The Role of Audiology in Concussion: Interview with Dr. Liz Fuemmeler

Ashley Hughes 0:09
Hi, my name is Ashley Hughes. Thank you for joining us again for This Week in Hearing. Today, we’re lucky to have Dr. Liz Feummeler with us. She is a vestibular specialist. And we’ll be asking her questions about her work. And so first, I’m just going to ask Liz to introduce herself and to tell us a little bit about her background.

Liz Fuemmeler 0:27
Sure. So yeah, like you said, I’m Liz, I am a fairly new grad, I still consider myself a new grad. And I probably will for like 20 years. But I graduated in 2019, from Purdue University’s program, and I’ve been working in solely vestibular and concussion actually is my subspecialty. So I’ve been working solely in vestibular for the last three years, I work at a private practice. Before I got into vestibular, I thought I was really going to be well rounded. But you know, things change. And I in my experience has kind of led me to vestibular. So I didn’t always think I was going into it. But I’m really happy that I’ve landed in this subset. But yeah, I’m originally from Missouri. I obviously live in Missouri now, and really enjoy what I do.

Ashley Hughes 1:11
Awesome. Thanks, Liz. I can definitely relate to the always considering yourself a new grad, because it’s been eight years and I still refer to myself as that. I know. Reminds me of you know, Jason, my husband, we’ve been married for 11 years. But we joke around that until we have kids, we’re going to call ourselves newlyweds, which means we’re going to die as newlyweds. I love that. All right. So we’re just gonna jump right in here with a couple of questions. The first question I was hoping you could address for us is, why do you think audiologists should be knowledgeable on the topic of concussions?

Liz Fuemmeler 1:44
Yeah, so this is, you know, concussion and audiology is kind of I feel like a newer idea. There’s not very many people who really specialize or tried to advance this subset of concussion, audiology. One thing that I think is interesting. So in like the last 10 years, there’s been more focus on concussions in general. And a lot of that came out with the big NFL study that was done that showed that repeated head injuries can cause obviously, lifelong issues and damage to the brain. And so I think there’s increased public awareness on head injury and really a focus on how can we better diagnose when individuals have head injury? How can you better diagnose it, intervene and appropriately manage it so that they don’t get that second impact syndrome, which can really, really lead to that lifelong cognitive issue, or sometimes for some even death. And so I think, you know, the public has really turned an eye on this, why audiologists are, I think should be knowledgeable about this is one of the top three symptoms that are described post head injury is tinnitus. One of the other top three is dizziness, and then headache. And so two out of three really relate to our sub field. And we have a lot of tools in which we can be really helpful to a management team and a diagnostic team. Because many times you know, when people experience a concussion, for example, a physical therapist might not know what to do with a complaint of sound sensitivity. But we as audiologists know, there’s a lot of things we may look at or suggest or recommend. So I think, you know, in looking at head injury in general, and looking at some of the symptoms that are being experienced, there’s definitely a role for an audiologist being on the management team, you may not see every head injury patient but at least serving as a resource for helping those patients.

Ashley Hughes 3:28
Awesome. Thank you, so you touched a little bit on some of the side effects of the impacts when somebody has a concussion. Can you tell us a little bit more dive a little deeper into the impact it can have on hearing and balance issues?

Liz Fuemmeler 3:40
Sure, yeah, this is what’s really difficult, I think, and there’s not a lot of research. I mean, there’s some preliminary research, of course on head injury in general with the auditory and vestibular system. As far as the extensive disorders that can go on. I think a lot of that research hopefully will come out in the next five to 10 years. But what we do know is sometimes there’s anatomical changes that can happen to the auditory and vestibular system. And so some of these we’re very familiar with, for example, I always tell students who are with me, one of the things we’re always looking to rule out is semicircular canal dehiscence, which is basically that thinning or hole in the bony surrounding of the inner ear that can cause sound sensitivity, dizziness, etc. So that’s an example of a true anatomical change that can occur after you hit your head. Most common disease disorder, for example, is BPPV, that positional vertigo. So there’s some things that we know in the literature and that are in all of our textbooks that we should look for and be able to identify the new kind of edge in vestibular science is there may be some things along different reflex pathways that are disrupted post-concussion that we maybe haven’t been doing the best job about evaluating or focusing on. And that’s really where some of my tests come into play. I say my tests but they’re completely from Mayo Clinic, Arizona is how I base my protocol. I just perform them and really trying to stay up to date on the literature for what else to be helpful. But in the end, my goal with testing is number one to rule in or out anatomical changes or you know, function changes to the inner ear. And then number two, I’m looking at what along those reflex pathways is abnormal or what makes them symptomatic. So for many people shaking their head after you’ve hit your head, even a week or two or multiple weeks after makes you super Dizzy makes you nauseous. And we know in vestibular, that head movement activates the vestibular ocular reflex. And so there’s ways we can test the VOR in more detail. So for example, we may not see a rotary chair, that’s one way to look at mid frequency VR, we may not see a rotary chair difference or change. But maybe the really high frequency functional dynamic visual acuity where we have them read numbers off of a screen or read letters off of a screen to see if their vision changes while they move their head. That’s where we may see changes. And it makes sense, you know, fits with the patient’s profile that Oh, when I moved my head, I get really dizzy or I get nauseous or I can’t see well. So there’s kind of more in depth tests that maybe aren’t part of the typical vestibular evaluation. But we know of and we can do and help patients kind of identify why they’re not feeling back to normal.

Ashley Hughes 6:18
super interesting. And it will be interesting to see in the next, you know, 5-10 years, do these become part of the, you know, typical vestibular evaluation? In your clinical practice how do you screen your patients for concussions? Or like Do you have a recommended protocol for clinicians and students who are interested in this tip?

Liz Fuemmeler 6:37
So there is no recommended protocol for concussion evaluation. And I think that’s really just due to the lack of published research in the audiology realm. Like I said, there’s very few of us doing it. And I know for a fact like I haven’t published anything on concussion, just because I’m so busy seeing all the patients, I do know that a lot of us will incorporate and there was actually just an article that came out in Audiology Today, Bree Myers was one of the authors on it, that looked at other screening ocular motor screening tools that you can perform. So one example that I always do and recommend to audiologists that’s super easy is called Convergence. And you can use something as simple as a popsicle stick, it’s testing the eyes ability to focus on an object really, really close to the face. And this is known to be abnormal in patients who are in an acute concussion phase. And so you’re able to test that do a quick screener. And that may give you a sign of whether it’s their ocular motor eye related complaints are normal or related to their head injury.

Ashley Hughes 7:38
I could be incorrect, but I think screeners like that are already done by neurologists. Correct. So just be kind of integrating that into our practice.

Liz Fuemmeler 7:44
Yes. And you know, there’s a lot of other it would probably take me a really long time to go through all the protocol and like different ways that I assess concussion patients, but like I said, the main goal is to, first of all evaluate if there’s vestibular issues going on, and especially permanent vestibular damage. And then the second thing is to look at reflex pathways and see if there’s anything there that looks disrupted. And then we use that data. I don’t ever diagnose someone with a concussion, you know, I’m working with a neurologist or with their primary care to say you think that they have a suspected head injury or concussion, here’s what some of their symptoms they describe, and maybe why they’re feeling this way. And I hope direct treatment and recommendations like, oh, because this convergence was abnormal, they probably need to see optometry or because this makes them super dizzy, they probably need to go see a physical therapist to really work on the vestibular ocular reflex. So our testing helps direct treatments. It helps record recovery. So recovery happens naturally the brain wants to heal. And our testing just kind of provides some data points along the recovery mechanism to say, Are you healing appropriately? At what point do you plateau? And are there any other interventions that you need?

Ashley Hughes 8:56
Awesome, super interesting. Maybe, uh, maybe down the road, we can do Episode Two with you to talk more about more about what you do on a regular basis. Um, you touched on this a little bit when you talked about your collaboration with neurology and optometry and things like that, but what are what role do you see audiologists playing on a concussion evaluation and management team?

Liz Fuemmeler 9:18
Yeah, so I think you know, what was super interesting. I trained at Mayo Clinic, Arizona for my fourth year. And I think their setup was very unique because the audiologist was on the forefront for concussion evaluation. So along with a neuropsychologist and a neurologist, the audiologist was the one helping evaluate from the beginning. And I think that’s really cool, because first of all, it elevates our profession to something that’s very unique, unique and honestly just useful to the team in general. But I think utilizing our scope of practice to exactly and you know, I work very I work a lot with neurologists because you know, neurologists obviously understand abnormal eye movements and those brain connections better than we do. But they don’t necessarily have the tools like we do the standardized equipment and tools to be able to really assess- Is this normal for the age? Like if you have an 80 year old that fell and hit their head, are their eye movements that they’re seeing on the bedside normal for their age? Or is it because of the fall? You know, and so I think that’s where we can be really helpful. But yeah, definitely working with a lot of professionals is the key, you know, with concussion. And I think audiology, like I said, can help with the diagnostic on the forefront, but also help give objective measures along the recovery timeline. Because that’s really where we help physical therapy is we can be kind of that judgment point of like, are they getting better because maybe the patient doesn’t feel like they’re getting better, but physiologically, their results are getting better. And so that’s really helpful in concussion, there’s a lot of different types of concussions, you would see. One example is athletes, athletes want to get back to the field ASAP. And so they may say, I don’t have any symptoms at all, I’m good to go, I need to get back. And we know that we don’t want to risk a second impact for them. And so we kind of have to use our objective testing to say, well, I know they say they feel fine. But actually, there’s still some abnormalities. And sometimes it’s the opposite. Like someone who gets hurt at work, who doesn’t want to go back to work says, I’m feeling so terrible. And you can really use objective measures, which a lot of physical therapy offices don’t have to provide evidence to the primary care neurologist to say things are looking better than they used to, and physiologically, you know, this aspect has improved.

Ashley Hughes 11:35
Awesome. And to me when I hear that, another part of it that I hear is for concussion, vestib, and really, in general, there’s so much value in a cross functional team.

Liz Fuemmeler 11:46
Yeah, definitely. And, you know, one thing that’s interesting, so concussion is a really interesting subset, because there is not one test that can diagnose a concussion. And so the whole idea of post head injury evaluation is it has to be interdisciplinary. And you know, usually if someone walks into the ER has a head injury, and it’s having some sort of symptoms, they’ll do a head scan, CT scan or something like that, and then discharge them. And as long as you know, if things get better, great if things don’t get better- now what? maybe they see somebody else, but it’s all working together. And that’s why I think I really like it. Like I work with optometrists, athletic trainers, physical therapists, neurologists, like all these people that I may not normally work with in a typical audiology environment. So I think that is really neat to collaborate on.

Ashley Hughes 12:31
It’s awesome for the patient and for the providers to get a better understanding of the patient as a whole.

Liz Fuemmeler 12:36
Yep exactly.

Ashley Hughes 12:38
So I’m going to ask you one more question. What resources do you think audiologists can use to gain more knowledge on concussion?

Liz Fuemmeler 12:45
This is a hard, hard question, because I honestly don’t know of many that are specific for Audiology. I will say that I have consulted quite a few of our just original textbooks and reviewing like, what head injury can result in what does a labyrinthine concussion look like? Why would I see SCD post head injury, all those aspects. So I think, you know, there’s been a lot of preliminary research about how hitting your head can affect the ear. So I think resorting to some of that basic knowledge is super helpful. And then I look to a lot of the physical therapy journals. So physical therapists have kind of been owning concussion for a while. And you know, sometimes in some places, they still own dizziness. And I think that’s fine. But I do think that there is a role for audiologists to work really well with physical therapists so that we can both be more productive and more efficient with treatment. We see many times, you know, I’ll see patients who have had a concussion, usually the protocol is send them straight to physical therapy. And then if they don’t get better, then maybe send to me or something like that. And ultimately, it’s possible that the patient never needed physical therapy, you know, for some of their complaints, maybe it’s all ocular, and they need to go to optometrist and neurology for headache management. So I think there’s a lot of things you can learn from looking at the other journals, like the physical therapy journal is where I get a lot of information, and hopefully, audiology will come forth with a lot of research specific, you know, articles on concussion.

Ashley Hughes 14:19
Awesome. Well, Liz, I’ve known you since you were a student, as you know, and I love hearing you talk about this. It reminds me a lot of our work together when you were president of the SAA where your passion is just contagious. And I think that you’ll you know, you’ll attract a lot of people to the vestibular sector of Audiology. I love your collaborative approach that you’re not saying audiologists need to be the only people but audiologists need to be part of this. And with these other disciplines, we can provide the best care. And I know you keep talking about research coming out in the next five or 10 years and I am just confident that your name is going to be on that research. So I gotta get some time here. So I am sure it will

Liz Fuemmeler 15:01
come over to the concussion world anytime there’s plenty of room for everybody. There’s a lot of head injuries.

Ashley Hughes 15:08
Is there any way that our listeners can contact you if they have questions that they’re interested in getting more involved in concussion management?

Liz Fuemmeler 15:15
For sure. So first of all, I will put in a plug because I do host a podcast with a another fellow SAA member, Daniel Romero, he’s at Vanderbilt. So he’s a professor there. But we host a podcast that’s called a dose of dizzy. I did do an entire episode on concussion evaluation and management. So I honestly think it was like the second or third episodes, you might have to go back a couple years. But that’s a really good review. Some things have changed, but for the most part, that’s pretty accurate. And then so you can find a dose of dizzy podcast anywhere that you listen to podcast, we’re also on Instagram and Twitter. And then my personal Instagram is Liz feum, you can find me I’m usually linked on the Dose of Dizzy stuff, too. So feel free to contact me there.

Ashley Hughes 15:58
And I lied. I want to sneak one more question under. When I talk with students, a lot of them are worried about limiting themselves by taking like a vestibular only or, you know, hearing aid only fourth year or final year placement excuse me. What advice do you have for students who are interested in getting some more balance experience but are concerned about limiting themselves after graduation?

Liz Fuemmeler 16:21
So one thing that I think has changed since I was in that position. So when I was going into my fourth year, I wanted to find the most well rounded fourth year experience. And I’m still very happy that I did it because I think when you are strong in other subsets it makes you a better audiologist in general. However, I think the profession of Audiology has changed, you know, in the last four years from when I was a student, and I don’t know if I would make that same decision because and I was recently just talking to someone about this but when you have medical issue, are you wanting to see a generalist or a specialist for that issue? And I know for me myself, I would probably want to go to the specialist who’s really you know, diving deep into that subfield and actually can provide me the answers I need with vestibular because there’s not necessarily strong academic resources at every single university. You know, it’s you may do vestibular but if you do vestibular half a day a week. It’s really hard, vestibular is difficult field and concussion too, its every case is so different, that you need to be like really strong in it, to feel good about diagnosing patients and really taking care of them. So I think, you know, it’s hard to make a decision. I think as a student, when you’ve had all these different experiences, it’s hard to make the plunge. But if you have interest in vestibular and you already feel that pull, I say just go for it because the need in our field is huge. We need so many more vestibular audiologist, there’s I have people who drive three and four hours to come see me which is crazy when dizziness is so common. So I think the more experiences you can get that are specialized in vestibular, the better. I know, as a student I did like a T35. It’s a research grant through the NIH. So you can do that between second and third year. They have four places you can do that at. So that’s a good example of where you could get in a vestibular lab and really learn the basics. Obviously, if you can find an externship that either is vestibular heavy or vestibular only, I think that’s nice. And I appreciated as soon as I accepted my job and full of vestibular, my externship let me go full time, vestibular so that I could really you know, feel up to speed. So that may be a conversation for students to have with their externship site. Like if I accept a job and a subset Can I like go deep in that subset until I leave? Because I think that really helped me you know, for the last three months, I did vestibular full time, and I think that really helped me be more prepared for being on my own.

Ashley Hughes 18:44
I bet that’s awesome that you had such a supportive placement.

Liz Fuemmeler 18:48
Definitely.

Ashley Hughes 18:49
Thank you again, Liz. Really appreciate you joining us again, we had Dr. Liz Feummeler, she’s a vestibular specialist. So thank you for joining us on this Week in Hearing and hopefully you’ll join us again next week.