Aural Rehab Final Exam

4 components of Boothroyd model of AR

sensory management, instruction, perceptual training, and counseling

Counseling (4)

-a part of a person-centered approach that helps people learn about and adjust to a disorder, condition, or situation and cope with their feelings, thought, and behaviors

-infused throughout interactions

-Goal to set clear and realistic expectations and improve quality of life

-within scope of practice to provide counseling for clients with communication disorders

informational counseling (3)

-educating patient and or families about nature and impact of HL, variety of interventions available, how interventions work to reduce negative impact

-need to assess patient and or family needs prior to making therapy plans

-establish through questionnaires

Adjustment counseling

-helping patients and or families identify and address internal barriers and external barriers

internal barriers

denial, shock, stress, perceived stigma, readiness for intervention

external barriers

how to access services, learning new info related to interventions and therapy, evaluating info, associated with ear condition: support, ongoing support to implement skills to manage adjustment and challenges to living with a HL

Person-centered care (8)

-relationship between the professions and patient-mutual trust and respect

-partnership focused on client needs

-active listening/empathic listening

-involve family and communication partners to make decisions and set goals

-clinician is genuine and transparent when interacting with clients

-clinician fully accepts and respects their client

-clinician practices empathy to understand the world as their client does

-culturally responsive care

Stages of health behavior change (5)

-precontemplation

• build awareness for my need to change

-contemplation

• increase my pros for change and decrease my cons

-preparation

• commit and plan

-action

• implement and revise my plan

-maintenance

• integrate change into my lifestyle

Motivational interviewing tools (4)

-purpose is to elicit self motivational statements to make patients realize that they are using their own free will in deciding to change

-the circle (info, education, advice, encouragement, support, ongoing support)

-the line (degree of desire to change)

-the box (pros and cons)

Dynamic range (4)

-usable range of hearing

-normal hearing at 95 dB range

-difference in dB between threshold and discomfort

• pure tones

• speech

-challenge to address in people with HL due to smaller dynamic range, increased threshold and reduced tolerance for loud sounds

Time of HA fitting in children (3)

Best practice:

• 1/3/6 EHDI recommendation (1 month-all children screened, 3 months-all HL identified, 6 months-intervention)

• promotes optimal opportunity for S/L development

Reality:

• average age of HA fit is 9.2 months

Time of HA fitting in adults (2)

Best practice:

• as soon as significant HL is identified

Reality:

• Delay of up to 8.9 years until HA uptake after HL identified

Components of HAs (4)

-Microphone (converts sound from acoustic to electric)

-Amplifier

-Receiver or speaker

-Battery or power supply

Microphone of HA (5)

-Transducer

• converts from acoustic to electrical signal

-Sound waves move diaphragm back and forth

-Coil attached to diaphragm also moves back and forth

-coil wrapped at magnet

• oscillating coil over magnet creates current

-Electrical signal sent to amplifier

Amplifier of HA (2)

-electronic device that increases the amplitude of the voltage (current) of signal

-generates a larger current electrical signal

Receiver of HA (2)

-Converts electrical signal (from amplifier) to acoustic signal

-Considered a small loudspeaker

• Delivers signal through tubing or earmold

Battery of HA (3)

-+/- proper insertion

-Battery life

• 3-22 days depending on HA type, battery, HA use

• Rule of thumb- larger batteries last longer

-Minimize battery drain by putting tab bag on or opening battery door when not in use

How do HA’s work?

1. microphone picks up acoustic signal and transduces to electrical

2. amplifier makes it louder and manipulates signal

3. receiver transduces electrical signal to acoustic and send to ear

Bone conduction aid and candidates (3)

-bypasses outer and middle ear

-delivers sound via vibration through mastoid

-candidate:

• CHL

• People who can’t use traditional HAs

• People with drainage

• no external ear (microtia/anotia)

Body aid and candidates (6)

-cord connects case to earmold worn in the ear

-worn inside a pocket

-powerful HA/low feedback

-easy to adjust controls

-AA batteries

-Candidate:

• kids with severe-profound HL

Standard behind the ear (BTE) and candidates (5)

-larger controls

-2 components: unit and HA

-Can be used with assistive listening devices

-less feedback, easy to clean, fewer repaired

-Candidate:

• mostly children or adults that prefer style

• typically more severe-profound HL

• simple dexterity

Open fit/RITE/RIC and candidates (4)

-very small BTE (less power)

-Thin plastic tubing runs from HA to ear dome

• Clear tubing - open FIT

• Wire inside tubing - RITE/RIC

-No earmold required (have dome)

-Candidate:

• mild-moderate HL

In-the-ear (ITE) and in-the-canal (ITC) and candidates (3)

-all components housed in 1 unit

-enhanced amplification of high frequencies

-candidates:

• mild-moderate HL

• people who don’t want 2 pieces of HA

• easiest to manipulate except for nylon thread

Completely-in-canal (CIC) and candidates (6)

-cosmetically appealing and easy to insert/remove

-reduction of occlusion effect (when ear is plugged, hear themselves louder) and feedback (HA squeals)

-sound localization improvement

-less gain needed

-Elimination of wind noise

-Candidate:

• need manual dexterity to take in and out of ear

• no huge fingers

• mild-moderate HL

Over the counter HAs and candidates (4)

-mostly for mild (to moderate) perceived hearing loss

-do not require consultation with audiologist or other hearing health care provider

-self fit

Cost: $300-500

HA Gain (3)

-concept:

• the amount of amplification a HA provides when conversational sounds enter the HA

• greater the HL, the greater the gain needed from a HA. the gain in a HA can be adjusted

-affects on person with HL:

• if there is too little gain, person may not perceive benefit from HL. if the gain is too high, persons may reject HA

Causes of feedback (5)

-earmold or dome fit

-wax

-internal feedback (problem with HA itself)

-External microphone covered

-Anatomically small ear canals

Real ear measurement (8)

-objective measure

• tube inserted in ear canal near eardrum

• HA placed on top of ear

-measures sound pressure levels near eardrum

• determine if HA is delivering target gain

-not always performed-15%-20%

• ask families is this was performed

• really important for children! (important for speech and language. Child can’t always vocalize quality of sound)

Frequency response (2)

-Concept:

• filters used to emphasize high vs low frequency HL so that it matches the shape of the audiogram. Frequency response can be adjusted

-Affects for people with HL:

• if a person has a HF HL and has low frequencies included in the signal (meaning they are not filtered out), they will most likely not like the sound of the HA and could even reject it

Output limiting (6)

-Concept:

• the maximum output of a HA when a loud sound enters the HA (90dB) and the volume is turned all the way up. Output can be adjusted

• prevents signal from becoming to loud for persons with reduced dynamic range

• addresses problems of recruitment (sounds being abnormally loud for people with SNHL) due to a reduced dynamic range

• limits maximum power output (MPO)

-Affects for person with HL:

• If a sound from a HA exceeds the person’s tolerance for sound, then the sound will be uncomfortable, potentially damaging and may result in a person rejecting the HA.

• Concept of limited dynamic range among SNHL relates to this HA electroacoustic property

electroacoustic properties of HAs (4)

-output level (SPL)

-gain

-frequency range

-distortion

Distortion (2)

-Concept:

• HAs can distort sound when amplified, but the total distortion should not exceed 4%

-Affect for people with HL:

• if there is too much distortion, the individual user will complain that the HA is noisy and will not want to wear

Microphone on CI (2)

-picks up sound from environment

-Mic converts acoustic sound to an electrical signal and sends to speech processor

Speech processor on CI (4)

-Unit receives electrical signal from microphone and arranges the speech signal into a code

-Analyzes the speech signal into its frequency components of speech (high, mid, low) using band pass filtering concepts.

-sound is also being compressed here based on individual need.

-The amount of current is controlled by the program developed based on the T (threshold) and C (comfort) level responses from individual user

Transmitter on CI (3)

-coil and magnet

-unit receives the coded electrical signal from the speech processor

-sends the signal across the skin via radio frequency waves and magnet holds the coil in place

Receiver/stimulator/electrode array on CI (4)

-receives the coded electrical signal from the transmitter and sends signal to the electrode array in the cochlea

-electrode is implanted through the RW alongside the basilar membrane

-Electrical signals are allocated to each electrode based on their place in the cochlea. High freq sounds get allocated to the basal end of the cochlea, low freq sounds get allocated to the apical end

-nerve fibers get stimulated based on which electrode is activated

Why use HAT? (3)

-hearing aids are not enough

-they can help people hear better in many situations

-legislation mandates HAT in public facilities and schools

Where are HATs useful? (3)

-in noise

-distance

-reverberation

inverse square law

lose 6 dB of direct sound for each doubling of distance

Frequency modulation (FM) (7)

-enables HAs to wirelessly connect with external microphone, to improve speech signal for listener

-Uses radio waves

• allocated stations for education

-transmitter

• a radio station

-receiver

• a radio

-individual or group (sound field amplification systems)

-FM boot

-cochlear implants

Advantages for FM (6)

-very portable

-very easy to set up and use

-offers great flexibility of movement (up to 300 feet)

-used indoors or outdoors

-appropriate for mild to profound losses

-no fluctuation in strength of signal

Disadvantages of FM (5)

-receivers are required for everyone

-receivers vary in quality and durability

-potential for outside interference

-receivers and transmitters must be on the same channel

-must be 1 free channel between systems used in close proximity

T/F: you can leave the room and still hear the presentation

True

T/F: this system can be used indoors or outdoors

True

T/F: you must have a receiver to use this system

True

T/F: you must have a hearing aid to use this system

True kind of since there are groups

T/F: you can use FM in multiple rooms in a building

True

T/F: I can use my FM receiver with your FM transmitter

False

Bluetooth (4)

-uses short range wireless technology (10 meters)

• not suitable for long-range listening venues

-enables HAs to wirelessly connect with cells, TVs, computer, tablets, HA’s and CIs, or remote microphones

-very high-freq radio waves to transmit data

-creates a binaural signal in HA or CI

Remote mics (3)

-wireless system designed to help individuals hear and understand speech in noisy situations and over distances

-some RMs work together with HAs, while others are designed for those with some normal hearing

-Parts:

• transmitter-includes microphone

• receiver

  • universal

  • integrated

  • stand alone

Hard wired HAT device pros and cons (3)

-Pocket talker

-Pros:

• low cost

• flexible uses

• easy to use

• good for clinical setting or nursing home to deliver information

-Cons:

• generic amplification

• wired, not wireless

• unable to hear other in a big conversation

Cochlear implants (3)

-electronic device that can provide a sense of sound to a person who is profoundly deaf or severely hard of hearing.

-Bypasses a nonfunctional inner ear and stimulates nerve with electrical current

-implant is surgically placed under the skin behind the ear

CI eligibility for adults (3)

-18 years of age or older

-moderate to profound SNHL in both ears

-limited benefit from amplification defined by preoperative test scores of <50% sentence recognition in the ear to be implanted and <60% in the opposite ear or binaurally with HAs

CI eligibility for children (2-17) (3)

-severe to profound SNHL in both ears

-limited benefit from binaural amplification

-speech perception tests <30%

CI eligibility for children (9-24 months)

-profound SNHL in both ears

-no medical contraindications

-limited benefit from binaural amplification after HA trial and with monitoring auditory milestones

Components of CI (8)

-microphone

-transmitter

-external magnet

-speech processor

-receiving antenna

-internal magnet

-receiver

-electrode array

How a CI works (3)

1. sound picked up with a microphone

2. sound processed through band-pass filters (sorts sound based on frequency)

3. Signal sent to corresponding area on cochlea (basil-high frequency, or apex-low frequency)

Pre-surgery for CI (2)

-comprehensive audiometric testing

-determining candidacy

• multidisciplinary approach

• decision making

  • fully informing patients/families

surgery for CI (5)

-3 hour procedure

-approval from 3rd party payer

-scalp shaved

• mastoidectomy apporach

-Chochleostomy

• electrode insertion into scala tympani

-intraoperative monitoring by audiologist

• test integrity of electrode once in place

Post-surgery for CI (4)

-hook-up

• mapping

-follow-up schedule

• re-mapping

-therapy

-education

Possible complication of CI surgery (9)

-bleeding

-infection

-meningitis

-facial paralysis

-tinnitus, vertigo

-ear numbness

-device failure

-migration

-older devices-magnet has to be surgically removed prior to any MRI procedure

Hook-up process for CIs (6)

-3-4 week process

-mapping

• process of programming the CI (external units)

• establish electrical threshold current levels for each electrode (T)

• establish loudness tolerance-maximum electrical comfort levels (C)

• dynamic range

  • difference between T and C levels for all channels

  • recommended maps for children, adjust for the specific individual

Band-pass filtering concept with CIs (2)

-low pass and low frequencies are delivered to the apex end of the cochlea

-high pass and high frequencies are delivered to the basil end of the cochlea

Time factors that affect the outcome of CIs in children (2)

-age at time of implant

-pre-implant duration of deafness

Hearing factors that affect the outcome of CIs in children (2)

-auditory skills/hearing prior to implant

-appropriate programming

brain factors that affect the outcome of CIs in children (4)

-neuroplasticity

-medical radiological

-cognitive ability

-consistency of use

Therapy factors that affect the outcome of CIs in children (2)

-mode of communication

-quality of educational and habilitative environment

Other factors that affect the outcome of CIs in children (3)

-family and vocational support

-additional special needs

-maternal education

Time factors that affect the outcome of Cis for adults (2)

-age at time of implant

-older adult vs younger adult

Hearing factors that affect the outcome of Cis for adults (4)

-pre vs. post lingual

-etiology of HL

-residual hearing prior to implant

-appropriate programming of device

Brain factors that affect the outcome of Cis for adults (4)

-neuroplasticity

-medical radiological

-cognitive ability

-consistency of use

Therapy factors that affect the outcome of Cis for adults

access to rehabilitation services

Other factors that affect the outcome of Cis for adults (2)

-family and vocational support

-additional special needs

General expected outcomes for children (3)

-listening time

• full time use by 3 months

-changes in vocalization

• perception of changes in voice by 3 months

-alerts to name

• 25% of the time by 3 months

• 50% by 6 months

Concept of an imperfect signal generated by the CI (4)

-the sound produced by the CI is an electronic digitized signal that is interpretable by the brain but has limitations

-The CI uses a series of band pass filters to deliver frequency to different places along the cochlea (high freq-basal area, mid freq-middle area, and low freq-aplical area). this means that a band pass filter passes frequencies within certain ranges and rejects or attenuates others outside a specified frequency range. therefore each bandpass filter represents multiple frequencies and not just one

-there are a limited number of electrodes that can be safely activated within the small space of the organ of corti; totaling up to 22 electrodes. One electrode will receive coded information from a bandpass filter (high pass, mid pass, or low pass). This means that there is not a 1:1 correspondence between one electrode and one frequency, but rather one electrode will be stimulated by multiple different frequencies

-The combination of an artificial, digitized signal, that is band pass filtered and then sent to a fixed number of electrodes results in an adequate but less than perfect signal for a CI user to interpret