From the Desk of Gus Mueller
Our 20Q topic this month focuses on the audiologic sequelae related to traumatic brain injury (TBI) - in particular, mild TBIs, commonly referred to as concussions. Centers for Disease Control defines a TBI as a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury. Most of you have watched a professional football player being carted off the field after suffering such an injury. While these Sunday afternoon TBIs, watched by millions, receive considerable attention, they are a very small percentage of the total TBIs that occur annually. In the U.S., there are about 2 million TBIs each year. Since 2000, over 400,000 active duty military members have suffered a TBI.
Probably 75 to 85% of TBIs are classified as “mild.” This level of injury once was mostly considered a benign event, but has generated attention in recent years because of some of the adverse neuropsychological outcomes. Along with this attention has been an increased interest in the potential audiologic disorders that could result. To update us on the current thinking in this area, we have this month’s 20Q author, Gail Whitelaw, PhD.
Dr. Whitelaw is a clinical associate professor and Director of the Speech-Language-Hearing Clinic at The Ohio State University in Columbus, OH. She is also the audiology faculty member on the Leadership Education in Neurodevelopmental and Other Disorders (LEND) grant at Nisonger Center at Ohio State. She is actively involved with interdisciplinary practice and education as part of interdisciplinary healthcare teams, including teams working with patients with traumatic brain injury and their families.
Most all of you know Dr. Whitelaw through her involvement with leadership aspects of the profession of audiology, including serving as the President of the American Academy of Audiology, Chair of the Board of Governors of the American Board of Audiology, and President of the Ohio Academy of Audiology.
Gail also is nationally known for her commitment to exemplary clinical education for AuD students, and only fitting, she recently received the Outstanding Clinical Educator Award from the American Academy of Audiology. We’re thankful that she's helping educate us here at 20Q regarding the audiologist’s role with the TBI patient.
Gus Mueller, PhD
Browse the complete collection of 20Q with Gus Mueller CEU articles at www.audiologyonline.com/20Q
20Q: The Audiologist's Role With Patients Who Have Mild Traumatic Brain Injury
After reading this article, professionals will be able to:
- Describe the characteristics of concussion and traumatic brain injury, including those related to hearing/balance/listening.
- List the professionals who comprise an interdisciplinary/multidisciplinary team needed to support patients with mild traumatic brain injury.
- Develop a test battery for assessing patients with mild traumatic brain injury.
- Discuss audiologic management of patients with concussion/traumatic brain injury.
1. Why should patients with traumatic brain injury be of interest to audiologists?
There are several reasons. As you know, many audiologists today are concerned about what they perceive as threats to the profession, such as the role of over the counter (OTC) hearing aids. However, there are patient populations that seek services of audiologists yet often report that our profession has overlooked their needs. Audiologists such as Richard Gans, PhD. often talk about ways to “diversify the audiology portfolio”. I ask our AuD students, “How are we essential in the lives of patients?” The needs of the population of patients with mild traumatic brain injury (mTBI) provide opportunity to ‘diversify our portfolios’ while providing services to those with hearing, listening, and/or balance deficits.
2. I really haven’t had experience in this area. What exactly do you consider a mild traumatic brain injury?
According to the Centers for Disease Control (CDC, 2020), a TBI is caused by “a bump, blow, or jolt to the head that disrupts the normal function of the brain.” A TBI may be classified as “mild” (i.e., a brief change in mental status or consciousness), yet have a long-term impact on the life of the patient despite this classification. Most TBIs that occur each year are considered to be mild and are also referred to as concussions. Technically, there is no difference between mTBI and concussion, with brain functioning being disrupted. Physicians may use the term concussion when the patient is believed to have an issue that is insignificant. Patients who experience a mTBI/concussion may have a short duration (less than one minute) of loss of consciousness, change in mental state, a period of amnesia, and deficits in neurological functioning. While not generally life-threatening, long term effects may be serious and significant.
3. Have audiologists always been interested in TBI?
If you work in a larger clinic, these patients certainly have been referred for audiologic testing in the past. So yes, historically, audiologists have been involved in evaluations related to head injury, often related to temporal bone fractures as the result of injury caused by motor vehicle accidents (MVAs). The interest in the effects of these injuries on the ears and hearing goes back a century. In 1926, Ulrich described longitudinal and transverse fracture, addressing whether the otic capsule was spared or involved (March, 2017). Otologic interest in skull fracture resulted in a team approach for this population and “site of lesion” information from an audiologic evaluation. This simple approach underestimates the types of auditory, balance, and other issues with the current patient population with TBI.
4. What are the common causes of mild TBI for the patients that we are seeing today?
Head injury has received attention related to sports injuries, including football, soccer, and even in recreational activities such as dodgeball. The most extreme example of TBI may be Chronic Traumatic Encephalopathy (CTE) that has been reported in some professional football players. The association between mTBI and neurodegenerative disease is also of interest (Gardner & Yaffe, 2015). The types of MVA have changed since the historic concerns about temporal lobe fractures. Currently, deploying of airbags in a MVA is known to result in mTBI/concussion, often with accompanying auditory/vestibular symptoms (Yaremchuk & Dobie, 2001). Falls are reported as the leading cause in children under 4 and in adults over 65 years, which highlights the critical role of the audiologist in fall prevention. Blast injuries and explosions also result in mTBI, particularly in the military population (Theodoroff, Lewis, Folmer, Henry, & Carlson, 2015). Physical abuse may also result in mTBI.
5. What is the scope of this problem?
It is estimated that 1.7-2.8 million Americans experience mTBI each year. Over the span of six years (2007–2013), rates of TBI-related emergency department visits increased by 47% (Taylor et al., 2017). Although many people that have experienced a mTBI present at the emergency room, they are often discharged when stabilized. Most do not report having been unconscious and it is a myth that only those that have lost consciousness have a significant brain injury. Many patients who are quickly discharged report not being asked about issues like cognitive changes, or perceived changes in hearing or vision. They state that they are not told to be aware of these issues. For many people with mTBI there are life-altering changes in these areas following hospital discharge, referred to as postconcussion syndrome (PCS).
6. Is there a demand for audiology services with this population?
I participate in a monthly support group for patients who have had traumatic brain injury and their families. Each month, new members seek me out to ask about how to address their issues, often reported as tinnitus, dizziness, hearing loss, inability to hear in background noise, or a combination of these things. Some of these patients have seen an audiologist and/or otolaryngologist and report that being told that they had a normal audiogram and they are hearing well. In other cases, patients report that they were examined at the hospital immediately after the accident and were discharged with no follow-up noted. They were not aware of symptoms of post-concussion syndrome until days or weeks after their head injury.
7. You've mentioned post-concussion syndrome (PCS) a few times. Can you tell me more about that?
Post concussion syndrome is described as “…a symptom complex with a wide range of somatic, cognitive, sleep, and affective features, and is the most common consequence of traumatic brain injury” (Barlow, 2014). It affects physical, emotional, and cognitive functioning in both children and adults (Jaber, Hartwell, & Radell, 2019). Headaches, dizziness, tinnitus, auditory perceptual issues, visual perceptual issues, anxiety, depression, and short-term memory issues are often reported with PCS. These issues often have a negative synergy and contribute to executive functioning deficits. Patients with post-concussion syndrome frequently report hearing, listening, and balance issues following a mild traumatic brain injury (Vander Werff & Rieger, 2019; Najib & Linens, 2019). These issues can persist for weeks, months, or years.
8. Who, then, manages these patients?
Ideally management of patients with mTBI is handled by a team, with the audiologist as an important team member. But working with this population requires that audiologists think beyond the “usual suspects” on their team. Interprofessional practice (IPP) emphasizes the most effective and comprehensive care for patients, and is a critical consideration in working with those that have had mTBI/concussion. Physiatrists, or Physical Medicine and Rehabilitation (PM&R) physicians, are often the professionals who coordinate care for these patients. Neurologists and Neuropsychologists manage the head injury and cognitive components of the injury. Psychologists may address the anxiety and depression often associated with mTBI and may utilize cognitive behavioral therapy to address a range of issues. Optometrists and Neuro-optometrists manage visual and visual perceptual needs. Physical therapists may address a range of issues, including vestibular rehabilitation and driving rehabilitation. Athletic trainers may be part of a concussion team working with recovery from sports-related injuries. Speech/language pathologists have a critical role in addressing overall communication as patients often report skills that have changed significantly since their head injury, including word finding difficulties and a slowed speed of language processing.
9. Specific to audiology, how do patients with mTBI present?
Patients who have had mTBI usually present with subtle yet significant complaints. Some patients have hearing loss that has been undetected and they present for the first time for audiologic assessment following their accident. Others have had a previous hearing screening or audiologic evaluation, with results demonstrating normal detection levels. Their complaints are often difficulty hearing in less than optimal environments (Bergemalm & Borg, 2001; Roup, Powell, & Leigh, 2018). They frequently report that their speed of processing is slower than pre-TBI. Tinnitus that interferes with listening/concentration/attention is frequently reported. It is not unusual for patients to report sound tolerance issues (e.g. hyperacusis) following their injury (Fagelson & Baguley, 2018). People who are post concussive often report vestibular dysfunction.
10. Will I pick up these factors using my typical case history?
Maybe not. As with every audiological assessment, patients with mTBI have idiosyncratic presentations. Taking a careful case history is critical and it often needs to focus on a broader perspective than with a typical patient without head injury. Because mTBI can impact many aspects of the patient’s life, the person may want to address how their communication is impacting their work life, social life, and family communication. Some patients with mTBI report emotional lability, anxiety, and depression that interact with communication issues. Additionally, communicating may be challenging due to post-injury cognitive and/or speech-language deficits. Many patients report that answering questions or reporting case history is stressful and they become confused or forgetful. These factors suggest that having the patient’s medical records and a communication partner available are of benefit for at least the initial audiological appointment.
Guidance from the World Health Organization emphasizes that functional impacts and the social/emotional impacts are critical in addressing communication issues. Utilizing a measure of “authentic assessment”, such as the Client Oriented Scale of Improvement (COSI) (Dillon, James, & Ginis, 1997) or Adult Auditory Performance Scale (Woolf & Roup, 2019) will provide insight into both functional deficits and may be used as a measure of change if treatment should be initiated. This step is critical as self-report is one of the strongest indicators of functional deficits as it relates to both behavioral and electrophysiological audiologic measures (Gallun, Papesh, & Lewis, 2017).
Pending the patient concerns, using a tinnitus questionnaire, such as the Tinnitus Handicap Questionnaire or the Tinnitus Reaction Questionnaire, or a sound tolerance questionnaire, such as the Khalfa Hyperacusis Question, also is recommended.
11. What tests do you recommend for my audiologic assessment for these patients?
Audiologic evaluation will be guided by each patient's concerns. Obviously, a conventional audiologic evaluation is critical, if this has not already been performed prior to your seeing the patient. Tympanometry and acoustic reflexes should be included, unless sound tolerance is a concern. Addressing sound tolerance and tinnitus in this population may be even more important than determining hearing status.
The most crucial aspect to assess is patient concerns regarding their functional listening. Most report listening deficits in less-than-optimal listening environments, which reinforces the need for speech-in-noise testing at a minimum. Ironically, most mTBI patients seen in our clinic with previous audiologic evaluations report that speech-in-noise testing was not performed, regardless of this being one of their main concerns. Electrophysiologic testing may be able to provide additional information and may contribute to measures of recovery following treatment (Musiek, Baran, & Shinn, 2004).
12. It sounds like speech-innoise testing is pretty important?
Speech-in-noise testing may be the most important aspect of the evaluation, pending patient complaints—many have suggested it be conducted for most all patients, not just this special population. Building the preferred speech-in-noise testing into the test battery is less critical than assuring that speech in noise is assessed. The Words in Noise (WIN) test uses monosyllabic words in a background of seven different signal-to-noise ratios (SNRs) of multitalker babble, and is often used in this patient population when evaluated at Veteran’s Administration Medical Centers (Wilson, 2003). Both the BKB-SIN (designed for 5-14 years) and the QuickSIN provide the ability to use an adaptive approach. The R-SPIN can address predictability and may be particularly useful for patients with more significant hearing losses and/or language deficits. Again, the specific test is irrelevant as long as speech-in-noise is evaluated.
13. What about auditory processing disorders in this population?
It has long been established that concussion/mTBI can result in auditory processing disorders. Dichotic listening deficits following mTBI have been reported, including re-emergence of an ear advantage (for example, a significant right ear advantage is noted when it was previously minimized). Some patients report that they are able to “hear” better in one ear than the other, despite having the same detection thresholds in both ears. Temporal processing disorders are often identified and in agreement with patient self-report of a “slowing” of their auditory processing abilities (Turgeon, Champoux, Lepore, Leclerc, & Ellemberg, 2011; Gallun et al., 2017).
14. Should I be doing speech tests that could possibly identify auditory processing disorders? And if so, what tests?
As noted previously, deficits are anticipated in dichotic listening and temporal processing in patients who have had mTBI. A number of speech tests can be used to identify auditory processing disorders with this population. It’s important to recall that a critical aspect is to tax the auditory system and to incorporate a test battery approach. A variety of tests and test batteries have been used with this population. Test batteries such as SCAN-3A: Tests for Auditory Processing in Adults and Adolescents (Keith, 2009) have been utilized. Other dichotic listening tests include Dichotic CVs and 1-, 2-, and 3- pair dichotic digit recognition performance (Strouse & Wilson, 1999). Dichotic Digits and CVs provide reduced linguistic loading and can provide useful information about the patient’s listening abilities. Additionally, the Gaps-in-Noise test (Musiek et al., 2005) has been used as tool with this population.
15. I think you mentioned earlier that these patients also have balance and vestibular issues?
Yes, most certainly. A significant number of people who have had concussion report vestibular issues (Alsalaheen et al., 2010). As with auditory assessment, there is no consensus on vestibular assessment for people that have had mTBI. One approach that has been useful in assessing vestibular and cognitive issues in patients with head injury is the American Institute of Balance-Vestibular Cognitive Integration protocol (Gans & Kurtzer, 2017).
16. Can amplification be used to address hearing/listening issues in this population?
Obviously, hearing loss should be addressed with amplification. Well fit amplification often addresses communication issues for the patient, which is no surprise. However, issues with tinnitus and/or sound tolerance may impact the hearing aid fitting. Many patients report that tinnitus impacts their attention and concentration and it can interact with or interfere with their ability to hear and listen (Roberts, 2016). Additionally, speech-in-noise issues may warrant greater consideration for remote microphone use or accessories. For some patients that have worn hearing aids in the past, revisiting current fittings and needs is critical for reprogramming.
17. What about fitting hearing aids to the patients with normal hearing?
We talk about the use of mild gain hearing aids for this population, however this is probably a bit of an outdated term in the current era of hearing aids. Well fit hearing aids can enhance soft consonants of speech, improve SNR with use of multiband directional technology, and utilize background noise algorithms to improve comfort and reduce distractions for patients. These can be used for those individuals with normal peripheral hearing and functional communication deficits that fall into a hearing difficulty (HD) category (Roup, Post, & Lewis, 2018). It is critical to recall that detection thresholds reflect listening in quiet and do not address listening in less than optimal situations. Both research and anecdotal evidence support using hearing aids with this population (Beck et al., 2018). The fitting is predicated on medical clearance, as is our clinic protocol for anyone being fit with amplification who demonstrates normal hearing detection thresholds. Real-ear measures should be utilized as part of the fitting protocol (Roup, Whitelaw, & Baxter, 2018).
18. Do you also recommend rehabilitative audiology for these patients?
Retraining of auditory skills is possible and desirable in this population. Care must be used to balance auditory training with other types of rehabilitation. Although brain rest for about a year post mTBI was recommended in the past, more recent approaches suggest that treatment soon after mTBI is beneficial. Treatment should be coordinated by the physiatrist or neurologist related to overall brain recovery. Auditory retraining used for adults with hearing loss can be also used with those that have mTBI and include:
- Listening and Communication Enhancement, https://www.lacelistening.com/
- Angel Sound, http://angelsound.tigerspeech.com/
- clEAR: Ears train the brain: https://www.clearworks4ears.com/
From my own experience, these patients are motivated to perform auditory training and achieve “retraining” of their auditory systems (Roup, Ross, & Whitelaw, 2020).
19. A lot of things to consider. It sounds like I could be the entry point for rehabilitative services for many of these patients?
Absolutely. Audiologists may not provide all services but may be the professional that connects patients with other professionals that will address needs. Some patients may also experience issues related to driving, particularly if the injury was the result of a motor vehicle accident. Driving rehabilitation or use of a driving stimulator are options that can address these issues and improve the quality of life for the patient. More information on driving simulators can be found at www.drivesim.osu.edu. Many patients report that they have not been connected with a speech-language pathologist and need support to enhance top-down language skills to support their recovery and learn how to employ communication strategies. Use of speech-to-text devices, like the Live Scribe pen or Otter voice meeting notes can provide support for enhancing communication.
20. How do I connect to this patient population?
From my observation, this population is a field of dreams for audiology…if you build it, they will come. Setting up a meeting with local professionals, including physiatrists, will certainly yield referrals. Most rehabilitation hospitals do not have an audiologist on their team but are anxious to provide services that meet the needs of the patient. Most communities have support groups for people that have had mTBIs and their families. These groups are generally welcoming to professionals either as a presenter or as a member. They provide the opportunity for us to share our professional knowledge but more importantly, to learn about the impact of traumatic brain injury from the real experts - the patients themselves.
Alsalaheen, B.A., Mucha, A., Morris, L.O., Whitney, S.L., Furman, J.M., Camiolo-Reddy, C.E.,...& Sparto, P.J. (2010). Vestibular rehabilitation for dizziness and balance disorders after concussion. Journal of Neurologic Physical Therapy, 34(2), 87–93. doi: 10.1097/NPT.0b013e3181dde568
Barlow, K.M. (2014). Postconcussion syndrome: A review. Journal of Child Neurology, 31(1), 57-67.
Beck, D.L., Danhauer, J.L., Abrams, H.B., Atcherson, S.R., Brown, D.K., Chasin, M.,...Wolfe, J. (2018) Audiologic Considerations for People with Normal Hearing Sensitivity Yet Hearing Difficulty and/or speech-In-Noise Problems: why do so many people with “normal hearing” report that they have hearing problems? Hearing Review; 25 (10), 28-38.
Bergemalm, P.O., & Borg, E. (2001) Long-term objective and subjective audiologic consequences of closed head injury. Acta Otolaryngology, 121, 724-734.
Centers for Disease Control (CDC). (2020). TBI: Get the facts. Available from: https://www.cdc.gov/traumaticbraininjury/get_the_facts.html
Dillon, H., James, A., & Ginis, J. (1997). Client Oriented Scale of Improvement (COSI) and its relationship to several other measures of benefit and satisfaction provided by hearing aids. Journal of the American Academy of Audiology, 8, 27-43.
Fagelson, M., & Baguley, D.M. (2018). Hyperacusis and disorders of sound intolerance: Clinical and research perspectives. San Diego: Plural Publishing.
Gallun, F.J., Papesh, M.A., & Lewis, M.S. (2017). Hearing complaints among veterans following traumatic brain injury. Brain Injury, 31(9), 1183-1187.
Gans, R.E., & Kurtzer, D.A. (2017) Vestibular-cognitive integration: A concussion case study. Journal of Otolaryngology ENT Research, 6(4), 00170. doi: 10.15406/joentr.2017.06.00170
Gardner, R.C., & Yaffe, K. (2015). Epidemiology of mild traumatic brain injury and neurodegenerative disease. Molecular and Cellular Neuroscience, 66(Pt B), 75-80. doi: 10.1016/j.mcn.2015.03.001
Jaber, A.F., Hartwell, J., & Radell, J.D. (2019). Interventions to address the needs of adults with postconcussion syndrome: A systematic review. AJOT: American Journal of Occupational Therapy, 73(1), 7301205020p1‐7301205020p12. doi:10.5014/ajot.2019.028993
Keith, R. (2009). SCAN–3:A tests for auditory processing disorders in adolescents and adults (SCAN–3:A). New York: Pearson.
March, A.R. (2017). Temporal bone fractures. Medscape - Otolaryngology and Facial Plastic Surgery. Retrieved November 21, 2017, from emedicine.medscape.com
Musiek, F.E., Baran, J.A., & Shinn, J. (2004) Assessment and remediation of an auditory processing disorder associated with head injury. Journal of the American Academy of Audiology, 15, 117-132.
Musiek, F.E., Shinn, J.B., Jirsa, R., Bamiou, D.E., Baran, J.A., & Zaida, E. (2005) GIN (gaps-in-noise) test performance in subjects with confirmed central auditory nervous system involvement. Ear & Hearing, 26(6), 608–18.
Najib, S., & Linens, S.W. (2019). Vestibular Rehabilitation Therapy Improves Perceived Disability Associated with Dizziness Postconcussion. Journal of Sports Rehabilitation, 28 (7): 764-768.
Roberts, L. (2016) The mechanism and time course of tinnitus associated with hearing impairment. In D.M. Baguley & M. Fagelson, M. (Eds.) Tinnitus: Clinical and research perspectives (pp. 13-33). San Diego, CA: Plural Publishing.
Roup, C.M., Post, E., & Lewis, J. (2018). Mild-gain hearing aids as a treatment for adults with self-reported hearing difficulties. Journal of the American Academy of Audiology, 29, (6), 477-494.
Roup, C.M., Powell, J., & Leigh, E.D. (2018, April). Auditory processing in adults with a history of mild traumatic brain injury and normal hearing. Presentation at the American Academy of Audiology annual convention, Nashville, TN.
Roup, C.M., Ross, C., & Whitelaw, G.M. (2020). Hearing difficulties as a result of traumatic brain injury. Journal of the American Academy of Audiology, 31, (2), 137-146.
Roup, C.M., Whitelaw, G.M., & Baxter, J. (2018, April). Is normal hearing really normal? A protocol for adults with subjective hearing difficulties. Presentation at the American Academy of Audiology annual convention, Nashville, TN.
Strouse, A., & Wilson, R.H. (1999). Recognition of one-, two, and three pair dichotic digits under free and directed recall. Journal of the American Academy of Audiology, 10, 557–571.
Taylor, C.A., Bell, J.M., Breding, M.S., & Xu, Z. (2017) Traumatic brain injury-related emergency department visits, hospitalizations, and deaths: US 2007-2013. MMWR Surveill Summ, 66(No. SS-9), 1–16. doi: http://dx.doi.org/10.15585/mmwr.ss6609a1
Theodoroff, S.M., Lewis, M.S., Folmer, R.L., Henry, J.A., & Carlson, K.F. (2015) Hearing impairment and tinnitus: Prevalence, risk factors, and outcomes in US service members and veterans deployed to the Iraq and Afghanistan wars. Epidemiology Reviews, 37 (1), 71-85.
Turgeon, C., Champoux, F., Lepore, F., Leclerc, S., & Ellemberg, D. (2011). Auditory processing after sport-related concussions. Ear & Hearing, 32(5), 667‐670. doi:10.1097/AUD.0b013e31821209d6
Vander Werff, K.R. & Rieger, B. (2019) Auditory and cognitive behavioral performance deficits and symptom reporting in postconcussion syndrome following mild traumatic brain injury. Journal of Speech, Language, Hearing Research, 62(7), 2501-2518.
Wilson, R.H. (2003) Development of a speech in multitalker babble paradigm to assess word-recognition performance. Journal of the American Academy of Audiology, 14(2), 453-470.
Woolfe, E.E., & Roup, C.M. (2019). Using the adult auditory performance scale to identify self-perceived hearing difficulties. Poster presented at the American Academy of Audiology annual convention, Columbus, OH.
Yaremchuk, K., & Dobie, R.A. (2001). Otologic injuries from airbag deployment. Otolaryngology—Head and Neck Surgery, 125(3), 130-133.
Whitelaw, G.M. (2020). 20Q: The audiologist's role with patients who have mild traumatic brain injury. AudiologyOnline, Article 27081. Retrieved from www.audiologyonline.com