Interview with Bernhard Kellerhals MD, Physician and Author
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Topic: Tinnitus Rehabilitation by Retraining
Topic: Tinnitus Rehabilitation by Retraining
AO/Beck: Dr Kellerhals, thanks for spending a little time with me. I know you have co-authored a book titled Tinnitus Rehabilitation by Retraining. I think the book adds to the tools we use to treat tinnitus. Can you please tell me about the two groups of patients you have worked with?
Kellerhals: Working as an ENT-specialist and Head-and-Neck surgeon at the university hospitals of Basel and Bern, I realized there were two patient groups who were, and are, severely neglected: patients with chronic pain syndromes and tinnitus patients. The neglect was, and is, due to the uninspiring fact that both conditions
cannot be cured by the type of traditional medicine we have learned. However, both groups desperately need help.
I first started an interdisciplinary pain clinic and later I changed to tinnitus rehabilitation, which is the only topic I am dealing with since my retirement. When I started treating tinnitus patients as an ENT specialist, I was essentially helpless for most of the patients. Nonetheless, the longer I cared for tinnitus patients the more I learned, and I realized although we cannot cure tinnitus, there is much that can be done for these patients. My own ideas were confirmed and complemented by the neurophysiological tinnitus theory of Jastreboff and his Tinnitus Retraining Therapy (TRT) which I learned in the UK.
AO/Beck: I understand you did some experimental work with rats to help explain and refine your tinnitus theory?
Kellerhals: Yes. My wife and I did some exciting rat experiments with tinnitus. Essentially, we found that growing rats would start to lose body weight when they experienced tinnitus. However, after they recovered from tinnitus, using habituation, their body mass increased again. In continental Europe, we were among the first promoters of a tinnitus rehabilitation program, based on the original TRT. I think that over the years, slowly, the majority of ENT specialists in Europe have changed to tinnitus rehabilitation programs, instead of ineffectively searching for pharmacological treatment modalities.
AO/Beck: And Dr. Kellerhals, I believe you are a Meniere's patient yourself?
Kellerhals: Yes, Dr. Beck, that is correct. My own medical history includes severe Ménière's Disease over a period of 15 years, followed by unilateral deafness and tinnitus. However, I believe my personal history did not influence my decision to take care of tinnitus sufferers. Nonetheless, it has probably increased my credibility!
AO/Beck: What inspired you to write the book, and who did you write it for?
Kellerhals: We wrote our book primarily for our patients. However, we intended to promote tinnitus rehabilitation among my fellow ENT doctors and other health care professionals who work with tinnitus patients. The book was written originally in German and is in its' fifth edition. The English and Italian translations followed soon after that. As you know, the foundation of tinnitus rehabilitation is proper instruction about tinnitus. If tinnitus remains a strange and terrifying burden, it cannot be overcome. When well instructed, a tinnitus sufferer loses a lot of nightmares and they are able to recover. Of course, a realistic approach and realistic expectations are necessary. I believe oral instruction must be complemented by a written text, and so the book helps the patients to understand the situation and to effectively manage it.
AO/Beck: Very good. Would you please tell me about tinnitus theory ?
Kellerhals: Jastreboff's neurophysiological model says that tinnitus is a central problem, although it is caused by damage to the inner ear. In fact, tinnitus does correspond to unnecessary neural activity in the central hearing system. This leads to my computer model of tinnitus: Tinnitus is a software problem and the central hardware is intact. Because of the high incidence of inner ear damages, tinnitus is widespread in the general population, probably up to 30% of all people have tinnitus to some degree. Tinnitus can be associated with hearing loss, hearing loss due to aging (presbycusis), noise exposure, head trauma, ear disease, ototoxic drugs and many other causes. No one is immune from tinnitus.
AO/Beck: Please explain the fundamentals of your Tinnitus Rehabilitation by Retraining program?
Kellerhals: Tinnitis rehabilitation is based on four fundamental facts, they are...
Kellerhals: TRT concentrates on counseling and the avoidance of silence. Rehabilitation adds analysis and improvements in somatic, psychological and social levels. These are explored according to individual needs, using psychotherapy, relaxation techniques, body work or other complementary therapies. Very often, scrutinizing the personal life situation of the tinnitus sufferer leads to crucial insights about the necessary changes in life style, choices and personal relations. Willingness to change is an indispensable prerequisite for any rehabilitation success, not just tinnitus.
AO/Beck: How do you handle silence avoidance and what is your experience with noise generators used to mask tinnitus?
Kellerhals: In 34% of our patients, noise generators were fitted. However, our experience showed that other means for silence avoidance, such as live water fountains, perhaps a room fan, and the like, are equally effective. It seems best to leave the choice to the patient. The bedroom companion, too, has to be taken into account! Our statistics show, that silence avoidance during the whole night is of enormous importance. During the daytime, no one, except perhaps monks in a monastery, has silence. Our data show that nightly silence avoidance leads to significantly better results than silence avoidance restricted to daytime and/or in the late evening or during nightly periods of insomnia.
AO/Beck: How do you measure success and what are the success rates with your program?
Kellerhals: In tinnitus rehabilitation, success cannot be measured easily. Tinnitus loudness does not reflect the patient's progress, because loudness measured in dB remains stable in each patient. Therefore most authors use questionnaires. Questionnaires rarely measure the individual problems in an appropriate manner. Complicated questionnaires measuring overall quality of life do exist, but none is adapted to tinnitus problems. Tinnitus itself often remains the same with subjective variations of its intrusiveness. But when the sufferer starts to discuss their real problems instead of merely repeating the complaints about tinnitus, they clearly start an improving process. Such subtle changes sometimes indicate the first steps of improvement. Improvement must not be measured in terms of tinnitus abolition (which rarely occurs) but in terms of life quality. As you can imagine, our patients are extraordinarily severe cases: Because of tinnitus and/or other incapacitating health problems, 25% of our patients are totally or partially unable to work. Our own statistical evaluations repeatedly revealed an improvement rate of about 70%, which equals the success rates of other rehabilitation centers. But what about the 30% unsuccessful rehabilitation attempts? They must not be left alone, they have to be followed with repeated consultations at regular intervals.
AO/Beck: What about tinnitus and hearing loss together? What is your preferred way to address that?
Kellerhals: If possible, hearing aids have to be fitted. Sometimes the fitting of hearing aids changes their lives in such a tremendous way, that it solves the tinnitus problem as a single measure. If not, silence avoidance is added. Many patients wear hearing aids during daytime and a noise generator at night.
AO/Beck: Is tinnitus a psychosomatic disorder?
Kellerhals: The answer is yes and no. Modern psychosomatic theories stress the point that our linear thinking (A causes B, and B causes C) does not conform with reality and has to be replaced by network models where everything influences everything. Any condition or
handicap, such as tinnitus, influences and is influenced by innumerable processes on the somatic, psychological and social levels. But tinnitus is not a psychosomatic disorder in the traditional meaning of the term, where psychosomatic disorders are separated from somatic disorders. Tinnitus is real, it is not a mere fantasy!
AO/Beck: For readers who might want to learn more about tinnitus, or purchase your book, how can they find the book?
Kellerhals: The book can be ordered through any book seller with the following
Information; Kellerhals B and Zogg R, Tinnitus Rehabilitation by Retraining, Karger Basel/Freiburg/NewYork/Sydney, ISBN 3-8055-6930-0.
AO/Beck: Thank you for your time and knowledge this morning Dr. Kellerhals. It has been a pleasure working with you and I wish you and your patients continued success with your program.
Kellerhals: Thank you too Dr. Beck. It has been my pleasure.
AO/Beck: Dr Kellerhals, thanks for spending a little time with me. I know you have co-authored a book titled Tinnitus Rehabilitation by Retraining. I think the book adds to the tools we use to treat tinnitus. Can you please tell me about the two groups of patients you have worked with?
Kellerhals: Working as an ENT-specialist and Head-and-Neck surgeon at the university hospitals of Basel and Bern, I realized there were two patient groups who were, and are, severely neglected: patients with chronic pain syndromes and tinnitus patients. The neglect was, and is, due to the uninspiring fact that both conditions
cannot be cured by the type of traditional medicine we have learned. However, both groups desperately need help.
I first started an interdisciplinary pain clinic and later I changed to tinnitus rehabilitation, which is the only topic I am dealing with since my retirement. When I started treating tinnitus patients as an ENT specialist, I was essentially helpless for most of the patients. Nonetheless, the longer I cared for tinnitus patients the more I learned, and I realized although we cannot cure tinnitus, there is much that can be done for these patients. My own ideas were confirmed and complemented by the neurophysiological tinnitus theory of Jastreboff and his Tinnitus Retraining Therapy (TRT) which I learned in the UK.
AO/Beck: I understand you did some experimental work with rats to help explain and refine your tinnitus theory?
Kellerhals: Yes. My wife and I did some exciting rat experiments with tinnitus. Essentially, we found that growing rats would start to lose body weight when they experienced tinnitus. However, after they recovered from tinnitus, using habituation, their body mass increased again. In continental Europe, we were among the first promoters of a tinnitus rehabilitation program, based on the original TRT. I think that over the years, slowly, the majority of ENT specialists in Europe have changed to tinnitus rehabilitation programs, instead of ineffectively searching for pharmacological treatment modalities.
AO/Beck: And Dr. Kellerhals, I believe you are a Meniere's patient yourself?
Kellerhals: Yes, Dr. Beck, that is correct. My own medical history includes severe Ménière's Disease over a period of 15 years, followed by unilateral deafness and tinnitus. However, I believe my personal history did not influence my decision to take care of tinnitus sufferers. Nonetheless, it has probably increased my credibility!
AO/Beck: What inspired you to write the book, and who did you write it for?
Kellerhals: We wrote our book primarily for our patients. However, we intended to promote tinnitus rehabilitation among my fellow ENT doctors and other health care professionals who work with tinnitus patients. The book was written originally in German and is in its' fifth edition. The English and Italian translations followed soon after that. As you know, the foundation of tinnitus rehabilitation is proper instruction about tinnitus. If tinnitus remains a strange and terrifying burden, it cannot be overcome. When well instructed, a tinnitus sufferer loses a lot of nightmares and they are able to recover. Of course, a realistic approach and realistic expectations are necessary. I believe oral instruction must be complemented by a written text, and so the book helps the patients to understand the situation and to effectively manage it.
AO/Beck: Very good. Would you please tell me about tinnitus theory ?
Kellerhals: Jastreboff's neurophysiological model says that tinnitus is a central problem, although it is caused by damage to the inner ear. In fact, tinnitus does correspond to unnecessary neural activity in the central hearing system. This leads to my computer model of tinnitus: Tinnitus is a software problem and the central hardware is intact. Because of the high incidence of inner ear damages, tinnitus is widespread in the general population, probably up to 30% of all people have tinnitus to some degree. Tinnitus can be associated with hearing loss, hearing loss due to aging (presbycusis), noise exposure, head trauma, ear disease, ototoxic drugs and many other causes. No one is immune from tinnitus.
AO/Beck: Please explain the fundamentals of your Tinnitus Rehabilitation by Retraining program?
Kellerhals: Tinnitis rehabilitation is based on four fundamental facts, they are...
- An identical tinnitus is well tolerated in three out of four patients. This proves, that individual influences decide the severity of the suffering. The influencing factors arise from three levels; somatic, psychological and social.
- As measured by tinnitometry, the loudness of tinnitus remains stable despite the varying subjective loudness sensation. Again, the subjective loudness depends on somatic, psychological and social factors.
- Tinnitus is a central problem. This explains, why there is no pharmacological cure.
- Our conscious perception is highly selective. Our ears perceive many thousand times more information than our conscious perception is able to handle. The most significant sounds and information are sent towards conscious perception in the cerebral cortex. The overwhelming surplus of sounds never reaches conscious perception. Tinnitus, too, can reach the level of conscious perception. However, subcortical selection can be redirected through rehabilitation to diminish the significance of the tinnitus signal, and this is called habituation.
Kellerhals: TRT concentrates on counseling and the avoidance of silence. Rehabilitation adds analysis and improvements in somatic, psychological and social levels. These are explored according to individual needs, using psychotherapy, relaxation techniques, body work or other complementary therapies. Very often, scrutinizing the personal life situation of the tinnitus sufferer leads to crucial insights about the necessary changes in life style, choices and personal relations. Willingness to change is an indispensable prerequisite for any rehabilitation success, not just tinnitus.
AO/Beck: How do you handle silence avoidance and what is your experience with noise generators used to mask tinnitus?
Kellerhals: In 34% of our patients, noise generators were fitted. However, our experience showed that other means for silence avoidance, such as live water fountains, perhaps a room fan, and the like, are equally effective. It seems best to leave the choice to the patient. The bedroom companion, too, has to be taken into account! Our statistics show, that silence avoidance during the whole night is of enormous importance. During the daytime, no one, except perhaps monks in a monastery, has silence. Our data show that nightly silence avoidance leads to significantly better results than silence avoidance restricted to daytime and/or in the late evening or during nightly periods of insomnia.
AO/Beck: How do you measure success and what are the success rates with your program?
Kellerhals: In tinnitus rehabilitation, success cannot be measured easily. Tinnitus loudness does not reflect the patient's progress, because loudness measured in dB remains stable in each patient. Therefore most authors use questionnaires. Questionnaires rarely measure the individual problems in an appropriate manner. Complicated questionnaires measuring overall quality of life do exist, but none is adapted to tinnitus problems. Tinnitus itself often remains the same with subjective variations of its intrusiveness. But when the sufferer starts to discuss their real problems instead of merely repeating the complaints about tinnitus, they clearly start an improving process. Such subtle changes sometimes indicate the first steps of improvement. Improvement must not be measured in terms of tinnitus abolition (which rarely occurs) but in terms of life quality. As you can imagine, our patients are extraordinarily severe cases: Because of tinnitus and/or other incapacitating health problems, 25% of our patients are totally or partially unable to work. Our own statistical evaluations repeatedly revealed an improvement rate of about 70%, which equals the success rates of other rehabilitation centers. But what about the 30% unsuccessful rehabilitation attempts? They must not be left alone, they have to be followed with repeated consultations at regular intervals.
AO/Beck: What about tinnitus and hearing loss together? What is your preferred way to address that?
Kellerhals: If possible, hearing aids have to be fitted. Sometimes the fitting of hearing aids changes their lives in such a tremendous way, that it solves the tinnitus problem as a single measure. If not, silence avoidance is added. Many patients wear hearing aids during daytime and a noise generator at night.
AO/Beck: Is tinnitus a psychosomatic disorder?
Kellerhals: The answer is yes and no. Modern psychosomatic theories stress the point that our linear thinking (A causes B, and B causes C) does not conform with reality and has to be replaced by network models where everything influences everything. Any condition or
handicap, such as tinnitus, influences and is influenced by innumerable processes on the somatic, psychological and social levels. But tinnitus is not a psychosomatic disorder in the traditional meaning of the term, where psychosomatic disorders are separated from somatic disorders. Tinnitus is real, it is not a mere fantasy!
AO/Beck: For readers who might want to learn more about tinnitus, or purchase your book, how can they find the book?
Kellerhals: The book can be ordered through any book seller with the following
Information; Kellerhals B and Zogg R, Tinnitus Rehabilitation by Retraining, Karger Basel/Freiburg/NewYork/Sydney, ISBN 3-8055-6930-0.
AO/Beck: Thank you for your time and knowledge this morning Dr. Kellerhals. It has been a pleasure working with you and I wish you and your patients continued success with your program.
Kellerhals: Thank you too Dr. Beck. It has been my pleasure.
