**Transcript of Cyberseminar**

**Mild TBI Diagnosis and Management Strategies**

**Mild TBI Diagnosis and Management Strategies: Diagnosis and Management of Central Auditory Defects**

**Presented by Sheila Pratt, PhD; Gabrielle Saunders, PhD**

**November 21, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact**Sheila.Pratt@va.gov**or Gabrielle.Saunders@va.gov.*

Moderator:At this time, I would like to introduce our speakers. Speaking first we have Sheila Pratt, she is a research audiologist at the Geriatric Research Education and Clinical Center in the VA Pittsburgh Healthcare System and an Associate Professor in the Department of Communication, Science and Disorders at the University of Pittsburgh. Joining her today is Gabrielle Saunders the Associate Director of the National Center for Rehabilitative Auditory Research and Associate Professor at Oregon Health Science University. I would say the department but I am afraid I will butcher it. At this time, I would like to turn it over to Sheila. 

Sheila Pratt:Let me get started here. First off, I would like to welcome everybody who is attending. I want to first say that in this area of mild TBI and looking at auditory function there is really more questions than there are answers so I would not assume to know all the answers. Also, we are going to be focusing again primarily on the auditory system and hearing but with an emphasis of looking at mTBI resulting from blast. 

Now first off I think I would like to know who is in the audience and so I do have a poll question. If you would vote in, I would get an idea of who is out there. 

Moderator:Thank you if our attendees would simply click the circle next to the answer that best says your job description: military audiologist; VA audiologist; military SLP; VA SLP; physician neuropsychologist or behavioral health professional or other. It looks like about two-thirds of our audience have responded, we have a nice array across the board with sixteen percent military audiologist, around thirty-eight percent VA audiologist, about two percent military SLP, nine percent VA SLP, six percent physician neuropsychologist or behavioral health professional and about twenty-seven percent identify as other. Thank you to our respondents. 

Sheila Pratt:Great, thank you that gives me a good idea of how to focus this a bit, let me go back here. Again, the focus is going to be on central auditory processing deficits. When we think about this from an audiological perspective oftentimes, we come from a developmental orientation. I think we have to be very careful to not necessarily take that perspective because it can lead us I think astray when we are thinking about some of the veterans we are seeing in the audiology clinics. We have to think about it more from an acquired perspective and primarily from a trauma perspective. Although we can see central deficits from various other factors like cardiovascular disease, metabolic diseases, tumors. Then there are some people that argue that even there can be experiential effects that can impart  the central auditory system for example if we have somebody who has a long standing hearing loss the chances are high that it affects the central system, adversely affects the central system. 

Now relative to mild traumatic brain injury, as some background, it is one of the most common injuries in the military service for the recent conflicts. It is estimated that about fifteen to twenty-five percent of military personnel deployed in Iraq and Afghanistan have experienced trauma consistent with mTBI. 

Now there are various definitions of mTBI and depending on the definition that you use, there may be more or less people that can be classified as mTBI. The more common definition that is used in the private sector is one by the American Congress of Rehabilitation Medicine. It specifics that it is a physiological disruption of brain function and so it assumes there is some damage to the brain and that there is some altered mental state, loss of consciousness or loss of memory or focal neurological deficit that may or may not be transient. There is a time where there is alteration of consciousness or mental state so it has to be limited to thirty minutes, posttraumatic amnesia has to be less than twenty-four hours and then if you are using the Glasgow Coma Scale the score after thirty minutes has to be thirteen to fifteen. That is a little bit less useful in the military and so the operational definition for the military has more to do with what might occur in theater and what symptoms you might see directly from the insult. Usually it is from blast. 

The most common consequence of mTBI in the military in the current theaters is from blast and it can occur from the pressure waves directly but you also might see secondary, tertiary and quaternary insults that can result in mTBI. I think when we are thinking about the auditory system we also need to be very cognizant of the noise that is associated with the blast. So you have the pressure wave and then you have the acoustic wave that follows it. Some of the damage to the auditory system can be in response to the noise itself.  

Some of the neural effects and I think many of the researchers are just beginning to understand some of the neural effects of blast in these mTBI folks. Typically, there are no gross abnormalities on structural neural imaging so on structural CTs or MRI you cannot see any kind of abnormalities. But when they look at biochemically and biomechanically and if they are looking at more smaller units of damage or micro lesions, they are starting to see more damage and with more blast exposures they are seeing much more diffused damage across the brain. Although we like to talk about specific structures especially in auditory system that might be affected by blast the more blast exposures especially with high intensity blast we are going to see more damage throughout the total brain although some areas might be more affected than others. There is also evidence that they are seeing small bleeds that might have not shown up on some standard metrics and also when they look at to some extent with functional MRI and then diffusion tense or imaging they are seeing more effects damage to the white matter tracks. All of that has implications not only for hearing and audiology but for cognitive function and other types of brain activity. Now some of the physical symptoms that you see are very common as headache and other pain, impaired sensory function especially in hearing and onset of tinnitus is very common consequence of blast. We may see balance problems associated with dizziness and nausea associated with that indicating vestibular problems, vision can be impaired or affected in about ten to fifteen percent, some will experience some taste and smell issues. Then a good proportion may actually have multi-sensory impairments especially combination of hearing deficits and vision deficits. We will have these dual sensory impairments in some of the folks that we see. There are also reports of just general loss of energy and malaise with these patients. 

Now cognitively, we will see difficultly with attention and concentration and that is very, very common; problems with reduced processing speed, reduced reaction time, and memory issues both long and short-term where they may be more forgetful but also working memory so memory at more of an executive function level may be impaired. Because of all of this some of them may have impaired decision making skills and then with some of the patients we might also see speech and language difficulties epically at a relatively subtle level and sometimes it is hard to pick apart what is attention and concentration and what is speech and language issues. When we are testing hearing all of these factors can impact our results so I think although they may or may not affect hearing per se, they are going to have an impact on how a person listens and pays attention to acoustic information and affect our ability to test them. 

Behaviorally there is a whole host of things that we might see with these patients—increased irritability, they may be quicker to anger, some will have anxiety, sadness, depression, some hypersensitivity, we will see impulsivity. Some will have sleep disturbances where they may sleep to much or not enough and then some may over medicate with drugs, alcohol and tobacco. Now, there is a question that popped up from Pam Feehan about vision problems and I think that the vision problems that we will see with these types of patients can vary just as much as what we see in auditory domain. It may be at a basic sensory level, but it also is likely to appear at more of a processing level. Then when it is combined with similar auditory impairments then it just compounds the problems that they have. 

Now the time course on what we see with these patients is getting a lot of discussion in the literature. Commonly, especially in the civilian domain it is believed that most of the overt symptoms tend to dissipate within days or weeks but they should be dissipated by about three months. For the most part these people tend to look relatively normal by three months. More and more people are arguing that there are some subtle differences that some of these patients may have or some may have subclinical symptoms that may persist for a long time and it may be that they are not normal, but they are not functioning at the level that they did before the insult. They may complain about problems with hearing but when we test them, they look very normal on the standard tests that we give them but they do not believe that they are functioning at a normal level. 

There is also some indication that some of the symptoms may become more evident over time and more problematic over time and we do not know whether they are getting worse or whether they are in different contexts. So they may be functioning a common thing that we are hearing in the clinic is that they function fine when they are were deployed but when they came home and they went back to school or back to work then they started noticing the problem or the family started noticing the problems they were having. Some of it may be that over time, they get worse and some of it may be the context in which they are trying to function. There are also some concerns about age and age at which they had the injury and whether there is neural degeneration with age. At a recent conference, Frederick Gallun presented some age effects on auditory function in people that were blast exposed and he was arguing, and it was pulmonary date, but he was arguing that the older individuals, those middle-aged individuals in their forties and fifties who are blast exposed were looking much worse than the younger veterans or soldiers. He was arguing probably that their systems are much less resistant or resilient and they were looking much worse than the younger veterans. There is also concern that these younger guys that are in their twenties and early thirties that when we look at them twenty or thirty years from now, when we start seeing some central problems with normal again, that these fellows may look much, much worse. 

There are also some other issues, actually a whole host of issues that make it difficult to pin down what is going on with some of these patients and even in the research it is difficult to interpret the research. Oftentimes the mTBI is missed especially if there are other more serious, more obvious injuries so if they break an arm nobody is going to be as concerned about somebody who does not seem to have an overt or obvious head injury. Many people that are coming into the clinic some of the reports indicate that they are not really sure whether they were concussed or not so their awareness of having an mTBI, having a head injury is rather vague and the reports are hard to take apart at times. Because of that, I think that is why many of these fellows that we are seeing clinically do not have formal diagnoses of the mTBI. They come in and there is every indication that they probably have some type of brain injury but because their reports are so vague it is hard to really classify them sometimes. Also, there are a lot of variability in terms of the nature of the blast, what the magnitude of the blast, how far away they were, how frequently they were exposed to blast. Whether they were in a contained environment or whether they were in a closed building or vehicle when the blast occurred. All of that can contribute to the variability of the people that we see. There are also many arguments in the literature about the comorbidity of PTSD. Some say that it co-occurs at a high rate with mTBI, some say it is an independent factor. However, we do see it together and we need to be cognizant of it and work with it when we see it both in the patients that we see. One thing that is very clear though is that this patient population is highly variable and I do not know if we actually develop a standard protocol for assessment or treatment because we have to treat them individually because of the variability. 

Now when we look at blast and the impact on the auditory system, the most common effect of blast is to the tympanic membrane and the middle ear structures. We are going to see that much more commonly because it is more exposed and it is more exposed to the pressure wave. However, we will see cochlear damage that results in sensory hearing loss and that is fairly common, some of it in direct response to the blast and some of it probably to the noise of the explosion. Then we will see high levels of tinnitus associated with blast exposure. However, less common and quite clinically remarkable because they are coming in at higher numbers than we ever anticipated and those are the central auditory deficits. Some of it may be specific the central auditory system but I would argue that probably a lot of it is a consequence of cognitive deficits that we see in the auditory domain. So it may be cognitive functions that are subtended by the auditory system or just specific to hearing so they may have auditory memory processing deficits, but we may not be seeing them in the visual domain. 

Now some of the symptoms that we are hearing from these patients are that most common one is a complaint of difficulty hearing and noise and in complex listening and social situations. Listening and noise is probably their primary complaint even more so than tinnitus in many of these patients. A good number of them have normal hearing test results on standard audiometric testing including word recognition and quite. Now some of them may complain that they do not hear words well in quiet but they are still within normal levels. Because of their difficulties in noise, we are likely to see elevated hearing handicap scores and way elevated beyond what we would expect given their hearing test results. There are also complaints from families or concerns expressed by family and many of them are having trouble in work settings and in schools where they have to do intense focused listening. But I have to say that there is no real consensus on the assessment protocol, how to best go about figuring out what is going on with these patients. There has been a lot of discussion I know on audiology blogs about how to best assess these folks. 

Now, there has been a little bit of research about the auditory system and where we might most likely see the damage from blast exposure, we tend to see it in lower and mid brain stem thalamus. There is concern about the corpus callosum, cerebellum and then the orbital frontal region of the brain. But I have to say that the work on looking at damage to the white matter track would suggest that even communication between parts of the brain is a risk factor as well. 

Now a question just came up about the auditory cortex and the temporal lobes. There are some concerns about that but I think the concern is more about the tracks in and out of the temporal lobe. When they are looking at damage to the white matter tracks, the temporal lobe is showing up as a region where those white matter tracks are not communicating as well and as efficiently as they should. 

To talk about a possible model of assessment I want to talk about some publication by Gallun at the Portland VA and then I am also going to talk about a data pull that was done here at the Pittsburgh VA, a chart pull at the Pittsburgh VA. It gives you an idea of some of the issues associated with developing a test battery to look at central auditory function in these patients that are coming in. Now, this publication is 2012, it was in the *JR&D Journal* and it is freely accessed online. In this publication and I should say that the reference is at the end of this PowerPoint slide set. They looked at thirty-six blast-exposed trends. They did not designate a priori whether they could be classified as having mTBI or not, they did that through interview after they had been enrolled. Of the blast-exposed, there were seventeen that they designated as non-TBI and nineteen that were TBI. Thirty-nine percent of that group said they had reduced hearing even in quiet even though they had relatively normal audiometric, standard audiometric results and then seventy-eight percent reported difficulty hearing in speech in noise. What that says is that even those they could not designate as TBI had difficult hearing and noise and probably had some central damage even though from report they could not classify as TBI. Then they had a control set of veterans that were included in the study.  Again, most of the subjects in their group had normal to mild hearing loss on standard testing. They did air and bone, they did the NU-6 and DPOAEs on them and looked relatively normal. 

They set up their central test battery to look across the auditory system, to try to figure out where the weakness in the system might occur. They did some electrophysiological testing where they did auditory brain stem response and long latency responses and that they did with an oddball paradigm. They also did a series of standard central auditory tests, which looks at spectro-temporal processing. It tends to look at right hemisphere dysfunction and communication between hemispheres. They did a Gaps-in-Noise test, which looks at temporal processing. It also taps into communication between hemispheres, but also assesses targets the left hemisphere. They also included Masking Level Difference, which tends to be more of a test of brain stem function, Dichotic Digits that again is more of an inter-hemispheric test where you are listening across ears. Then the Staggered Spondaic Word test where again it is more linguistic than the other test, it takes more linguistic processing and fuses images across the two hemispheres. Then as part of their inclusion batter, they did the Quick SIN, which is a speech in noise test, but I am including it under the central test because many times people use a speech in noise test-to-test central function. 

Now the overall pattern of results from their group is that they found normal ABR, which is fairly typical in the literature with this population but abnormal later responses especially the P300 where amplitude and latency were affected. Then the left ear N100 amplitude was affected in the blast-exposed. For the behavioral test results, they found more borderline Frequency Pattern Test but  Dichotic Digits, but they did find an abnormal Gaps-in-Noise, Masking Level Difference, and Staggered Spondaic Words. 

This is just an illustration of the electrophysiological results. This is the control group, that is the blast-exposed group, and you can see where the amplitude especially in the right ear through here where the amplitude is substantially reduced and they also found a delay in the response. Now some pilot work that we have done here we found a similar type of pattern where it is mostly in the later responses, the later components and it is reductions in amplitude and delays in those functions. 

In terms of the behavioral responses we had the Frequency Pattern, the Gaps-in-Noise, MLD, Dichotic Digits and SSW here Staggered Spondaic Word test and how they plotted their behavioral results were the percentage of subjects with abnormal test results and the dark bars are the blast-exposed subjects and the lighter gray bars are the control. What is readily apparent is that these blast-exposed fellows really had many abnormal results although it is not at a hundred percent so not all of them had abnormal results. They did a grand total of abnormal results over here again, you can see that there are way more many controls that had no abnormal results on these tests. Then the blast-exposed tended to have much more overall abnormal results. In some ways, I would expect somewhat higher percentage of abnormal results but we did have a mixture of subjects. Some of them were classified as mTBI and some were not. That may have diluted the results a little bit. 

What I want to do now is to talk about a chart review that has been completed at the VA Pittsburgh and it was initiated by Lindsay Jorgensen who is currently now at the University of South Dakota and at the Sioux Falls VA. We pulled charts from forty-five veterans who had a history of blast-exposure so I am just going to talk about these results, how they are consistent with the Gallun results or in some respects a little bit different. But to give you another perspective on how we might assess these folks or want type of battery we might use. We looked at forty-five veterans again they were all blast-exposed, they all had normal or near normal standard audiometric test results but they all complained of substantial difficulty with hearing and noise in difficult listening situations. Most of them were male as you would expect, they were relatively young and their NU-6 scores were consistent with good speech perception in quiet. Their HHIA-S, their hearing handicap score screener was very high on this group of veterans. When talking to them many of them had suggestions of having mTBI but when we looked in the chart only a little over fifteen percent of them had formal diagnoses of mTBI and a similar number for PTSD. They were probably under diagnosed for mTBI. 

The central test that were done on this group, and not all tests were done on all of them, but we did:  Masking Level Difference, we did a Gap Detection Test, Staggered Spondaic Words and then the SCAN 3:A which is a battery of tests that is a central auditory screener was used and that is commonly used with adults as well as children. It has a bit more of a developmental perspective so there may be some issues with the SCAN 3:A just because it has more of a developmental approach to it. What we can see here but I guess I should back up a little bit, about half of them that received Masking Level Difference had abnormal results and we saw similar performance on Gap Detection and the Staggered Spondaic Word test. But even those that were not abnormal outside the normal range were on the low end of the normal range. Then we did the SCAN 3:A and I will just finish up here on with these results. What we found is that they tended to have normal overall scores so the SCAN 3:A overall score was not that useful, but what we found were abnormal results on Figure Ground Tests so in the presence of noise and then in competing sentences. But even in some of the other subtests where they had competing noise they were no the lower end of normal. 

In concluding here, a sample given the results of the Gallun study and what we are finding in the chart review as well as some other evidence in the literature. We need to sample across the auditory system and look at different types of functions. Clearly, we need to do a standard audiometric battery, see how they hear in quiet, typical standard tympanometry to assess middle ear function, DOPAEs to document cochlear function. It is critical that we do  Hearing Handicap Scale and I like the  HHIA because I think it separates out those who also have PTSD so you can look at the emotional component from just auditory handicap portion. Then there is a whole host of other scales and questionnaires that may be useful. 

I think we should use auditory electrophysiological measures, minimally the ABR and the P300. I also think we need to look at cochlear function at a super threshold level like the temporal fine structure tasks. I think the MLD is helpful, the Gaps-in-Noise, SSW. I think we should be using some type of speech in noise test with different types of linguistic load. There is some indication that testing spatial hearing might helpful and tests of auditory memory and executive function where we look not just at hearing per se, but the interaction between audition and hearing. Then for those that have dual sensory impairments we also need to make sure of what their visual status is. 

Because I am running out of time, I think I will stop here and these are some references that you can refer to. I will just hand it over to Gabbi. 

Gabrielle Saunders:Hello good afternoon, good my presentation is up. Thank you, Sheila, you gave a wonderful introduction to what I am going to be talking about. Thank you everyone for checking in. What I am going to be talking about then is what can we do to help the individuals that Sheila described primarily individuals with clinically normal hearing and yet who have these kinds of complaints. 

What you see on the screen right now is pretty much what Sheila described, the difficulties they have and they reflect the kind of problems of central auditory processing. Quick question –have you encountered veterans like this in your practice?  I am sure that depends on who you are. 

Moderator:I am sorry I pulled up the wrong poll, let me try this again, there we go. Alright, quick question, have you encountered veterans like this and it looks like yes. 

Gabrielle Saunders:That would kind of reflect about five years ago we did a poll of VA audiologist who ask whether they encountered such people and at that time we found that ninety-two percent of people were seeing these kinds of veterans one to three times a month or more. That is pretty much what I would expect if you deal clinically with these individuals. 

What are our options? What are the options for rehabilitation? What we would suggest is that you can either take a bottom up approach and by that, we mean enhancement of acoustic signal or a top down approach, which would be teaching compensatory strategies. I am going to talk about all of the different approaches that are on this screen. I know many of you are audiologists and you will be very familiar with these because I do not know exactly who the audience I will talk in a bit more detail than certainly audiologists would need. 

The first thing is hearing aids. Hearing aids are the standard rehabilitation for hearing impairment. What can a hearing aid do? Well hearing aids amplify sound to make them louder; it can shape the output to compensate for different frequency impairments and they can adjust for abnormal loudness. But what they cannot do is figure out what is the signal and what is the noise. In other words, they cannot really improve the signal-to-noise ratio and of course, they cannot restore clarity. Now if we map this back onto the kind of problems that the individuals we are talking about have, they really do not need the signal amplified, the group that I am talking about so that is really not going to help them. But what they do need is improved signal-to-noise ratio. So a hearing aid does not seem to be the obvious solution for these individuals. Now, one could argue that a hearing aid could be helpful because it is possible that by decreasing the effort the person needs to decode the auditory incoming signal, it may free up more processing capacity for the central processing. Many audiologists do fit mild gain hearing aids for this population and in fact, Sheila and I are going to be embarking on a study where we are looking at this as an intervention. As yet, we do not have data to that end. 

Next how about a Personal FM  system and as I say I am not sure who knows what an FM is or is not. Essentially the individual is provided with a transmitter and microphone and a receiver. So the receiver on the right of the screen looks like a little hearing aid and what it does it picks up the radio wave signals that are transmitted from this microphone transmitter. The microphone transmitter can be worn by the person who needs the help or it can be worn by somebody who is talking and the signal goes directly from that transmitter to the user’s hearing aid receiver. 

What are the advantages of the FM system? Well we know that if they use are used properly they will improve the signal-to-noise ratio. They are one of the most effective kinds of supplement to a hearing aid. What can that do? Well again, it will clean up the signal so it will make available more high-level resources for high level processing. We know they are really successful with children with auditory processing problems and you can get them with and without amplification. They seem a pretty logical form of rehabilitation to try with this population of veterans. Now the downside is that you have to wear something, it is not affixed to the problem. If it is going to help you, you are always going to have to be wearing the FM system. 

Finally Computerized Auditory Training became kind of a very popular thing in audiology and people still are evaluating how effective it really it is. Basically, what it does is suggesting that the brain is capable of changing and through persistent and repeated stimulation, you can improve the clarity of the signal, you will be able to process things better. There are lots of commercially available programs out there and in general, what the program does is adaptive. You start training and if you are getting the answers right in whatever the task is, the program makes it harder and if you are getting it wrong it makes it easier and you go up and down. It pushes you to the maximum of your limit. The programs track performance, they give you little pleasing reinforcement feedback. You have to do for a long time and intensively in order to generate cortical change. [I am pressing my computer to move on the screen here].

What are the advantages? If the auditory training were to work, it would possibly be a fix for central auditory processing difficulties. And if that is the case you would fix it, you would need a device and that would be a wonderful thing. You could also train at your own convenience, which again is good in this day and age. The down side is it does require discipline and a time commitment and we really do not know yet how effective auditory training is and I am going to talk about some data towards the end of my presentation. As I say there are a variety of different auditory training programs, the one that we use I do not have a slide about it is called the Brain Fitness or Brain HQ program from Posit Science and you can look that up, if you search for Posit Science you can find out about it. It basically trains attention, memory and temporal processing which data show are some of the problems that these population of veterans have. 

The other thing is Communication Strategy Training. Patients and their family  note that in a real world situation they are having difficulties. It would be really nice if such individuals would know strategies to improve the situation for them. You can teach them communications strategies. Here at the NCRAR we have a bunch of these brochures that we give out to patients, which hopefully they read and we talk through them as well. They train problem-solving skills in real world communication situations. 

What I am going to move on to now is a description of a study we did evaluating some of these interventions with veterans. We looked at veterans who reported being exposed to a blast, who had clinically normal hearing sensitivity but reported those functional hearing difficulties that we talked about already. This is the design of the study that we did, just to give you an overview so you would where our data came from. We basically recruited them and then they were randomly assigned to one of four interventions. They either received the educational brochures and counselling or they got the counselling and they did the auditory training, the Posit Science auditory training program or they did the education and had an FM system or they did all three—education, auditory training and the FM system. They had these attached for twelve weeks and then they came back for testing. 

We did a huge test battery with them, I am not going to talk through that, I am just going to focus on these four measures that I am going to refer to. The first two speech in noise. One important question is on the face of it these individuals have clinically normal hearing and by that I mean they have normal hearing sensitivity and normal understanding of words, which is a atypical clinical test that people do. They complain they have difficulty hearing in noise so is this the case so we did some speech-in-noise test but right now you really do not need to know the details. Then the data I am going to present today come only from our subjective measures and the subjective measures I am going to report on are the SSQ-C as is known the Speech Spatial and Qualities Questionnaire and something called the Cognitive Self-Report Questionnaire and I have a few slides about each. The SSQ-C that was something developed by Stuart Gatehouse and Bill Noble. Essentially it is designed to measure self-reported hearing difficulties for speech, the spatial processing and sound quality. This is a special version called the SSQ-C, which compares the four interventions. It looks something like this and this is just one of sixty-four different questions. It will give a statement, you are talking with one other person and there is a TV on in the room, without turning the TV down, can you follow what the person is saying. For the SSQ-C you will compare your ability to hear now with before the study. So if nothing has changed, you would have a score of zero, you get a negative score if it is worse and you get a positive score if it got better. As I say there are sixty-four questions that look at speech, understanding situations, spatial, location things and quality of sound. The other questionnaire is the CSRQ, Cognitive Self-Report Questionnaire. This is a questionnaire that was put out there by Posit Science, the developers of the auditory training program we use. It is not a questionnaire that many people use but it is interesting because it tries to look at daily functioning on these eight scales: attention, executive function, memory, language, vision, hearing, energy and satisfaction so it looks something like this. There are questions on the left – I lose my train of thought – less often, same as before, more often or does not apply. You will see that all of the things listed are all kind of cognitive processing types of things in the different scales and I think it actually has some use. 

What I am going to present to you in the next few minutes are some case studies of veterans who were randomized to receive the FM system and who were randomized to use the auditory training program with a view to thinking about how can we figure out who will benefit from which kind of intervention. First case is an FM user so he was an Army veteran and as you can see he was exposed to a number of different blasts and head injuries so he experienced a few blasts that were close by. As noted he is not sure whether he lost consciousness but they did cause him headaches. He had a vehicle accident where his Humvee fell in a hole and he transferred from the vehicle and hit his head and then he also had a concussion from civilian life. However, he has been through a fair amount, or his brain has. The second individual is somewhat similar, he had a bunch of different blasts, a vehicle accident and he also fell from a gun turret and all of these loss of consciousness along the way and headaches perhaps. This one for the first two things you will notice he said he did not really have headaches or loss of consciousness, but meanwhile he was exposed to those blasts. All of the injuries that are happening to the brain even if they were not immediate they are cumulative and so again his brain has gone through a lot of trauma even if it did not happen in one obvious event. That actually is the interesting thing about these veterans is that they have cumulatively gone through so much. 

First of all some baseline information, their age and gender and things like that but what  I want you to note is the fact that both of these have normal hearing thresholds, anything less than twenty or twenty-five is considered normal and their speech these are percentages they are almost getting hundred percent. It is also important to note the different kind of diagnosis they have been given by the VA. One of them has a PTSD diagnosis, one of them we were not really sure there were indicators he might have PTSD but it was not totally obvious from his notes and one has an official TBI diagnosis the other does not. Already we are seeing kind of variation in these individuals even though if you just look at their audiometric data you would conclude these individuals have stayed the same. They are representative of the rest of the study group and yes most of the study group was male, everyone could hear, they have normal thresholds, normal word recognition and again there is a variety of PTSD, TBI diagnosis. 

Now let us think, they appear to have normal hearing, but here are the scores for the speech in noise test. As you see Case 1, everything in red is below normal performance based on noise. Case 1 had below normal performance on all of our different speech in noise measures. Second individual on the other hand had average or better than average speech in noise performance so here these two individuals are diverging even though from the audiologist point of view they came in looking the same. Then just to put this in relation to the study group, most people in the study group performed below normal on one of our speech in noise tests. So that is also interesting that as a group they have abnormal understanding of speech and noise. 

What do these people think of the FM system? Case 1 this individual thought the FM system was so helpful for him. He said he wore it most days a week, all day on those days, he found it very useful. He was attending school, he found it incredibly useful in his classes, and at the end of the study he could not keep our FM system but he went straight to the VA audiology clinic here in Portland and managed to obtain one from them. And he will tell you that it helped him psychologically, he is like the spokesperson for an FM system at this point. Second individual on the other hand said no did not use it much, I tried, I gave up. He said it sometimes worked well in restaurants but most of the time it just picked up background noise and did not work for him. 

How about their performance on the outcome measures? What I have here is a graph of the performance on the arrow on that SSQ-C so that is the Speech Spatial Quality Questionnaire. What I have here the red diamonds illustrate the first case, the one who really liked the FM and the second one illustrates the case of the other individual who did not like it and the x’s are the group average for the whole study population. What do we see? We see first of all that as you would expect the individual who liked the FM had much higher scores. It is interesting to me to note that he had poorer performance in his mind on the spatial scale and that is actually very validating. An FM system is going to mess up all of your spatial cues because basically everything is just coming directly into your ear; you get no binaural information about the source of the signal. In many ways, this validates his other responses that he gives very high things one because he correctly noted that he FM system did not help him spatially. But on the other scales, he was reporting a lot of benefit. 

This is the CSRQ scores, on the bottom, we have the eight different scales and if the scale is higher, there is more benefit. Again, the red line and that diamonds is the first person who liked his FM and the blue is the one who did not like it. Once again red scores are higher than blue scores, but what is interesting here, if you step back and say what is an FM going to do, well it should help you with your hearing. Lo and behold, it improved his hearing a lot. If you have more resources freed up, to process it could help you with your memory and again, his memory score is high and as a result, it is going to improve your general satisfaction with life. Again, this sort of validation in his responses, remember there is absolutely no way this thing should help his vision and indeed it did not. No reason it should particularly help his energy or his attention the FM system and really it did not so again, it is sort of the questionnaire scores are as much as you would expect based upon their reports from the FM system. 

This is as I say the important thing that we are interested in is we have two individuals who would benefit from an FM system and how can we select. First of all thinking back to the speech and noise performance. The first individual had poor speech and noise performance, the second one did not, so really you would not expect somebody who did not need help in speech in noise to benefit from an FM system and indeed, he did not. One thing to look at is baseline speech in noise performance which means you have to measure speech in noise performance which is not something typically done in the clinic. Lifestyle that is another important consideration when you are selecting an FM system. The first individual used it for school, which is an ideal use for an FM system. The other individual did not really find a good use for it and so again, that is something to consider. Unpretending of how and when to use it which is critical and this is a problem with FM systems for all different populations, people do not use it and a lot of it seems to be poor instruction. If you remember our veteran reported that, it picked up background noise, well that is kind of exactly the opposite of what should be the case if you are using it properly, so we are responsible for that. We may be did not explain to him and check in that he knew how and when to use it, but again if someone does not know how and when to use it they are not going to get benefit from it. That is again something that is the burden is on the clinician to make sure the patient is instructed properly. Finally the underlying etiology, so if veteran two did not have any measureable speech in noise problems but had all these reported difficulties, and incidentally he did have a diagnosis of PTSD, it could be that his problems are more associated with PTSD than they are from some form of central auditory processing deficit. An FM system would not be expected to help him. Again, you have to consider the underlying etiology of the problem. 

Now, I only have a few minutes left, looking at the auditory training, I have a third case here on somebody who received auditory training and again the key point is that they had various head injuries and blast-exposures same for this individual here. Again, normal hearing and a variety of PTSD, TBI diagnosis. These two individuals, the first individual had some below average performance on speech in noise tests; the last one had pretty average performance. Both of them, let us look at the first line here, both of them completed some of the training, neither of them completed all of it. The training was a lot, it was forty sessions of training for an hour a day. The first individual, case 3 felt like the program really helped and felt like, she was a she, had greater awareness and keener insight having done it. She did not like all the tasks but really felt like there was some value to it. Second case did not feel there was much benefit and in general, it was boring and too long. In terms of their subjective outcome, once again, case 3 who liked it has higher scores on the SSQ, likewise on the CSRQ and again I would point out that they were training to fix their hearing. The test also trained on attention, not particularly on language, but again they got a higher score there. It was training attention so that sort of again gratifying that that scale went up whereas again vision, energy and memory did not. 

What can we say our considerations for whether you use auditory training? Well baseline performance on speech in noise again, the veteran who seemed to benefit from the auditory training had below average speech and noise performance whereas the other one did not. Maybe severity is something also to consider. So the third veteran had many, many more complaints than the first one did and they were all very much associated with the kind of things we were training to do with processing, time and fast speech and following long conversations. Whereas the other veterans did not report those kinds of problems. 

Another important thing if you are going to put someone through an auditory training program that takes an hour a day, they need to have availability of time and they need to be motivated to do it. Veteran 3 was somebody who was not working, but was looking for employment so she, a-had the time and b-she was very  motivated whereas the other individual was working full time and did not have time to train. Finally the underlying etiology again it may be that the individual who did not benefit may be has more problems coming from PTSD than CAPD and so we should not be trying to fix Central Auditory Processing Disorder types of problems if their problems are really associated with PTSD. How do we distinguish them? That is another whole issue, but it is something we should be considering. 

To wrap up I would say that our data show that both interventions can work but there is a lot of individual variability, there is a lot of different things to consider and ideally we would be able to predict who will and will not benefit upfront, but really we do not yet know how to. Just before you sign off, I do not think it matters whether this comes out live to me but we are genuinely interested to know what other things you think we should be considering other than the ones on that slide, other than severity of problems. [Can I have my slide back]?

Moderator:We actually have to leave this up if we want. 

Gabrielle Saunders:You have to leave it up to go because I really do want to see all these answers I think they are going to be very interesting. 

Moderator:I can minimize it a little bit so you can see better. 

Gabrielle Saunders:Great, yes, so they can answer and I can move on. Anyway, in addition to these kinds of things I would love to hear what other thoughts and things we should consider because it is important to us to know. Then just to let you know that our research on this has not ended, the study I just reported on has ended and we have to analyze all the data. But as I mentioned earlier we are going to be looking at mild gain hearing aids for this population, other colleagues here at NCRAR are looking at a relationship between combat blast injuries and sports concussions and what cumulatively is going to happen. Then we are also working with the Portland VA Audiology Clinic to implement our findings as well. 

That is it, there are pictures of Portland which is where I am located and I think we have gone over our time, if you want to email questions to Sheila, your first speaker or me, Gabrielle Saunders, we would love to hear from you. Thank you. 

Moderator:Thank you to both of you for those wonderful presentations. If you both have a few minutes to stay on we do have some questions that came in. 

Gabrielle Saunders:Yep I can do that. 

Moderator:Great, thank you. The first question, Sheila this came in during your presentation. Are we just assuming that normal CAP functioning pre-morbid any history questions about school performance to assist with determining pre-morbid state like depression?

Sheila Pratt:I do not think that we can assume it in all cases. I know on the chart review we try to separate out those that might have had some pre-morbid conditions. There is some research actually in preparation for this study where they were looking at brain function in folks that had depression prior to their blast-exposure and in terms of their brain function, that population looks very different from those that did not have depression prior to their TBI. They probably do function quite differently and may show up very differently on test results. 

Gabrielle Saunders:I can just say that for our study, we actually did about pre-deployment processing difficulties and we did not allow anybody that said they had difficulties in school and such like we actually did not put them in our study. Across the board I do not know if they would have a different outcome but I can say that these individuals with these kinds of processing difficulties post-deployment did not all have problems after deployment and we very much asked about that. 

Moderator:Thank you both for those responses. Sheila I believe this on also came in when you were presenting. Jorgensen et al study how many were also diagnosed with PTSD.

Sheila Pratt:It was a little under fifteen percent. Where they were co-morbid, was that the question?

Moderator:It did not specify but I think so. 

Sheila Pratt:There was a little overlap I cannot remember the numbers right off the top of my head but most of those with PTSD, it was a little under fifteen percent that also had PTSD. 

Gabrielle Saunders:Can I butt in again because I find this very interesting. Ours I think it was more like across the board it was like half of them had PTSD and we did not try to in any way exclude people with PTSD. But what is really interesting to me as I looked the other day we had two different test sites, the Portland VA and Tampa VA. Tampa VA about seventy-something percent of those had PTSD diagnosis and only about thirty percent from Portland. I think what this does, I do not think the populations were different, I think it is that these diagnoses are dealing with conditions that are so vague that it is really hard to be certain what you are diagnosis. I felt that maybe the mental health clinics at Tampa are more willing to give out PTSD diagnosis because our populations do not differ functionally on anything or report wise on anything so I think it is pretty interesting. 

Moderator:Thank you for those responses. Sheila were you able to include a reference for the Temporal Fine Structural Test in your reference slides.

Sheila Pratt:No, I did not include that. 

Moderator:Our attendee who wrote in would they be able to contact you offline?

Sheila Pratt:Yes, they could. The task itself is downloadable from Brian Moore’s website, just Google Brian Moore, his lab would come up and he has a number of software packages that are just downloadable from his site. But they can email me as well. 

Moderator:Thank you. They also have a comment; there is a difference between normal hearing sensitivity for simple tones and normal hearing for living. 

Sheila Pratt:Completely agree. 

Moderator:VA diagnosis of PTSD and/or TBI there will be variability in diagnosis unless all SMs are evaluated by the same physician, which is unlikely. 

Sheila Pratt:I mentioned that just now, I am sure that is true. 

Moderator:Great. You were providing treatment for some patients for example each case even with normal test results, case 2. 

Gabrielle Saunders:Yes because our study was to try and work out what kind of rehabilitation to give to veterans. All these individuals had sought help from audiology or had reported to the TBI clinic that they were having auditory problems. The inclusion for the study was reported blast-exospore, reported functional hearing difficulties and clinically normal hearing. Yes, because they wanted help.

Moderator:Great, looks like we have about four questions remaining. What other providers were involved in these veterans care regarding their communication problems, SLP, neuropsychologists, neurologists. 

Gabrielle Saunders:If that is for me, any or all. This was a specific study and I have to say we did not document whatever else they were getting but we were also not intervening in anything. This was supplementary to anything else they may have been treated but they were definitely all attending the TBI clinic, many of them have mental health providers. I have to say I do not know, I know we can find out from their notes.

Moderator:Thank you. What is the best method for ordering, tracking Brain HQ particularly with low number of patients? 

Gabrielle Saunders:I do not know if you looked at Brain HQ. When we did this study, it was a DVD you put in the computer and it ran and you uploaded the data to the internet. The program now is very, very different, I really think it is very, very cool you can go on there  if you want to do some demo training but I do not really know what happens with the data. I am pretty sure you can get the veteran to log into their account in front of you and you can see what their scores are for all their different training tasks. If you wanted to track, an individual’s progress I am pretty certain you can quite easily. 

Moderator:Thank you. 

Gabrielle Saunders:Everything used to go to a database and I assume it still does but to be honest I do not know now. 

Moderator:This question is also for you. If a patient does not have the time to do a training and the lifestyle would not benefit from an FM what would be the logical next step for treatment?

Gabrielle Saunders:Communication strategies are I think something that would definitely potentially help them. I wish we knew, I do not think we do, I just do not think we know. I mean I think it is important to figure out whether or not we need to be focusing on the PTSD kind of aspects or if it is auditory processing difficulties. If it is the auditory processing difficulties nowadays you do not have to fit an FM, you can fit a blue tooth; there are all sorts of other ways you can get the remote microphone effect. That still may be the way to go, I think we do not know and that is why we are going to be looking at mild again hearing aids. 

Moderator:Were other factors such as sleep deprivation and the effects of meds considered in addition to PTSD?

Gabrielle Saunders:They will be covariates but they are the kind of things that I want to see on that list. We did not include subjects who had major neurological problems, major alcohol and drug abuse but medications they could have had medications I am pretty certain it was not affecting their performance in the lab. These are good points that they could all be impacting things if they were on strong medications or something. 

Moderator:Thank your. What percentage had tinnitus?

Gabrielle Saunders:Quite a high percentage, I do not know it off the top of my head but I would say more than thirty percent had tinnitus. It is a lot, tinnitus is another symptom as it were of this blast-exposure. 

Sheila Pratt:This is Shelia, I have to say that we were surprised on our chart review that it was not that high, the report of tinnitus, which surprised us, it was relatively low in our group. 

Moderator:We have an attendee write in that says in the Gallun et al study very few had tinnitus that was long lasting requiring treatment. 

Sheila Pratt:Yeah. 

Moderator:In any of these studies, were the subjects evaluated for processing in other modalities?

Gabrielle Saunders:In our study, no, they were not. I have actually been talking about doing a study because it seems like the visual processing difficulties are prevalent among this population too. Where again they have normal visual acuity but they are reporting problems reading and concentrating when they read and things like that. We did not do that but I think that is very important to establish. Have you Sheila?

Sheila Pratt:I agree with you, in our chart pull we did not look at that, but I agree it is very likely that they also have visual processing problems. 

Moderator:The next question, have you found any success with lace?

Gabrielle Saunders:I am laughing because we are in the process to submit a paper on lace, it was for hearing impaired older adults. We showed no support for lace for that population, these are typical older, age related hearing loss and we showed now support for lace in a randomized control trial. Now I would say that there were some people in the lace groups who benefitted but when you look and compared with people who did not get lace and who got a placebo kind of training or cancelling the group averages did not differ. I really doubt that lace would be effective for this particular population because I think it is too general, I think this population could benefit from something like the Brain HQ, which is very, very focused on temporal...

Moderator:Your conference is scheduled to end in five minutes. 

Moderator:You can ignore that I will get us more time. 

Gabrielle Saunders:Which is very focused on temporal auditory processing which makes sense that would help? Lace is just very general tasks and I would not expect it to help with this group. Disappointed it did not help in the age related hearing loss either. 

Moderator:Any success with low gain hearing aids with remote mikes?

Sheila Pratt:I would have to talk to the clinicians first I do not know. 

Gabrielle Saunders:I do not know either, but we are going to look at that somewhat. 

Moderator:Gabbi, how do your CRS scores jive or compare with cognitive scores attained from SLPs or neural psychologists?

Gabrielle Saunders:I do not know, I cannot answer that because we have not looked at SLP scores. It will be interesting to hear from an SLP what they think of the CSRQ actually. 

Moderator:The final question for Gabbi, are there any tools to gauge a veterans interest in using auditory training software?

Gabrielle Saunders:I realize as I develop all these questionnaires that have lots of subtle questions about things, I think just simply asking them. I mean there are things in the world called patient decision aids that essentially help a patient choose an intervention. I am talking about patient decision aids for deciding whether or not you should have your left toe amputated or whether you should take medicine for your thyroid, I do not know what, there is everything out there. To think through all the pros and cons of auditory training and to be able to give that to somebody makes a lot of sense. Asking them if you have any time, do you aveh interest, this is what it looks like, do you like sitting in front of a computer I think we should just ask them very simple questions and that will get the answer. 

Moderator:Thank you both so much for taking the time to present to us. Thank you to our audience members especially those of you that were able to stay on for the Q&A. I am going to close out the session and when I do please take just a moment to fill out the survey questions that are going to pop up on your screen, it is your opinions that help guide the topics that we have presented. Once again I want to thank you so much for everybody joining us, and I see we had one remaining question come in but I am going to ask that person to contact you offline as we have exceeded our time. Thank you once again everyone and have a wonderful day. 

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