Cochlear Implant Rehabilitation for Adults
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Welcome to Naama's Blog. I hope you will ask any questions you have here in the comment area below. You can also post your thoughts on what I have written or anything else related to adult rehabilitation. Members may comment on any posting by logging into your account. If you are not a member but wish to comment, please send your submission to . If you would like to write to me directly, please email me at: The Blog is intended as both a patient and a professional resource. This printable brochure may be used to refer adults and family members who may benefit.


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Listening to the Sounds Around You

Posted By Naama Tsach, PhD, Tuesday, February 23, 2016
Updated: Monday, February 22, 2016

Today we will discuss the issue of environmental sounds. Typically, this topic receives less attention compared to speech perception. However, for many CI recipients the perception of environmental sounds is very significant and has a unique positive contribution to their quality of life.

According to CI user' reports, the ability to perceive environmental sounds helps them to feel connected to their environment. For example, these sounds help them to know whether they are home alone, whether someone is taking a shower or washing dishes, whether someone is knocking on the door or ringing the doorbell. The perception of environmental sounds contributes to one's sense of orientation and confidence.  As one of my patients once said, "I use my CI regardless of I am home alone or with others; I even use it when I go out to work in my garden by myself." The benefits provided by cochlear implants are not restricted to communication with others.

Immediately after the implant is switched-on, you are exposed to a world of sounds. The gate opens and a range of auditory stimuli flow in.  You hear others’ speech as well as the sounds of animals, nature, music, appliances, cars, and much more.  Access to all of this information can make you very happy; it can also be irritating or even overwhelming.

At first, new CI recipients may experience this blend of sounds as unwanted noise that mainly interferes with understanding speech. This aspect of hearing with a CI is very personal and is affected by a range of fact of factors that make up your pre-implant experience such as duration of deafness, amount of residual hearing, and hearing aid utilization.   

If you had a significant hearing experience prior to receiving a CI, you may be very happy that these sounds have become accessible to you again. However, it will take time to get used to the quality of these environmental sounds. During the initial states of implant usage, you may feel a bit disappointed.  The sounds may not be what you remember them to be.  Sounds may seem to be different, less pleasant, and less clear. After a period of time, the way you perceive sounds will improve and you likely will learn to understand and enjoy the richness of your new world of sounds.

If you did not have a significant hearing experience prior to implantation, these sounds may be initially meaningless and even distracting. Over time the fog will clear and environmental sounds will become increasingly meaningful and useful.

Tips for Improving Environmental Sound Perception 

·      Share your experiences with your audiologist.  Are there any specific sounds that bother you or make you feel uncomfortable? You may find it useful to keep a journal of your daily experiences. Your audiologist may adjust your map based upon your experiences, or provide direction on use of noise reduction strategies in your processor, or encourage you to relax and hopefully gradually adapt to listen to these sounds.

·      Understanding environmental sounds takes time and practice. As you become a more experienced CI user, you will reap more benefits from your access to environmental sounds. You will recognize them and enjoy listening to the sounds around you. 

·      When you notice a sound you do not recognize, ask a family member or friend to identify it for you.  This process will improve your listening skills as well as your auditory orientation.

·      Work intentionally and actively on your environmental sounds perception skills. Try concentrating on a different sound each time. In order to practice perception of a sound, it is helpful to listen in a quiet space free of distracting sounds. When you are at the beach, you can practice listening to the sounds of the waves; in the parking lot you can practice listening to the sound of your car door locking; at home, you can listen to the sound of running water and compare it to the sound of dripping water; you can listen to the sounds generated by different kitchen appliances.

·      Learn which sounds are typical of specific environments to aid you in the identification process. Which sounds do you hear? Which sounds are more important for you to listen to? What are the sounds that are more pleasant for you to hear? Which sounds are less pleasant? Improving your awareness of the sounds in specific environments will help you to identify them.

·      Recognition of environmental sounds will help you to determine which environmental sounds interfere with speech perception. Accordingly, you may use that information to help plan your conversation settings.

Although the benefits of cochlear implants do not typically include perception and understanding of environmental sounds, you shouldn't underestimate the importance of these hearing skills. Your auditory learning includes this aspect of hearing; learn to appreciate it and derive the full benefit and satisfaction of your listening achievements.


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Constructive Communication

Posted By Naama Tsach, PhD, Tuesday, February 9, 2016
Updated: Saturday, February 6, 2016

Creating Constructive and Supportive Communication with Family and Friends

This post is devoted to a particularly challenging issue—addressing the attitude of your family and friends towards cochlear implantation and the rehabilitation process that follows. Likely your family and friends will support your decision to pursue a cochlear implant and wish you the best possible results in the hopes for a better quality of life. Family and friends can be a great source of support for you during the process. The main message I want to convey in this post is not to underestimate the importance of open communication with the people closest to you regarding the circumstances that led you to cochlear implantation. This will be an opportunity for your family to learn more about your life, and also an important opportunity for you to gain their understanding and constructive support.


Hearing loss is often called the "invisible disability". People with hearing loss may make extraordinary efforts to communicate with typically hearing people. Sometimes they give up the opportunity to fully understand what has been said in order to avoid a situation that they view to be embarrassing. However, if the person with hearing loss shared the responsibility for improving communication with others, (s)he could improve the situation. The "invisible" nature of the impairment puts all the burden on the person with hearing loss.


People with normal hearing, even those who have a close family member who has hearing loss, are not always aware of all the implications and the severity of the communication limitations that hearing impaired people experience. This is especially true when the hearing impaired person has normal speech.
When people who have hearing loss decide to undergo cochlear implantation, the main reason is not necessarily to help their family members and friends to communicate with them. Typically the person pursues a CI primarily for herself and it is critical that the people closest and most important in their lives understand their motives.


People with normal hearing are not aware of how difficult it is for people who have hearing loss to function in difficult acoustic environments or complex communication situations. It is important that you share with your relatives and friends the kinds of environments that are especially difficult for you (e.g., noisy restaurant, outdoors, gym, parties) as well as difficult communication situations (e.g., business meetings, multiple speaker conversations, talking with children or people who have accents). What do you feel in these situations? How do you deal with your difficulties? What could make things easier? What could make it worse? All of these topics should be discussed.


Such dialogue can improve family members’ understanding of your daily challenges. It enables you to share your concerns. Feelings of joy and satisfaction in light of the benefits you derive from the cochlear implant can be shared, even if they are not yet obvious to others. Enhancement of speech reading and the ability to respond to someone who calls your name are two examples of exciting experiences that family and friends are not always aware nor can they appreciate these milestone for you without this kind of sharing of your feelings and experiences.


I want to share a story with you. A woman with a cochlear went on a vacation with her mother and sister. They were eating in a noisy hotel dining room when she heard the waiter who was standing behind her asking them if they wanted an extra drink. She replied to the waiter and then she said excitedly to her mother and sister, "Did you see that? I understood what he said even though he was standing behind me!" Her mother and sister reacted with indifference and she was deeply hurt by their reaction. She explained to me afterwards, "They did not realize how impossible this situation would have been prior to my having received a cochlear implant and they did not understand my feelings of accomplishment."


Another reason to discuss these issues is that many people experience a new world of sound after implantation. Initially some may be challenged by learning to understand speech with competing environmental sounds. Family members and friends can help during this stage by identifying environmental sounds for the new CI recipient. Another auditory challenge is to be able to focus on the most relevant sounds in the presence of other sounds. This is a complex auditory skill that often improves over time. Family members can help by taking steps to minimize the environmental sounds at home (e.g.: turning off noisy appliances, closing doors).


Involving family members in the rehabilitation process may contribute in many positive ways. Family members might join you for your appointments with the cochlear implant team, at lectures, and for meetings with other CI recipients. Family members who consistently attend the rehabilitation and auditory training sessions have a better understanding of the process and may then assist during your home practice sessions. By being part of the process, they will better understand what you are going through and be positioned to support and encourage you as partners in the path you have chosen.

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The Hearing Assessment

Posted By Naama Tsach, PhD, Tuesday, February 2, 2016
Updated: Wednesday, January 27, 2016

The Hearing Assessment (Prior to Cochlear Implantation)

I will start our journey together with a discussion on the hearing assessment performed prior to cochlear implantation. Those of you who are currently going through this process are most welcome to join me as well as CI users who have already experienced the routine hearing follow-ups after implantation.

The cochlear implant candidacy process includes a medical examination, auditory assessment, and sometimes a psychological evaluation. The goal is to obtain information to provide reliable answers to two key questions:

(1) Is a cochlear implant the most appropriate hearing assistive device?

(2) Are there any medical restrictions for the surgery?

This step in the process requires the cochlear implant team to have broad theoretical knowledge and clinical experience.  First the team must collect the relevant information concerning the hearing abilities of the candidate. The role of the audiologist and speech pathologist is to gather information regarding your current amplification and communication status in order to be able to compare it to your expected future outcomes using a cochlear implant.

Audiological Evaluation

The first step in the hearing evaluation is to have your pure-tone audiograms taken with and without your hearing aids. The audiogram determines the type and degree of the hearing loss. The audiogram can indicate the origin of your hearing loss and whether it originates in the inner ear or elsewhere. The severity of the hearing loss is reflected by the pure tone average hearing thresholds. This information serves as a key parameter in the decision regarding whether the candidate meets the audiological criteria for cochlear implantation. Information regarding which sounds are perceived best by the CI candidate is reflected by the shape of the audiogram. The audiogram also enables the audiologist to compare ears as well as aided and unaided outcomes. It is also helpful to have your past audiological records. Comparison of your audiograms over time can indicate whether the hearing loss is stable, fluctuating, or progressive.

Since the decision for implantation is based upon a comparison between the benefit you receive from hearing aids and the expected benefit from cochlear implantation, the hearing evaluation is performed with appropriately fit hearing aids.

The aided audiogram provides information regarding your current amplification. Other relevant information regarding your hearing aids includes the purchase date, recent tuning, and maintenance. Sometimes there is a need to return to the hearing aid audiologist for adjustments or overall maintenance. Occasionally, a trial period with different (better fit) hearing aids is recommended.

In order to minimize the steps to determine candidacy, my recommendation is to visit your hearing aid dispenser a month before your first visit to the CI center for any necessary refitting and maintenance. If the dispenser's recommendation is to purchase new hearing aids, you should wait until after you begin your evaluation process at the implant center to avoid wasting money if you are a good CI candidate. Sometimes, in borderline cases, candidates will be encouraged to try newer or stronger hearing aids and then be re-evaluated.

Speech Perception Evaluation

The next step of the hearing evaluation is speech perception testing. Understanding speech is a complex task; difficulty level depends on many variables. For example, when the speech stimuli provides context and verbal information (such as in tests using simple everyday sentences), a CI candidate can use this type of information to repeat sentences—even if (s)he had not understood every word.  Tests that use single words are harder because they don’t provide context. 

Single words perception tests can vary in their level of difficulty. The more familiar and longer the words, the easier they are to be understand. Short "nonsense” words are hardest to perceive.

Most cochlear implant teams base their evaluation on tests of both words in sentences and single words. Single word tests provide more information on the ability of the candidate to perceive the various components of speech. However, sentence tests are more reflective of the candidate's ability to manage a conversation.  Since many conversations occur in noisy environments, speech perception testing is often completed in background noise to better replicate real life communication challenges.

Some candidates are unable to understand speech presented in an "open set" stimuli, as described above. For these individuals, it is common to use "closed set" tests. In "closed set" tests, the answers are presented as in a multiple-choice test.

Another communication aspect that may be evaluated is speech-reading ability (often referred as "lip reading"). This evaluates the benefit people derive from visual information such as the speaker’s lips and facial expressions combined with auditory information in order to understand speech. Gathering such data can show the positive contribution of cochlear implantation to speech reading performance. Enhancement in speech reading may also be reflected in the ease of communication reported by CI users.

Speech perception evaluation is performed for each ear separately and both ears together. The decision on whether to recommend cochlear implantation, as well as which ear should be implanted, are based upon these results.

Informal Assessment of Communication Status

Besides formal testing, there are other relevant data, usually collected through conversation or by using various self-reported questionnaires. Such data includes information on the history of the person’s hearing loss, auditory rehabilitation, lifestyle and communication challenges, and the communication modes used by the candidate.

Last but not least, a few words about expectations…

In one of the upcoming posts, I will discuss expectations about cochlear implantation.  This issue continues to be relevant beyond the candidacy phase. You should feel free to discuss your expectations with your CI team.  It is important that you have realistic expectations about your outcomes as well as the rehabilitation process (e.g., mapping, auditory training, and medical follow ups).

Do not hesitate to share rationale for pursuing CI as well as your dreams and future goals.  Feel free to ask your team about any question you have on the process.  After they have gathered all the above information, they will be able to give you reliable answers to many of your questions including examples of how the cochlear implant may affect your life.  This discussion will provide you with important perspectives regarding the ongoing nature of the rehabilitation process. It will also clarify your future responsibilities to maximize your success with your new implant.  



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Welcome to Naama's Blog

Posted By Naama Tsach, PhD, Wednesday, January 27, 2016
Updated: Tuesday, January 26, 2016

I'm so excited to have the chance to share with all of you. My name is Naama Tsach and before we start, I would like to introduce myself. I am a speech and language therapist (SLT) and an educational audiologist. I recently received my PhD from Tel-Aviv University. I came to the US from Israel three years ago due to my husband's work. We have three wonderful sons and two dogs, and we live in beautiful Maryland.

For 20 years I have dedicated my professional life to the rehabilitation of deaf and hard of hearing children and adults and research in deaf education. I have worked as an educational audiologist in special education and mainstream education settings, taught in college, and supervised SLT students, educators and rehabilitation teams. As a SLT, I worked in rehabilitation of adolescents and adult cochlear implant (CI) recipients in the Cochlear Implant Program at the Bnai-Zion Medical Center, Haifa, Israel.

My experience with adult CI users supports the importance of auditory rehabilitation following cochlear implantation. I was there to challenge the auditory ability of new CI recipients, to direct and support their building of new auditory skills, and to continually find ways to move forward.

I encouraged my patients to view their progress in a positive way, as a "glass half full" and to take advantage of every auditory skill they have acquired to improve their lives.  CI users' awareness and understanding of auditory rehabilitation have great potential for improving their CI outcomes. Their attitudes, needs, hopes and goals serve as key variables in every step of the rehabilitation process. I truly believe in consistent, structured, professional support after cochlear implantation. This kind of individual long-term support increases the chances for CI recipients to use their device regularly and maximize their outcomes.

Much has been written for parents of implanted children but there is less available for adults with cochlear implants. This blog is for you: CI candidates and recipients who have gone through cochlear implantation as adults.

In this blog I will share with you my longstanding experience in working with dozens of teenagers and adults. Together we will use this unique platform to discuss various issues at the heart of the rehabilitation process that are reflected in everyday life.

Before we start, I want to thank my patients, courageous people who have chosen to change the course of their lives by giving themselves the chance to enjoy the world of sound to improve their communication. Their trust and willingness to include me in their private world and devote themselves to a long-term auditory rehabilitation process was not taken for granted.

I have joined these people on their fascinating personal journeys and I was exposed to the complex nature of the adaptation and rehabilitation process following cochlear implantation. I shared moments of disappointment and difficulty, as well as moments of happiness and satisfaction, and of course I have witnessed a process of significant improvement in many aspects of their lives. I learned how cochlear implantation can be a life-changing step. My patients were the best partners for my own professional journey. Thanks to them I was exposed to the wonders of technology and broadened my understanding about communication and hearing impairment. Above all, they taught me about the power of the human spirit.

Each person is unique in his own way, and has a different experience with the implant. Yet, there are many common topics and experiences that are important to share. One can definitely learn from someone else's experience and use it as a source of knowledge and encouragement to improve their adaptation and rehabilitation following cochlear implantation.

I wish you all the best and look forward to the future. 

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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.