Frequency Discrimination Training With and Without Game Format to Treat Tinnitus: A Systematic and Meta-Analysis Study

Abstract

To evaluate the effectiveness of Frequency Discrimination Training (FDT) programs with and without an integrated game format for treating a person with tinnitus. Searches were conducted in Medline, PubMed, Web of Science, Elsevier, Springer, Scopus, and ProQuest databases from early 2000 to 2024. FDT studies of non-randomised and randomised clinical trials that used validated tinnitus handicap index were considered. A total of six articles from non-randomised (four studies) and randomised clinical trials (two studies) met our inclusion criteria. Both types of studies were rated as good quality, as assessed by the Mixed Methods Appraisal Tool. However, the levels of evidence were generally limited by factors such as lack of blinding, failure to calculate effect sizes, and absence of follow-up assessments after the treatment period to monitor outcomes. According to the random-effects model, Frequency Discrimination Training (FDT) reduces tinnitus handicap with a medium effect size of 0.5104 (95% CI: 0.2478 to 0.7729), regardless of game integration. When considering FDT without game integration, the effect size remained medium at 0.473 (95% CI: 0.14 to 0.780). In contrast, FDT with game integration demonstrated a large effect size of 0.90 (95% CI: 0.29 to 1.50) in reducing the handicap caused by the tinnitus. A substantial effect size was observed in THI score reduction among tinnitus participants trained with FDT integrated with a game compared to those without integration.

Introduction

Tinnitus is a perception of sound in the brain without external sound [1]. The prevalence of tinnitus is 14.7 in Europe [2]. About 43.2% of individuals with tinnitus had hearing impairment ≥ 25 HL [3]. In a person with tinnitus comorbid with hearing loss, relatively normal hearing functioning neurons extend their support to the impaired neurons corresponding to the hearing loss [4]. Hearing loss impairs the function of inner and outer hair cells in the cochlea, leading to abnormal spontaneous neural firing at the dorsal cochlear nucleus. The auditory cortex detects this firing and perceives it as tinnitus, altering the tonotopic frequency organisation [5]. Concurrently, the limbic system triggers negative emotions, activating the sympathetic nervous system (ANS) and causing distress [6], particularly in individuals with bothersome tinnitus.

Hearing loss impairs receptor function in the inner ear, resulting in abnormal spontaneous neural firing at the dorsal cochlear nucleus. The auditory cortex detects this firing and perceives it as tinnitus, altering the tonotopic frequency organisation in the auditory cortex. In individuals with bothersome tinnitus, the limbic system triggers negative emotions, activating the sympathetic nervous system (ANS) and causing distress.

Several auditory management strategies for tinnitus have emerged based on models and theories causing tinnitus. A gold standard approach in treating tinnitus is providing passive sound stimulation to mask it [7]. Recent studies on active sound stimulation in suppressing tinnitus have shown convincing positive outcomes over the gold standard approach [8–12] as these researchers based their hypothesis on selective attention to a target non-tinnitus sound (1/3 rd octave below tinnitus pitch) from tinnitus sound which eventually results in reversal of old maladaptive cortical remap.

An active form of sound enrichment to treat tinnitus is the frequency discrimination task (FDT). Hoare et al. [13] have demonstrated that perceptual training interrupts tinnitus generation through active listening conditions. Frequency discrimination training (FDT) is an auditory perceptual training that requires active listening in attending to the target tone (1/3 rd octave below the frequency of tinnitus) in the presence of distractors (tinnitus frequency), which influences the functional reorganisation of maladaptive frequency coding in the primary auditory cortex [14, 15]. The neuronal strength of the vicious cycle (Auditory, limbic, and autonomic nervous system) breaks down as the now damaged neurons are tuned to an actual frequency without any support from neighbouring neurons, and this process continues whenever a tinnitus patient actively discriminates target tones (1/3 rd octave below tinnitus pitch) from distractor tone (tinnitus pitch). The limbic system redefines an emotion [16], and the activity in the sympathetic nervous system is rollbacked, resulting in either habituation of perception [17] or habituation to reaction [18]. Several researchers who have used frequency discrimination auditory training reported effective treatment programs for tinnitus; however, the magnitude of improvement varies across the study due to methodological differences [8, 15, 19, 20].

Frequency discrimination training (FDT) programs without game format have been effective in reducing tinnitus, but clients often find the tasks repetitive and boring. Over time, it has been reported that participants lose interest in distinguishing the target sound (one-third octave below the tinnitus pitch) from the tinnitus sound, leading to inaccurate task completion and decreased attention away from tinnitus. This diminishes the training’s effectiveness and may result in negative participant experiences, reducing their willingness to continue in the study. To address these challenges, incorporating a game-based format for perceptual discrimination tasks can enhance enjoyment and engagement, encouraging regular participation and potentially improving tinnitus relief. Game-based training may facilitate compliance and significantly reduce attrition by leveraging intrinsic motivation. Patients can use tinnitus software in game format at home over an extended period. In the perceptual game, clients are instructed to interact with the training program rather than react to the stimulus presented by the software [7, 10, 12]. In an auditory discrimination training program in a game format, clients are instructed to discriminate the target sound from the distractor sound to unfurl a puzzle piece [20]. The FDT program integrated with the game format in the computerized program has shown increased attention away from tinnitus and reduced tinnitus severity [20, 21]. Hemanth and Vipin [20], as well as Wise, Kobayashi, and Magnusson et al., [21] have used FDT in interactive training modules incorporating elements of gameplay, such as decision-making, strategy development, and competition, which reduced tinnitus by enhancing intrinsic motivation to use it regularly and consistently. This review aims to investigate the effectiveness of frequency discrimination auditory training programs, both in general and specifically when integrated with and without a game format, for individuals with tinnitus.

Methods

Search strategy: Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist was used to identify the search strategy, study selection, data extraction, quality assessment, and data synthesis. A database search was conducted in March 2023. Initially, databases were searched using the keywords ‘tinnitus’ AND ‘auditory discrimination training’, ‘tinnitus AND ‘frequency discrimination training’, ‘tinnitus’ AND ‘auditory discrimination therapy’, ‘tinnitus AND frequency discrimination therapy’, ‘tinnitus AND auditory perceptual training’. The following databases- Medline, PubMed, Web of Science, Elsevier, Springer, Scopus, and Proquest- were used to search for relevant articles. Using multiple keywords, it was ensured that only articles mentioning tinnitus, frequency discrimination training, auditory discrimination training, or any perceptual training programs integrated with and without game format were extracted. Search results are screened for duplicates and review articles. Two authors screened according to the objectives of the study and the eligibility criteria mentioned as per Participants, Intervention, Control, Outcome, and Study Design (PICO). The articles selected by either author were screened by reading the full text for final agreement and inclusion. Any differences in opinion between the two authors were reconciled by jointly reviewing the articles once again for a final consensus.

Eligibility criteria: Inclusion criteria were identified according to the PICO. Participants were adults with tinnitus having hearing loss. The intervention was frequency discrimination training. The outcome measured was tinnitus severity, documented in the Tinnitus Handicap Inventory (THI). Tinnitus severity was compared between pre- and post-training with and without frequency discrimination task (FDT). All the articles were in English and published in countries like Spain, India, and New Zealand.

Exclusion criteria were case reports and case series studies. Articles with insufficient information on any PICO criteria were excluded. The stages and reason for the exclusions are presented in Fig. 1.

Fig. 1.

Summary of the systematic literature search

Data Extraction

A reporting form was developed specifically for this task used for data extraction. Extracted data comprised the following details: study design, participants (inclusion and exclusion criteria, sample size, tinnitus characteristics, and hearing loss), training task and stimulus (including the amount of training), compliance and follow-up (including dropout or exclusion), outcome measures; and findings (outcomes, statistical comparisons, and significance levels). Any differences in reporting, if noted, were revised and checked once again.

Data Synthesis and Meta-analysis

Meta-analysis was conducted for similar studies. The studies included had the same intervention method and outcome measures with low heterogeneity. In our study, the article included the Tinnitus handicap inventory (THI) questionnaire as an outcome measure. The test for heterogeneity is given in the results section of the meta-analysis. The studies that did not contain THI as the outcome measurement were excluded from the meta-analysis. Metaanalysis was performed using Jamovi and Review Manager Software (Revman V5.3). Deep Meta tool (version 1.0) was used to derive the mean and standard deviation for the available data.

Results

A total of 45 articles related to frequency discrimination tasks and tinnitus were identified from the database. Thirty articles were excluded after removing review articles, duplicates, articles published in other than English, mismatch in outcome measure, and study populations not matching the target population. Two additional relevant articles were found in the reference list of the 15 articles. Seven articles were excluded upon reviewing the abstracts of these 17 articles because of insufficient data and pilot study. Furthermore, four articles were excluded after reviewing the full text of ten articles due to article types such as case series, case reports and short communication. Two of the remaining six articles are randomised controlled studies, and four are non-randomised studies. These studies evaluated the effectiveness of frequency discrimination tasks with and without game formats in reducing tinnitus handicap. This review aims to assess the impact of integrating frequency discrimination tasks with and without game formats on tinnitus severity.

Ultimately, six articles published between 2002 and 2023, met all inclusion criteria. These studies were conducted in Spain (3), India (1), and New Zealand (1). Details of these studies are provided in Table 1.

Table 1.

Summary of studies investigating the effect of frequency discrimination task on tinnitus patients (n = 6)

	Year	Location	Study design	Participants	Duration of training	Outcome measures
1. Herraiz, C [22]	2006	Spain	Prospective descriptive study	• Two groups (treatment and control group) • 27 patients and 26 patients, respectively	• 10 min discrimination task, twice a day for 30 days	• THI • VAS
2. Herraiz, C [23]	2006	Spain	Prospective descriptive design	• 35 patients • Two groups 1. ADT – 14 patients 2. WLG- 21 patients	• 10 min of auditory discrimination task, twice a day for 30 days.	• THI • VAS
3. Herraiz, C. [24]	2010	Spain	Prospective randomised trial	• 41 patients • ADT patients were randomly assigned to 2 groups 1. SAME (same freq. as tinnitus pitch) 2. NON-SAME (freq. near to tinnitus pitch but not same) • WLG patients- control group – 26 patients	• ADT consisted of a 20-minute task (two 10-minute tracks) once per day for 30 days.	• THI • VAS
4. Hemanth, N.[20]	2021	India	Time series	• 16 participants with flat mild to moderate HL	• 45 min for 15 days	• THI • TFI
5. Wise, K., [21]	2016	New Zealand	Randomised Control Trial	• 31 Subjects • Two groups	• 30 min every day • 20 consecutive days	• TFI • THI • Attention measurements • AEP
6. Wise, K., [12]	2015	New Zealand	Pre and post-test control group design	• 8 Subjects	• 30 min every day • 20 consecutive day	• THI • Psychoacoustic measurements

THI- Tinnitus Handicap Inventory; TFI – Tinnitus Functional Index; AEP- Auditory Evoked Potentials; ADT-Auditory Discrimination Task; HL-Hearing Loss: WLG-Waiting List Group: VAS-Visual Analogue Scale

Study Characteristics

Participants

Six studies were utilised for the analysis part. Overall, 130 tinnitus participants were included in the study. The mean age range of the groups included in the study was 12 to 60 years. The tinnitus severity varied among the studies; for example, Herraiz et al. [19, 22, 24] and Hemant et al. [20] recruited participants suffering from mild to moderate tinnitus. Wise et al. [12] recruited participants with chronic tinnitus severity. Therefore, the overall tinnitus severity ranged from mild to chronic severity, and tinnitus severity was assessed based on the standardised tinnitus questionnaire THI. All the studies examined the efficacy of FDT on change in tinnitus percept reflected in THI.

Quality Assessment

The quality assessment was done separately for non-randomised (Table 2) and randomised (Table 3) studies. The Mixed Methods Appraisal Tool (MMAT) (2018) was used for the quality assessment, which included separate sets of rating criteria for non-randomised and randomised studies. The selected studies had straightforward research questions, and the results of each question were clearly explained. The randomised control trial studies were rated as good quality because the participants were randomly assigned to either a control or experimental group, each group’s treatment effect was compared with the baseline, and participants took the assigned intervention. Even the non-randomised studies were rated as good quality. It is because the sample collected was representative of the target population, the sample size was appropriate to the study’s objective, and the outcome at the baseline was compared after providing treatment. The study’s duration, the participants’ sampling, and the measurements undertaken were clearly explained in all the studies.

Table 2.

A quality appraisal of included studies using the mixed methods Appraisal tool (2018) - randomised trials

References	Is randomisation appropriately performed	Are the groups comparable at baseline	Are there complete outcome data	Are outcome assessors blinded to the intervention provided	Did the participants adhere to the assigned intervention
Herraiz et al., (2010) [24]	Yes	Yes	Yes	No	Yes
Wise, K. (2016) [21]	Yes	Yes	Yes	No	Yes

Table 3.

A quality appraisal of included studies using the mixed methods Appraisal tool (2018) – non-randomised trials

References	Is the sampling strategy relevant to address the research question	Is the sample representative of the target population	Are the measurements appropriate	Is the risk of non-response bias low	Is the statistical analysis appropriate to answer the research question
Herraiz et al. (2007) [22]	Yes	Yes	Yes	No	Yes
Herraiz et al. (2006) [19]	Yes	Yes	Yes	No	Yes
Hemanth et al. (2022) [20]	Yes	Yes	Yes	No	Yes
Wise, K., (2015) [12]	Yes	Yes	Yes	No	Yes

Study Designs

Wise et al. [21] and Herriaz et al. [24] conducted a randomised controlled trial where participants were randomly allocated to different treatment groups. Hemanth et al. [20] and Wise et al. [12] used a short-term time series design and pre-and post-test comparison research designs. Herriaz et al. [22] used a perspective non-randomised pre-post test control group design.

Comparable Groups

Studies with no control group were marked as ‘no’. Studies had a control group and provided sufficient detail to allow comparison with the intervention group, which was scored as ‘yes’. All the RCT studies had comparable control and experimental groups with tinnitus severity ranging from mild to chronic, even though the number of participants in each group varied. Whereas in non-randomised studies, Wise et al. [12] and Hemanth et al. [20] did not have a control group in their studies, the samples recruited in the study were matched regarding tinnitus severity and hearing loss. These studies compared the FDT effect before and after the intervention.

Outcome Measurement

The most commonly used questionnaires were tinnitus handicap inventory (THI), tinnitus handicap questionnaires (THQ), and tinnitus functional index (TFI) in the selected studies. The present study considered the THI score in the baseline and after providing the treatment. The perception change in tinnitus reflected in the THI was compared between baseline and after providing the treatment.

Blinding

Blinding of the participants and the experimenters to the treatment allocation is the most preferable or ‘gold standard’ design. Studies of RCT (randomised controlled trial) did not mention blinding. Therefore, it was marked as a ‘no’in the quality assessment.

Type of Sampling

Irrespective of randomised and non-randomised studies, the data collected from the purposive sample is representative of the target population and relevant to address the research question. All the participants in the selected studies had tinnitus and were included by short-listing them based on the severity of tinnitus and hearing loss.

Outcome Measures

In all the studies, standardised questionnaires were used in the outcome measurements. Six studies have used the tinnitus handicap inventory (THI). The Tinnitus functionality index (THI) was used in two studies. The Visual Analogue Scale (VAS) was used in three studies. Two studies have used attention tasks, and in one study, the auditory electrophysiological response was correlated with the behavioural response. The outcome measurements used by each study are reported in Table 1. The present study considered the severity of tinnitus reflected in THI.

Findings

Nonrandomised studies noted a significant reduction in tinnitus percept after providing treatment compared to baseline. In randomised studies, a significant reduction in tinnitus percept was found in the FDT group compared to controls. Participants deemed FDT treatment more credible.

Herraiz et al. [19, 22, 24] used the tinnitus handicap inventory as an outcome measure in all three studies to investigate the effect of FDT. Herraiz et al. [19] found a reduction in tinnitus percept reflected in the THI score in the FDT group compared to the control group. In yet another study by Herraiz [24] found a statistically significant effect on THI in the non-same group (FDT training was provided in the one-third octave below tinnitus pitch) compared to the same group (FDT training was provided in the same frequency of tinnitus pitch). The reduction in scores of THI was significant in the FDT group (same and non-same group) compared to the waiting list control group. Furthermore, a significant reduction in THI score was found in the ‘non-same group’ compared to the ‘same group’. It infers that FDT was effective among Tinnitus patients trained to discriminate the target stimulus presented in the one-third octave below the tinnitus frequency from the distractor stimuli. In the above-explained studies, the participants reacted to the stimulus presented rather than interacting with the stimulus. Wise et al. [12, 21] used interactive gameplay in FDT by incorporating decision-making, strategy development, and competition to increase intrinsic motivation. It is hypothesised that FDT in gameplay introduces rewards that enhance intrinsic motivation and yield potential benefits. Their research report revealed a significant reduction in mean THI after 20 training days compared to the baseline. Like the previous study, Hemanth et al. [20] have used FDT integrated with games to treat tinnitus in hearing-impaired individuals with flat audiogram configuration patterns. A significant reduction in THI was found after the treatment compared to the baseline. However, three subjects reported no change in tinnitus perception and score in THI by the end of the treatment regime.

Meta-Analyses

The analysis utilised the standardised mean difference as the primary outcome measure, employing a random-effects model to assess the data. Tau² was estimated to measure the true effect size variability across studies: tau² = 0 indicates low heterogeneity, while higher values indicate greater variability. Additionally, the Q-test for heterogeneity and I² statistic were used: a significant p-value (< 0.05) from the Q-test suggests heterogeneity [25], with higher I² values indicating more substantial heterogeneity [26]. Suppose tau² > 0, a prediction interval for true outcomes was provided. Studentised residuals and Cook’s distances assessed outlier studies. Furthermore, funnel plots with rank correlation and regression tests checked for publication bias: symmetrical plots suggest no bias, while asymmetrical plots indicate potential biases like publication bias.

Question 1: Does the FDT Reduce the Perception of Ringing Sounds in Tinnitus Patients?

A total of 116 participants with tinnitus were interviewed to investigate the effectiveness of FDT on change in perception of tinnitus reflected in THI using meta-analyses. The studies related to frequency discrimination training and tinnitus are comparatively low. Even though a handful of studies evaluate the efficacy of FDT for tinnitus individuals, the outcome measures used in those studies differ. We have identified only six studies with similar outcome measurement (THI), where the pre and post-treatment outcomes were assessed for the effectiveness of FDT on the severity of handicap in tinnitus individuals.

A total of k = 6 (df = 5) studies were included in the analysis (Fig. 4). The observed standardised mean differences ranged from 0.2822 to 1.2019, with most estimates being positive (100%). The estimated average standardised mean difference based on the random-effects model was 0.5104 (95% CI: 0.2478 to 0.7729). Therefore, the average outcome differed significantly from zero (z = 3.8100, p = 0.0001). According to the Q-test, there was no significant heterogeneity in the true outcomes (Q (5) = 3.6625, p = 0.5990, tau² = 0.0001, I² = 0.0001%). An examination of the studentised residuals revealed that none of the studies had a value larger than ± 2.6383. Hence, there was no indication of outliers in the context of this model. According to Cook’s distances, none of the studies could be considered overly influential. Neither the rank correlation nor the regression test indicated any funnel plot asymmetry (p = 0.2722 and p = 0.2550, respectively) (Fig. 2). It indicates that the distribution of effect sizes aligns with what would be anticipated under the assumption of no bias (See Fig. 3; Table 4).

Fig. 2.

Funnel plot showing the FDT in tinnitus patients. The standard mean difference (MD) is on the x-axis, and the standard error (SE)is on the y-axis

Fig. 3.

Funnel plot for FDT integrated without game format. The standard mean difference (MD) is on the x-axis, and the standard error (SE)is on the y-axis

Table 4.

Meta-analysis results for the FDT on tinnitus patients

Question 2: To Determine the Effectiveness of Frequency Discrimination Auditory Training without Interactive Gameplay

Three studies have used computer-based software without a game format to treat tinnitus patients using frequency discrimination training procedures. A total of 82 participants were included in these studies. A total of k = 3 studies were included in the analysis. The observed standardised mean differences ranged from 0.3228 to 0.7032, with most estimates being positive (100%). The estimated average standardised mean difference based on the random-effects model was 0.473(95% CI: 0.14 to 0.780). Therefore, the average outcome differed significantly from zero (z = 2.6595, p = 0.0078). According to the Q-test, there was no significant heterogeneity in the true outcomes (Q(2) = 0.6699, p = 0.7154, tau² = 0.0001, I² = 0.0001%). An examination of the studentised residuals revealed that none of the studies had a value larger than ± 2.3940. Hence, there was no indication of outliers in the context of this model. According to Cook’s distances, none of the studies could be considered overly influential. Neither the rank correlation nor the regression test indicated any funnel plot asymmetry (p = 1.0000 and p = 0.5117, respectively) (Table 5). It suggests that the effect size distribution is expected under the assumption of no bias.

Table 5.

Metaanaysis results for the FDT without game format

Question 3: Determine the Effectiveness of Frequency Discrimination Auditory Training with Interactive Gameplay

Three studies have used computer-based software integrated with a game format to treat tinnitus patients using a frequency discrimination training procedure (Table 6). A total of 34 participants were included in these studies. A total of k = 3 studies were included in the analysis. The estimated average difference based on the random-effects model was 0.90 (95% CI: 0.29 to 1.50) for FDT integrated with the game. Therefore, the average outcome differed significantly from zero (z = 2.34, p = 0.02). According to the Q-test, the true outcomes had no significant heterogeneity (p = 0.16, tau² = 35.65, I² = 50%). Neither the rank correlation nor the regression test indicated any funnel plot asymmetry (p = 0.3333 and p = 0.1061, respectively) (Fig. 4). It implies that the distribution of effect sizes conforms to the expected distribution under the assumption of no bias.

Table 6.

Metaanaysis results for the FDT integrated with game format

Fig. 4.

Funnel plot for FDT integrated with the game format. The standard mean difference (MD) is on the x-axis, and the standard error (SE)is on the y-axis

Discussion

The first objective of this study was to evaluate the efficacy of frequency discrimination training on tinnitus severity. Overall, 6 of the six studies reported a statistically significant change in the reduction of tinnitus severity. The standardised mean difference (SMD) of 0.51 suggests a significant reduction in tinnitus severity following frequency discrimination training compared to before training, the difference falling within medium size. The variability observed among the effect sizes of the studies included in the meta-analysis is not statistically significant, as reflected in the Q test. The I² of 0% indicates that variability in the effect sizes is attributed to sampling error. Furthermore, a tau-squared value of 0.0001 indicates that the variability observed among the effect sizes of the individual studies is extremely small.

The second objective was to investigate whether FDT integrated with the game is effective in reducing tinnitus severity compared to those without integrated with the game. The observed variability among the effect sizes of both studies (integrated with and without) is not statistically significant in the Q test. The I² in the studies of FDT without integration with the game yielded 0%, indicating that variability in the effect sizes is attributed to sampling error. However, the I² of 50% in studies of FDT integrated with game indicates moderate heterogeneity, a substantial proportion of the variability in effect sizes is due to true differences between studies rather than chance alone. The standardised mean difference (SMD) is 0.47 for Frequency Discrimination Training (FDT) without integration with a game and 0.90 for FDT integrated with a game, indicating a notable decrease in tinnitus severity following frequency discrimination training compared to before training. The difference represents a medium effect size for FDT without game integration and a large effect size for FDT with game integration.

In the abovementioned studies, except for Wise et al. [12, 21], none have considered the pretraining measurement. Although the subjective response reflected in standardised outcome measures overlays, the psychological response often diminishes over time. Meanwhile, according to Wise et al. [21], the THI score was 37.5 in the initial and pretraining assessments, reflecting a stable baseline, and after training, the mean THI score was reduced to 30. A stable pretraining measure and a notabletable change in tinnitus severity post-treatment reflect the benefit of FDT integrated with the game. It is equally important to investigate whether the shifts in severity from one category to a lesser category in the outcome measures between the pretest and post-test is a clinically significant change in the least 20 points in mean THI between the former assessment and current assessment is required for the difference to be considered clinically significant [12]. None of the studies of FDT integrated with and without games would facilitate a significant clinical benefit. In addition, the maintenance effect beyond the training period is absent in all the studies. Although studies required time and resources to assess the maintenance effect, the benefit received after training is maintained or reduced is questionable and requires follow-up assessment.

In all these studies, the evidence of treatment effectiveness was documented by the subjective standardised THI questionnaire having good test-retest reliability [27]. To prove the treatment’s effectiveness, the evidence should be substantiated by high-quality, robust, objective measurements, which these studies lack. Based on reviewing these studies, we recommend combining the EEG-based connectivity model and self-reported outcome measures to help us understand the neurophysiological basis of intervention and its findings correlating with subjective outcome measures.

Conclusion

The frequency discrimination training integrated with a game format encourages participants to engage with the software and stay motivated. Published studies on FDT integrated with games have shown a significant effect size.

Funding

The authors acknowledge the Department of Science and Technology, Government of India, for financial support, vide Reference No. DST/SATYAM/2020/413 (G) under Science and Technology for Yoga and Meditation (SATYAM) to carry out this work as a part of the project.

Declarations

Ethical Approval

The institutional ethical committee approved the study (JSSMC/IEC /011222 /30 NCT /2022-23).

Conflict of Interest

Authors have no conflicts of interest that are directly relevant to the content of this review.