician in the clinical context are often
higher than the ambulatory blood pressure recordings done
outside the clinic—typically described as the ‘‘white coat effect’’
(Hansen et al., 2006). On the other side, measurements of
clinical symptoms outside the clinical or laboratory settings
are hampered by low controllability, which can lead to noisy
signals. An adequate item selection (items should measure the
respective moment, should be short and can be answered in
a view seconds) with respect to the research question is a
key element for using the EMA approach. We consider both
types of measurements, in the clinical/laboratory context and
in real life, as important for both comprehensive diagnostic
assessment and evaluation of treatment effects. While there is
already a rich collection of tinnitus research tools than can
be used in the laboratory or clinical context, the research
tools for assessing tinnitus in real life are still limited
and shall be improved by the EMA approach presented
here.
Fourth, the technical integration of additional sensor data
allows the objective measurement of contextual and biological
variables. With the current development, we are using the
microphone of the smart phone to measure the environmental
sound pressure level for assessing the effect of external sounds
on perceived tinnitus loudness and distress. This goes beyond
earlier developments where this integration was not possible
(Henry et al., 2012; Wilson et al., 2015). In this manuscript
we only want to mention this option of the technical platform.
Detailed analyses will be reported elsewhere and will also take
into account the variance of these measures in the different types
of smartphones. Further implementation in the future might
also integrate biosensors for objective assessment of biological
parameters (e.g., heart rate).
Fifth, the TYT is a non-commercial product and is available
all over the world for no costs and without advertisements.
To ensure the longitudinal assessment, the technical
framework is constantly maintained and updated by the
team. Furthermore, the technical implementation allows offline
use to ensure that permits the use even in areas without internet
connection.
smartphone app use, which includes that the anonymized data
can be used for scientific purposes. The analysis of anonymized
data from the smart phone app has been approved by the Ethics
Committee of the University Clinic of Regensburg. Before the
start of the study, all volunteers agreed with informed consent
and no vulnerable populations were involved. To recruit the
patients, the TYT app was advertised at the webpages and
Facebook pages of the Tinnitus Research Initiative, the TINNET
COST Action and the webpage of the participating research
groups.
Data Collection
There are three types of data collected by the TYT platform:
1. The ‘‘registration questionnaires’’ consists of three
questionnaires that were completed by the app-user upon
registration. The registration questionnaires include the
Tinnitus Sample Case History Questionnaire (TSCHQ,
Langguth et al., 2007), the short Version of the Tinnitus
Questionnaire (miniTQ, Hiller and Goebel, 2004) and a short
questionnaire asking for the individually most disturbing
tinnitus related aspect.
2. The ‘‘state questionnaire’’ is designed to assess tinnitus and
situation-specific variables with eight short questions during
everyday life. The state questionnaires constitute the main
part of this EMA study. The smartphone app will notify the
user at several time points during the day to fill out the
state questionnaire. The state questionnaires are delivered
randomly within a time frame that can be set by the user
(see the ‘‘Technical Realization’’ Section for more details). We
decided to give the user more freedom for this setting in order
to enhance the usability of the app and allow adaptation to the
individual needs. This, however, also enhances the variability
in the number of sampling points and the time lag between
them. The selection of data analysis methods need to take this
into account.
The state questionnaire consists of eight questions. With
the first question we ask the patient if she/he perceives
the tinnitus at this moment (answer with yes or no). The
second and third question ask about the loudness of the
tinnitus and how stressful the tinnitus is. The patients can
give their answers on a VAS by moving a slider between the
endpoints. Technically, the VAS was implemented as a slider
without pre-set values to avoid anchoring affects (Tversky
and Kahneman, 1974). The endpoints are ‘‘not audible’’
(question 2) or ‘‘not stressful’’ (question 3) on the left side
and ‘‘maximal loudness’’ (question 2) or ‘‘maximal stressful’’
(question 3). The questions 4 and 5 ask for the emotional
valence and arousal respectively, using the self-assessment
manikins (SAM) developed by Bradley and Lang (1994).
Question 6 asks if the person feels currently stressed on
a VAS (endpoints ‘‘not stressed’’ and ‘‘maximal stressed’’).
Question 7 asks how much the user concentrated on the
task that she/he was doing at the moment (VAS with the
endpoints ‘‘not at all’’ and ‘‘fully concentrated’’). Question 8
asked if the user was irritated at this moment (answer
with yes/no).
MATERIALS AND METHODS
‘‘TYT’’1 was implemented as a technical realization of the
envisaged EMA approach. The TYT platform will be outlined
below. A detailed description of the technical aspects is published
elsewhere (Pryss et al., 2015a,b; Schickler et al., 2015).
Recruitment
TYT is an open-access platform at no costs for the users. Upon
registration, the users have to agree with the terms of the
1 www.trackyourtinnitus.org
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The state questionnaire was implemented to allow fast
answering by the user. Typically, it takes less than a minute
to complete the state questionnaire.
3. The sound pressure of environmental sounds was measured
using the built-in microphone of the smartphone while the
user was answering the state questionnaire. The microphone
recordings were set to record with a resolution of 16 bit
for both, the Android and the iOS devices. While intersubject comparison of the sound pressure measures is
limited because of the different smartphone manufacturers,
an intra-subject comparison between different moments
will be possible. The sound pressure measurements are
not reported in this manuscript and is subject to further
analyses.
purposes. The user can select between two settings for the state
questionnaires: in the ‘‘standard settings’’, the user receives the
state questionnaires at random time points between 8 a.m. and
10 p.m. (can be adjusted) following a randomization algorithm
described by Pryss et al. (2015b). A maximum number of 12 state
questionnaires per day is allowed by system. In the ‘‘custom’’
settings, the user can define an own schedule with time points
where she/he wants to receive the state questionnaire. The TYT
platform was developed by the authors of the manuscript (RCP,
AB, JS, MR) with additional support by several programmers
from the University of Ulm (see ‘‘Acknowledgments’’ Section,
Jochen Herrmann, Robin Kraft, Robin Zöller, Aliyar Aras, Marc
Schickler). The TYT platform is developed for users with chronic
tinnitus. No prior knowledge of EMA is required to use the app.
Technical Realization
Data Management
High emphasis is placed on data management of the TYT
platform. Given the automated procedures, the data collection
is highly standardized for all participants. Data entry masks
are designed carefully to only allow the entry of meaningful
data and minimize the risk of wrong entries (e.g., defined value
ranges). The data collection of TYT is continuously ongoing.
Therefore, strict rules for data analysis were defined in order
to reduce reporting biases: at fixed time points during the
year, the database is frozen. Data analysis will always be done
using the most recent database freeze. The data reported in this
article contains the data collected between April 2014 (start of
the TYT platform) and February 2016. Further analysis on the
dataset have been published elsewhere (Probst et al., 2016a,b) and
additional analyses will be performed in the future. This will also
include time-series analyses to explore temporal relationships
between the tinnitus loudness or distress and the emotional state
or the perceived stress level.
The Front-End (Figure 1) of the TYT includes two smart
phone applications for iOS (implemented using Objective C)
and Android devices (implemented using Java), and the
www.trackyourtinnitus.org website (implemented using the
Open-Source PHP-Framework LARAVEL: Code Bright, Otwell,
2016) for the registration and display of the results. Both smart
phone apps are freely available for English and German speaking
users in the respective app stores. The Back-End consists of a
MySQL database running on a Linux Server for the storage of
the collected data from all mobile devices. The data on the smart
phone devices are stored in the internal SQLite database of the
mobile device. If the user is online while he is answering the state
questionnaire, the answers between the mobile device and the
server will be synchronized immediately. If the user is offline,
this synchronization process will be triggered the next time the
user is online. In all cases, only anonymized data is transferred
and the data transfer is encrypted using the secure sockets layer
(SSL) technology. The user has the option to review his own
data within the app or download the dataset using the web
interface. The anonymized data of all users are stored in a central
database maintained by the University of Ulm for research
Data Analysis
The influence of the duration of app-use on the perceived
tinnitus loudness and distress was tested by means of regression
FIGURE 1 | Frontend of the TrackYourTinnitus (TYT) framework including the website and the smart phone applications for iOS and Android.
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FIGURE 3 | Histogram of the Mini-Tinnitus Questionnaire (Mini-TQ)
sum scores of the participants. During the registration process,
the participants are required to fill out the Mini-TQ. The Mini-TQ measures the
strength of the tinnitus distress on a scale from 0 to 24.
FIGURE 2 | Age distribution of the participants.
analysis. Statistical analysis was done using the statistical software
package R2 .
to test the influence of the study duration on the tinnitus
loudness.
The duration of app-use measured in days was used as a
regressor in this model, the tinnitus loudness as regressand
(tinnitus loudness ∼ app-use duration). Duration of app-use
did not predict tinnitus loudness, β < 0.001, t (6291) = 1.26,
p = 0.21. Furthermore, the duration of the app-use did not
explain the variance of the tinnitus loudness significantly,
R-squared <0.001, F (1,6291) = 1.58, p = 0.21. Similarly, we
investigated the influence of the duration of app-use on tinnitus
distress (tinnitus distress ∼ app-use duration). The duration of
app-use did not predict tinnitus distress, β < 0.001, t (6264) = 1.3,
p = 0.19. Also, the duration of the app-use did not explain the
variance of the tinnitus distress significantly, R-squared <0.001,
F (1,6264) = 1.7, p = 0.19. Additionally, we calculated a paired
t-test comparing the mean of the first 5 sampling state
questionnaires against the mean of the last 5 state questionnaires
for each user. Again, there was no significant influence of
time neither on tinnitus loudness (t (61) = 1.25, p > 0.2)
nor on tinnitus distress (t (61) = 0.38, p > 0.7), indicating,
that app-use did not have a negative impact on the users’
tinnitus.
The same type of paired t-test was repeated for the subjects,
which used the app for less than 1 month. We selected all users
with more than 5 days of app-use and less than 30 days of use.
Also for this group of users, there was no significant influence of
time neither on tinnitus loudness (t (133) = 0.53, p > 0.5) nor on
tinnitus distress (t (129) = 0.79, p > 0.4).
To give an impression of the fluctuation of tinnitus
loudness and tinnitus distress over time, a random selection of
three participants is illustrated in Figure 4.
RESULTS
Study Sample
A number of 857 volunteers (26.9% female, 73.1% male)
participated in the data collection between the launch of
the app in April 2014 and February 2016. To recruit the
patients, the TYT app was advertised at the webpages and
Facebook pages of the Tinnitus Research Initiative, the TINNET
COST Action and the webpage of the participating research
groups. The average age of the participants was 44.1 years
(standard deviation: 14.1 years, Figure 2). Upon registration,
the participants completed the Mini-Tinnitus Questionnaire
(Mini-TQ) for the assessment of tinnitus-related distress.
The average sum score over all participants was 13.9 points
(SD 6.0, Figure 3, maximum score of the Mini-TQ is
24 points).
Influence of Study Participation on Tinnitus
Symptoms
An important question is whether the continuous participation
in the study, with repeated measurements of tinnitusrelated symptoms, leads to a worsening or improvement
of tinnitus symptoms. To analyze this question, we
selected a subgroup of subjects that have used the app
regularly for at least a month. Linear regression analysis
was calculated for these users (n = 66) in this timeframe
2 www.r-project.org,
version 3.3.1.
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studies. It is therefore important to mention that our results are
in line with the previous studies on mobile assessment of tinnitus
(Henry et al., 2012; Wilson et al., 2015). The large amount
of sampled data allows the analysis of more specific research
questions about tinnitus which are reported elsewhere (Probst
et al., 2016a,b).
From a clinical point of view, there could be the concern that
the tinnitus increases by the repeated assessment (and therefore
a reminder) of the tinnitus perception. It is notable here that
the tinnitus perception did not change as a result of repeated
sampling, neither tinnitus loudness nor tinnitus distress. This
is in line with the study by Henry et al. (2012) in which it was
shown that tinnitus did not change during a 2 week assessment
period with four measurements each day. Furthermore, we also
analyzed the data of users with only a short duration of app-use.
In principle it would be possible that users where the app-use
has a negative impact on their tinnitus stop using the app,
while the users without negative impact use the app for a longer
time. This is clearly not the case since the paired t-tests on
the subgroup of subjects with short app-use duration did not
reveal a significant difference between the first and the last state
measurements either. These findings further support the notion
that assessment of tinnitus symptoms during everyday life is a
safe method that is not increasing neither tinnitus loudness nor
tinnitus distress.
The aim of the TYT platform is: (1) to enable real-time
assessment of tinnitus variations and reduce the effect of recall
bias; (2) to investigate the factors influencing the increase
and decrease of tinnitus symptoms at the individual subject
level; (3) to enable the longitudinal assessment of tinnitus
symptoms and their dynamic processes; (4) to introduce
tinnitus measurements with higher ecological validity in real-life
conditions as opposed to tinnitus measurements in the lab
or the clinic, and therefore establish ecological momentary
assessment (EMA) methods for tinnitus research; and (5) to
implement and validate tinnitus assessment with smart phones
as a cost-effective assessment tool that can be applied for large
populations.
Future technical implementation will also enable monitoring
of clinical treatments. The effects of clinical treatments are
currently typically assessed by weekly or monthly questionnaires
and can therefore hardly be used to investigate dynamic
changes during the treatment phase. Although EMA has
been used in other domains to monitor treatment progress,
e.g., for antidepressant treatment (Barge-Schaapveld and
Nicolson, 2002), it has not been used for the assessment
of tinnitus treatments yet. Another benefit of EMA was
revealed by the study of Barge-Schaapveld and Nicolson
(2002), which demonstrated an increased reporting of sideeffects. The side effect of increased dizziness was reported by
35 patients using EMA while only seven patients reported
increased dizziness to their general practitioner (BargeSchaapveld and Nicolson, 2002). This suggests that the recall
bias of retrospective assessment not only influences the
measurement of treatment related symptom reduction but also
the reporting of treatment-related side effects. Additionally,
frequent assessment of treatment effects with smart phones
FIGURE 4 | Example of three individual tinnitus patients. Measurements
of the tinnitus loudness (black) and tinnitus distress (gray) on 30 consecutive
days are shown for the three individuals. The tinnitus loudness and tinnitus
distress were both measured on a visual analog scale (VAS) and converted to
numerical values in the range of 0 (“not audible”/“not stressful”) to 100
(“maximal loudness”/“maximal stressful”).
DISCUSSION
We have introduced the TYT app as a new platform that
allows the assessment of tinnitus-related symptoms during the
everyday life of people with tinnitus. The app is available
in the two major app stores for Android and iOS devices.
Between April 2014 and February 2016, the app was used by
857 people with tinnitus, with the majority of users between
30 and 60 years old. The amount of tinnitus-related distress
as measured with the Mini-TQ covered the full range of the
measurement spectrum showing that the app was used by
people with various levels of tinnitus distress. However, further
studies will need to clarify, whether the population using the
app is representative to the general tinnitus population. The
recruitment of patients via the internet and the app stores
introduces a new way in patient recruitment compared to earlier
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could help to learn more about reasons for study drop out by
providing more precise data of what has happened immediately
before drop out.
However, beside all the excitement about the new
opportunities and advantages of EMA, we also want to mention
the drawbacks of this method, which mainly arise from the low
controllability of our sampling method. Since the assessment
with smart phones is not completed under the supervision of
clinical staff, the correct usage of the device as well as the identity
of the user cannot be guaranteed. Also, there is little control
over the situation and circumstances of the app usage, which on
one side enhances the ecological validity of the measurement,
but on the other side reduces its controllability. It is, therefore,
important to mention that EMA should not be considered as
a substitute for standard questionnaires used in the clinical
routine, but rather be seen as a complementary method with
additional value for both clinical practice and for basic as well
as clinical research. We are looking forward to a new wave
of studies using EMA for its various applications in tinnitus
research.
AUTHOR CONTRIBUTIONS
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data analysis, conception and implementation of the
TrackYourTinnitus app, drafted and revised the manuscript.
RCP: substantial contribution to the design of the study, data
analysis, conception, implementation and maintenance of the
TrackYourTinnitus app, drafted and revised the manuscript. TP
and BL: substantial contribution to the design of the study and
data analysis, drafted and revised the manuscript. JS, AB and
MR: substantial contribution to the conception, implementation
and maintenance of the TrackYourTinnitus app.
ACKNOWLEDGMENTS
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Schlee et al.
Measuring Tinnitus Variability: the TrackYourTinnitus App
Conflict of Interest Statement: The authors declare that the research was
conducted in the absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
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