Cochlear Implant Rehabilitation for Adults
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Auditory adjustment, spontaneous auditory learning, and auditory rehabilitation following Cochlear Implantation

Posted By Naama Tsach, PhD, Monday, June 22, 2020

Yesterday I noticed that I was hearing without even trying.

Adults who receive cochlear implants rarely are offered clinician-guided auditory rehabilitation after their surgery. They are often told that the process they will go through, in learning to access the new auditory signal via their cochlear implant, will occur spontaneously as they adjust to their new hearing.

This approach works for many people, especially if individuals had typical hearing as children and experienced hearing loss as adults and their period of deafness was relatively short prior to receiving a CI. However, this process of spontaneous adjustment does not occur for all adults. Learning to use the new signal from a cochlear implant is especially difficult for those who were deaf as children and received their CI as adults.

What impacts spontaneous auditory learning?

Spontaneous auditory learning during daily routines is impacted by various factors including one’s ability to understand speech while occupied with other daily activities, opportunities to listen at work and at home, and whether the individual has feedback on their mistakes. Being able to constructively address such feedback is key to helping an individual improve their listening skills.

Following cochlear implantation, people who had typical hearing for most of their lives learn to adjust to sounds that are different from what they remember as sound. Sounds may seem strange or confusing at the beginning but typically become meaningful over time. One’s auditory memory will help an individual interpret the sounds they hear. A recipient may experience some ups and downs during the first year following implantation especially if they have very high expectations regarding their improvement rate. Some people will struggle in complex communication listening situations such as listening in noise or listening with multiple speakers. In most cases, the CI recipient will learn to handle these challenges over time and with experience, their comprehension will improve.

Later Deafened CI Recipients

People who have lost hearing later in life will generally become acoustically attentive to their surroundings. Before implantation, given that their auditory function was limited, such individuals tend to have been selective in their auditory attention focusing mainly on speech directed at them. After a period of time using their CI, a late deafened person will typically find themselves unintentionally perceiving and reacting to speech and sounds around them. They will grasp words and sentences from the radio and TV, parts of a conversation held between colleagues without even looking at them, and many other auditory stimuli. "Yesterday I noticed that I was hearing without even trying" is an important milestone and a great accomplishment, one that most people can expect to experience after few months. As they become active listeners, they will naturally practice their hearing in many daily situations.

In addition, most people will continue to strive to hear better. They will challenge themselves to function as close as possible to the level in which they did before losing their hearing. They have the drive and the knowledge of what good hearing is, and they will find their own ways to achieve the most out of their CI, including the use of additional technologies as needed such as assistive listening devices, apps, and making full use of programming options on their sound processor.

Early Deafened Adults

In contrast to CI users who had typical hearing for much of their lives and lost their hearing as adults, there are a growing number of adult CI users who were deaf as children. For this group, the decision to pursue a cochlear implant entails some uncertainty. They may have questions that cannot be answered with certainty about their outcomes. Since they either have no memory of typical hearing (either because they never had it or it was for a short period time during early childhood), it is difficult for such individuals to know what to expect regarding CI outcomes.
For an early deafened adult, the acoustic information provided by a CI may be confusing, overwhelming, and exhausting. Some people are bothered by the sound level they receive from their CI and perceive it as “noise.” It takes time to learn to interpret both environmental and speech sounds and attach meaning to them.

Not only do such recipients need to learn to attach meaning to the sounds they are hearing, they must also deal with many sounds they may not have even known existed. In addition to adjusting to their new hearing, they will deal with some key questions:

• What constitutes typical hearing?
• What are the limitations of typical hearing?
• To what extent can a CI allow someone to function like a person with typical hearing?
• Will I be able to enjoy music?

With regard to music, some early deafened adults will be interested in listening to music including songs they may have learned about from others but have never actually heard.

New Listening Opportunities and Challenges

 This group of early deafened CI adults will need to learn how their ability to listen is affected by factors related to the environment, the speaker, the content and more. Like late deafened individuals, they should seek accommodations that may improve communication. They will need support and guidance in practicing tasks that previously seemed impossible to them, such as talking on the phone. Since most in this group are accustomed to concentrating on speech that is targeted directly at them, they will need to work to consciously change their old habits to become acoustically attentive to a larger sphere of sound. All of these challenges may be challenging especially if they attempt it without a clinician-guided auditory rehab program. 

The speech perception outcomes of adults with early deafness are typically lower than those of people who had generally typical hearing in the past. To understand speech without lipreading, CI adult users with early deafness rely heavily on contextual strategies. The differences show not only in their ability to perceive speech sounds and sentences in quiet but especially in their ability to understand speech in noise. If their use of auditory information was limited during most of their life, they may have great difficulty in processing auditory information. These tasks will be more difficult still with speech that is normal to fast-paced or require auditory memory skills.

Adult CI recipients with early deafness often struggle to learn how to identify speech sounds, separate several sounds that are occurring at the same time, and understand speech in noise. In addition. their auditory processing skills limit their speech understanding to a slow speech pace, and to tasks that do not overload their limited short-term auditory memory skills. This means that, over a long period of time, they would have to train their hearing and listening skills in accommodated conditions of quiet rooms, slowly paced speech, and individually-tailored training tasks. These conditions do not exist in most everyday situations, which is what makes their chances to experience spontaneous auditory learning nearly impossible.


Cochlear implantation is the beginning of a rehabilitation process that requires learning, adjustment, and training. There are CI users who will be able to negotiate the process using self-training resources with the support of their audiologist, family, and friends. They will adjust and quickly regain speech perception skills. These skills, combined with previous listening habits and cognitive and auditory abilities, will allow them to cope with the communication and acoustic challenges of everyday life.

Others will need the support provided through a clinician-guided auditory rehab program. Such programs allow an assessment of the patient’s speech perception, listening, and use of hearing in everyday life. Typically, such patients require individualized training before being able to say “yesterday I noticed that I was hearing without even trying.” Spontaneous auditory learning is possible for some of these patients. It’s a real breakthrough and a dream come true.

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Tips for People Who Converse with CI Recipients on the Telephone

Posted By Naama Tsach, PhD, Thursday, May 14, 2020

Within the space of a few months, telecommunication in COVID-19 has become the main way to communicate with the people in our lives. Face-to-face communication has been replaced by video-chatting and phone calls. In today's post, I'll discuss telephone use and ways to reduce communication difficulties.

Phone calls have always been a challenge for many people with hearing loss including those who use a cochlear implant.

We usually read and write about what cochlear implant users can to successfully hold telephone conversations.  For example, we may advise someone to use technologies that work in concert with a CI and/or to use Assistive Listening Devices (ALDs), or to make phone calls while in a quiet room. There are a number of ways for someone with hearing loss to improve their likelihood of having a successful and enjoyable telephone conversation and I will discuss these in depth in this post.

When you begin practicing using the phone, choosing the right partner is one of the most important things to do. You would most likely choose someone you know well and feel comfortable with, someone who is patient, and someone who is willing to help you. Regardless, talking on the phone can be a real challenge, even for CI users use the phone regularly. In order to make it easier and avoid some of the obstacles, you might want to discuss what helps you ahead of time with your phone call partners.

So, this post is written for your phone conversation partners to provide them with practical tips and guidance that may help the person with a cochlear implant.

Here are some points to think about, and some requests that someone may want to bring to the conversation partner’s attention:

  • In order to talk on the phone with your CI user friend, move to a quiet room, keep the closed to reduce background noise, and avoid interruptions.
  • Do not call your CI user friend while driving unless you are equipped with a high-quality headset with a microphone adjacent to your mouth. Even then, it would be best to wait until you have reached your destination (if possible).
  • Do not call your CI user friend while walking down the street or if you are in a noisy or echo-prone space. Noise that is insignificant for you, can make the call difficult for your CI user friend
  • If your CI user friend calls you when you are somewhere noisy and you cannot move to a quiet room, describe the situation and let them decide whether to hold the conversation or have you call back later.
  • Do not talk to your CI user friend when you are on speaker phone, as the CI user will hear you from a distance along with disruptive background noises.
  • Speak just a bit slower than usual.
  • Help your friend by Noting the reason and/or the topic of the conversation. Having that information will help him or her to follow your remarks.
  • If you want to tell a long story, it may be best if you could break it into short passages to allow your friend to stop you if information is not accurately understood.  
  • Always encourage your friend to ask for clarification if (s)he needs that. Be patient and repeat yourself as needed. If there is a certain word that wasn’t understood even after repetition, you may want to express yourself using other words or phrases.
  • If you are having difficulty understanding your CI user friend, do not hesitate to ask for clarification. You may want to ask him or her to repeat what was just said, say it another way, or even spell the word you did not understand.
  • If you provide information that includes names of people or places, or you are scheduling an appointment, allow your CI user friend to verify that they understood the name correctly. You may want to send the details by email or text to avoid misunderstandings.

Good Luck! Your patience will help your friend develop the confidence and skills to be comfortable making phone calls.

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Adult Implant Use During the COVID-19 Crisis

Posted By Naama Tsach, PhD, Monday, April 27, 2020

Tips to Consistently Use your CI during Stressful Times

The post is dedicated, with love and understanding, to the cochlear implant recipients who may be taking a break from their CIs during the difficult coronavirus timeframe.

  •  Maintain a routine. During a timeframe of uncertainty, concern, and worry—such as that we are all going through right now—it is very important to maintain our routines.  Cook healthful foods, exercise, dress up, and even wear shoes. Your CIs and hearing are part of your routine.
  • Stay connected! Stay involved! Every sound has its meaning. Stay oriented with what's going on around you.
  • Be independent and strong. Feeling in control is always important, especially now.
  • Do not indulge in silence. Despite the ease of falling into a routine of isolation and silence, force yourself to interact in normal ways. It can be difficult later to return to your good auditory functions and to effectively cope with a flood of auditory stimuli.
  • Consider the effect of not using your cochlear implant to access sound on your family members. They have become accustomed to a certain level of communication with you. If you turn off, they now need to adjust to the fact that for several hours a day (or more) you may be disconnected. At a time like this, there is tremendous value in good communication, engagement, and partnership. Your attentiveness and communication are significant not only for you, but also for the people who live with you.
  • Research on recipient utilization has demonstrated a correlation between the number of hours a day that adult CI recipients use their CI and their speech-perception abilities. It was found that during the first year of CI use, adults with good speech perception skills used their CIs for an average of 3 hours a day more than people with poor speech perception.

 Stay home, stay connected, enjoy your hearing, and be safe!


For further reading on this topic, please see: Schvartz-Leyzac KC, Conrad CA, Zwolan TA (2019). Datalogging statistics and speech recognition during the first year of use in adult cochlear implant recipients. Otology & Neurotology; 40 (7), 686-693.


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Hearing people can be so mean

Posted By Naama Tsach, PhD, Monday, November 4, 2019

“Hearing people can be so mean” noted one of my patients during a session. We were talking about a reaction that she sometimes experiences when she asks an acquaintance "What did (s)he just say?" Questions intended to help someone understand what is being discussed are sometimes perceived by typically hearing friends as being overly probing.  The young woman discussing this issue was born deaf and she remembers often asking for help by asking such questions. She prefers paying the price of being judged by some people as having bad manners to being out of the loop.

Others with hearing loss may experience similar conflicts. We expect people to be more sensitive, considerate, and aware of the difficulties people are encountering but too often even friends and family fail to appropriately respond. Professionals sometimes use the "earplugs experience" as a demonstration of what it’s like to have hearing loss. In reality, the experience of being deaf or hard of hearing is so much more complicated. It sounds trivial to ask people with hearing loss to simply explain their needs to friends and others around them. But they may not know where to start because of the lack of understanding regarding what it means to be deaf.

This post is about self-advocacy and the importance of people with hearing loss being proactive about explaining the difficulties they encounter as well as their needs as people who are deaf or hard of hearing people. This includes anyone with hearing loss, regardless of the technology they use.

My comments and recommendations are drawn from many years of working with adult CI recipients and learning about their experiences and interactions with the "hearing world."  These are topics that should be explained when practicing self-advocacy and educating your friends and family about your needs as someone with hearing loss.

·       The influence of a noisy environment. Did you know that many people with typical hearing think that a noisy environment has no impact on the ability of someone with hearing loss to hear? It may be assumed that people with hearing loss cannot hear the background noise. Clarification is needed.  Noisy environments make hearing and understanding even more difficult for people with hearing loss compared to people with typical hearing. In order to gain the same level of speech understanding, people with hearing loss need a better signal to noise ratio (e.g., the difference between the noise and the speech needs to be greater, favoring the speech level). Though people with typical hearing can often understand speech when speech signal level is the same as the noise level (or even a bit softer), people with hearing loss generally cannot understand speech unless the volume level is significantly higher than the noise. Knowing that would enable others to understand:

o   Why you're asking them to turn down the TV volume

o   The need to not sit near the air conditioning or to a working dishwasher when having a conversation with you

o   Why you are encouraging friends and family to choose quiet restaurants

o   Why you are often too busy or have other plans when invited to events in noisy places. Assistive Listening Devices (ALDs) that require your friends/ family/colleagues cooperation can be extremely helpful since they may provide you with a better signal to noise ratio by decreasing the level of the surrounding noise and increasing the level of the speaker's voice. It's important to note that during many daily situations, noise levels are too high for people with hearing loss meaning that they are forced to lose a lot of the auditory information and invest a large level of effort in trying to compensate for their limited auditory perception.


·       The influence of the number of speakers in a conversation. As the number of speakers increases, the ability of deaf and hard of hearing people to follow the conversation decreases.  People with hearing loss may not be able to rely solely on auditory information and may need visual cues (e.g., speech reading). In a conversation with more than one person, person may need to locate each speaker visually in order to supplement what he is hearing with speech reading. When people are not speaking one-at-a-time, understanding may be impossible. Having visual cues to supplement the auditory signal becomes even more important when a conversation is taking place in a noisy environment. Knowing that would let your friends understand why:

o   You prefer to meet with a group of friends in a bright place and not in a dark one

o   You need to position yourself such that you are able to see all of the speakers’ faces

o   You are asking people to remove their hands from their face while talking

o    Overlapping conversations leave you out of the loop.


·       The amount of effort that's required for keeping up with the conversation. Many people with typical hearing are unaware of how exhausting it can be for someone with hearing loss to follow a multi-speaker conversation in a noisy environment. You can read about listening fatigue in my previous post


·       Dealing with communication gaps and misunderstanding.  Did you know that many people with typical hearing believe that speech reading replaces what someone with typical hearing perceives via listening alone?  People sometimes believe that deaf and hard of hearing people have a unique ability to derive the whole meaning of what has been said by focusing on a speaker's face. Clearly this is false belief that should be addressed. It is not possible to completely perceive speech sounds in the absence of hearing them. People with typical hearing are not aware of the various strategies deaf and HOH people use in order to understand speech based on incomplete auditory input. They do not know that in order to understand whether somebody said "doll" or "tall" you need to use linguistic context since speech reading alone would not be helpful in recognizing which of the words were spoken.  People with typical hearing are often not aware of the fact that people with hearing loss do a lot of guessing. For example, they might need to guess the name of a person they were introduced to because they did not perceive it completely;  they might guess what had been said in conversation with more than one person since they might miss some of what had been said. They might smile and nod in the wrong places. These are typically done daily, and such guesses may lead to misunderstanding.

As people with typical hearing are exposed to a lot of auditory information—without even knowing they were listening to it—much of this information may not be perceived by a person with hearing loss. Parents of young deaf children are usually instructed by professionals to mediate the environment for their young children in order to:

·       Encourage their listening skills

·       Expand their knowledge and curiosity

·       Improve their orientation and their sense of involvement.

Many of these young children continue to seek this kind information as adults, reaching out to their friends, colleagues, spouses and relatives.

When your friends better understand the challenges you face, they are likely to be much more cooperative and helpful when you ask: "What did (s)he just say?"   

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The Challenge for Adults of Learning to Listen

Posted By Naama Tsach, PhD, Tuesday, April 30, 2019

Today I would like to share some thoughts about learning to listen, which is not the same as learning to hear.

When people come across the phrase “auditory training,” one often associates this term with computer-based listening practice. Alternatively, one might have an image of someone sitting in front of a speech-language pathologist covering his/her her mouth and asking the person to repeat words and sentences or answer questions.

However, when I work with my patients as part of their auditory rehab program, my goal is to help them become better listeners. Listening is more than being able to hear and repeat auditory stimuli. Who are the ones who will eventually benefit the most from their CIs? I believe it is those with congenital hearing loss who have been transformed into active listeners as well as those who lost their hearing later in life and then managed to recover their listening skills.

Why is it that adults who can hear with their cochlear implant(s) don’t necessarily listen?

People, especially those who have never heard before, may be accustomed to the option of living largely in a quiet world. They may prefer to not use their hearing technology in noisy environments, especially when it is unlikely to that they will be having any significant verbal communication (e.g., when using public transportation). Before cochlear implantation, some people have removed (or turned off) their hearing aids in uncomfortable auditory situations so their tendency is to do the same thing with their cochlear implant. Although their audiologist may encourage them to use their CI throughout their day, they may retain old habits and not  use their hearing device(s) for a few hours each day.

Other people will use their CIs throughout the day but will listen only to what they perceive as directed to them, as they used to do before. That is, they would listen to people who are talking to them and would ignore any other auditory stimuli. Therefore, they would miss a lot of significant information. 

What types of auditory stimuli may be missed by CI users?

·         Side or background conversations: if these conversations occur in proximity to you, the speakers may assume that you could (or even should) understand what has been said. Or, when two people at your place of work are talking about their preferences regarding the New Year’s party date, they might expect you to express your opinion or at least to be aware of their view.  

·         A comment or a question that is not directed to someone specifically, but can be significant, such as: “Does everybody know they are going to close the parking lot earlier today?”

·         Information provided during over public announcement systems at work, in transit stations (airports, train stations)

·         Background music anywhere (and everywhere)

These examples demonstrate huge challenges in terms of auditory perception and speech understanding. However, being aware of these situations and trying to get the most out of them would result in more attentive listening; active attempts to resolve insufficient understanding; better sense of orientation and inclusion; and Improved ability to apply your auditory skills into your everyday life.

What can an adult CI recipient do to improve their listening skills?

·         Strive to actively use your cochlear implant(s) throughout the day. If you have difficulty doing that, share your experience with your professional team (audiologist, speech pathologist). Many issues can be resolved with mapping, use of assistive listening devices, and/or a clinically-guided auditory rehabilitation program.

·         Know that indirect communication is significant and try to make use of any opportunity to listen during your daily routines. Think about the gain you may derive by being more attentive and more involved.

·         Examine how you might Improve acoustic conditions in your workplace and home.

·         Adjust your location at work that so you maximize visual access to as many people as possible. Try not to sit with your back turned into the center of the room which may prevent you from being able to make eye contact with co-workers.

·         Attempt dual tasking by practicing speech perception and auditory understanding skills while undertaking other (quiet) tasks (i.e., cooking, painting). This may help improve ability to react to speech even when you are busy with another activity.

·         Develop personal weekly listening goals.  These might include listening to public announcements at one’s workplace or when using public transportation (possibly with a co-worker or friend helping), listening to conversations between two other people when this occurs behind you, or listening to the GPS navigator in your car. (Try this last one when driving a known route so as not to be dependent on 100% speech understanding.)

Mastering Learning to Listen

It is not trivial to expect someone with hearing loss, who has been accustomed to attending only to speech that is directed at them, to start listening to a surge of auditory input from all directions. Even some people who had nearly normal hearing in the past but have been deaf for many years sometimes become selective listeners—focusing on speech that is addressed to them. Nonetheless, ongoing listening is a challenge worth taking on.

A few days ago, when I asked one of my patients how he did during the prior week, he told me that he surprisingly understood a short conversation between two people in his workplace without seeing them. I was thrilled! I knew he had made an amazing breakthrough. He has become more attentive to spoken communication occurring around him and is now more involved and oriented. The benefits for a CI user who becomes a good listener is not limited to his/her auditory rehab sessions because (s)he can use their "auditory training" in so many situations every day. I know that from now on my patient will progress at a faster rate and will better enjoy to a much greater degree the contribution that his cochlear implants make to his quality of life. And that is the point of it all!

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Listening to Songs with a Cochlear Implant

Posted By Naama Tsach, PhD, Tuesday, April 2, 2019


Many adults who experienced hearing loss later in their lives have memories of their favorite songs from the time when they had more hearing. These songs elicit feelings and reminiscences that relate to different times in their past, and songs that they long to hear again. 

People connect to songs through melody, words, or both.

The experience of listening to songs with a CI is challenging. The perception of music with the implant is imperfect. The main challenge is to recognize the melody but there are other challenges as well including:

• Isolating a specific sound in the presence of other sounds
• Distinguishing between various musical instruments
• Distinguishing between the vocalist(s) and musical instruments

To understand the lyrics of a song, you would need to be able to understand words in the presence of musical accompaniment, which is a very difficult speech perception task. Nonetheless, you may enjoy listening to songs with your CI—even if you have never listened to the specific songs before.

In this post we will describe some principles that may help you enjoy listening to songs.

Following the words of a song can also be difficult for people with typical hearing. In order to understand the lyrics, even people with typical hearing listen to a song multiple times or read the lyrics while listening to a song. Some people are less concerned about the lyrics and simply enjoy listening to songs without understanding all of the words.

It is more difficult to understand the lyrics of a song if:

• There are several vocalists, rather than one
• The musical accompaniment includes many instruments, rather than one or two
• The instrumental accompaniment is markedly louder than the singer, masking the vocalist’s voice
• The vocalist’s articulation is not clear
• The song’s tempo is fast
• There are few or no repetitions of lyrics
• The song lyrics are in a language other than yours

Word Pronunciation in Songs

The rhythm and inner structure of words in a song may change when it’s being sung. Do you know the word “slehey?” In the Christmas song Jingle Bells, we typically pronounce the word “sleigh” as “sleheigh.” (“Oh what fun, it is to ride, in a one-horse open sleigh”). Or in Leonard Cohen’s famous song Hallelujah, the last word in the chorus is pronounced “Halleluhuhuhu-jah.” That means what? Yes, that’s correct. And it's not trivial.

Some songs include a chorus of “na na na” including Freed from Desire by Pink and the second half of the song Hey Jude by the Beatles. In Hey Jude there is a four-minute vocal segment comprised mainly of “na na na.”

When people sing, they often need to stretch their breath until the end of the musical phrase. This can cause the last words, and especially the last sounds in the sentence, to sound weaker and less clear.

Practice Listening

Before starting your practice, choose a quiet place, close the door (and the window), and ask other people in your house to reduce background noises. In addition, it’s highly recommended to use an assistive listening device such as a streaming accessory. If you use a CI on one ear and a hearing aid on the other, don’t take your hearing aid off when you listen to music.

Now, let’s discuss choosing a song. People who listened to songs in the past may choose to listen to the songs they loved before. People who have never listened to songs before may start by listening to popular songs or to songs by popular artists. You may also ask relatives and friends for their recommendations—that’s a good way for you to participate in music with the people you spend time with.

After choosing a song to listen to (and considering the conditions mentioned above), print out the song lyrics. Although there are versions of songs which have the lyrics appearing in music videos, these are not necessarily the best versions for you to start practicing with.

Almost every popular song has several cover versions. Among many versions of the same song, note that the ones that were recorded during live performances may be more difficult to follow. Start by listening to the acoustic version of the song—one vocalist with one instrument, or even only the vocalist version without any musical accompaniment. Sometimes these versions are slower; that’s helpful when you’re listening to the lyrics. You can progress gradually. Listen to the same song in different versions with more than one vocalist. Also listen for the richer and more complex musical accompaniment until you reach the original version of the song. You may also find a version of the song melody without the vocal (i.e., singing). This can be an interesting experience too. At the end of the process, you can choose the version that you enjoyed the most.

Some CI users prefer to listen to male singers and others prefer to listen to female singers. It can be another criterion for you when choosing your favorite song version. If you find a vocalist who is easier for you to understand and who you particularly enjoy listening to, try listening to more of that artist’s songs.

Listen to the songs you love repeatedly until you learn some of their words by heart. This is a nice exercise for your memory. It will also allow you at some point to listen to that song without the lyrics in front of you in order to understand it as well as recognizing it spontaneously (even when you stumble upon it). And you may even sing it!

Now, let’s practice listening to Hallelujah (by Leonard Cohen) step by step:

Hallelujah (Leonard Cohen):

1. Imogan Heap, no musical accompaniment, with lyrics:

2. K.D. Lang accompanied by piano:

3. Jeff Buckley accompanied by guitar:

4. Melody without singing:

5. Leonard Cohen, official version, with vocal and instrumental accompaniment:

Good luck and have fun!

For additional reading about music appreciation with a cochlear implant:

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Listening Effort and Fatigue: Part 2

Posted By Naama Tsach, PhD, Wednesday, October 31, 2018


In the last post, Part 1 on fatigue, we discussed in detail why people with hearing loss may experience fatigue when listening. In this section, we will explore what happens when someone receives a cochlear implant, and what can be done to lessen fatigue associated with listening.

The auditory input provided by a cochlear implant is different from that which is provided by hearing aids. In addition to the extended frequency and intensity ranges provided by a CI, the cochlear implant converts the acoustic signal into an electrical signal and performs frequency and intensity compression's. Therefore, CI users should acquire new connections between auditory input and its meaning. These connections are acquired by learning to interpret the new signal and requires the listener’s attentiveness.

CI users cope with many environmental sounds that were not accessible to them before. Throughout the initial period of CI use, people strive to interpret and learn the meaning of sounds, which may require a lot of concentration. Understanding environmental sounds is rewarding as it improves one’s sense of orientation, safety, and independence. At the same time, these sounds that are now within the hearing range and have meaning, may distract CI users’ attention while they are trying to understand speech.

As was mentioned in the previous post, restricted auditory memory—especially among people who have never experienced typical hearing and older adults (who had typical hearing in the past)—also contributes to more difficult listening effort. Even when sounds are audible and speech perception has been greatly improved with cochlear implantation, listening can still be very demanding.

The process of adjusting to the CI is not always an easy one. In addition to extensive auditory learning, there is a process of experiencing and investigating the technology boundaries. Besides the feelings of gratefulness and relief, people might feel overwhelmed, frustrated and even disappointed. These feelings need to be addressed. This is a process of change, growth and re-organization that is not necessarily obvious. Coping with these challenges can be exhausting.

As CI users improve their ability to perceive speech, they may gradually and naturally become less dependent on speech reading. This is a great gift and an important achievement. On the other hand, people may report negative changes in their family and friends’ behaviors. They can even occur among colleagues at work. People who knew the person before he or she received a CI may now perceive them as having better hearing than they actually have. They challenge them by being less careful in making eye contact, talking to them from a distance, and speaking too fast. The consequences are an increased load and effort required by CI users to keep up.

What can you do?
• Try to arrange your schedule keeping in mind expected fatigue and level of alertness needed for specific activities. If need be, plan for a “time out” (i.e. taking a rest or removing the CI for a short time).
• Be aware of challenging environments that may cause stressful communication conditions. Some of these situations can be managed.
• Organize and accommodate the acoustic conditions at home and at any other relevant space to make them as comfortable as possible:

  • Small room + closed door + covered walls + acoustic ceiling: YES
  • Open space + open/no door + bare walls + high ceiling: NO

• Whenever possible, turn off or quiet appliances such as the dishwasher, air conditioner, microwave, fish tank.
• Try various sound processor programs or adjustments that may help you manage communication in challenging acoustic environments. It might take some time for you to investigate and understand your options but it is definitely worth trying.
• Use assistive listening devices in daily situations that are challenging for you such as lectures, phone calls, and meetings.
• Consider/improve your bilateral hearing.
• Share your experiences with your family and friends and guide them to support and help you communicate with them.
• There is a link between fatigue and motivation, so keep yourself highly motivated. It can be done by setting practical and meaningful goals (e.g., I wish to improve my understanding and active contribution in work meetings and/or family gatherings or I wish to go out to a nice quiet restaurant with friends). Your mood can also affect your motivation, your energy level, and your overall functioning. Try to focus on your gains rather than on your difficulty. This is easier said than done but with the right attitude and support, it is attainable. Focus on the rewards such as the intellectual and social benefits you gain rather than on the listening effort; this may help you to not feel fatigued.
• A guided auditory rehabilitation program may provide you with goals, motivation, and strategies (such as auditory training materials) that may improve your auditory skills as well as your ability to use other resources involved in the listening process.

We can summarize by saying that cochlear implantation enables access to expanded auditory information; some CI recipients may need to work hard in order to accommodate a life filled with new sounds. Such efforts may result in additional fatigue. Know that this is an integral part of the CI journey. Be patient, try to ease the burden by managing your daily environment, and share your experiences with those who can help you get through the process.

Good Luck!

Recommended Reading
McGarrigle R, Munro KJ, Dawes P, Stewart AJ, Moore DR, Barry & Amitay S. (2014): Listening Effort and Fatigue: What Exactly Are We Measuring? A British Society of Audiology Cognition in Hearing Special Interest Group White Paper, International Journal of Audiology, Early Online: 1–13.

Pichora-Fuller MK, Kramer SE, Eckert MA, Edwards B, Hornsby BWY, Humes LE, Lemke U, Lunner T, Matthen M, Mackersie CL, Naylor G., Phillips NA, Richter M, Rudner M, Sommers MS, Tremblay KL & Wingfield A (2016): Hearing Impairment and Cognitive Energy: The Framework for Understanding Effortful Listening (FUEL), Ear and Hearing, 37, 5S-27S.

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Listening Effort and Fatigue: Part 1

Posted By Naama Tsach, PhD, Tuesday, October 23, 2018

Today we will talk about the fatigue associated with listening effort. Listening involves both auditory and cognitive processing. We hear with our ears but we listen with our brains and consequently people whose auditory input is of a lesser quality may expend more mental effort to listen. The fatigue may be described as a feeling of being tired, exhausted or having low energy or a low motivation to listen.

Fatigue associated with listening effort is reported by many people with hearing loss including those using cochlear implants. Statements such as these are not uncommon from people with hearing loss of all ages.

• I feel that my brain is working nonstop and it takes a lot of energy for me to listen.
• I am bursting with auditory stimuli that I cannot filter.
• My brain needs to process what I am hearing faster than it used to do before.

Such comments are more common with CI recipients who used hearing aids for many years (when they could have benefited more from cochlear implants) and also from those adults who had significant hearing loss at birth or early childhood and were implanted later in life.

People with hearing loss may refer to communication conditions as stress inducing situations since they require significant listening efforts and can potentially involve communication breakdowns and misunderstanding.

What kind of listening effort may be required of people who are deaf and hard of hearing? Why do CI users report fatigue associated with listening?

People with hearing loss may perform complicated auditory processing in order to understand speech because of imperfect auditory perception. They may work hard to: localize sound, identify who is speaking, distinguish speech from background sounds, and recognize speech sounds as well as cues for emphasis and intonation. They may rely upon visual information for speech reading to supplement what they are receiving auditory. In many real-life situations, accessibility to visual cues may be restricted due to imperfect lighting conditions, difficulty in localizing the speaker and other factors.

Consequently auditory and visual cues might not be sufficient and people with hearing loss may need to rely upon previous knowledge regarding a conversation. They may also draw upon their linguistic knowledge (e.g., Is this word likely to be a noun?) and on other kinds of supporting clues. If all of this isn’t difficult enough, they may need to process the spoken information rapidly—based upon the speaker's pace of speech or to stop the speaker to ensure they understood what was said. They also need to remember everything they heard already and use different cognitive and language skills to fill in the whole meaning.

People who have never experienced typical hearing, as well as older adults who had typical hearing in the past, may experience greater difficulties with recalling auditory input and this also contributes to their effort to communicate effectively. Since auditory memory skills are imperfect, the individual with hearing loss must put a great deal of effort into understanding speech—even when they can recognize single words

Consequently, fatigue can be an inevitable consequence of listening with hearing loss. What fatigue in adult CI recipients? How can we manage fatigue and improve quality of life for adults post CI? We’ll talk about it soon, on our next post.

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Being a Personal Auditory Trainer

Posted By Naama Tsach, PhD, Wednesday, April 25, 2018


You’ve been asked to be a personal auditory trainer

What do you need to know? 


You’ve been asked to be a personal auditory trainer by a friend or relative. What does that mean? What’s involved?

You will help them work towards better hearing and ease in communicating. You are going to have the very special opportunity to make an important contribution to your friend’s fascinating journey.

Here are some tips for you—a first time auditory speech perception trainer. I hope you find them to be both practical and applicable.*


  • Pay attention to the space where you are practicing. During the early rehabilitation timeframe, it is important to keep the auditory training environment as quiet as possible. Practice speech perception in an enclosed space. Close the door and the windows and turn off any appliances that you can that create noise. If there is noise in the house, try to reduce it before starting to practice. It’s possible that you will not be aware of all these interfering noises because we often “tune them out unconsciously.” Hence you may be surprised to find out that your CI user friend is more sensitive to noises in the environment than you are. My advice is to look for a quiet room and adjust the conditions together with the trainee.

  •  Begin by sitting no more than three feet from the trainee.

  • The first step is to verify that the implant is working. Ask the trainee to turn off the hearing aid in the ear opposite to the CI ear and see if they hear the following sounds: /i/ /a/ /u/ /s/ /sh/ /m/. If the person has two cochlear implants, check each one separately.

  • Encourage the trainee to be attentive to environmental auditory stimuli and help them to identify any sounds that they are hearing (e.g., car noise, a dog barking outside). When unplanned "auditory events" occur during the session (e.g., phone or door bell ringing, someone knocking on the door, an airplane, rain), raise the awareness of your friend to these sounds prior to your own reaction to them.

  • Since the aim is to improve auditory speech perception, you should "hide your mouth" to avoid providing speechreading cues to the trainee. You will probably need to cover your mouth up to your nose. You can use a piece of paper or even better, a speech or acoustic hoop designed restrict visual cues without impacting the intensity or sound quality of one’s voice during therapy. Such hoops can be found online from CI company stores or from other educational institutions such as this one:  You can even make one yourself; there are instructions here:

  •  Speak a little slower than your normal speaking rate, and use comfortable speech intensity (do not raise your voice).

  •  Expect that several repetitions of the stimuli will be needed.

Auditory training should become a part of the CI recipient's life routine, since auditory learning after cochlear implantation is a long-term process. Therefore, your long term commitment, patience, and positive support will be highly valued.

A number of earlier posts suggest specific practice routines. I urge you to go back and take a look at the following. These are perfect ways for a personal auditory trainer to work with an adult recipient.

* For individual assistance, questions and verification requests, please ask your friend to contact their audiologist or speech pathologist.


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Audio Books

Posted By Naama Tsach, PhD, Thursday, November 2, 2017
Updated: Thursday, November 2, 2017

Favorite Home Practice Tools to Improve Speech Understanding:
Audio Books, Speech Sounds, and More


Audio Books: Why people like them for auditory practice

Audio books are widespread and accessible. They include wide-ranging topics and are available for non-fiction, biography and fiction and span many different languages and personal interests. Many adult CI recipients use audio books as a home practice tool to improve their speech understanding skills. Usually the narrator is a clear speaker who is reading at a normal speech pace (meaning not too fast). While listening to audio books, you can read along with the written text if you wish. These are significant positives, making the use of audio books the most common self-practice tool for adult CI recipients.

Audio Books: What’s their downside as a practice tool?

Anyone who has used audio books knows that there are also some negatives associated with their use as a practice tool. First, recorded speech sounds different from natural speech because the acoustic signal is restricted (contains fewer auditory cues) and therefore might be more difficult to process. Secondly, the content is sometimes recorded at a pace which may be too fast and overly challenging for a CI recipient—depending upon where they are in their rehab process. It may be technically impossible to slow down the narrator’s reading speed. (And if it is possible to slow the pace, this could cause distortion of the speech signal.) Some audio books have background music that make the speech even more difficult to understand. In addition, listening to audio books requires more than just good speech perception of everyday language as book text may use less frequently used vocabulary, longer sentences, and more complex syntax.

One can look at the use of audio books from two perspectives:

  • On the one hand, for many people, they are too difficult to use, especially during the early rehabilitation timeframe (when the motivation to practice is the highest but auditory skills are still limited).
  • On the other hand, they provide challenging practice. For individuals who are able to cope with the complexity they provide, audio books can be an effective and engaging practice tool.

More ways to practice your auditory skills

Speech sounds can be presented either solitary (/s/), as part of a syllable (/sa/), or in a single word context (bus). Good speech understanding does not always indicate that someone has excellent perception of speech sounds. For example, the last word in the following sentence can be perceived—regardless of one’s access to all of the acoustic information: "I bought a new _a_"(car).” If the CI user knew that the person talking had an old car that was always breaking down, he would have contextual knowledge that supports speech understanding even when all of the words heard were not understood.

So if words can be understood based on context cues, why is it so important to improve the accuracy of speech sound perception? In order to capture new words with minimal linguistic redundancy, you must be able to perceive the word's components. This is also true in cases of single word presentations or proper names when there is no context to enable someone to fill in the gaps. In addition, knowing which sounds you perceive less well, or which sounds tend to get mixed up with others (e.g., /b/ with /p/, /k/ with /t/) will help your audiologist fine tune and to monitor your CI.

Practicing understanding simple greetings, questions and simple sentences is easy to do and can be very rewarding when you implement these skills into your everyday life.

  • You might practice recognizing the names of friends, co-workers and relatives.
  • You may find it useful to practice single letters, numbers and other words that may help ("c like Charley") clarify words that you are having difficulty with.

Improving auditory memory skills and capacity may make it easier for you to follow sentences, conversations, and even lectures. You can use word lists that contain letters, numbers, and words related to different topics (i.e., shopping, food ingredients, packing for travel, city and country names) and practice different repetition tasks. Start with two words and gradually increase the number. You can also practice auditory memory by using sentences, such as understanding instructions with ascending complexity (1) take the book and put it on the table, (2) take the pencil and put it on the table, (3) take the pencil and put it on the book. More advanced practice could include recall of details from a short story or recipe, or how to get from your home to another location with specific directions.

Comprehensive practice of hearing skills might include the activities above and more. Many of these suggested activities rely upon the assistance of another person. In the next post, we will discuss some guidelines and tips for relatives or friends who assist you with your home training.

Good luck.


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The mission of the American Cochlear Implant (ACI) Alliance is to advance access to the gift of hearing provided by cochlear implantation through research, advocacy and awareness.