Beyond Hearing Aids: Audiologic Rehabilitation

1. Beyond Hearing Aids: Audiologic Rehabilitation Robert W. Sweetow, Ph.D. University of California, San Francisco

2. Why do patients seek our help?

3. Elements of Communication (Kiessling, et al,2003; Sweetow and Henderson-Sabes, 2004)

4. Potential impediments to achieving mastery of these elements • Hearing loss • “Although it is true that mere detection of a sound does not ensure its recognition, it is even more true that without detection the probability of correct identification is greatly diminished”. (Pascoe, 1980) • Global cognitive decline • Maladaptive compensatory behaviors • Neural plasticity and progressive neurodegeneration • Morest, 2004 • Loss of confidence • Saunders and Cienkowski (2002)

5. Goal is to relieve HANDICAPPING effects (WHO, 1997) • Audiogram doesn’t show these effects • This information is obtained through counseling • These effects are constantly changing

6. The problem is…. hearing aids don’t ….. • resolve impaired frequency resolution • rectify impaired temporal processing • undo maladaptive listening strategies • “properly” reverse neural plastic effects • correct for changes in cognitive function • meet “unrealistic” expectations

7. Expectations vs. Goals • Expectations has a product orientation • Patient assumes passive role • Whatever goes wrong is the professional’s fault • Goals has a rehabilitation orientation • Patient assumes active role • Patient shares in the process

8. The biggest mistake we currently make may be… • Making hearing aids the focus of our attention, when the focus should be… • Enhancing communication

9. What do we do for a patient receiving an artificial limb? What do we do for a cochlear implant patient? What do we do for a patient with a balance disorder? What do we do for a hearing impaired patient?

10. What happened to Aural Rehabilitation? • declined because outcome measures concentrated on auditory training and speechreading and didn’t consider emotional and psychological by-products • boring? • too speech pathology like? • too time consuming? • lack of reimbursement

11. Benefits of AR Programs • Reduced return rate of hearing aids • Increased sale of assistive listening devices • Fewer trouble-shooting visits • Referrals from friends, co-workers, and family members • Free advertising provided by satisfied hearing aid users • Good community relations

12. Decrease in return rates from 9 – 3% for participants attending 3 one hour AR classes Northern and Beyer, 1999

13. Top-down influences of cognition on perception • Bottom-up influences of perception on cognition Baltes et al 1994, 1997

14. Examples of good group rehab formats • Hickson’s ACE • Kricos • Weyner • Abrahamson • Beynon, et al • Northern and Meadows • Abrams, Chisholm, et al • Hawkins

15. Evidence based review of auditory rehabilitation and training in adults (Sweetow and Palmer, 2005) • Group • Beynon, Thornton and Poole, 1997 • Chisolm, Abrams, and McArdle, 2005 • Individual • Kricos and Holmes, 1996 • Montgomery, Walden, Schwartz, and Prosek, 1984 • Walden, Erdman, Montgomery, Schwartz, and Prosek, 1981 • Rubenstein and Boothroyd , 1987 • Kricos, Holmes and Doyle, 1992 • Wright, B., Buonomano, Mahncke, and Merzenich, 1997 • Bode and Oyer, 1970

16. Newer AT studies • Stecker, Woods and Yund, 2006 • Adaptive training using low frequency noise and CV and VC syllables produced more improvement (~10%) than did introduction of amplification (6%) • Hearing aids produced greater benefit for 0 dB vs. 10 dB SNR, while training produced the opposite effects, i.e. greater benefit at 10 dB SNR than 0 dB SNR • Increasing training duration provided diminishing returns. Scores increased by ~2% for each doubling of the training interval after the first week • Significant training effects were found both in new, and in experienced hearing aid users

17. Can human adults have plastic changes? Kraus (1995); Recanzone (1995) showed changes in duration and magnitude of mismatched negativity response for adults trained on synthetic phoneme discrimination tasks Vasama and Makela (1995) showed changes using auditory evoked magnetic fields (magnetoencephalography) Tremblay, et al (1998, 2001) showed enhanced NI-P2 on novel speech sounds and demonstrated training effects

18. Training-related physiological changes have been attributed to…… • 1) a greater number of neurons responding in the sensory field • 2) improved neural synchrony (or temporal coherence) • 3) neural “decorrelative” processes whereby training decorrelates activity between neurons, making each neuron as different as possible in its functional specificity relative to the other members of the population. • This process assumes that information common to two stimuli is disregarded, while responses to unique features of each stimulus are enhanced.Tremblay, 2006

19. Tremblay (1998) demonstrated that physiological changes occur quite rapidly, and precede changes in perception. • All individuals showed significant physiological changes in the MMN following one 45-minute training session. • The magnitude of the MMN continued to increase with additional training, but the time course of perceptual changes was variable.

20. Aural (auditory, audiologic) rehab…… Should NOT be considered an add-on! Incorporate it at the very beginning

21. Rehabilitation Components Plasticity driven Behavioral compensation practiced Communication strategies learned

22. Does cortical plasticity help or hinder rehab? • Landry, et al, Hrg Jour 65,8,26-28.

23. The reduction of hearing-loss-induced deficits of function,activity, participation, and quality of life through sensorymanagement, instruction, perceptual training, and counseling, (Boothroyd, 2006) • The goal of rehabilitation is to restore quality of life by eliminating, reducing, or circumventing these deficits and limitations. This goal can be addressed through a combination of: • sensory management to optimize auditory function. • instruction in the use of technology and control of the listening environment. • perceptual training to improve speech perception and communication. • counseling to enhance participation, and deal both emotionally and practically with residual limitations.

24. How can a person be trained to form whole perceptual units from auditory fragments?

25. Grouping of sounds (Bregman’s streaming) • Allows you to segregate, or focus on one sound (violins) or conversation (from one person) • Conversely, multiple sounds can cohere into a single perception • Grouping Principles • Sounds that start together, group together • Spatial location is a grouping principle • Expectations, or the “likelihood” principle • Amplitude (similar loudness will group) • Pitch (similar will group)

26. Training is not a new concept…. But now we have the means to do it effectively……via computer aided auditory rehabilitation….so that….. • It can be performed in a private, non-threatening environment • It can proceed at the individual’s optimal pace • Progress assessment can be done automatically

27. Some Characteristics of CAAR • Programs should provide patient with knowledge of correct responses • Software should include repetition and rehearsal of content and illustrative examples • Animation and/or video should be included • Patients should be encouraged to provide suggestions • Can include confusion matrixes

28. Examples of Computer Aided Aural Rehab (CAAR) • Computer aided speechreading training (CAST); Pichora-Fuller and Benguerel, 1991 • Computer Assisted Speech Perception Evaluation and Research (CASPER); Boothroyd and Hanath-Chisolm, 1988) • ALVIS (Austin Veterans’ Hospital); Kopra, et al 1986; Sims et al, 1986) • CAAR videodiscs (Tye-Murray, 1988; 1992) • Dynamic Audio Visual Interactive Device (DAVID); Sims, NTID

29. What we can learn from learning theory • Distribution of practice should be suitable for the task to be learned. • Active participation by the learner is superior to passive receptivity. • Practice material should be varied so that the learner can adapt to realistic variation and so that his motivation during drill is improved. • Accurate performance records need to be maintained in order to evaluate progress and effects of training. • The most useful single contribution of learning theory is the provision for immediate knowledge given to learners regarding their performance. Wolfle (1951)

30. Experience is a wonderful thing. It enables you to recognize a mistake when you make it again.

31. What we can learn from neuroscience… • Appropriate feedback (Holroyd et al. 2004, Birdsong studies) • Motivation (Kilgard and Merzenich, 1998) • Reward (Benenger and Miller, 1998) • Training near threshold (Blake et al., 2002) • Incremental training: Go slow and steady (Linkenhoker and Knudsen, 2002) • Speed and spacing of the training (Hairston and Knight, 2004, Marquet, 2001)

32. Neuroscience-Based Training Principles • Intensive Training Exploits Plasticity & Cortical Reorganization • Extensive Training Maximizes Generalization & Reduces Functional Deficits • Salient Reinforcement Induces Learning Merzenich & Jenkins, 1995

33. Time-Compressed SR Exercises: Temporal Processing Degraded Signal Processing Auditory Closure Grammatic Closure Vocabulary Building Working Memory SR in Noise Exercises: Selective Attention Degraded Signal Processing Auditory Closure Grammatic Closure Vocabulary Building Working Memory AT Tasks Target Multiple Goals

34. What factors should be considered to create a comprehensive program? • Should be cost effective • Home training • Must be practical and easily accessible • Proceed at the patient’s optimal pace • Interactive • Maintain interest and attention while minimizing fatigue • Train near threshold • Should integrate listening training with repair strategies (i.e. bottom up and top down) • Measurement and feedback (to patient) regarding progress or lack of progress • Verifiable via remote or “datalogging” • Should give patient “responsibility” • Reinforcement may be lower cost, better results

35. Top-down influences of cognition on perception • Bottom-up influences of perception on cognition Baltes et al 1994, 1997

36. Hearing impairment deficits vs age related declines • Cognitive Function • decreases with age • Contextual & Linguistic Skills • Not impacted by either • Temporal Processing • Impacted by both; older listeners require twice the gap detection; modulation detection is correlated with detecting speech in noise (Sousa) • Interactive Communication Skills • Could be impacted by both or neither

37. LACE(Listening and Communication Enhancement) • My colleagues on this project are….. • Jennifer Henderson-Sabes • Monica Miller • Gerry Kearby • Earl Levine • Rob Modeste • Isaac Trumbo • Adam Lundeen

38. Disclosure

39. LACE Objectives • Get the patient involved • Make the patient recognize difference between hearing and listening • Build patient confidence • Provide the patient with communication strategies • Reduce RFC • Reduce unnecessary patient visits

40. LACE(Listening and Communication Enhancement) • Cognitive • Auditory Memory • Speed of Processing • Degraded and competing speech • Background noise • Competing speaker • Compressed speech • Context / Linguistics • Interactive communication All of the above are designed to enhance listening and communication skills and improve confidence levels

41. www.neurotone.com www.lacecentral.com

42. Results • Procedural learning versus perceptual learning

44. Score 1st to 4th Quarter Difference in Average MW MW

45. Even a 1 dB reduction in SNR has been estimated to be commensurate with a 6-8% improvement in percent correct scores for sentence recognition (Crandell, 1991; Wilson et al, 2007) • 5 dB SNR loss = 20% quality estimation (Killion (2011)

46. All changes are significant from week to week, except 3 vs 4 Notice the N!!!

47. Percentage of trained subjects showing improvement • 60% improved on all training tasks • 83% improved on all but one of the training tasks • S/B = 87% • CS = 84% • TC = 88% • TW – 80% • MW = 75% • QuickSIN = 85% ; 45% (>1.6 dB) • HINT = 55% • HHIE = 76% • CSOA = 65%

48. “Variables Affecting Outcome on Listening and Communication Enhancement (LACETM) Training. Sabes JH and Sweetow RW. International Journal of Audiology. 2007, 46(7):374-383. • 83% of subjects improved on all but one of the LACE training tasks. • Improvements were also seen in subjective and objective outcome measures, for example, 45% improved by >1.6 dB on the QuickSIN. • Older subjects completed the training in a shorter period of time. • The greatest improvements were shown by the subjects with the poorest initial speech intelligibility and hearing handicap. • Performance on any given test cannot reliably predict overall improvement, though poorer scores on HHIE, CS, TC, and SB were correlated with greater improvement. • Clinical expertise is necessary when determining who should participate in computerized aural rehabilitation.

49. Olson and Preminger, 2011LACE study • New HA users in the training group experienced the largest improvement in dB SNR of all groups; 2.4 dB after 2-weeks and 2.9 dB after 4-weeks.

50. Olson and Preminger, 2011LACE study • Listening effort on the SSQ was significantly correlated (r =.37, p =.048) with perceived benefit from training on the IOI, such that higher benefit was reported by persons who also reported a reduction in listening effort. In contrast, perceived benefit was not correlated with the amount of reduction observed in dB SNR on the QuickSIN™.