2017 ATRR: An interview with Jim Henry

James Henry, PhD. is certified and licensed audiologist with a doctorate in Behavioral Neuroscience. He is employed at the National Center for Rehabilitative Auditory Research (NCRAR) located at the VA Portland Health Care System. He is also Research Professor in the Department of Otolaryngology – Head & Neck Surgery at Oregon Health & Science University.

For the past 23 years, he has devoted his career to tinnitus research. He has received funding for 25 grants to study various aspects of tinnitus clinical management. His overall goal is to develop and validate clinical methodology for effectively helping individuals who are afflicted with bothersome tinnitus.

What made you first interested in tinnitus? How did your research career develop to where it is now?

I became interested in pursuing a career in Audiology because of my deaf daughter. When she was 5 years old I returned to school to earn an M.S. in Audiology. Following school, I was hired as a research audiologist at the Veterans Affairs hospital in Portland, Oregon where I discovered an avid interest in research. I spent the next 6 years in the Behavioral Neuroscience doctoral program at Oregon Health & Science University (OHSU). My OHSU research lab was directed by Dr Jack Vernon, and my research advisor was Dr Mary Meikle. They were both pioneers in the field of tinnitus and I had the great opportunity to learn from them. My doctoral dissertation focused on measurement of tinnitus, which cemented my interest in doing tinnitus research as a career. I have been doing it ever since.

My first funded grant was a pilot study to perform computer-automated tinnitus measurement. I have continued that work to the present. I also became interested in Tinnitus Retraining Therapy (TRT) and attended Dr Jastreboff’s TRT training course in 1997.

I received a grant in 1999 to compare outcomes between TRT and Tinnitus Masking (Dr Vernon’s method) and that study led to two other studies evaluating TRT. My combined experiences led to the development of Progressive Tinnitus Management (PTM), which is the method we have focused on for about the last 10 years.

What research are you currently involved in?

I would have to say that further refinement and expansion of PTM is my highest priority. What has always driven my research is the desire to improve clinical services for people who suffer from tinnitus. Until a cure is discovered, the best we can do is to mitigate effects of tinnitus and help people live normal lives in spite of their unremitting tinnitus. PTM is a stepped-care program of clinical management, and the intervention levels focus on teaching self-help skills to enable people to know what to do whenever their tinnitus is bothersome.

We have adapted PTM to provide the self-help education over the telephone. We recently completed a randomised controlled trial (RCT) to evaluate “Tele-PTM” and observed very positive outcomes. This demonstrated the ability to provide tinnitus services remotely, which makes these services accessible to anyone, anywhere. We are working to continue developing and testing Tele-PTM.

We are currently in the early stages of conducting an RCT to evaluate the Desyncra device for tinnitus treatment. Participants are randomised to either be treated with the device or to receive “standard-of-care.” Systematic reviews have revealed that Cognitive Behavioral Therapy (CBT) has the strongest research evidence for tinnitus management, so we are using CBT as our standard-of-care control group.

A question of particular relevance to the Veterans Health Administration is whether the onset of tinnitus for a Veteran many years after leaving the military can be caused by noise or other ototoxins experienced during military service. This question is important because tinnitus is the most prevalent of all service-connected disabilities for U.S. Veterans. At any point in their lifetimes, Veterans can claim tinnitus caused by exposures during the military, and thousands of these claims are received every month. The NOISE Study (Noise Outcomes in Servicemembers Epidemiology Study), which has been underway for 3 years, enrolls military members and recently-discharged Veterans who complete comprehensive testing and questionnaires. The study is designed as a longitudinal study to evaluate Veteran participants annually for 20-30 years.

As I mentioned, we continue to develop our computer-automated tinnitus evaluation system (TES). The TES performs standard tinnitus psychoacoustic testing (loudness match, pitch match, minimum masking level, residual inhibition) plus special tests that have been developed. Our goal is to develop standardised methodology that is practical and informative for clinical and research application.

We are also collaborating with Dr Jeremy Turner who has developed a gap detection test for objective detection of tinnitus. The method measures whether a silent gap embedded in a background of sound can be detected. Numerous studies have shown that animals (following noise exposure or salicylate) with tinnitus show deficits in detecting these silent gaps. It is hypothesised that humans with tinnitus will also show such deficits. Our site is testing the method with humans.

Are there any particular challenges in working with the Veterans population with tinnitus?

I’m in research so I don’t directly see patients at the Veterans Affairs (VA) hospital where I work. As I mentioned earlier tinnitus is the most prevalent of all service-connected disabilities for Veterans. As of 2015, almost 1.5 million Veterans had received a service-connected tinnitus disability award, meaning the VA decided they have tinnitus (the disability) and that it was caused by exposures while in the military (the service connection). I am in constant touch with numerous VA audiologists who tell me about their experiences with Veterans who report tinnitus. It is clear that at least one out of three Veterans who attend Audiology clinics have tinnitus – either as a primary or
a secondary problem. There are over 1300 VA audiologists working at almost 500 Audiology sites of care, and they had almost 2.4 million encounters with Veteran patients last year. Without question, tinnitus is a huge problem for Veterans and for the VA. Probably the biggest challenge in meeting the tinnitus needs of these Veterans is the lack of standardisation between audiologists and between Audiology sites of care. A primary reason tinnitus services are inconsistent is that most Audiology doctoral (Au.D.) programs in the U.S. do not provide substantive training in tinnitus management. Further, despite VA recommendations for tinnitus management and the Clinical Practice Guideline for tinnitus published in 2014 by the American Academy of Otolaryngology/Head & Neck Surgery Foundation (AAO-HNSF), VA audiologists are typically unfamiliar with these recommended procedures and do not adhere to any particular protocol for tinnitus management. This is not just a VA problem, but an international problem – evidence-based guidelines for tinnitus management exist, but patients cannot expect to receive evidence-based care for their tinnitus. 

What aspect of your work personally gives you the greatest satisfaction?

Without a doubt, helping people is the most satisfying aspect of my work. We do not run a clinic, but our controlled trials require many participants who are significantly bothered by their tinnitus. We regularly hear back from them about how much they have been helped. I further derive great pleasure from completing studies and getting them published, which expands work in my lab around the world with the potential of helping many more people.

You recently were awarded the Jerger Career Award by the American Academy of Audiology. How did that feel?

It’s an unbelievable honour for me and I had no idea I was even nominated. I discovered early on that the best research, at least in my case, comes from collaborative efforts. When you put a bunch of brains together working on the same project, it is synergistically effective. I have to give credit to the many individuals who have contributed to my research. I have been extremely fortunate to work with many very talented and gifted individuals. I am constantly amazed at the quality of work they do, and how much they know—they make me look good. The NCRAR is an ideal auditory research environment because it provides all of the necessary infrastructure. Finally, I have been supported by the VA Office of Research and Development for my entire career. They have constantly stepped up to support tinnitus research and the NCRAR. So, while my name goes on the award, it reflects the efforts of many people over many years.

You have been involved in tinnitus research for many years now. What research topic or question currently excites you?

I’m particularly interested in the use of sound to suppress tinnitus. We have known for decades that residual inhibition can be induced consistently for the majority of people with tinnitus. Residual inhibition is usually a temporary effect of tinnitus suppression lasting up to a few minutes. I am interested in the prospect of a systematic study to determine acoustical parameters that might prolong residual inhibition such that this could become a clinically viable technique. There has also been research looking at different acoustical protocols for suppressing tinnitus on a long-term basis. Sound can be “notched” around the tinnitus frequency, “matched” to the tinnitus frequency, or delivered in some way intended to manipulate brain plasticity such that tinnitus-related neural activity is disrupted, ultimately resulting in a reduction or elimination of the tinnitus percept. I have begun work in this area and find it to be an exciting line of research.

Moving away from your own research, what’s your favourite piece of tinnitus research that’s been done by others, and why?

That’s a tough question to answer because there is so much good research out there. I have to give credit to the many “unsung heroes” who are doing tinnitus mechanisms research in their laboratories. I visited Dr Richard Salvi’s lab at the University of Buffalo (in New York) not too long ago and had the opportunity of speaking with all of the researchers working in his lab. I was astounded at the variety and quality of the research that is being done there. This kind of work gives me great hope that there will indeed be a cure for tinnitus in the future.

What do you think is the biggest challenge facing tinnitus research at the moment?

The biggest challenge is finding a cure for tinnitus, i.e., some treatment that can safely eliminate the perception of tinnitus. Of course, this challenge is particularly difficult because finding a cure will likely require understanding the neural mechanism(s) of how tinnitus is triggered and what sustains it over time.

What are the challenges of translating current research into clinical practice?

We can experiment with invasive techniques on animals to evaluate potential methods of treatment for tinnitus. We must use clever procedures, however, to infer the existence of tinnitus in animals and whether any manipulations actually suppress the tinnitus. With humans, we cannot normally conduct invasive techniques, but humans can tell us exactly what they are perceiving and if there is any change in their perception. So, I’d say the big challenge is in
translating tinnitus mechanisms research that is done in animals to see if inferences based on the research hold true with humans. An example of this is Dr Turner’s study that I’ve already mentioned. The next phase of his research is to determine if his gap detection method that has been shown to work in animals also works in humans.

What might you say to a sufferer who asks you whether there will ever be a cure for tinnitus?

I would first point out that there is abundant research being carried out around the world that is targeted at finding a cure for tinnitus. Tinnitus is gaining greater visibility and the number of tinnitus-related studies is continually increasing. In 2016 alone, there were 368 peer-reviewed publications listed in PubMed with tinnitus in the title. Compare this number to the approximately 10 articles per year 40 years ago, 50 per year 20-30 years ago, and 100 per year just 10 years ago. This should be encouraging news to anyone suffering from tinnitus.

Is there any advice you would give to others considering a research path in tinnitus?

I strongly endorse the clinical model of practicing evidence-based medicine. Such evidence is derived mainly from systematic reviews, which summarise results of controlled trials to specify, with minimal bias, what methods have an evidence-base in the literature. In my area of study, i.e. clinical research to develop and validate methods of tinnitus management, controlled trials are desperately needed. We can get excited about new methods, devices, etc., but until they are reported in systematic reviews as showing benefit, the credible evidence is limited or nonexistent. For these reasons, my advice for clinical researchers would be to design and perform controlled trials to test the efficacy of any method that is purported to be efficacious.

Finally, is there anything else you would like to share with our readers?

This question could really put me on a soapbox because I am passionate about the need to standardise the field of tinnitus management. In spite of what seems to be a vast amount of research taking place, there is little evidence that researchers are collaborating to make their research more efficient. This “silo” approach could be greatly improved by creating an international committee of the most prominent tinnitus researchers and assigning them the task of working together to establish common goals and methodologies for attaining those goals. Standardisation in tinnitus management techniques is needed and that will require some kind of credentialing program for clinicians to become qualified and certified “tinnitus care providers.” Such a program will require a panel of experts to create
a program of official verification that a provider has achieved criterion standards regarding training, supervision, and experience. Until we reach this point, the tinnitus sufferer is mostly at the mercy of anyone who claims to offer help.

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