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Cochlear Implant Rehabilitation for Adults
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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 sthomas@acialliance.org . If you would like to write to me directly, please email me at: naama@acialliance.org. 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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Emotional Impact

Posted By Susan Thomas, Wednesday, June 15, 2016
Updated: Monday, June 13, 2016


 

Emotional Impact of Cochlear Implantation

How does cochlear implantation impact people on an emotional level? Though it is difficult to find empirical data documenting the emotional effect of cochlear implants on adult recipients, this is an extremely important issue. How can one find information about emotional effects? One source is the abundance of online videos documenting the first moments of hearing after CI activation. In addition, there are published studies that assess quality of life benefits for adult CI users.

Most CI candidates and their families view videos posted on the Internet documenting the first sounds and words heard by adults and children at activation. Watching these videos, one can witness the tremendous excitement of the recipients and their families—often expressed with tears of joy and relief. Studies examining the effect of CI on adult quality of life document that there is general improvement and satisfaction over time.

But what happens in between? Relying on these two sources of information (i.e., videos and quality of life studies) might lead to the impression that the timeframe following CI is characterized mainly by a great happiness and that once a cochlear implant is activated, individuals experience a continuous increase in your quality of life. However, many CI recipients know from their personal experience that the reality is much more complicated. My experience with many adult CI users, has taught me that not everyone experiences the same level of joy when the implant is activated. Importantly, for some people, the first period of CI use is characterized by significant emotional challenges.

Let's start by stating the obvious; severe to profound hearing loss is not a life threatening condition. Adults' motives are not linked to health conditions in the same way that many other surgeries are but rather are driven by a desire for a better quality of life. This includes improved communication with family members and in the as well as better environmental orientation. These hopes may be dashed in light of difficulties that arise initially. The challenge of adapting to the CI and the gradual—not immediate—acquisition of auditory skills can cause intense emotional distress and disappointment. Emotional difficulties may be experienced by adults with wide-ranging hearing histories. In this post, I would like to share some experiences that I have witnessed.

Recipients Who Experienced Progressive Hearing Loss

People who lost their hearing progressively later in life might experience the sound provided by a CI as unpleasant (not "natural") and their speech perception via CI might not meet their expectations. They might not accept the time required to adjust to the CI. Their wish is to experience normal hearing again. It will take them some time to acquire improved hearing skills and to accept that their CI cannot provide normal hearing. Someone who lost their hearing later in life may be disappointed when their auditory progress does not occur as quickly as they had anticipated.
It may appear that people who had progressive hearing loss have the least need for auditory rehabilitation given their prior auditory perception. On the other hand, such recipients may experience high levels of stress. They may derive special benefits from an auditory therapist who can help them to recognize their achievements rather than dwelling on their difficulties. A therapist can also help the new recipient understand the gradual nature of the rehabilitation process, provide answers to questions and help them remain positive about the process.

Recipients with Usable Residual Hearing in One Ear

People who have usable residual hearing in their non-implanted ear may feel that the hearing aid continues to provide the dominant hearing information during the initial timeframe after activation while the implanted ear provides less usable information, even to the extent that information from the implanted ear interferes with speech understanding. Auditory training improves the implanted ear auditory abilities as well as contributes to the CI users' faith in the potential auditory benefits of the implanted ear. The concern is that people with functional hearing in their non-implanted ear do not continuously use their implant and may not give their implanted ear sufficient opportunity. An auditory therapist can help such recipients to maximize the benefit from the sound from cochlear implant and merge the two sources of sound.

Prelingually Deaf Recipients

This group includes people who never experienced normal hearing and must learn to adjust to entirely new auditory stimulation. During the first period after implantation, the auditory information they receive may be incomprehensible and may be perceived as disturbing noise. The silence that engulfed them before cochlear implantation is gone and they are exposed to many sounds without the ability to distinguish or choose which sounds are worthwhile to focus on. These recipients may struggle to acquire basic auditory skills such as identifying environmental sounds, speech sounds, and words and phrases. They may also need to learn about the impact of various acoustic environments on speech perception.
Prelingually deaf recipients who come to CI may also need to learn a good bit more about spoken language communication. During the rehabilitation process, CI recipients are gradually exposed to new sounds and they expand use auditory information in their daily life. This is a fascinating journey in which CI users' experience auditory learning and growth, however they also become more aware of their past and present limitations. This rehabilitation process requires emotional strength and support.

Concluding Thoughts

It is important to remember that the course of adjustment and rehabilitation is very personal and there are various possible scenarios relative to one’s emotional adjustment. Every scenario is legitimate and should be accepted sensitively and patiently by the CI recipient’s family, their CI team, and by the CI user himself. One’s emotional reaction is not predictable. It is affected by a variety of personality factors and by the course of the auditory learning as well as the support from the recipient’s family, social environment, and his or her CI team.

Recommendations

If you are experiencing emotional difficulties arising from cochlear implantation, know that you're not alone. Like many other starts in life, the beginning of the path can be difficult but it does not necessarily imply the future and there is no reason for despair. Remember how brave you were choosing to go through the surgery. Continue to have faith that your dreams for a better quality of life will eventually come true. As explained in this and earlier posts, CI rehabilitation is hard work.
In addition, CI rehabilitation is a very dynamic process that requires emotional adjustment skills, flexibility, positive thinking and faith in yourself and your CI team. If you feel that the process of adaptation to the cochlear implant is an overwhelming emotional burden, please seek professional support. You can contact your CI team and seek the appropriate assistance.

 

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Adult CI Support Groups

Posted By Susan Thomas, Wednesday, June 8, 2016
Updated: Friday, May 27, 2016

I am so happy to welcome back a special guest in my Blog. Linda Daniel is an audiologist and Auditory Verbal Therapist who serves as the director of HEAR in Dallas. Linda accepted my request to share her unique experience with us in initiating a support group for adult cochlear implant recipients. This is the second of two posts highlighting various challenges and dilemmas faced by adult CI recipients. Their discussions also provide an optimistic perspective of the potential benefits that adults can derive from participation in such support groups as part of their rehabilitation program. Thank you Linda!
Best Regards, Naama 

 

Adult CI Support Groups: Linda Daniel Guest Blog/Part 2 

The Adult CI Support Group at HEAR In Dallas has a few other goals and purposes. We do not have captioning at this time for several reasons. First, captioning services are costly and there are no dues for the group. Second, everyone who attends is working on listening and communication skills along with learning to advocate for themselves. During the sharing, participants are encouraged to raise their hand and request clarification when needed or state what would help them such as “Could you please speak a little slower?” or “Could you please take your hand away from your face?” The group is a safe and understanding environment for practicing these strategies and allows participants to build skills and courage to do so “out there.” We have had hearing health professionals attend as well; they share their questions and concerns about interacting with individuals with hearing loss and the participants are gracious in coaching them in how they can be more sensitive to those they serve. The two-way sharing is such a beautiful and touching experience for all.

Excerpts from One Group Discussion
At one meeting, I posed these questions to the group: “Why do you come to the support group meetings? What do you get from it?” As they took turns sharing, I recorded their comments. This is a summary of what some of the participants shared.

FT—42 year-old man, post-linguistic progressive hearing loss, years of hearing aid use, and then CI 5 months ago

I was rather by myself just by being male then I became isolated even more as my hearing deteriorated. I didn’t admit I had a hearing deficit, which just made me more isolated. With hearing loss, there is so much unknown to experience – everything is all new ---and it’s good to be with people who are struggling like me. I now know I’m not alone in the struggle—we are struggling together. I come here to feel community and meet people who can sympathize and empathize with what I’m going through. This group is unique because we come together to support each other; the other group I’ve been to is a lecture-based group but does not provide the personal closeness and sharing of this group. I am grateful to hear from people who have had a CI for over 20 years share their experiences; I’ve had mine just five months. I learn so much from people at all stages of the journey.

RB--congenitally deaf, lifelong hearing aid user, CI and AR in her 30’s

So many CI users don’t feel Deaf and don’t feel Hearing. We’re in between the two groups. With the support group of people in the same situation, I now see that we can have a sense of belonging. We are a group—we do have a community: we are the group in between Deaf and Hearing! I also benefit from this group because we strive to strengthen our self-advocacy skills. I hear what others have done to advocate for themselves and it gives me the courage to try it myself. I feel so empowered when I break through one of my barriers. We’re learning to speak up for ourselves in the group…we tell each other is we can’t hear them, if they talk too fast or too soft. This helps me do this too in other situations that come up in life!


PS—55 year-old woman, post-linguistic progressive loss, years of hearing aid use, will get CI soon

I don’t have a CI yet and I’m amazed at the bravery I’ve heard from everyone’s sharing tonight. I’ve read tons of things about CIs but at the group, these are REAL people who have them and I feel honored to meet people who have the strength to go through this. My supervisor at work told me the most unbelievable thing that showed me how completely she does not know what my hearing loss is about and why I need a CI. She actually told me if I didn’t stress out, my hearing would come back. In the group, people showed me their reality with hearing loss and validated my experiences and my needs. These people have experienced what I am going through. With a hearing disability, we need so many people to assist us with so many things. It gets so awkward going through life misunderstood or being looked at like there’s something wrong with me.

BV—50 year-old woman, post-linguistic progressive loss, years of hearing aid use and recent CI

I came to the group originally because I wanted to meet a new community that has the same issues that I face as a CI recipient. I keep coming back because of the wonderful people I have met. Seeing all the bravery and courage makes me glad to come back. We talk about snags in our daily lives such as how to order food at a drive-through. It’s a frustration hearing people just don’t understand but the people in the group know what it’s like! Though we are all different in many ways, we all have a core of similar experiences. We give each other tips to handle life experiences. I also like this group’s FB page. We can throw out any question we want and others will respond and I get so many answers to read and see which one will work for me. When you’ve felt “different” for so long as a person with hearing loss, it’s great to feel the “same” as everyone in the group. It’s a great feeling and I take that feeling with me when I go home.

FE—30 year old woman, deaf since four years of age; years of hearing aid use, CI two years ago

I don’t always want to explain my CI to everyone over and over and deal with all the misconceptions about getting a CI. I’m lucky that I work in the field of deaf education because I’m around people who understand hearing loss. In the support group, I feel “power in numbers!” I get strength being with people who have CIs. I learn something new every time I am with people who have CIs. Deafness is The Invisible Handicap; hearing loss is very misunderstood. In the group, everyone understands how I feel. It reinforces that there are not CI “successes” and “failures.” Rather, there are a range of experiences and differences. Hearing what everyone goes through helps me count my blessings. The grief still comes back with the denial and the sadness and the group is where I know people understand how I feel.

GT—20 years old, congenitally deaf, CI since 2 years of age with Auditory-Verbal Therapy

I wanted to meet people like me so I could make friends with people who know how I feel. My mom is in the field of deaf education and even she can’t fully understand what I’m going through. But meeting others who have CIs, I feel they really understand what I’m going through. It’s nice to hear that I’m not the only one who struggles in a drive-through and who pretends to understand what someone says when I really don’t. Sometimes we laugh when we share the crazy things we ‘mishear’ during our day and what happens because of that! One lady shared that she nearly got fired when she told a co-worker something about a person in the office that she thought she heard but it wasn’t even close to right! We gasped, then laughed and nodded our heads, knowing how easily that can happen.

FS--deaf since age four; years of hearing aid use, CI in her mid-30’s

Before coming to the group, I though I was the only person with a hearing loss. I am the only person in my family who is deaf. The first time I came, I saw so many people like me and I was so excited. I love sharing experiences with each other, learning from each other and teaching each other about different devices. As much as my family loves me, they just don’t know how to support me. With the support of the group, I don’t expect as much from my family. I love this group—I come every time. I want to be independent. I don’t want my husband to have to be my ‘hearing’ for me all the time. One professor I had in college told me about the Disability Office and I found out about CART (Computer Assisted Real-Time Captioning). That was such a big step for me to be independent. This group helps me feel so much better and helps me know how to navigate life situations on my own.

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Adult CI Support Groups

Posted By Susan Thomas, Wednesday, June 1, 2016
Updated: Friday, May 27, 2016

I am so happy to host a special guest in my Blog. Linda Daniel is an audiologist and Auditory Verbal Therapist who serves as the director of HEAR in Dallas. Linda accepted my request to share her unique experience with us in initiating a support group for adult cochlear implant recipients. Her upcoming two posts highlight various challenges and dilemmas facing by adult CI recipients. Their discussions also provide an optimistic perspective of the potential benefits that adults can derive from participation in such support groups as part of their rehabilitation program. Thank you Linda!
Best Regards, Naama

  

Adult CI Support Groups: Linda Daniel Guest Blog /Part 1

After decades of working with children with hearing loss, HEAR In Dallas, my aural rehab private practice, now serves many pre- or post-linguistically deafened adults who have elected to pursue a cochlear implant. As I worked with them and listened to their experiences and struggles, I thought they would greatly benefit from meeting others in
Similar situations. One by one, as they came to therapy, I asked if they were interested in my starting a support group; each person answered “Yes” without hesitation.

I am a rehabilitative audiologist and host the group once a month in the evening in my office. We just finished our 7th month of meetings. Typically about a dozen CI users attend, ranging from college age through older adults. Though their ages and life stages are different, they feel great comraderie with one another as they share their joys and
struggles as people with hearing loss living in the mainstream of society. I function as the professional advisor of the group and attend every meeting.

In addition, I am the “ears” of the group. During our time together, if someone makes a comment or asks a question and it appears that they misheard the previous person’s comments, I clear up the miscommunication. We usually meet for 1 1/2 hours. If there are newcomers, we go around the circle and provide brief introductions—name, duration of hearing loss, when implanted. Then I state the topic of the evening such as “What I like most about my CI” or “My greatest struggle with my CI” or “What this group means to me." Meeting topics are solicited from the group for future meetings. We sit in a circle and everyone takes turns sharing. We pass a timer and each person sets it for three minutes before starting to share; the format is relaxed and interactive. The timer is a guide for an approximate time to share; after a person shares, others freely comment or ask a question of that person. They love their individual time to share and the free-flowing interaction and comfortable nature of the format. There is no advice giving, no discussion of the hearing health professionals, no promotion of device manufacturers. The primary goals are meeting others with a CI, sharing one’s experiences, dialoguing with others on topics of interest, gaining strength and learning tips from one another, and feeling a sense of belonging and community.

Excerpts from One Group Discussion
At one meeting, I posed these questions to the group: “Why do you come to the support group meetings? What do you get from it?” As they took turns sharing, I recorded their comments. This is a summary of what some of the participants shared. I will include additional participant comments in my next blog post.

RV—26 year-old woman, hearing aids fitted at 15 months and started Auditory-Verbal Therapy, then received a CI at age 4

Even though I’ve had a CI since I was 4, I have never been to a CI support group. I go whenever I can because I meet other people with cochlear implants and communicate with them without worrying what others think of me. In one meeting we talked about how others treat us differently and the misconceptions they have about us. It’s funny and sad at the same time what people say to us; it’s as if they don’t give a thought to how we feel before they start talking. One woman was at a party and the hostess told her, “You can go sit over there with my grandpa: he’s deaf too.” Come on! Really? We laughed and shook our heads; we all could feel what she felt. I take our group strength and solutions with me into my daily life in the hearing world. If you are struggling with your hearing in the hearing world, “This is definitely where you should go!”

SJ—39 year-old woman with congenital hearing loss, no intervention until CI and AR a year ago

The meetings have been a wonderful opportunity for camaraderie with people in similar situations. It has helped me feel not so alone in my experience with hearing loss. Nobody in my daily life has any understanding of my life before and after the CI. Being able to share my story with like-minded people.

 

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Unilateral Hearing

Posted By Susan Thomas, Wednesday, May 25, 2016
Updated: Tuesday, May 24, 2016

  
 

Thoughts about Unilateral Hearing, Unilateral Cochlear Implantation, 
and Bilateral Cochlear Implantation

During the early days of cochlear implantation, the procedure was performed in one ear only. Some users continued using their hearing aid in the non-implanted ear, sometimes with little benefit. Some CI users even noted that that their hearing aid might be interfering to some degree with their speech understanding but continued to use amplification to keep their residual hearing active in the event that they were able to benefit from future technology.

Growing awareness of the disadvantages of unilateral hearing loss and the benefits of bilateral hearing led, to two important changes relative to cochlear implantation:

  1. Bilateral implantation became a rehabilitative path chosen more for both adults and children;
  2. Criteria for implantation expanded to include people with some functional hearing in the non-implanted ear (e.g., moderate to severe hearing loss with some open set speech recognition). 

Appropriate candidates benefit from the advantages of bilateral hearing when using a conventional hearing aid in one ear and CI in the other. We'll talk about this topic in another upcoming blog post.

This blog post is directed mainly to those who have one CI—either those who do not use a hearing aid in the contralateral ear or those who use a hearing aid in the other ear but derive minimal benefit. Unilateral hearing should be considered in the context of the following questions:

  • What are the disadvantages of unilateral hearing?
  • What are the benefits of bilateral cochlear implantation?
  • When should someone choose to "go" bilateral?

The answer to the last question should be made on a case-by-case basis considering factors such as functional hearing in the non-implanted ear, years of hearing deprivation, and the person’s age. There is no conclusive answer that applies for all individuals. However, we can discuss the different effects of unilateral hearing on communication function as well as the advantages of bilateral cochlear implantation.

There is no doubt that unilateral CI can significantly contribute to one's auditory skills and quality of life. Many environmental sounds and speech sounds become accessible for unilateral CI users and a significant improvement is usually experienced in speech perception, especially in quiet conditions.

We have learned from those with normal hearing in one ear and hearing loss in the other ear, as well as the experience of people using one cochlear implant, that unilateral hearing imposes limitations for various situations in everyday life. Children with single-sided deafness, who have normal hearing in one ear, are at risk for lower language performance as well as social and academic difficulties. Many of these children report fatigue during class and difficulties in coping with school requirements. Adults with single-sided deafness may also experience difficulty in social settings, inattentiveness, stress, and headaches. Evaluations of people with normal bilateral hearing point that hearing with two ears contributes significantly to speech understanding, especially when listening to speech in noisy environments.

The challenges of unilateral hearing are due to reduced auditory ability in the following types of situations:

  1. Speech is directed to the side of the "poor" ear;
  2. Individual has difficulty knowing the speaker’s location to aide speechreading;
  3. Detection and understanding of soft sounds as two ears provide “redundancy”;
  4. Understanding speech in noisy situations.

Unilateral CI users often report on similar difficulties. Yet we cannot consider single-sided deaf individuals and those with bilateral hearing loss with one CI as one and the same because a cochlear implant does not provide normal hearing. Therefore, the difficulties of unilateral CI users are typically greater compared to those of people with normal hearing in one ear. 

These considerations are at the heart of why we should closely examine the potential benefits bilateral cochlear implantation for everyone. So, what can we learn from the literature? We find research focusing on adults' auditory function with one CI versus two CI's (i.e., how their function changed with a second CI). We can also find research comparing the function of adults who have unilateral CI with adults who have bilateral CI. A review of 20 studies* highlights the following key findings: 

  1. Speech perception in quiet. There are no consistent findings of bilateral advantage over unilateral CI use.
  2. Speech perception in noise. Studies consistently demonstrate the benefit of two cochlear implants over one and these advantages increase as the acoustic conditions worsen.
  3. Localization. Studies demonstrate the benefits of bilateral hearing to identify the location of a speaker or environmental sounds.
  4. Daily activities and quality of life. Self-reported questionnaires found bilateral CI benefits for spatial hearing, ease of listening, quality and clarity of sounds, and social interactions. These findings suggest that bilateral cochlear implantation has real potential to enhance communication and orientation, reflected in various daily situations, and thereby improving quality of life.

As is the case for an initial cochlear implant, the decision on a second CI is affected by various parameters beyond the patient's motivation to take another step towards better hearing. There are pros and cons that are unique to each person. If you wish to consider a second cochlear implant, the recommended first step is to consult with your CI team. Realistic expectations are important. While there is the potential for quality of life improvements, it is important to recognize that bilateral CI will still not provide normal hearing. Further, one must consider that there are rehabilitation requirements in order to maximize outcomes with the second CI and that this is essential to your success!

*Van Schoonhoven J, Sparreboom M, van Zanten BG, Scholten RJ, Mylanus EA, Dreschler WA, Grolman W, Maat B (2013). The Effectiveness of Bilateral Cochlear Implants for Severe-to-Profound Deafness in Adults: A Systematic Review. Otology & Neurotology, 34 (2), 190-198.



 

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Self-Learning Tips: Part 2

Posted By Susan Thomas, Monday, April 18, 2016
Updated: Tuesday, April 12, 2016

 

Using Recorded or Other Materials in Self-Learning Rehabilitation

There are a number of recorded and written auditory rehabilitation programs that were developed specifically for rehabilitation post cochlear implantation. You may also use other general materials such as books on tape (in different lengths and linguistic levels but preferably with minimal background music or noise) or English as a Second Language teaching materials such as Rosetta Stone®.

• Using written materials will be more effective if you are able to be creative and adaptive in their use. In addition to repetition, be aware of the appropriate speech rate of the stimuli presentation. You can use the same stimuli in a more normal (higher) speech rate with time, as your speech perception skills improve. Similarly, you can use more speech-reading (lip-reading) cues during the first period of training, moving towards auditory-only perception with time. Another way to adjust the existing materials to your needs is to add stimuli that have specific relevance to your life. For example, you may include the names of your relatives and friends, common sentences from your everyday life and so on.

Recorded materials are typically more difficult to understand than live voice and may pose greater auditory challenges. You may find recorded materials to be overly challenging during the early rehabilitation timeframe. If this is the case, try using them later when you are a more experienced CI user. Not every CI user has a positive experience with recorded materials so don’t feel that using them is a requirement. Adjust auditory training materials to your own auditory abilities.

• There are a number of interactive rehabilitation programs that run on one’s personal computer and are designed to help cochlear implant recipients practice and improve their listening skills. Some of these products are free including Angel Sound™ Tiger Speech available at http://angelsound.tigerspeech.com/.

• If you wish to develop your appreciation of music, practice listening while reading the lyrics for songs. These can typically be downloaded from music websites. You may wish to begin with children’s songs—which often have simple words, a strong beat and a limited number of instruments. When you feel you can move forward, build a hierarchical list of songs considering certain parameters. These parameters might include tempo, quantity and type of instruments, single vocalist songs versus multi-vocalist bands, etc. Even people with normal hearing are unable to understand every word in every song. Be selective about the songs you are choose and don't be surprised if you miss some words. It’s not a competition! You might also check out the websites of the CI companies for more tips and music listening products.

• When watching TV, try following some speakers without using captions.

Talking on the phone presents special challenges and will be discussed separately in a future blog posting.

• Establishing and expanding auditory memory skills can have important implications for your ability to understand speech. The longer you had poor discrimination with your hearing aids, the longer and harder you must work on your auditory memory skills. This kind of work can be done using repetition tasks utilizing lists of words (e.g., repeating 2-5 words out of 10 word list). As your speech perception skills improve, you can use words from a given category (e.g., names of cars, football players) or a given topic (e.g., work, summer, vacation). For advanced CI users, you might repeat 2-3 sentences from a list of short sentences or work on perception of two-phase instructions (e.g., "Take your shirt and put it under the table") or listen to a short story and try to recall as many details as possible.

Report specific difficulties in speech perception to your audiologist (e.g., the consonant /z/ perceived as /s/ and vice versa). Some difficulties may be resolved with mapping adjustments. Most will be resolved with CI usage and auditory practice. It is possible that you will not be able to identify all the consonants and vowels. However, it may not impede your communication interactions since people always use context combined with verbal information to understand speech.

In summary, there are many ways for you to improve your auditory skills outside of a formal rehabilitation program with a trained professional. The above is intended to give you ideas; your CI team may offer additional guidance. The world of sound surrounding us provides countless opportunities for auditory learning. It requires your attentiveness and dedication as well as constructive support from your family and friends. However, if there are emotional or other difficulties associated with adapting to your cochlear implant and the rehabilitation process, don’t try to do everything alone. Reach out to the appropriate professional for support in getting back on a positive track.

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Self-Learning Tips: Part 1

Posted By Susan Thomas, Tuesday, April 12, 2016
Updated: Monday, April 11, 2016
Post surgical support for many adults consists mainly of appointments with their CI audiologist for the purpose of monitoring speech perception and mapping the sound processor. If you are one of many CI users who does not have access to a Speech Language Pathologist, this post will have special relevance for you.

Practical tips for self- learning auditory rehabilitation

• In the absence of speech language therapist to help manage the rehabilitation process, you are the case manager of your own rehabilitation. This is an important responsibility with many implications.

• First, you will need to pursue available professional resources yourself. Ask questions of your mapping audiologist and don't wait until your next meeting if you need answers. Immediate answers can be crucial. Report any changes in your hearing or other issues to your CI team.

• Ensure that you understand how to maintain and use your processor. The recipient kit comes with different accessories. You might not need them during the initial period of using your CI, but later on they can be very useful. Ask for professional guidance to enjoy the full benefits of your technology.

• Use your CI regularly throughout the day. If there are any restrictions or difficulties in your CI daily use, inform your audiologist and look for suitable solutions.

• Knowledge can be a great source of strength. In order to acquire this knowledge, participate in lectures and conferences, read professional papers and books, visit the online website for the company that manufactured your device, and stay abreast of technological improvements.

• Online CI users groups can provide you with many practical answers as well as emotional support.

• Document your hearing follow-up outcomes and ask your audiologist to explain any changes.

• Offer to participate in research at your CI center. This could provide you with additional knowledge as well as additional opportunities to meet and talk with the CI team.

• Be optimistic but realistic about your rehabilitation goals. Discuss your goals with your audiologist. Setting realistic rehabilitation goals is often the key to a sense of accomplishment and success.

• Be aware of the fact that spontaneous auditory learning during natural situations is not always possible. Typical everyday (noisy) acoustic conditions mask parts of the speech signal. In addition, natural communication interactions include a lot of inaccessible speech information (e.g. multiparty conversations, classroom situations, group meetings, and so on). Therefore, especially in the first period of your CI experience, you need to set aside time in a favorable setting to practice your hearing skills.

• Ask family members and friends to help clarify sounds. Choose one person to be your auditory trainer. If possible, this person should accompany you to as many meetings with your CI team as they can to help motivate you to acquire auditory skills. It may require lots of patience on their part for the repetitive practice required for success. They will also want to be there when you wish to share your concerns and frustrations. From my experience, these partners experience high levels of satisfaction and gratification for your trust and for the chance to be a part of such an important phase of your life.

• Know that auditory learning after cochlear implantation is a long-term process, characterized by changes in objectives and in the pace of progress along the way. We will discuss this issue in the future. However, for now, it is important to note that efficient auditory learning should become part of your daily life. This is not a short-term effort, but a long-term commitment.

In my next post, I will share information on specific recorded and other materials that you may find useful in your auditory self-learning rehabilitation program.

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Adult Rehabilitation Post CI

Posted By Susan Thomas, Tuesday, March 1, 2016
Updated: Sunday, February 28, 2016

Adult Rehabilitation Post Cochlear Implantation: Why is it important?

People sometimes ask about the need for adult auditory rehabilitation after cochlear implantation. How can one teach hearing? Are there special speech and language therapists who work with adult CI users? Is adult rehab really necessary?

Such questions, together with a belief that modern cochlear implant technology is sufficiently robust to allow the auditory learning process to happen on its own, sometimes discourages adult CI recipients from seeking appropriate auditory rehabilitation after implantation.

There are people who acclimate to the sound provided by a cochlear implant relatively easily and some even note that their auditory learning proceeds rapidly and smoothly.  Often they are individuals who had normal hearing for most of their lives and experienced relatively short periods of bilateral deafness. Such individuals may be well served with periodic mapping sessions and being able to direct questions to their audiologist with no additional rehab support.

Other people find that they need guidance in learning to understand the auditory signal provided by their newly activated cochlear implant. Some feel that their speech understanding is restricted to certain situations (e.g., people who speak clearly and at a slower pace, quiet one-on-one environments). Some people may understand speech, with time, in specific communication situations and using strategies, such as prior knowledge of a topic, content cues or context. However, when they are exposed to new words (for example, names of people) or to terms not used frequently, these strategies may not work for them and they may have difficulty perceiving speech sounds. Another group of CI recipients who may derive benefit from auditory rehabilitation are those who experience the new auditory signal as an almost meaningless blend of sounds. Some people even find that the new sounds disrupt their prior speechreading ability.

The support of an expert in the adult hearing rehabilitation process can help address all of these issues. We can also describe this process as guidance in finding meaningful footholds in the presence of an abundance of auditory data.

It is well accepted that people can improve their physical fitness with the help of an expert who takes into account one’s physical abilities and lifestyle and then customizes an exercise program appropriate for one’s age, fitness and agility. Similarly, an auditory therapist can suggest training activities appropriate for your hearing history, communication skills, and lifestyle. A therapist can help you with a hierarchical auditory training program that includes exercises that consider: (1) type of auditory task (e.g. detection, discrimination, understanding and auditory memory); (2)linguistic content (e.g., monosyllables, short/long words, sentences, every day spoken language versus more formal written language); and (3) presentation method of the auditory stimuli (with or without speech reading, rate of speech, recorded or live speech, telephone).

Adaptation to a cochlear implant is a dynamic process. While adapting to new hearing aids can take a few weeks or even months, hearing access after cochlear implantation changes dramatically immediately and during the first few months and continues to improve during the first few years after cochlear implantation. Therefore, the rehabilitation goals vary according to the individual’s hearing history and where (s)he is in the process. The rate of progress and rehabilitation goals differ between CI users due to various parameters including previous use of hearing aids, amount of residual hearing, non-implanted ear functional hearing, spoken language skills, daily use of spoken language, age, physical condition, additional disabilities, cognitive state, family support, and motivation.

Short term rehabilitation goals:

One of the first short term rehabilitation goals for CI user "A" might be establishing the ability to detect speech sounds while for CI user "B" a first rehabilitation goal might  be discrimination between speech sounds. At a later stage of rehabilitation, one of the rehabilitation goals for CI user "A" might be recognition of two-syllable words (presented in a closed set of 3 to 4 words) and for CI user "B" the goal might be to understand short everyday sentences on a given topic (presented in a relatively slow speaking rate with repetition as needed).

At a more advanced stage, the goals for user "A" might include enlarging the sets of two-syllable words presented in recognition tasks, moving towards the ability to identify and understand words from a given category and recognition of short everyday sentences (presented in a closed set of 3-4 sentences). For user "B" the goals at a more advanced stage can include understanding short everyday sentences and expanding auditory memory skills (3-5 words presented in a closed set of 10 words). As you can see from these examples of two adult CI users, a customized rehabilitation based on an assessment of individual needs is essential.|

CI recipients can benefit significantly from an expert's help in adapting short-term rehabilitation goals to their current auditory abilities as well as in determining long-term rehabilitation goals. Working constructively towards appropriate goals will enable an adult recipient to identify and celebrate the steps of his or her progress. It will help the recipient to focus on their achievements rather than being frustrated by the hearing skills that they have not yet acquired.

There is also much to say about the emotional experience that is an integral part of almost every adult CI recipient's rehabilitation process and we will discuss this element in a separate posting. Your rehabilitation therapist can be a significant source of support for you and for your family. Ongoing communication with the speech and language therapist provides CI users with a reliable source of information about a range of topics.

From personal experience, I can say that I encountered many CI candidates who were not certain they would be able to attend weekly or bi-weekly rehabilitation sessions, mainly due to workplace commitments. After implantation they all made time in their busy schedules to attend the rehabilitation sessions, depending on their progress and needs. Weekly or bi-weekly sessions provide the speech language therapist with the ability to track process and offer a reliable basis for collaborative work with the audiologist. CI users who are more aware of their CI usage patterns and rehabilitation programs can promote their own needs in effective ways. Involving a professional in the long-term rehabilitation support following cochlear implantation will positively contribute to the process by making it easier and more enjoyable for the recipient and his or her family and by potentially resulting in better long term outcomes.

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Listening to the Sounds Around You

Posted By Susan Thomas, Tuesday, February 23, 2016
Updated: Monday, February 22, 2016

Today we will discuss the issue of environmental sounds. Typically, this topic receives less attention compared to speech perception. However, for many CI recipients the perception of environmental sounds is very significant and has a unique positive contribution to their quality of life.

According to CI user' reports, the ability to perceive environmental sounds helps them to feel connected to their environment. For example, these sounds help them to know whether they are home alone, whether someone is taking a shower or washing dishes, whether someone is knocking on the door or ringing the doorbell. The perception of environmental sounds contributes to one's sense of orientation and confidence.  As one of my patients once said, "I use my CI regardless of I am home alone or with others; I even use it when I go out to work in my garden by myself." The benefits provided by cochlear implants are not restricted to communication with others.

Immediately after the implant is switched-on, you are exposed to a world of sounds. The gate opens and a range of auditory stimuli flow in.  You hear others’ speech as well as the sounds of animals, nature, music, appliances, cars, and much more.  Access to all of this information can make you very happy; it can also be irritating or even overwhelming.

At first, new CI recipients may experience this blend of sounds as unwanted noise that mainly interferes with understanding speech. This aspect of hearing with a CI is very personal and is affected by a range of fact of factors that make up your pre-implant experience such as duration of deafness, amount of residual hearing, and hearing aid utilization.   

If you had a significant hearing experience prior to receiving a CI, you may be very happy that these sounds have become accessible to you again. However, it will take time to get used to the quality of these environmental sounds. During the initial states of implant usage, you may feel a bit disappointed.  The sounds may not be what you remember them to be.  Sounds may seem to be different, less pleasant, and less clear. After a period of time, the way you perceive sounds will improve and you likely will learn to understand and enjoy the richness of your new world of sounds.

If you did not have a significant hearing experience prior to implantation, these sounds may be initially meaningless and even distracting. Over time the fog will clear and environmental sounds will become increasingly meaningful and useful.

Tips for Improving Environmental Sound Perception 

·      Share your experiences with your audiologist.  Are there any specific sounds that bother you or make you feel uncomfortable? You may find it useful to keep a journal of your daily experiences. Your audiologist may adjust your map based upon your experiences, or provide direction on use of noise reduction strategies in your processor, or encourage you to relax and hopefully gradually adapt to listen to these sounds.

·      Understanding environmental sounds takes time and practice. As you become a more experienced CI user, you will reap more benefits from your access to environmental sounds. You will recognize them and enjoy listening to the sounds around you. 

·      When you notice a sound you do not recognize, ask a family member or friend to identify it for you.  This process will improve your listening skills as well as your auditory orientation.

·      Work intentionally and actively on your environmental sounds perception skills. Try concentrating on a different sound each time. In order to practice perception of a sound, it is helpful to listen in a quiet space free of distracting sounds. When you are at the beach, you can practice listening to the sounds of the waves; in the parking lot you can practice listening to the sound of your car door locking; at home, you can listen to the sound of running water and compare it to the sound of dripping water; you can listen to the sounds generated by different kitchen appliances.

·      Learn which sounds are typical of specific environments to aid you in the identification process. Which sounds do you hear? Which sounds are more important for you to listen to? What are the sounds that are more pleasant for you to hear? Which sounds are less pleasant? Improving your awareness of the sounds in specific environments will help you to identify them.

·      Recognition of environmental sounds will help you to determine which environmental sounds interfere with speech perception. Accordingly, you may use that information to help plan your conversation settings.

Although the benefits of cochlear implants do not typically include perception and understanding of environmental sounds, you shouldn't underestimate the importance of these hearing skills. Your auditory learning includes this aspect of hearing; learn to appreciate it and derive the full benefit and satisfaction of your listening achievements.


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Constructive Communication

Posted By Susan Thomas, Tuesday, February 9, 2016
Updated: Saturday, February 6, 2016

Creating Constructive and Supportive Communication with Family and Friends

This post is devoted to a particularly challenging issue—addressing the attitude of your family and friends towards cochlear implantation and the rehabilitation process that follows. Likely your family and friends will support your decision to pursue a cochlear implant and wish you the best possible results in the hopes for a better quality of life. Family and friends can be a great source of support for you during the process. The main message I want to convey in this post is not to underestimate the importance of open communication with the people closest to you regarding the circumstances that led you to cochlear implantation. This will be an opportunity for your family to learn more about your life, and also an important opportunity for you to gain their understanding and constructive support.

 

Hearing loss is often called the "invisible disability". People with hearing loss may make extraordinary efforts to communicate with typically hearing people. Sometimes they give up the opportunity to fully understand what has been said in order to avoid a situation that they view to be embarrassing. However, if the person with hearing loss shared the responsibility for improving communication with others, (s)he could improve the situation. The "invisible" nature of the impairment puts all the burden on the person with hearing loss.

 

People with normal hearing, even those who have a close family member who has hearing loss, are not always aware of all the implications and the severity of the communication limitations that hearing impaired people experience. This is especially true when the hearing impaired person has normal speech.
When people who have hearing loss decide to undergo cochlear implantation, the main reason is not necessarily to help their family members and friends to communicate with them. Typically the person pursues a CI primarily for herself and it is critical that the people closest and most important in their lives understand their motives.

 

People with normal hearing are not aware of how difficult it is for people who have hearing loss to function in difficult acoustic environments or complex communication situations. It is important that you share with your relatives and friends the kinds of environments that are especially difficult for you (e.g., noisy restaurant, outdoors, gym, parties) as well as difficult communication situations (e.g., business meetings, multiple speaker conversations, talking with children or people who have accents). What do you feel in these situations? How do you deal with your difficulties? What could make things easier? What could make it worse? All of these topics should be discussed.

 

Such dialogue can improve family members’ understanding of your daily challenges. It enables you to share your concerns. Feelings of joy and satisfaction in light of the benefits you derive from the cochlear implant can be shared, even if they are not yet obvious to others. Enhancement of speech reading and the ability to respond to someone who calls your name are two examples of exciting experiences that family and friends are not always aware nor can they appreciate these milestone for you without this kind of sharing of your feelings and experiences.

 

I want to share a story with you. A woman with a cochlear went on a vacation with her mother and sister. They were eating in a noisy hotel dining room when she heard the waiter who was standing behind her asking them if they wanted an extra drink. She replied to the waiter and then she said excitedly to her mother and sister, "Did you see that? I understood what he said even though he was standing behind me!" Her mother and sister reacted with indifference and she was deeply hurt by their reaction. She explained to me afterwards, "They did not realize how impossible this situation would have been prior to my having received a cochlear implant and they did not understand my feelings of accomplishment."

 

Another reason to discuss these issues is that many people experience a new world of sound after implantation. Initially some may be challenged by learning to understand speech with competing environmental sounds. Family members and friends can help during this stage by identifying environmental sounds for the new CI recipient. Another auditory challenge is to be able to focus on the most relevant sounds in the presence of other sounds. This is a complex auditory skill that often improves over time. Family members can help by taking steps to minimize the environmental sounds at home (e.g.: turning off noisy appliances, closing doors).

 

Involving family members in the rehabilitation process may contribute in many positive ways. Family members might join you for your appointments with the cochlear implant team, at lectures, and for meetings with other CI recipients. Family members who consistently attend the rehabilitation and auditory training sessions have a better understanding of the process and may then assist during your home practice sessions. By being part of the process, they will better understand what you are going through and be positioned to support and encourage you as partners in the path you have chosen.

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The Hearing Assessment

Posted By Susan Thomas, Tuesday, February 2, 2016
Updated: Wednesday, January 27, 2016

The Hearing Assessment (Prior to Cochlear Implantation)

I will start our journey together with a discussion on the hearing assessment performed prior to cochlear implantation. Those of you who are currently going through this process are most welcome to join me as well as CI users who have already experienced the routine hearing follow-ups after implantation.

The cochlear implant candidacy process includes a medical examination, auditory assessment, and sometimes a psychological evaluation. The goal is to obtain information to provide reliable answers to two key questions:

(1) Is a cochlear implant the most appropriate hearing assistive device?

(2) Are there any medical restrictions for the surgery?

This step in the process requires the cochlear implant team to have broad theoretical knowledge and clinical experience.  First the team must collect the relevant information concerning the hearing abilities of the candidate. The role of the audiologist and speech pathologist is to gather information regarding your current amplification and communication status in order to be able to compare it to your expected future outcomes using a cochlear implant.

Audiological Evaluation

The first step in the hearing evaluation is to have your pure-tone audiograms taken with and without your hearing aids. The audiogram determines the type and degree of the hearing loss. The audiogram can indicate the origin of your hearing loss and whether it originates in the inner ear or elsewhere. The severity of the hearing loss is reflected by the pure tone average hearing thresholds. This information serves as a key parameter in the decision regarding whether the candidate meets the audiological criteria for cochlear implantation. Information regarding which sounds are perceived best by the CI candidate is reflected by the shape of the audiogram. The audiogram also enables the audiologist to compare ears as well as aided and unaided outcomes. It is also helpful to have your past audiological records. Comparison of your audiograms over time can indicate whether the hearing loss is stable, fluctuating, or progressive.

Since the decision for implantation is based upon a comparison between the benefit you receive from hearing aids and the expected benefit from cochlear implantation, the hearing evaluation is performed with appropriately fit hearing aids.

The aided audiogram provides information regarding your current amplification. Other relevant information regarding your hearing aids includes the purchase date, recent tuning, and maintenance. Sometimes there is a need to return to the hearing aid audiologist for adjustments or overall maintenance. Occasionally, a trial period with different (better fit) hearing aids is recommended.

In order to minimize the steps to determine candidacy, my recommendation is to visit your hearing aid dispenser a month before your first visit to the CI center for any necessary refitting and maintenance. If the dispenser's recommendation is to purchase new hearing aids, you should wait until after you begin your evaluation process at the implant center to avoid wasting money if you are a good CI candidate. Sometimes, in borderline cases, candidates will be encouraged to try newer or stronger hearing aids and then be re-evaluated.

Speech Perception Evaluation

The next step of the hearing evaluation is speech perception testing. Understanding speech is a complex task; difficulty level depends on many variables. For example, when the speech stimuli provides context and verbal information (such as in tests using simple everyday sentences), a CI candidate can use this type of information to repeat sentences—even if (s)he had not understood every word.  Tests that use single words are harder because they don’t provide context. 

Single words perception tests can vary in their level of difficulty. The more familiar and longer the words, the easier they are to be understand. Short "nonsense” words are hardest to perceive.

Most cochlear implant teams base their evaluation on tests of both words in sentences and single words. Single word tests provide more information on the ability of the candidate to perceive the various components of speech. However, sentence tests are more reflective of the candidate's ability to manage a conversation.  Since many conversations occur in noisy environments, speech perception testing is often completed in background noise to better replicate real life communication challenges.

Some candidates are unable to understand speech presented in an "open set" stimuli, as described above. For these individuals, it is common to use "closed set" tests. In "closed set" tests, the answers are presented as in a multiple-choice test.

Another communication aspect that may be evaluated is speech-reading ability (often referred as "lip reading"). This evaluates the benefit people derive from visual information such as the speaker’s lips and facial expressions combined with auditory information in order to understand speech. Gathering such data can show the positive contribution of cochlear implantation to speech reading performance. Enhancement in speech reading may also be reflected in the ease of communication reported by CI users.

Speech perception evaluation is performed for each ear separately and both ears together. The decision on whether to recommend cochlear implantation, as well as which ear should be implanted, are based upon these results.

Informal Assessment of Communication Status

Besides formal testing, there are other relevant data, usually collected through conversation or by using various self-reported questionnaires. Such data includes information on the history of the person’s hearing loss, auditory rehabilitation, lifestyle and communication challenges, and the communication modes used by the candidate.

Last but not least, a few words about expectations…

In one of the upcoming posts, I will discuss expectations about cochlear implantation.  This issue continues to be relevant beyond the candidacy phase. You should feel free to discuss your expectations with your CI team.  It is important that you have realistic expectations about your outcomes as well as the rehabilitation process (e.g., mapping, auditory training, and medical follow ups).

Do not hesitate to share rationale for pursuing CI as well as your dreams and future goals.  Feel free to ask your team about any question you have on the process.  After they have gathered all the above information, they will be able to give you reliable answers to many of your questions including examples of how the cochlear implant may affect your life.  This discussion will provide you with important perspectives regarding the ongoing nature of the rehabilitation process. It will also clarify your future responsibilities to maximize your success with your new implant.  

 

 

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