Tinnitus/Hyperacusis: A Rehabilitative Model

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

 

Are you still applying this approach? If so how is it working out for you?

 

Actually, you are merely parroting my mantra on here. You just used more verbosity to make the same points I have made repeatedly.
It should be a slow ascent from the abyss of injury. Too much sound is bad early or ever. Too much protection and you end up living in your parent's basement because you can't tolerate noise.

How quickly should one emerge with more sound exposure? Play it by ear.

 

Mostly, yes I am.

I say ‘mostly’, because I haven’t been quite as systematic about it as I could be – perhaps having you comment on this, bring me back to the framework again, will motivate me to be even more systematic.

But yes – mostly I have been using this as my rehabilitative framework.

I started out being really careful about noise exposure – I was using plugs a lot, I was avoiding every bit of noise I could, I was even sometimes wearing plugs when I was by myself. My thought was that, like any acute injury, rest and relaxation is an absolutely necessary first step, while inflammation is high. And so even when noise exposure was low, I would sometimes plug up, just to reduce ear fatigue, keep them from being overworked.

I also plugged up more early on, because early on more things were bugging me. Just like my back, in the initial stages of tinnitus/hyperacusis, everything was serving as a trigger. A plate on the counter, a grocery checkout beep, a car horn…anything seemed able to set me off. Since I was using pain/discomfort as my guide, whenever one of these sounds hurt, I’d protect (I’ll stress as I did before: use pain/discomfort as your guide, not anxiety).

My tolerance for sound has been increasing greatly over the last few months. Plates clinking can still bother me, but the grocery checkout is no problem, and most real-world sounds are okay. In line with that, I’ve been reducing how much I use my plugs, letting my ears hear more. I still wear plugs for louder events, or events of longer duration, but my tolerance for noise is increasing. Right now I’m at the point where I’m plugging up for anything greater than 75 dB for over 1 hour. If it’s under 75 dB or less than an hour duration, I’m letting my ears hear it. Louder or longer, and I’m plugging up. And then I’m still sometimes plugging up just for rest/relaxation: if, for instance, I’ve had an energetic day at work, been talking all day, listening to others, etc., etc., then I might come home and throw the plugs in for the evening, just to give them a break. There’s no exact science to this obviously – it’s pretty subjective. But this approach is sort of akin to how the official workplace guidelines say you can listen to 90 dB noises safely for 2 hours, 80 dB for 4 hours, 70 dB for 8 hours, and so on and so on. But for us this is all personal, and I’m trying to use my own ears as a guide – if they feel tired/overworked, I plug em up for a bit. If they feel okay, I let them go (again, use pain/discomfort as your guide, not anxiety).

I also revert back to a more careful stance after known noise exposure. I’m not talking about a single car horn or anything like that – my ears are mostly hardened to that kind of thing at this point, and I don’t expect major spikes from things like that. But, like, for instance, I attended a party last weekend (with plugs) where the music/conversation was around 90 dB for a good 3 hours. I’ve been experiencing a bit of a spike from this most of the week, and so have reverted back to an earlier level of care this week – offering my ears more relaxation, letting them catch back up, allowing any new inflammation that may have resulted from this to dissipate. Is this necessary? Nobody knows. But it’s been working, I think. Today is the first day where I’m feeling like my ears are back to normal, rested and relaxed. And so as of today I’m going to move back into “increase resiliency” mode, rather than “protect and repair” mode.

Would my ears be recovering even without this framework? Maybe? Maybe not? Who knows. But as I suggested in my initial post, there’s decades of rehabilitative science underlying the ideas, and so it seems more likely to help than to hurt. If you decide to try it, consider updating this thread for progress – others would likely be interested.

 

Nice to see you John. So happy to know that you agree. Good bye.

 

The way you describe your Hyperacusis/reactive Tinnitus is almost exactly how I would describe my own. So this gives me some hope that you are experiencing progress. Funny you mentioned “plates of the counter”. If there is one type of noise that I cannot stand now, it is one dish merely touching another dish! Feels like the inside of my brain is getting shocked! Apparently that frequency of noise is gasoline for Hyperacusis. If I or my wife are doing dishes, I have to plug up or run. Anyway, the battle continues, and I will give this thread high consideration. J

 

I get what you are saying on a theoretical level, but with the risk of heightened or worsening T, making the initial leap of faith is currently beyond me.

The short term pain of spiking etc too disabling and discomforting to risk.

I am intrigued as to how you get on and will hopefully be inspired! Keep posting your progress, but don’t do anything reckless!

 

That does not work for people with severe hyperacusis because once you get out of home there will be peaks of sound that will exceed by far your tolerance. There will be the odd 100 dbs sounds and all the progress Will be erased in seconds, and back to square one. I know because I have already tried.

 

what happened @Juan? Did you get a permanent worsening?

 

This is tough, I know. Certainly you can't control for all sounds, and often the unexpected ones are the worst. My hyperacusis is no longer bad, and was never *severe*, so I can only imagine how frustrating it must be.

My recommendation, for severe hyperacusis, would mostly be the same though, possibly with a few extra precautions to protect outside the house. In fact, I would recommend that you protect at all times outside the house, and to only work on increasing your aural capacity *in the house* under well-controlled conditions. For instance, for 30 minutes/day purposely turn on music 2 dB louder than you normally would, and relax and listen. And then plug back up when you leave the house. Continue this... increasing both duration and volume of the music, while still protecting outside. Get yourself to the point where you can listen to music at 75 dB for at least 30 minutes, in the protected confines of your own home. This will take time, of course - if hyperacusis does anything, it tries our patience. But once you're there, and you're hardened to 75 dB noises, start weakening the level of your outside protection. If you have been using 20NRR plugs, now go to 18s and do that for two weeks. Then go to 16s and do that for 2 weeks. Or 4 weeks... use your own body as a guide. Keep listening to sounds in the house - get yourself up to 80 dB for 30 minutes, then drop outside protection to 14NRR... and so on, and so on.

It'll be painstaking and I don:t mean to make it sound easy. But there is a process... you just have to be patient, go slow, expect setbacks, and stay the course.

 

Hi @MattS -- I generally agree with your approach. I'd just point out--speaking from experiences--that the path to greater resiliency is not linear. That is, hyperacusis can improve for a while, but then can regress for a while. So exposure to various noise levels has to constantly be monitored, and will likely go up and down. The trend is what you're looking for.

 

Yes, I lost hearing permanently due to exposure to loud sounds, and now it is harder for me to understand TV (I am using subtitles more and more) and to understand speech in noise, and certain voice pitches. Once hearing loss starts it is harder to cope with hyperacusis, as your ears naturally try to hear the sounds that you no longer hear due to hearing loss. This makes sounds amplified. It is a catch 22 situation.

So maybe you built up some tolerance and as soon as you start getting hearing loss on a certain frequency, your tolerance to sound will decrease on that frequency too.

 

After the "two years in terror" without using hearing protection at all, I started doing what you suggest. It didn't fully work, as my hyperacusis was too severe, and sound would hurt me through earplugs and earmuffs.

The "crisis" was over by that time, and everyone started repairing and building stuff like crazy, there was construction everywhere and it was hard to navigate around all that without being exposed to the odd very loud noise, and that was enough to kill me ears for a good 3 weeks or more.. and it also made me get hearing loss after a few years.

 

Yikes, yours sounds like a unique situation to be sure. I wish you a peaceful and quiet next chapter in your life.

 

Thanks Lane, this is very good advice. I kind of realized that I had made everything sound very linear, and knew I should try try to find a way to include how to handle ups and downs, explain that it might not always be quite so downhill. You said it perfectly, so thanks for that.

 

My hyperacusis just was very severe.. and I tried to live a more or less normal life, so was exposed to normal (which sometimes means loud) noise.

 

John, I also plug up every time we're doing dishes, or emptying the dishwasher. Every time. My wife even warns me now that she's about to.

Indeed, I think this is my goal: to be able to listen to plates clinking again!

 

Understandable Elfin - there is definitely a delicate balance re too much / too little exposure. And many others on here take a more protective approach as well (e.g. @Bill Bauer ). I think to some extent it will come down to individual personalities and outlooks on life, risk aversion, etc. But I'll periodically post on my progress, so that we can start building up some evidence re the approach.

 

@MattS

There is definitely something to be said for your approach and found myself often wondering the same thing. When my hyperacusis is worse and my mood down my tinnitus is or seems worse. When my tolerance is better it bothers me less. In some of us, there must be a psychological component to hyperacusis, at least partially...
In wish you the best. You're essentially taking one for the team, but don't overcook it and stay safe!

 

Thanks Bartoli.

I *think* I'm being responsible about things, even if it sounds like I'm stretching myself out a bit. Indeed, the part of the approach that I didn't stress, but which really is a big part of it, is that I'm really working hard to ensure that I don't go over capacity. And that means making sure that I don't get caught with my pants (plugs) down, so to speak.

And so, kind of like I suggested with Juan about stretching things out inside your home, but being really careful outside, that's mostly what I'm doing right now. I know I can handle 75db noises for short durations, but any time I even think I *might* hear something louder than that, I'm plugging up. And I won't stop that until I've demonstrated to myself that I can handle 80dbs in my house (at which point I expect I'll be able to
handle short-duration traffic situations). Hopefully that will protect me from experiencing "accidents" that set me back (of course there's this party I have to attend in 2 weeks...but that's a whole nother ball of wax).

Protection against accidental noise exposure during the gradual rehabilitation is actually a really important part of the whole "approach", so I sort of wish I had expressed it better in the original post. But, it's expressed now at least, for those who read this far.

Anyway, I really will keep everyone posted on how I'm doing. And as you know @Bartoli , I'm keeping close data on my tinnitus levels...so I should be able to track whether I'm improving, regressing or staying stable.

 

Yep, my wife too. We live in the same world. Here's to that world becoming ever more livable.