Post on 09-Apr-2018
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Re/habilitation of CochlearImplantees
Madhuri GoreDr. SRCDr. SRCInstitute ofInstitute of
SpeechSpeech
andand
Hearing
EXIT>
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Re/habilitation and Goals
The goal of rehabilitation is to help the
person integrate the implant in his/herlife and obtain maximum benefit from
it.
In other words, learn to hear with theimplant so that he/she can function as
normally as is possible.
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Re/Habilitation and what it involves
Re/Habilitation is a long process and
involves a team approach. It requirescommitment and belief because results
cannot be seen in a short time. It often
requires a lot of hard work, but the goal is
easier to attain.
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Components of Re/habilitation
Programming the speech processor, or
Mapping Facilitating acquisition of listening skills,
Acquisition of language and speech
One to one therapy Providing support to implantee/parents
Support of other professionals
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What is Mapping?
Mapping refers to the process of
programming the Speech Processor. Thisprocess is crucial to providing maximum
speech information. Hence it is a key part of
the re/habilitation.
Mapping is done with the computer.
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More about Mapping
The basic aim of mapping or
programming is to establish the useful rangeof electrical stimulation for each electrode
channel.
Two measures are obtained- T levels or
thresholds and C levels or maximumcomfort levels.
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Methods of programming
Behavioral responses
Electrically evoked stapedial reflex
electrically evoked Auditory Brain stem
response
Neural response telemetry
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T and C levels
Threshold (T) refers to the smallest amount
of current that can elicit a sensation ofhearing.
Comfort (C) level refers to the upper limit of
stimulation that is permissible for a particular
channel.
Balanced C levels lead to a clear
perception of sound.
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Behavioral Techniques
Techniques to establish behavioral
thresholds are similar to those used forAudiometry.
Since behavior testing takes long, a pre
requisite is- adequate exposure to the task
prior to implantation.
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Behavioral Methods
VRA- for children below- 2 yr.
A response is accepted if it is time locked tothe stimulus.
Play Audiometry
These methods are modified slightly to
establish C levels
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Behavioral Indices
With very young children non-volitional
responses offer evidence of hearing.Examples of changes in behavior are...
momentary stilling
change in facial expression
touching the stimulating coil .
These responses help to condition the child
later
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Measurement ofC levels
Measuring Comfort levels is easier than T
levels (in some children...). Adults & older children can be trained to
give responses to locate levels of maximum
comfort.
In young children levels are set from
observation of the child.
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C levels continued---
The procedure to establish a comfort level in
older children & adults is a rating scale-- Children (& adults) describe the sound as
being too loud, comfortable or soft.
Another method is the use of electrical stimuli
to establish thresholds of reflex/as well as the
EABR.
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Neural Response Telemetry
NRT is a novel method to obtain Tlevels &
can be done just after surgery. The process does not require childs co-
operation.
NRT utilizes the implanted electrodes not
only to give a signal but also to measure the
response. The specific relationship between
the response & T levels helps to set the
level.
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When is the Speech Processor
turned on?
The Speech Processor is turned on 3 -4
weeks after surgery.
Different people (of course children) respond
in unique ways at this time.
Children may take longer to adapt to the new
device.
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Some reactions at the first switch
on...
Speech sounds like chipmunks speaking
speech sounds like guitar strings beingtwanged
speech sounds like mm mm
I can understand Speech
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How is the speech processor
worn?
A body level speech processor is worn in a
pouch/pocket sewed on to the shirt in amanner similar to hearing aids or on a belt.
A BTE is worn over the ear.
The microphone is held on the ear by a small
tube(mic lock) in young children.
In humid areas, the speech processor is
placed in a small plastic cover.
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Learning to wear the Speech
Processor
Some children take time to wear the speech
processor, other children dont. Children must be motivated to put on the
speech processor the whole day, but this
requires patience.
Remember many children( and Parents)have overcome this problem.
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Learning to Listen
A person who is implanted has to learn to
use the device. The Speech Processor provides access to all
the speech sounds.For example a person
with an implant will hear eee, and sss
which he may not have heard with thehearing aid. But it takes a while for the brain
to recognize them as such.
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What are the aims of listening
training?
The basic aim is to help the person
recognize and understand the signals hereceives from the implant.
This will help him/her to communicate and in
the case of young children to learn to speak.
Listening training will also help him learn tospeak clearly.
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Can a child put on another childs
processor?
Speech Processors must NEVER be
exchanged.
Each person has a unique MAP which may
be totally unsuitable for another and may
cause harm.
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Remember.
The basic premise for any training is the
belief that the child/adult will learn to listen
and understand.
Children take longer
Above all --- it takes some time to make
sense of what is heard.
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Some techniques .
Consistency Highlighting the auditory stimulus
Reducing visual cues
Setting the tasks so that success is easy andskills are acquired step by step.
Joint activities
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The importance of consistency
Consistent input reduces confusion and
increases the rate of progress. It is importantto be consistent whether the patient is a child
or an adult.
Use of standard phrases for e.g.in the
beginning reduces frustration. With young children it ensures faster
language acquisition.
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What are the stages of learning to
listen?
Awareness-- First in a one to one setup then
in other places Discrimination- he/she learns that sound are
different.
Recognition- he/she learns to recognize
many sounds like his/her name.
Comprehension-the child learns the meaning
associated with the sound.
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Why is a one to one approach
necessary?
A one to one approach ensures that the
persons needs are met. The task is set up so that he can go through
the listening practice at his rate.
The whole session is utilized to provide good
communication models
There is less chance of using signs
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What kind of support is needed for
the family?
Knowledge about care of the speech
processor Understanding of what the implant can do
and how to optimize listening situations
Highlighting the indices of progress
Social & emotional support
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Care of the Speech Processor
Protect from water,heat
Protect from static discharge, avoidsynthetic clothing
Listening check every day
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ESD, What is that? ESD refers to Electro Static Discharge.
ESD can corrupt a MAP
Sources of ESD are synthetic clothing,woolen pullovers, duppattas, sarees, plastic
mosquito nets.
Plastic/fiber glass slides
Computer screens Grounding oneself on metal prevents ESD
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What Parents Should Do everyday
Do the Ling 7 sound test every morning
and if possible in the afternoon. Thesounds are /a/,/u/,/i/,/m/,/s/,/sh/&,/ow/.
Replace batteries regularly
Learn basic trouble shooting Be alert to any differences in childs
behaviour.
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What is the difference in rehab with hearingaids & cochlear implant?
There is really not much difference in
rehabilitation with a hearing aid and implant.
With an implant there is consistentpresentation of sound, which may not always
be present with a hearing aid.
It is possible to fine tune the processor.
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How is listening practice begun?
The first step is to draw attention to all the
sounds in the environment. For e.g. Listen! Iheard the bell. This must be done every
single time.(consistency)
Games to highlight presence or absence of
sounds like Stop/Go, musical chairs etc Over time this will carry over to real life.
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Next step.
The next step is to draw attention to
differences in sound. Imitation is aneasy method to use with young
children.
Imitation of tonal changes in voice, andany other differences are taught.
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The final step
The final step i.e. understanding is reached by
associating spoken speech with meaning. All
conversations help to achieve this goal. Techniques
like repetition e.g. up up up, use of hand cue for
key words are used.
Simultaneously, sentences used every day are
practiced. Story telling is a useful & enjoyable method.
Reading helps with older children.
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Otitis Media
Otitis Media refers to fluid in the middle ear.
EarPain, tenderness around implant, or ANYsuspicion of middle ear fluid must be taken
seriously. It is important to consult the ENT
surgeon IMMEDIETLY.
Antibiotic course is given for a longer time.
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Factors which promote success
with an implant
Shorter period of deafness prior to implant
Number of functioning nerve fibers Environment that promotes the development
of listening skills
A family that is supportive, committed and
motivated
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Who is being Re/Habilitated?
Parents..
Or Children?
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