Alternatives to rem and their effectiveness

[Volusiano]

Yeah, that part I understood perfectly already. It’s not just Phonak, but all aid brands do this to their traditional feedback manager like you said.

The part I don’t understand, and nobody has been able to explain to me, is that @DamonHill claims that REM was required in order to “unlock” some further gain in the highs that the Phonak feedback manager “has locked up”. I didn’t know that simply doing the REM adjustment would enable anyone to “cheat” the feedback manager into getting more gain than the feedback manager allows, at least without any consequential result like causing feedback to resume where the feedback manager was trying to avoid by locking up the gain in the first place.

[Luga]

I would also imagine that REM is unable to predict how well or poorly the user will react to the prescribed gain. In my experience, with a fair amount of loudness recruitment given my loss i worry about having to “walk around with a headache for three months while I ‘just’ get used to them”… to paraphrase your earlier point.

[Um_bongo]

You can see where the feedback sawtooth peaks are and put gain back in where the aid isn’t saturated but the FBM might be turning down the signal.

[PeterH]

@Um_bongo
Yes. Then you can turn on the App and create a user program, with (for example) a 6dB increase in high frequencies. It works, you hear better definition, WITHOUT feedback.

Try replicating that in Target. In my experience, it won’t let you (on APD anyway).

Peter

[DamonHill]

What I meant is that Phonak Target didn’t allow my audiologist to increase gain for certain frequencies beyond a safety limit set by Target itself, based on my audiogram.
But the REM proved that I needed some more gain, because apparently I wasn’t getting as much gain as necessary on those high frequencies, due to my ear canal “configuration“.

So, the REM automatically changed the thresholds in Target and unlocked some additional gain on those frequencies. Meaning that now trembles can be set higher than what Target had assumed based on my audiogram.

And, by the way, feedback hasn’t been an issue since then (maybe because I wear custom moulds with minimum vents-size, which the REM has taken into account anyway).

I hope I’ve been clearer.

P.S.: I did an automatic REM and not a manual one, whatever that means!

[PeterH]

@DamonHill
Sorry Damon, I believe it’s because of the feedback threshold that Target decides, on gain limits, not anything about exceeding dangerous limits to your hearing.

This is my programming, and all the white area should be available, without causing harm. However, the dotted line (feedback threshold) stops my G50s going above that line, where they need to be. This is also my Tinnitus range, so I struggle with speech in noise. Ironically, if I increase the those frequencies in the app, there’s no feedback!

My private Audiologist, who was previously a Phonak partner, before they fell out, found this hugely frustrating. This isn’t his programming. This is using the APD fitting formula by the way.

I now believe that this is the reason I struggle over 2K with Phonak’s “first fit”. When I last went for an adjustment at the local NHS hospital, I complained about clarity of speech and was told (with a similar Target fit), that the HAs weren’t powerful enough!

At that point, I decided to own my hearing loss!

Peter

[PeterH]

@DamonHill

So, the REM automatically changed the thresholds in Target and unlocked some additional gain on those frequencies. Meaning that now trembles can be set higher than what Target had assumed based on my audiogram.

It likely unlocked an area above their feedback threshold is my guess.

I would like to get hold of the REM equipment. I mentioned it to my Audiologist, but he didn’t do one.

Peter

[x475aws]

@Um_bongo

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.

True, the various strategies to improve our hearing have to involve modifying the sound in some way besides just amplifying to targets. But they have to work off of some baseline. When hearing aid manufacturers are developing and testing their software, do you think they fit their test users using REM in order to eliminate one source of variability? IMO it would be foolish not to.

@Um_bongo

The point about verification is that it’s meant to show you how the aid actually performs in under stress,

I don’t understand this. In my understanding, REM tunes the aids to compensate for individual characteristics of the ear coupling and the user’s ear canal anatomy. I’m not aware of it being a performance or stress test of any sort. Isn’t that what test boxes are for?

@Luga

In my experience, with a fair amount of loudness recruitment given my loss i worry about having to “walk around with a headache for three months while I ‘just’ get used to them”

It seems that REM often finds that gains are too low, and therefore often results in increased gain. So, if prescribed gains using standard rationales are too loud for you because of recruitment, then it might happen that you’d be comfortable pre-REM, and experience too much amplification post-REM. That’s a case of one error (prescription too loud for you) being cancelled out by another error (aids not tuned for your ear canal and coupling characteristics). If your provider insists that you live with recruitment because “REM says everything is ok” then he or she is incompetent.

[DamonHill]

Yeah, it’s like you‘ve said, my audiologist only mentioned the thresholds, it was my assumption they were safety thresholds and not related to feedback.

But the point is that REM allowed more gain on the higher frequencies that wasn’t available for my audiologist to configure before. Which is the reason why REM did a good service to me.

[Um_bongo]

@x475aws

I don’t understand this. In my understanding, REM tunes the aids to compensate for individual characteristics of the ear coupling and the user’s ear canal anatomy. I’m not aware of it being a performance or stress test of any sort. Isn’t that what test boxes are for?

The point being that the hearing aid will produce different amounts of gain under different ‘stress’ conditions so what you’re measuring in the hearing aid office isn’t how your aid works in reality.
So what’s the point of a test that can’t measure the gain that it’s actually meant to verify?

Look, REMs/LSM are valid - I used mine on Friday to eliminate a low pitch issue that was causing tonal masking for a client in louder background noise. However, unless you know what you’re doing with the result and realise the limitations of the test wrt hearing aids with dynamic AI performance, you’re not doing your client a service.

The reason why the aids get over programmed during a REM session is that they know (via AI) that they aren’t being used in a loud or challenging situation; so the output is lower for a given input. When you take them into the real world, the aids compensate for background noise by further increasing gain and output thereby exceeding the ‘target’ you set them to in your nice quiet office.

[DaveL]

@tenkan

Thanks for your post about REM. up until 2-1/2 years ago my 3 Audis all used REM.
First Audi did magical work.

Second Audi team was wonderful provided I got the older owner. She retired. Sole owner always used REM. Sold me my second set of Phonaks. I was in hearing aid h,ll from then on. I couldn’t hear behind me at all. I worked on construction sites. I fired her. Had been a customer for about 8 years. Her REM use didn’t help me

Third Audi always used REM with the HA he sold me. They never worked.

My take. The choice of Audi is far more important than whether they use REM

I hope manufacturers get back to basics. HA should work in the environment we live in. Mine didn’t because the dispensers didn’t know how to set them up.

[x475aws]

@Um_bongo

So what’s the point of a test that can’t measure the gain that it’s actually meant to verify?

The same reason you set ignition timing on a car with that adjustment, even though you know it advances the spark automatically.

The same reason you buy pants in a certain waist and inseam, even though your waist expands and shrinks, and your pants ride up when you sit down.

The same reason you install solar panels at the correct tilt and azimuth, even though the sun’s angle varies.

[Um_bongo]

Those are with known datum points and established variances. A stopped clock is right twice a day……

You don’t have a ‘zero’ point with a dynamic prescription that’s doing its own thing. Like I said before: great starting point, use it judiciously and understand what you’re testing and how that relates to the real world functionality of the hearing aids.

[x475aws]

@Um_bongo

The point being that the hearing aid will produce different amounts of gain under different ‘stress’ conditions so what you’re measuring in the hearing aid office isn’t how your aid works in reality.
So what’s the point of a test that can’t measure the gain that it’s actually meant to verify?

I think this article addresses that very concern. Some (all?) manufacturers’ fitting software has a REM mode that disables special processing. And if that mode is too time-consuming to use during an appointment, then the proper stimulus and patient positioning during REM will yield accurate representation of gains, despite special processing being active.

https://hearingreview.com/hearing-products/testing-equipment/testing-diagnostics-equipment/modern-hearing-aids-programmed-verification-rem

[von]

Thank you all for your assistance, experiences and perspectives. I have a consultation with a second practitioner in couple days…very much looking forward to it. She is out of the way, but I think it might be worth it just to be comfortable I’m getting proper care rather than quick sale (impression I got with last person). in short, they seem more upfront what they do or don’t do. I really was ok with no rem as i know it to be, but at least sell me why…they hadn’t.

Someone make a good point (sorry forgot who)…even if they “will do” rem…it might not be as good as another verification tool being they don’t usually do it. This was why I would ask, and I would always get the “we can”…so was a red flag for me…I understand now there are other options that don’t mean wont be as good…so…thanks everybody for your input…I feel more at ease now no matter what direction I go.

take care all.

[PeterH]

@DamonHill
I had a play on Target last night. My starting setup was this, with the dotted line stopping increases in G50 & G65 high frequency gains:

I decided to do the built in REM and feedback test. I’ve done this before, with no improvement, but this time, however, I added 5dB OVERTUNING. I’ve not done this before but the results seem dramatic:

I’ve been in the house all day, so haven’t been in a testing environment, but it looks promising.

I also read the following yesterday:

It appears that remote access can bypass the estimated feedback line.

Peter

[DamonHill]

Thanks a lot Peter,

Good to know! I’ll report it to my remote audiologist, in case he’s not aware of it.

My ear molds are pretty much closed (below 1mm vent diameter) and fitting very tight, so I don’t think there’s much risk of feedback with me!

[DamonHill]

By the way, how did you do the built-in REM? Did you buy the REM equipment?

[PeterH]

It’s not really REM. I think its called Feedback and Real Ear. I did put my fingers over the vents for this, to hopefully allow more headroom. I don’t think this made much of a difference though, as I’d tried that before. I think it was Overtuning that made the difference. The process was slightly different with the Marvel aids, but the results were the same.

[DamonHill]

Forgive my ignorance, but what’s overtuning?