Mild TBI Diagnosis and Management 

Strategies

Gabrielle Saunders, Ph.D.

National Center for Rehabilitative Auditory 

Research (NCRAR) 

http://www.ncrar.research.va.gov/ 
Common Subjective Complaints of Blast 

Exposed Veterans

“I can’t follow a 

conversation in a 

crowded room” 

“Sometimes I get 

frustrated when people 

talk too fast or mumble”

“My hearing problem 

impacts both my 

work and family 

relationships”

“I have difficulty with 

focus and concentration” 
Poll question: 

Have you encountered Veterans 

like this? 

Yes No 
What are the options for Rehabilitation?

Bottom-Up 

approaches: 

Enhancement of the 

acoustic signal

 Amplification

 FM systems

 Auditory Training

Top-Down approaches: 

Teaching compensatory 

strategies

 Auditory Training of

Memory 

Attention 

Language

 Communication skills
Amplification

Hearing aids - the standard rehabilitation for hearing 

 impairment. 

What a hearing aid can do: 

Amplify sounds

Shape output

Adjust for abnormal loudness 

growth

What a hearing aid cannot do:

x Determine what is ‘signal’ vs. 

what is ‘noise’

x Improve the signal-to-noise-ratio 

(yet) i.e. filter noise

x Restore clarity

Can a hearing aid help auditory processing disorders?

Perhaps - by decreasing the effort required to hear thus 

freeing up more processing capacity 
Personal FM system

FM receiver worn 

behind the ear 

picks up the signal

Transmitter with 

microphone 

FM radio waves
Personal FM system

Advantages:

 Will improve signal-to-noise ratio (SNR) if used correctly

 By doing so more resources are made available for use in 

higher level auditory processing

 Successful for children with auditory processing problems

 Available with and without amplification

Disadvantages: 

x Requires the user to wear a device 

x Is a ‘prop’ not a fix
Computerized Auditory Training (AT)

• Aim to harness the brain’s capacity for physical and 

functional change through repeated and persistent 

stimulation i.e. neural plasticity 

• Commercially-available programs

• Program features: 

Adaptive, push performance to upper end of limit

Track performance, - can thus provide feedback and 

rewards 

Require intensive and near-daily training over a period of 

weeks in order to generate cortical change
Computerized Auditory Training (AT)

Advantages:

 Potential for sustainable change (a fix) for processing 

difficulties. 

 No device required 

 Can train at own convenience

Disadvantages:

x Requires discipline and time commitment before 

any benefit may be realized.
Communication strategies education

 Train problem-solving skills in real world communication 

situations
Evaluation of Approaches to Auditory 

Rehabilitation for mTBI

PI: Gabrielle Saunders

Co-Is: Terry Chisolm & Paula Myers

Research Audiologists: Melissa Teahen & 

Michelle Arnold

VA RR&D grant #: C7054R. 
Participants

 OEF/OIF Veterans

 Normal or near normal peripheral 

hearing sensitivity

 Reported blast exposure during 

deployment

 Self-reported functional hearing difficulties

 Recruited from Portland and Tampa VA 

medical centers
2-site randomized controlled trial

Consenting, Screening

Baseline Testing

Post-intervention 

testing

Education+

FM System

Education +

Auditory Training + 

FM System

Education +

Auditory 

Training

Education

(Control) 

Random assignment to intervention

8-12 weeks
• Speech-in-noise (Listening in Spatialized Noise)

• Speech-in-noise (HINT)

• Gap detection (Adaptive Tests of Temporal Resolution)

• Time Compressed Speech

• Working memory (Digit Span Test)

• Dichotic listening (Staggered Spondaic Word test)

• Attention/Interference (Stroop Color Word Test)

• Functional Hearing Questionnaire

• Speech Spatial and Qualities Questionnaire - comparative 

• Cognitive Self-Report Questionnaire 

• Psychosocial Impact of Assistive Devices Scale
Speech Spatial and Qualities 

Questionnaire - Comparative (SSQ-C)

• Designed to measure self-reported auditory 

disability for speech, spatial processing and 

sound quality relative to before intervention.

 

Gatehouse & Noble (2004) Int. J. Audiol 43(2):85-99
Speech Spatial and Qualities 

Questionnaire- Compare (SSQ-C)

You are talking with 

one other person and 

there is a TV on in the 

same room. Without 

turning the TV down, 

can you follow what 

the person you’re 

talking to says?

Not applicable

Much worse Much better

-5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5

Unchanged 

Comparing your ability now with your ability before 

this study

Not applicable

Much worse Much better

-5 -4 -2 -3 0 -1 +1 +2 +3 +4 +5

Unchanged 

Comparing your ability now with your ability before 

this study You are talking with 

one other person in a 

quiet, carpeted 

lounge-room. Can you 

follow what the other 

person says?
Cognitive Self Report Questionnaire 

(CSRQ)

• A 64-item questionnaire assessing daily 

functioning on 8 subscales:

Attention, Executive function, Memory, Language, 

Vision, Hearing, Energy, Satisfaction. 
I lose my train of thought... Less 

often

Same as 

before

More 

often

Does not 

apply

My ability to pay attention 

to more than one thing at a 

time is...

Better Same as 

before

Worse Does not 

apply

My ability to remember 

phone numbers is...

Better Same as 

before

Worse Does not 

apply

My ability to hear things 

clearly is .... Better Same as before Worse Does not apply

My peripheral vision is... Better Same as 

before Worse Does not apply

I engage in activities with

other people...

More 

often

Same as 

before Less often Does not apply

My ability to focus on a

task is... Better Same as before Worse Does not apply

Cognitive Self Report Questionnaire 

(CSRQ)
Case studies

2 Veterans who used an FM system

2 Veterans who used the Auditory Training program
Case 1 – FM user

Army Veteran who served 5.5 mth deployment initial Iraq 

invasion 

5 blasts within 100m and dozens of others further away

– Experienced headaches (maybe due to protective gear)

– Not sure whether he lost consciousness

Vehicle accident – humvee fell into a 6ft hole

– Thrown from vehicle and hit head

Fall in civilian life

– Concussion 
Case 2 – FM user

Army Veteran who served 2007-2008 in deployment in 

Iraq 

10-20 blasts

– No headaches or loss of consciousness

Vehicle accident

– No headaches or loss of consciousness

Fall from gun turret 

– Head aches, confusion, loss of consciousness
FM users

Age Gender

PTA L/R

(dB HL)

Word 

recognition 

L/R (%) PTSD TBI

Case 1 29 M 8.8/2.5 88/92 Y Y 

Case 2 34 M 8.8/7.5 88/96 ? N 

Study 

gp

33.9 M 

81% 

12.6/11.7 96/96 Y 

52% 

Y 

21%
Baseline scores

LISN-S 

Talker 

advantage

LISN-S 

Spatial advantage

HINT 

 

Case 1 > 1 SD 

below norms

> 1 SD 

below norms

Poorer than 

25th percentile 

Case 2 Average Average Better than 75th 

percentile

Study gp. > 1 SD 

below norms

> 1 SD 

below norms

At 50th 

percentile
Results:

Case 1

Used FM 3-4 days/week for 8 hr./day

Very useful in classes

Obtained FM from audiology clinic

Helped him ‘psychologically’

Case 2 

Hardly ever used it. Tried it but gave up 

Sometimes FM worked well in restaurants and at home.

Not helpful for 

System picked up background noise

Did not work well for him
-2

-101234

123

Benefit [Range: -8 to +8]

0 

2 

4 

1 

More benefit

3 

-2 

-1 

Speech Spatial Qualities 

Benefit [Range: -5 to +5]

SSQ-C scores for FM users

Case 1

Case 2

X All subjects
-4

-2

0

2

4

6

8

10

1 2 3 4 5 6 7 8

Benefit [Range: 

-8 to +8]

0 

2 

4 

6 

More benefit

8 

-2 

-4 

X 

CSRQ scores for FM users

Case 1

Case 2

X All subjects
Results: What seems to predict outcome? 

Baseline speech in noise performance 

Veteran 1 had poor performance, Veteran 2 did not 

Life style

Veteran 1 used it for school, Veteran 2 didn’t find a good use for it 

Understanding of how and when to use it 

Veteran 2 reported it picked up background noise. Surprising if 

used properly (system had directional settings)

Underlying etiology 

Problems of Veteran 2 may be associated with PTSD not CAPD 

from mTBI. 
Case 3 - AT

Army Veteran who served 2006-2007 deployment in 

Afghanistan 

4-5 mortar and rocket blasts a week 

– No headaches or loss of consciousness

Fall

– Head injury, loss of consciousness and amnesia for the event
Case 4 - AT

Army Veteran who served in Iraq during 2004

Exposed to about 20 IED/mortar/rocket blasts

– Experienced headaches

One humvee blast

– Hit head on window, lost consciousness, felt dazed

Two vehicle accidents within two weeks 
AT users

Age Gender

PTA L/R

(dB HL)

Word 

recognition 

L/R (%) PTSD TBI

Case 3 52 F 11.6/13.3 100/100 Y Y 

Case 4 46 M 6.6/10.0 92/92 Y N 
Baseline scores

LISN-S 

Talker 

advantage

LISN-S 

Spatial advantage

HINT 

 

Case 3 Average > 2 SD 

below norms Average

Case 4 Average Average Average
Results:

Case 3 

Completed 30 of 40 training sessions 

Felt program really helped

Has ‘greater awareness’ and ‘keener insight’ 

Did not like all tasks

Case 4 

Completed 16 of 40 training sessions 

Feels training did not improve his hearing 

Some exercises were fun, some were boring, overall 

the training was too long
-2

-101234

Benefit [Range: -8 to +8]

0 

2 

4 

1 

More benefit

3 

-2 

-1 

Speech Spatial Qualities 

Benefit [Range: -5 to +5]

SSQ-C scores for AT users

Case 3

Case 4

X All subjects
-4

-202468

10

1 2 3 4 5 6 7 8

Benefit [Range: -8 to +8]

0 

2 

4 

6 

More benefit

8 

-2 

-4 

X 

CSRQ scores for AT users

Case 3

Case 4

X All subjects
Results: What seems to predict outcome? 

Baseline speech in noise performance: 

Veteran 3 had poorer performance than Veteran 4

Severity of baseline reported problems: 

Veteran 3 specified processing time, fast speech and following 

long conversations/verbal instructions as problems. Veteran 4 

reported fewer and less severe problems. 

Time availability and motivation: 

Veteran 3 was not working but was looking for employment 

while Veteran 4 worked full time

Underlying etiology: 

Problems of Veteran 4 may be associated with PTSD not CAPD 

from mTBI
Summary

Data show both interventions can work BUT there is 

individual variability
Clinical take-home message

Factors to consider: 

– Baseline problems

– Motivation to use intervention

– Life style 

– Time availability

– Speech-in-noise ability

– Other?

Ideally we could predict who will and won’t benefit up 

front – but don’t yet know how to. 

 
Open-ended responses please

Poll question: 

Based on your clinical practice 

and knowledge, what else should 

we consider? 
Future and ongoing translational research

 Provision of mild gain hearing aids for this population and 

examine the relationship between auditory symptoms in 

mTBI and PTSD - Sheila Pratt (PI). 

 Correlations between multiple combat blast insults 

and sports concussions in collaboration (NCRAR and Oregon 

Health & Sciences University Sports Medicine Concussion 

Team

 Collaborating with Portland VA 

Audiology Clinic on clinical 

implementation of research 

findings
Thank you for listening
Contact information 

• Sheila.pratt@va.gov

• Gabrielle.saunders@va.gov

Questions? 
Mild TBI Diagnosis and 

Management Strategies

Sheila Pratt, Ph.D.

Geriatric Research Education and Clinical Center 

VA Pittsburgh Healthcare System

And

Department of Communication Science and Disorders

University of Pittsburgh

Pittsburgh, PA
Pole Question

Who is in the Audience?

• Military Audiologist

• VA Audiologist

• Military SLP

• VA SLP

• Physician

• Neuropsychologist or Behavioral Health 

Professional

• Other 
Central Auditory Processing Deficits

• Developmental 

• Acquired

• Trauma (e.g., mTBI)

• Cardiovascular

• Metabolic

• Tumors and other structural abnormalities

• Experiential 
Mild Traumatic Brain Injury

(Hoge et al., 2008; Terrio et al., 2009; Wilk et al., 2010)

• One of the most common injuries to military 

service members in recent conflicts.

• ~15-25% of military personnel deployed in 

Iraq and Afghanistan have experienced 

trauma consistent with mTBI.
Common Definition 

(American Congress of Rehabilitation Medicine; Kay et al., 1993)

• A physiological disruption of brain function 

manifested by alteration of mental state, loss of 

consciousness, and/or loss of memory or focal 

neurological deficit that may or may not be 

transient, but where the severity of the injury does 

not exceed the following:

• Loss or alteration of consciousness for less than 30 min

• Post-traumatic amnesia for less than 24 hours

• After first 30 min a Glasgow Coma Scale score of 13-15
Military Operational Definition

“...an injury to the brain resulting from an external force 

and/or acceleration/deceleration mechanism from an 

event such as a blast, fall, direct impact, or motor vehicle 

accident which causes an alteration in mental status 

typically resulting in the temporally related onset of 

symptoms such as: headache, nausea, vomiting, 

dizziness/balance problems, fatigue, insomnia/sleep 

disturbances, drowsiness, sensitivity to light/ noise, 

blurred vision, difficulty remembering, and/or difficulty 

concentrating.” 

(Defense and Veterans Brain Injury Center, 2006)
mTBI and Blast

• Commonly a consequence of explosive blast 

(Taber et al., 2006; Warden, 2006).

• ~75% of military mTBI cases are associated with blast 

exposure. 

• Pressure waves

• Secondary, tertiary and quaternary insults

• High-intensity noise
Neural Effects

• Typically a lack of gross abnormalities on structural 

neuroimaging scans (i.e., CT, MRI; Niogi & Mukherjee, 

2010; Tombaugh et al.,2007).

• Biomechanical and biochemical evidence of 

ultrastructural brain damage and cell death(Cernak et al., 

2001).

• Micro-lesions that become more diffuse with increased 

numbers of blast exposures (Davenport et al., 2012).

• Small cortical and sub-cortical bleeds (Taber et al., 2006). 

• Changes in functional activation and white matter 

integrity (e.g., fMRI, diffusion tensor imaging; 

MacDonald et al., 2011; Matthews et al., 2011).
Physical Symptoms

• Headaches and other pain

• Impaired sensory function

• Hearing and tinnitus

• Balance 

• Dizziness

• Vision

• Taste and smell

• Multisensory impairments

• Nausea

• Reduced energy
Cognitive

(Belanger et al., 2005; LeBlanc et al., 2006; McAllister et al., 2006; 

Ruff et al., 2010) 

• Attention and concentration

• Processing speed

• Reaction time

• Memory 

• Decision skills

• Speech and language difficulties
Behavioral

(Sheedy et al., 2006 and others)

• Irritability

• Quick to anger

• Anxiety 

• Sadness and depression

• Hyper-arousal

• Impulsivity

• Sleep disturbances

• Overuse of drugs, alcohol and tobacco
Time Course

(Bales et al., 2009; Corrigan et al., 2010; Ivins et al., 2009; 

Terrio et al., 2009) 

• Commonly believed that most overt symptoms 

tend to dissipate within days to 3 months of the 

brain injury for most mTBI patients.

• Subtle or sub-clinical symptoms may persist.

• Some symptoms may become evident or 

problematic later and in different contexts.

• Concerns about age at injury and increased 

neural degeneration with age.
Other Issues

• Often missed if in the presence of other more 

obvious or serious injuries.

• Many military personnel and veterans with 

mTBI do not realize they have been concussed. 

• Many do not have a formal diagnosis of mTBI. 

• Nature, magnitude, and frequency of blasts 

vary.

• PTSD?

• Substantive variability across patients.
Blast and Auditory System

(Belanger et al., 2011; Gondusky & Reiter, 2005; Helfer et al., 2005;

Patterson & Hamernik, 1997)

• Most common effects of blast

• Tympanic membrane and middle ear damage

• Cochlear damage resulting in sensory hearing loss

• Tinnitus 

• Less common but clinically remarkable

• Central auditory deficits

• Cognitive deficits subtended by the auditory system
Central Auditory Dysfunction

• Complaints of difficulty hearing in noise and 

complex listening and social situations

• Many have normal results on standard 

audiometric testing including word recognition 

in quiet

• Elevated hearing handicap scores

• Impact on family, work and school

• No consensus on assessment protocol
Auditory System and Related 

Regions at Risk

(Chafi et al., 2010; Taber et al., 2006) 

• Lower and mid brainstem

• Thalamus

• Corpus callosum

• Cerebellum

• Orbitofrontal
Central Auditory Dysfunction 

and Blast Exposure (Gallun et al., 2012) 

• 36 blast-exposed 

• 17 non-mTBI, 19 mTBI

• 39% reported reduced hearing in quiet since blast 

exposure 

• 78% reported difficulty hearing speech in noise

• 29 non-blast-exposed controls

• Normal to mild hearing loss on standard 

audiometric measures 

• Air and bone conduction puretone thresholds, NU-6, 

DPOAE
Central Tests

• Auditory electrophysiological testing

• ABR, LLR with an oddball paradigm

• Behavioral tests of central auditory function

• Frequency Pattern Test, Gaps-in-Noise, 

Masking Level Difference, Dichotic Digits, 

Staggered Spondaic Words

• Speech perception in noise

• Quick Speech-in-Noise (Quick SIN) 
Overall Pattern of Results

• Normal ABR but abnormal LLR results (right 

ear P300 amplitude and latency, left ear N100 

amplitude).

• Normal Frequency Pattern Test and Dichotic 

Digits, but abnormal Gaps-in-Noise, Masking 

Level Difference, and Staggered Spondaic 

Words.
Abnormal LLR Results 

(N100 and P300 Components)
Number of Abnormal 

Behavioral Results
Chart Review at VA Pittsburgh

(Jorgensen et al.)

Characteristics

Gender Male-43 Female-2

Age Median=29.5, SD=11.07

NU-6 Scores Right-96.8% Left-96.3%

HHIA-S Score Mean=26.39, SD=8.85

mTBI Diagnosis 15.5%

• 45 veterans with history of blast-exposure. 

• Normal or near-normal standard audiometric test 

results.

• All complained of difficulty hearing in noise and 

difficult listening situations.
Behavioral Central Tests

• Masking Level Difference

• Gap Detection

• Staggered Spondaic Words

• SCAN 3:A
SCAN 3:A

Subtest Performance

 Norm Mean SD

Auditory Figure Ground 0 dB 25-40 19.6 6.9

Competing Words: free recall 24-40 24.2 7.5

Filtered Words 23-40 34.5 3.7

Competing Words: directed 

ear

39-60 41.1 8.8

Competing Sentences 63-70 62.5 7.2

Auditory Figure Ground 8 dB 37-40 36.4 8.4

Time Compressed Sentences 56-60 57.5 3.1
Sample Testing Protocol

• Sample across the auditory system and functions

• Standard audiometric battery

• Air and bone conduction thresholds 

• What to do with patients with hearing loss?

• Speech in quiet

• Tympanometry

• DPOAE

• Hearing handicap scale (e.g., HHIA)

• Other scales and questionnaires
Central Tests

• Auditory electrophysiology

• Minimally ABR, P300 

• Possible behavioral measures 

• Temporal fine structure

• MLD

• GIN

• SSW

• Speech in noise and/or with competing signals with differing 

linguistic loads

• Test of spatial hearing

• Auditory tests of auditory memory and executive function

• Visual processing and reading tasks
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