Cochlear Implant Rehabilitation for Adults
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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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How to Begin Talking on the Telephone with Your Cochlear Implant

Posted By Naama Tsach, PhD, Tuesday, August 22, 2017

Why is it hard for cochlear implant recipients to hear on the telephone?

Acoustically, the telephone signal has a more limited frequency band than a typical speech signal, the phone instrument distorts voices, and there can be an echo and/or other noises that make comprehension difficult for anyone but most especially for people with hearing loss. These challenges combined with the inability to use speech reading when talking on the phone are significant barriers to fluent telephone conversations. The lack of eye contact that prevents you from receiving visual cues for speech reading also pertains to the person you are speaking to as he or she cannot see your facial expressions or other nonverbal cues either—cues that typically help someone to know that you did not grasp completely what was just said.

Hence it is important to tell the person you are talking to when you don’t understand. The other person may not be aware of your lack of understanding unless you tell them.

Telephone Tips When Starting Out:

  1. Choose your partners carefully. This is good advice for life in general and is highly recommended when you begin talking on the phone with your CI. Begin with people who will be mindful and tolerant as a conversationalist as they will likely need to make adaptations for you. You probably know which friends or family members have relatively clear speech. You should ask for their help and guide them with some basic principles.
  2. At first, you should be the initiator of phone calls. Call your partner(s) from a quiet room.
  3. Use your preferred method of connecting from your processor to the telephone. There are several connection methods available including Bluetooth, telecoil, or another ALD (Assisted Listening Devices) that can help you. Ask your audiologist and make sure that you have been updated with every device that can work with your CI. I also recommend that you review our previous blog post by Erin Schafer on Assistive Listening Devices for Cochlear Implants.
  4. If you don't use an ALD to connect to the telephone, take care to find the best position to hold the telephone receiver before you make a phone call. This position may be different from where you held the phone with your hearing aid.
  5. Ask your practice partners to take your phone calls when they are also in quiet spaces. Ask them not to converse with you when they are driving a car, sitting in a restaurant, or using a speakerphone. Ask them to wait until they are in an ideal acoustical environment to talk.
  6. Do not feel embarrassed to inform your partners that you did not understand what they just said! Remember that if you do not inform them at the moment when you missed something they said, there is an increased chance of further misunderstandings. Let them know in advance that they should expect that you will not understand every word.
  7. Ask your partners for clarifications such as “I did not understand.” “Please say it again.” “Could you speak slower?" Guide them to use basic clarification strategies such as slowing down their speaking rate and conveying the message using other simple words rather than repeating precisely what they said before. When you miss a name of a place or a person and you are not sure you have understood the word in full, your partner could spell the word ("N" as in Nancy, etc.) or briefly describe the person or the place ("My sister Ann whom we visited last Sunday" or any other significant clue).
  8. If the conversation includes instructions, information regarding meetings and so on, check back by repeating what was said and then writing it down.
  9. One last tip is relevant if your speech is not perfectly clear (i.e., you have imperfect speech intelligibility). Speechreading is an important source of information for many people—not just those with hearing loss. People who have normal hearing may use speechreading in some situations without knowing they are doing it. These situations include understanding speech in noisy environments, especially when the listener is in conversation that is not their native language or they are listening to someone with lower speech intelligibility. If your speech intelligibility is lower than typical speech, a communication partner may need clarification on the telephone as well.
  10. Remember, both of you will need to be patient and use the clarification strategies described above.
  11. You might also try the telephone practice tools from the CI companies, all of which are available for free in the rehab areas of the company websites. These may help you develop the confidence to converse with a real person!

What is the right time to start telephone practice?

I suggest starting telephone practice only after you are able to understand short, simple sentences without speechreading. Some people can do this immediately after device activation, some are able after a few months, and others are ready only after a year of CI use. Not everyone implanted at a later age will be able to understand speech on the phone. Talking on the phone can be a challenging mode of communication for a CI recipient as it requires the person to have robust speech perception skills, to have pursued specific training and practice, and to have high auditory processing abilities (which may be based upon previous hearing experience).

Good luck and have fun!

Naama Tsach

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Can you "fail the test” and still be a successful CI user?

Posted By Naama Tsach, PhD, Tuesday, June 6, 2017


The speech perception evaluations done as part of the follow-up for CI recipients are typically reflected by a percentage, which some people perceive as a “grade.” However, unlike grades in school, there are no standards and there is not a simple definition for what is a good grade. Some people would consider 30% on a test of understanding words in sentences in quiet as a huge success because they never had any auditory speech understanding before CI. Other people, after the same period of CI experience, would consider a score of 90% in quiet and 50% in noise as successful; those individuals might have had a pre-CI “grade” of 40% of words in sentences in quiet and 10% in noise. There are speech perception tests that simulate comprehension in more realistic conditions, such as recognition of common sentences in noise. Other tests are used to evaluate perception of speech sounds, words, and sentences in quiet conditions in closed set (i.e., multiple choice) or in open set (i.e., words or sentence repetition task). Recipients should always seek the help of their CI audiologist to help them understand their outcomes and what they mean in terms of personal improvement.

Objective Versus Subjective Assessments

One should take these scores with a grain of salt. Remember that they represent specific speech perception skills (those that are directly evaluated by these tests) and do not represent your overall CI outcomes. For example, a score of 95% word recognition in quiet conditions may not cheer up a CI user when they realize that a colleague approached them with a short question and they missed it. For others, a "lower" grade (of say, 40%) does not represent the significant advancement they’ve experienced in being able to combine speechreading with listening much more effectively—an advancement that makes them feel very positive about their decision to undergo cochlear implantation.

Therefore, if a recipient feels that numerical scores don’t seem consistent with their own perceived experience and (s)he then asks "Am I doing well?", one should consider other ways of representing a subjective evaluation.

How did hearing loss affect the person’s life before the cochlear implant?

The goal is to evaluate the contribution of the CI to one’s communication and how it is reflected in different situations in life. It's important to consider how hearing loss affected an individual before CI and what kinds of difficulties affected his or her decision to undergo cochlear implantation. For example, someone might contemplate:

  • Could you understand some speech without speechreading?
  • If you could, what restrictions did you have? Did you need to stay close to the talker, listen in a quiet room, and close the door?
  • Did you understand certain talkers better than others?
  • Did you ask people to slow down when they were speaking?
  • Do you remember how much effort you put into having a conversation, especially with unfamiliar speakers?
  • Do you remember how often you asked people to repeat or speak more slowly?
  • Did you give up the chance to fully understand people, given the frustration in getting it right?
  • Did people touch or tap you to get your attention? 
Assessing Quality of Life Changes

To assess the CI contribution to one’s quality of life and sense of successful CI use, an individual should consider improvements in the ease of communication, sense of security and orientation, and enjoyment in listening.

  • Does the CI make it easier for the person to have a conversation?
  • Can the person now understand a more rapid pace of speech?
  • Does (s)he ask people to repeat less frequently?
  • Does (s)he feel that it is easier to understand people whose voices were previously very difficult to understand, such as children or those with heavily accented speech?

If a person answers “yes” to some of these examples, it indicates benefit in daily situations that contribute to quality of life.

Satisfaction Isn’t Easy to Quantify

In addition to improvements in auditory speech perception, an individual may simply enjoy listening to the voices of beloved people, to street noise, animals and nature sounds, and music. These feelings of pleasure are priceless. It is true that there are people who will respond to daily greetings and understand simple questions, even without having any eye contact with the speaker. There are also CI recipients who will talk on the phone. However, they are not the only successful CI users. Everyone may define the benefits they derive from their CI and can feel satisfied and accomplished by them.

Satisfaction following cochlear implantation can be affected by the extent to which the CI enables someone to meet their own communication needs. These needs vary depending upon whether the recipient relies upon written communication at their work place or if they need to use spoken language extensively, whether an individual is working in a quiet or noisy environment, whether they use sign language with relatives and friends or not. The sense of self-accomplishment should mainly rely on the person’s recognition of the different contributions that a cochlear implant makes to their everyday life.
Keep in mind that the reason for someone to undergo cochlear implantation is typically to improve their quality of life, not to get As on tests. The auditory information provided by cochlear implantation provides much more than numeric results on clinical tests.

CI recipients should share their insights regarding benefits and expectations with relatives and friends as well as with their CI professionals. Accepting diversity, appreciating achievements, and continuing to improve hearing skills is all part of one’s CI enjoyment.

Naama Tsach

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Utilizing Assistive Listening Devices

Posted By Naama Tsach, PhD, Thursday, May 11, 2017
Updated: Wednesday, May 10, 2017


The improved access to sound provided by assistive listening devices is generally accepted for those who use hearing aids. This same benefit extends to cochlear implant users of all ages. Read Erin Schafer’s guest blog post and learn about how these technologies can be used in a variety of settings.

Erin Schafer Ph.D. is an Associate Professor at the University of North Texas in the Department of Audiology and Speech-Language Pathology. She teaches courses and publishes peer-reviewed research on the assessment and (re)habilitation of adults and children with hearing loss or auditory disorders. She is a Board Member of the Auditory Implant Initiative, serves as President of the Educational Audiology Association, and is Editor of the Journal of Educational, Pediatric, and (Re)Habilitative Audiology.

Thank you Erin, for this important blog post, which is an enriching addition to our blog resource library.

Naama Tsach PhD

Assistive Listening Devices for Cochlear Implants

The selection of assistive devices for users of cochlear implants has grown tremendously over the past 10 years with today’s devices offering more affordable, simpler, and easy-to-use wireless products to improve hearing in noisy situations, over the phone and to the television. Although I cannot speak to my personal experiences with these devices, I am able to share with you the findings of our recent published research as well as some practical uses of each device.

Improving Hearing in Noisy Situations

For many years, individuals with cochlear implants have been able to connect their sound processors to frequency modulation (FM) systems, which wirelessly transmit a signal from primary talker to the listener with the implant. These systems were helpful for improving speech recognition and listening ease, particularly in noisy environments. However, many FM systems are expensive, sometimes cumbersome to connect to cochlear implants, and are susceptible to interference from the environment. Many of today’s wireless accessories, however, use digital transmission, which is less susceptible to interference and, in many cases, is much more affordable. Examples of these accessories include the Wireless Mini Microphone and Mini Microphone 2+ that can be used with Cochlear processors (in partnership with GN Resound) and the Phonak ComPilot and RemoteMic accessories that can be used with Advanced Bionics processors. Although MED-EL is not offering wireless accessories, MED-EL processors may still be used with existing FM and digital transmissions systems available from Oticon, Phonak, and many other manufacturers.

According to our research, the Mini Mic is was able to substantially improve average speech recognition in quiet by 10% and in noise by up to 65% in 16 adults with Advanced Bionics implants when compared to performance with the cochlear implant alone. A more recent study that is in progress included two groups—a group of listeners with bilateral cochlear implants and a group of listeners with a cochlear implant on one ear and a hearing aid on the other. This study showed that, in both groups, use of the Mini Microphone 2+ was able to improve speech recognition substantially, and the benefit achieved with the Mini Microphone 2+ was similar to the benefit obtained with a higher-end remote-microphone system. Results of these studies provide evidence that the new wireless devices are beneficial. A 65% increase is a huge benefit!

Although use of these wireless accessories requires a cochlear implant user to adjust processor settings and to ask the primary talker to use a small microphone, the benefits are notable, particularly in noisy situations. This accessory will be helpful in the car, when the primary talker is at a distance (e.g., church or lecture), or at large family gatherings, parties, or other social situations.

Improving Hearing Over the Phone

Hearing over a mobile telephone may also be improved with new wireless accessories available from Cochlear (Phone Clip) and Advanced Bionics (Phonak EasyCall Accessory). Both of these wireless accessories connect to mobile phones via Bluetooth and allow users to communicate hands-free through the small device that is clipped near the user’s lapel. The benefit of using the Phone Clip was documented in a study including 16 adults with Cochlear sound processors where speech recognition was improved by 18% in quiet and 29% in noise when compared to performance in a test condition where the phone was held close to the processor microphone.

All listeners, including those with normal hearing, experience difficulty hearing over the phone when in noisy listening situations, such as parties, grocery stores, and restaurants, and sometimes these calls are really important! A trial period with a wireless phone device may offer a solution to some difficulties over the phone and result in more fluid conversations. Regardless of the manufacturer, all CI processors have a telecoil setting that can be coupled to telecoil-enabled mobile devices and landline phones to improve hearing and ease conversational difficulties.

Improving Television Listening

Signals from the television may be streamed directly to the ears of individuals with cochlear implants via new wireless accessories, such as the ComPilot and TVLink II for Advanced Bionics processors and the TV Streamer for Cochlear sound processors. These devices are fairly simple to set up and can provide substantial benefit. For example, we conducted a study with 16 adults with Cochlear sound processors who completed a test of auditory and visual recognition through a television. Their performance improved by 8% in quiet and 23% with noise in the background when compared performance with their cochlear implant alone.

The potential benefits of a streaming device for the television are obvious and may serve as a mediator for your household, especially if you like to turn up the volume quite a bit. Some individuals with implants have difficulty hearing the television, particularly when other sounds are present including the washing machine, dishwasher, water running, and children playing (or yelling in my house). A wireless device allows the user to hear the television at a normal and comfortable volume, regardless of the noise in the background.

I hope you will consider giving some of these new wireless devices a listen because many adults with cochlear implants have experienced great benefit from these devices. Happy Listening!

Erin C. Schafer, Ph.D.
University of North Texas

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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.