Hi all,
If you'll extend me a short tether, I'd like to use an analogy to help explore ideas regarding tinnitus/hyperacusis rehabilitation.
The analogy:
I have a bad back. Really bad; always have. Over my 44 years I've herniated 5 discs (three lumbar, two cervical; first time at age 23), and my last MRI showed an almost complete deterioration of my L4 and L5 discs. Moreover, the MRI showed evidence of a birth defect in my L4 vertebrae that has allowed a 25% shift of that vertebrae out of normal spinal alignment - as a result, my nerve pathways are narrowed there, and thus these nerves tend to get more easily knocked around and grazed and pinched. It's pretty bad.
My last herniation occurred three years ago, getting out of my Lexus SUV. Just twisted funny or something, and pop, the disc exploded. As a result, I was left unable to bend, to fully extend my right leg while walking, or to sit, for 4 months. I bought a standing desk, and literally stood for 4 months straight, even in work meetings.
But I also did physiotherapy, and have continued with my physiotherapy to this day. Originally it was three times/week for the first four months, then down to twice a week, and now because I've progressed so far I go once a week for maintenance, which is a schedule I will keep for life.
The intensity of these physio treatments has changed over time as well, of course. First they had me laying on my back and lifting one leg off the ground four inches for three seconds, and then putting it back down. That was it: lift one leg four inches. And fuck it was tough! A couple weeks later they had me lifting it eight inches. Then twelve. And so on. Baby steps. Crazy little baby steps.
Eventually I began new exercises, adding weight and starting "normal" (back-safe) workouts. But here the baby steps continued. Five pounds of weight for two weeks. Then six. Then eight. Then ten. And so on, and so on. And it's worked, of course. At this point, despite my biologically inferior back, and my multiple injuries, I now walk, run, jump, swim, play baseball, play golf, etc., etc., etc.
It hasn't been perfectly smooth sailing, of course. At the beginning I'd re-injure myself all the time. Like, every third day I'd move this way or that, and the nerves would get twinged or something. And every time this happened, the nerves would stay on fire for between 18-hours and 3-days (sound familiar, all you tinnitus spike sufferers?). But eventually the tweaks started happening less often, and then less often still. Moreover, when they did happen, they became less serious - they were almost always the 18-hour variety instead of the 3-day variety. I was building up capacity and resiliency.
Other times I'd overdo it. I remember one time my physiotherapist got just a bit too optimistic, and had me try a few new moves in the same week, and I ended up really tender and nervy for about a week. Other times I'll increase the weights just a bit too much, too quickly, and will end up tweaking myself for another week. But mostly I'm good these days: as long as I stay the course, keep up the exercise, and always only increase the weights ever so slightly from last time, then I'm mostly good to go.
This is where the analogy can end, because it's set up the ability to make two related points:
1. There is no reason that I can think of to expect that an injury to the ears should require a rehabilitative perspective that is any different than the one used for an injury to any other part of the body. Sure, the types of exercises need to be very different, but the overall premise of slowly, gradually strengthening aural capacity should nonetheless hold.
2. There are essentially ZERO programs out there that do this for people with aural injuries. Audiologists are not trained in this manner, physiotherapists don't treat ears - the whole field of hearing science is lacking a formal rehabilitative model that adheres to the general principles of aural injuries.
I mean, the scientific research into tinnitus/hyperacusis is so fucking behind, there are new 2019 papers in top journals (e.g. PLoS Biology) that are reporting for the first time that an inflammatory process may be responsible for some of the symptoms we experience. Are you kidding me? It took until 2019 to recognize that an injury to the ears would lead to inflammation, and that that inflammation may play a role in the injury process?? This is literally 40 years behind the sports medicine field, which has been treating inflammation as the number one factor in injury/rehabilitation for decades. And probably 60 years behind the arthritis field. It's crazy.
But anyway, back to the analogy:
What my physiotherapist does with me is simple, and scientifically-based: every week he has me undertaking exercises that are right at the tip of my capacity, without ever going over that capacity. By being at the tip of my capacity, he allows me to continue challenging my body, hardening it further, making it more and more resilient to future injury. But he knows never to go over that tip, because that's when injuries happen. It's a delicate balance, and one that you sometimes miss slightly. But it's where rehabilitation needs to be, because too far below the tip of capacity, and you lose all rehabilitative growth.
So how would this translate to tinnitus/hyperacusis?
Well, it seems to me we have injured ears. Like my back, when the injury is in an acute stage, rehabilitation needs to be extremely gentle, and re-injury (spike!) is likely to occur, easily and often. But also like my back, you want to keep the injury limber - don't let it get too stiff, or to atrophy too much. So even if you can only move your leg 4 inches for 3 seconds (or listen to noises of 50dB for 1 hour), then make sure you do that. Use pain (or tinnitus increases) as your guide, and don't go past your capacity...but do go to the top of it. Do hit the tip of your capacity.
And then, slowly and gradually, begin stretching the system out. If you started at 60dB for 1 hour, raise the dBs to 62 and/or increase the duration to 2 hours. Do that for a week and then raise it to 64. If that feels comfortable, raise it to 67. And so on, and so on, and so on.
Will you make a mistake? Will you have a setback? Almost certainly. But as long as your capacity building is gradual, and you don't get too ambitious too quickly, any setbacks should be manageable. Just back off for a week, let your system settle back down, and then resume building that capacity.
Also: there is this huge debate about whether to use ear protection or not. Should you? Shouldn't you? Well, an inflammation model provides the answer to this too: at the beginning, while the injury is acute, absolutely use protection for anything that feels uncomfortable. Do this for a month, or two months, or maybe 4 months like with my back... truthfully, we don't know the actual timeframe that an aural injury remains acute. So use pain/discomfort (not anxiety!) as your guide. But eventually, begin weaning yourself off the protection. This should coincide with the gradual increase in noise exposure. For instance: once you get to exposing yourself to 70dBs, it would make sense to lose the ear protection in all scenarios where sound is below this. And then lose the protection for 73dBs, and then 76, and then 80, and so on, and so on. (Yes, I'm advocating for increasing beyond 80... keep hardening the system, keep increasing capacity and resiliency, so long as tinnitus/hyperacusis remains calm (obviously at some point you'd need to stop - maybe at 90dBs for 10 seconds, or something like that - but you want your system hardened sufficiently so that it can be resilient to all the random noise that life can give it - bus exhaust, and motorcycle engines, and ambulance sirens and alarm clocks, and grocery store check outs).
Am I a doctor? No. (Well, actually I am, but not a medical one). Is this official medical advice? No. Has it worked for me? Not yet - I'm very early in this rehabilitative journey. But everything I've written is backed by decades of injury rehabilitation research. Moreover, I'm not advocating for anything that should be remotely dangerous, because it's your own tinnitus/hyperacusis pain/capacity (not anxiety!!) that continually defines your rehabilitative progress. So rather than waiting for the tinnitus/hyperacusis field to catch up (could be decades), consider the logic of what I'm saying, and see if you can't build up your own capacity too.
Hope some of you find this helpful.
-Matt
If you'll extend me a short tether, I'd like to use an analogy to help explore ideas regarding tinnitus/hyperacusis rehabilitation.
The analogy:
I have a bad back. Really bad; always have. Over my 44 years I've herniated 5 discs (three lumbar, two cervical; first time at age 23), and my last MRI showed an almost complete deterioration of my L4 and L5 discs. Moreover, the MRI showed evidence of a birth defect in my L4 vertebrae that has allowed a 25% shift of that vertebrae out of normal spinal alignment - as a result, my nerve pathways are narrowed there, and thus these nerves tend to get more easily knocked around and grazed and pinched. It's pretty bad.
My last herniation occurred three years ago, getting out of my Lexus SUV. Just twisted funny or something, and pop, the disc exploded. As a result, I was left unable to bend, to fully extend my right leg while walking, or to sit, for 4 months. I bought a standing desk, and literally stood for 4 months straight, even in work meetings.
But I also did physiotherapy, and have continued with my physiotherapy to this day. Originally it was three times/week for the first four months, then down to twice a week, and now because I've progressed so far I go once a week for maintenance, which is a schedule I will keep for life.
The intensity of these physio treatments has changed over time as well, of course. First they had me laying on my back and lifting one leg off the ground four inches for three seconds, and then putting it back down. That was it: lift one leg four inches. And fuck it was tough! A couple weeks later they had me lifting it eight inches. Then twelve. And so on. Baby steps. Crazy little baby steps.
Eventually I began new exercises, adding weight and starting "normal" (back-safe) workouts. But here the baby steps continued. Five pounds of weight for two weeks. Then six. Then eight. Then ten. And so on, and so on. And it's worked, of course. At this point, despite my biologically inferior back, and my multiple injuries, I now walk, run, jump, swim, play baseball, play golf, etc., etc., etc.
It hasn't been perfectly smooth sailing, of course. At the beginning I'd re-injure myself all the time. Like, every third day I'd move this way or that, and the nerves would get twinged or something. And every time this happened, the nerves would stay on fire for between 18-hours and 3-days (sound familiar, all you tinnitus spike sufferers?). But eventually the tweaks started happening less often, and then less often still. Moreover, when they did happen, they became less serious - they were almost always the 18-hour variety instead of the 3-day variety. I was building up capacity and resiliency.
Other times I'd overdo it. I remember one time my physiotherapist got just a bit too optimistic, and had me try a few new moves in the same week, and I ended up really tender and nervy for about a week. Other times I'll increase the weights just a bit too much, too quickly, and will end up tweaking myself for another week. But mostly I'm good these days: as long as I stay the course, keep up the exercise, and always only increase the weights ever so slightly from last time, then I'm mostly good to go.
This is where the analogy can end, because it's set up the ability to make two related points:
1. There is no reason that I can think of to expect that an injury to the ears should require a rehabilitative perspective that is any different than the one used for an injury to any other part of the body. Sure, the types of exercises need to be very different, but the overall premise of slowly, gradually strengthening aural capacity should nonetheless hold.
2. There are essentially ZERO programs out there that do this for people with aural injuries. Audiologists are not trained in this manner, physiotherapists don't treat ears - the whole field of hearing science is lacking a formal rehabilitative model that adheres to the general principles of aural injuries.
I mean, the scientific research into tinnitus/hyperacusis is so fucking behind, there are new 2019 papers in top journals (e.g. PLoS Biology) that are reporting for the first time that an inflammatory process may be responsible for some of the symptoms we experience. Are you kidding me? It took until 2019 to recognize that an injury to the ears would lead to inflammation, and that that inflammation may play a role in the injury process?? This is literally 40 years behind the sports medicine field, which has been treating inflammation as the number one factor in injury/rehabilitation for decades. And probably 60 years behind the arthritis field. It's crazy.
But anyway, back to the analogy:
What my physiotherapist does with me is simple, and scientifically-based: every week he has me undertaking exercises that are right at the tip of my capacity, without ever going over that capacity. By being at the tip of my capacity, he allows me to continue challenging my body, hardening it further, making it more and more resilient to future injury. But he knows never to go over that tip, because that's when injuries happen. It's a delicate balance, and one that you sometimes miss slightly. But it's where rehabilitation needs to be, because too far below the tip of capacity, and you lose all rehabilitative growth.
So how would this translate to tinnitus/hyperacusis?
Well, it seems to me we have injured ears. Like my back, when the injury is in an acute stage, rehabilitation needs to be extremely gentle, and re-injury (spike!) is likely to occur, easily and often. But also like my back, you want to keep the injury limber - don't let it get too stiff, or to atrophy too much. So even if you can only move your leg 4 inches for 3 seconds (or listen to noises of 50dB for 1 hour), then make sure you do that. Use pain (or tinnitus increases) as your guide, and don't go past your capacity...but do go to the top of it. Do hit the tip of your capacity.
And then, slowly and gradually, begin stretching the system out. If you started at 60dB for 1 hour, raise the dBs to 62 and/or increase the duration to 2 hours. Do that for a week and then raise it to 64. If that feels comfortable, raise it to 67. And so on, and so on, and so on.
Will you make a mistake? Will you have a setback? Almost certainly. But as long as your capacity building is gradual, and you don't get too ambitious too quickly, any setbacks should be manageable. Just back off for a week, let your system settle back down, and then resume building that capacity.
Also: there is this huge debate about whether to use ear protection or not. Should you? Shouldn't you? Well, an inflammation model provides the answer to this too: at the beginning, while the injury is acute, absolutely use protection for anything that feels uncomfortable. Do this for a month, or two months, or maybe 4 months like with my back... truthfully, we don't know the actual timeframe that an aural injury remains acute. So use pain/discomfort (not anxiety!) as your guide. But eventually, begin weaning yourself off the protection. This should coincide with the gradual increase in noise exposure. For instance: once you get to exposing yourself to 70dBs, it would make sense to lose the ear protection in all scenarios where sound is below this. And then lose the protection for 73dBs, and then 76, and then 80, and so on, and so on. (Yes, I'm advocating for increasing beyond 80... keep hardening the system, keep increasing capacity and resiliency, so long as tinnitus/hyperacusis remains calm (obviously at some point you'd need to stop - maybe at 90dBs for 10 seconds, or something like that - but you want your system hardened sufficiently so that it can be resilient to all the random noise that life can give it - bus exhaust, and motorcycle engines, and ambulance sirens and alarm clocks, and grocery store check outs).
Am I a doctor? No. (Well, actually I am, but not a medical one). Is this official medical advice? No. Has it worked for me? Not yet - I'm very early in this rehabilitative journey. But everything I've written is backed by decades of injury rehabilitation research. Moreover, I'm not advocating for anything that should be remotely dangerous, because it's your own tinnitus/hyperacusis pain/capacity (not anxiety!!) that continually defines your rehabilitative progress. So rather than waiting for the tinnitus/hyperacusis field to catch up (could be decades), consider the logic of what I'm saying, and see if you can't build up your own capacity too.
Hope some of you find this helpful.
-Matt
Member
