Curtis J. Billings

Electrophysiological assessments of cognition and sensory processing in TBI: applications for diagnosis, prognosis and rehabilitation.

Traumatic brain injuries are often associated with damage to sensory and cognitive processing pathways. Because evoked potentials (EPs) and event-related potentials (ERPs) are generated by neuronal activity, they are useful for assessing the integrity of neural processing capabilities in patients with traumatic brain injury (TBI). This review of somatosensory, auditory and visual ERPs in assessments of TBI patients is provided with the hope that it will be of interest to clinicians and researchers who conduct or interpret electrophysiological evaluations of this population. Because this article reviews ERP studies conducted in three different sensory modalities, involving patients with a wide range of TBI severity ratings and circumstances, it is difficult to provide a coherent summary of findings. However, some general trends emerge that give rise to the following observations and recommendations: 1) bilateral absence of somatosensory evoked potentials (SEPs) is often associated with poor clinical prognosis and outcome; 2) the presence of normal ERPs does not guarantee favorable outcome; 3) ERPs evoked by a variety of sensory stimuli should be used to evaluate TBI patients, especially those with severe injuries; 4) time since onset of injury should be taken into account when conducting ERP evaluations of TBI patients or interpreting results; 5) because sensory deficits (e.g., vision impairment or hearing loss) affect ERP results, tests of peripheral sensory integrity should be conducted in conjunction with ERP recordings; and 6) patients state of consciousness, physical and cognitive abilities to respond and follow directions should be considered when conducting or interpreting ERP evaluations.

Aided cortical auditory evoked potentials in response to changes in hearing aid gain

Abstract Objective: There is interest in using cortical auditory evoked potentials (CAEPs) to evaluate hearing aid fittings and experience-related plasticity associated with amplification; however, little is known about hearing aid signal processing effects on these responses. The purpose of this study was to determine the effect of clinically relevant hearing aid gain settings, and the resulting in-the-canal signal-to-noise ratios (SNRs), on the latency and amplitude of P1, N1, and P2 waves. Design & Sample: Evoked potentials and in-the-canal acoustic measures were recorded in nine normal-hearing adults in unaided and aided conditions. In the aided condition, a 40-dB signal was delivered to a hearing aid programmed to provide four levels of gain (0, 10, 20, and 30 dB). As a control, unaided stimulus levels were matched to aided condition outputs (i.e. 40, 50, 60, and 70 dB) for comparison purposes. Results: When signal levels are defined in terms of output level, aided CAEPs were surprisingly smaller and delayed relative to unaided CAEPs, probably resulting from increases to noise levels caused by the hearing aid. Discussion: These results reinforce the notion that hearing aids modify stimulus characteristics such as SNR, which in turn affects the CAEP in a way that does not reliably reflect hearing aid gain. Sumario Objetivo: Existe interés en el uso de los potenciales evocados auditivos corticales (CAEP) para evaluar la adaptación de auxiliares auditivos y la plasticidad relacionada con la experiencia, asociada a la amplificación; no obstante, se sabe poco sobre los efectos del procesamiento de las señales de los auxiliares auditivos sobre esas respuestas. El propósito de esta investigación fue determinar el efecto clínicamente relevante de los ajustes de ganancia de auxiliares auditivos y las relaciones señal/ruido (SNR) resultantes en el conducto auditivo, sobre la latencia y la amplitud de las ondas P1, N1 y P2. Diseño y muestra: Se registraron en nueve adultos normoyentes los potenciales evocados y las mediciones acústicas en el conducto auditivo externo en condiciones de amplificación o sin ella. En la primera condicion, se envió una señal de 40-dB al auxiliar auditivo programado para proveer cuatro niveles de ganancia (0, 10, 20 y 30 dB). Como control, se parearon niveles de estímulos sin amplificación con las salidas de los estímulos amplificados (p.ej., 40, 50, 60 y 70 dB) para efectos comparativos. Resultados: Cuando los niveles de la señal están definidos en términos de niveles de salida, los CAEP con amplificación fueron sorprendentemente menores y tardíos que los CAEP sin amplificación, probablemente como resultado de los incrementos en los niveles de ruido, causados por el auxiliar auditivo. Discusion: Estos resultados refuerzan la idea de que los auxiliares auditivos modifican las características de los estímulos como la SNR, la cual a su vez afecta los CAEP en una forma que no refleja confiablemente la ganancia del auxiliar auditivo.

Predicting perception in noise using cortical auditory evoked potentials.

Speech perception in background noise is a common challenge across individuals and health conditions (e.g., hearing impairment, aging, etc.). Both behavioral and physiological measures have been used to understand the important factors that contribute to perception-in-noise abilities. The addition of a physiological measure provides additional information about signal-in-noise encoding in the auditory system and may be useful in clarifying some of the variability in perception-in-noise abilities across individuals. Fifteen young normal-hearing individuals were tested using both electrophysiology and behavioral methods as a means to determine (1) the effects of signal-to-noise ratio (SNR) and signal level and (2) how well cortical auditory evoked potentials (CAEPs) can predict perception in noise. Three correlation/regression approaches were used to determine how well CAEPs predicted behavior. Main effects of SNR were found for both electrophysiology and speech perception measures, while signal level effects were found generally only for speech testing. These results demonstrate that when signals are presented in noise, sensitivity to SNR cues obscures any encoding of signal level cues. Electrophysiology and behavioral measures were strongly correlated. The best physiological predictors (e.g., latency, amplitude, and area of CAEP waves) of behavior (SNR at which 50 % of the sentence is understood) were N1 latency and N1 amplitude measures. In addition, behavior was best predicted by the 70-dB signal/5-dB SNR CAEP condition. It will be important in future studies to determine the relationship of electrophysiology and behavior in populations who experience difficulty understanding speech in noise such as those with hearing impairment or age-related deficits.

Clinical Use of Aided Cortical Auditory Evoked Potentials as a Measure of Physiological Detection or Physiological Discrimination

The clinical usefulness of aided cortical auditory evoked potentials (CAEPs) remains unclear despite several decades of research. One major contributor to this ambiguity is the wide range of variability across published studies and across individuals within a given study; some results demonstrate expected amplification effects, while others demonstrate limited or no amplification effects. Recent evidence indicates that some of the variability in amplification effects may be explained by distinguishing between experiments that focused on physiological detection of a stimulus versus those that differentiate responses to two audible signals, or physiological discrimination. Herein, we ask if either of these approaches is clinically feasible given the inherent challenges with aided CAEPs. N1 and P2 waves were elicited from 12 noise-masked normal-hearing individuals using hearing-aid-processed 1000-Hz pure tones. Stimulus levels were varied to study the effect of hearing-aid-signal/hearing-aid-noise audibility relative to the noise-masked thresholds. Results demonstrate that clinical use of aided CAEPs may be justified when determining whether audible stimuli are physiologically detectable relative to inaudible signals. However, differentiating aided CAEPs elicited from two suprathreshold stimuli (i.e., physiological discrimination) is problematic and should not be used for clinical decision making until a better understanding of the interaction between hearing-aid-processed stimuli and CAEPs can be established.

Sensitivity of offset and onset cortical auditory evoked potentials to signals in noise.

OBJECTIVEnThe purpose of this study was to determine the effects of SNR and signal level on the offset response of the cortical auditory evoked potential (CAEP). Successful listening often depends on how well the auditory system can extract target signals from competing background noise. Both signal onsets and offsets are encoded neurally and contribute to successful listening in noise. Neural onset responses to signals in noise demonstrate a strong sensitivity to signal-to-noise ratio (SNR) rather than signal level; however, the sensitivity of neural offset responses to these cues is not known.nnnMETHODSnWe analyzed the offset response from two previously published datasets for which only the onset response was reported. For both datasets, CAEPs were recorded from young normal-hearing adults in response to a 1000-Hz tone. For the first dataset, tones were presented at seven different signal levels without background noise, while the second dataset varied both signal level and SNR.nnnRESULTSnOffset responses demonstrated sensitivity to absolute signal level in quiet, SNR, and to absolute signal level in noise.nnnCONCLUSIONSnOffset sensitivity to signal level when presented in noise contrasts with previously published onset results.nnnSIGNIFICANCEnThis sensitivity suggests a potential clinical measure of cortical encoding of signal level in noise.

Uses and Limitations of Electrophysiology with Hearing Aids

There is currently a strong interest among both audiologists and hearing researchers to find a physiological measure that can be used as a marker of how amplified sounds are processed by the brain (i.e., hearing aid fitting) or how the brain changes with exposure to amplified sounds (i.e., hearing aid acclimatization). Currently, auditory evoked potentials are used, or proposed to be used, for both of these purposes to some degree. It is clear from the literature that some of these uses are potentially useful clinically while others are quite problematic. The current state of aided cortical auditory evoked potentials will be discussed relative to their application to hearing aid fitting/verification and in understanding hearing aid acclimatization. Future areas of promise as well as current gaps in the literature will also be addressed.

Background noise can enhance cortical auditory evoked potentials under certain conditions.

OBJECTIVEnTo use cortical auditory evoked potentials (CAEPs) to understand neural encoding in background noise and the conditions under which noise enhances CAEP responses.nnnMETHODSnCAEPs from 16 normal-hearing listeners were recorded using the speech syllable/ba/presented in quiet and speech-shaped noise at signal-to-noise ratios of 10 and 30dB. The syllable was presented binaurally and monaurally at two presentation rates.nnnRESULTSnThe amplitudes of N1 and N2 peaks were often significantly enhanced in the presence of low-level background noise relative to quiet conditions, while P1 and P2 amplitudes were consistently reduced in noise. P1 and P2 amplitudes were significantly larger during binaural compared to monaural presentations, while N1 and N2 peaks were similar between binaural and monaural conditions.nnnCONCLUSIONSnMethodological choices impact CAEP peaks in very different ways. Negative peaks can be enhanced by background noise in certain conditions, while positive peaks are generally enhanced by binaural presentations.nnnSIGNIFICANCEnMethodological choices significantly impact CAEPs acquired in quiet and in noise. If CAEPs are to be used as a tool to explore signal encoding in noise, scientists must be cognizant of how differences in acquisition and processing protocols selectively shape CAEP responses.

Cortical signal-in-noise coding varies by noise type, signal-to-noise ratio, age, and hearing status

The purpose of this study was to determine the effects of noise type, signal-to-noise ratio (SNR), age, and hearing status on cortical auditory evoked potentials (CAEPs) to speech sounds. This helps to explain the hearing-in-noise difficulties often seen in the aging and hearing impaired population. Continuous, modulated, and babble noise types were presented at varying SNRs to 30 individuals divided into three groups according to age and hearing status. Significant main effects of noise type, SNR, and group were found. Interaction effects revealed that the SNR effect varies as a function of noise type and is most systematic for continuous noise. Effects of age and hearing loss were limited to CAEP latency and were differentially modulated by energetic and informational-like masking. It is clear that the spectrotemporal characteristics of signals and noises play an important role in determining the morphology of neural responses. Participant factors such as age and hearing status, also play an important role in determining the brains response to complex auditory stimuli and contribute to the ability to listen in noise.

Phoneme and Word Scoring in Speech-in-Noise Audiometry

PURPOSEnUnderstanding speech in background noise is difficult for many individuals; however, time constraints have limited its inclusion in the clinical audiology assessment battery. Phoneme scoring of words has been suggested as a method of reducing test time and variability. The purposes of this study were to establish a phoneme scoring rubric and use it in testing phoneme and word perception in noise in older individuals and individuals with hearing impairment.nnnMETHODnWords were presented to 3 participant groups at 80 dB in speech-shaped noise at 7 signal-to-noise ratios (-10 to 35 dB). Responses were scored for words and phonemes correct.nnnRESULTSnIt was not surprising to find that phoneme scores were up to about 30% better than word scores. Word scoring resulted in larger hearing loss effect sizes than phoneme scoring, whereas scoring method did not significantly modify age effect sizes. There were significant effects of hearing loss and some limited effects of age; age effect sizes of about 3 dB and hearing loss effect sizes of more than 10 dB were found.nnnCONCLUSIONnHearing loss is the major factor affecting word and phoneme recognition with a subtle contribution of age. Phoneme scoring may provide several advantages over word scoring. A set of recommended phoneme scoring guidelines is provided.

Aided Electrophysiology Using Direct Audio Input: Effects of Amplification and Absolute Signal Level

PURPOSEnThis study investigated (a) the effect of amplification on cortical auditory evoked potentials (CAEPs) at different signal levels when signal-to-noise ratios (SNRs) were equated between unaided and aided conditions, and (b) the effect of absolute signal level on aided CAEPs when SNR was held constant.nnnMETHODnCAEPs were recorded from 13 young adults with normal hearing. A 1000-Hz pure tone was presented in unaided and aided conditions with a linear analog hearing aid. Direct audio input was used, allowing recorded hearing aid noise floor to be added to unaided conditions to equate SNRs between conditions. An additional stimulus was created through scaling the noise floor to study the effect of signal level.nnnRESULTSnAmplification resulted in delayed N1 and P2 peak latencies relative to the unaided condition. An effect of absolute signal level (when SNR was constant) was present for aided CAEP area measures, such that larger area measures were found at higher levels.nnnCONCLUSIONnResults of this study further demonstrate that factors in addition to SNR must also be considered before CAEPs can be used to clinically to measure aided thresholds.