SWC June 2009 Newsletter

1) Why is it that under certain circumstances I can hear almost normally with the implant while, at other times, I just cannot hear at all? I realize noise is a factor but there are times when it does not seem to be a noise issue. It is frustrating when I cannot really figure out if there is something wrong with my processor.
Thank you,
Elaine

Dear Elaine,

Thank you for your question. What you are reporting is a very common complaint of cochlear implant users. More often than not patients who normally hear well with their cochlear implants still find themselves in certain situations where they experience difficulties hearing. With a cochlear implant, the damaged hair cells are bypassed and the auditory nerve is stimulated directly. The cochlear implant does not result in "restored" or "cured" hearing, although it allows for the perception of sound "sensation." While you can hear “normally” with the implant in some situations, other, more difficult listening conditions, will unfortunately remain more challenging.

There are internal and external factors that influence hearing. The internal factors are issues within the patient, including but not limited to state of mind and/or stress level in a particular situation, or, more generally, experience listening with a cochlear implant, experience manipulating the speech processor, switching programs, adjusting volume and sensitivity settings, comfort level with using assistive listening devices, etc. Most common external factors that influence hearing are noise, distance, and reverberation, or poor acoustics. When you feel that there is no noise in the background you may still be in a poor acoustic environment influenced by reverberation.

My advice is to take note of the situations when you have difficulties hearing and to discuss them with your audiologist. Try to describe to your audiologist in detail where you were, who else was there, who was speaking, what program and setting you were using, and what changes you have tried making by manipulating settings on your processor. Since you have 3-4 (depending on your CI device) program slots in your processor, your audiologist can MAP each program for different listening situation and you can try them out in the real world to see if various speech processing strategies are more helpful.

2) What exactly takes place when a new implantee is being trained to use
their CI? Is there a progression of exercises from the easy to the difficult? Are there different types of implantees, such that different approaches for training them are needed? If yes, what types are there and how is each type best trained?
Thanks,
Omer

Omer,

There are different types of approaches to aural rehabilitation for cochlear implant recipients. The goal of aural rehabilitation is to maximize the benefit you can receive from using your cochlear implant. Baseline testing with the implant is necessary before the beginning of therapy to obtain a starting point of difficulty and also to have a reference point for documenting progress. There are different types of implantees in that they have varying hearing loss history backgrounds and different levels of auditory skills. Some therapists focus solely on building auditory skills via removing visual and other clues from their exercises. Other approaches focus more on improving overall communication function by teaching the patients to combine auditory and visual input. Obviously if a patient is an excellent lip-reader, there is no need to work on interpreting visual cues, and most attention is devoted to the auditory modality. It’s important to choose the start level carefully since your therapist wants to set achievable goals.

The exercises then progress from easier to the more difficult. You want to make progress without feeling frustrated. For patients who have minimal auditory skills prior to the implant, the first steps of therapy typically focus on exercises that have to do with presence vs. absence of sound and then the discrimination or identification of environmental sounds, or speech sounds vs. noise. Once the patient is able to identify non-speech sounds using auditory only mode, speech exercises are introduced. Understanding speech is the most important goal of therapy since for the majority of people the purpose in getting a cochlear implant is to improve their communication. When linguistic material is introduced, exercises can be closed-set or open-set materials. Closed-set materials are significantly easier since the patient has choices of answers in front of them. An open-set exercise does not offer a patient multiple choice so to speak, making the question unexpected. The first basic skill in speech recognition is pattern perception. In pattern perception, the patient is expected to differentiate long, multisyllabic words from single syllable or two-syllable words. For example, in a closed-set training, a patient is given a sheet with four groups of words or pictures. One group contains words like “ball”, “shoe”, “fish”, another “cookie”, “doggie”, “mommy”, yet another “hotdog”, “toothbrush”, “airplane”, and finally- “birthday cake”, “ice-cream cone”, etc. The purpose is for the patient to be able to identify the length of the word based on listening alone. Once this is achieved in a closed-set format with four choices, the size of the set can be made larger, until the patient is able to do the task in an open-set format, where the therapist says a word and the patient has no choices in front of them.

From pattern perception, the therapy moves to sound identification in sentences, and then in words. Usually vowels are targeted first, and then the consonants. The easier material is presented using sentences since we all use redundancy or our knowledge of language to fill in the missing information. And then the material is presented in short phrases and in single words, making the task gradually more difficult. Again, as in the earlier step, therapy starts with closed-set materials and progresses to open-set materials. Once the patient is able to identify words in an open-set formal using auditory only modality, more challenging listening situations can be introduced, like listening in the presence of background noise. For each patient the beginning of therapy falls at a different point based on their pre-implant auditory perception skills, and each patient progresses at their own speed.

Now patients can do the training themselves by using a computer based listening program. Cochlear Americas, the company that produces and supports Nucleus devices recently came out with an improved version of their auditory rehabilitation program “Sound and Beyond”. The new “Sound and Way Beyond” program is helping people improve vowel, consonant speech discrimination along with training in telephone use and music enjoyment. It is an interactive computer program. You can read about the program on www.cochlear.com

Whatever form of therapy you choose, you will be making your journey through the new world of listening easier by not only learning more about your hearing, but also by being able to measure your success

3) What I would like to know is if there is any research, or best practice
papers, out there stating bilateral implantation has demonstrable
benefits for people who have/need an implant? I hear often from consumers
that they are being told that one there is not justifiable benefit and thus
insurance, VA medical centers, etc. will only support (pay for) unilateral
implantation.
Rich

Rich, thank you for this question. As you say so eloquently, insurance companies need justifiable benefit and proof of medical necessity to approve bilateral implantation. Cochlear Implant companies along with patients, their families, and hearing-impaired advocates have been fighting an uphill battle with various insurance companies trying to make bilateral implantation a new standard of care. I would like to refer you to the “Let Them Hear” (LTH) Foundation at www.letthemhear.org. The LTHF provides help to hearing-impaired individuals both in terms of information and support, especially for people, who do not have access to funding and healthcare resources. They have an Insurance Advocacy Program that helps people appeal their denial claims.

Also, to quote the site:

“Great news on the cochlear implant insurance reimbursement front. Aetna recently changed its policy to include coverage for bilateral cochlear implants for eligible insurees over the age of 12 months. Their change of heart came just as an advocacy group was to file a class action lawsuit against them.

The Let Them Hear Foundation is to be commended for its diligence in helping to persuade Aetna to join the four other national health insurance companies currently covering bilateral cochlear implants. After 2 1/2 years and 28 appeals during which Aetna argued that bilateral cochlear implants were experimental and/or investigational, Let Them Hear won a classic David vs. Goliath battle. According to Let Them Hear, there are over 40 published scientific articles refuting Aetna’s claims.

In addition to Aetna, the other leading health insurance companies covering bilateral cochlear implants for eligible candidates are: CIGNA, Blue Shield, Blue Cross Association, Tufts, Harvard Pilgrim and Medica.”

The fight for bilateral implantation becoming a standard of care in the eyes of medical insurance companies is an uphill battle. You can also consult with the cochlear implant manufacturers to obtain further information on approvals and appeals at www.Cochlear.com., www.advancedbionics.com, and www.medel.com

Olga Lish is an Audiologist in Brooklyn, New York. Olga received her Master of Science degree from Brooklyn College CUNY in 1998.

Olga spent two years as part of the Cochlear Implant Team at Lenox Hill Hospital, eight years as the coordinator of the Cochlear Implant Program in Long Island College Hospital, and is currently part of Dr. Shirley Pollak’s audiological team.

Olga’s areas of expertise include pediatric audiology, auditory processing testing, and cochlear implant evaluations and programming. .