Auditory Processing Disorder After Concussion, TBI, or Stroke: When You Can Hear But Can’t Keep Up
You have recovered from your concussion. Your headaches have settled, you are back at work, and people around you think you are doing well. You had your hearing tested and everything was normal.
So why is following a conversation still so difficult?
You struggle to keep up when someone speaks quickly. A conversation in a restaurant leaves you exhausted. You miss what your colleagues are saying in meetings, ask for frequent repetitions, and find spoken instructions impossible to remember.
Perhaps you have started avoiding busy places because the effort of listening is too much.
If any of this sounds familiar, there may be more to investigate than your routine hearing test has revealed.
A brain injury can affect how you process sound, even when your ability to hear sounds remains normal. These difficulties can occur after a concussion, traumatic brain injury (TBI), or stroke. When the brain's ability to analyze and interpret auditory information is affected, acquired auditory processing disorder may be the cause.
At Auditory Pathway, I want people experiencing these difficulties to know that they are not imagining them, that there are ways to investigate what is happening, and that they do not have to accept struggling with listening as an inevitable part of life after brain injury.
What Is Acquired Auditory Processing Disorder?
Auditory processing is the work your brain does with the sound that reaches your ears. It helps you distinguish speech from background noise, follow the flow of a conversation, make sense of rapid speech, and interpret the details that allow spoken words to become meaningful information.
Hearing a sound is the first step in being able to process that sound, so normal hearing does not mean normal auditory processing.
A hearing test measures the softest sounds you can hear at different pitches. It does not tell us how effectively your brain processes complex auditory information.
Following a brain injury, some people develop new difficulties with these more demanding listening tasks. This is often described as acquired auditory processing disorder.
The word acquired matters. It refers to difficulties that develop following an event or injury, rather than a pattern of auditory processing disorder that began in childhood.
A concussion may appear relatively mild from the outside, yet the effects on listening can be substantial. A more severe TBI or stroke can also affect the brain systems involved in processing auditory information. The nature of the difficulties varies from person to person, depending on the injury and the functions affected.
Not everyone who struggles to listen after a brain injury has APD. Attention, memory, language processing, hearing changes, and other post-injury effects may contribute to similar symptoms. That is one reason a careful assessment matters.
Why Listening Is So Exhausting After a Brain Injury
One of the most frustrating things about acquired auditory processing disorder is that other people may not see the effort involved.
You might be able to sit through a meeting, have dinner with friends, or follow a conversation with your partner. From the outside, you appear to be managing. But you know how hard you are working to keep up.
You are concentrating intensely on what people say, trying to fill in the words you missed, filtering out other conversations, and holding onto the information long enough to understand it. When someone changes the subject or speaks more quickly, you may have to work even harder.
By the end of the conversation, you feel drained.
Research involving adults with mild traumatic brain injury has found an association between reported hearing difficulties, listening effort, and performance on certain auditory processing and auditory working memory tasks. This supports the importance of considering listening effort as part of the clinical picture, rather than looking only at whether a person can detect sounds.
Listening fatigue is not proof of APD, and it can have several contributing causes after a brain injury. However, when listening takes considerably more concentration than it used to, it's worth investigating.
Signs of Acquired Auditory Processing Disorder in Everyday Life
The difficulties are not always obvious. They often become most apparent in situations where listening is complicated, fast paced, or mentally demanding.
- You struggle to understand speech in background noise
- People speak too quickly for you to keep up
- You hear the words, but the meaning is not always clear
- Listening leaves you exhausted
- Spoken instructions are difficult to retain
- Everyday sounds feel harder to tolerate
These experiences are consistent with auditory complaints reported after concussion and TBI, although no single symptom identifies the cause. Research has documented difficulties with speech in noise, rapid speech, sound sensitivity, and listening-related tasks in some people whose routine hearing thresholds are within normal limits.
If you recognize several of these experiences, particularly if they began after an injury, it is reasonable to ask whether your listening difficulties need further assessment.
Can You Have APD After a Concussion If Your Hearing Test Is Normal?
Yes. A normal hearing test does not rule out an auditory processing disorder.
A routine audiogram measures how quietly a person can hear tones at different frequencies. Other hearing tests assess speech recognition and different aspects of auditory function. These tests are important, but they do not necessarily capture the difficulties a person experiences when following rapid conversation, separating competing voices, or managing complex listening environments.
A study by Vander Werff and Rieger (2019) examined adults with ongoing symptoms after mild TBI and found differences in certain neural responses to speech, particularly in relation to background noise. The findings add to evidence that auditory processing may be affected after concussion, although the study does not mean that everyone with persistent post-concussion symptoms has APD.
The distinction matters because people can be left without an explanation for their difficulties when a hearing test is normal.
The next question should be: "What is happening when you try to process the sounds you can hear?"
That requires looking beyond hearing thresholds.
How Is APD Assessed After a Brain Injury?
An auditory processing evaluation aims to investigate how a person processes auditory information and whether particular listening abilities are affected. If you are still searching for a provider, our guide to APD testing near me explains how telehealth evaluations work.
The assessment should begin with your experience. When did the problem start? What type of injury did you sustain? Which listening situations are the hardest? What has changed at home, socially, or at work? What else is going on?
A clinician may then consider appropriate testing of abilities such as:
- Speech in noise: How effectively you understand and distinguish speech sounds when background noise is present
- Binaural processing: How the brain functions when different information is arriving at both ears at the same time
- Temporal processing: How you perceive and interpret timing patterns and changes in sound
- Auditory memory and listening demands: Whether retaining spoken information is contributing to your difficulties
The exact assessment depends on the person, their symptoms, the nature of their injury, and their ability to participate in testing.
It is also important to consider other possible contributing factors, including hearing loss, attention, working memory, language difficulties, fatigue, and sound sensitivity. These can coexist with auditory processing disorder, and a collaborative approach with other rehabilitation professionals may be appropriate. ASHA's guidance on TBI assessment specifically identifies speech-in-noise, temporal, and binaural processing among areas that warrant consideration.
An assessment should provide more than a label. Its purpose is to help clarify the nature of the difficulties, identify relevant strengths and weaknesses, and guide decisions about what support may be useful.
More important than a label of APD is validating concerns. If you are experiencing difficulty with listening, even if an APD diagnosis is not made, there is always something that can be done. For more on this, read why you don't need an APD diagnosis to take your listening difficulties seriously.
Auditory Training for Listening Difficulties After Brain Injury
At Auditory Pathway, I offer individualized auditory training for all people who are suitable candidates. You do not even need to have a diagnosis of APD; you just need to be having trouble with your listening and want help.
I use Buffalo Model Auditory Training. A typical round of auditory training includes 13 weekly sessions, each lasting one hour, with the final week including a reassessment of auditory processing skills. Most people only need one round of auditory training, although individual needs can vary.
Auditory training is designed to work on targeted auditory skills, rather than simply asking someone to listen harder. The assessment and subsequent reassessment help inform the clinical plan and evaluate changes.
It is important to be realistic about the evidence. Research into auditory processing interventions in adults, particularly adults with difficulties following brain injury, remains an evolving area.
The goal is to identify meaningful needs, provide appropriate intervention, and evaluate how it is helping.
When Sound Sensitivity Is Part of the Picture
Some people experience sound sensitivity alongside auditory processing disorder. They may find everyday sounds uncomfortable and overwhelming, while also struggling to follow speech.
These difficulties deserve individual consideration. Sound sensitivity is not the same as APD; however, the two can often go hand in hand.
Auditory Pathway also provides support for sound sensitivities such as hyperacusis and misophonia. Where appropriate, this may form part of a broader plan that takes account of the person's listening difficulties, daily demands, and goals.
What If You've Been Told It's Just Part of Recovery?
Recovery after a concussion, TBI, or stroke can involve many different challenges. Some symptoms improve with time; others persist or become more noticeable when a person returns to work, social activities, or other demanding routines.
It is possible to be making progress in one area and still need help in another.
If conversations remain difficult, you are avoiding situations because listening is exhausting, or you cannot keep up with spoken information as you once did, you do not need to wait before raising these concerns.
You can discuss them with your rehabilitation team and ask whether a more detailed auditory processing assessment is appropriate.
This does not mean that every persistent listening problem is APD. It means the difficulty deserves to be understood rather than dismissed without intervention.
How Auditory Pathway Helps After a Concussion, TBI, or Stroke
Auditory Pathway is a specialist telehealth audiology practice, supporting people with auditory processing disorder, tinnitus, misophonia, and sound sensitivities.
Through individual appointments via Zoom, I provide auditory processing evaluations and, when appropriate, Buffalo Model Auditory Training. The aim is to understand what is making listening difficult and find a suitable pathway forward. Curious how remote care works? See our Telehealth FAQ.
I work alongside your existing healthcare and rehabilitation team. An auditory processing evaluation does not replace neurological, hearing, speech-language, or other assessments that are needed following a brain injury. Instead, it can help investigate the processing side of the difficulties and contribute to a broader picture of the person's needs.
You do not have to be certain that you have APD, or even have a diagnosis, before asking questions. If your listening has changed after a concussion, TBI, or stroke, a conversation about your symptoms can be a useful place to start.
If you can hear people speaking but struggle to follow what they say, there may be more to explore than your hearing test alone is telling you. Book a complimentary discovery call to talk it through.
US: (914) 228-2231 · Ireland: +353 21 603 6160
References
- https://www.asha.org/practice-portal/clinical-topics/traumatic-brain-injury-in-adults
- https://www.tandfonline.com/doi/full/10.1080/02699052.2019.1641624
- https://www.ovid.com/jnls/ear-hearing/abstract/10.1097/aud.0000000000001462~associations-between-auditory-working-memory-self-perceived
- https://pubs.asha.org/doi/10.1044/2024_PERSP-24-00068
- https://pmc.ncbi.nlm.nih.gov/articles/PMC7956904
- https://www.ncbi.nlm.nih.gov/books/NBK608767
