Is REM required for an optimal fitting?

I’m new to this world, doing a trial with my first instruments (Oticon Duals). My audiologist does not have the equipment to do real ear measurements. She is new, fresh out of school, she is very nice and very eager to help me but she seems to be very reliant upon the Oticon software. The way her process has gone, she first programmed in my audiogram, then we checked to see how that sounded, at the first visit we made minor adjustments for my own voice and she sent me on my way. 2 weeks later I had my second visit, we adjusted a few different things, both own voice and other sounds, and then my next visit is this Friday.

I’m closing in on the end of my trial period and I have to decide if I want to stay with her or return the instruments and find an audiologist who uses REM.

Can I get the proper fit for me without going through REM? When I asked her why she didn’t have the equipment, her response was that it was dated technology that the new generation of instruments and their accompanying software rendered unnecessary, and that a great fit was absolutely going to happen without using REM.

Can I get there from here?

Do you need a real-ear measure to have a successful hearing aid fitting? No. Should you have one? Yes.

The real-ear measure provides quantitative information about how the hearing aid is responding in your ear. Everyone’s ear canal has different acoustic properties, especially when plugged up with a hearing aid. This has a direct effect on the output of the hearing aid.

The goal of most hearing aid fittings should be restoring speech audibility without making sound too loud. By ensuring a match to a prescription for your hearing loss you can be assured that the hearing aid is programmed provide audible speech while, hopefully, not being too loud.

The catch is that this initial programming is not where most fittings should end. Everyone is different and everyone tolerates sound differently. You should expect some adjustments after the initial prescribed fitting.

If the patient drives the fitting the hearing aids will often be inappropriately fit, as recently shown by Consumer Reports. Most people do not want the hearing aids to be as loud as they should be. There are reasons that real-ear measures are done. It’s not crucial that you have this information for a successful fitting but it provides valuable information about the service that is provided.

One thing that does concern me is your last statement.

Real-ear is not outdated, the technology continues to advance along with advanced hearing aids. Modern hearing aids have not circumvented this need. I am aware of two manufacturers that have built some form of real-ear measurement into the hearing aid, these are Starkey and Widex. All this said. If you are happy with your current hearing aids and you feel that they are improving your quality of life, you have been successful.

I find this somewhat interesting and would like to try to understand it better. Are you saying that the gain really needs to be a little higher than what the wearer thinks should be “normal” and then allow the brain to adjust to the louder level so that it becomes the new normal, comfortable level? If so, would this be to maintain/ensure the proper proportional frequency amplifications across the spectrum while trying to provide the most benefit? Or maybe I’m trying to make it more complicated than it needs to be. :wink:

Grandpa

This is probably the reason some fitting software has option to select the experience level of the user… To moderate the volume while the user adjusts to the new sounds.

I’m very interested, as well, what the criteria is for “as loud as they should be”? I would think that someone with already damaged hearing would want to have the volume as low as possible to get the desired improvement. If I listen to an Ipod at 10 and I can hear the music and understand all the lyrics, why do I need to crank it to 20? Noise damage is how too many of us got on this path in the first place. What is the ill affect of being conservative with the hearing aid volume?

Also, how does one know the audiogram is really all that accurate? I have tinnitus. A lot of the time I don’t perceive the tone turn on, but can hear when it goes off. Too late to push the button at that point. Is the testing process intuitive enough to overcome such variables?

This is where we old differ. REM is part of the best practices, and IT IS THE ONLY way to validate a fitting. It is true that some of the new instruments (oticon part.)
are activated by voice. That is why we use speech like stimulus.

So REM is not outdated. It takes a few minutes, I always do it…

Neither widex nor starkey have a real ear mesurement integrated. What they do have is
RECD which is not really the same (Phonak old supero had something identical call RECD direct- they did call it right!). REM is about verification.

by the way, if she decides to do REM in the traditional mode using a sweep.
Oticon do have an option to deactivate noise reduction, feedback canceler etc.

So it is REM friendly in that sense

OK, this may not be the best approach but it’s the one I’ve settled on.

My Oticon Duals help me, no doubt. All I have to do is take them out on the way to bed and try to have a conversation with my wife to quickly understand how much they are doing for me. But I still just don’t feel comfortable with them on a number of levels. And I’ve got the issue with my current audiologist that I explained in this post.

So, I found an audiologist here in town covered by my insurance AND who has REM equipment. We spoke at length and she has fitted a lot of Oticon Deltas in the past but really liked the new Phonak instruments and now does a lot more Yes iXs than Duals. So, I’m going to go to her to get fit for the Yes iXs using her fitting methodology.

I got my current audi to extend my Oticon trial for another two weeks so I’ll have almost 3 weeks with both of these instruments in my possession, with time for a subsequent fitting adjustment session on the Yes iXs. I’m going to see how I like them and the second audiologist versus the Oticons and the first audiologist, then I’ll keep the ones I like and return the others for a refund (minus the fitting fee).

I didn’t want to just walk away from my current audi without giving her a chance, but I also didn’t want to deprive myself of the opportunity of trying an audi who does use REM and has more experience, as well as trying the Yes iXs.

Seemed like a reasonable compromise. I’ll have a BIG balance on my credit card for a month but I’ll make that work. Will report my experience on a different thread. Thanks for the inputs on this one.

Hmmm … so how do you perform a REM on Audio IXs when they have frequency compression turned on?

not sure if this is a real or rhetorical question, and since I don’t know jack about this stuff I couldn’t answer either way.

But it does concern me.

Can an audi do REM with a user wearing Yes iXs?

In the Destiny line they used RECD, but they are now doing a true SPL measurment with the S Series. I find that the added information about how a patient should be fit is just as important as the loss itself. No one is truly average.

You can certainly make a REM measurement at the ear drum.

However as REM is fitting to a target number i.e. an equation and NOT the client, I’m not sure what target you would be trying to reach!

The REM kit would need to know the Phonak aid model, fitting algorithm in use, and what frequency compression had been selected in order to calculate the target sound pressure needed. Phonak would also need to provide the REM people with the equations needed to determine the target sound levels.

The same would apply to Visible Speech systems.

I’m happier using In Situ Audiometry which actually involves the client’s ears!

Overall I suspect that these techniques are great for finding major faults in the hearing aid set up, such as faulty speakers or wild resonances … but in reality it’s not often that I see these situations anyway. (Exception: Traditional BTE fittings with all that plumbing however DO warrant a bit more care because of all the weird resonances possible)

REM etc measurements will however show some industry-wide things: typically how most aids are very weak at providing good low frequency or high frequency performance! But what can you do about universal problems such as these?

Tech. if you program the YES using NAL NL1, you should be able to get verify via rem.

E.D. is right in that there might be certain differences due to the sound recover or so.
However, the appropiate Rem signal is speech signal (hence visible speech).

you can verify OBJECTIVELY that soft sounds are audible, loud sounds are loud but not uncorfotable sounds.
Furthermore, you get a score and you can fine tune to instrument to get the highest speech undr.

I can not imagine myself not using this tool at all. Overall, it is easy to fine tune the aid.
Finally, REM or Speech mapping is part of the current best practices when fitting HI’s. this is a cold hard fact

I had previously owned a Aurical and a FP 35 which where both a Pain to use. But the Verifit the best machine out there.
It has become quite popular this days

you can verify OBJECTIVELY that soft sounds are audible

You can verify that soft sounds meet a certain numeric target - but how can you say that the target is actually audible?

Hi Richard,
When you’re doing a rem, i’d turn off as many advanced features as you can, even feedback control if you can manage it without causing FBK; and definitely frequency compression. That way you can match to the target without the aid treating the test signal as noise, impact noise, feedback etc. If you’re using frequency compression, there’s a chance that the Rx won’t give you a target for those higher frequencies anyway.
This is especially important with aids like the Yes as it will most often be an open fit and the only signal used for open fits (with the reference mic turned off in the probe mic system) is a pure tone or a warble tone.
Once you’ve matched the target to set the frequency response, turn all the advanced bits back on and i’m afraid that we just assume that they are doing what they say on the tin!
I’ve found importing RECD and REUR data from a probe mic system into the software is a pretty good way to get much better match to target with the added bonus that you can use it with proprietary Rx’s and let the client try several different Rx’s for preference.