Alternatives to rem and their effectiveness

So I understand very much about the essentials of rem fitting to maximize performance to match your prescriptions as close as possible but as many you know, not many do the traditional rem and rely more on the different forms of verifications, such as in-stu or auto rem (like Oticon I think does).

I’m getting new devices, but it’s really hard to find audiologist within 40 miles that is up front about doing rem (seems more like a option with some, which I think is just as bad being they probably wont be very good at it being they don’t do it. While at the same time find an audiologist specializing in my desired brand as well. (trying to find both in one was a challenge. I did, but not easy). But it is much further away than my first auxologist.

All that said is there anybody here that has had a good experience using others forms of rem such as the ones mentioned above?
So in short…anybody with NO real ear measurements done (rem) and happy with the results of what they did instead?

Ty.
Eric

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Welcome to the forum, sure you’d best head on over to the DIY section of the forum, your overthinking the REM, it’s just a another tool in the toolbox, the forum is full of people still complaining about their experience with REM, it’s certainly not the holy grail of fitting, lots of really good results from in-situ and self fitting ones HAs.

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There are many satisfied hearing aid users who never had REM performed. It is a tool that when used properly can speed up the process of achieving satisfaction. If the practitioner knows how to use it, REM is great for seeing what is happening at the eardrum. If the practitioner is not intimately familiar with REM or does not have one, satisfaction can still be achieved. When I was still in practice I wanted all the tools available to help me do the best possible for my patients, REM was a necessity in my opinion. That being said, a practitioner who listens to you and has the knowledge and experience will probably make you a happy hearing aid user.

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I am new to hearing aids, three weeks and counting. I visited a local audiologist and she did the test and provided me with a copy of the audiogram. I liked her but after doing days of online research I contacted her and ask if she does REM test. She said she can… at their centrally located office but normally doesn’t. Well, that got me thinking. If she didn’t do it, why not purchase from an online provider at a much lower cost. In the end, that’s what I did. I purchesed the Phonak L90-RL’s from an online supplier in Kansas City and saved a lot of money ($2847 vs $6500) and I am very pleased. They preset them to my audiogram and shipped them the same day. I had them in just two days. After several weeks of wearing them, I contacted their audiologist and he connected to my devices and did another test and made a minor change. I have since purchased a reconditioned Phonak TV connector ($89+ shipping on eBay) and I really like it as well.
So far, I couldn’t be more pleased. The online company has basically the same unlimited adjustments and four year warranty as what the local office did. I may encounter issues down the road, but for less than half the price I was willing to give it a shot.

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It’s not a given that every time REM is done that the hearing aids are always found to be off target and adjustments need to be done. There might also be a chance that they’re already at or very close to target such that no adjustment is needed, in which case no REM adjustment would have been needed to be done. So then it wouldn’t have made a difference if REM were performed or not, except that you wouldn’t know that you’re already up to target or not unless you did the REM test.

Some HCP like mine claims that she used to do REM and found that most of the times the aids were up to target, so she stopped doing REM unless the patient complains that they’re not happy after a number of adjustments, then she would use REM to verify as a debugging step in a later phase if deemed necessary. Her answer didn’t impress me though. I decided to go the DIY route after I heard that.

Other HCPs, like a few on this forum, and Dr. Cliff for sure, will tell you that they find REM adjustments to be necessary most of the times based on their experience. So they choose to do it as a best practice right up front to eliminate the chance of the hearing aids underperforming to target because they think there’s a high chance that they would underperform, and it’s a worthwhile time investment anyway, regardless of whether the aids are or are not underperforming to target as often as someone might think or not.

But like @gorgeguy said, you can still get toward a good fitting in the end that is satisfactory to the patient without REM. But it just might be longer to get there if the aids underperform and REM weren’t done up front and that fact is not known up front. So DIY’ers are still able to get to a satisfactory result without the luxury of REMs. It might take them more self adjustments sessions to get there, but then they can cram many self adjustment sessions as they want into a much shorter period of time because they’re DIY and don’t need to wait for office appointments with an HCP.

FWIW here are my thoughts on REM:

I don’t know how anyone who understands the purpose of REM can normalize any practitioner’s failure to use it. But since this thread is from someone who has difficulty accessing a practice where REM is performed, I realize that some of the responses may be aimed toward helping him deal with his situation rather than defending omission of REM.

Novice hearing aid wearers are the ones who are most harmed by failure to use REM, since they have no frame of reference against which to judge what they hear.

REM discussion is clouded by the very confusing fact that REM, as it’s practiced, adjusts gain toward some standard rationale rather than toward whatever gain curves were chosen by the fitting software. The logical way for it to work would be for the fitting software’s gain curves to be transferred into the REM apparatus (automatically or manually), and then have the REM procedure adjust gain so that probe microphone levels match those curves. But that apparently isn’t how the equipment out in the field works.

The key difference in DIY vs. professional fitting, vis-à-vis REM, is that the DIY user can judge what’s getting to his eardrums by how it sounds to him. But novice hearing aid wearers are at a disadvantage in DIY also.

The subject of Real Ear Measurement (REM) is probably the most discussed hot button amongst hearing aid users.

When I first learned of REM, after my Phonak Marvel 70s were issued, I consulted with 8 audiologists in my area. Only 2 endorsed it, the other 6 laughed at it. My original audiologist does not endorse it.

Still curious, I drove to an audi 2 1/2 hours away. I had REM performed, then I left the country for vacation. My experience was horrible. I sent the HAs to my original audi to have them restored to factory settings and original programming.

Here is what I find confusing about the US hearing aid industry:

  1. I was told that hearing aids can’t be issued in the UK or Australia without REM, so why is there no standard here in the USA on how a hearing aid is issued to a client? You’ll find quotes from audis at audiologyonline.com that say not everyone buys into REM.

  2. Even amongst audis who endorse REM, there seems to be several methods of performing REM. Again why no standard procedure in this country?

  3. While REM supposedly ensures the proper levels are delivered to your ear canal, by far most of us struggles with speech in noise. So how does REM help us underatand speech, when background noise cancels out any/all speech?

Best practice? Find an audiologist that knows his business and will take the time to address your needs rather than sell you on a product or service.

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That would be like marking your own homework though. The manufacturer could just turn around and say ‘well it hits our target’ and wash their hands of the standardisation of fit/gain that REM is designed to achieve.

My main issues with REM concern loudness growth and manufacturer implementation of gain control using AI, directionality and channel based noise management.
1: Loudness growth - even with normal cochlears we don’t ALL like the same levels of loudness growth - just go to the cinema, listen to adverts to experience different dynamic range and uplift compression. With damaged cochlears, this is more extreme and people can find hearing aids errant in this respect.
2: Gain control - for speech vs noise - when you sit down in the Audiologists office, it’s a false environment (possible quieter than usual), unlikely to have traffic noise, background music, one major speaker and possibly a little bit of office babble in the background.
Your hearing aid goes into the ‘this is pretty easy’ mode, sets the mics to Omni, pinna effect to sound good, minimal directionality, minimal noise in channel management and limited effort from the on board AI. You get the probe tube stuffed down the side of the hearing aids, the audilogist (if they are any good) runs a live speech test, (if they are any better) they do a live speech simulation over a background noise source, all the while they tweak the output so the curves look pretty as they now pronounce ‘YOU CAN HEAR - EVEN IN BACKGROUND NOISE!’. The AI in the aid might have played ball - picked out the noise source geometry and successfully subtracted it from your hearing plus it kicked in extra amplification to boost the primary speech in there.
You leave your audiologist’s office feeling pleased as punch that the Dr Cliff recommended REM specialist was worth that extra couple of thousand on the bill.

Two days later you head to a restaurant, bar, supermarket checkout, chrurch coffee morning - wherever. And your new fangled AI hearing aids that you’ve been diligently charging and wearing all week are struggling to pick up converstations around you, or you can hear some voices but not others: why is this happening? why is the evangelical Dr Cliff’s technology tuning service not doing what it said on the tin?

Well, like I said above, the test room wasn’t really putting the aid through it’s paces - barely out of second gear to be honest: so, there’s that, plus your shiny audiologist didn’t necessarily understand that you like your loudness growth to be mixed down and rise very gently with your dynamic range (unlike NAL2 or DSL driving everything at 11), so now you’ve got a bit of a headache from all that extra volume. Also ‘YOU’ don’t quite understand that what your audiologist means by the term noise isn’t exactly what you think it is. The result being that SPEECH within SPEECH babble (or at least competing speech from multiple sources) is hugely difficult to resolve - and no basic REM system has this level of functionality to test a hearing aid to this kind of level - simply because nobody has written the standard to which it should be tested. Even basic Live Speech Mapping is a bit wobbly as not everyone agrees - the layer below, like DSL and NAL2 are basically just good guesses in somebody’s opinion - simply because, even all the Prof’s cant quite decide if it’s better to provide equal loudness to the loud and soft bits in speech or retain dynamic range within sylables.

So, ‘All hail the holy grail’ DrCliff’s approach to REM is all well and good, but what if you hate your verified target ? Are ‘you’ wrong? do you get to walk around with your headache for three months while you ‘just’ get used to them?

This is why all the manufacturers use a slightly different fitting formula which works as a baseline on their products to best utilise the way their AI implements their software. Also you get a ‘soft-start’ with all the major products to drop 80% of the gain in on day one and wind things up from there. Purists argue that this ‘isn’t hitting the target’ - until you point out to them that their target (although based on the Audiogram) contains a raft of assumptions, some of which may not consider the actual situation of the client, the ear canal, the previous experience, the loudness preference, the amount of time spent in actual noise vs speech/speech babble: plus whether the aid is actually ‘doing it’s thing’ when you measured it.

So: a REM system, a good tool, not necessarily a sliver bullet or holy grail. Especially if you don’t understand the shortcomings of the test.

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REM will not help you understand speech. REM will only help deliver the amplification that the tool thinks you need to compensate for your hearing loss.

There’s a new test called ACT (Audible Contrast Threshold) where it measures your threshold of audibility in noise. It’s a language-independent test so you don’t need to listen to words in noise to see if you can understand the words or not. It’s only a few minutes as long as your HCP has the proper audiometer that supports it and the license for it. Once your ACT score is measured, your HCP can input it into a hearing aid software like the Oticon Genie 2 and it will adjust the noise suppression parameters accordingly based on your ACT score.

Of course there have been other SIN tests before this ACT test came along, like QuickSIN, HINT and WIN.

This certainly isn’t the case in the UK. I’ve had UK NHS aids from 2009 to 2023. I have only been offered REM once, and the machine wouldn’t connect. My private Audiologist didn’t use REM, but I got great results.

I actually bought my Phonak Audeo P-90s from an online Company, and all they needed was my latest Audiogram.

Exactly this. My audiologists office is luckily on a noisy road, and he took my outside to test his programming. It’s right by some traffic lights, so he waited until a large Heavy Goods Vehicle, then started talking. I was facing across the road, with Autosense on, and I heard every word.


Although I’ve never had REM, I understand that it partly analyses how the sounds from your hearing aids are reacting inside you ear canal, and makes the adjustment it sees as being correct. I just can’t see how it knows how you Cocklea reacts.

In my case, I have pretty loud Tinnitus over a range of mid to high frequencies. Although I can clearly hear the test tones, above my Tinnitus, those frequencies seem to need more help that Phonak’s first fit. I also self programme in a quiet environment, I can test any alterations every couple of days. It’s a long process, as I often change too many things :slight_smile:

Peter

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How the cochlea reacts is factored into the results of your hearing test. Though, as I type this, it occurs to me to wonder how ear canal characteristics, the same ones that REM compensates for, enter into hearing test results.

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How?

The test only measures thresholds. There’s no loudness graduation, no agreed test in noise, no practical definition of which noise to use, etc.

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In my case, REM was crucial because it unlocked some further gain in the high frequencies that Phonak Target didn‘t let my audiologist to adjust otherwise.

But yeah, I live in Italy and nobody does it here, I had to drive 300 kms to find a center that would that to me!

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This is very interesting to hear. I didn’t know that it can be done like this. Wouldn’t it be detrimental to the longevity of the receiver and hearing aids to overdrive the amplification beyond what the manufacturer allows in the first place?

@PeterH is saying, ok, REM makes sure that the right amplification makes it to the eardrum, but what about what happens after that, inside the ear? My answer is, amplification targets are derived from hearing test results, and hearing test results are determined by what sounds you perceive once they get through your ear, including the cochlea, and your nerves and your brain. So that’s how cochlear function is factored into REM – through the amplification targets.

I don’t understand what the various hearing challenges you mentioned have to do with REM. It isn’t meant to address those challenges, just to help make sure that prescribed gains are reaching the eardrum. If you believe that there’s any value to the gain targets developed by the profession, then it’s worth making sure they’re achieved, and that’s what REM does. It’s not a guarantee that no further adjustments will be needed, but it gets the patient to the prescribed starting point.

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@Volusiano
Phonak’s feedback management restricts the gains, not the limits of the hardware
Peter

Thank you, that helps me understand

Yes, I understand about the feedback management restriction on the gain margin. But wouldn’t the feedback management restriction apply to any kind of gain curves, regardless of whether it’s the REM adjusted gain curves or not, without any differentiation?

The problem is that the hearing aid is likely to perform differently in the real World and so won’t hit the same target that you just verified/or it’ll over hit by some margin. I accept that when REM is done properly, it’s a useful tool in providing a baseline, but like I’ve already explained, it’s not a silver bullet.

The point about verification is that it’s meant to show you how the aid actually performs in under stress, but unless you can fool the process it’s not indicative of how the aid works in reality. Ideally you’d say; well why don’t the manufacturers just put in a ‘REM mode’ to actually verify the aid? They do, but the problem is this still doesn’t tell you if you’re going to like how it performs in real situations.

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Yes, the Phonak feedback manager does take a chunk out of the output: like they all do to an extent.