Today I will be waxing philosophical…

An article in today’s Globe and Mail – one of Canada’s long-standing national newspapers – is about about Lars Ulrich, the drummer with Metallica and includes the quote: “I would get up from my bed in a hotel room to go turn the television off.  But the television wasn’t on. The sound was in my head.”

For those readers who have been living under a rock for the last umpteen years, Metallica is arguably the best rock band ever and they have tons (or in the metric system, tonnes) of social responsibility.  I believe that the proceeds of this latest concert go to support the local food banks.

Metallica in Toronto

I am sure that every single clinical audiologist has been dismissive about complaints of tinnitus over their careers – after all, this is a weekly  or even daily occurrence and the world doesn’t seem to end.  And I must admit to being rather insensitive to this as well, at least when I first began as an audiologist in the early 1980s.

Part of my initial insensitivity, is that I had only experienced tinnitus “academically”, and even then, research was equivocal about the etiology and the long term prognosis.  It was a topic that we learned about in school, regurgitated a couple of lines about on the ensuing term-test, but it wasn’t something that was relevant. 

It would be easy to blame the educational system about my indifference about tinnitus, but then again, back in the late 1970s we just didn’t know as much as we should have about tinnitus.

And despite my years of being a clinical audiologist, and almost 40 years of research and education by groups such as the American Tinnitus Association , we don’t know that much more now.  But let expand on that last sentence;  I think that this is really a twofold statement, and also quite erroneous. One element relates to the amount of knowledge that is in the literature, and the other relates to the uptake of this knowledge by the front line clinician.

The year 1990 marks the turning point in our knowledge of tinnitus. This is when the publications of Pawel J. Jastreboff, Jonathan Hazel, and their colleagues came out with a neurophysiological explanation of tinnitus and an associated therapy – not a cure, but certainly something concrete that audiologists could use.  This particular approach is called Tinnitus Retraining Therapy (or TRT) and this, along with several other well-researched clinical approaches, have provided tools that could be used by front line clinicians when confronted with clients who complained of tinnitus.

Since that time, I must admit to being more sensitive to the needs of clients – especially musicians – that complain of tinnitus.  But I had practiced a full decade without that attitude.

One can argue that this is a characteristic of any clinical field- “if I didn’t learn about it in school, it doesn’t exist”.  I have heard this from my audiology and medical colleagues on numerous occasions.  What is “not mainstream must not be relevant”, or until something happens such as a well-respected researcher writing academic papers or books appear that summarize quite complex research. 

Regretting some of life’s choices!

I recently read a book called “The Polyvagal Theory” that describes in an easily digestible format the mind/body connection.  This was just a “hippie” idea back in the 1960s but now is central to all of medicine, especially in the domain of performing arts medicine.  The book is full of biochemistry and biological processes but it provides the beginnings of a framework for how our attitudes and emotional states may translate to real measurable physical changes and pathologies.

I think that the assessment and care of people experiencing tinnitus is like this as well.  We don’t need to fully understand each and every step about the physiology or psychoacoustics before we can begin to develop and provide therapies. Of course these therapies will be altered as our models of pathologies such as tinnitus improves, but we shouldn’t stay on the side lines waiting for the final score before we offer some modicum of clinical assistance.

When a musician comes to my office complaining about tinnitus, I can be sure that this will be a much longer appointment than otherwise scheduled; often requiring more than one session.  And this is certainly a change from the 1980s where I admit to being more dismissive. 

Knowledge affects clinical treatment, and clinical treatment facilitates knowledge.