As long as American soldiers are sent off to fight on noisy battlefields, many are bound to come home with hearing-related injuries. The continuing conflicts in Iraq and Afghanistan are no exception. However, the ear-related disorders that military audiologists are diagnosing this time around are markedly different from the problems common among soldiers who fought wars in previous decades.
Widespread exposure to improvised explosive devices, or IEDs, has resulted in much greater numbers of traumatic brain injuries, or TBI, that manifest as more complex acoustic trauma such as central auditory processing disorders (CAPD), as well as many more complaints of tinnitus and non-hearing-related complications. That's different from the experience of those who fought in the first Persian Gulf War, Vietnam, and other conflicts of the 20th century. In those theaters of war, soldiers were also exposed to hazardous noise, but the source was typically small-arms fire and the hearing injuries were more commonly found in the ear instead of the brain, according to military audiologists.
Earlier wars produced more penetrating injuries to the brain, as contrasted with the recent epidemic of closed-head trauma. Audiologists refer to the damage done by IEDs to troops in Iraq and Afghanistan as a “signature injury” of those conflicts.
“Soldiers now have very good helmets and other kinds of body armor to protect them and allow them to survive in situations where they previously might not have survived,” explains Marjorie Leek, PhD, interim director of the Department of Veterans Affairs (VA) National Center for Rehabilitative Auditory Research (NCRAR) at the Portland (OR) VA Medical Center. “The closed-head injuries we're seeing occur within the brain, and there isn't a good way to protect against that.”
Diagnosing these newer auditory processing disorders has been challenging, but audiologists and other healthcare professionals are rising to the task. They've devised innovative, multi-disciplinary approaches to address health problems related to TBI and are seeing positive results from their comprehensive diagnostic and treatment programs and follow-up studies, says Lucille Beck, PhD, the VA's Chief Consultant for Rehabilitation in Audiology and Speech.
While hearing-related injuries continue to be the single largest category of casualties among soldiers returning home from the military theater in recent years, the news isn't all grim, says Beck.
She observes, “We do lots of routine examinations before [soldiers] retire from the military as part of an overall physical. Lately we're seeing a larger percentage leaving the service with good hearing compared to previous years.”
AREAS OF IMPROVEMENT
The improved results are attributed to a number of factors, including the following:
* There have been technological advances in devices that protect soldiers' hearing while maintaining their ability to communicate and hear well in dangerous combat environments.
* The military has taken more proactive measures in recent years by instituting educational programs before deploying soldiers to combat so they are skilled in using these devices during battle.
* Audiologists have been deployed overseas in recent years to assess hearing damage to soldiers amidst the fighting and to provide other types of front-line assistance. Providing quicker care and giving soldiers in-depth assessments sooner if hearing problems are detected is helping prevent greater hearing damage.
* Over the past couple of years, the U.S. Army has implemented a policy requiring soldiers to be given a pre-deployment audiogram and post-deployment test to identify hearing readiness in case they need to be re-deployed. This also helps uncover any early warning signs so action can be taken quickly if problems are identified.
* New educational programs are being used to raise general awareness of the importance of protecting hearing so military personnel are motivated to use protective devices and develop other good habits to reduce exposure to noise in combat and in life in general after they are discharged.
On the research front, military audiologists have a significant budget to pursue a wide range of hearing-related studies to help professionals care for returning soldiers, as well as to address hearing problems in the general population. The bulk of VA-funded hearing health research takes place at the NCRAR in Portland. It receives about $6 million a year to support about 40 different studies ongoing at any given time, says Leek.
Results from many of these studies are shared with the larger audiology profession through peer-reviewed journals and presentations at meetings. The findings enhance the knowledge base for all practitioners in the field, she says.
In particular, there has been growing national interest in traumatic brain injuries and concussions in football players and other athletes who often experience head trauma. Front-page news stories have highlighted this growing problem and there is greater interest in understanding how to diagnose and treat these conditions. Military studies related to this issue are of specific importance to those caring for civilians with similar problems. In addition, the VA's team-based approach to this health issue has drawn interest from healthcare disciplines outside of audiology.
As a result, says Lucille Beck, some organizations, including the American Speech-Language-Hearing Association (ASHA), have asked military audiologists and other military professionals to educate speech pathologists and audiologists on diagnostic testing for TBI and to discuss their treatment methodologies.
NOT YOUR GRANDADDY'S WAR
The rules of engagement in Iraq and Afghanistan are very different from those of earlier conflicts. American soldiers are combating enemies who often use IEDs as a weapon of choice in their arsenal, which is dramatically altering the types of hearing-related and other injuries inflicted upon them, according to Col. Kathy Gates, who is Integrated Service Chief for the Audiology and Speech Center for the Joint Hospital Army Navy at Walter Reed National Military Center in Washington, DC, and at Bethesda Naval Hospital.
Military audiologists are finding soldiers returning to the U.S. with fewer obvious hearing problems because their actual ears have often not been damaged in combat, says Gates. However, soon after returning home, a growing number of soldiers (either still on active duty or discharged) have begun complaining of central auditory processing-related problems. These include difficulty understanding speech in noisy environments, trouble understanding rapid, complex sentences, and ringing in their ears that's often associated with tinnitus.
“Use of IEDs wasn't a common tactic in past conflicts,” says Gates. “Noise is always a problem in conflict and war, but it's different this time around.”
Among redeploying soldiers returning from combat duty in 2008 from Iraq and Afghanistan, about one in every four that were assessed was found to have tinnitus and other changes in hearing, according to data compiled by the Armed Forces Health Surveillance Center.
Deploying service members are required to have a pre- and post-deployment health assessment, and the military looks for problems related to tinnitus, balance, noise exposure, and hearing changes as part of a comprehensive exam. In 2008, a new policy was instituted requiring all service members to get pre-deployment and post-deployment audiograms to identify any early concerns when they return home and allow them to receive proper follow up, Gates says.
She adds, “The post-deployment audiogram has put discipline in the process and helped us identify those that need additional services. We've also obtained additional dollars to make sure we establish minimum standards of hearing care across the army.” That standard also includes a new requirement that all operational forces be given an annual audiogram as part of a revamped hearing conservation program. Since 2006, there has been an army-wide tracking system for audiologists and for commanders to know the hearing readiness of their soldiers, Gates says.
Soldiers returning from overseas receive their post-deployment audiogram at their home installation in the U.S. If changes are found in their hearing, they're referred to an audiologist for further evaluation. They may also self-refer if they are experiencing hearing difficulty or auditory processing problems. Soldiers with hearing complaints while still in combat increasingly have access to audiologists, trained medics, and care centers closer to the front lines before returning to the U.S. (see below).
A TEAM-BASED APPROACH TO TBI PATIENTS
Service members who need follow-up care in the U.S. have access to audiology services through their local military treatment facility. After they leave active duty, military personnel and reserve duty members receive care and treatment through a VA facility. Currently, the VA offers audiology services at all 153 of its medical centers in the U.S. and at a total of 230 sites, including its outpatient clinics, says the VA's Beck.
Beck adds that her agency has moved aggressively to establish a team-based approach to diagnosing and treating newly discharged soldiers from Iraq and Afghanistan with TBI who are arriving at VA medical facilities with symptoms of central auditory processing disorders (CAPD) and tinnitus. The teams consist of audiologists working closely with rehabilitation physicians, psychologists, nurses, speech-language pathologists, physical therapists, neurologists, and others to identify the problems and develop individualized treatment plans for each patient.
Aside from difficulty hearing in background noise, TBI patients are reporting many other complaints that warrant a wider range of healthcare expertise, says Beck. These may include memory loss, difficulty following conversations, poor concentration, headaches, and inability to sleep. Once a patient's condition has been diagnosed and evaluated, individualized treatment plans are necessary because most patients experience a different mix of symptoms, she notes.
Over the last 5 years, the VA has set up “polytrauma/TBI teams” at 108 facilities and clinics throughout the country.
In many instances, patients require hearing aids or other amplification, and the VA provides whatever technology they require, says Beck. Many receive FM systems, which work well in noisy situations. Some receive wireless technology, which can be connected to cell phones. And many patients also benefit from rehabilitative treatment.
VA audiologists can generally respond to TBI patients' tinnitus symptoms using a new clinical management protocol. It was developed through a research initiative at the Auditory Research Center at the Portland VA Medical Center. Since tinnitus patients experience varying symptoms and don't respond uniformly to the same treatment, the protocol instructs practitioners to design individual management plans. These plans, which can include hearing aids and sound therapies, have been producing positive patient outcomes, Beck reports.
The success of the VA clinical protocol for tinnitus can have benefits beyond the veteran community since tinnitus is common in the general population. Beck has discussed the protocol with non-government audiologists and also spoke on it before the Invisible Wounds Caucus in the U.S. Congress last fall, which was chaired by Rep. Harry Teague (D-NM), a strong supporter of veterans healthcare.
VA's research response to TBI
The VA's auditory researchers are so concerned about the large number of young soldiers coming home with traumatic brain injuries that they decided to study it closely to devise better diagnostic capabilities and treatments, says Marjorie Leek at the NCRAR.
“These injuries are so unusual and it's so new that there aren't good ways of diagnosing and treating all the symptoms,” Leek admits. “The people [with TBI] tend to be young and healthy except for their war injury, and now they suddenly have difficulty understanding speech in noisy environments. These are complaints we typically hear from elderly people.”
In 2007, the VA began a joint study with Walter Reed on soldiers recently returned from Iraq and Afghanistan who were exposed to loud blasts in combat, such as those from IEDs. The study, which ended last fall, is intended to determine the functional effects of those injuries. With that information, researchers hope to improve the diagnostic component so audiologists will know what tests can detect if there's a central auditory processing disorder. The findings are under review.
Another active study related to TBI is focusing on whether or not rehabilitative therapies, such as auditory training, can make a difference in managing patients exposed to loud blasts, says Gabrielle Saunders, PhD, a research scientist and NCRAR's deputy director of education, outreach, and dissemination. Other approaches include FM systems, counseling, and communication tips. That study, which is being conducted in Tampa and Portland, is expected to continue for 2 more years, says Saunders.
Studies like these are important, says Leek, because individuals with TBI who go to an audiologist complaining of mild hearing loss or other symptoms might not get a proper diagnosis if the practitioner isn't conducting the right tests. They also might get less than optimum treatment if the practitioner isn't informed of all the options and their potential benefits.
She adds, “If an audiologist is unaware that there are central auditory processing problems they might tell patients their hearing loss isn't much to worry about,” says Leek. “Central processing testing isn't routinely done and rehab isn't routinely done. With our research, we're trying to establish what tests audiologists should be using for which types of patients.”
She continued, “If a young person who's been exposed to a blast goes to an audiologist complaining of not being able to hear in noisy situations or having difficulty with people talking too fast, that should be a red flag for the audiologist to look for central processing problems. This could also apply to young people who've had sports injuries.”
The Army has always considered hearing protection on the battlefield a high priority. But while soldiers have long been trained in how to use protective hearing devices in combat, it was widely known that many of them were non-compliant, in part because they were afraid the devices would cause them to miss important communication during battle.
However, since 2008, the Army has made a formal hearing education program part of basic training for recruits before they ever see conflict. So states Maj. Jillyen E. Curry-Mathis, Army Hearing Program Manager at Fort Jackson, SC, which is the army's largest basic training facility in the U.S. Curry-Mathis, who worked as a pediatric audiologist for a decade before joining the military, is now in charge of four components of the army's hearing program: hearing readiness, operational hearing services, clinical hearing services, and hearing conservation services.
Curry-Mathis plays an important role in the basic training of these recruits. Among the issues her educational sessions cover are why it's critical to have good hearing in combat, how noise damages hearing, and how to wear hearing protection properly. She encourages soldiers to embrace the concept of using technology that both protects their hearing and enhances communication ability in combat situations.
In 2008, about 45,000 soldiers were trained at Fort Jackson, but the program was relatively new and not everyone took those classes that year. However, by 2010, every soldier going through basic training at Fort Jackson received the hearing care education as part of the overall program.
Curry-Mathis reports, “Drill sergeants tell us compliance [on wearing protective hearing devices] among trainees changes dramatically after education.” Thoroughly training soldiers how to use their protective hearing devices is the only way to boost compliance significantly once they get to the area of conflict, asserts Col. Gates.
She says, “It's our goal to make sure we're giving soldiers the needed protection and communication device that will also allow them to accomplish their mission. The key to success is training. We can't just hand [the devices] out and expect the soldier to wear them. We don't hand a soldier an M16 and then deploy. They're trained with it first. The same thing applies with an earplug. We're in the process of making this a standard part of education at all our training sites.”
AUDIOLOGY ON THE FRONT LINES
Curry-Mathis understands first-hand the importance of getting soldiers to wear their earplugs and other devices in battle to conserve their hearing, and she no doubt shares her personal experience with the trainees she's educating. In early 2008, she was stationed at the U.S military base in Baghdad, where she was responsible for screening soldiers in the field who were exposed to loud blasts.
With her portable audiometer in a rucksack on her back, Curry-Mathis would climb aboard a Blackhawk helicopter and regularly fly out to soldiers wherever they were stationed and screen anyone who had concerns about loud noise exposure. In the field, she conducted gross assessments. If the outcome suggested more tests were needed, the soldier was flown to a Baghdad where the tests would be performed at a health center.
“It was a huge advantage that I could go to them in the field because it wasn't always possible for a soldier to leave his unit for a couple days to get his hearing assessed,” she recalls.
Curry-Mathis also coached soldiers in Iraq on how to use protective hearing equipment. She routinely carried about 20 sets of tactical communication and protective systems, or TCAPS, in her rucksack when she traveled to the front lines. They weighed 60 or 70 pounds. At six feet tall, Curry-Mathis didn't mind carrying all that equipment around, she says, as long as it was helpful for the soldiers.
Another way she helped improve the military's front-line response to hearing problems was by training medics to assess soldiers for hearing impairment if they had complaints about another injury after an incident.
“Hearing injuries are the most under-identified problems since they're painless and there's no blood,” Curry-Mathis explains. “We showed the medics how to ask some key questions, depending on the type of incident. If a blast occurred, the medic should ask soldiers if they were wearing their earplugs, whether their ears are ringing, and whether they feel like they have any hearing loss. We also showed them to look for a ruptured eardrum by looking in a person's ears. It's important just to get the soldiers to start talking about it.”
As of last summer, the army had audiology technicians in Iraq, but none in Afghanistan, says Gates. She adds that the army was looking at increasing its audiology capabilities there soon.
HEARING LOSS EDUCATION BOOTH
In a collaborative program with the Department of Defense, VA researchers created portable education booths that can be installed in high-traffic areas at military medical centers and army bases. The booths, like that shown in Figure 1, are still in the testing phase. They are intended to heighten awareness among active military personnel and veterans about the importance of good hearing and how to protect against harmful noises on the battlefield and in everyday life. The booths feature various interactive modules on a computer screen, explains Robert L. Folmer, PhD, a research investigator at the NCRAR in Portland, who is also an associate professor of otolaryngology at Oregon Health & Science University in Portland.
The pilot project is starting out with three booths, and will eventually be disseminated throughout the country, says Folmer. The first was installed last year on the main floor of the Portland VA Medical Center, and the other two were scheduled to be set up late last year at army bases in Fort Lewis, WA, and Fort Bragg, NC. The plan is to place them up in medical waiting areas where soldiers might have time to check out the booth while they're waiting for an appointment.
The booths are compact—6-by-9 feet—and wheelchair accessible. When someone enters the booth, the person sits down and puts on headphones connected to a computer touch screen. Soldiers are offered a choice of several modules. For example, says Folmer, they can test their own hearing at some of the higher frequencies and have the results printed out on the spot, with a possible recommendation depending on the findings.
Another module is more educational. It explains how hearing works and how it's damaged by loud sounds. The booths at the army bases will also allow soldiers to check how well their earplugs fit. Another program demonstrates what speech and music might sound like with hearing loss.
“Our hope is to get soldiers to use their protective devices once they experience how difficult it is to have hearing loss [using these simulated situations],” says Folmer. “The booths at the army bases will stress the importance of being ready for duty and ready to carry out their mission, hear the enemy, and employ good strategies to protect their hearing. The booths at the VA hospitals will mainly stress quality-of-life issues for veterans who are already home [from combat].”
To ensure the booths are effective, Saunders is running a trial. One aspect of the trial entails asking a veteran to use the program or read information that's contained in a module found in one of the booths. Those veterans will be followed to see if the new information changes their attitude about hearing care and affects their behavior patterns, Saunders says. Results of the trial are expected later this year.
PRIORITY ON CARE AND PREVENTION
The Department of Defense and Department of Veterans Affairs continue to be leaders in developing new ways to diagnose and treat hearing disorders. Americans currently serving in the military as well as veterans benefit from the preventive measures and care protocols developed by VA and DOD clinicians and researchers. A vigorous emphasis on hearing prevention and education has begun to show results, as fewer of the soldiers being discharged from the military are leaving with hearing problems.
“Hearing loss doesn't need to be a byproduct of military service, and we're working hard to reverse that trend,” says Col. Gates.
Beyond the military, the good news is that most of the findings and diagnostic and treatment protocols being developed have beneficial applications to the broader population.
“There is very good collaboration between the private sector and VA audiologists,” says Beck. “We expect that to continue.”