Real ear measurement vs. in-situ audiometry

Hearing Aids
#81

I can see what you’re imagining, but in this method patients who happen to be particularly good at guessing what the words are wouldn’t be provided with full audibility, which doesn’t seem fair. And again, keep in mind that test-retest variability on word recognition testing is 50% in some cases. You can reduce that variability by doing 100s of words, but it starts to get time consuming. The variability would also be impacted by the volume of the audio file, and how far the patient was from the machine. Unless you put a reference mic on the patient to ensure the volume of the presented word list was standardized, but then we’re basically just one step away from REM.

TrueBrit thinks REM is useless because he doesn’t know how to use it.

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#82

Where/how does an audiologist learn to do proper REM and hearing aid fitting in general? I’m guessing it’s not formal education.

#83

It is absolutely formal education. It was taught to me in my degree program and they had been teaching it for years. It’s standard, preferred practice and any academic program that is NOT teaching it should have their accreditation pulled. HIS programs may be more variable; I know that our local program is great. International programs, I don’t know.

For older practitioners who went through their program prior to REM being standard, there are all sort of places where they can learn it. But I suppose it would be nice to have access to a mentor who had been doing it for a long time. Part of the skill and experience involved is just being able to recognize by sight where you might be running into a physical problem versus a programming problem, because you can make things weird if you are trying to crank the gain at a frequency location that is actually only showing up as low because of a venting issue or a probe tube pinch.

The biggest barrier to improving clinical practice in all areas of healthcare is just momentum. “This is just how I’ve always done it and I don’t want to learn something new.” Change is uncomfortable.

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#84

It’s funny - that is exactly my problem. When I get the word recognition part of the hearing test I score very high, whereas my actually word rec in real life situations is far from that. I believe it’s due to the fact that given the word and several seconds, I am good at figuring it out. However, in a conversation I don’t have time to examine the spuds I heard to determine the word…

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#85

Agreed to a point with threshold sounds meeting target, but I think where REM is slightly too prescriptive is that it takes little account of what I’ll call the ‘tone curve’ ie the preferred shape of loudness/gain-growth through the residual dynamic range.

It would be really handy to get an app on an aid where the audiologist sets the boundary parameters; ie threshold and MPO, but the user gets an interface where (globally or per channel if needed) they can amend the shape of the compression. Imagine a square with a diagonal line across it (bottom left to top right) to represent the CR, but you can drag that line to a curve and drop axis points on it.
The more top-left, you make the curve, the earlier the gain kicks in for lower intensity sounds, the more bottom right, the flatter the initial response. This method allows both experienced and inexperienced users to optimise loudness growth globally or in a more refined way.
If you want to patent that, I’ll take a stake in the royalties; if you don’t, Phonak will bring it out ‘exclusively’ in their next app anyway.

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#86

The book “Fitting and Dispensing Hearing Aids, Third Edition” is loaded with REM explanations and directions. It’s absolutely a recommended practice, but the forums here can leave the impression that it’s controversial or optional or a money grab.

#87

I would add that after 40+ years of the tests, the lists are not hard to figure out, particularly the 2 syllable words. Example:
If I hear only plane, I know that it is airplane. I think they need more lists. I also have quit giving them the answer if I only heard half of the word. Fortunately, I function a bit better than my WRS would suggest. I do miss words in real life quite often.
Dan

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#88

My VA audiologist will set my aids to the prescription settings then do a REM test, at least I believe it is REM, to see what it looks like, then now after many months of fitting adjustments he records that setting by doing what I believe is the REM test and saves it. He has shown me the prescription set, and the what I call works for me setting and they really don’t look even close.
But over my 18 plus years having hearing test, I have come to understand that if I want a correct fitting I don’t guess that I hear the peep, I only indicate when I really hear the peep. It has made a world of difference in the settings of my aids. I have also learned that the VA policy is to set hearing aids to a comfortable setting which for me isn’t going to allow me to understand speech or enjoy music, or hear even half of what I want and need to hear. At first the aids were uncomfortable and I lowered the volume but over time I have adjusted to the full sounds that I should be hearing.

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#89

Excellent comment/post. “But over my 18 plus years having hearing test, I have come to understand that if I want a correct fitting I don’t guess that I hear the peep, I only indicate when I really hear the peep. It has made a world of difference in the settings of my aids.”

I think this is exactly what I do. I try to anticipate the beep snd push the button. Also I do guess at the word being spoken. I think I do this because I Do Not want my hearing to have gotten worse. (Needless to say my hearing is what it is) Hearing Tests are so Very stressful for me. I’m only cheating myself. cvkemp thank you for your comment. It woke me up snd hit a home run with me.

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#90

I have seen the progression of my hearing loss, it isn’t a steady loss it comes in increments. I can go years with no change then it seem like over night it makes a leap change. My loss has been fairly stable for about 4 years I am expecting another leap very soon.

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#91

The SRT spondee testing is actually intended to be a closed-set test. That is, the audiologist is supposed to familiarize you with them first. I don’t think many do this with adults because it’s time consuming and it mostly doesn’t matter much, but from that perspective it really doesn’t matter if you have them memorized.

For WRS, I present different word lists from year to year, but I doubt very much that my patients have that one memorized from the previous year.

#92

I like TrueBrit’s reasoning. The REM may be useful, but is not the end. It needs to be followed by Fine Tuning, but that is done over a long period of time and many visits to the audiologist.
And that is only when the patient has specific complaints. Not easy to express easily for many people.

So why not do both? The REM, and then the “acid test” - audiogram and word test inside the box, which gives uniform reference, and completely disconnected from the fitting software, i.e as the wearer would be in real life?

#93

I think all apps have volume adjustments and tone (treble bass) adjustments.
The myPhonak goes a bit further. It has a three segment EQ, and the settings can be saved as a new program.
There are even more adjustments in the Speech in Noise type programs where it is possible to set the strength of the algorithm.

But more would be welcome as Um-bongo suggests. It could be hidden behind Advanced Users not to confuse the other folks.

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#94

No good clinician doesn’t fine tune though.

Aided pure tone testing in the testbooth is what REM replaced; it’s faster and it gives you more information. There’s no need to do both. We still use aided thresholds testing in situations where we cannot use REM, like bone anchored hearing aids (although testbox verification against prescriptions is available for BAHAs now) and cochlear implants. Various types of aided speech testing can be useful although, given its massive variability, WRS is less useful than you might think.

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#96

I have experienced REM when there were blasts of noise coming out of the speakers.
But I recall that somebody here said that this method is not good.
So, what is considered the 'best ’ method of REM?

And, if you could please describe it, what is the process of 'live speech mapping? What equipment is involved?

#97

All REM involves putting a microphone next to the eardrum to measure the output of the hearing aid. The main portion is live speech mapping where you will hear a calibrated speech recording. It may be a someone talking about carrots, or about the eye, or just a stream of speech in different languages. Its function is simply to present all of the critical components of speech to support comparison of the hearing aid output against prescriptive targets and you may hear it a bunch of times as the clinician adjusts things. However, there is also a sweep of loud beeps that the clinician uses to measure maximum output to ensure that it is within the safe range. Audibility verification for /s/ just sounds like a hiss. RECD measurement uses a foam tip and is sort of quiet engine noisy. There may be components where you hear types of noise or babble, sometimes from a separate speaker, but I think the majority of clinicians are still running those tests in the testbox rather than on ear.

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#98

Yes, I have found that after trialing several pairs of hearing aids over 6 months, an added benefit is that I am now an expert on carrots.

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#99

“The carrot is a long, reddish yellow vegetable which has several thin leaves on a long stem and which belongs to the parsley family. Carrots are grown all over the world in gardens, and in the wild, in the field.”

I’ve never heard it. I had to look it up to know what you were talking about. I can understand why it has been used for verification.

#100

I learned a slightly different approach when I came over to Seminole County FL.

In essence it’s just vocal delivery which relies on the audiologist gabbling away at 65dB on the Vu meter, then you look at the peaks in the REAR to see how they match up with the re-proportioned speech-banana.
The weakness is that it relies on a human input, but the strength is that it relies on a human input; you can shout, talk in weird local languages, play background noises and music to validate most types of programming. Recently I’ve been using it to see if the More 1s are better left in their standard program (with VC function) or whether they need dedicated programming for different situations.
The upshot is broadly that for most ‘conventional’ losses up to severe they are pretty good in the standard program, but some Moresound tweakery helps with the more severe losses. As you go from severe to profound the individual programs come into their own. However, if you’re wearing them, you probably already know this.

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#101

Thanks, Neville.

What is the prescriptive target for speech?
If, during the speech mapping REM, the software breaks the speech into frequency bands, and compares them with the prescription (target), wouldn’t it be similar to using a bursts of noise that also contain all the frequencies that are in speech?

My wife decided that she does not want the Phonak Virto because she has problems with the batteries. She had a stroke years ago, and it left permanent marks.
She wants only ITC, and there are only two rechargeable ITCs as far as I know. Signia Insio and Starkey model whatever it is called. But I have read somewhere that positioning the HA on the charging contacts is not easy.
So that only leaves the Signia Insio AX.

We have left Specsavers, collected the money, and made an appointment at Hearing Australia. It is also a chain, but more expensive than Specsavers, and owned by the government.
The government scheme has some written requirements for verification, but not in great detail.

So, what I would really like to know, is how much fitting that would be considered really good is done automatically using the Signia software, and how much needs to be done manually, or even using external software and equipment.

Signia Connexx software includes some REM method, and possibly other verification methods like in situ audiogram. Are these any good?
Signia has a series of YouTube videos showing stages of fitting HAs, but it may not be complete.

Also - should my wife be given a choice between say the NAL method and the proprietary Signia method of calculating the prescription? Some audiologists say that they demonstrate both, and let the patient decide.

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