Usefulness of Yoga in the management of tinnitus during COVID-19: A narrative review

Abstract

The emergence of Coronavirus disease 2019 (COVID‐ 19) has resulted in an unprecedented global health crisis. Tinnitus is the most commonly reported symptom when the COVID-19 impacts the auditory-vestibular system. There are a variety of management strategies for amelioration of tinnitus including Yoga. The present review deals with three issues: one, occurrence of tinnitus in persons affected by COVID-19; two, the impact of COVID-19 situation on tinnitus severity; and three, the potential of Yoga as an intervention strategy. Literature search was carried out through search engines like PubMed, Cochrane, Web of Science and Google scholar using keywords like ‘tinnitus’, ‘COVID-19’ and ‘Yoga’. The relevant studies were identified and the findings summarized in a narrative manner. Based on the evidence obtained in the present review, the authors propose that yoga can be used as an effective strategy in overcoming the psychosocial factors associated with COVID-19 particularly in this pandemic and related lockdown situation. It is also proposed here that teleyoga can serve as a practical, feasible and safe mode for providing therapeutic services for tinnitus-related issues particularly in the present pandemic situation.

1. Introduction

Coronavirus disease 2019 (COVID-19) was first reported in Wuhan, China [1]. According to WHO [2], approximately 173 million cases of COVID 19 had been reported globally as of 8 June 2021. Persons affected with COVID-19 may be asymptomatic, or show only mild symptoms, or manifest severe illness resulting in death. Cough, shortness of breath and fever, are some more common symptoms shown by those affected with COVID-19. Weakness, muscular pain, sore throat, general feeling of discomfort and loss of taste/smell are some of the less common manifestations of COVID-19 [3].

COVID-19 may affect cardiovascular, renal, gastrointestinal, immune response and nervous systems [4]. It is also known that some viral infections damage auditory system causing sensorineural hearing loss [[5], [6], [7]]. On this rationale, one can hypothesize that novel COVID-19 may affect the auditory system too. Almufarrij et al. [8] in a rapid systematic review reported some studies that found audio-vestibular symptoms like hearing loss, vertigo and tinnitus in persons with confirmed COVID-19.

Tinnitus denotes a condition wherein persons perceive sound, in ears or in the head, even when there is no external stimulation. It is an auditory disorder seen in 10–15% of the world population, many a times with psychological consequences [9]. However, a lower prevalence of 6.7% is reported for the Indian adult population [10]. Tinnitus is characterized as ringing, buzzing or whistling sound. Persons suffering from tinnitus are often depressed, irritable, insomniac, and/or have poor quality of life. It has been hypothesized that there is a relationship between tinnitus, on the one hand and the activity of the auditory and limbic systems, on the other hand [11]. Symptoms like depression, anxiety and other psychological problems are seen in persons with tinnitus because the limbic system of the brain is related to emotions [12].

Though there are many models that attempt to explain the physiology of tinnitus, the pathophysiology of tinnitus remains unknown. Many models of the pathophysiology of tinnitus posit that negative or emotional reaction to tinnitus may cause the disorder to become chronic [13,14]. In the present COVID-19 situation, worries about the pandemic nature of the of the disease, concern about living conditions, pressure imposed as result of the constant need to maintain good hygiene, and monetary burden resulting from the pandemic will negatively impact the psychological as well as the social well of the population at large [[15], [16], [17]]. It is probable that this pandemic situation leads to an increase in the incidence of an auditory disorder like tinnitus which is associated with psychological stress.

Tinnitus has been managed through medicines (sedatives, antidepressants and anxiolytics, and Ginkgo biloba), auditory methods (sound therapy, tinnitus retraining therapy), psychological strategies (cognitive behavioural therapy, counselling) and other methods (electromagnetic stimulation, biofeedback). All these strategies have brought in variable results in different persons. Yoga is reported to reduce sympathetic activity [18] which in turn reduces the level of stress hormone cortisol [[19], [20], [21]]. As tinnitus is often associated with stress and anxiety, it is believed that Yoga can effectively overcome/reduce the severity of tinnitus.

Yoga is a holistic system of exercises that has its origins in ancient India. It is a system that encompasses physical postures (asanas), breathing exercises and meditation (Yoga nidra) [22,23]. The goals of Yoga are thought to be “inner peace and union of mind, body and spirit” [24]. It is reported that Yoga brings in different benefits like reduction of stress and anxiety and a feel of well-being [24,25] thus improving quality of life to its practitioners. It is necessary to strengthen the host immunity both to control the potency of the agent as well as to prevent spread of infection. In this regard, the traditional Indian therapies like Ayurveda and Yoga have the potential to be some non-specific methods of augmenting host immunity [26]. There is evidence to show that Yoga and Ayurveda systems can be add-on management options in preventing COVID-19 pandemic (see Umesh et al. [26] for a detailed review). Umesh et al. [26] have collated evidence to show the potential of Yoga and Ayurveda systems which have the potential to prevent COVID 19 infection by acting on immune system as well as strengthening respiratory and mental health aspects.

There are some reports that have documented Yoga as a tool to address chronic subjective tinnitus [23,27,28]. It is theorized that Yoga acts on the sympathetic nervous system by reducing its activity thereby stimulating the parasympathetic system [21]. Such suppression of the activity of the sympathetic nervous system makes one feel calm and less stressful that in turn leads to decreased tinnitus distress. Hence, certain yogic practices, specifically pranayama, are reported to reduce tinnitus severity [23,[27], [28], [29]].

The incidence of tinnitus has increased in the past one year due to COVID-19 [30]. COVID-19; affected patients have reported tinnitus either as a presenting complaint [[31], [32], [33], [34], [35], [36], [37]] or as a subsequently occurring complication [[38], [39], [40]]. The present review deals with three issues: one, the occurrence of tinnitus in persons affected by COVID-19; two, the effect of COVID19 on tinnitus severity; and three, the potential of Yoga as an intervention strategy in overcoming tinnitus particularly in this pandemic and related lockdown situation. In addition, the review discusses, although briefly, the use of teleyoga services to manage tinnitus in this pandemic situation. It is proposed here that teleyoga can serve as a practical, feasible and safe mode for providing services to overcome tinnitus in the present scenario where lockdown and maintaining safe physical distance is the order of the day.

2. Methods

Literature search was carried out through search engines like PubMed, Cochrane, Web of Science and Google scholar. The keywords used were ‘tinnitus’, ‘COVID-19’ and ‘Yoga’. Key words with Boolean operators, in isolation and in combination, were used as MeSH terms with an idea to identify maximum relevant reports from literature already published. Literature search, in stages, allowed searching of publication relevant to different aspects of the present review (for example, Yoga and tinnitus, COVID-19 and tinnitus etc.). Findings of the reports relevant to this study were summarized in an Excel spreadsheet. No limit was placed on the publication period. The two authors decided on the relevance of the publications, independently and then collectively, to the present review; appropriate summary of the findings of the publications relevant to this study were made within the text of this review. Separate tables with findings of relevant publications in each of the focused areas of this review are presented.

3. Results

3.1. Tinnitus and COVID-19

There were 43 publications which reported tinnitus as a presenting symptom or as a later clinical manifestation of COVID-19. Of these, 10 most recent and relevant articles with different study designs were selected for discussion. Table 1 has a summary of these results. All these studies were published in 2020, and in English. Two of these were case reports [31,32] and one a case series study [33]. Degen et al. [31] reported a healthy 60-year-old man who experienced tinnitus after 13 days of intensive care treatment. Though hearing loss - COVID 19 association is well evident in this instance, it should be noted that the medicines taken (azithromycin and furosemide) might have confounded the results. However, on the basis of lack of symmetry in hearing loss, the role of ototoxic effect in causing hearing loss was ruled out by the authors in this patient. In another case study, Fidan [32] reports on a female patient aged 35 years who complained of tinnitus and otalgia, but who only later tested positive for COVID-19. Cui et al. [33], in a study of COVID-19 patient presentations requiring otolaryngology consultation analysed the medical records of twenty hospitalized COVID-19 patients and reported only one patient complaining of tinnitus.

Table 1.

Studies reporting tinnitus as a presenting symptom or as a later clinical manifestation of COVID 19.

Sl No.	Author, Year, Type of Study	Partici- pants	Method/Tools used	Findings
1	Degen et al., 2020 [31]: Case report	A person with COVID-19, aged 60 years	Evoked potential test to confirm hearing loss.	The patient reported bilateral hearing loss as well as loud tinnitus after he was shifted from the ICU to ward. Hearing testing showed profound sensorineural hearing loss in the left ear and total hearing loss in the right ear. Basal turn of the right cochlea showed decreased fluid signal although partial (MRI Scan).
2	Fidan 2020 [32]: Case report	A female patient, 35 years old, with COVID - 19.	Audiometry and tympanometry.	Patient complained of otalgia and tinnitus. ENT examination showed hyperemia and bulging tympanic membrane Hearing testing showed right conductive hearing loss with Type B tympanogram.
3	Cui et al., 2020 [33]: Case series	20 COVID-19 patients	Medical records of the patients were analysed	One patient showed otitis externa while a second patient complained of tinnitus.
4	Viola et al., 2020 [34]: Questionnaire based study	185 patients in 15 Italian hospitals	An online 10-item close-ended questionnaire that tapped, among others, demography, nature and presence of audio-vestibular problems like tinnitus and dizziness, and their association with other disorders like migraine in persons affected with COVID-19.	43 (23.2%) subjects reported tinnitus. 14 (7.6%) complained of both tinnitus and balance problem. Patients described their tinnitus variously as recurrent (17/43) as occasional (10/43), as continuous floating (7/43), as persistent (4/43), as pulsatile (3/43) and as continuous (2/43).
5	Elibol 2020 [35]: Retrospective observational study	155 persons with COVID-19	Retrospective and archival study. Anamnesis and patient medical histories were analysed.	2 out of 155 reported tinnitus while one patient reported sudden hearing loss.
6	Lechien et al., 2020 [36]: Observational study	1420 persons with COVID-19 in 18 European hospitals	Epidemiological and clinical data were obtained through a standardized questionnaire.	5 out of 1420 patients reported tinnitus (0.3%)
7	Liang et al., 2020 [37]: Not mentioned	86	Demographic information, clinical characteristics and laboratory findings Self-made questionnaire was used to document neurosensory dysfunctions including tinnitus.	3 out of 86 had tinnitus (3.5%). Tinnitus tends to appear much before the classical symptoms of COVID-19.
8	Freni et al., 2020 [39]: Prospective study	50	Hearing Handicap Inventory and Tinnitus Handicap Inventory, among others, were administered twice; first when the disease process was active, and a second time, 15 days after the patients tested negative for SARS-COV-2.	Tinnitus appeared or worsened in 10 patients (20%). There was a statistically significant difference in these symptoms between active phase of COVID-19 and post COVID-19.
9	Ozcelik Korkmaz et al., 2020 [38]: Prospective observational cohort study	116	Patients were interviewed for symptoms associated with COVID-19. Follow up was done on telephone	13 out of 116 reported tinnitus (11.2%) on follow up, and a further 6 (5.76%) showed hearing loss.
10	Munro et al., 2020 [40]: Not mentioned (Letter to the editor)	121	Follow up study. Participants were reviewed 8 weeks after discharge from the hospital: clinical history relating to hearing and tinnitus was reviewed.	Sixteen (13.2%) patients reported a change in hearing (N = 8) and/or tinnitus (N = 8) on follow up. Four in the first group and 3 in the second group reported a pre-existing hearing loss.

Liang et al. [37] reported that neurosensory dysfunctions, including tinnitus, may occur in the beginning stage of COVID-19 much earlier than the onset of typical symptoms. Three other publications [[38], [39], [40]] reported the results of prospective studies wherein the patients were followed for some time. All these studies reported that the patients reported tinnitus as a delayed clinical manifestation after recovering from COVID-19. The findings of these studies are given in Table 1.

A general and common finding of studies summarized in Table 1 is that tinnitus is a frequent manifestation in COVID-19 patients. Almufarrij & Munro [30], in a recent systematic but a short review, reported that tinnitus was the more common audio-vestibular problem reported by COVID-19 patients in relation to hearing loss and vertigo). They reported a pooled estimated prevalence of 14.8% for tinnitus.

3.2. Impact of COVID 19 on tinnitus severity

The COVID-19 situation being a stressor may influence the perceived tinnitus. There were five studies which looked into the issue of worsening of pre-existing tinnitus because of COVID-19.

The COVID-19 situation being a stressor may influence the perceived tinnitus. Shi et al. [41] reported a female patient, aged 64 years, who came to a local hospital with the complaint of tinnitus. Audiological evaluation and MRI of the brain showed normal results. The patient had no past or present problem of vertigo, otorrhea, otalgia, ear infections, otologic surgery or trauma, or exposure to noise (occupational or recreational). After a detailed review of past history, the patient recalled that tinnitus appeared right after her travel to Wuhan province during COVID-19 pandemic in the month of February 2020. She also reported that she was extremely upset after learning that one of her neighbours contracted COVID-19 and could not sleep the whole night as a result. Tinnitus became more obvious after this. This case report shows that psychosocial factors such as anxiety and insomnia related to COVID-19 can have negative influence on tinnitus. It is also reported that the patient showed rapid recovery after psychiatric intervention and therapy.

Schlee et al. [42] investigated 122 persons with tinnitus at two points of time in 2018 and in 2020 (COVID- 19 pandemic situation) to understand the effect of COVID situation (as an environmental stressor) on tinnitus by comparing tinnitus-related distress. German version of Tinnitus Handicap Inventory (THI) and Tinnitus Questionnaire (TQ) were administered. Results indicated that COVID-19 did impact life by worsening tinnitus distress which was a result of increased severity of tinnitus. People who perceived psychological distress (grief, frustration, stress and nervousness) also reported exacerbated tinnitus-associated distress. People who got a higher score for psychoneurosis also complained of tinnitus and tinnitus associated distress. Anzivino et al. [43] administered THI [44] on 16 persons affected by chronic subjective tinnitus, but self-stabilized without any treatment. They reported an increase in 12 of the 16 patients during handicap increased by one level in 12 out of 16 patients during COVID-19 pandemic-lockdown situation. More specifically, 9 patients moved from mild to moderate category while 3 patients shifted from moderate to severe level on THI. These findings suggest that the COVID situation does influence tinnitus severity.

Xia et al. [45] compared the tinnitus population visiting different hospitals in 2020 during COVID-19 with those who reported in the corresponding period of the year 2019. Patients with tinnitus were managed either on sound therapy with educational counselling (STEC) or on educational counselling (EC) alone. Anxiety and severity of tinnitus was assessed before and two months after therapy in both the time points. The authors reported a large increase in anxiety scores for patients managed in 2020. In addition, the authors reported that both the treatment methods were less effective in tinnitus patients of the year 2020. The authors suggested that the differences in anxiety scores between years (2019 and 2020) and treatment methods (STEC and EC) indicate that EC alone cannot ameliorate the stress related to COVID-19. The authors concluded that a inadequate stress management can worsen tinnitus and associated anxiety.

Beukes et al. [46] conducted an online survey to study the effect of COVID situation on persons complaining of tinnitus and also to identify factors influencing their tinnitus. It was found that COVID-19 worsened tinnitus in 40% of those surveyed. Furthermore, tinnitus worsened in persons who kept themselves isolated, or slept poorly, or in those who did not exercise enough. Similarly, persons who experienced psychological (depression, anxiety, irritability) and financial problems found tinnitus more worrisome during the pandemic.

3.3. Tinnitus and Yoga

There are six publications which have reported the results of studies on Yoga as a treatment strategy to overcome tinnitus.

Kroner-Herwig et al. [47] compared the therapeutic effect of two strategies - Tinnitus Coping Training (TCT) and Yoga - on tinnitus. Forty-three persons with tinnitus of an average duration of 4.5 years were divided into 4 treatment groups - TCT 1, TCT2, Yoga and a self-monitoring control group. The group TCT2 was constituted for controlling the therapist effect. The participants were tested for the sensation level of perception of their tinnitus, the level at which tinnitus could be masked, and on the German version [48] of TQ [49] at three points - before therapy, after treatment and 3 months after therapy. Participants of each group were trained over ten sessions, each of 2-h duration. The TCT training focussed on patient education (on hearing and tinnitus-related issues) and progressive relaxation. An experienced Yoga trainer carried out Yoga (Hatha Yoga). Yoga training included to exercises to promote relaxation and body perception. Furthermore, the participants were also trained to achieve a state of consciousness (relaxed) through ‘pranayama’ exercises (breathing), and ‘asanas’.

The group which underwent TCT training performed better than the group that underwent Yoga training on two variables - control of tinnitus and ability to ignore tinnitus. Psychological distress, as measured on the TQ, was the lone factor which decreased in all the study groups. However, participants in the TCT groups performed the best. Generally, participants who received TCT treatment were more satisfied on the treatment they received than participants in the Yoga treatment group. In fact, participants who received Yoga did not find the training helpful.

Pandey et al. [27] compared the effectiveness of Bhramari Pranayama on tinnitus with results from three other groups of participants who underwent Ginkgo biloba (group 2) or masking therapy (group 3) or a combination of all these modalities (group 4). The Bhramari Pranayama technique combines a relaxing posture, production of a sub-tinnitus level (in the present study) humming sound, and simultaneous pressing of the closed eyelids. The study was carried out on 84 individuals who complained of tinnitus. Routine audiological evaluation which included pure tone, speech, and impedance audiometry was carried out on all participants after obtaining a detailed case history. Results of audiological evaluation showed that some individuals had tinnitus and normal hearing while others had tinnitus along with unilateral or bilateral sensorineural hearing loss.

The 84 participants of the study were randomly segregated into 4 groups with 25 ears in each group. On a random basis, the first group received pharmacotherapy, the second masking therapy, the third Bhramari Pranayama while the fourth group received a combination of all the three therapies. Pre- and post-therapy status of tinnitus was evaluated as per the protocol of Hall and Haynes [50]. THI [51] and the Hospital Anxiety and Depression Scale (HADS) [52] were administered before and after therapy to evaluate the stress-induced effects of tinnitus.

The post-therapeutic scores on tinnitus loudness, THI and scores on HADS were significantly lower for all the 4 treatment groups in comparison with pre-therapy scores. Additional statistical analyses revealed that the group which had ‘all the three treatments’ (group 4) scored the best on all the three parameters investigated in the study. The group which practised only Bhramari Pranayama followed Group 4. In addition, different therapies brought in a different result on tinnitus. The authors concluded that Bhramari Pranayama, in isolation as well as in combination with other therapeutic modalities, provided significant relief to the patients from their tinnitus. The authors recommended that Bhramari pranayama may be an economical and supportive therapy for tinnitus. Bhramari pranayama probably acts on neuromodulation principles.

Kreuzer et al. [53], in a randomized controlled trial on 36 persons with chronic tinnitus, investigated the efficacy of two techniques - mindfulness and body-psychotherapy-based program. The program included mindfulness, meditation, self-massage, and breathing exercises, specifically developed for persons with tinnitus, as the main components. Group therapy was performed in two stages, with an interval of 7 weeks between the stages. Randomized participant selection allowed patients to receive treatment either immediately (experimental group) or later (control group). Following treatment, there was a significant change in the complaints, as measured on the German version of Tinnitus Questionnaire (TQ), made by the members of the two groups. The analysis indicated an improvement in Though the TQ scores, between baseline to week 9, changed for members of both the groups, the change was greater for members in the intervention group. The results point to the usefulness of mindfulness- and body-psychotherapy-based techniques in reducing tinnitus. However, studies on larger samples are needed to substantiate these findings.

Koksoy et al. [23] investigated the effect of Yoga in 12 patients who had chronic tinnitus for 5.4 years, on an average. The participants underwent Yoga training for 12 h spread over 12 weeks (one time in a week). The researchers and a certified Yoga teacher conducted Yoga training. Each hour of training consisted of warm up (15 min of pavanamuktasana - stretching of the whole body), practice of 18 asanas (30 min) and practice of 5 types pranayama and meditation (15 min). Yoga training carried out on a given day was recorded on a worksheet and given to participants with instructions to practice Yoga as often as possible. The participants were assessed on THI [51], Tinnitus Severity Instrument using a subjective analog scale [54,55] and Tinnitus Stress Symptom Scale (TSI) [56] before and after completion of Yoga therapy. Test scores on THI and TSI were significantly decreased following Yoga intervention. The authors concluded that Yoga training was effective in reducing tinnitus.

Another case control study reported by Niedzialek et al. [28] investigated the effect of Yoga training on mental distress arising from tinnitus. The study group (Yoga group) consisted of 25 persons with chronic tinnitus of longer than 6 months and an age matched control group (no treatment) consisting of 13 persons with chronic tinnitus. ENT examination as well as audiological assessment was conducted on all participants. Pure tone hearing evaluation was carried out on all participants. Participants of the study group received Yoga instruction and training from a qualified Yoga instructor over 12 weeks. There were two sessions of Yoga, each week, each session lasting for 90 min. In addition, participants were asked to practice Yoga at home (some exercises at least) for 30 min, 2 to 4 times every week. The investigating team assessed, before and after therapy, the impact of tinnitus on every day life of the participants on Tinnitus Functional Index (TFI) [57]. At the end of 12 weeks of Yoga, the TFI score of participants in the study group was significantly lower than their pre-therapy scores while the scores of the participants in the control group remained the same. The post therapy scores of the treatment group was particularly lower in 5 of the 8 sub scales of TFI, namely, auditory, intrusiveness, quality of life, sleep and sense of control of tinnitus. The authors concluded that Yoga brings in beneficial effects on the everyday life of persons suffering from tinnitus and that it can be a complementary therapy for such affected persons.

Ismail et al. [58] investigated the efficacy of bee-humming respiratory training (BHRT) on reducing tinnitus loudness (TL), tinnitus annoyance (TA) and quality of life measures in persons aged ≥65 years old with bilateral chronic subjective tinnitus. The authors characterized BHRT as “humming-sound-induced vibration in the skull and brain.” Intervention comprised pranayama (slow and deep-inhalation) followed by prolonged bee-humming audible vibratory resonance. This parasympathetic activation/augmentation, it is believed, will improve physiological and mental alertness, reduce stress and anxiety, and in general, have a positive effect on the quality of life. The study employed a prospective, single-blind design, a randomized-controlled intervention for-tinnitus using BHRT. 46 elderly people with tinnitus were randomly assigned to either the BHRT group (23 patients) or the control group (23 patients). Participants received BHRT for 30 min every day for four weeks. Significant BHRT-induced reductions on TL, THI, TA and cardiovascular/respiratory autonomic functions were seen in members who received BHRT whereas no such changes were observed in the members of the control group. These results point to the beneficial effects of BHRT in reducing tinnitus-related factors in elderly persons with chronic subjective tinnitus.

4. Discussion

A review of published literature on the perception of tinnitus in persons who have contacted COVID-19, increase in the severity of existing tinnitus, and Yoga as an interventional strategy for amelioration of tinnitus during COVID-19 pandemic is attempted here. Literature search was carried out with appropriate keywords and Boolean operators. Review suggested that tinnitus and stress are often reported together [12,59] and that stress worsened the severity of existing tinnitus [59]. Recent research on COVID-19 has documented the consequences of COVID-19 on the psychological health of affected persons. It is shown to lead to stress, anxiety and depression [45,60,61]. Studies (discussed under section 3.3 Tinnitus and Yoga) have amply demonstrated that COVID-19 related stress worsens the severity of tinnitus. It is speculated that increased occurrence of tinnitus during COVID-19 could be due to the effect of lockdown and its sequel. There is evidence to state that lockdown forced people to stay indoors where the environmental sounds are decreased both in loudness and variety. The absence of sounds in the home environment might have enhanced the perception of tinnitus [43]. Social distancing, another effect of lockdown, may also worsen the existing tinnitus.

4.1. Yoga for tinnitus during COVID -19

Yoga is an ancient Indian system of physical and mental exercise and is considered to be the science of holistic living. There is evidence to state that an individually tailored Yoga protocol can lead to a reduction of as much as 50%–90% of symptoms in persons who experience mild to moderate degree of stress or anxiety thereby promoting positivity and wellbeing [62]. If this is indeed true, then it can be hypothesized that Yoga can be used as an interventional approach for persons with tinnitus which is often associated with stress, anxiety, depression and sleeping disorders especially in this COVID-19 situation.

There are some studies (discussed under section 3.2 above) which provide empirical proof for the benefits of Yoga in overcoming tinnitus. Pandey et al. [27] used Bhramari Pranayama in overcoming tinnitus-related handicap and distress whereas Koksoy et al. [23] and Niedzialek et al. [28] used combination of Yoga asanas, pranayama and meditation to improve the quality of life of patients with tinnitus. All these three studies demonstrated that Yoga can be an effective interventional strategy for overcoming tinnitus, or reducing its severity.

Direct evidence for demonstrating the role of Yoga in overcoming tinnitus is limited, but there is strong evidence to demonstrate the effectiveness of Yoga in overcoming the psychological factors associated with tinnitus. Li et al. [63], after a review of 35 clinical trials and randomized control trials, supported the potential benefits of Yoga in relieving symptoms of stress and anxiety. Cramer et al. [64] reported, in a systematic review and meta-analysis of randomized controlled trials, that Yoga might be an effective as well as a safe management strategy for persons with heightened anxiety. Saeed et al. [65] have asserted that mindfulness-based meditation and Yoga individually as well as an adjunctive therapy reduce depression with the positive effect lasting for more than six months and with no apparent side effects. There is additional support for the findings of Saeed et al. [65] from Cramer et al. [66]. Rusch et al. [67] following their meta-analysis of 18 trials involving 1654 participants concluded that mindfulness meditation significantly improved sleep quality. Overall, there is overwhelming evidence to show that regular Yoga practice is helpful in reducing stress, anxiety, depression and improving sleep pattern thus enhancing the overall well-being and quality of life [24].

There is significant evidence on the beneficial effect of Yoga in overcoming the psychological stress associated with tinnitus [23,27,28]. Results of many systematic reviews/meta-analysis [66,67] support the positive effect of Yoga in reducing stress. The cumulative evidence on this issue suggests that Yoga is a promising tool that brings relief from tinnitus especially during this COVID-19 situation. In addition, as people have only limited physical activity in the lockdown period, Yoga can be a very practical, safe and feasible alternative in overcoming tinnitus. On the basis of an examination of the documented evidence, the present review proposes a module of Yoga (as detailed in Table 2) for overcoming the effects of tinnitus. These techniques help in overcoming stress, anxiety and depression by reducing the sympathetic activity, which in turn may help reduce the severity of tinnitus.

Table 2.

Yoga module for tinnitus.

Sl. No	Name of the practice	Benefits
1	Neck rotation/Neck bending (forward, backward, bending sideways)	Strengthens neck muscles and helps in the balance of prana (vital energy) in the head region
2	Surya namaskara	Promotes physical, mental and psychosocial well being
3	Kapalbhati	Helps overcome lethargy and enhances psychological wellbeing
4	Sectional breathing	Enhances the lung function, self-awareness and calmness
5	Nadishuddhi pranayama	Balances the vital energy, reduces stress, strain, and fatigue, and promotes mental calmness
6	Bhramaripranayama	Restores equilibrium and regulates metabolism
7	Nadanusandhana pranayama	Promotes calmness of mind, avoids negative thinking and helps overcome mental obstacles
8	Deep relaxation/Yoga nidra	Promotes relaxation and increases self-awareness by overcoming mental obstacles

Telehealth services are evolving and gaining greater acceptance in this present COVID situation. Telehealth service is a means to provide cost effective, patient friendly and most importantly safe service to the needy clinical population. Aazh et al. [68] in an UK based survey offered tinnitus therapy for 113 patients through telehealth mode and found that 80% of the patients accepted teletherapy for tinnitus. Central Council for Research in Yoga and Naturopathy (CCRYN - an organization of Government of India has released an advisory on tele-Yoga services (Version 1.0) in July 2020. Tele-Yoga service refers to the delivery of Yoga modules through elaborate demonstrations and instructions for the interested to practice Yoga at home. The modules consist of Yoga postures (asana), breathing exercises (pranayama), meditation, relaxation techniques and counselling on virtual video platforms. In the current scenario of COVID-19 emergency, where maintaining physical distance is of utmost importance, tele-Yoga is a most welcome, cost effective, fast, and easily accessible service that overcomes geographical barriers. Tele-Yoga may be considered a safe and effective therapeutic tool to overcome tinnitus in the present COVID 19 situation.

The relationship between Yoga and tinnitus, however conjectural, can be summarized as follows: The precise cause of tinnitus is not known. It is said that a mechanical abrasion of cochlear structures leads to the sensation of tinnitus. Tinnitus leads to stress which in turn increases the perception of tinnitus. It is a vicious cycle. It has been documented that Yoga stimulates the parasympathetic nervous system thereby reducing the activity of the sympathetic nervous system [21] which in turn reduces stress and anxiety [58]. There is empirical evidence to show that certain yogic practices, specifically pranayama, reduce tinnitus severity [23,[27], [28], [29]]. Therefore, if people with tinnitus who experience higher level of tinnitus-induced stress and anxiety are made to practice Yoga, then it may lead to reduced stress – tinnitus induced or otherwise - and thereby helping the affected people from the negative effects of tinnitus. Yoga can be a complementary therapy for patients affected with tinnitus [28].

5. Conclusions

On the basis of a review of literature relating to Yoga and tinnitus, it can be stated that Yoga is a promising management strategy for reducing psychological effects like stress, anxiety and depression commonly associated with tinnitus. This is especially so during COVID-19 situation when so much importance is given for indoor stay and practicing physical (social) distancing. Tele-Yoga guidelines of CCRYN provide easy, feasible and cost-effective strategies to overcome the effects of tinnitus in the present pandemic situation.

It must be noted that the relationship between COVID 19 and tinnitus is conjectural. The presence of two conditions (COVID 19 and tinnitus) is assumed to be a relationship between the two. The relationship between tinnitus stress – anxiety is bidirectional. As COVID 19 and the associated variables also increases stress – anxiety which in turn increases the already present tinnitus. Though the evidence on the amelioration of tinnitus through Yoga is somewhat subjective as well as indirect [[63], [64], [65], [66]], it nevertheless shows the possibility of Yoga as a therapeutic strategy for reducing tinnitus – COVID 19 or no COVID. More systematic studies are warranted on this issue.

The present review has restricted itself to literature search of free online databases. It is possible that we might have missed some publications on the subject of this review. Limited number of studies reviewed here warrants conducting randomized control trial and other interventional studies exploring the effectiveness of Yoga/tele-Yoga in managing persons with chronic tinnitus during COVID crisis.

Funding

This research did not receive any grant from any funding agency.

Author contributions

Ms. Apoorva H M: Conceptualization, methodology/study design, literature search and review, formal analysis and investigation, data curation, and writing the original draft

Dr. M. Jayaram: Conceptualization, methodology/study design, validation, formal analysis and investigation, data curation, reviewing and editing the drafts, supervision and project administration.

Dr. Neetinakumar J Patil: Conceptualization, methodology/study design, data curation, writing the original draft

Declaration of competing interest

None