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Welcome to Naama's Blog. I hope you will ask any questions you have here in the comment area below. You can also post your thoughts on what I have written or anything else related to adult rehabilitation. Members may comment on any posting by logging into your account. If you are not a member but wish to comment, please send your submission to . If you would like to write to me directly, please email me at: The Blog is intended as both a patient and a professional resource. This printable brochure may be used to refer adults and family members who may benefit.


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Auditory training using your own word lists can be fun!

Posted By Susan Thomas, Tuesday, March 21, 2017




In my last post, we discussed building your own word lists. Now let’s review how best to use those lists in your home practice.

Repeating words read aloud can help reinforce your auditory memory. However, over time you may experience two shortcomings of this practice tool: (1) You may memorize the words after some practice and/or (2) The process may become boring.

After repeating words from your lists, try using them in other ways. Here are some tasks that might be performed using your word lists in enjoyable and challenging ways that will encourage you to practice your auditory skills. These tasks require you to use abilities other than auditory perception. You might use judgment, auditory memory, and your sense of humor. Tasks may require implementing world and linguistic knowledge, social understanding, and more. Therefore you should expect to find these tasks more challenging, even if you have already easily identified these words as they were presented to you from a list. Don’t hesitate to ask your practice partner for repetitions.

Speech perception tasks that involve understanding and thinking (not just identification of a single word from a known list) serves to better simulate the communication challenges you experience in everyday life. So now, after this long introduction, let’s move on to some practical examples.

Foods: Instead of simply reading the words, ask the person who is practicing with you to share their shopping list for his or her next supermarket visit. You can also ask them to read you a list of ingredients and then you could guess what might be prepared with those foods (e.g., "What might be prepared with vinegar, lemon juice, honey, mustard, salt and garlic?"). If there are words that you’ve not practiced before, include them anyway (and add them to your list).

Numbers: Instead of simply repeating random numbers, ask your trainer to read you useful telephone numbers and then feel free to add them to your contacts. Hey, how did you manage not having the phone number of the best pizza take-out in town? If you easily recognize one-digit numbers, ask them to read you phone numbers as a group of two 3-digit numbers (e.g., 202-354-097-1). If you can grasp two and three-digit numbers, ask them to read you prices of products. You can also ask them to occasionally tell you the wrong price so you will have to initially recognize the number you heard and then to decide whether it is correct as a price. You can ask your trainer to tell you about their relatives' ages, or even practice solving simple math problems using your auditory perception skills.

Letters: Instead of reading you random letters, ask your trainer to spell out the names of family and friends (or places around the world). After you cite the word, have the person tell you something you did not know about it. Another exercise might be to ask your trainer to spell out short words but to state the letters in reverse order. If you recognize letters very easily, your trainers can say more than one letter at a time, which can be great training for your working memory (e.g., a/I, r/p, l/a, n/e).

Find the word that doesn't match: Ask your trainer to say four words, each word separately or two at a time (e.g., train, bus, car, bicycle) and identify the word that doesn't fit.

Auditory perception of a word in a sentence: Your trainer could read simple sentences, including target words from your word training lists. You could use speechreading to help you grasp the entire sentence—except the target word or words will be voiced with a covered mouth—no visual information would be provided for these specific words. Prior to the sentence presentation, you need to define the semantic field (or topic of the target words. For example, days of the week: "I am taking Yoga class every Monday" and the covered word would be Monday. Or sports activities and days of the week: "I am taking Yoga class every Monday" with the covered words being Yoga and Monday. Or names of the states: "Which state has the larger population—Maryland or Ohio?"

Syntax and morphology: The first step would be to set the task words; then you could be asked to judge whether the covered word is in the correct form. For example, for have/has/had: "She have a birthday last week" or walk/walking/walked: "I saw him walking away".

These examples illustrate some of the ways you can practice identifying specific words in meaningful contexts while reinforcing auditory understanding in communicative situations.

Before we conclude, I want to address the important issue of preventing access to speechreading while practicing auditory skills. There are different ways to do so. For example, you could ask your trainer to sit or stand behind you. I personally do not recommend that particular approach because it precludes any eye contact between the person practicing and his/her trainer. This makes the exercise unrealistic and not very pleasant.

Rather, you may want to sit side by side and agree that during the training, you will not look towards the speaker's face. Tasks that require a combination of speechreading and auditory-only perception (such as in a sentences that should be presented visually with certain covered words), the speaker can use a sheet of paper to cover the lower part of their face. You should guide your trainer to do it in a way that will prevent visual information or speechreading but not distort the sound (i.e., avoid placing the paper on the mouth).

In future posts, I will offer more ideas for auditory training exercises involving not only single words but also complete sentences, telephone use, auditory memory skills, listening in different acoustic conditions, listening to different language materials, and more.

All that remains for me is to encourage you to continue practicing, being creative, and enjoy your auditory training!

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How to Build your Own Auditory Training Word List

Posted By Susan Thomas, Wednesday, February 22, 2017
Updated: Wednesday, February 22, 2017

This post was written at the request of a reader who noted:

I would like to involve my family in my auditory training by having them read words or sentences to me. Can you provide suggestions of home practice tools for this purpose?

This is a wonderful request that will help others looking for home practice materials.
I do have mixed feelings about this request. On the one hand, I believe that after receiving a cochlear implant, recipients of all ages benefit from working with a professional trained in auditory rehabilitation. Such professionals can help recipients choose and adapt auditory training materials to meet their needs. On the other hand, we know that most adults do not receive such support post CI and their auditory practice is likely to be done independently. Hence, I will do my best to guide you. I would also be more than happy to respond to any comments or inquiries from our readers regarding their experiences in using home practice techniques.

Our current goal is to create lists of words that could serve as a foundation of your auditory listening inventory and will later serve you when you create lists of sentences for further auditory training. So, let's roll up our sleeves and get to work.

Creating Word Lists

The first part is fun. Think of words that are most useful to you—at home, at work and in other everyday situations. Include important words such as names of relatives and friends, nouns, pronouns (i.e., I, we, you, she, her, them, it, this, that), verbs, auxiliary verbs (i.e., be, can, could, do, have, may, might, must, shall, should, will, would), adverbs, and adjectives. Include same verbs in different morphological forms (drive, drives, driving). For future practice, add common question words (i.e., what, why, where). In addition, include numbers (1-100), colors, and letters. Update the list occasionally with relevant words. At the end of this process, you should have a very long list from which you can build various auditory training lists.

Example of a (partial) List:

Bob, John, Kathy, Mom, Dad, Rockville, Maryland, yes, no, don't, what, how, when, why, who, do, does, are, is, want, take ,give, build, drive, clean, play, tired, happy, coffee, tea, water, soda, lunch, dinner, breakfast, egg, nuggets, guacamole, room, car, big, small, green, great, beautiful, one, two, A, B .

In addition to the word list, you should make a list of everyday phrases and greetings. These might include:

  • Good morning
  • What's up?
  • Have a good one
  • Thank you

Congratulations! You now have a very long list of working materials. The next step is to build your training lists. I will illustrate how to create lists of words that require different levels of auditory perception skills. Practicing speech perception of the same word in different environments (different word lists) will help you identify specific differences between speech sounds, which will enhance your word perception (even beyond the words that you have included in your original list).

Example #1: Word lists based on letters

  1.  Beginner level (easy): w,s,b,I,k,m,o,q. To make it easier, you can divide the list into two groups.
  2. For more advanced training you can use the following list of letters: a,c,e,f,i,j,h,l,m,o,u,r,t,v,w,x,b. Again, to make it easier, you can divide the list into two or three groups.
  3. The following lists would demand even higher auditory perception skills: b,c,d,e,g,p,t,v or f,h,j,k,l,m,n,s,x

Example #2: Word lists based on food names

  1.  Beginner level: Include words of different lengths and varying vowel patterns: avocado, tomato, cheese, egg, lettuce, rice, cucumber, corn, chicken, and cream cheese.
  2. For more advanced training, you can use the following list of mid-length (two syllable) words: chicken, onion, nuggets, pizza, orange, lettuce, mango, pumpkin, ice cream, pasta, ketchup, and mayonnaise.
  3. This next list would be even more difficult since it includes only short (one-syllable) words: soup, bread, rice, cream, bean, corn, egg, cheese, toast, beef, steak.
  4. For an even greater challenge, you can use short words with very similar vowels sounds, such as: bean, cream, cheese, beef, mint.

Start with short lists of disparate words

When you adjust your practice materials to your auditory ability, note that the more similar the words (in their length, vowel and/or consonant sounds) and the longer the list, the greater the level of difficulty. Therefore, my advice is to start practicing using relatively short lists that include words that differ in as many parameters as possible, and then move on to longer lists that include words that are more similar to each other.

During practice sessions, you may have difficulty distinguishing between some words. Try practicing your auditory discrimination skills using specific words that are difficult (e.g., fun and sun). Ask your practice partner to read you the words and highlight the sounds that distinguish them (i.e., “f” and “s” in this example) by emphasizing or prolonging the first consonant. Repeat difficult exercises a week later and see if you have improved.

Share your experience with your audiologist

When you next visit your audiologist, share your experiences. (S)he may be able to explain why you have difficulty with specific auditory features and suggest how to move forward with your auditory training.
I hope that some of these tips will be helpful to you in getting started. Please feel free to send me any questions and I will do my best to assist you.

How can you use your word lists? In the next post I will share some practical uses for your lists. Hopefully you'll discover that auditory training can be fun.

Good luck!

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A First Anniversary Blog Post

Posted By Susan Thomas, Wednesday, January 25, 2017
Updated: Tuesday, January 24, 2017


Last month was my blog's first anniversary so I thought it would be a good time to sum-up what we have done over the past year. If someone had told me two years ago that I would write a blog on adult rehabilitation for the ACI Alliance, I would have never believed them. Yet, life presents us with opportunities and this blog has given me a new and unexpected way to express my love for my profession and my patients.

It all started when Donna Sorkin and I spoke about my experience with adult rehabilitation following cochlear implantation. Many of the people I had worked with had congenital hearing loss though some had lost their hearing later in life. Of the total population of CI recipients, 60% are adults. Unlike pediatric recipients, most adults do not receive auditory rehabilitation services as part of their rehabilitation process. Moreover, adult CI recipients have difficulty finding resources to support their rehabilitation journey.

18 Posts Published So Far

Consequently, in Donna's kitchen, this blog was born. Eighteen posts have been published to date, aimed to present a broad perspective and offer practical advice to enhance the challenges faced by a diverse population of adult CI recipients. This diversity includes wide-ranging expectations, rehabilitation needs, and outcomes.

I wrote about perception of environmental sounds, music appreciation, emotional effects and improvement in recipients’ quality of life. These topics demonstrate the various CI benefits and suggest that subjective evaluation of benefits made by recipients themselves, is as important as objective assessments of speech perception ability performed by professionals.

Some of the posts included practical advice on topics related to constructive communication with family, professionals and friends to facilitate support and cooperation following implantation. In addition, there were posts that presented the questions faced by audiologists in the process of evaluation of CI candidates, and issues regarding bilateral CI. Although I emphasized the importance of auditory rehabilitation provided by speech pathologists, tips for self- auditory training were also suggested. Linda Daniel, an audiologist and Auditory Verbal Therapist shared her moving experience in initiating a support group for adult cochlear implant recipients. Thank you Linda! Another writer we were privileged to host is musician Richard Reed, who lost his hearing later in life and was implanted after nearly 10 years of significant hearing loss. His touching story demonstrates some of the challenges, as well as achievements, he experienced during his unique rehabilitation journey. I take this opportunity to invite other writers to contribute to our blog.

Future Posts

What about future blog posts? The next posts will include instructions on how to develop your own training materials and use them in creative and fun ways. Other posts will discuss related topics such as speechreading, how to deal with noisy environments, and strategies to improve listening on the telephone. You are most welcome to suggest other relevant topics.

As both a speech pathologist and audiologist who previously relied on direct face-to-face communication, writing a blog is a very different kind of communication. Therefore, I would like to thank the readers who wrote to me; your questions and comments were thought provoking and you helped me focus on important topics of interest.

I would like to thank the extraordinary Donna Sorkin, who presented me with this exceptional platform, enabled me to freely express my professional insights and perspectives, and supported me all the way with her positive encouragements and suggested edits. I also want to thank Susan Thomas—without her dedication and technical support, I might be writing these posts only for myself.

Best wishes for a healthy and thriving 2017.

Naama Tsach

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Music Appreciation Following Cochlear Implantation

Posted By Susan Thomas, Wednesday, January 4, 2017
Updated: Tuesday, January 3, 2017


Our last blog post was by musician Richard Reed, who was late deafened and subsequently received a cochlear implant. I would like to follow up on Richard’s touching personal account with some professional observations based on my work with adult recipients.

Many CI recipients experience initial frustration in appreciating music. Perception of the richness of music requires various auditory skills including being able to distinguish between sounds that are similar (but differ in their frequency and/or intensity) as well as the ability to follow rapid changes in the music. Cochlear implants cannot convey all of the characteristics of music due to the limited number of electrodes. Regardless of the type of listening device, the auditory system of people with severe to profound hearing loss typically cannot accurately represent the acoustic characteristics of music.

Music appreciation is not an assured outcome of cochlear implantation but many recipients do seek it as an additional benefit that adds to quality of life. The ability to appreciate and enjoy music depends on many individual factors such as age (teens often spend a lot of time listening to music), musical education (before or after the CI), life experiences, and personal preference. It is important to note that not every person with typical hearing enjoys music to the same extent. Some people prefer to read books, watch TV, or go to the theater rather than listen to music or attend concerts.

If you previously enjoyed listening to or playing music and consider musicality as a contributor to your quality of life, you may wish to pursue a specific practice program. According to studies and clinical observations, there are differences in enjoyment of music by CI recipients. Nonetheless, people can enjoy listening to music following cochlear implantation, even if it is not the same experience that they remember prior to losing their hearing (if late deafened) and receiving a CI.

Discerning melody is the most difficult challenge

The difficulty in perceiving music by CI recipients relates primarily to one’s ability to recognize the melodic components of music and isolate a specific sound in the presence of other sounds. For example, listening to a vocalist in the presence of instrumental accompaniment or distinguishing between different musical instruments playing at the same time are difficult tasks. Listening to classical orchestral music, large group ensembles, or lyrics with loud instrumental accompaniment can be frustrating experiences for CI recipients. However, since there are so many styles of music, you can be selective in your music choices and pursue those with strong rhythm, solos, or vocalists with an accompaniment of only one or two instruments. You may be encouraged by studies and personal accounts indicating that auditory training for music can result in improved music perception as well as greater music enjoyment.

What can you to improve your appreciation of music?

When dealing with music appreciation (and other topics related to rehabilitation following cochlear implantation), there are two key factors that affect individual’s satisfaction: (1) duration of CI use and (2) quality of therapy/practice. Longer periods of CI usage combined with specific music therapy and self-practice often results in higher levels of music enjoyment. With patience, persistency and hard work you can improve your appreciation of music.

Professional music therapists utilize systematic programs for individuals or small groups. Musical selections and music-making activities may be modified for participants' preferences and needs. Research on CI recipients, both adults and children, revealed positive effects of music therapy on self-esteem, communication skills, music perception, and music enjoyment.

Self-practice is less structured and can be undertaken independently in different ways. For example, you may choose your own materials and progress according to your own schedule and preferences. You can also use materials designed specifically for CI recipient music training. (I’ve provided some examples below.)

When you practice on your own, you should follow a few guidelines:

  • Practice when you are well rested.
  • Choose a quiet environmental with minimal background noise
  • Ensure that you have the best possible sound system with appropriate volume. Use direct audio input, Bluetooth or assistive listening device to connect to your sound processor
Attentive Listening

Attentive music listening is more effective than simply being exposed to music. When you listen attentively, you can selectively identify musical characteristics. You may ask yourself:

  • Do I recognize the rhythm?
  • Have I noticed the dominant instrument change?
  • Do I recognize what is playing now?

In the early stages, I recommend using videos that enable you to see which instruments are playing. When you become familiar with different pieces of music, ask yourself questions:

  • Can I recognize the selection that I’m listening to?
  • What feeling do I have while listening to certain music?
  • Do I have a preference for a certain style?

Try to listen to different music styles, even those that you did not previously listen or did not enjoy listening to in the past. While listening to songs, you may ask yourself:

  • When did the vocalist start or stop singing?
  • Can I identify repeated words or phrases?
  • Which is easier for me to listen to—a male or female vocalist?
  • Are there specific singers I prefer to listen to? 

Read the lyrics while you listen to songs to further help you enjoy your musical training experience. These principles may help you adjust your practice. You may want to share your experience with friends who have typical hearing and ask them to recommend musical selections.

Where to Start Your Practice Program

Start by listening to simple musical pieces, including familiar music you remember from the past. It is preferable to listen to music accompanied by only one or two instruments versus a large band or ensemble. Many CI recipients prefer to start listening to instruments such as piano, cello, saxophone, bass and drums. Note that almost any song or musical piece can be performed as a one-instrument solo.

Choice of Songs

Begin by listening to songs which have one vocalist accompanied by a limited number of instruments. You may even fall in love with some new songs that you did not notice in the past. Select relatively slow tempo songs by singers who have clear articulation. Nursery rhymes and holidays songs that are familiar to you are often a good choice to begin with.

What practice materials are available to help improve your music appreciation?

The cochlear implant companies all have excellent music rehabilitation materials. I encourage you to explore their websites to find materials for your use.

Advanced Bionics rehAB offers Musical Atmospheres, an interactive online program designed to help teens and adults with cochlear implants explore their music perception skills. It guides users through different musical features with increasing complexity (i.e., solos versus duets). This hierarchical training program invites you to experiment with a variety of tasks from basic (distinguishing between a human voice and the sound of musical instruments) to intermediate and advanced (i.e., identifying specific instruments, a vocalist's gender, or song lyrics).

Cochlear Americas offers HOPE Notes, a music rehabilitation tool developed by Richard Reed. (View Richard’s prior blog post to learn his story). HOPE Notes includes original and traditional songs and tunes, sometimes played in various ways to allow different listening experiences. The DVD includes captions that literally describe the music (Which instrument is now playing? Which chords are dominant?) This can be very helpful as you are learning to listen. I recommend using the DVD with the User Guide because it provides both theoretical and practical tips and most importantly—it encourages you to work on improving your music perception and appreciation. Richard's practical and positive approach, as expressed in the HOPE Notes tool, is both a source of support and an effective self-training program. The product is available for purchase from Cochlear.

MED-EL designed the first Spotify playlist for CI users. The playlist was created by MED-EL’s in-house musicologist, Johanna Pätzold, based upon research on music and cochlear implants. The list includes a variety of songs by various artists using different styles to enable as many CI users to enjoy using it and to motivate recipients to listen to music. The list includes popular and familiar songs, with emphasis on the vocals and with limited “special musical effects”. The list was created utilizing parental advisory guidelines, so it can be used as a family's playlist. The lyrics are available, allowing users to follow along.

It can be a motivating experience to use the MED-EL Munich Music Questionnaire to Record Music Listening Habits of People with Post-lingual Deafness after Cochlear Implantation. The questionnaire provides an interesting perspective about changes in your music listening habits as well as a means of improving your awareness of your own music listening skills. You can fill out this questionnaire two months after your switch-on, then 6 months later, as a means of documenting your progress.

This is a brief introduction to the topic and an overview of CI company music rehab tools. More content is available on the CI company websites.

To sum up…Music was important to many people prior to losing their hearing. With your cochlear implant, hard work and dedication, you may be able to regain this important part of your life. Best of luck!

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What's Old is New Again if We're Lucky

Posted By Susan Thomas, Wednesday, November 30, 2016
Updated: Tuesday, November 29, 2016


After losing his hearing due to an ototoxic antibiotic, musician Richard Reed was unable to appreciate music—or even have a so-called "normal" conversation—for nearly ten years. Then he had CI surgery in 2002.

At lectures and performances Richard demonstrates how music, voices, and nature sounds through his CI. Once again, he is playing organ and piano in Blues and Rock & Roll bands. He was inducted into the Rhode Island Music Hall of Fame in 2015.

It is my honor to share Richard's story in our blog.

What’s Old is New Again if We’re Lucky

While searching our cluttered basement, I came across boxes full of reminders from my first- and worst- decade of late-deafened adulthood. Thanks to Cochlear Implant surgery and rehabilitation, I've been able to hear again, and quite well, for fourteen years. Why had I held on to this stuff? Why had I shlepped those musty memories along through three moves? There's no good reason. We let go when we're ready.

One carton was mostly wires wrapped around obsolete assistive listening devices and gadgets; another held hopeful articles on hearing loss breakthroughs and a small stack of my dismal audiograms. In the years before the deluge of virtual journalism, family and friends used to send me stories about grieving and loss. It's funny and poignant to see my long-gone mom's elegantly eccentric handwriting scrawled across a tragic tale: "Saw this and thought of you!"

One folder contained ads for Ginkgo Biloba and other tinnitus treatments and "cures", an expired warranty for state-of-the-art analogue hearing aids, and a thick catalogue offering amplified telephones as big as old phone books. Contemplating having to sort the contents into four piles (keep, toss, recycle or Salvation Army), I whispered sarcastically "This will be fun!" Then I smiled to realize that when I'd packed most of this stuff, I couldn't have heard myself say anything.

There were only two post-CI mementos in the lot: the first and only CD I ever bought, "Rubber Soul" by The Beatles and a hardcover copy of "Walden" by Henry David Thoreau.

I've written elsewhere about how foolish it feels in retrospect to have attempted The Beatles as my first post-CI music. Although very familiar and sorely missed, those songs were way too harmonically rich, their production too sonically dense. They're actually enjoyable again now, but it's strange that "Nowhere Man" is less than three minutes long. It seemed a lot longer a few days after CI activation. I tried listening to it two or three tortuous times, but knew right away it wasn't going to work. So I walked to the nearby library to look at audiobooks.

My father had been re-reading Walden before he died. I'd held on to his copy meaning to at least crack its cover, if not all of its secrets. But I hadn't taken the time to do either. Finding Walden among the Narragansett Library's audio books—knowing I had that old hardcover at home to read along with—felt like a sign from above.

It wasn't.

Like its ancient namesake pond, the 19th century tales in Walden are beautiful and deep. So it's probably best if their narrator doesn't sound like a 21st century robot chipmunk. Thoreau once said, "Read the best books first, or you may not have a chance to read them at all." A caveat for beginner CI users: Read along while listening to simple audiobooks at first, or you may not be able to listen for more than a paragraph or two. Returning to the library, I swapped Walden for The Witches by Roald Dahl. It was light-hearted. Its narrator used a few different accents which only sounded sillier in Early CI Robot Chipmunk English. Much better.

Fast forward back to the basement: those old boxes were heavy, literally and figuratively. At the very bottom of the pile was a mislabeled under-the-bed storage container full of sweeter memories: favorite cassette tapes from before I lost my hearing. Wow! There were a few thousand great old songs. And if I'm only able to enjoy hundreds and hundreds of them due to the inherent Lo-Fi of CI, that's still an amazing grace. I'm glad I hadn't tossed them out in a quiet fit of melancholy while still deaf.

Except for the sentimental things and the memories they trigger, all the information in those old boxes---the books and articles, the music on antiquated tapes, the obsolete technology of my land-line relay telephone, even my medical records—can now fit in a device smaller than one of those old cassettes. I was pondering that when the lights went out.

"Hey!" I yelled.

"Oops, sorry", I heard Emily shout from three basement rooms and a staircase away/ "I didn't know you were down there!"

Being able to hear my girlfriend's faraway voice didn't feel particularly special at the time. CI users grow accustomed to everyday aural miracles. It's only in remembering and writing it down now that I feel the weight of it, like a warm comforter on a cold night. I really should spend more time just being amazed.

"What are you doing?" Emily asked from the stairway.

"Looking for a cassette player," I replied.


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Cochlear Implants and Adults with Congenital Hearing Loss

Posted By Susan Thomas, Wednesday, November 16, 2016
Updated: Friday, November 4, 2016

Cochlear Implants and Adults with Congenital Hearing Loss –
It's worth considering!

My previous blog post described the process of expanding the boundaries of CI candidacy to include teenagers and adults who communicate with sign language, have minimal use of oral language, and little functional use of their residual hearing. The experience of providing cochlear implants to congenitally deaf adolescents refined our understanding of the different ways in which people benefit from cochlear implantation including subjective benefits that need to be evaluated using quality of life measures rather than more typically applied measures of language perception.

When the first congenitally deaf adult candidates arrived at our clinic, we already had experience in providing CIs to adolescents with congenital deafness. Although sometimes the motivation for teenagers was at least in part to please their parents, the interest of adults with congenital hearing loss in cochlear implantation was typically derived from a desire to improve their quality of life. Some of these adults had typically hearing spouses and/or children. Many struggled with academic and career issues related to their hearing loss. They wished to improve their ability to communicate with people with typical hearing—mainly by enhancing their speechreading. They wished to be able to perceive environmental sounds to a greater degree and to be more independent in their daily activities. Some expressed hope for understanding speech without speech reading, to be able to talk on the phone, and to enjoy listening to music. Some wanted to improve their speech intelligibility. They were excited about the benefits they might gain from the new technology and didn't want to miss the possibility to experience improved access to sound.

Some of those adults who expressed interest in CI had experienced important benefit from conventional hearing aids when they still had usable residual hearing; they hoped CI would advance access to sound as they remembered it. Most of these adults were involved in the Deaf community; however, unlike their teen counterparts, most were not concerned about social acceptance (or rejection) by the Deaf community.

While teenagers usually received ongoing support from their families (who attended mapping and auditory rehab sessions with them), adults were generally accompanied by a family member at the candidacy phase only and negotiated the post surgery rehabilitation process post implantation alone. Moreover, their ability to commit to a long intensive rehabilitation process, which might involve the loss of working hours among other things, was difficult.

Auditory stimulation prior to cochlear implantation is an important issue for adults with congenital hearing loss if they have not used amplification recently. The long-term lack of auditory amplification has to be taken into account when determining the appropriateness of CI, communicating realistic expectations, and providing appropriate rehabilitation.

Adult CI recipients with congenital hearing loss have benefited importantly from auditory rehabilitation provided weekly by an auditory rehabilitation professional. In my experience, some patients require support starting at the early stage of adjusting to the new auditory signal since they may experience the new sound as strange, unfamiliar or even unpleasant. The rehab professional can help determine whether the unpleasant sensations are within the normal range for a recipient's process of adaptation. In addition, s(he) can document progress and consult with the audiologist and surgeon.

Auditory training helps CI recipients learn to identify the differences between environmental and speech sounds and improve their listening skills. As recipients become more experienced, they often report hearing new environmental sounds, which is thrilling for auditory therapists as they witness the gradual development in their patients' listening attentiveness! Learning to recognize environmental sounds is an exciting experience that extends one’s world knowledge and improves a sense of involvement and orientation.

Adult CI recipients with congenital hearing loss can also learn to recognize some speech sounds. Recognition of specific speech sounds enables them to gradually acquire an auditory inventory of dozens of words and phrases. It is important to note that most of these recognition skills are restricted to structured and quiet rehabilitation settings. After a period of time, some of these recipients excitedly report that they are able to identify certain words and common phrases in real life situations (e.g., when their child calls Mom or Dad, when someone calls their given name, when co-workers greet them "good morning" or ask "What's up?" in a relatively quiet acoustical environment).

Another important achievement is continuous use of the sound processor. Many people with congenital hearing loss did not use their hearing aids consistently prior to the CI and others haven't amplification for years. The experience of continuous connection to the world of sounds can be an important benefit.

After several months, many CI recipients report enhanced speech reading and easier communication. They may report fewer requests for clarification, fewer misunderstandings, and an improved ability to understand people with imperfect or unclear speech. For example: "Suddenly I realized that I could speak with my young daughter's friends, who until recently had to seek my daughter's help when talking to me. Now they could communicate with me directly".

From my experience, CI rehabilitation goals for adults with congenital hearing loss typically do not include the improving the recipient’s own speech intelligibility nor achieving complete auditory speech understanding (based solely on the auditory modality). The rehabilitation of adults with congenital hearing loss focuses on:

  • Taking advantage of basic acquired auditory skills in order to improve the perception of environmental sounds
  • Facilitating oral communication
  • Modifying old habits that often result in someone ignoring auditory stimulation, changing the pattern of behavior to more auditory attentiveness 

It is my feeling that post CI rehabilitation of adults with congenital deafness is like adding rungs to a ladder. In some instances, it can make the ladder more accessible for those who could have never before have climbed it. In other cases, it can make the climbing more pleasant and comfortable, thereby improving the climbers' opportunity to reaching even higher levels.

Good luck to you all.

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Cochlear Implantation for Adults with Prelingual Deafness

Posted By Susan Thomas, Tuesday, October 18, 2016
Updated: Thursday, October 13, 2016


Cochlear Implantation for Adults with Prelingual Deafness*

Deafness in Adults: Age of Onset Matters
Adult CI candidates who once had normal hearing and experienced hearing loss later, or had some degree of hearing loss in childhood that worsened over time, typically have spoken language skills including intelligible speech. In contrast, adults with congenital deafness (present at birth) who never derived significant speech perception benefit from conventional hearing aids, generally have less well developed spoken language skills. If they did not use amplification consistently, there is an even greater chance that their use of spoken language is more limited.

Despite the fact that the individuals in the described categories may have similar audiograms indicating bilateral profound hearing loss, their spoken language skills may differ significantly. Further, expected outcomes with a cochlear implant are also quite different.

Congentially Deaf Adults
The speech intelligibility of congenitally deaf adults may be poor. Spoken language may be hampered in other ways and listening ability may be quite limited. These CI candidates likely are unable to detect all speech sounds and many environmental sounds are not detectible. Many such individuals do not demonstrate spontaneous listening behaviors and will require speechreading and/or sign language, even in quiet. Repetition and a slower speaking rate may also be needed.

CI Outcomes for this Adult Population
In light of the above, it can be generalized that congenitally deaf adults will continue to need speechreading and/or sign language following cochlear implantation. Nonetheless, we cannot predict with certainty that they would not benefit from the auditory information they would derive from a cochlear implant. Some individuals with this hearing profile may even gain some open set listening with a CI.

Although cochlear implantation has advanced dramatically, device outcomes are impacted by many factors including patient characteristics. In assessing candidacy, it is important to consider:

  • What are your expectations? Can a CI help you to fulfill some or most of these expectations?
  • Will you undergo rehabilitation to help you realize potential benefits? 

With regard to rehabilitation, it is important to both follow through and find a means to customize a program to meet the person’s specific needs—both subjective and objective outcomes. Assessment of outcomes should include a range of possible benefits including access to speech, one’s own spoken language, environmental sounds and music. Changes in life circumstances may also affect communication needs. Such changes may include, for example, living with parents versus living independently; mainstream educational settings as opposed to supportive settings; moving into a workplace that does not fully accommodate hearing loss.; or expanded social interactions with a greater range of people.

A broader appreciation of possible benefits allows one to assess CI outcomes more accurately, particularly for this group of adults. Therefore, a consideration of CI candidacy should be undertaken without preconceived notions regarding potential benefits of the intervention on someone’s quality of life.

Our ability to understand this complexity is key to defining needs, goals and rehabilitation strategies which may augment the opportunity for a prelingually deaf adult to realize the full benefit of a cochlear implant over time.

In the next post we will discuss these potential benefits.

* Prelingual hearing deafness is defined as hearing loss present at birth or prior to the acquisition of language.

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A Retrospective Look at Cochlear Implantation, Part 2

Posted By Susan Thomas, Tuesday, September 13, 2016
Updated: Monday, September 12, 2016

A Retrospective Look at Cochlear Implantation in Older Children with Prelingual Hearing Loss 

Part 2: Experiences of Older Deaf Children Using Hearing Aids

In the mid 1990s, parents of older deaf children observed the benefits of cochlear implants for young children. Many deaf children were using hearing aids with minimal benefit and were struggling, sometimes in mainstream classrooms. The negative impact of the child’s hearing loss on academic progress became more evident as the children moved into upper grades.

Parents recognized that communication and educational support typically decline as children get older—despite the fact that academic and social activities become more challenging. Though their children were not the ideal age for cochlear implantation, parents felt that their children deserved the opportunity to try new technology that could enhance communication and quality of life. The children themselves typically shared their parents' dreams. Many were integrated into mainstream school settings and experienced their hearing loss as a significant disability that CI could potentially mitigate, at least partially. Many CI teams, however, had concerns about making the intervention available to this population. It was clear that in order to achieve maximum benefit, older implanted children would need to be enrolled in intensive auditory rehabilitation programs designed to address their unique needs.

What have we learned from these later implanted pediatric recipients?

We learned that the speech perception skills of someone who is prelingually deaf and later implanted is a key indicator of expected auditory skills post CI. We also confirmed the effect of age at the time of CI as a key parameter in other auditory outcomes. Children who were implanted at a later age differed significantly from children who were implanted at an early age in various aspects including the course of the rehabilitation process, the pace of progress, and the eventual outcomes.

We also learned that later implantation can facilitate progress in communication skills. Over time, many of these older children experienced significant improvement in their communication function. Some gradually changed their communication habits from using primarily visually based communication with little meaningful auditory information to an auditory supported method of communication. Long term outcomes included enhanced speech reading including understanding speech without visual clues in certain situations, better speech intelligibility, music appreciation, increased ability to understand speech on the telephone, and improved perception of environmental sounds. Parents reported that their children were more self-confident in various social situations and functioned more easily in their regular classrooms.

Interest Increased from Families

Due to the positive impact of later implantation for mainstreamed children, we saw an increase in interest in CI from this population. Typically, candidates were children and adolescents who attended special classes for children with hearing loss. Many students communicated using sign language—either sign alone or total communication. Many had significant spoken language delays of 4 years or more and some had disabilities in addition to their hearing loss.

This new group of candidates challenged CI teams in many ways. Not only were they thought to be "too old" to benefit from CI, their oral language skills were often poor. There were questions regarding their ability to enhance their auditory abilities when their communication mode was not based upon listening and spoken language. There were also concerns regarding whether they would be sufficiently motivated to complete the needed intensive rehabilitation that would likely take many months, or even years.

The decision on whether a child was an appropriate CI candidate was even more complicated in instances in which there were additional disabilities. If candidacy was approved for a child with additional disabilities, it was critical that the family had realistic expectations regarding likely outcomes and the need for a unique course of follow-up rehabilitation. Clinicians and family members together needed to collaborate to build realistic rehabilitation goals. We also needed to gain the support of the child’s educational team and ensure that the classroom environment would be supportive.

In the program where I worked in Israel, we initiated efforts at the national level with the Ministry of Education to increase the educational support and rehabilitation resources provided to students with cochlear implants. We communicated and coordinated with school staff to establish a collaborative process during the candidacy evaluation stage and throughout the rehabilitation process. We visited schools to meet not only with educators, but also with a child’s classmates. We adopted an approach of acceptance and respect for the use of sign language. The message conveyed by the CI team regarding use of sign language by candidates and their parents was that CI does not exclude the use of sign language. For these later implanted children, it was important to encourage the children's continued use and further development of sign language skills. Accordingly, professionals from the CI team used signed Hebrew along with spoken language (total communication) with these candidates and CI users.

What insights have we gained from these later implanted children?

We learned that the amount of auditory language that an older candidate already has in place, as well as the frequency of using such language, is a factor in determining CI outcomes. Motivation is a highly influential variable regarding participation in CI rehabilitation. The CI recipient's cooperation with the rehabilitation demands and their willingness to take on proper maintenance of the CI cannot be taken for granted with older children or adolescents. Given the later age, cochlear implantation may conflict with their identity relating to hearing loss; such conflicts must evaluated to determine an appropriate path forward. Teenagers must address which community they identify with and whether a CI will present identity concerns. Do they identify as having hearing loss, being part of the Deaf community, or being part of a new paradigm allowing them to be deaf but functioning within the hearing world with CI?

Auditory rehabilitation is essential for progress; a lack of consistency in their auditory training program can interfere with progress. We also learned that collaboration between the CI team and the educational team is critical to the progress of the older child or teenage cochlear implant user.

Beyond all of the complexities and challenges, we learned that CI provides significant benefits for this group of candidates!

Important Benefits in Older Children Changed Minds

Implanted teens and children with the above age and communication characteristics were able to identify many environmental sounds and their awareness of auditory stimuli in their environment improved significantly. They reported meaningful enhancements to speech reading. In many cases, following intensive long-term auditory training, they were able to understand simple sentences without speech reading. This ability was usually restricted to quiet conditions, certain speakers, and short sentences on an identified topic. However, this was a groundbreaking experience related to auditory comprehension. Some of older recipients were able to reply to simple questions and react spontaneously to greetings in everyday situations. Some even managed to talk on the phone with their parents, usually when the conversations were relatively structured and on specified topics. Most of these recipients used their device regularly and were positive regarding their decision to pursue a cochlear implant.

With these insights, CI clinics began to open up their programs to this new population of older children and adults. This required a new approach for follow-up rehabilitation, which will be addressed in future posts.

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A Retrospective Look at Cochlear Implantation

Posted By Susan Thomas, Tuesday, August 30, 2016
Updated: Monday, August 29, 2016
A Retrospective Look at Cochlear Implantation in Adults with Prelingual Hearing Loss

Part 1: Introduction

Today’s post takes a retrospective look at CI in adults with prelingual hearing loss. This has been informed by the experiences of of implanted adults with this type of hearing history and my personal and professional experience as an educational audiologist at schools and as an auditory rehabilitation therapist on a CI team in Bnai-Zion Medical Center in Haifa, Israel.

During the late 1980s, when CIs were first approved for use in the US, there were two major groups of recipients. The first group was people with post lingual hearing loss, those who previously had normal or near normal hearing and lost their hearing later in life. The second group encompassed young children (and later, infants) with prelingual profound hearing loss.

Adults with prelingual deafness differ from these two groups in many aspects. This group was included in expanded FDA guidelines beginning in 1998.

A Change in Perspective

How did we get to the point of considering CI as an appropriate, beneficial option for adults who had never heard before? Why consider CI for adults and adolescents whose communication required visual information rather than auditory information? What benefit might people who rely upon sign language as their preferred and dominant language derive? How did it come to pass that in spite of the well-documented advantages of early implantation and shorter periods of deafness that there are now so many prelingually deaf CI users who have gone through implantation at a later age?

The current reality results from nearly a decade of clinical experience and research. The accumulated knowledge, both theoretical and clinical, altered the perceptions, both among professionals and among people with congenital hearing loss regarding the potential benefits of CI for adults who were deaf at birth but opted to pursue CI as adults.

Pressure for Change Based on Parent Advocacy and Clinician Support

This change in candidacy criteria was supported by persistent parents advocating for their older children and teenagers as well as by determined adult CI candidates with prelingual hearing loss. These people have recognized the limited benefit of conventional hearing aids for those with profound hearing loss and pressed for an opportunity to experience the potential advantages of CI. Such parents and adults were aware of the fact that CI cannot provide the same benefits for these individuals that it offers young children and postlingual adults; nonetheless they chose to pursue this path.

This candidacy expansion process was encouraged and facilitated by CI professionals who foresaw the likely benefits of CI for this population. The complexity of CI rehabilitation for these candidates was recognized and professionals developed intensive, customized rehabilitation programs. Implantation of "challenging" candidates not only broadened CI criteria boundaries, it also extended the definition of CI success. Implantation of prelingually deafened older children and adults provides examples of the diverse ways in which cochlear implantation contributes to quality of life.

My next post on this topic will address the process of learning to listen with a cochlear implant as a prelingually deafened adult or adolescent.

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Quality of Life Improvement

Posted By Susan Thomas, Tuesday, August 16, 2016
Updated: Sunday, August 14, 2016

Quality of Life Improvement Following Cochlear Implantation

Recipients Anticipate that Better Hearing will Improve Quality of Life

The expectation that one’s quality of life will improve with a CI arises from the recognition of the all-encompassing negative effect that a hearing loss has on one's well-being. Adult CI candidates typically anticipate that better hearing following CI will lead to a better quality of life.

Although the research on CI outcomes focuses on auditory skills, there are a growing number of studies that have assessed the way cochlear implantation impacts on quality of life. According to these studies, adult CI users often report positive effects such as easier communication and socialization, greater independence, expanded occupational opportunities, improved sense of well-being, decreased levels of self-perceived hearing handicap, and decreased levels of depression and anxiety. However, outcomes vary and there is no reliable way to predict the impact of CI on different aspects of one's quality of life.

Quality of Life Improvements Vary by Individual

The improvement in quality of life following CI is an individual experience that can be expressed in many different ways. This blog post will focus on individual experiences, rather than quantitative data. I am sure many readers have their own unique insights regarding the contribution that a cochlear implant made to their quality of life. These personal insights are a valuable source of information for CI candidates, CI users, families, and professionals. Different people assess improvement in their quality of life according to different measures and hence weigh the impact in different ways.

A patient of mine was happy with his CI from the very first weeks after following activation. He enjoyed listening and trying to detect environmental sounds that he had never heard before. He experienced the auditory information he was receiving as a new and intriguing gift. He felt he had been blessed with his improved sound awareness even though he never managed to understand sentences without speechreading. Importantly, we had never defined "understanding sentences without speech reading" as a practical goal for him given his hearing history. Another CI user, who was considered a "star patient" based upon her speech perception outcomes, felt frustrated because the CI did not provide her with normal hearing. It took time before she recognized and appreciated the benefits of the CI and its contribution to her quality of life.

Expectations: Everyone is Different

Many CI users deal with "emotional baggage" which includes a sense of hearing impairment, experiences of difficulties in communication and social interactions, and expectations—theirs, family members’ and friends’. These, as well as other factors, affect perception of the CI contribution to a person’s quality of life. A judgmental attitude towards people's perception of their quality of life is useless. There is no objective right and wrong. CI users, families and professionals should respect the variety in outcomes, as well as the possible gaps between the user's feelings and their "actual" auditory achievement. We all need to be patient and supportive.

Quality of Life Benefits Are Not Just About Speech Perception Scores

Although the improvement in quality of life correlates with the improvement in speech perception, it is important to note that it is not restricted to a certain objective level of speech perception skills. Even people with relatively "poor" auditory skills can experience meaningful contributions to their quality of life.

The following examples illustrate two CI users who differ in their auditory functioning. Both are satisfied with the contribution that a CI made to their quality of life.

One person is grateful that the CI allows her to feel safer and more oriented to her surroundings. She wrote:

"I gained the ability to hear a variety of sounds and use them daily. I especially appreciate my ability to understand invisible sounds. The CI made a huge change in my life as I now can rely more on hearing and less on sight and touch. In the past, when I locked the car I've always been trying to open the door in order to check if it is locked. Today I don't need to check anymore. I can be at home on the second floor and figure out that my husband is washing dishes downstairs without seeing him. I can hear my children fighting and go to stop them. Before I had the implant nobody stopped their fighting." 

The other woman, who previously worked as a director of a large company, reported on a huge improvement in her ability to cope with group meetings. She is able to talk on the phone with family and friends, she can follow some TV programs (without captioning), and she enjoys listening to music.

It is clear that these two examples represent women with different auditory abilities, pre and post implantation. Yet, both of them use the CI regularly (even when they are at home alone). They both experienced an improved sense of well-being and significant benefit in daily situations in which they previously struggled before they received a cochlear implant.

Assessing Your Quality of Life Changes

To assess the contribution of the CI to your quality of your life, you might ask yourself some question comparing your pre-implant feelings to your current situation post CI. For example, before receiving a CI:
• What were the reasons you pursued a CI?
• In what ways has your hearing disability limited your daily life?
• Which specific situations were difficult for you to cope with before the implant (i.e., at home, work, or with certain people).
• Did you avoid certain situations and why?
• What strategies did you use in order to cope with these difficulties?
• Did you experience any stress or depression due to your hearing disability?

Now, post cochlear implantation, consider the following:

• Do you enjoy listening with your CI?
• Do you feel there is enhancement in communication (hearing, speaking, and speech-reading)? Can you define these situations?
• Do you feel more comfortable in social and communicational situations that used to be stressful prior the implantation?
• Do you feel more self-confident to do things you did not do in the past?
• Do you feel more independent?
• Do you feel that you have achieved the goals that you set for yourself prior to implantation? Which goals have already been achieved? Which goals have not yet been achieved?
• Are you satisfied with your CI?

Focusing on benefits can be a very empowering, constructive, and supportive method of action that may contribute to your perception of improved quality of life. Some studies note quality of life improvements as early as 9 months post implantation. However, the auditory outcomes continue to improve for the first few years. It is important to view the improvement in quality of life as a long-term process and expect the growth of benefits resulting from your CI to be reflected in various aspects of your life over time.

Further Reading:

Loeffler C et al. 2010. Quality of Life Measurements After Cochlear Implantation. The Open Otorhinolaryngology Journal, 2010, 4, 47-54 47 1874-4281/10. Bentham Open Access

Zaidman-Zait A. 2010. Quality of Life among Cochlear Implant Recipients. In: JH Stone, M Blouin, editors. International Encyclopedia of Rehabilitation.

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