American Speech-Language-Hearing Association

Using Computerized Auditory Training Clinically for Adults With Cochlear Implants

Introduction

While it is widely acknowledged that cochlear implants (CIs) provide robust improvements for many persons, some individuals receive little benefit from these devices, particularly those who have congenital or prelingual hearing loss (Zwolan, Kileny, & Telian, 1996). One reason for this is because the duration of deafness is strongly predictive of postoperative performance (Blamey et al., 1996; Shipp & Nedzelski, 1995). In addition, learning to interpret the electrical signals provided through an implant may take a few months to almost 2 years (Luntz, Shpak, & Weiss, 2005; Valimaa, Maatta, Lopponen, & Sorri, 2002) for persons with postlingual hearing loss. This period may be even longer for individuals with prelingual hearing loss.

In an effort to quantify the amount of time required for auditory learning to occur, Watson (1991) proposed a unique relationship between the complexity of the auditory stimulus and the difficulty of the listening task that is trying to be mastered. Generally, the more complex the stimulus, the longer the training time required. Auditory stimuli range in difficulty from simple tones to connected speech. Similarly, auditory tasks for understanding speech range in difficulty from detection to comprehension. Therefore, the more difficult the listening task or the auditory stimuli, the longer the training time required. For example, for normal hearing listeners, the duration of training required for discriminating simple tones is between 2 and 4 hours, whereas learning to discriminate complex sounds requires over 20 hours of training. This means that a long training period is likely needed for CI users to master a very difficult task (comprehension) while trying to derive meaning from complex stimuli (connected speech). Some researchers have proposed that CI users may benefit from some form of structured listening activities beyond passive listening (Fu, Nogaki, & Galvin, 2005; Watson, 1991). Given the training principle described above, it is only logical that additional training beyond the CI itself may be necessary for some individuals, particularly those with prelingual hearing loss, to obtain open set speech recognition. We focus here on recent clinical intervention studies evaluating structured auditory training programs with adult CI users.

Expanding Diversity of CI Users

The number of CI users continues to increase due to expanding candidacy requirements, including individuals with prelinguistic deafness (Waltzman, Roland, & Cohen, 2002) and those with more residual hearing (Waltzman, 2006) and those who use bilateral CIs (Peters, Wyss, & Manrique, 2010). Research has indicated that prelingually deafened implant users may have unique communication needs following surgical intervention (Zwolan et al., 1996). For example, while individuals with prelingual deafness may report overall satisfaction with device use, they often obtain poorer speech recognition ability in comparison to their postlingually deafened counterparts. In fact, prelingually deafened adults rarely achieve open set speech understanding (Bodmer et al., 2007). Clinical practice patterns suggest that after receiving a CI, adults are typically left on their own to adapt to the new distorted sensory stimulation. While many persons may be counseled about the importance of practicing listening by using audio books or reading aloud, very few are actually referred for formal auditory training or listening therapy.

Auditory Training

Several researchers have suggested that adults may benefit from intensive aural rehabilitation programs that include auditory training and strategies to enhance their understanding (Heydebrand, Mauze, Tye-Murray, Binzer, & Skinner, 2005). However, access to these services is limited because these services are not adequately reimbursed by public insurance providers such as Medicaid and Medicare (Garber, Ridgely, Bradley, & Chin, 2002). While access to auditory training may not have been a critical variable in outcomes of postlingually deafened individuals, it may be of more importance for implant users with congenital deafness because of the longer duration of deafness.

Auditory training has captured renewed interest from researchers and clinicians alike (Kricos & McCarthy, 2007; Moore & Amitay, 2007). Computerized auditory training programs have been applied to varied clinical populations, including child language learners, second language learners, elderly with cognitive deficits, and individuals with hearing aids (Lively, Logan, & Pisoni, 1993; Merzenich, Pandya, & Tremblay, 2005; Sweetow & Palmer, 2005; Tallal et al., 1996). Fortunately, clinicians now have an unprecedented opportunity to provide auditory training for their CI users with the recent development of new computerized auditory training programs. Some of the programs that are available are summarized in Table 1.

Table 1. Auditory training programs that could be used for adult or adolescent CI users.

 

Product and Company

Type of Training Stimuli

Type of Task

Suggested Retail

Seeing and Hearing Speech;
Sensimetrics
  

Vowels, consonants, stress, intonation, length, and everyday communication

Analytic and synthetic

$85.00

Sound and Way Beyond;
Cochlear Americas 

Interactive computer training activities with vowel, consonant, sentence, telephone, and music stimuli

Analytic and synthetic

$99.00 for Cochlear recipients;
$290.00 for other CI recipients

SoundScape;
Med-El 

Sentence level with options to adjust amount of noise, rate of speech, or gender of speaker. Telephone training activity also available. Scoring presented at end of session, but not stored.

Primarily synthetic

Free

Speech Perception Assessment and Training System (SPATS);
Communication Disorders Technology 

Predominantly syllable training using 100 of the most important sounds for speech perception; sentences from multiple talkers. Training in quiet or noise available. Program tracks and stores performance.

Mostly analytic, some synthetic

$150.00 for 1-year license

The Listening Room (CLIX);
Advanced Bionics

Interactive listening at word and sentence level with discrimination and identification activities; telephone and music training options available.

Analytic and synthetic

Free

Defining Auditory Training

Auditory training can be described as an intervention in which listeners are taught to make perceptual distinctions about sounds that are presented systematically (Schow & Nerbonne, 2007). Programs may be formal or informal but are often structured around the type of training stimuli, the targeted skills, and the level of difficulty (Robinson & Summerfield, 1996). Generally drill-like activities using targeted stimuli (e.g., /bi/ vs. /bu/) are described as analytic, whereas sentence completion tasks are considered synthetic (Schow & Nerbonne, 2007). Most computerized auditory training programs provide options for both types of listening activities, as indicated in Table 1.

Access to Auditory Training

Although audiologists are aware of the benefits of aural rehabilitation programs (Hawkins, 2005), access to such programs is limited and has not changed in the last 30 years (Prendergast & Kelly, 2002). The primary barrier to providing increased services is likely the lack of time in busy clinical settings. However, computerized auditory training programs now provide the option of training in a home environment. This type of training program may (a) increase the training opportunities for adults and adolescents, (b) increase the benefit achieved by the implant user, and (c) reduce potential dissatisfaction with the CI. While options for training with computer programs may have been limited in the past, many programs are now readily available to most clinicians who have access to the Internet. Therefore, computerized training programs provide appropriate and accessible rehabilitation options for implant users that we as audiologists can recommend for our clients.

Efficacy of Auditory Training With CI Users

An early study examining auditory training with CI users showed large gains in speech understanding for children but small gains for adults (Dawson & Clark, 1997). This preliminary finding suggested that adults would not benefit from training. However, these results should not be considered conclusive because the population studied was small and included only one adult, one adolescent, and three children.

A summary of more recent studies is presented in Table 2. Fu, Galvin, Wang, and Nogaki (2004) demonstrated significant improvement when adults with CIs completed a daily computerized training program. All participants trained for 1 hour each day, 5 days per week. Training materials focused on both vowel and consonant discrimination and identification tasks from the Computer Assisted Speech Training Program developed at House Ear Institute (Fu & Galvin, 2007). Both vowel and consonant recognition improved, from 22% to 36% and from 25% to 38%, respectively. Miller, Watson, Kistler, Wightman, and Preminger (2008) evaluated the effect of the Speech Perception Assessment and Training System (SPATS; described in Table 1) with a group of experienced CI and hearing aid users. Sixteen CI users between 26 and 90 years of age were assigned to either a treatment or control group. For persons in the training group, speech understanding of Hearing in Noise Test sentences significantly improved an average of 13% after 24 hours of training compared to the control group. In addition, participants reported that the training increased the awareness of their individual speech sound difficulties. Similarly, Stacey and colleagues (2010) evaluated a 15-hour computerized home auditory training program for adult CI users. Eleven participants trained for 1 hour, 5 days per week. for 3 weeks. Researchers reported that neither sentence recognition nor vowel perception improved after training, yet consonant discrimination did improve significantly by 8%.

Table 2. Summary of studies evaluating computerized training programs with adults using CIs.

 

Investigators

Participants

Training Parameters

Training Program

Before Training

After Training

% Change

Fu, et al. (2004)

N =10;
ages =
25–60 years

Frequency =
5 x wk;
length =
1 hour/day; duration =
1 month;
total =
20 hours;
location = home

Vowel and consonant training

Vowel
= 22%
Consonant = 25%

Vowel
= 25%
Consonant = 38%

Vowel
= 15.8%*
Consonant = 13.5%*

Miller, et al. (2008)

N = 16;
ages =
26–90

Frequency =
2 x wk;
length =
2 hours;
duration =
6 weeks;
total =
24 hours;
location = clinic 

Syllable and sentence training in quiet and noise (adaptive)

CNC
= 47%
HINT (Q) = 68%
HINT (N) = 41%

CNC
= 53%
HINT (Q) = 81%
HINT (N) = 50%

CNC
= 6%
HINT (Q) = 13%
HINT (N) = 9%

Stacey, et al. (2010)

N = 11;
ages =
23–71

Frequency =
5 x wk;
length =
1 hour/ day;
duration =
3 weeks;
total =
15 hours;
location = home

Training with words in isolation and in sentences

Vowel
= 45%
Consonant = 39%
Sentences = 47%

Vowel
= 7.5%
Consonant = 47%
Sentences = 47%

Vowel
= 2.5%
Consonant = 8.0%*
Sentences = -.25%

Note. CNC = Consonant-Nucleus-Consonant test; HINT = Hearing in Noise Test; Q = in quiet;
N = in noise.

*p < .05

In summary, these findings suggest that there is potential for computerized training programs to enhance performance of CIs for adults. Overall, compliance was described as good, which suggests that most clients will complete the training, but not all of them. Another underlying theme of these studies is that variable performance was observed so that some persons obtained larger improvements than others. All three studies described here concluded that additional research is needed to help better identify characteristics of persons who may benefit from such training. But as clinicians, the fact that improvements can occur, and that most participants completed the training, is encouraging. Several options that we can suggest to our patients with implants are described below. 

Low-Cost Auditory Training Options for Adults With CIs 

Several reasonable training programs are available that are either free through the Internet or available at a reasonable cost. The list of programs described in Table 1 is not meant to be exhaustive but rather representative of products that are easy for clinicians to access and that have either been designed for use with implant users or had research conducted with implant users. Several programs can be downloaded from the Web for free or at a very low cost. Most have easy-to-follow, step-by-step directions. While several of the products listed in Table 1 can be accessed and used immediately, others, such as SPATS or Seeing and Hearing Speech, may require the clinician to receive some training before implementing them. Regardless of the clinical situation, there is some type of auditory training option available to suit the needs of clients with CIs. 

Case Study of a Prelingual Deaf Adult Using CLIX 

A case study of one of our clients illustrates how computerized auditory training can be incorporated into their aural rehabilitation plan. The client, Mrs. S., was a 59-year-old woman born with a profound bilateral sensorineural hearing loss. Mrs. S. consistently wore hearing aids throughout her youth and attended an oral school for the deaf. She received speech therapy regularly as a child and predominantly used oral communication. However, as a young adult she stopped wearing her hearing aids and began signing, and since that time she used American Sign Language as her primary communication mode. She received her first CI in 2003 and her second implant in 2008. Mrs. S. began receiving speech therapy through a university-based graduate student clinic in the fall of 2009, approximately 1 year after her second implant. The primary complaint was that she was frustrated with her inability to understand speech and concerned about her own speech production ability. Therefore, the long-term goal for Mrs. S. was to improve her speech production and listening abilities. Short-term goals included identifying the Ling sounds, environmental sounds (e.g., car horn, dog barking, and ambulance siren), family member names, and common phrases, as well as discriminating between one-syllable cognate pairs (e.g., bath/path). The client was seen for a 60-minute therapy session each week. 

The CLIX training program (see Table 1) was used as a therapeutic activity in the clinic setting and as a supplemental at-home training program for the client throughout the duration of therapy to help achieve her goals. The CLIX program is a computer-based program that provides interactive listening activities designed for teens and adults with CIs. The program can be downloaded free of charge by registering at The Listening Room sponsored by Advanced Bionics. The purpose of CLIX is to help CI users improve their sound identification and discrimination abilities by training with words both in isolation and in phrases. Three features of CLIX made it appropriate for this particular client. First, training is available at multiple levels so that it can be used by individuals with varying listening abilities. There are six different levels beginning with the warm-up level, which focuses on discriminating sounds in isolation. The listening activities become more difficult as the levels increase. The training stimuli also increase in difficulty from word detection in isolation—at the end, middle, or beginning of a phrase—to discrimination of two words within a phrase. Second, training can be conducted in quiet or in noise, which is a communication situation frequently reported as very difficult for implant users. Finally, training with the CLIX program is user-friendly and does not require significant time by the student clinician to instruct on its use. 

Before training, a placement test is given (provided with the download of the program). This placement test gives the user a suggested starting point for training with the program. Users can move up levels whenever they feel that the current level is not challenging. Mrs. S. was given a 20-minute tutorial on downloading and using the program during one therapy session in the clinic. She was instructed to practice daily for approximately 10 to 15 minutes. 

Results after 4 months of therapy and training are presented in Table 3. Mrs. S. reported that she practiced at home 15 to 20 minutes per day, 4 days per week. In addition, she attended the 60-minute weekly session in our clinic. Progress was noted on each objective. In addition, Mrs. S. stated that she enjoyed the CLIX program because it was free, allowed her to practice in the convenience of her own home, and allowed her to practice on a level that matched her listening abilities. Mrs. S. has remained in therapy and is continuing to work through more difficult listening levels of CLIX. 

Table 3. Results of identification goals for Mrs. S. after 4 months of weekly therapy and daily CLIX training.

Goal

Before Therapy and
CLIX Training

After Therapy and
CLIX Training

Ling sounds

67%

91%

Environmental sounds

80% (closed set)

90% (open set)

Family member names

65%

95%


We acknowledge that it is not clear whether the progress obtained by this client was due to the individual speech therapy, the supplemental CLIX training, or a combination of therapy and CLIX training sessions. Of note is the fact that this client had a history of oral education and used oral communication as a child. Some research has suggested that better outcomes with implants are observed for those with a history of oral communication (Klop, Briaire, Stiggelbout, & Frijns, 2007). Clearly, additional investigation would be needed to determine the contribution of each component of therapy provided in this case as well as additional underlying factors. Regardless of the reasons for this client's progress with therapy, clinicians should be cognizant of the resources that are readily available for clients' use. 

Anne D. Olson, PhD, CCC-A
University of Kentucky
aolso2@email.uky.edu

Tara B. Canada, BHS, graduate student
University of Kentucky 

References 

Blamey, P., Arndt, P., Bergeron, F., Bredberg, G., Brimacombe, J., Facer, G., Whitford, L. (1996). Factors affecting auditory performance of postlinguistically deaf adults using cochlear implants. Audiology and Neuro-Otology, 1, 293–306.

Bodmer, D., Shipp, D. B., Ostroff, J. M., Ng, A. H., Stewart, S., Chen, J. M., & Nedzelski, J. M. (2007). A comparison of postcochlear implantation speech scores in an adult population. Laryngoscope, 117, 1408–1411.

Dawson, P. W., & Clark G. M. (1997). Changes in synthetic and natural vowel perception after specific training for congenitally deafened patients using a multichannel cochlear implant. Ear and Hearing, 18, 488–501.

Fu, Q. J., & Galvin, J. J., III. (2007). Perceptual learning and auditory training in cochlear implant recipients. Trends in Amplification, 11, 193–205.

Fu, Q. J., Galvin, J., Wang, X., & Nogaki, G. (2004). Effects of auditory training on adult cochlear implant patients: A preliminary report. Cochlear Implants International, 5(Suppl. 1), 84–90.

Fu, Q. J., Nogaki, G., & Galvin, J. J., III. (2005). Auditory training with spectrally shifted speech: Implications for cochlear implant patient auditory rehabilitation. Journal of the Association for Research in Otolaryngology, 6, 180–189.

Garber, S., Ridgely, M. S., Bradley, M., & Chin, K. W. (2002). Payment under public and private insurance and access to cochlear implants. Archives of Otolaryngology—Head & Neck Surgery, 128, 1145–1152.

Hawkins, D. B. (2005). Effectiveness of counseling-based adult group aural rehabilitation programs: A systematic review of the evidence. Journal of the American Academy of Audiology, 16, 485–493.

Heydebrand, G., Mauze, E., Tye-Murray, N., Binzer, S., & Skinner M. (2005). The efficacy of a structured group therapy intervention in improving communication and coping skills for adult cochlear implant recipients. International Journal of Audiology, 44, 272–280.

Klop, W. M., Briaire, J. J., Stiggelbout, A. M., & Frijns, J. H. (2007). Cochlear implant outcomes and quality of life in adults with prelingual deafness. Laryngoscope, 117, 1982–1987.

Kricos, P., & McCarthy, P. (2007). From ear to there: A historical perspective on auditory training. Seminars in Hearing, 28, 89–98.

Lively, S. E., Logan, J. S., & Pisoni, D. B. (1993). Training Japanese listeners to identify English /r/ and /l/. II: The role of phonetic environment and talker variability in learning new perceptual categories. The Journal of the Acoustical Society of America, 94, 1242–1255.

Luntz, M., Shpak, T., & Weiss, H. (2005). Binaural-bimodal hearing: Concomitant use of a unilateral cochlear implant and a contralateral hearing aid. Acta Otolaryngologica, 125, 863–869.

Merzenich, M., Pandya, P., & Tremblay, K. (2005). Roundtable discussion: Plasticity and auditory training. Seminars in Hearing, 26, 144–148.

Miller, J. D., Watson, C. S., Kistler, D. J., Wightman, F. L., & Preminger, J. E. (2008). Preliminary evaluation of the speech perception assessment and training system (SPATS) with hearing-aid and cochlear-implant users. Proceedings of Meetings on Acoustics, 2, 1–9.

Moore, D., & Amitay, S. (2007). Auditory training: Rules and applications. Seminars in Hearing, 28, 99–109.

Peters, B. R., Wyss, J., & Manrique, M. (2010). Worldwide trends in bilateral cochlear implantation. Laryngoscope, 120(Suppl. 2), S17–S44.

Prendergast, S., & Kelly, L. (2002). Aural rehab services: Survey reports who offers which ones and how often. Hearing Journal, 55, 30–35.

Robinson, K., & Summerfield, A. Q. (1996). Adult auditory learning and training. Ear and Hearing, 17, 51S–65S.

Schow, R., & Nerbonne, M. (2007). Introduction to audiologic rehabilitation (5th ed.). Boston, MA: Pearson Education.

Shipp, D. B., & Nedzelski, J. M. (1995). Prognostic indicators of speech recognition performance in adult cochlear implant users: A prospective analysis. Annals of Otology, Rhinology & Laryngology. Supplement, 166, 194–196.

Stacey, P. C., Raine, C. H., O'Donoghue, G. M., Tapper, L., Twomey, T., & Summerfield, A. Q. (2010). Effectiveness of computer-based auditory training for adult users of cochlear implants. International Journal of Audiology, 49, 347–356.

Sweetow, R., & Palmer, C. V. (2005). Efficacy of individual auditory training in adults: A systematic review of the evidence. Journal of the American Academy of Audiology, 16, 494–504.

Tallal, P., Miller, S. L., Bedi, G., Byma, G., Wang, X., Nagarajan, S. S., … Merzenich, M. M. (1996). Language comprehension in language-learning impaired children improved with acoustically modified speech. Science, 271, 81–84.

Valimaa, T. T., Maatta, T. K., Lopponen, H. J., & Sorri, M. J. (2002). Phoneme recognition and confusions with multichannel cochlear implants: Vowels. Journal of Speech, Language, and Hearing Research, 45, 1039–1054.

Waltzman, S. B. (2006). Cochlear implants: Current status. Expert Review of Medical Devices, 3, 647–655.

Waltzman, S. B., Roland, J. T., Jr., & Cohen, N. L. (2002). Delayed implantation in congenitally deaf children and adults. Otology and Neurotology, 23, 333–340.

Watson, C. S. (1991). Auditory perceptual learning and the cochlear implant. American Journal of Otology, 12(Suppl.), 73–79.

Zwolan, T. A., Kileny, P. R., & Telian, S. A. (1996). Self-report of cochlear implant use and satisfaction by prelingually deafened adults. Ear and Hearing, 17, 198–210. 

About the Authors

Anne D. Olson, PhD, is currently an Associate Professor in the Division of Communication Sciences and Disorders at the University of Kentucky. She received her bachelor's degree from the University of Florida in 1981 and her master's degree in audiology from the University of Texas in 1985. She graduated from the University of Kentucky in 2010 with her doctorate in rehabilitation sciences. Her research area is focused on rehabilitative audiology. 

Tara B. Canada is currently a graduate student in speech-language pathology in the Division of Communication Sciences and Disorders at the University of Kentucky. She received her bachelor's degree from the University of Kentucky in 2009. 

Audiologic Rehabilitation Resources on the ASHA Web site 

Abrams, H. (2009, September 1). Audiologic management of the older patient. The ASHA Leader, 14(11), pp. 14–17. 

Audiologic/Aural Rehabilitation Reimbursement Issues

Aural Rehabilitation and Its Instrumentation

Knowledge and Skills Required for the Practice of Audiologic/Aural Rehabilitation

Selected ASHA Practice Policy Documents  

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