Objectives

2. 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.

3. Agenda • 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?

4. Why do adults needs rehabilitation post CI?

5. 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

6. “We’re not training the ears. We are training the brain to interpret what the ears hear.” • *Doreen Pollack, Auditory Verbal Pioneer

7. 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

8. Benefits of Rehabilitation • With progressive loss, adults may have been 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

9. 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

10. Is rehab part of the CI process?

11. (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

12. 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)

13. 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.

14. How do I know if I need rehabilitation?

15. Questions to Consider • Do you understand most speakers easily and completely? • Are you able to understand a speaker without seeing 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

16. What are typical types of rehabilitation for adults after cochlear implantation?

17. Types of Adult Rehabilitation Post CI • Main Categories of Therapy • Auditory Therapy • Speech Therapy • Speechreading Training • Appropriate Use of the Sound Processor • Training on Repair Strategies • Environmental Manipulation • Music Appreciation Training

18. 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

19. 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.

20. 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

21. 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

22. 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

23. 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 LTearney@cochlear.com • Practice! • Talk to successful users

24. 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 re-establish it • Select strategies that increase fluency and ease of conversation • Evaluate success and whether the strategies you chose were appropriate

25. 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

26. 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

27. 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

28. 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

29. What Helps Us Enjoy Music • 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

31. Who should be involved in my rehab?

32. 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

33. 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

34. 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

35. 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?

36. 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

37. 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

38. 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

39. 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

40. 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.

41. 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

42. 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

43. 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

44. 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!

45. 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

46. 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

47. 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”

48. What have others done? Three Case Studies…

49. 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

50. 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