REM and the DIY'er who use a provider initially

Let’s say you use a provider initially and had REM done after you get your hearing aids from the provider. As part of the REM, they increase the hearing aid amplification to match your target prescription.

Then when you come home and want to make other adjustments using your own downloaded software and hardware interface and go from there.

What if you want to add a new built in program? Will it be based on the REM adjusted amplification? Or will it be based on the original audiogram?

What I’m asking is whether the REM adjustment creates a new baseline audiogram that overrides your original audiogram? If not, is the REM adjustment stored somewhere in the hearing aids going forward such that any adjustment you make to the hearing aids will take the REM adjustment into consideration?

Let’s say you do in-situ audiometry and your hearing loss has changed somewhat and you want to re-prescribe based on the new in -situ result. Will REM need to be redone after this new prescription is set to override the original audiogram based prescription? Or is the REM adjustment information already built into the hearing aid permanently somehow that even a re-prescription based on either a new in-situ result or even a newly obtained audiometry from a new test is entered into the software?

Copying our resident professionals like @Neville and @um_bongo to see if they can help answer this question? Thanks!

You should be able to answer this question yourself.

  1. Look at each of your individual gain settings
  2. Make whatever changes
  3. Look at each of your individual gain settings again

No, REM provides a measure of what the hearing aid is outputting at the eardrum and then gain is adjusted to match targets. If you adjust the gain on your own from there without resetting the fit you are adjusting around the REM adjustments but if you tell the software to refit everything then the REM adjustments are lost and you are back to first-fit until you re-load your saved file.

I wouldn’t generally recommend running the in-situ as it it not the same measure as a traditional audiogram and does not, as some believe, provide a more “true” audiogram*. As to whether running the in-situ will delete the adjustments made when your provider did REM, I think, off the top of my head, that it depends on the manufacturer? The only in-situ I’ve ever found at all beneficial rather than detrimental is widex’, but I recall that running it wipes out previous adjustments (irritatingly) rather than just overlaying changes on top of them.

The tricky bit with self-adjusting is probably considering the biological side rather than just the technological side. The brain adapts to a certain extent given the chance. I recall reading a study, done back when auto-learning in hearing aids was in vogue, that suggested that forcing a patient to live with a certain gain setting for a few months before adjusting to comfort resulted in better longer-term outcomes than adjusting for comfort straight off and then trying to increase them to target (although the latter seems a more popular approach). That is, the former group ended up being comfortable with higher gain and had associated intelligibility benefits. I am sure that I will inevitably be a self-fitter when it comes time for me to wear hearing aids, as any provider probably would be, and I imagine that given the opportunity to adjust for comfort at any time it would be very difficult to force myself to NOT fiddle and simply adapt. Especially given that the biological adaptation is not total, not guaranteed, and we don’t know exactly what its time course is. It would be easier to force yourself to live with a certain setting if you knew precisely how long you needed to do that in order to know that neural adaptation had pretty much reached its limit.

From that perspective, if someone who was a DIY fitter were to go out and have REM done*, it might be a good idea to try to live with the end result for a few months before making any changes. Another thing floating in my brain, and I no longer know exactly where this knowledge comes from which makes it less trust-worthy, is that perception of medium and loud may be more flexible than perception of soft. You can use hearing aids in certain ways to push someone’s perception of “loud” upwards to a certain limit (i.e. they used to feel that 70 dB HL was “loud” and now they feel that 90 dB HL is “loud”, which is more appropriate). You can get used to soft sounds being loud, but unlike medium and loud levels they may never come to feel “soft” the way they did when your hearing was normal, and then you need to make a choice about whether you want to hear something at a level louder than you would ideally prefer, or not hear it at all. Neural coding of softness partially has to do with the number of neurons activated, and with the loss of specificity that comes with hair cell damage you can’t quite get back to it.

As an aside, pediatric hearing aid users often do better with their amplification than those who get hearing aids as adults. In part because their brain is wiring up with the hearing aids, but also in huge part because pediatric prescriptive targets provide quite a bit more gain, and thus more audibility, than adult targets. If you are playing around, flip over to DSL child and see how you do :grin:.

At the end of the day, though, this may not matter. If you are self-fitting and you are satisfied with the sound of your hearing aids, does it matter that you may not be optimizing your hearing? If you feel like all of your needs are being met, then perhaps there is no need to force yourself to tolerate a bit more high frequency gain for the sake of getting 88% of conversation instead of 80%.

(*There is some skill in taking a good audiogram, and there is certainly skill in running REM. Presumably, you are working with a good audiogram and good REM settings. I’ll say too that there are little errors that can show up in an audiogram that a provider may be so familiar with that they will adjust the fitting to compensate for what they know is an error in the audiogram, which would perhaps be hard for a self-fitter to do.)

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I’m aware that the REM adjustment will reflect on your individual gain setting and you can use that as a reference for REM adjusted amplification going forward.

But what I’m asking is more than that. What I’m asking is “Is that all the provider does? Make adjustment to that individual gain setting to match the target result? Is there nothing STORED anywhere for the adjustment to reuse?”

Like my questions implied:

  1. What happens if you want to add a Music program? Do you need to ask your provider to run REM again just for the Music program? Then run REM again if you want to add a Comfort program? A Speech-in-Noise program? That seems rather cumbersome everytime you want to add a new program.

  2. What if your hearing changes ? Do you have to rerun REM again for a new audiogram? Or for a new in-situ audiometry result? Again, that seems cumbersome as well.

The idea of running REM is to be able to tell how off the hearing aid is amplifying against the targeted prescription. Once we know how much the hearing aid is off the target, can’t that information be stored somewhere so that this discrepancy can simply be reused without having to run REM every single time a new program or new audiogram is introduced?

From the perspective of a DIY’er who employs the service of a provider up front to get the REM done as a one time thing, it’d be great if the adjusted discrepancy is stored somewhere and gets re-used every time the DIY’er updates the prescription or add a new program, without needed the provider’s service again each time to rerun REM.

I guess one can manually store the original amplification before REM, then observe the new amplification after REM, then store the discrepancy values on paper for each frequency, then make the same type of adjustment each time to avoid doing the REM again, assuming the fitting does change, of course. But that’s a lot of work. It would have been nicer if the REM adjustment is stored inside the programming for that fitting, and can be automatically re-applied for new audiogram or program addition. So my real question I guess is whether such a setup to store the REM adjustment exists? Surely that should also help save the provider’s time in having to redo REM each time something changes as well?

No, for most manufacturers any additional programs will be based off of the main program so any adjustments made during REM will be carried over. Some manufacturers (e.g. Resound) would need an extra step.

If your hearing changes, again most manufacturers will allow you to enter a new audiogram and update the fitting for that audiogram while maintaining gain fine-tuning. Generally, I would expect adult hearing to decline faster than their ear canal changes, assuming no great fluctuations in weight. With pediatrics, because the ear is growing so quickly, we re-do RECDs and adjust for ear canal acoustic changes at every appointment.

That being said, we will commonly re-do REMs once a year. A three-year old hearing aid is not always outputting what a new hearing aid is.

Ideally so long as you save the RECD in the programming, which for many manufacturers you can, that would be enough to ensure that the hearing aid was hitting targets. In practice that’s not true. But the manufacturers creating a system to save how far off-target their hearing aids were would be admitting that their hearing aids don’t meet prescriptive targets…

Also, keep in mind that the real-ear measures will also depend on the acoustic coupling, if you are switching that up.

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Thanks for a great and thorough response, Neville!

What you said about it may not be ideal for a provider to treat themselves certainly makes sense because they may fiddle with things more than they should, instead of forcing themselves to get used to things and adapt, which may be a better approach. Kinda like doctors are bad patients because they know too much, maybe.

On the other hand, the ability to fiddle to get things to the way you’re happy with is also beneficial as long as you’re happy with the end results like you said. As a DIY’er, I feel like I’ve been able to converge toward a point where I’m happy with my settings. I’ve also tried to diverge from there to different points to see if I’d be happy with those divergences or not, and I was not, so that reinforces that the settings I chose are probably the best for me.

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No problem. It’s Sunday and I’m caffeinated, which makes me chatty. :laughing:

One of the nice things about Oticon (or widex, or signia) is that you can set up multiple “main” programs. So you could theoretically seet up VAC, NAL, and DSL main programs and the switch back and forth between them to see what the differences were. Phonak, which I see a lot of, doesn’t let you do this. They give you dramatically more access to adjust the subprograms in their automatic program, which can be very powerful, but I often wish I could make more than one automatic program. I would guess that the vast majority of providers program to NAL-NL2, but there is still a reasonably robust population of adult DSL programmers (as opposed to child DSL, which is the pediatric norm). DSL and NAL gain targets have converged over time, which does suggest that their are zeroing in on some “optimal” prescription, however their compression prescriptions are still quite different, and I would find it really beneficial to have a more solid answer about when to use what.

(And for all that prescriptive targets and the ideals that support them are very important, I think that some providers who scoff as DIY fitting forget that audiology is really quite young and we are still missing a lot of answers when it comes to finding the perfect fitting. Systematizing it, taking the ‘art’ out of it, truly is important, but we aren’t there yet. And for those providers who are all ‘art’, who do not understand the science and why it is important . . . well, they don’t have access to any special knowledge that the self-fitter does not.)

Good question.

I tried to circumvent the problem by having my audiologist print out the REM curves and reusing them. Turned out that the Oticon OPN’s that I tested, retained the REUG (Real Ear Unaided Gain) as part of their programming. So after I plugged them into my Hi-pro, I was able to get the curve, that describes the amplication in my ear canals with the custom domes from Oticon Genie. I plugged in that REUG curve into Phonak Target.

Of course this doesn’t take into account the amount the HA’s deviate from target. I use the in-situ audiogram to take that into account. When I measure the air conduction loss, it is actually not an audiogram, but the value at which I can just hear a tone with my HA’s. It’s an approximation. Some profiles don’t take the in-situ into account, IIRC NAL2 doesn’t, but Phonak Adaptive Digital Contrast seems to work nicely with it.

Phonak Target seems to estimate the RECD values. I think it calculates them from the feedback test.
Based on audiogram, RECD and REUG it calculates the intial fitting for me, which I can tweak afterwards.

In a month I will be going to the hospital, where I will be tested and prodded. I hope that they will do a REM again, and that I will get the results home with me. It’s a nice young physician, that is interested to see how DIY programmers perform compared to professionals: A study done by the Amsterdam University showed that DIY almost always programmed worse. :slight_smile: So I am interested in the outcome!

All comments to improve my DIY approach are very welcome, of course.

In the Smart Fit 1.3 software, there is a menu option called “Autorelate” by which one can specify which other programs any changes in the modified main program will be carried over to.

I would think the best thing, if possible, would be for a DIY’er to have a working relationship with an audiologist and periodically see that audiologist for an annual ear checkup (audiogram, etc.), REM for the HA performance, and, if you’re really lucky, the provider would sympathize with your desire to self-fit, and advice you if there were any change in fit, how your DIY’ing fits in with that, how it affected your past fit, and if you want to keep DIY’ing, if you’re fit has changed, what you might want to keep in mind as you go forward, assuming your tweaks have been global enough that they show up as the provider examines your old fit vs. contemplating adjusting it.

To make concrete what I’m suggesting, I just changed my profile from “First-Time User” to “Experienced (Nonlinear)” and I will probably show up with changed domes for my 1st year re-exam. So it will be pretty easy for the audi to see in the software and hardware what I’ve done compared to her original fit and give me her advice going forward.

I wish there were a “comparison” setting in the fitting software that could print out comparative differences, say, between patients when those patients are just different versions of yourself.

The reason I am suggesting DIY’ing should be done in conjunction with a provider to some extent is just that DIY’ers probably can’t do any sort of decent REM’s on their own (expense of equipment, properly inserting microphones, etc). I have seen the AutoREM item in the Smart Fit 1.3 software but don’t feel disposed to run it.

I guess it could work that way. It could also work this way after your Audi notices that your hearing aids settings don’t match the database settings from your last session;

  1. You get the look :face_with_raised_eyebrow:
  2. You get about ten seconds to explain your self-programming endeavors
  3. Bam; Your hearing are reset back to the original Audi settings

Or maybe that’s just the method used by the VA. Hahahaha.

The ReSound software documents "sessions " Haven’t looked to see if all sequential fits are saved on a per patient basis but if one wanted CYA insurance in dealing with a DIY’er, one could always save different sessions as different patients entirely, identified by fitting date and suffix abbreviations, etc. That’s what I’ve done with my own experimenting plus separately saving the audi’s initial fit as read from my HA’s.

Edit_Update: @Neville. I checked out sessions under a single patient for the ReSound Smart Fit 1.3 software. The “sessions” entry for that patient does save the fitting for a specific date and time. When you look at the patient and see the various sessions listed in reverse chronological order, there is a dropdown with two options, “LAUNCH” or “DELETE.” If you pick LAUNCH, it’s back to the future and you will launch the fitting software with the settings as they were saved at that session (I only determined this by cursorily glancing over the gain table and the description of the experience profile set at a given session).

The one thing with the ReSound software that seems to keep you from maintaining a continuous life history of a patient under one set of entries is there only seems to be allowed for each patient ONE audiogram and set of word recognition scores. So it seems if you do a new exam, you’d have to start a new patient entry for the same person (but could just be my ignorance of not yet having found how you move the patient from audiogram to audiogram, etc).

I’m not sure why you’re telling me this.:slightly_smiling_face:

Because I suggested that your audi might not remember your settings? Certainly she has them all saved, but the software is ponderously slow to load and you can’t load two instances and flip back and forth. So actually comparing little details from one to the next can be tricky. I’m not saying that I never go out of my way to do it (usually with judicious use of the print screen function), but if your provider doesn’t know that you’ve been self-fitting she may miss it. Some of the manufacturers pop up a window asking whether you want to use the settings from the software or the hearing aids that might flag that changes have been made, but other manufacturers pop up that window every time regardless.

Some of the manufacturers keep an audiogram history internally, others don’t. Most providers I know run the manufacturer software inside of a different software system, which will keep the entire history of audiograms itself.

I certainly agree that the software is ponderously slow but I’m using a 2011 computer that doesn’t have the fastest processor, RAM, and SSD currently available (swapping out an HD for an SSD definitely speeds things up a LOT!).

Beside PRINT SCREEN, one could effectively use a screen capture tool to compare old settings and new settings side-by-side. Older Windows versions have the Snipping Tool. The latest version of Windows 10 has a supposedly improved utility, Snip & Sketch, that makes it easier to draw on and edit your screen capture within the same utility. There is also the trick to run more than one copy of a program to create a secondary user account, then from within your account go to the program location, right click on the main program, and with one instance of the program already running, pick from the context menu, “run as another user,” which launches the program as if run by another user but from within your account (you’ll be asked for that user’s logon name and password). Not sure how that would work with fitting software as each instance probably wants to lock onto key system resources such as audio channels, BT, etc. So it might be safer just to stick with one running program instance.

Another safer approach would just be to have more than one computer running another copy of the program from another synced copy of the program database on a different nearby monitor but I notice the ReSound software says that a user is only allowed a single install on one computer.

I wasn’t sure that you were familiar with the most recent ReSound fitting software. That’s why I mentioned that the ReSound software stores its fitting history for a patient but not the history of audiograms, apparently. And again, may just reflect my ignorance but there didn’t seem to be any way to automatically import audiograms from another source.

Would it be correct to think of REM as a test of how far your hearing aids are from the ideal? So, if, for a specific frequency, the software is set for 41 db gain for 50 db input, and REM might show the actual output to be 85Db spl, instead if 91? If you had that measure for the major points, 500 Hz, 1k, 2k, etc., could you use that as a rough guide for self-fitting? Say, my left one is 6db low for all frequencies and my right is 3 db low?

In other words, would the measures of REM hold up as a general trend that you could use if you re-ran first fit?

It’s really quite remarkable that in the Netherlands all talk on REM is about amplication effects from the ear canal, whilst here on the forum everyone talks about REM as an adjustment to the HA’s for being off spec.

Last time I sent my aids in for repair, they said they recalibrated them, so I always assumed that the would be close to spec. Seeing that the audio gram only has 5dB steps and can easily be >2dB wrong, I never thought that it would have a great impact.

The REUG, real ear unaided gain only accounts for the hearing canal. After that they do indeed insert the HA’s and try to generate the desired sound levels. Could that step be to assess the HA’s taking the REUG values into consideration?
The RECD, Real-Ear-to-Coupler Difference, would than be the REAG with the REUG taken into account.

Does anyone have an idea about what number of dB’s is likely here?

The REUG values are dependent on both your canal and your domes/molds. So if you switch them out, you shouldn’t expect to get good results by reusing them.

The RECD is dependent on the functioning of your HA’s. If you feel that they are degrading, inputting the old values of the RECD won’t help much. You should get new RECD values or have them looked at.

I discussed this with my audician. They had no fee for doing a REM. She called the main office and they didn’t where to file it under, too. So she is still doing it for free! :blush: Quite willing to pay for it, though.

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I went to an online chain in Tilburg (Netherlands). I am considering to get my Wireless Noahlink for the Marvels. He did a REM, but would the Target software and the in situ audiogram in combination with my own feedback be sufficient and reliable?

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In situ versus REM

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My Insitu audiogram and the audiogram done via the headphones is different by quite a lot. It’s a lot better with headphones but I hear a lot better with the insitu audiogram. I’ve never had REM done as the NHS don’t seem to do it.

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Is REM a method for the audiologist to see what is best for the client, or is it also valuable when testing your own hearing, and not having to rely on just your feeling (re your hearing)?
ps: I also have bone c. loss, see my audiogram in the profile.