Download CI Rehabilitation Not Just for Kids

Objectives
• Provide an understanding of why many CI
recipients benefit from some rehabilitation
• Explain what rehab might be for you
• Provide resources for you to pursue a rehab
program that makes sense for you
We will not describe for you what is an appropriate rehabilitation
program for any one individual as that will vary with the person’s
unique needs.
Agenda
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Why do adults needs rehabilitation post CI?
Is rehab part of the CI process?
How do I know if I need rehabilitation?
What are the typical types of rehabilitation for
adults after cochlear implantation?
• Who should be involved in my rehab?
• What are some tools I can use on my own?
• What have others done?
Why do adults needs rehabilitation post CI?
Comprehension: It’s not just
about the ears
• Often assumed that better technology = better hearing
• Matching the right technology to a person’s hearing loss is
critical but comprehension is not just about technology
• People rely on many skills when listening with a cochlear
implant including auditory memory, cognitive ability,
localization, repair tactics, and conversational skills (not an
exhaustive list)
• Most of the above skills can be improved with training and
practice
“We’re not training the ears. We are
training the brain to interpret what
the ears hear.”
*Doreen Pollack, Auditory Verbal Pioneer
Aural Rehabilitation Post CI
Many factors impact on hearing performance
• Age of onset/duration of deafness
• Amount of residual hearing
• Use of residual hearing and an oral approach
prior to implantation including whether person
used amplification
• Motivation
• Number of hours the device is worn
• Opportunities for conversational practice
• Some people improve quickly while others take
several years to maximize their improvement
Benefits of Rehabilitation
• With progressive loss, adults may have been
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without sound for years (or even decades)
May need assistance learning to recognize
speech and environmental sounds again
Break old habits and integrate new sound
With prelingual deafness, CI may provide greater
access to sound than the recipient ever had
Regardless of hearing history, rehab should be
considered
Bilateral Implantation
• 14-15% of CI surgeries now involve 2nd ear
• Increasing trend
• People need guidance on how to maximize
outcomes with 2nd CI
• Focus on improving comprehension in 2nd ear
while also integrating the new access to sound
with the first implant
Is rehab part of the CI process?
(Re)habiltation and Cochlear Implants
• With children, assume the child and family will
have training
• Pediatric centers have pediatric rehab specialists
on staff who work with the entire family
• Some centers require family to sign a “contract”
• Not necessarily so with adults. May:
• Assume you don’t need rehab
• Be a shortage of trained personnel in clinic
• Wait for you to ask for help
Survey of Clinics on Adult Rehab
• Most CI clinics say they provide services to
adults
• Some clinics say “if needed”
• Anecdotal comments from adults indicate
many didn’t know their clinic offered direct
rehab services for adult CI patients
• Most adult recipients say clinic provided:
• Training on using the sound processor
• General practice ideas (i.e., books on tape)
Rehab for adults is generally more informal
(than it is for children) and it is left up to the
individual CI recipient to determine a program
that is appropriate for him/her.
The reality: most recipients don’t know what
they should be doing and we all can benefit
from coaching.
How do I know if I need rehabilitation?
Questions to Consider
• Do you understand most speakers easily and completely?
• Are you able to understand a speaker without seeing
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his/her face? What if the speaker is at some distance?
Does comprehension in noise remain largely the same?
Can you follow, and participate in, a group discussion?
Are you able to use the telephone easily and with full
comprehension of most speakers?
Are you free of anxiety (related to communication) in new
environments (i.e., phoning someone you don’t know,
communicating in an unknown setting)?
If the answer to any of these questions is “no,” you should
consider some form of rehabilitation
What are typical types of rehabilitation
for adults after cochlear implantation?
Types of Adult Rehabilitation Post CI
Main Categories of Therapy
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Auditory Therapy
Speech Therapy
Speechreading Training
Appropriate Use of the Sound Processor
Training on Repair Strategies
Environmental Manipulation
Music Appreciation Training
Developing Auditory Skills
• We begin with basic perceptional skills
• Detecting sounds (I can hear it)
• Discriminating between sounds (i.e., some people
have difficulty determining whether a sound is a “p” or
a “t”)
• We move to more difficult tasks
• Identifying sounds (phonemes) or single words
• We then can participate in everyday conversations at
different levels of difficulty
• Comprehending using listening and cognitive skills
and interact with others appropriately
• Managing the conversation by knowing the
characteristics of the speaker, physical environment, the
message
Hierarchy of Auditory Skills
Detection  Discrimination  Identification  Comprehension
• Different exercises address different skills along the hierarchy
• Most professionals believe people need to master the early
skills (detection, discrimination, identification) before they
can master everyday communication. Studies have shown
that training on phonemes (sounds) may generalize to
sentence recognition and is a critical first step.*
• It is helpful to undertake exercises that address identification
of sounds/words as well as comprehending and participating
in everyday communication as part of your rehab program
• We will review some specific tools you can try later on
*Hunt P, “What is analytic training?” Adult Aural Rehabilitation Guide, Cochlear Ltd, 2005;
Plant G Commtram: a communication training program for profoundly deaf adults, NAL,
1984.
What is auditory therapy
for adults?
• Also called auditory rehabilitation
• Utilizing listening activities to help CI recipient
adjust to the new signal
• May involve working on parts of speech or typical
words or phrases that the recipient encounters
• Integrating new hearing into a previously
established communication system
• Breaking old habits to encourage full use of the
auditory signal and less dependence on visual
information
What is speech therapy?
• Conducted by a therapist, generally along with
auditory therapy
• Access to the full range of speech sounds allows
CI recipient to better self-monitor their speech
• Therapist may work with recipient on specific
sounds, syllables, words or phrases
• Voice quality (i.e., pitch, nasality) in speech
may be addressed
What is speech reading skill building?
• After receiving a CI, most individuals find
they are less dependent on speech reading
• Nonetheless, outcomes vary and some CI
recipients may chose to reinforce their
speech reading skills post CI
• About half of clinics surveyed provided
speech reading skill building
• HLAA members may have other suggestions
Sound Processor Training
• Many recipients aren’t optimally using their
processor
• Used appropriately, SmartSound can improve
understanding in difficult listening environments
• Ask for help from your clinic if you’re not sure or if
the settings don’t work optimally for you
• View guidance:
http://www.cochlearamericas.com/products/2303.asp
• Talk to Cochlear expert Linn Tearney: 800.523.5798
or [email protected]
• Practice!
• Talk to successful users
Training on Repair Strategies
• Learn/re-learn strategies you used before CI
• Strategies to increase access to everyday conversation
• Recognize when communication has failed and why and
developing skills to re-establish communication
• Emphasize turn-taking, talking, listening
• Bring aspects of communication under your control (without
being controlling)
• Some of your objectives might include:
– Anticipate elements of the setting so you can develop
strategies that will work for you
– Identify skills that help you maintain communication
– Recognize when communication has failed so you can reestablish it
– Select strategies that increase fluency and ease of
conversation
– Evaluate success and whether the strategies you chose were
appropriate
Environmental Manipulation
• You can never completely control your environment
• You can minimize listening challenges to maximize
listening skills
• Be proactive about selecting locations for meetings
and social events to ensure the best possible
hearing environment
• Think about seating placement/locations that work
best for you
• Use sound processor options maximally
• Use assistive listening devices
Use ALDs with your CI
• Learn all you can about ALDs
• Try them out and determine what works best for
you
• Remote microphones work with CI’s (just as
they did for you with hearing aids)
• Use all of the listening in noise options on your
sound processor
• Ensure public facilities (i.e., theaters) have ALDs
in place and that they are in good working order
Assistive Listening Device Training
• If you need guidance on this, talk to your clinic
• Many recipients report being overwhelmed by the
options on the processor and various ALDs options
at turn-on and don’t try them initially
• Get advice from other recipients and learn “tricks
of the trade”
• www.cochlearamericas.com/Support/46.asp
Music Appreciation Training
• A relatively new interest area and not typically
offered by clinics
• All implant companies are exploring how to
enhance music for recipients
• CI’s are designed for speech perception
• Speech and music share some acoustic
characteristics but there are differences also
• Pitch and tone quality are harder to convey
• Research suggests practice helps
What Helps Us Enjoy Music
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Listen in quiet environments with good acoustics
Use direct-connect to your sound processor
Keep the volume of the music down
Start with music that is “simple” and/or was
familiar to you prior to getting your CI
Download the words to songs so you can track
what you’re hearing
Some types of music may seem better than others
Acknowledge that music may not sound the same
as before but you can still enjoy it
Practice, practice, practice—train your brain!
“Music and Cochlear Implants” from Cochlear
Who should be involved in my rehab?
Do I need a rehab therapist?
• Some needs may be appropriately
addressed within the context of clinic visits
(i.e, speech processor settings, ALDs,
telephone training)
• Discuss other skill building areas that would
help
• Get a referral for a therapist who works with
adults (at or outside the clinic)  Ask, don’t
wait for someone to tell you
• Discuss individual AND group therapy
options
Rehabilitation Professionals
• Typical background: speech pathologist or
audiologist
• May be: Certified Auditory-Verbal Therapist (AVT)
but this is not necessary
• May work primarily with children (not an issue if the
person has interest in extending skills to adults)
• May be in a CI clinic or not
• Key: You need to be comfortable working with the
person because (s)he will be both coach and expert
Friends and Family Members
• Friends and family members can and should be
part of your rehab program
• Participate or administer exercises
• Help alert you to new sounds and identify what
you are hearing in a positive, helpful manner
• Provide feedback on where you need work/help
• Provide patience, enthusiasm, and encouragement
What are some tools or ideas that I can
apply—under the guidance of a
professional, on my own, or with a
friend/family member?
Special Skill Building Areas or
Tools to Build Skills
• Listening exercises with a friend or family
member
• Use of Interactive Computer Software
• Books on Tape
• Telephone Training
Repetition and Redundancy
•Practice makes perfect—just as it does with
golf, tennis, skiing, dancing
•Repetition and redundancy provide the
opportunity for the brain to learn new sounds
•Working with a rehabilitation professional can
help ensure you are practicing correctly and not
reinforcing bad habits
•All of the suggested tools should be used
repeatedly and if possible, every day over a
designated period of time
Using Exercises at Home
•Identify those sounds or words that you know you
have difficulty with
•Ask a professional for help on how to tackle
problematic areas (word or sound lists)
•Be sure to let your mapping audiologist know which
sounds or words you have difficulty with so (s)he
can check your map or suggest other practice
techniques
Involve Friends and Family
•Involve family and friends who are supportive
•Start out easy and work up
•Have the person assisting, sit beside you on the
side of the implanted ear
•Use regular volume (do not use a raised voice)
•Minimize background noise
•Use speech that is full of expression and natural
rhythm
Interactive Computer Software
• Tool to build listening skills in your own home and
at your own pace
• Research has shown that with moderate training
on targeted phonemes can improve speech
perception by as much as 15-20%*
• Most packages include report-back mechanism for
sharing of results with therapist or audiologist
• Great for the new CI recipient (or someone who
wants to improve) or post 2nd CI (to work on
newly implanted ear)
*Fu, Qian-Jie et al 2005, 2008; Sweetow R et al 2005, Wu J-L et al 2007.
Sound and Beyond
• Self directed, interactive software program for
adults allowing user to move at his/her own pace
• Various levels of difficulty
• Sounds, sentences, distinguishing between
different voices and between men/women
environmental noises, music
• Not specific to Nucleus technology
Books on Tape
• An accessible and enjoyable form of rehab
• Most clinics recommend use of books on tape
• Some people like to begin with children’s books
that they are familiar with
• Others prefer using adult books
• Start out easy with speakers that are
comfortable for you (pick your gender
preference), slow pace, clear speaker, no
background music/noise
• May begin with tape + book initially (depending
upon how hard it is for you) and work up to
tape alone
Books on Tape Continued
• Start out easy with speakers that are most
comfortable for you (pick gender preference, slow
pace, clear voice, no background music/noise.
• Graduate to more difficult readings, speakers that
are more difficult for you, faster pace
• Repeat phrases or words out loud, especially
those that are difficult to understand for you 
practice active listening (also called using auditory
feedback loop)
• Some people like using car time to listen to tapes
• Key: Dedicated time every day until the task
becomes easy for you
Telephone Training
• Can be the most challenging listening task
• If you don’t know how to best use your sound
processor on the phone, ask your audiologist for
more training
• Try the telecoil with different settings and
with/without mixing
• Some people like using a speaker phone
• Set aside time each day with a patient friend
• Try different phones—both landline and wireless
• Begin with closed set and move to open set
• Use alphabetical cues to verify information
• PRACTICE!
Cochlear Implants and Cell Phones
• Many people may not have used a cell phone
before CI
• Wireless phones can be your best phone but there
are differences—try them before you buy!
• www.cochlearamericas.com/support/354.asp
• Wireless phones are rated for hearing aid (and CI)
compatibility (M4 is best) and for T-coil usage (T-4
is best)
• Accessories are available and may help:
www.cochlearamericas.com/support/355.asp
Phone with Confidence—why Scott
developed it
• Wanted to improve telephone competence
• Developed “Phone with Confidence” for that
purpose
• Didn’t want to call other people until he felt he
had some mastery of using the phone
• The Phone with Confidence recordings allowed
him to do that in a safe, comfortable
environment
• Purpose: (1)Develop listening skills and (2)
develop confidence in his ability to make calls
Phone with Confidence
• New service from Cochlear Americas coming in
July (in Cochlear Community website)
• Call in to a free 800 number that allows you to
listen to word lists and a reading
• Listen first without text
• Listen again with the text in front of you
• Call back as many times as you wish
• Provides opportunity to become comfortable with
listening and overcome “telephone fright”
What have others done?
Three Case Studies…
Scott: Bilateral CI Recipient
• Hard of hearing as a child, progressive hearing
loss
• Received 1st CI at age 25 in 2005
• Received 2nd CI at age 27 in 2007
Scott: Rehab Post 1st CI
• No rehab recommended
• Asked and was given word lists, which he used
with a friend
• Used books on tape in car driving to work (25
minutes x 2 x 5) for 3 months
• Generally preferred male voices, no accents
• Trial and error—checked out tapes from the
library
• Listened to NPR on radio (not overly challenging
for him)
• No therapist and nothing beyond the above
Scott: Rehab for 2nd CI
• Used Sound and Beyond to focus on specific challenges
• Started with listening in quiet
• Distinguish between certain sounds (“p” and “t”)
• Worked on identified vowels and consonants
• Sentences were relatively easy for him so he did not
work on them
• Worked on listening in noise
• Used 2-4 times/wk for one hour each time over 2 month
period
• Plans to go back to work on certain sounds that he has
more difficulty with
• Likes to use as a comparative check after re-mapping
• Can alert his CI audiologist accordingly
Robert: A CI at 80 (Who said you can’t
teach an old dog new tricks?)
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Progressive hearing loss dating to WWII service
Wore hearing aids and used ALDs effectively
Hearing loss had progressed—pursued CI
Sought help from auditory therapist (Speech
Path) who works primarily w/ children & families
but has some adult patients
• Therapist provided coaching and suggested a
home exercise program
Robert’s Rehab Program
•Therapist provided lists of phonemes (sounds) that
Robert’s wife read to him regularly
•Robert recorded results (consistent errors emerged)
•Reported back to audiologist; she made changes in
his map to reflect sounds Robert had difficulty with
•Utilized interactive software w/ focus on sounds and
words
•Used books on tape, first with text and later w/out
•Worked on music; best result with familiar music
Robert’s Rehab
•Worked intensively for 4 months until results
improved
•Felt focus on phonemes helped him make sense
of the new auditory information he received
•Continues to provide feedback to his therapist
and audiologist for suggestions and follow-up
Ingrid: Deafened at 18 months
•First CI in “unused” ear at age 29; 2nd CI in
amplified ear at age 33
•Rehab w/auditory therapist after 2nd CI to improve:
•Listening ability thru optimal use of bilateral CI
•Auditory self-monitoring of speech
•Auditory memory and tracking
•Long Term Goals: confidence in listening, “train the
brain” to process new auditory information, monitor
speech through listening, develop auditory
capabilities in “new” ear and integrate with 1st CI
Ingrid’s Perspective about Rehab
•Initially fearful to face her weaknesses
•Didn’t want to feel like a child again—therapist as
coach was comfortable for her
•Felt therapy done properly could both help her
progress with auditory skills and build her self
esteem and confidence
•Priorities: improve pronunciation, enjoy music,
easier listening with her family and others, and less
dependence on visual clues
Ingrid’s Program and Progress
•Encouraged to use Sound and Beyond every day,
especially vowel section.
•Encouraged to vocalize out loud as she used Sound
and Beyond (active listening, auditory selfmonitoring)
•Develop lists of sounds and words she wants to
articulate and practice these sounds and words in
meaningful contexts throughout the day
•Therapy was conducted in person, over the phone,
via email—therapist as coach
•Therapist continued to make recommendations on
words that she should practice
Encouraging Adult Rehab
Options in Your Community
• If few adult options in your community, ask your
clinic how to expand such opportunities
• Work with other CI recipients in your community
• Possibilities to explore:
• University graduate programs
• Hearing health care (non CI) centers
• Therapists who provide services to children
• Work with organizations representing people with
hearing loss to express interest
• Explore both individual and group possibilities
Resources on Adult Rehabilitation
•Getting Started for Adults (CD from Cochlear Americas)
•Music and Implants: Piercing the Puzzle Together (Cochlear
Americas)
•HOPE Online: New sessions for adults (captioned) starting in
Fall 2008—see www.cochlear.com/HOPE)
•Various articles by Mark Ross in Hearing Loss magazine
including a review of Sound & Beyond (Nov/Dec 05) and Aural
Rehabilitation (Jan/Feb 07) See www.hearingloss.org
•Resource for rehab professionals: Adult Aural Rehabilitation: A
Guide for CI Professionals (Cochlear Americas)--$100
Thank you… Any questions?
Please contact me if you think of
questions later:
Donna Sorkin
[email protected]