Inside Clinical Research | May 2017 Hearing Review
Following last month’s interview with Richard Tyler, PhD, we turn our attention to another world expert in tinnitus, James A. Henry, PhD, a research career scientist at the VA National Center for Rehabilitative Auditory Research, and recipient of the 2016 Paul B. Magnuson Award for his innovative work on the treatment and management of tinnitus—the highest honor for VA rehabilitation investigators.
Beck: Good Morning Jim. Thanks for your time this afternoon.
Henry: Hi Doug. Thanks for your interest.
Beck: For professionals less familiar with you and your interesting work regarding management of the tinnitus patient, I’d like to note that, although you have an MS in audiology, your PhD was in behavioral neuroscience.
Henry: Exactly. I earned my PhD at Oregon Health & Science University (OHSU) in 1994, and my dissertation addressed tinnitus loudness measures and how they relate to loudness recruitment.
Beck: And, of course, that background—as well as working with learned colleagues over many years—set you up to be one of the primary authors of Progressive Tinnitus Management (PTM)?
Henry: Thanks, yes. I’ve had the honor of working with many talented people. In fact, PTM was the result of many collaborators, including Tara Zaugg, AuD, Paula Myers, PhD, Caroline Schmidt, PhD, Christine Kaelin, MBA, Emily Thielman MS—and others too numerous to list here.
Beck: OK, so prior to your development and publication of PTM, perhaps the most popular treatment for tinnitus was some form of simple masking using white noise or pink noise. How is PTM different from other management protocols?
Henry: Well, as you mentioned, masking, which was introduced by Dr Jack Vernon, was more-or-less the method of choice in the 1980s. Of course, in 1990, our mutual friend and colleague Dr Pawel Jastreboff introduced Tinnitus Retraining Therapy (TRT). TRT has been a prominent tinnitus management protocol ever since. Drs Vernon and Jastreboff were pioneers who greatly advanced the field.
As you know, Doug, we’ve conducted a number of studies involving masking and TRT. We ended up formulating our own approach to tinnitus management, which eventually became PTM. PTM is unique in many respects, but does include components from both masking and TRT. A major focus with PTM is to utilize an individualized stepped-care type of clinical protocol. PTM involves five levels of clinical care.
Beck: Is it correct to say that people with a lesser tinnitus sensation, and less need of professional care, would often be characterized by Level 1 within PTM? Then, we go up the ladder to Level 5 as people experience increasing difficulties from their tinnitus and require more specialized and significant care?
Henry: That’s the basic framework. There are specialized Tinnitus Clinics, and in that environment you could argue each patient needs a full work-up. However, the large majority of patients with tinnitus are not particularly bothered by their tinnitus, so a full work-up is not warranted. They are, however, likely to have hearing loss, so they should all have their hearing evaluated. PTM Level 1 Referral stipulates that any patient complaining of tinnitus should be appropriately referred, and the default referral would be for a Level 2 Audiologic Evaluation.
Beck: What is involved with PTM Level 2?
Henry: Level 2 involves a basic audiometric assessment, brief tinnitus assessment, and dispensing of hearing aids, if warranted. The brief tinnitus assessment utilizes the Tinnitus and Hearing Survey (THS, see https://goo.gl/V8K9qo), which is a one-page, easy-to-administer, 10-item questionnaire that provides information as to whether tinnitus-specific intervention might be helpful to the patient.
Oftentimes, patients confuse tinnitus with hearing problems. If they perceive their tinnitus as particularly loud, and they notice they miss conversations and words, they might easily and reasonably blame their tinnitus for their communication problems…but of course, we know that many of these people have hearing loss—so the more likely culprit in this scenario is the hearing loss. The THS helps clearly distinguish between tinnitus-specific and hearing-specific problems.
Beck: I totally get that. In other words, they hear their tinnitus, so it’s easy to blame it for their difficulty perceiving words, and of course, they don’t “hear” their hearing loss, so the hearing loss is essentially invisible to them.
Henry: Exactly, and that’s something we’ve run into a lot, which is why we developed the THS. Combining results from the THS and the audiologic evaluation provides the information needed to help patients take the best path toward meaningful solutions.
Beck: Jim, a few years ago, I wrote that some 80% of all patients with sensorineural hearing loss (SNHL) had tinnitus, and some 80% of all patients with tinnitus had SNHL (the “80/80 Rule”). So, first let me ask you, does the “80/80 Rule” ring true for you?
Henry: I’m not sure of the exact numbers, but they’re in the ballpark and the concept is certainly correct.
Beck: So, I would venture an “educated guess” that, given PTM and excellent clinical skills and cognitive behavioral therapy (CBT), roughly 90% of all tinnitus patients can be effectively managed. Does that seem about right?
Henry: Well, I’m glad you said “managed” rather than “cured,” because, as you know, we cannot cure or completely eliminate tinnitus. So, back to your question: Can we effectively manage about 90% of people with tinnitus? Yes, probably, but I feel more comfortable saying the majority of people with tinnitus can effectively self-manage their reactions to tinnitus if they receive appropriate clinical care.
Beck: OK, fair enough. What are your thoughts as to the difference in results when using hearing aids versus combination devices (hearing aids with sound generators)?
Henry: We have conducted two trials, and we found both devices [hearing aids and the combination devices] provided excellent management overall, although there were no statistically significant differences between the two devices.
Beck: However, in one of your trials, I believe the group with combination devices experienced a better outcome on the Tinnitus Functional Index (TFI)?
Henry: Yes, there was more than a 6-point further improvement on the TFI for the combination devices, but that improvement was not statistically significant. There are now three studies in the literature (including our two) with the same findings: significant improvement using both hearing aids and combination devices, but no significant difference in improvement between devices. What’s really needed is a large-scale study to definitively answer the question as to whether built-in sound generators provide additional benefit for tinnitus beyond the use of hearing aids.
Beck: So, although many sounds are beneficial for helping to manage tinnitus (as measured on the TFI and other measures), there are no clear cut “best” sounds?
Henry: That’s correct. Sound in general can be therapeutic for managing tinnitus. The basic principle is that use of sound has the capability of promoting habituation, stress reduction, and/or distraction. And different sounds have different effects on different people. That’s why, with PTM, we teach patients about the different types of sounds, how they can be effective for managing tinnitus, and how to determine the best sound to use in each specific situation when tinnitus is problematic.
Beck: Are there particular sounds you would recommend avoiding?
Henry: Any sound that is aversive in any way should be avoided. Also, as we all know, louder sounds should be avoided (or protected against), even if they are well tolerated. Provided the sound is not aversive or damaging, it really comes down to preference—what the person likes to listen to and how well the sound mitigates any negative effects of tinnitus. So far there is no proof that any one sound is better than any other sound for this purpose. In general, we recommend letting the patient choose sounds that are pleasant and helpful.
Questions about which sound to select might include: Does it help to promote habituation to the tinnitus? Does it provide a sense of immediate relief from the tinnitus? Does it distract attention away from the tinnitus? More generally, does it lessen any negative effects caused by the tinnitus? If patients have hearing loss, then hearing aids can also be helpful for the tinnitus. In such cases, it is recommended to use combination devices so sound therapy can be added to the amplification if desired by the patient. Combination devices produced by different manufacturers have different options, and it would be good to know what those are to assist in choosing devices that are preferred by the patient.
Beck: I’ve found that tinnitus patients, more often than not, prefer natural sounds like ocean waves over sounds like white noise, and it’s more likely that rain sounds would be preferred over pink noise. Has that been your experience?
Henry: More-or-less, yes. However, each patient is different and some may prefer white noise, which others may find aversive. Avoid any sound that is deemed aversive; other than that, it’s really wide open. With PTM, we teach patients how to use a systematic process to choose sounds that are most helpful for their tinnitus-problem situations.
Beck: And so, if the patient likes the sound of the ocean, and they choose to listen to that as their personal background sound all day long, that pretty much provides them a TRT-like approach. For the patient who needs more, they can turn up the ocean sounds and arguably get more relief from their tinnitus, and that provides them with a masking approach.
Henry: Exactly. Flexibility is the key! I should add that sound therapy can include any form of music and even speech presentations, such as audiobooks, podcasts, and guided imagery. When all types of sounds are available, the options for “sound therapy” are almost unlimited. This is especially the case when connecting to the internet. A smartphone can be a powerful sound therapy device. There’s also the ability to stream audio from a smartphone to hearing aids.
Beck: OK then, we started to describe PTM Levels 1, 2, 3, 4, and 5, and we got a little sidetracked. Before I let you go, can you give me a sentence or two about each level?
Henry: Sure. So Level 1 is just a referral level, getting them into the right office. Level 2 is the audiometric evaluation and completion of the THS, as well as hearing aids (or combination devices) if appropriate.
If patients need tinnitus-specific intervention after that, they can move up to Level 3 Skills Education. Level 3 normally involves two sessions with an audiologist and three with a mental health provider—all focused on teaching skills to help patients self-manage any negative effects of tinnitus. The audiologist addresses how to use sounds effectively in various situations, and the mental health provider teaches coping skills based on Cognitive Behavioral Therapy (CBT). Levels 1, 2, and 3 take care of the needs of the great majority of patients complaining of tinnitus.
Patients needing further services are offered Level 4 Interdisciplinary Evaluation, which involves an in-depth evaluation by both an audiologist and a psychologist. The psychologist has to be very familiar with tinnitus and how it can interact with insomnia, anxiety, depression, PTSD, etc.
Level 5 Individualized Support is the provision of individualized services and is ongoing for however long the patient requires them.
Beck: This is very useful information, and I urge our colleagues to learn more about PTM. To this end, I’ve asked Dr Henry to recommend some resources, and these appear in the online version of this article. Jim, I appreciate the insight and knowledge you’ve shared with us today.
Henry: Thank you, Doug.
Correspondence can be addressed to Dr Beck at: [email protected]
Tinnitus and Hearing Survey. Available at: https://www.ncrar.research.va.gov/Education/Documents/TinnitusDocuments/THS.pdf
Recommended Readings on PTM
Henry JA, Zaugg TL, Myers P, Schechter MA. Using therapeutic sound with Progressive Audiologic Tinnitus Management. Trends Amplif. 2008;12(3):185-206.
Henry JA, Zaugg TL, Myers P, Schechter MA. The role of audiologic evaluation in Progressive Audiologic Tinnitus Management. Trends Amplif. 2008;12(3):169-184.
Henry JA, Zaugg TL, Myers, PJ, Kendall CJ, Turbin MB. Principles and application of educational counseling used in Progressive Audiologic Tinnitus Management. Noise and Health. 2009;11(42):33-48.
Henry JA, Zaugg TL, Myers PJ, Kendall CJ, Michaelides EM. A triage guide for tinnitus. J Family Practice. 2010;59(7):389-393, 2010.
Meikle MB, Henry JA, Griest SE, Stewart BJ, Abrams HB, McArdle R, Myers PJ, Newman CW, Sandridge S, Turk DC, Folmer RL, Frederick EJ, House JW, Jacobson GP, Kinney SE, Martin WH, Nagler SM, Reich GE, Searchfield G, Sweetow R, Vernon JA. The Tinnitus Functional Index: Development of a new clinical measure for chronic, intrusive tinnitus. Ear Hear. 2012;33(2):153-176.
Myers PJ, Griest S, Kaelin C, Legro MW, Schmidt CJ, Zaugg TL, Henry JA. Development of a progressive audiologic tinnitus management program for Veterans with tinnitus. J Rehab Res Devel. 2014;51(4):609-622.
Henry JA, Frederick M, Sell S, Griest S, Abrams H. Validation of a novel combination hearing aid and tinnitus therapy device. Ear Hear. 2015;36(1):42-52.
Henry JA, Zaugg TL, Griest S, Thielman E, Kaelin C, Carlson KF. Tinnitus and Hearing Survey: A screening and assessment tool to differentiate bothersome tinnitus from hearing difficulties. Am J Audiol. 2015;24(1):66-77.
Henry JA, McMillan G, Dann S, Bennett K, Griest S, Theodoroff S, Silverman S, Whichard S, Saunders G. Tinnitus management: Randomized controlled trial comparing extended-wear hearing aids, conventional hearing aids, and combination instruments. J Am Acad Audiol. In press.
Henry JA, Thielman EJ, Zaugg TL, Kaelin C, Schmidt CJ, Griest S, McMillan GP, Myers P, Rivera I, Baldwin R, Carlson K. Randomized controlled trial in clinical settings to evaluate effectiveness of coping skills education used with Progressive Tinnitus Management. J Sp Lang Hear Res. In press.
Books about PTM
Henry JA, Zaugg TL, Myers PJ, Kendall CJ. How to Manage Your Tinnitus: A Step-by-step Workbook. 3rd ed. San Diego: Plural Publishing Inc; 2010. (Note: This book also was published independently by VA Employee Education System and distributed to VA audiologists.)
Henry JA, Zaugg TL, Myers PM, Kendall CJ. Progressive Tinnitus Management: Counseling Guide. San Diego: Plural Publishing Inc; 2010. (Note: This book also was published independently by VA Employee Education System and distributed to VA audiologists.)
Henry JA, Zaugg TL, Myers PJ, Kendall CJ. Progressive Tinnitus Management: Clinical Handbook for Audiologists. San Diego: Plural Publishing Inc; 2010. (Note: This book also was published independently by VA Employee Education System and distributed to VA audiologists.)
Original citation for this article: Beck DL. Progressive tinnitus management, habituation, and more: an interview with James A. Henry, PhD. Hearing Review. 2017;24(5):38-40.