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Audacity ...a British Society of Audiology Publication

issue 11 March 2018 .............................

12 Jay Jindal BSA Guidance on verification of hearing...

26 Dr Cherilee Rutherford Tools for person centred management of tinnitus

34

Audiology in Zambia: an overview of ear and hearing care services...

41 Top Ten Q’s Hearing aids for Music, exploring the music listening ...

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Editor in chief Welcome to the 11th Edition of Audacity.

T

his Spring edition is the second one for the team here in North Wales. The current plan is to produce a paper magazine twice yearly, a Spring edition in March and an Autumn edition in September. The option of a more interactive online version of the magazine is being explored and I’m aware that there were some questions about this in the recent membership survey. I look forward to hearing what your thoughts are on this as we consider moving Audacity forward. We’ve been really pleased by the number of submissions we’ve received for Audacity this time around, it’s great to see such an interest in the magazine. Success of Audacity relies on your interest and we understand how difficult it is to get something to us when you are so busy with other commitments. Thank you to everybody who has taken the time and made the effort. We look forward to receiving more articles from more of you in the future. So, what can you expect in this edition? We’re really pleased to be able to include two featured articles; one by Gwen Carr on the potential role and benefits of Tele-audiology with teenagers and another by Cherilee Rutherford, introducing three new tools that have been designed to help deliver person centred care in tinnitus management. Look out for ‘Top Ten Qs’ in the Clinical Catch Up section. This is following on from the popular Q&A article in our last edition and is the new BSA version of the very successful 20Qs from the desk of Gus Mueller. I’ve been in touch with Gus and he has given Top Ten Q’s a thumbs up! This will now be a regular feature in Audacity. The BSA Today section includes updates from all the BSA Special Interest Groups (SIGs); the Professional Guidance Group (PGG) and the Learning Events Group (LEG). Take a look at the fantastic work they’ve been doing over the last six months and at what they have planned going forward. Look out for opportunities to get involved in the work of these groups. You may be aware that BSA held its inaugural e-conference last December. If you weren’t able to attend, catch up with the Learning Events Group (LEG) summary and Sebastian Hendricks’ review, explaining how his team managed to attend on line as a department. Remote access to learning and events is an increasingly popular way for people to engage and I’m sure there’ll be more of this kind of event

from BSA going forward. Don’t miss out on the next one. Also in this edition Research Round up includes an update from 3 of our UK research centres whilst Ear Globe includes articles from Malawi and Zambia and once again Ear to the Ground will summarise audiology related media articles and social media chattering. You may have noticed that the Essentials section is missing from this edition of Audacity. This section usually contained Audacity advertising rates, organisational membership of BSA and Council membership and BSA examination passes. As this information is readily accessible on the BSA website we have decided not to include as a regular feature of Audacity. We hope you enjoy this edition.

Jane Wild, Editor-in-Chief On behalf of the editorial team E: jane.wild@wales.nhs.uk

editorial


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Contents 3

Editorial

7

Chair’s Message

12

Expert writing about topical areas in audiology

Ear Globe – audiology around the world

41

Information and updates from all aspects of the work of the BSA

Featured Articles

34

Liz Midgley

BSA Today

26

Jane Wild

Find out about the latest charity and humanitarian work going on within audiology, both in the UK and abroad, with some opportunities for you to get involved.

Clinical Catch-up

Short articles on relevant clinical topics.

50 Research Round-up

A spotlight on major ongoing research projects in the audiology community worldwide

58 Ear to the Ground

A guide to all things Ear-related in the media

Audacity is published by: The British Society of Audiology Blackburn House, Redhouse Road, Seafield EH47 7AQ UK. E: audacity@thebsa.org.uk W: www.thebsa.org.uk

Design: Pinpoint Scotland Ltd


BSA Today

BSA Today

Ear to the ground

Ear to the ground

W: www.thebsa.org.uk Section Editor Suzanne Tyson, Senior Chief Audiologist

Section Editor Abigail Jones, STP trainee

Section Editor Susan Boon, Chief Audiologist

Section Editor Sueann Meyer, Senior Clinical Scientist

BSA Today

Section Editor Shanelle Canavan, STP trainee

Section Editor Sarah Bent, Principal Clinical Scientist

Section Editor Katie Bentley, STP trainee

Section Editor Susannah Goggins, Principal Clinical Scientist

Editor in Chief

Section Editor Stephanie Greer, Pre-Registration Clinical Scientist

Section Editor Sarah Canton, Principal Clinical Scientist

Section Editor Matthew Evans, Principal Clinical Scientist

Jane Wild, Consultant Clinical Scientist and Editor-inChief of Audacity

5

Meet the team

Ear to the ground

Clinical Catch-up

Clinical Catch-up

Clinical Catch-up

Research Round-up

Research Round-up

E: audacity@thebsa.org.uk


Research Round-up

Section Editor Sophie Wareham, Clinical Scientist

Section Editor Jenny Townsend, Principal Clinical Scientist

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Featured articles

Section Editor Bridget Akande, STP trainee

Section Editor Joanne Goss, Advanced Practitioner Audiologist (Aural Rehabilitation).

Ear Globe

Ear Globe

Welcome to our new section editors

Section Editor Beverly Soden Primary Care lead for West area BCUHB

Section Editor - Ear Globe Beverly has lived and worked as an audiologist in North Wales for the past 17 years. She recently took up a post in 2016 as the Primary Care lead for West area BCUHB, an innovative new service delivering Audiology services to GP surgeries across Gwynedd and Anglesey.

Section Editor Amber Roughley STP trainee

Section Editor - Ear Globe I am currently a second year STP trainee based at Ysbyty Gwynedd in Bangor. I graduated from the University of Sheffield in 2016 with a degree in Biomedical Science.

The British Society of Audiology publishes Audacity as a means of communicating information among its members about all aspects of audiology and related topics. Audacity accepts contributions, features and news articles concerning a wide range of clinical and research activities. Articles typically emphasise practical rather than theoretical material. Audacity welcomes announcements, enquiries for information and letters to the editor. Letters may be in response to material in Audacity or may relate to professional issues. Submissions may be subject to editorial review and alteration for clarity and brevity. Please email audacity@thebsa.org.uk for further information. Audacity is published in March and September. Contributions should preferably be emailed to: audacity@thebsa.org.uk or sent to; Editor in Chief, Audacity, Blackburn House, Redhouse Road, Seafield, EH47 7AQ. Views expressed in Audacity do not necessarily reflect those of The British Society of Audiology, or of the editors. The Society does not necessarily endorse the content of advertisements or non-Society documents included with their mailings. The Society reserves the right to refuse to circulate advertisements, without having to state a reason.

E: audacity@thebsa.org.uk

W: www.thebsa.org.uk


chair’s message

7

Chair’s Message - March 2018 In Consideration of Excellence

2. The advancing of education in Audiology

The strapline for the British Society of Audiology which appears as part of our logo on all our publications, our website and our correspondence for all to see is “Promoting Excellence in Hearing and Balance”. What does “Excellence” mean to you? My son always tells me if I want to know anything to “Google it like any normal person” so I did and here are some definitions and comments I came across.

3. The furthering of research in Audiology and the dissemination of the results of such research

“Excellence means greatness; the very best” “Achieving excellence is never easy to do” “Excellence is a quality that people appreciate because it’s so hard to find” “It is the quality of excelling; of being truly the best at something”. “It involves trying to put quality into everything you do” And my very favourite quote attributed to Sujatha Das in September 2014 “Excellence is the result of caring about what we do and of putting our very best effort into what we care about. It is an outward expression of inner integrity, passion and a strong sense to make a true difference”. (Ref 1) If this is a definition of excellence I am proud to include the word as part of the BSA’s logo. Members of the BSA promote excellence in research and clinical practice to make a true difference in our understanding of the ear, its function and pathology, to develop evidence based practice and to make a real difference in people’s lives with hearing and balance problems. If we strive for excellence in all that we do and are passionate about what we do we will make a difference. Although expressed in slightly less impassioned words, I believe that the aims of the BSA as stated when the organisation was set up in 1967 were motivated by the desire to pursue excellence. These aims were:1. To promote learning and advance education in the subject of audiology. 2. To provide a common platform for discussion among the various disciplines involved in audiological work. 3. To promote the status of audiology as a discipline. These are remarkably similar to our current aims as stated on our website:1. The furthering of the study of Audiology, hearing and balance science, particularly in the diagnosis, alleviation and prevention of hearing and balance difficulties.

4. Raising awareness and improving the understanding of Audiology If the BSA, as an organization of people who are passionate about what they do, manages to achieve the aims of the original society and the current aims of the modern BSA, we will make a difference. How do we, the BSA, try to achieve these aims? We write and review BSA recommended clinical procedures based on the best evidence that are used worldwide and regarded as gold standard; we have creative and inventive ideas for research to expand our knowledge which may be published in the BSA’s journal, the IJA; we meet in Special Interest Groups with people who share our own interests but who may have different professional backgrounds or perspectives from us; we learn and network with each other through face to face and on-line scientific meetings; we offer impartial and evidence based advice when requested by governmental bodies for instance.This list isn’t exhaustive and maybe you can think of other important areas that make up and define the BSA, helping the organization to achieve its aims and pursue excellence. One of the reason I became involved with the BSA, not just as a member for the whole of my career but more recently as a Trustee and officer is that I care greatly about the field of Audiology in its widest sense. I know that the other Trustees and advisors who make up the BSA council share the same passion. If you too feel that you have a strong sense to make a true difference please volunteer your time to join any of our Special Interest Groups, the Professional Guidance Group (PGG) or the Learning Events Group (LEG) and also watch out for vacancies for Trustees of the BSA as they arise. The BSA celebrated its 50th anniversary last year. May the very important work of the BSA continue for many more years with people of integrity who are passionate about what they do to steer the organization into the future. May the BSA always promote excellence in hearing and balance. Reference 1. https://www.linkedin.com/.../20140916044626-33383-whatexcellence-means-to-me

With best wishes

Liz Midgley Chair

chair’s message


obituary

8 Obituary – In memory of Robert Ross Adlard Coles

Robert Ross Adlard Coles 18 December 1927 – 16 December 2017

Ross was a founder of scientific audiology as it exists today, being instrumental in establishing the clinical role both of audiological physicians and audiological scientists and in establishing tinnitus as an important disorder worthy of research endeavour and clinical support. His greatest legacy will probably be the number of young people that he has encouraged to undergo a career in audiology, especially via the MSc in Audiology programme, whose alumni include numerous audiologists around the world now in leadership positions. His qualities as an educator and guide at a personal level are remembered in many of the sentiments that have been expressed in the days since his passing. His warmth, generosity and good humour will be lasting memories for many in the audiology community. Ross was the son of the championship sailor Adlard Coles OBE, which explains the love of the water and sailing that Ross had throughout his life. He was a member of the university sailing team at Cambridge in 1947, 1948 and its captain in 1949. He sailed for many years but unfortunately his ability to participate in sailing was curtailed later in life by various injuries. He joined the Royal Navy Medical Service (now Institute of Naval Medicine) in 1953, after completing his medical training at Clare College Cambridge and St Mary’s Hospital London. His naval career was mainly at the Royal Navy Medical Service at Alverstoke near Gosport, although he served at Suez in 1956 and also served on HM Royal Yacht Britannia in 19591960, where he was sailing master of the Queen and Duke of Edinburgh’s racing yacht Bluebottle. Although qualified in ear surgery, his interests focused on auditory research and he would characterise himself as an audiological physician. He was particularly engaged in his early research on the damaging effects of noise on the ear, particularly military exposures from gunfire and ship engine room noise. In the early 1960s, Ross began an attachment from the Royal Navy Medical Service to work at the Medical Research

obituary

written by: Professor Mark Lutman Council’s Wernher Institute on Deafness at King’s College Hospital, London. He mainly carried out audiometric surveys of noise-exposed personnel, initially those on aircraft carrier flight decks and later of submarine engine crews and Royal Marine recruits using the new military self-loading rifle. One of his collaborators at the Wernher Institute was Chris Rice; that collaboration continued when Chris left to join the newlyformed Institute of Sound and Vibration Research (ISVR) at the University of Southampton. Ross and Chris formed the Audiology and Human Factors Group (later Human Sciences Group) at ISVR in 1965, with the two of them as joint chairs. Ross was seconded part-time to ISVR in 1965 until he retired from the Royal Navy in 1970 and joined ISVR as a full-time academic. During his secondment to ISVR, his research interests changed gradually from the effects of noise exposure towards the increasingly scientific subject of diagnostic audiology, setting up the Wessex Audiology Clinic at ISVR. That changing interest was reflected in his becoming a founder member of the British Society of Audiology in 1967. At the time, site-of-lesion testing in audiology was its most challenging area, in an era where electric response audiometry was in its infancy and before the widespread availability of imaging techniques such as high-resolution CT scans and MRI. He was successful in gaining a large rolling programme grant from the Medical Research Council to develop new audiological techniques, including tympanometry and acoustic reflex testing, cortical and brainstem electric response audiometry. Underpinned by the developing scientific discipline and research base in audiology at ISVR and elsewhere, he was successful in persuading the Department of Health to introduce audiological scientists into the forthcoming Hospital Scientific Service of the NHS, which in turn led to the establishment of the MSc in Audiology programme at the University of Southampton in 1972. Also Ross instigated a number of short courses in audiology and vestibular func-


obituary

9 tion at the university, which attracted widespread national and international attendance. The next phase of his career echoed the increasing importance being placed on hearing disorders, when the Medical Research Council established its Institute of Hearing Research (IHR) in Nottingham with Professor Mark Haggard as Director, having outstations in Glasgow, Nottingham, Cardiff and Southampton. Ross was appointed as Deputy Director based in Nottingham. His specialism changed again as he became increasingly interested in tinnitus, which had received too little attention previously. His work at IHR was initially split between clinical aspects of the National Study of Hearing and his research on tinnitus, supported by his development of the specialist Nottingham Tinnitus Clinic, one of only three such clinics in the UK. He held an honorary position as a Consultant with the NHS during his time at IHR. As work on the National Study of Hearing wound down in the latter part of the 1980s, he focused mainly on tinnitus research and clinical practice. While at Nottingham, he inaugurated the Nottingham Tinnitus Course, which has since become the European Tinnitus Course and continues to attract participants from all over the world. He retired from the IHR and the NHS in 1992, becoming Chair of the British Society of Audiology in early retirement between 1994 and 1996, also generously donating the medallion worn by all future BSA Chairs. Throughout his career at ISVR and IHR, Ross maintained a side interest in medicolegal audiology and particularly personal injury claims for noise-induced hearing loss. He was a medical expert in the ground-breaking trials that established the principle that noise-induced hearing loss qualified for compensation in English law. In one trial he was in the witness box for a total of 6 weeks. He provided witness testimony as a medical expert in many thousands of cases both during his working career and after retirement until the last few years when he gradually withdrew from such work. It is testament to his expertise that he has co-authored two publications that are so well known by judges and lawyers that they are simply referred to by pet names: the Black Book and the CLB guidelines. These were not his only published works: Ross published widely in medical and scientific journals with a total of almost 200 publications between 1957 and 2016. Ross has made outstanding contributions in so many ways. His patients will attest to the caring interest that he has shown, especially those with debilitating tinnitus. His research prowess is reflected by his world-wide reputation. He was a founder of scientific audiology in the UK, a patient teacher and mentor for many students and researchers in audiology. Above all, he was a gentle giant of a man who generously shared his knowledge, experience, time and good humour with us all.

www.thebsa.org.uk

Our website allows for online registration for new members and renewal of membership for current members. You can Facebook and Tweet us – or reach us in more traditional ways.

We are there for you – on your ipad, notebook or computer, in a format that is quick and easy to access.

Some of the key elements of the website are: • The BSA Chair’s message • Online access to electronic versions of BSA publications • Easy and free access to BSA Policies and Procedures • Easy access to our very popular recorded Lunch & Learn and Lightning Updates • Direct access and updates on the work of the BSA Special Interest Groups • Information about conferences and events • Information about global outreach projects • Job adverts and information and links to organisations.

Our deepest sympathy to his wife Kathy and his family.

obituary


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BSA Today

12

BSA Today BSA Guidance

Behind the scenes: BSA’s guidance on the verification of hearing devices using probe microphone measurements Jay Jindal Professional Development Consultant for British Society of Hearing Aid Audiologists (BSHAA), and Consultant Audiologist and Director of Audiology Planet Limited

As hearing aid verification equipment evolved, an update on the joint BSA/BAA guidance on real ear measurement became due. After a period of deliberation, BSA’s professional guidance group (PGG) agreed to take on the task and the current authors were given the remit at the beginning of 2016. When using a professional guidance document, we are not always aware of how much blood, sweat and tears are shed to reach publication. Authors of any guidance have a giant task; they not only review the latest evidence but also consider varying professional opinions. In the case of probe microphone measurement, where the opinion is still divided on various technicalities, the challenge is more pronounced. I have found out the hard way that an author must have significant resilience and commitment to the wider professional group.

the incoming comments and co-ordinated the discussions. Honestly, it would not be an exaggeration to suggest that there were a million emails exchanged (it certainly felt like it!).

Our focus was for the guidance to be: • Evidence based • User friendly • Non-specific to type of equipment • As concise as possible (only focussed on hearing aid verification but possible future appendices may include CROS devices and some aspects of digital technology such as directionality and noise management)

Therefore, it is only appropriate that I thank the co-authors and reviewers of the initial document who not only enriched the guidance but also helped me keep my sanity. It all began with couple of sleepless months reading the reference papers - I was almost dreaming this stuff in my sleep! That is when Ann-Marie’s apt intervention came in. She shaped the draft and made it much more legible than where I had left it. We were juggling hard between family-time, work and everything else-to get the guidance out.

The first consultation went well as we had more than 200 comments. Here is my opportunity to thank all those who took time from their busy lives and engaged with the consultation. Without these comments, we would not be where we are. The authors have a lot of respect and appreciation for those who provided supportive and constructive feedback that we could work with.

Our intention was for the process to be inclusive throughout. The first draft was sent to all the leading manufacturers and renowned industry experts in UK, Australia, America, and Canada. We left no stone unturned. I was the liaison for

It was at this point that Rob Ryman and Matt Murray became involved.They provided a fresh pair of eyes and made some very sensible suggestions to improve the guidance. We managed to rope in Matt Murray as co-author to help

BSA Today


BSA Today

13 Thank You and Good Luck Laura Laura Turton Operations Manager

You will know by now that Laura our Operations Manager for three years has moved on the exciting new opportunities and challenges. We have said many thank yous to Laura but wanted to include something in this edition of Audacity as the last farewell and a tribute to the great contribution that Laura made to the modernisation of the BSA. This is what Barry Downes, Trustee and Treasurer of the BSA wrote as a testimony to Laura and I agree with every word.

What’s new: • Use of modulated speech (ISTS) as verification signal • Recommendation of using REAR in favour of REIR for both NAL and DSL targets • Verification for open fittings • Method for verifying frequency lowering devices us carefully consider each comment and revise the overall document. Method for verifying frequency lowering devices The resulting draft was shared with an external peer reviewer and the received comments were implemented to produce the version for second consultation. At the time of writing, the latest draft is in circulation for consultation. We are hoping to do some further work to incorporate the comments from this round of consultation in early 2018, which means that by the time this piece is published, we may well have the guidance published on BSA’s website. We hope that this document will prove to be a great practice tool for audiologists who are involved in fitting hearing devices, up and down the country (and around the world). We have tried to accommodate the differing views in a non-partisan and practical way to produce a guidance for all, no matter where you practice and what equipment you use.

I had worked with Laura before she joined the BSA as our Operations Manager and this gave me every expectation that she would certainly be an asset to the Society especially in supporting our ambitious modernisation programme…..needless to say, Laura did not disappoint! She wasted no time in making the most of her new role and, as the BSA’s Treasurer since December 2015, I have had the pleasure and privilege of working with Laura for more than two years. During that time, she has provided me with invaluable support and assistance for which I’ve been immensely grateful and which I will greatly miss. As much as I’m saddened by Laura’s departure, I wish her every success and personal fulfilment from the next stage in her career. I can think of no better way to end my personal tribute to Laura than by quoting the words of Professor Kevin Munro in his Chairman’s Message in Spring 2014 when he explained the intention to appoint an Operations Manager. Laura fitted the description perfectly! “We will be looking to appoint someone with passion, energy, drive and the ability to motivate and inspire others.” We will (we already do) miss Laura but she will remain as an active volunteer for the BSA and I’m sure you won’t lose touch with her. The BSA council would like to wish Laura all the very best in her new role and thank her once again for her excellent contribution to the society. Liz Midgley Chair BSA

BSA Today


BSA Today

14 BSA Prize Winner Interviews

Interviews with prize winners from the BSA Conference 2017 The Thomas Simm Littler Prize Winner - Derek Hoare

The Ruth Spencer Prize Winner - Sarah Bent

The Thomas Simm Littler Prize in recognition of an academic contribution to the discipline of audiology was awarded to Derek Hoare (Associate Professor in Hearing Sciences, NIHR Nottingam Biomedical Research Centre) for his contributions to research on tinnitus and associated hearing related problems.

The Ruth Spencer Prize in recognition of a notable contribution to clinical services by a registered practitioner was awarded to Sarah Bent (Principal Clinical Scientist, Betsi Cadwaladr University Health Board) for her contributions to developing practice in relation to adults with dementia.

1. How do you feel about winning the Thomas Simm Littler Prize? I was honoured to receive this award, now on proud display in my office. Really it reflects how fortunate I am to work in a vibrant collaborative hearing research environment, surrounded by others with a passion for audiology. 2. What inspired you to explore this area of expertise? I studied neuroscience at The University of Manchester where I became fascinated by sensory processing and what happens when the senses go wrong. For my PhD I studied olfactory processing in the fruit-fly larva, trying to unravel the secret ‘code’ that it uses to differentiate thousands of different odour molecules. After such basic science it was a bit of a leap of faith into translational research on tinnitus, but one I’m glad I took. There is so much work to be done, but equally opportunities to make a real impactful difference. 3. What would you say is the one key take home message from your work in this area? The various systematic reviews I have been involved in indicate an increasing volume and increasing quality of clinical trials in the field of tinnitus. But tinnitus is complex and highly individual, so in a clinical trial you essentially start with a mixed population who are very unlikely to respond to any treatment in exactly the same way. As such, I would like to see greater use of mixed methods in tinnitus research. We need to know more about ‘improvers’, so that we can make informed treatment recommendations and predictions about treatment outcomes. 4. If you could give one piece of advice to people who are keen to develop and explore areas of interest in Audiology, what would it be? If you want to make a difference then do what’s important. There are infinite questions that could to be explored so we should put our time and resources into identified priorities. As translational researchers everything we do is driven by what is important to patients and clinicians. Some years ago a James Lind Alliance Priority Setting Partnership was instrumental in setting the research agenda for tinnitus. A further Partnership is ongoing right now to prioritise unanswered questions on hyperacusis, an important focus for us in the coming years.

BSA Today

1. How do you feel about winning the Ruth Spencer Prize? I was delighted to receive the award. I have had so much support from other clinicians and researchers on the developments for those living with dementia, particularly over the last 5 years, and it is great for our efforts to be recognised in this way. A further reward will be to see the BSA recommendations through to publication this year. 2. What inspired you to explore this area of expertise? It was a patient back in 2006 that sparked my interest in dementia; they had been a brilliant hearing aid user for years and a slight change of earmould type completely confused them, to the point of not even knowing what it was. There was little known across the profession about dementia at the time, and I have since been fortunate in being able to help to improve that locally and across the countries of the UK. 3. What would you say is the one key take home message from your work in this area Audiology is an excellent profession in its embrace of person-centred care and the need for individualisation, and those living with dementia have the potential to benefit from this above all else, with the commonly used phrase being “see me, not my dementia”. It is by understanding the common traits with different types of dementia, including those sensory challenges, and then by exploring the particular needs and strengths of the individual that we can really help. 4. If you could give one piece of advice to people who are keen to develop and explore areas of interest in Audiology, what would it be? I would repeat the advice that was given to me many years ago and has served me well. To get involved with others in the profession nationally and internationally that have similar interests, using opportunities to network, develop your own work and share this with others. By learning from each other within the audiology profession, and from other professions too, we can really make a difference for patients’ lives.


BSA Today

15 BSA Grow

An introdution to our online learning community In 2017, the year that BSA turned 50, a new membership benefit, BSA Grow, was introduced. BSA wants to promote excellence in hearing and balance through best use of evidence based practice and consultation with BSA members told us that you wanted flexible, bite sized learning for your CPD. BSA Grow is one way in which we hope to fulfil this vision. What is available on BSA grow? • Journal Clubs: quarterly journal clubs you can watch and use with your department or branch or take part in virtually • Lunch and Learn Webinars: 20 minute webinars to watch whilst taking your lunch break • Lightning Updates: 5 minute updates from the BSA on activities being undertaken • Learning Modules: up to 2 hours of different activities on topics with assessments earning your certificates • Forums: for students and on each of the Special Interest Groups • Libraries: on evidence of note • Live events: including the 1st BSA e-Conference which took place in December 2017 • Log on at times that suit you, minimising the impact on when you take time out to learn Why use BSA Grow?

Making the most of BSA Grow:

Promotes excellence in hearing and balance

Flexible

Bite sized CPD

Cost effective

Network through forums

Watch again and again

National and international speakers

Most resources free to members

Variety of learning options

• Dip in to BSA Grow on a regular basis and try to be active within the site • Take part in planned live events where questions and discussion with enhance your learning • Browse the library section for all of the recorded events • As a member, you’ll receive updates on new content and events

If you would like to contribute to any BSA Grow content or events, if you have any queries or you require any support please get in touch: bsa@thebsa.org.uk

BSA Grow 2017 Highlights

Lunch and Learn webinars

What has the National Acoustics Laboratories done for Audiology?

Harvey Dillon, Research Consultant, National Acoustic Laboratories, Australia; Visiting Professor of Auditory Science

BSA turns 50 – a look back on audiology Babies Benefit from High-Quality Hearing Aid Fittings

Marlene Bagatto, Au.D., Ph.D. – National Centre for Audiology, Western University, Ontario, Canada

Where it all began – an interview with Arthur Boothroyd

Arthur Boothroyd – Founding Member

Journal Club

How to run a journal club

Judith Bird, Clinical Scientist (Audiology), Addenbrookes Hospital, Cambridge

BSA Today


BSA Today

16 BSA Grow 2017 Highlights

Lunch and Learn Feature Veterans with post-traumatic stress disorder: Signs, symptoms and treatment The short communication is based on the online BSA Lunch and Learn seminar by Dr Manveer Kaur, Senior Clinical Psychologist, September 2017

Combat Stress is the UK’s leading Veterans’ mental health charity, with specialist expertise in the treatment of complex post-traumatic stress disorder (PTSD). Our service provides a 24 hour helpline for veterans and their families, community support and we have three residential treatment centres across the country.

er veterans to help normalise the symptoms, skills groups

A small, but significant, percentage of veterans will develop PTSD as a result of overwhelming experiences they faced during military service. During these experiences veterans may have felt intense fear, horror and/or helplessness at the situation and the memory of that incident becomes ‘stuck’ and not processed in the usual way. This results in a number of difficult symptoms for the veteran:

contact the triage team in your region:

• The memory coming back to them unpredictably during the day or at night in the form of nightmares • Feeling as if they are stuck ‘back in the past’ in the memory which is called a ‘flashback’ • Feeling constantly on edge and extra vigilant for possible dangers, threats and escape routes

to develop positive calming strategies and individual trauma-focused therapy to help them process the traumatic experiences. If you would like to refer a veteran to our service please

• North region of the UK including Scotland, North West England and North England Borders call 01292 561 350 or email outreachnorth@combatstress.org.uk • Central region of the UK including Wales call 01952 822 750 or email outreachcentral@combatstress.org.uk • South region of the UK call 01372 587 080 or email outreachsouth@combatstress.org.uk • Northern Ireland and Republic of Ireland call 02890 269 999 or email outreachireland@combatstress.org.uk

• Disrupted sleep and poor concentration • Avoiding going out or avoiding reminders of the bad memories • Being highly self-critical and blaming of themselves • Using unhelpful ways of coping e.g. alcohol and drug misuse, over-exercising, gambling Veterans often have several barriers to seeking help for mental health disorders, including stigma, denial, and a perception that civilian people will be unable to understand their experiences or help them. In the seminar, we end by discussing how a ‘typical’ veteran might present, highlight how their difficulties may have developed, and how we might work with them at Combat Stress. The treatment includes education groups with oth-

BSA Today

Biography Dr Manveer Kaur is a Senior Clinical Psychologist, who qualified from the University of Surrey in 2012. Following a 1 year post in the NHS, she moved to Combat Stress to specialise in the treatment of veterans with complex mental health problems. She has worked at Combat Stress for the last four years and has published an article on an innovative approach to adapting trauma therapy for veterans. Her areas of special interest are post-traumatic stress disorder, sexual trauma, working with diversity and therapy through interpreters.


BSA Today

17 BSA e-Conference

BSA Brilliancy gave us Global Brilliancy 2017 Review of the BSA’s first e-Conference Sebastian Hendricks Clinical lead and consultant audiovestibular physician & paediatrician on behalf of the paediatric audiology and audiovestibular medicine service Royal Free London NHS Foundation Trust

From the start, when Laura Turton told me that the e-Conferance was being planned, I was excited as I saw the potential of bringing high-quality CPD into the workplace. Thinking about our department, where we struggle to get funding for audiologists to access professional CPD, I asked if we could register as a department. Chris Cartwright and Laura took this idea further and … voilà we could. So, a room with a large screen and internet connection was booked, and those who wanted to attend were registered. We chose two mornings and whole of the third day. As none of us needed to travel or book accommodation, we could all sleep in our comfortable beds, and we only had to find the money for the registration. The cost of the e-Conference was much lower than even a couple of people attending an external conference elsewhere. Our clinics were blocked off, and we even offered our school hearing screeners the opportunity to attend for two specially selected lectures. I checked all IT and firewall issues were sorted, or at least, so I thought. The first day came, and I arrived in good time to the education centre, to find that the same Trust IT system seems to work differently there. Unfortunately, as we could not get connected despite support from IT and Laura, we all headed back to our offices. By the second morning, we finally had everything sorted. The first lecture on the second day lifted our mood immediately. After each talk, we stopped and discussed what we had heard, noted our reflections and possible changes for our own practice.

having the department together and facilitating the discussions. Although we selected two lectures specifically to watch jointly with the school entry hearing screeners, the content of those was more than challenging for them, so I would not recommend this for the majority of ATOs, unless there is new specific content designed for them. We also opened it up to our locum audiologist,Tasnim, who was keen to join us. You can read her specific thoughts below: “This was a great initiative which I was very grateful for being a single mother this made information at this conference accessible to me…At work and with anything in life it can be easy to fall into a routine and not think outside the box. This webinar was like pumping fresh ideas and curiosity back into me, and a few of my colleagues commented similarly. Reminding me why I enjoy audiology in the first place and the opportunity of research ideas. For me, it pushed me to contact my university to look into options of gaining a Masters. A truly invaluable experience being unable to attend a conference for such a long time due to childcare issues…I feel it would be great if these webinars were able to work on Tablets so we could access them on the go. I also felt the user interface experience was not great and this could also be improved. Looking forward to the next one.” Tasnim Araibia, Paediatric Audiologist I think Tasnim sums it all up. We now hope for the second one and send a big Thank You to all those who made this happen.

The third day was even better as we all knew the format. The discussions became more detailed and inclusive. I think it brought our department closer together and showed knowledge that was not so obvious before. I feel that this group learning experience is possibly better than just asking the presenter a question and receiving an expert answer. Everyone attending enjoyed this conference despite the technical difficulties. In my view, there is a huge benefit in

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18 SIG updates Learning and Events Group (LEG) Siobhán Brennan Learning and Events Group (LEG) E: siobhan.brennan@manchester.ac.uk

Carmel Capewell Learning and Events Group (LEG) E: carmel.capewell@gmail.com

During the first week of December, the UK’s largest Audiology e-Conference took place. The decision to offer this was following the observation within the Learning and Events group that many Audiology professionals are finding it increasingly difficult to find the time and finance to attend training and conferences.This is not dissimilar to educational trends in other professions. In addition to the challenges of attending conferences for delegates, speakers also have limited availability and the further they have to travel the less likely it is that we can lure them to our conferences. With all of this in mind, an intrepid team from the BSA Learning and Events Group attempted to put together an “e-Conference”. This LEG team was led by Laura Turton and included Chris Cartwright, Gemma Crundwell, Roulla Katiri and myself. We were very fortunate to work on this with the fantastic teams of Fitwise and Icohere©. To start with it was necessary to have a suitable platform that could cope with multiple formats; including online presentations, webinars and online chatrooms. In the last year the BSA has started to use Icohere© for their learning delivery. Technical difficulties were to be expected whichever platform was used and we found that NHS Trusts were cautious about allowing access to the software and so some delegates accessed the conference at home instead of at work. Laura Turton did an amazing job of recording all of the presentations before the conference started. Adding subtitles was challenging – we opened the presentations in Youtube© which can add subtitles automatically – however there were quite a few amusing errors! When these had been corrected the files were then returned to the Icohere team to add to the conference site.The presentations were available initially for a week, however we took the advice of the Icohere team who said that we were offering too many pres-

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entations for most people to get through in a week, so we extended the time for delegates to access the conference materials. One of the most exciting aspects of this type of conference for the programme committee was the reach that was possible in terms of speakers from anywhere in the world. For the first running of the e-Conference it was decided to limit the number of live events because these were the parts that were most likely to go wrong! Arranging them involved some very kind speakers being prepared to stay up very late or get up very early to cope with the global time differences! While the BSA could take certain steps to ensure that the technology was working, we had little control over the devices being used by the presenters so the potential for the technology to fail was higher than we would have liked. The live events were originally going to be in the format of a debate: ask 2 experts within a specific field who disagree on a particular topic, to present their opposing positions and then have a debate and perhaps a vote at the end. This was a nice idea but it was surprising quite how many speakers felt that they didn’t disagree with anyone about anything! One of the major advantages of a face-to-face conference is the opportunity to talk with colleagues. In an attempt to emulate this there were chat rooms each centred on different topics. We had high hopes that the discussions would be particularly interesting because we had such a wide range of delegates from different job roles and countries all over the world. However, the chat rooms were relatively quiet and we are considering ways that we can generate more conversation next year. From this summary it will have become apparent quite how many surprises that we had this year. Overall, we were really pleased how much interest there was in this conference both from speakers and delegates and the opportunities that this format offers us in terms of hearing from such high quality presenters based all over the world. We have learnt so much from this year we are very much looking forward to next year’s!

More information about our Special Interest Groups and its members is available on the BSA website.

www.thebsa.org.uk


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19 Balance Interest Group (BIG) Rose Butler Balance Interest Group (BIG) E: Rosie.Butler@mft.nhs.uk

Andrew.Wilkinson Balance Interest Group (BIG) E: Andrew.Wilkinson@UHBristol.nhs.uk

The recent meetings of the Balance Interest Group at the Ear Institute, UCL have focussed on updating the BSA Caloric recommended procedure and may we say a huge thank you to Vicki Kennedy (Clinical Scientist, Royal Liverpool University Hospital) who has been working tirelessly to edit previous versions and the flurry of comments to account for changes to practice. Work will soon commence on updating the C-VEMP recommended procedure to include guidance on O-VEMPs. Within our meetings we have discussed the great work being done across the nation to promote high quality assessment and management of patients with balance difficulties within a number of smaller regional groups. It is great that so many professionals are getting together to liaise and share ideas and thoughts on how best to manage this heterogenous patient group and we can all learn so much from each other. It is also an exciting time to be involved within advancing vestibular science, as the evidence base continues to grow, of particular interest is how best to use the vHIT. We realise there is a need for a guidance document on the procedure and more importantly the interpretation and it is anticipated that this will take some work to create. In the interim, therefore we will be publishing a Technical Note on the vHIT so watch this space! Furthermore, hospital departments and companies are trying to engage Neurologists’ interest into our ever complex area of audiological science and we hope this is something we as the BIG can drive forward with the support of Dr Diego Kaski (Consultant Neurologist, National Hospital for Neurology and Neurosurgery, Queen Square). Developing work from the USA at John Hopkins University on how to use the vHIT within the limitations of the HINTS protocol for acutely dizzy patients, has highlighted how we as vestibular professionals could improve access to services, namely vestibular rehabilitation in a timely manner for those patients who present to the Accident and Emergency ser-

vice and are discharged with a diagnosis of a peripheral vestibular insult. On this point Debbie Cane (Clinical Scientist and Senior Lecturer at University of Manchester) and Amanda Male (Highly Specialised Physiotherapist, RNTNE) have collaborated to develop a useful guidance document on provision of vestibular rehabilitation.This document aims to provide evidence-based guidance on how to deliver vestibular rehabilitation and is not designed to be prescriptive but rather highlight ways to holistically manage patients within a vestibular rehabilitation service. This document is currently in the final stages of editing and we hope will be released shortly. The BIG is also excited to mention the forthcoming BSA BIG conference which we are planning to host this Autumn and we are currently inviting speakers to attend. If you would like any particular speakers to be invited or have a desire for specific topics to be discussed please do not hesitate to contact our chair Andrew Wilkinson. The exact dates and location have yet to be finalised but the conference looks to be an exciting platform to discuss the hot topics in vestibular assessment and rehabilitation and learn from esteemed international colleagues. We have said a sad goodbye to long-standing members such as Dr Peter West (Consultant Audio-vestibular physician, Queen Alexander Hospital Portsmouth), who has since retired and stepped down from the BIG. Additionally, Dr Ghada Al-Malky (Head of Education and Senior lecturer in Audiology at UCL) is phasing out her attendance to the BIG. Debbie Cane and Paul Radomskij (Clinical scientist and Senior lecturer UCL Ear Institute) are also phasing out their membership to the group over the forthcoming months. These departures have made way for new members to join and for recruitment of a further three members. If you have an interest in the assessment and management of patients with balance difficulties we would love to hear from you.

Electro-physiology Interest Group (EPIG) Dr John E FitzGerald Electro-physiology Interest Group (EPIG) E: john.fitzgerald@nnuh.nhs.uk

Over the last six months members of the Steering Group have been working hard on the revision of Guidance for Auditory Brainstem Response testing in babies and Guidance for Cochlear Microphonic Testing. These two documents have undergone significant updates and they have

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20 been submitted to the PGG (Professional Guidance Group) in December 2017.The revised documents clarify a number of issues and will enable enhancement to practice. In early 2018, revision of the Guidelines for the early audiological assessment and management of babies referred from the newborn hearing screening programme is expected to be completed, offering clearer guidelines for clinical practice. The recommended procedure for Otoacoustic Emissions (OAEs) Testing in paediatric and adult audiology is also due to go out to membership consultation. During 2018 the EPIG steering group will be producing regular short articles of interest that will be e-mailed to EPIG members. This will include subjects such as a ‘reference to a scientific article’ with a brief summary and a personal view on what was of particular interest in the publication or ‘EP Tips’ that will focus on a specific area of clinical practice, taken from the EP guidelines - e.g. Why it is important to test 1kHz before proceeding to CM when 4kHz is absent or grossly abnormal or when to use a notch filter. Of course, questions won’t be limited to ABR testing of babies and in time will extend to OAE and SVR work. If you are interested developing your expertise and skills in electrophysiology work why not join the EPIG as a member, just e-mail on the contact above, membership is open to all BSA members.

Paediatric Audiology Interest Group (PAIG) Verity Hill Paediatric Audiology Interest Group (PAIG) E: verity.hill@uhcw.nhs.uk

We had our 1st PAIG meeting of 2018 in January where we congratulated each other on a great 2017 and put together our action plan for 2018. Things to look out for include: • A revised version of the Distraction Test Guideline and the Behavioural Observation Audiometry Guideline. We welcome comments from the BSA members when they come out for consultation. • Joy Rosenberg from Mary Hare has worked hard with Laura Turton to provide an e-learning course on educational audiology. Please look out for this on BSA Grow soon. • Myself at Coventry and Veronica Roscoe from Warwick will be looking and working on the impression taking guideline for under 5 years and will get the 1st draft

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together by the end of April 2018. • Karen Willis from Nottingham and Vanessa Sharp from Brighton are looking forward with working with the Electrophysiology SIG on the review of ‘Guidelines for the early audiological assessment and management of babies referred from the NHSP’. Unfortunately, we are losing Kinjal Mehta from the PAIG who has stepped down to finish her PhD studies. I would like to take this opportunity to thank Kinjal for all her dedicated work over the past 2 years and good luck for the future. We look forward to welcoming new committee members to the PAIG in the coming year and we always encourage new interested potential committee members to contact us via bsa@thebsa.org.uk the subject for the attention of the PAIG Chair. Please also get in contact if there is anything that you think PAIG should be looking at for 2018.

Cognition and Hearing Special Interest Group (PAIG) Christian Fullgrabe Cognition and Hearing Special Interest Group (CH SIG) E: Christian.Fullgrabe@nottingham.ac.uk

At the 2017 BSA Annual Conference in Harrogate, Piers Dawes “retired” from his role as the chair of the Cognition & Hearing SIG. Through his own research and active involvement in SIG activities, Piers has been very successful in raising awareness for and in channelling efforts to further explore the interplay between auditory and cognitive processes. As one of the SIG’s founding members, he has greatly shaped and inspired the Cognition & Hearing SIG, and he has played an instrumental and facilitatory role in many of the SIG’s achievements over the past years. These include the publication of a much-cited “white paper” on listening effort and fatigue (McGarrigle et al., 2014), and the drafting of proposals for development of assessment and treatment guidelines for adults with learning disabilities and adults with dementia, led by SIG members Siobhan Brennan and Sarah Bent, respectively. As the new chair, I would like thank Piers in the name of the entire CH SIG for his contributions. The SIG’s steering committee is scheduled to meet in early 2018 to discuss future work priorities of the SIG, as well as its general format and role within the BSA.This and all other meetings are open to interested SIG members.


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21 Adult Rehabilitation Interest Group (ARIG) Mel Ferguson, Adult Rehabilitation Interest Group (ARIG) E: melanie.ferguson@nottingham. ac.uk

This enthusiastic and productive group continues to make good progress. One of the most exciting developments is the innovative ‘Sound Practice’, which is an online resource that aims to promote good evidence-based clinical practice and innovations within UK audiology. The development of the website is well-underway, and clinical case studies that aim to address the three Es (effectiveness, efficiency, experience) are being collated. The formal launch of Sound Practice is anticipated to coincide with the BSA/BAA/BSHAA ‘Our Connected Future’ meeting. Jane Wild, who has been leading this development will give a presentation on Sound Practice at this meeting as part of ARIG’s commitment to future developments in the online world of connectivity. Oticon has kindly agreed to sponsor the development of Sound Practice. If you have any ideas or innovations you would like to include in Sound Practice – and this is open to anyone – let myself or Jane know. We want to hear about all the great AR work that is going on around the country. Our survey on Outcome Measures, which will form the basis of our soon to-be-developed Outcomes Toolkit, has taken a different direction. The original FOI approach to CCGs and Health Boards resulted in only limited responses. Freedom to obtain information is not quite as free, easy or effective as it might sound. Instead, the survey will be sent electronically to Heads of Service directly in the new year. So if you are a HoS please fill this survey in – there are no difficult questions and it will take about 10 minutes tops to fill in. It’s for a good cause, as we need to be able to show the value of all the good work that is being done every day in AR clinics. Meanwhile, we are developing the Toolkit, which will provide background information on a range of commonly used outcome tools, including their purpose, the what, why and when the tools should be used, the psychometric characteristics and scoring algorithms.

The work that ARIG members are doing contributes to and complements other national initiatives. For example, the development of the NICE Guidance on Adult Onset Hearing Loss (draft out for consultation between Nov-Jan, with final publication in May 2018), and the Action Plan on Hearing Loss groups delivering on research, living well, prevention and other areas. We have dedicated a section on BSA Grow to UK Adult Rehab. Here, you will find information relating to the rationing for hearing aids, including the recently published Cochrane Review on the effectiveness of ‘Hearing Aids for Adults with Mild to Moderate Hearing Loss’, and other research evidence. There is a comprehensive list of systematic reviews of AR interventions and other information to support AR delivery. Finally, it was a real pleasure when myself and Jane both received a BSA Members Award for our contributions to ARIG and other aspects of BSA work, as part of the 50th celebrations for the BSA. But it is even more of a pleasure working with so many talented and enthusiastic individuals. I am fully expecting 2018 to be a great year for ARIG. Adult Rehab is one of the most widespread clinical aspects of Audiology, and it’s important. Not just because of the huge numbers who access AR clinics seeking help for their hearing each year, but because of the impact good rehabilitation has on the lives of all those individuals with hearing loss, and their family and friends.

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BSA Today

22 Auditory Processing Disorder Special Interest Group (APD SIG) Nicci Campbell Auditory Processing Disorder Special Interest Group (APD SIG) E: N.G.Campbell@soton.ac.uk

I have recently taken up the position of APD SIG Chair again and would like to thank Pauline Grant for her dedicated work in moving both our SIG and APD as a field forward. Pauline is staying on as a valued member of our SIG. We say a big thank you and sadly goodbye to Kelvin Wakeham and Dilys Treharne. Both have made a very valuable contribution to our SIG during their terms of office. The BSA Global Brilliance e-conference (to celebrate the BSA’s 50th Birthday) was a great success. Thanks to Wayne Wilson (University of Queensland) and Sharon Cameron (National Acoustic Laboratory) - our invited APD speakers. Both gave excellent presentations! Wayne’s presentation “The Evolving Concept of (C)APD” offered a synthesis of the field and reviewed different approaches to and position statements on (C)APD and the key arguments affecting its evolution. It offered an interesting snapshot of what different perspectives are around the globe. Sharon’s presentation “New Directions in (C)APD Assessment – Current NAL research” focused on translational research currently being conducted at NAL into the development of novel assessment tools aimed at identifying specific deficits in auditory processing. APD continues to be an area of dynamic change. The last four years have seen a surge of interest in and publications

on APD, including position statements and guidance documents from around the world. The result has been to place APD on a scientifically more rigorous trajectory. An interesting development is that the 2017/18 ICD-10-CM (2017) now also includes a specific diagnosis Code, i.e. H93.25 for central auditory processing disorder (CAPD); a term used interchangeably with APD. The APD session at the BSA Annual Conference 2017 was well attended and generated some great discussion. Tony Sirimanna gave an overview of APD assessment and management in children. Doris Bamiou gave an overview of APD assessment and management in adults and I provided an update on the new BSA Position Statement & Guidance Document (2017) which was under consultation and peer review at the time. We are happy to announce that our new Position Statement & Guidance Document (2017), which is currently being ratified by the BSA Council, will be released early in 2018 (and hopefully well ahead of you reading this). Special thanks to all that contributed during the membership and public consultation process, as well as the two anonymous peer reviewers. We are currently working on our first ever APD module for BSA Grow (an online training programme) and have exciting plans for the year ahead. We have an exciting opportunity for new members to join our dynamic BSA APD SIG, which includes both clinicians and researchers from a range of different disciplines. Our APD SIG has excelled in recent years and shaped international thinking. More information about this and how to apply will be made available, just as soon as the BSA Council gives the go-ahead.

Global Outreach Special Interest Group (GO SIG) Gemma Twitchen Global Outreach Special Interest Group (GO SIG) E: bsaglobaloutreachchair@gmail.com

The Global Outreach Special Interest Group (GO SIG) are coming up to the anniversary of their first year as a SIG. We have had a busy year already and are in the midst of planning our activities for 2018. We are currently focusing on organising a BSA/ENT UK Inaugural global health conference, which is to be held in London on the 11th May. This event will be the first of its kind in the UK and we

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have confirmed some excellent speakers who will promote and publicise activities in this field to those that attend. We are hopeful that this will be a stimulating and well-attended meeting and will start the all-important conversations about the issues of hearing loss globally, develop a string UK network and seek out ways in which the BSA GO SIG can support some of this work. If you are interested in attending the meeting, please keep your eyes peeled on the BSA and ENT UK’s website for further details over the next few weeks and we hope to see you there! Another key area we are looking at developing is a network of all those who are interested in or have been involved in global outreach for hearing loss. If you have been working


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23 in or are interested in global outreach for hearing loss, we’d love to hear from you. If you opt to be part of the network, you will receive updates about what’s going on in this field; it’s also a chance for you to share stories, knowledge, ideas and opportunities to help people working or volunteering globally with hearing loss in developing countries. if you’re interested or even intrigued, please take this short survey. Thanks! https://www.surveymonkey.co.uk/r/525BDFQ At the time of writing the World Health Organisation had released their plans for the upcoming World Hearing Day on 3rd March 2018. The theme for the day was ‘Hear The Future’ and focused on: •

rising prevalence of hearing loss globally;

importance of appropriate preventative actions to stem the rise;

need to ensure access to rehabilitation services and communication for people with hearing loss.

The GO SIG were in preliminary conversations about our activity for this day and were also exploring whether we could fundraise or even collaborate in making a big splash about the great work being done in global outreach for hearing loss and promote our work further. The links to access WHO documents for WHD can be accessed here - http://www.who.int/pbd/deafness/world-hearing-day/en/. The GO SIG are always open to ideas and if anyone has any great ideas for fundraising or events, please do feel free to contact us on the email above.

Tinnitus and Hyperacusis Group (TH SIG) Derek Hoare Tinnitus and Hyperacusis Group (TH SIG) E: derek.hoare@nottingham.ac.uk

The objectives of the TH SIG remain as they have been with a current focus on the developing evidence based guidance and raising standards across the private and public sectors. We also aim, this year, to support CPD opportunities including development a BSA Grow module on tinnitus. Work continues on the ‘Clinical practice guidance for tinnitus in adults’ led by myself, and a ‘Recommended procedure for measuring sound sensitivity in people who have tinnitus or suspected hyperacusis’, led by Pete Byrom. Both will shortly be out for member consultation. The third document in development is a ‘Recommended procedure for fitting combination hearing aids for tinnitus’ led by Mag-

dalena Sereda and Julie Brady. Since our last update a survey of the experiences of 96 combination hearing aid users was completed, and a Delphi survey of 36 clinicians experienced in fitting combination hearing aids is ongoing, both supported by a BSA Applied Research Grant. Altogether, learning from these surveys will inform the final content of the recommended procedure. Once the new BSA tinnitus documents are progressed the SIG will be turning attention to guidance and recommend procedures for hyperacusis. Members should contact the SIG if there are specific hyperacusis procedures they would like to see developed. Priorities will also be informed in part by the results of the BSA supported James Lind Alliance Hyperacusis Priority Setting Partnership (www.hearing.nihr. ac.uk/research/hyperacusis-PSP). This is an ongoing project to generate a top-10 list of priority research questions on various aspects of hyperacusis including assessment, management, and healthcare delivery. Over 300 patients and clinicians contributed their questions about hyperacusis to stage 1 of this project. The next stage, over the coming months, involves two prioritisation exercises with patient and clinicians. Two developments in tinnitus are worth noting. First, the European multi-disciplinary practice guideline for tinnitus diagnosis, assessment, and treatment developed by members of the TINNET (http://tinnet.tinnitusresearch.net/) working group, including myself, is now complete and will be formally publicised at the 2018 international Tinnitus Research Initiative conference in March. NICE have also initiated development of tinnitus guidance, and we are delighted that Veronica Kennedy was appointed as clinical lead on the guidance; Veronica was a key member of the team who developed BSA guidance on tinnitus in children. The BSA TH SIG are a registered stakeholder for the NICE guidance and three members attended the initial meeting in October 2017 from which a draft scope was proposed. The draft scope was out for stakeholder consultation in November-December 2017, and the TH SIG submitted a response. At this stage the scope covers children over 5, young people, and adults with suspected or confirmed tinnitus, with specific consideration planned for people with tinnitus who also have hyperacusis, are profoundly deaf, or have cognitive difficulties. We look forward to continued input into the development of this important guidance over the next 2 years. And finally, we are delighted to welcome new members Kathryn Fackrell and Beth-Anne Culhane to the TH SIG. If you have any comments, suggestions, or questions for the TH SIG or would like more information on any of the initiatives described then please do get in touch on the email above.

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BSA Today

24 Professional Guidance Group (PGG) Donna Corrigan Professional Guidance Group (PGG) E: donna.corrigan@dmu.ac.uk

During 2017 there have been a few changes to the members of our team, with three advisors stepping down while we successfully recruited four new ones. I would like this take this opportunity to say a huge thank you to Robert Rendell who had to step back after exceeding his term of office after 25 years of his involvement in BSA and in more recent years the documentation side of things, his experience and knowledge has been very much appreciated and will be greatly missed - we even hope that he might return after a break from service! The current PGG membership includes myself as Cahir, Samantha Batty – Vice Chair, Jay Jindal, Barry Downes, Hema Bath, Paul White, Wasim Hussein and Andrew Horsfall The BSA resources page is one of the most visited pages on the BSA website and many of you will have noticed that we now ask you to sign in to access this page so that we can start to track its popularity. Since this began there has been an incredible 4,000 people log in to access documentation!

The PGG are responsible for making sure that all documents follow a robust development process in order to become published on the BSA website (http://www.thebsa. org.uk/wp-content/uploads/2016/05/Procedure-for-Processing-Documents.pdf page 6).

As always there are a significant number of documents within this process at the moment. New documents proposed or in creation

Documents not requiring/undergoing review at this time

Type of document

Existing documents in review

Recommended Procedures

11

5

2

Practice Guidance

10

15

2

Minimum Training Guidelines

1

0

5

Position Statements

1

0

0

Totals

23

20

9

With over 40 documents in review or creation it’s going to be a busy 2018, please check the BSA website regularly for both the public consultations on these documents as well as the newly published documents as they go live on the website!

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26

Tools for person centred management of tinnitus CD

Author and Correspondence

Dr Cherilee Rutherford, AuD Senior Audiologist, Ida Institute Correspondence address: Ida Institute 98 Egebaekvej Naerum 2850 Denmark E: address: crut@idainstitute.dk

In the UK, the prevalence of tinnitus (the proportion of the population who has the condition at a specified point in time) has been reported as 16.9% (Dawes et al, 2014) for adults between the ages of 40 – 69 years. Incidence refers to the number of new persons developing tinnitus over a specific time frame, and incidence studies for tinnitus in the UK have projected that there will be 324,000 new individuals with significant, self-reported tinnitus per year between 2012 – 2021 (Martinez et al, 2015). The evidence supporting psychological treatment options for tinnitus such as cognitive behavioural therapy (CBT) and acceptance and commitment therapy (ACT,) is stronger compared to that of non-psychological interventions. The delivery however of these psychological therapies is challenged by the shortage of clinical psychologists (Wan Suhailah et al, 2015) and the lack of standardised training in counselling and psychotherapy techniques that are available to audiologists (Taylor et al, 2017). Thompson et al (2017) conducted a Delphi review (a survey method to develop consensus among subject matter experts) to investigate which aspects of counselling and psychotherapy techniques are considered important for audiologists to include in their tinnitus management. The panel consisted of 39 members and included patients, audiologists, hearing therapists and psychologists from the UK. The results of the consensus review demonstrated a wide range of topics and techniques and the interested reader is referred to Thompson et al (2017) for a detailed description of these. For the purpose of this article on person centred tools for tinnitus management, it is interesting to highlight a few aspects that were deemed important by the Delphi re-

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view. There was universal consensus by the panel that it was important to dispel common misconceptions about tinnitus. Tinnitus education, and specifically education regarding etiology, maintenance, and progression was considered important. Discussing expectations of treatment, the emotional effects of tinnitus, relaxation, and opportunity to review and reflect on therapy sessions have been marked as important. In addition, common therapeutic skills such as developing the therapeutic relationship, empathy, encouraging discussion, active listening, socratic questioning, and signposting patients to suitable resources have all been agreed as important components of tinnitus management. When we listen to the stories from hearing care professionals around the world about treating patients with tinnitus, we often hear how daunted they feel to deliver services in this area. Many clinicians find it challenging to treat tinnitus patients, even though tinnitus is quite a common symptom. There are a number of reasons for uncertainty in tinnitus management. Tinnitus has different causes and patient experiences vary - a treatment that works for one patient may not work for another. Additionally, many clinicians do not specialize in tinnitus and may feel that they do not have adequate counseling skills or training to support the patient. Persons suffering with tinnitus often report how hard it is for them to find a clinician that is interested and willing to help with their tinnitus. They note that some medical staff shy away from “things they cannot fix”. They are told that there is no cure and that they simply just have to live with it. In December 2016, the Ida Institute facilitated a 2 day mini-seminar in Denmark to:


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27 1. Understand the challenges facing patients and clinicians managing tinnitus in daily life 2. Build knowledge regarding current practices and research, and

organisations, and online forums so that more people can have access to good quality first information about the symptoms they might experience.

3. Create a guide to support person centred practice to tinnitus patients.

1. Tinnitus First Aid Kit (www.tinnituskit.com) The First Aid Kit is an easy to use website full of information about tinnitus. It is intended for persons with tinnitus and has been designed to provide good quality information and support to patients from when they first become aware of it. It was developed in collaboration with the British Tinnitus Association (BTA). Patients are able to look at the causes of tinnitus as well as browse through some basic management options. By learning more about tinnitus and having access to some basic management strategies in the early days of having tinnitus, patients might be re-assured in the run-up to seeing a professional. The website is a source of reliable information about tinnitus and also links to other reliable sources like the BTA, American Tinnitus Association (ATA), and the Better Hearing Institute. It also contains information about basic sound therapy and relaxation tips that the patient may find helpful in the first instance. The website encourages individuals to explore some further tinnitus management strategies like considering treatment for hearing loss, sleep management and sound enrichment therapy. The website is a useful tool that could also be distributed to GP’s, patient

Question 1: “When you think of tinnitus, what do you think of? Say one or two words that describes how you feel about tinnitus Question 2: “What do you expect from this appointment?”

The challenge to seminar participants was: Can we find a way to dispense hope, compassion, and build resilience in a tangible way in the management of tinnitus? This question was posed to a group of hearing health professionals from Germany, UK, US, Italy, Canada, Switzerland, Denmark & Australia and out of the collaborative work from this group, three new tools have been designed to help deliver person centred care in tinnitus management.

bottom. By having it in this format, it also allows for easy comparison from one session to the next.

Question 3: “During the last week, was there a time when your tinnitus was less bothersome?” If the patient cannot think of a situation, you might ask, “Is there anything you know of that might help with your tinnitus or helped someone else?” 2. Tinnitus Thermometer The Tinnitus Thermometer is a tool to help patients explain how they are experiencing their tinnitus at the time of their appointment. It recognizes that patients might feel tinnitus and its effects differently from time to time, so it is important to start each session as a new beginning. This tool can be used in every appointment. The Tinnitus Thermometer tool consists of three questions to help structure conversations and measure how patients are experiencing their tinnitus in a particular moment. For each session there is a space to document the answers to each of the 3 questions and the thermometer / rating scale at the

Finally, you can explain the following: “The reason I have been asking you these questions is to gauge your ‘tinnitus temperature’ right now to find out what your concerns are about your tinnitus and how best to address those concerns. Are there other things about your situation you would like me to know? Or other things that you would like to know about?” After the patient has answered the questions and you have written down the answers, you can ask the patient to rate their level of discomfort on the Thermometer below the box. Ask the patient to, “Mark the number from 0-10, that best describes how much tinnitus

The Tinnitus Thermometer

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28 has bothered you in the past week, including today.” Zero indicates “No tinnitus,” and 10 is the “Worst possible tinnitus.” The Tinnitus Thermometer is also available as a telecare tool that can be completed prior to the appointment.This has the potential to help prepare the patient better for the upcoming appointment and can save time to allow for more discussion of management strategies during the appointment. 3. Tinnitus Communication Guide The Tinnitus Communication Guide was designed to help hearing care professionals communicate effectively with their patients. The way we talk about tinnitus can have a powerful impact on our patients and can help them feel hopeful about their future. Conversely, poor communication can make patients feel hopeless by the time they leave their appointment. Thus it is important to make an effort to communicate in a way that comforts and encourages your patients. The Tinnitus Forecast is a graph that can The Tinnitus Communication Guide

help explain to your patient that there is a difference between how present and loud the sound of tinnitus is and how much distress it causes them. The Tinnitus Forecast builds on prior work with patients of Dr. Laurence McKenna and Dr. David Scott, Royal National Throat, Nose and Ear Hospital, London. It is part of the Tinnitus Communication Guide. The yellow line is used to explain that tinnitus may always be present at more or less the same level of sound (sometimes a little lower, sometimes a little louder). The blue line represents the level of distress it causes them and how intrusive it is. The important message is to show the patient that although the tinnitus may continue to be present, the level of distress typically goes down over time and that almost everyone with tinnitus finds it becomes more manageable and less intrusive over time. It is very important for patients to understand this key point. Many patients have been told that their tinnitus, “Will never go away.” This does not mean that the patient will have to struggle with it forever. The goal of

this conversation is to give your patient a sense of hope and reduce their fear that they will always feel the same level of distress. By showing the difference between how present tinnitus is and how intrusive it is, clinicians can foster hope in their patients and help them think about their tinnitus in more constructive ways. Sharing this information with patients early in their treatment can have a big impact on how they cope with tinnitus in the long term. All Ida tools are developed by clinicians for clinicians through a process of co-creation and all materials can be accessed and downloaded freely from the Ida website: www.idainstitute.com.

Useful links Ida Telecare for Tinnitus: https://apps. idainstitute.com/apps/tinnitus-uk Ida Learning Hall (CPD and Online Tinnitus Community): http://idalearninghall.idainstitute.com Tinnitus First Aid Kit: http://www.tinnituskit.com Key References: Dawes, Fortnum, Moore et al (2014). Hearing in middle age: A population snapshot of 40–69 year olds in the UK. Ear & Hearing 35:e44–e51

The Tinnitus Forecast

Martinez, Wallenhorts, McFerran, Hall (2015). Incidence Rates of Clinically Significant Tinnitus: 10-Year Trend From a Cohort Study in England. Ear & Hearing 36(3): e69-e75 Wan Suhailah, Mohd Normani, Nik Adilah, Azizah, Aw, Zuraida (2015). The effectiveness of psychological interventions among tinnitus sufferers: a review. Med J Malaysia 70:188–97 Taylor, Hall, Walker et al (2017). A psychologically informed, audiologist-delivered, manualised intervention for tinnitus: protocol for a randomised controlled feasibility trial (Tin Man study). Pilot and Feasibility Studies 3:24

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30

Teleaudiology and teenagers: Minding the gap? CD

Author and Correspondence

Gwen Carr Honorary Senior Research Associate at the UCL Ear Institute

Gwen Carr is an Honorary Senior Research Associate at the UCL Ear Institute, and since her retirement from the role of National Programmes Lead for Antenatal and Newborn Screening for Public Health England in summer 2014, she has worked as an independent consultant primarily in the field of Early Hearing Detection and Intervention and Family Support. With a background in deaf education and paediatric audiology, Gwen was for many years Head of Sensory Services in a metropolitan authority and then spent four years as Director of UK Services and Deputy CEO of the National Deaf Children’s Society, before joining the England NHSP as Deputy Director to Professor Adrian Davis. Her current work focuses on service development, research and training which actively promotes family-centred and person-centred approaches to service provision both in the UK and overseas. She also serves as Co-Chair of the International Congresses for Family Centred Early Intervention, and as a member of the Quality and Clinical Governance Group of the Wales Newborn Hearing Screening Programme. Telepractice - the application of communications technology to provide services at a distance - is now established internationally as an effective approach to delivering services for a range of purposes, including such areas as education, counselling, therapy and healthcare. Telehealth is increasingly utilised to facilitate service access to underserved or remote populations, and also to extend routine clinician reach in many areas of healthcare. In the fields of audiology and early years deaf education specifically, there are some long established examples of providing diagnostic and early intervention services to families where distance from service centres is an issue - such as remote ABR assessments pioneered by Hyde and Campbell in Ontario, Canada1 and the Teleschool operated by Australia’s Royal Institute for Deaf and Blind Children2 to name but two. Teleaudiology with adult populations is also common practice in various countries, successfully overcoming barriers of geographical distance and limitations of physical access. But could there be a particular role for Teleaudiology beyond overcoming distance, for meeting the needs of those in the ‘gap’ between family oriented early support and adult focused provision - adolescents who in transitioning from childhood to adulthood, experience challenging issues in

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relation to their hearing loss, amplification use and engagement with audiological services? Rejection of personal amplification (or radio aids), together with disaffection with specialist services by teenagers is a situation widely recognised by both families and professionals. Research specific to adolescents with hearing loss has identified self-concept and self acceptance, the perception of ‘normalcy’, the inherent isolation of hearing loss, and anxieties about cosmetic appearance as key themes (Elkayam and English, 20033; Kent and Smith, 20064). The experience is not unique to the field of hearing loss however and useful insights may be gleaned from looking outside of our specialty. Challenges relating to adolescent compliance or adherence to treatment have been noted in relation to a wide range of conditions, where rejection or partial rejection of prescribed or recommended treatment has been reported as common even where the resultant outcome could be serious harm to physical health, such as in cases of chronic disease. Factors identified as significant during this crucial time of life when children are moving towards independence from their parents include not only parent and peer influence, psychosocial wellbeing, closeness of friends and family functioning, but also whether


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31 a treatment or intervention has immediate benefits and issues of internal locus of control (Taddeo et al, 20085; Cox and Hunt, 20156). Although lack of adherence to ‘treatment’ is not life-threatening in the case of teenagers with hearing loss, the years in which they experience the issues coincide with the very time they need optimum access to education and social experiences which rely on effective communication, and can have significant consequences for future life choices and long term wellbeing. Traditional

“I was able to relax at home whereas at clinic I feel fidgety and unsettled.......I could talk about things I wouldn’t say in person”. approaches to counselling often try to motivate and persuade or convince by demonstrating the positive impact of amplification on educational access, academic achievement and future career opportunities, as well as addressing psychosocial concerns such as self image and self esteem and fostering resilience. In today’s technological age however, when connectivity is widespread, adolescents have high levels of engagement with mobile devices, and ‘peak understanding’ of digital communications is reported as being in the mid teens (Ofcom, 20147), could Teleaudiology help by evidencing immediate impact of intervention and enhancing the ‘internal locus of control’? By capitalising on the elements of true personal interest, strengthening the patient’s role in managing their own healthcare and purposefully fostering direct engagement with intervention - all factors identified as significant in increasing treatment compliance (Ryan et al, 20118, Erdman et al, 19949, Hibbard and Greene, 201310. ) - could Teleaudiology be both a preferred style of access for teenagers and serve as a tool for self motivation?

A recent service quality improvement project sponsored by Sonova / Phonak in conjunction with paediatric audiology departments in England has sought to explore the potential role and benefits of Teleaudiology with teenagers. Phase One of the project involved conducting focus groups with adolescent hearing aid users who had good engagement with support services and positive attitudes to use of amplification, parents, teachers and clinicians who had expressed interest in Telepractice. Amongst topics covered were experiences of current typical care pathways including identification of ‘danger points’ for disengagement, attitudes towards and experiences of technology, and feelings about the importance and value of face-to-face counselling as opposed to remote contact. The young people involved demonstrated high levels of knowledge of technology and enthusiasm for Teleaudiology in principle. Whilst some clinicians expressed concerns that the clinician/patient relationship may be adversely affected, there was also significant appreciation of possible benefits, echoed by both teachers and parents, despite parents expressing some lack of confidence about their own technological competence and concerns about sustaining the good direct contact they enjoyed with their children’s audiologists. A period of trialling the Phonak Distance Support prototype in eight audiology departments was then implemented, testing out the reliability of the technology and its usability in real life encounters. Technical challenges in connectivity and functionality were addressed, distance appointments were mainly successfully completed, and encouraged by significant learning from the experiences (such as the importance of high quality accessible infor-mation for the participants in advance of the sessions), feedback about the positive balance of the clinician/patient relationship and reported increase of ‘ownership and control’ of the encounters by the young people themselves, the project moved to a second phase. Phase Two was carried out with one large NHS London trust11 and involved 21 twelve to nineteen year olds who had

disengaged from service delivery, characterised by frequent non attendance at clinic, either DNA or unexplained cancellation. Questionnaires exploring attitudes to hearing loss and hearing aids, perceived benefits of amplification, and levels and opinions of support received were completed by the young people, their parents and Teachers of the Deaf. In general there was significant congruence in views although some lack of clarity emerged in parent and student understanding of the role of the Teacher of the Deaf. In addition to the questionnaires, information was gathered through examining case notes and audiology records together with structured feedback reports from the remote sessions ( each participant undertaking at least two), verbatim session transcripts, records of communications between clinician and teen and semi-structured interviews with clinicians. Overwhelmingly the teen participants spoke positively of their Teleaudiology experiences and expressed a wish for it to be their default provision, with comments such as “it saved time for me” , “it was better than coming in” and “I would like all

“We hit our peak confidence and understanding of digital communications and technology in our mid teens”.

my appointments like this”. Students also reported being comfortable with the equipment, feeling relaxed during the sessions, and assessed their relationship with the audiologist during the distance sessions as being at least equal to when face to face in clinic. One student (female, aged 16) perceived the distance session as enabling her to be more open in her communication than when physically in clinic, commenting “I was able to relax at home whereas at clinic I feel fidgety and unsettled.......I could talk about things

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32 I wouldn’t say in person”. However, it is important to note that for two students with below age-appropriate language competence, it was not possible to achieve the audiological purposes of the appointment. Neither was the engagement process straightforward: despite real enthusiasm on the part of the students, there were still some DNAs and late log-ons and clinicians spent considerable time and effort in some cases in ensuring the appointments were fulfilled. Clinician beliefs on the importance of face-to-face discussion also influenced their satisfaction with the encounters from an audiologist perspective, even when the teen participant reported satisfaction from theirs, and the session transcripts revealed that the most successful encounters occurred where teen and clinician conversational language was most attuned.

earlier recognition of difficulties and to facilitate preventative action. So can Teleaudiology ‘mind the gap’ between early support and adult provision by providing increased control for adolescents and motivating engagement through tapping into personal interest and technological competence? Whilst there is much more to be understood about how it might be implemented, and since not all audiological functions can yet be achieved with a remote methodology therefore indicating a mixed approach would be most effective, this limited project would suggest that the signs are positive. It was certainly a catalyst for reengagement, and despite the challenges encountered, could well serve both to motivate engagement and - if introduced sufficiently early - even minimise chances of disaffection.

my ears: exploring perceptions of adolescent hearing aid users. Journal of Deaf Studies and Deaf Education 11(4): 461-476 5. Taddeo D, Egedy D and Frappier J-Y (2008), Adherence to treatment in adolescents. Paediatric Child Health, Jan: 13(1): 19-24 6. Cox L and Hunt J (2015), Factors that affect adolescents adherence to diabetes treatment; Nursing Children and Young People, Vol 27(1) Feb 2015 7. Ofcom (2014) - The UK Office of Communications: The Communications Market Report 2014, www. ofcom.org.uk 8. Ryan R M, Lynch M F et al (2011), Motivation and autonomy in counseling, psychotherapy and behaviour change: A look at theory and practice. The Counseling Psychologist 39(2): 193-260

The project may have provided some References 1. Campbell W and Hyde M (2010), insights too into factors leading to dis9. Erdman S A et al (1994), ImplicaeEHDI: Functions and Challenges. engagement, and although it would be tions of Service Delivery Models in A Sound Foundation Through Early inappropriate to generalise, scrutiny Audiology, Journal of the Academy Amplification 2010, Phonak conferof case notes revealed some common of Rehabilitative Audiology, Vol 27, ence proceedings, Chapter 6 (www. early experiences for the young people 45-60 phonakpro.com) and their families: complexity in achievBSA_A5_Landscape_Membership_Advert.V1.qxp_Layout 1 30/03/2017 12:14 Page 1 10. 1Hibbard J H and Greene J (2013) ing optimum amplification, inconsistent 2. RIDBC Teleschool; www.ridbc.org. What the evidence shows about service provision, ineffective and conau/teleschool patient activation, better health outflicting communication between agen3. Elkayam J and English K (2003), comes and care experiences. Health cies, change of Teacher of the Deaf at Counseling adolescents with hearing Affairs 32, No 2, 207-214 (www. key transition points and early frequent SA_A5_Landscape_Membership_Advert.V1.qxp_Layout 1 30/03/2017 12:14 Page 1 BSA_A5_Landscape_Membership_Advert.V1.qxp_Layout 1 healthaffairs.org) 30/03/2017 12:14 Page 1 loss with the use of self assessment reportings of lost and broken aids. Quite / significant other questionnaires. separately from any consideration of 11. CYPAC (The Children and Young of the American Academy Benefits ofJournal organisational membership include: British Society of Audiology method of service delivery - whether People’s Audiology Centre), St CURRENT MEMBER Audiology,toVol 4 Nothrough 9 attending, • Discountedof opportunities network remote or clinic-based - there may be Organisational Membership Thomas’ Hospital, London; Kieran TESTIMONIALS sponsoring or exhibiting at BSA events, including merit in taking a more focused longitudi- conferences, 4. Kent B lectures, and Smith (2006), They Joseph, Principal Audiologist and twilight journalSclubs and special It maximises opportunities membership include: forCURRENT MEMBER group workshops SA_A5_Landscape_Membership_Advert.V1.qxp_Layout 1 30/03/2017to 12:14 Page interest 1 nal view of family experience enable only see it when the sun shinesBenefits in of organisational Jolanta McCall, Head ert.V1.qxp_Layout 1 30/03/2017 12:14 Page 1 departmental staff to be onof Service • Discounted opportunities to network through attending, Benefits of organisational membership include: • Profile recognition on the BSA website and within the TESTIMONIALS Advert.V1.qxp_Layout 1 30/03/2017 12:14 Page 1 sponsoring or exhibiting at BSA events, including BSA_A5_Landscape_Membership_Advert.V1.qxp_Layout 1 30/03/2017 12:14 Page 1 MEMBER CURRENT BSA Council or Committee,

British Society of Audiology Organisational Membership

British Society of Audiology Organisational Membership

conferences, twilight lectures, journal clubs and special Audacity magazine • Discounted opportunities to network through attending, It maximises opportunities for as they don’t need to be interest group workshops sponsoring or exhibiting at BSA events, including departmental staff to be on • Receive a 30% reduction on advertising within the• Profile recognition on personal the BSA website and withinto thedo this. members conferences, twilight lectures, journal clubs and special BSA Council or Committee, Audacity magazine Audacity magazine It maximises opportunities for as they don’t need to be interest group workshops • Receive a 30% reduction on advertising within the Professor Michael Akeroyd, departmental staff to bewith on benefits including: personal members to do this. • All employees get full membership • Profile recognition on the BSA website and within the Audacity magazine BSA_A5_Landscape_Membership_Advert.V1.qxp_Layout 1 30/03/2017 12:14 Page 1 Director, Medical Research BSA Council or Committee, Professor Michael Akeroyd, Audacity magazine • All employees get full Council membershipInstitute with benefits including: of Hearing as to they don’t need to be Journal of Audiology Director, Medical Research Online access the International • Receive a 30% reduction on advertising within the Council Institute of Hearing Online access to the International Journal of Audiology personal members to do this. Research British Society of Audiology Access to the members’ only area of the BSA website Research Audacity magazine Access to the members’ only area of the BSA website Organisational Membership Professor Michael Akeroyd, Benefits of organisational membership include: 25% discount to all BSA events • All employees get full membership with benefits including: 25% discount to all BSA events As a department that covers enefits of organisational membership include: Director, Medical Research As a department that covers Access to Special Interest Groups all areas of Audiology, having • Discounted opportunities to network through attending, Benefits of organisational membership include: CURRENT MEMBER CouncilInterest Institute of Hearing Access tomembership Special Groups Benefits opportunities of organisational membership include: Online access to the International Journal of Audiology Discounted to network through attending, Benefits ofattending, organisational include: of Audiology, having access to the SIGs will help allforareas • Discounted opportunities network through Opportunity to apply up to £5,000 in research grants sponsoring or exhibiting BSAattoevents, including TESTIMONIALS Research sponsoringat or exhibiting BSA events, including sponsoring or exhibiting at BSA events, including Access to the members’ only area BSA website • Discounted opportunities to network through attending, conferences, twilight lectures, journal of clubsthe and special service development and • Discounted opportunities to network through attending, Opportunity to apply for up to £5,000 in research grants Audacity membership magazine access to the SIGs will help maximises opportunities for conferences, twilightinterest lectures, journal clubs and special group workshops “ Itdepartmental staff to be on conferences, lectures, clubs25% and special knowledge management. sponsoringtwilight or exhibiting at journal BSA events, including • Profile recognitionevents on the BSA website and within It maximises sponsoring orthe exhibiting at BSA events, includingopportunities for discount to all BSA BSA Council or Committee, interest group workshops service development and It maximises opportunitiesAudacity for Audacity magazine As a department that covers as they don’t need to bemembership magazine interest group workshops conferences, twilight lectures, journal clubs and special Available Membership Packages staff to be on conferences, lectures, tojournal clubs and special From Head of Service at • Receive a 30% reduction on advertising within the twilight personal do this. departmental Access to Special Interest Groups departmental staff to bethe on members ”all areas of Audiology, having It maximises opportunities for knowledge management. • Profile recognition on themagazine BSA and within Audacity Itwebsite maximises opportunities for NHS Tayside Audiology and interest group workshops Professor Michael Akeroyd, Profile recognition on the BSA website and within the interest group workshops BSA Council or Committee, • All employees get full membership with benefits including: • Departmental / Small Company includes all employees Director, Medical Research Opportunity to apply forBSA updepartmental toCouncil £5,000orinCommittee, research grants Balance Services Kings Cross Audacity magazine access to the SIGs will help staff to be onInstitute departmental staff to be on Council of Hearing Online access to the International Journal of Audiology Audacity and registered peopleFrom within the department as they don’t need to be • Profilemagazine recognition on the BSA website and within the Research • Profile recognition on the BSA website and within the Hospital Head of Service at Access to the only area of the BSAor website asmembers’ they don’t need to be service development and BSA Council Committee, Audacity membership magazine BSA Council or Committee, • Receive a 30% reduction on advertising within the 25% discount to all BSA events Packages start from £1,000 for up to 20 employees. 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ear globe: audiology around the world

34

Audiology in Zambia: an overview of ear and hearing care services situational analysis FACTFILE... Zambia is a land locked nation in Southern Africa with a population of approximately 17 million.

CD

Author and Correspondence Bhavisha Parmar BSc (Hons), MSc (Advanced Audiology) Volunteer Paediatric Audiologist (Sound Seekers), Lusaka, Zambia

Bhavisha is a paediatric audiologist with experience working within the NHS and private sectors in the UK. She has been a volunteering in Zambia since January 2017 with the UK charity Sound Seekers. Her main roles have been to establish a children’s hearing clinic which provides assessment and hearing aid fitting to children at risk of hearing loss, and working with the Ministry of Health to advocate for the provision of audiology services in the public health sector.

Background information: Zambia is a land locked nation in Southern Africa with a population of approximately 17 million.

Figure 1: Map of Zambia

There is no hearing loss prevalence data available for Zambia so we rely on regional studies and estimates from the World Health Organisation (WHO) to extrapolate the figures. The WHO estimates the prevalence of disabling hearing loss to be between 4-6% of the Zambian population, which would trans-

ear globe: audiology around the world


ear globe: audiology around the world

35 late to 600,000-900,000 people. There is no paediatric hearing screening programme in Zambia. A recent school screening based study within the Lusaka district found 11.5% of school aged children (n=1200) to have a disabling hearing loss as defined by WHO hearing loss classifications (Hapunda, 2015). Zambia is a low to middle income country. Like many other countries in Africa, there is a significant shortage of Ear, Nose and Throat (ENT) and audiology healthcare professionals. Currently in Zambia, there is one ENT Surgeon responsible for every 4 million people, and only one Audiologist (private sector) for the entire country. Current ENT and Audiology Provision in Zambia Currently, there are three establishments offering ear and hearing care in Zambia: 1. University Teaching Hospital (UTH) is the largest government referral hospital and is based in the capital city of Lusaka.The Ear, Nose and Throat department at UTH consists of 2 ENT specialists, 4 ENT general medical officers and 2 audiometricians. The clinic sees approximately 400-450 patients per month for consultations. Audiometry is carried out using manual audiometers in the two sound treated rooms in the ENT department. Historically, patients needing hearing aids were referred to the Zambia National Association for the Hearing Impaired (ZHANI) (for analogue hearing aid fitting) or Beit Cure Hospital. This year, a Children’s Hearing Clinic has been established within UTH with the support of the UK charity Sound Seekers (The Commonwealth Society for the Deaf). Diagnostic assessments and free digital hearing aids are now available for children of all ages. Sound Seekers has been actively involved in the development of government led, sustainable audiology services in Zambia by providing infrastructure, training and equipment since 2011. 2. An ENT and Audiology department was established within the Beit CURE Hospital (Lusaka) in 2009 with funding from Christian Blind Mission (CBM), an international Christian development organisation. The clinic has two ENT surgeons, three audio technicians and three ENT nurses. The audiology department currently provides diagnostic audiological assessments for patients of all ages including the use of auditory brainstem testing. So far this year they have assessed the hearing of 860 patients and fitted 189 of those patients with hearing aids. They have an effective follow up programme and see approximately 30 patients per month for review appointments post hearing aid fitting. Outreach clinics are carried out weekly to identify patients who would benefit from ENT and audiology services. 3. Ndola Teaching Hospital (NTH) is situated in the Copperbelt province. The audiology department was established by Sound Seekers in 2011 and services offered include

pure tone audiometry, tympanometry, otoacoustic emissions and digital hearing aid provision as well as outreach services. NTH has one ENT clinical officer and two audio technicians who were trained by Sound Seekers. On average NTH audiology department sees 164 patients per month for hearing assessments including weekly outreach visits to schools for hearing screening. Human Resource

Current Situation 2017 PUBLIC

PRIVATE

1

Consultant ENT Surgeons

1

1

2

Senior ENT Surgeons

1

1

3

Senior Registrar ENT

7

-

4

Medical Licentiates – ENT

2

-

5

Registered ENT Nurses

-

-

6

Audiologists

-

1

7

Hearing Instrument Specialists

3

4

8

Speech Language Therapists

0

3

9

Speech-language Therapy – Assistants

1

-

Table 1: Current human resource situation for ENT, audiology and speech and language therapy in Zambia.

There is great need for capacity building and training for audiology professionals in Zambia (as seen in Table 1). The Health Professionals Council of Zambia allows registration for Audiologists but a register does not yet exist for speech and language therapists or audio technicians. With this lack of recognition, coupled with the shortage of local/affordable training options, the numbers of specialised health professionals within ENT and audiology is likely to remain insufficient to meet the population need. It is also important to highlight that ENT and audiology services in Zambia are only available in the Copperbelt and Lusaka provinces. Further work is needed to establish ear and hearing care services throughout the country. The most common causes of hearing impairment are wax impaction, chronic suppurative otitis media and sensorineural hearing loss. This is consistent with data from the WHO (2013) stating that more than 50% of hearing loss is due to preventable causes. In developing countries less than 3% of people who need a hearing aid have access to one (WHO, 2013).This is due to low hearing aid production, high cost, insufficient numbers of ear and hearing care professionals and a lack of suitable hearing aid follow up care. In Zambia, digital hearing aids are provided by Sound Seekers through its Hearing Aid Refurbishment Project (HARP) in Beit Cure Hospital and through donations from its funding partners such as Hear the World Foundation. With the HARP, hearing aids are donated to the Sound Seekers London headquarters and then sent to the refurbishment lab housed within Beit Cure hospital’s audiology department. Audio techni

ear globe: audiology around the world


ear globe: audiology around the world

36 cians clean, analyse and reset the hearing aids before distributing among audiology clinics in Zambia and other Sound Seekers’ country programmes in Africa. Currently brand new hearing aids are too costly for the general population of Zambia and without the HARP, digital hearing aid technology would not be accessible. This year has seen landmark events in Zambia that can, with the support of the Zambian Ministry of Health and associated partners, help work towards providing equitable access and coverage of cost effective, quality health services for Ear, Nose and Throat and audiology services making ear and hearing care accessible to the local population . These events include the launch of Zambia’s first ever Ear, Nose and Throat Health Strategic Plan and the official opening of the first paediatric audiology clinic in the country, established with the support of Sound Seekers at University Teaching Hospital, Lusaka. The New Children’s Hearing Clinic Due to the significant need for audiology services within University Teaching Hospital and the lack of suitable paediatric testing equipment/training in the country, Sound Seekers have worked with the Zambian Ministry of Health to establish the first children’s hearing clinic at the UTH Children’s hospital. The Children’s Hearing Clinic is fully equipped to perform behavioural and electrophysiological tests. When a child is diagnosed with hearing loss, ear moulds can be made on site and digital hearing aids can be fitted. The clinic provides advice and support to parents and families as well as health professionals throughout the hospital. Throughout the year I have been on site to establish and run the clinic as a volunteer Audiologist. An ENT nurse has also been sponsored by Sound Seekers to train as an audio technician and will be working in the new clinic from January 2018 to allow for continuity and sustainability of the clinic. Information about the patients seen so far: Between July and September 2017, 73 patients were tested in the new children’s hearing clinic (Table 2). Normal hearing

32

Mild hearing loss

9

Moderate hearing loss

4

Severe hearing loss

3

Profound hearing loss

13

Testing not yet complete/could not test

12

years of age and all were born to hearing parents.This highlights the need to educate parents and communities on the impact of hearing loss in children so that diagnosis, intervention and support can commence as early as possible. The Children’s Hearing Clinic was officially launched by Dr Jabbin Mulwanda, Permanent Secretary, Health Services, on Friday 27th October 2017. The launch also celebrated the first ever Ear, Nose and Throat strategic health plan 2017-2021. Moving forward This ENT strategic health plan is a great step forward for ENT, audiology and speech and language therapy services. It is a result of collaboration between professionals from the CBM, Beit CURE hospital, Sound Seekers and the Zambian Ministries of Health and Education. With the launch of this plan comes a government commitment to develop audiology services. This includes the training of audiology and speech therapy health professionals, as well as the provision of the necessary infrastructure and medical equipment. The following words from the Permanent Secretary, reading the Minister of Health’s speech at the launch, confirmed the Ministry of Health’s commitment to the development of ENT and audiology services in Zambia: “It has come at a great time when we are restructuring the health sector, and I am glad to inform this meeting...that positions for ENT have been established in all our provisional centres. But most importantly, for this gathering, is that audiology positions have also been included in the current structure” Dr Jabbin Mulwanda, Permanent Secretary of Health Services, Ministry of Health This is an exciting time for Ear, Nose and Throat and audiology services in Zambia. With the recent commitment at a government level, efforts on the ground and collaboration with long standing partners Sound Seekers, CBM and Beit Cure Hospital, we are on the way towards the establishment of effective, accessible and sustainable audiology and ENT services. To read more about the progress in Zambia and Sound Seekers work please visit: http://www.sound-seekers.org.uk/volunteer-blog-bhavisha/ References • World Health Organisation, 2013. Millions of people in the world have hearing loss that can be treated or prevented. [Online] [Accessed 26 November 2017].

Table 2: Hearing assessment results for the children seen at the Children’s Hearing Clinic to date. Hearing loss classifications as per World Health Organisation (2008) definitions.

• Central Statistical Office ofZambia, 2010. Zambia Census of Population and Housing- National Analytical Report , s.l.: Central Statistrical Office.

Six children have now been fitted with hearing aids and are making good progress. The children diagnosed with profound hearing loss have been referred to special educational facilities with sign language provision. It is important to note that the group of children with profound hearing loss ranged from 3-8

• Hapunda, R., 2015. Prevalence of hearing loss in primary school children in central zone of Lusaka, Zambia, Nairobi: Dissertation submitted in partial fulfillment of the requirements for the award of the Degree of Master of Medicine in Ear, Nose and Throat-Head and Neck Surgery, University of Nairobi.

ear globe: audiology around the world


ear globe: audiology around the world

37 • Me, A. a. M. M., 2006. Reviews of practices in less developed countries on the collection of disability data . In: International views on disability measures: moving toward comparative measurement, research in social science and disability. Oxford: Elsevier, pp. 63-88. • Ministry of Community Development, Republic of Zambia, 2015. Zambia National Disability Survey, Lusaka: Central Statistical Office. • World Health Organisation, 2013. Grades of Hearing Impairment. [Online] • Available at: http://www.who.int/deafness/hearing_impairment_grades/en/ [Accessed 25 November 2017].

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ear globe: audiology around the world


ear globe: audiology around the world

38

Audiology in Malawi: from the first audiology clinic to the first audiology degree course FACTFILE... Malawi is a landlocked country with a population of 13.2 million. Lake Malawi, 580 km long, is the most prominent physical feature.

CD

Author and Correspondence Helen Brough Clinical Scientist Addenbrooke’s Hospital, Cambrdige E: helenbrough@africanbiblecolleges.net

Helen Brough trained as a Clinical Scientist at Addenbrooke’s Hospital, Cambridge. She volunteered in Malawi for 3 months in 2014, 3 months in 2015, and then became clinical lead at the African Bible College Hearing Clinic and Training Centre for 12 months (2016-17). She spent most of her time teaching clinical skills and working on service development projects, which included setting up a basic vestibular service and the first newborn hearing screening and diagnostics programme in Malawi. Since returning to the UK, she has been working as a locum in London. Helen has a special interest in humanitarian audiology and working with people with learning disabilities.

From the first audiology clinic to the first audiology degree course - an update from Malawi If you are a regular reader of Audacity, you may recall previous articles about the work of the African Bible College Hearing Clinic and Training Centre in Lilongwe, Malawi. The first audiologists arrived in Lilongwe in 2010, where they set up a clinic in a side room of the maternity ward and recruited some students to help out as translators. Just seven years later, there is now a purpose-built Audiology clinic staffed by a Malawian audiologist and a group of well-trained and highly motivated audiology assistants. The clinic continues to pioneer audiology services in Malawi, providing, in addition to the usual hearing assessment and rehabilitation services: • A comprehensive newborn hearing screening, diagnostics and habilitation programme • An early intervention service for young hearing-impaired children • A basic vestibular service • Support for a small number of patients with cochlear implants • Specialist clinics for people with learning disabilities • Regular outreach services to a large refugee camp • Regular satellite clinics at two hospitals in Central Malawi The major news for 2017 is that the African Bible College now has a Bachelor of Science Audiology programme which is approved by the Medical Council of Malawi and currently

ear globe: audiology around the world


ear globe: audiology around the world

39 The training course differs from the UK because it teaches students the skills required to provide and maintain effective audiology services in a low-income country with limited medical resources.This would include financial planning, learning how to make earmoulds, how to carry out dewaxing and the removal of foreign bodies from the ear canal (cockroaches are quite common!).

Your visit could shape the practice of a generation of audiologists

undergoing accreditation with the National Council of Higher Education. Since the beginning, the aim for ABC was a sustainable audiology service, and this requires a high-quality training course to provide audiologists for the future. Currently, there are only three Malawian audiologists, all of whom qualified through the University of Manchester, so it’s very likely that you have more audiologists working in your department than there are in the entire country of Malawi. As Malawi has over 18 million people (World Bank statistics, 2016), the need for more audiologists is very clear. Audiology is still a fledgling discipline in Malawi; one significant issue is that although the Medical Council is satisfied with the training course, the college still needs support from the Ministry of Health. With this support, it is hoped that the well-trained graduates will be offered opportunities to meet the needs of people with hearing loss all over the country. I am not aware of any other BSc Audiology courses in sub-Saharan Africa (outside South Africa) and expressions of interest have come from students as far away as Liberia. Competition for a place on the course is very high. All students must successfully complete the core curriculum in the first year at the African Bible College before they can be considered for the 4-year Audiology programme. Students must fund their tuition, food and accommodation (approximately 1 million Malawian Kwacha, or around £1000 per semester). These costs are over three times the gross national income per capita and therefore a considerable investment from the students and very often, their extended families.

The BSc Audiology programme has been launched with ten very keen students, but the future remains uncertain. The first year of the course includes courses in biology, mathematics and business studies, all of which can be covered by the current college faculty, however, in future years, there will be a growing need for experienced audiologists to visit and teach intensive courses. Is this something you would consider? Most of the course materials have been prepared, and the curriculum is designed to be flexible around the capacity of visiting lecturers. One course module can be taught in as little as 2 weeks or may be extended across a whole six-month semester, depending on the lecturer’s availability. Visiting lecturers are asked to raise support to cover their travel expenses whereas, on arrival their accommodation and food is provided at the college. You don’t need to be an experienced lecturer, just an experienced clinician with an ability to communicate your knowledge clearly and with enthusiasm. Volunteering to teach an intensive course does, as the name suggests, involve long hours, but whereas trips abroad to carry out short-term clinical work offers short-term benefits to a few patients, a short-term teaching role offers the opportunity for influencing long-term clinical practice.Your visit could shape the practice of a generation of audiologists. If you would like to know more, please contact Rebecca Bartlett at hearingabcclinic@gmail.com. Reference The World Bank Data, Malawi: https://data.worldbank.org/ country/malawi?view=chart, retrieved 8 January 2018.

Take home message Are you interested in training future audiologists in one of the poorest countries in the world? Malawi needs experienced audiologists to volunteer to teach their skills – could this be you?

ear globe: audiology around the world


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clinical catch-up

41

Top Ten Qs: Hearing Aids for Music, exploring the music listening behaviour of people with hearing impairments. CD

Author and Correspondence Dr Harriet Crook Dr Harriet Crook is Lead Clinical Scientist for Complex Hearing Loss at Sheffield Teaching Hospitals NHS Trust. She is actively engaged in funded research exploring Auditory streaming, Auditory processing in Cochlear Implant users and music listening with implants and hearing aids.

Following the positive response to the Q&A style article in our previous edition, we have decided to make this a regular feature. Following in the footstep of Gus Muller and his famous Audiology Online 20Q we plan to have a Top Ten Qs within every edition of Audacity.We’re really pleased that future Top Ten Qs will be introduced by Guest Editor, John Day.

What is HAFM all about? Does it have any relevance to me in everyday clinic? HAFM is much more than just a research project. At its heart it had the aim of helping people who wear hearing aids right now as well as providing data that can make improvements in the future as more evidence is gathered. The project has focussed on getting data from both hearing aid users and audiologists about how people are engaging with music using hearing aids, what is good already, and what problems are being encountered for a wide variety of listening conditions and all degrees of deafness. It is likely that a lot of the problems raised won’t be solved by hearing aid ‘programming’ – a big part is education and advice about hearing loss, along with use of ALDs and tips on listening to music in different places.

2. I’ve never asked my hearing aid clients about music, should I be? A simple answer is yes you really should! Our research has shown that 48% of participants in an online survey of 981 hearing aid users avoided listening to music because of their hearing loss either ‘often’ or ‘all of the time’. This is a staggering statistic given the strong evidence for benefit of music on health and well-being, and is something that audiologists have in their power to help change on a daily basis. Only one in five hearing aid users will ask their audiologist about music listening, so this is something we need to change by audiologists asking the hearing aid user and knowing some simple strategies to help listening. 3. So what sort of problems are people reporting? To start on a positive note here, we found hearing aids help a lot of people to hear music without any problems at all, and that in itself is a very encouraging. An important finding was that problems in live and recorded settings can be very different. Interestingly, feedback was not a big issue, and sudden changes in loudness were not common in either live or recorded settings. Distortion and too much treble were most frequently reported for live music listening. Another prob-

lem that was commonly reported was switching between speech and music in live performances or rehearsals. ALDs can help here, and it is important people are aware of what is available to them – if they don’t know about them they can’t make a decision to try or buy them for themselves. Anything else? A major finding was that hearing aid wearers often have a poor understanding of their own hearing loss and hearing aid functions and settings such as the loop, volume and program changes. Knowing how to use the basics can really help, and always giving access to a volume control is a must for music listening due to its much wider dynamic range than speech. We’re aware there are limits on what can be provided within the NHS but many hearing aid users are willing to try and buy – but they can’t do this if they don’t know enough about what is available and understand how it works. You most likely can’t do all of this in clinic either, so think about what resources you could give – please do use the HAFM website and we aim for this to be a single point of contact for information. 4. I don’t know much about music at all - am I going to be able to help someone who wants to listen to music with hearing aids? Yes – as an audiologist you can provide a great deal of benefit by providing information and making some simple changes. More resources will come from the project soon including a clinical guide for audiologists of all levels and a quick desktop guide to use to troubleshoot with your client. Our website www.musicandhearingaids.org is a great resource

clinical catch-up


clinical catch-up

42 to direct hearing aid users to for more specific help and we can also highly recommend two excellent, free Open University courses for 8 hours or 20 hours that can provide a useful introduction to music and terms used and are great for CPD. http://www.open.edu/openlearn/histor y-the-arts/culture/music/introduction-music-theor y/content-section-0 Our website will also soon have a dictionary for helping musicians and audiologists understand each other’s terminology better. 5. Will there be a guide that can tell me exactly what to do? I was discussing this with Paul Checkley of Harley street hearing very recently and we both agreed this is something we don’t think would be possible due to the huge range of listening settings, type of music and hearing loss, a ‘one size fits all’ solution is unlikely where we can specify exact programming changes or gain specifications that would work across groups of people with hearing loss. A lot of the simple changes work effectively and starting there then building up is the best route. Giving your client flexibility to try different programs and being systematic about the changes made so you can truly see what has worked and what has not and allowing hearing aid users to listen in clinic if they can, are really helpful strategies. Often, so many changes have been made it is hard for either the client or audiologist to know what has been successful. Start by fitting as accurately as possible to prescription and see the tips below. 6. So what are the key things from your research that can feed into clinic - what should I do? First take a really good history – find out when and where they listen to or perform music (whether it is live music, the venue size, types of instruments or voice, where they tend to sit or stand) and how they use their aids when they do (e.g. one or both aids, volume settings used, program used, any ALDs or loop), and ask what problems they experience, if any. We have found through

clinical catch-up

our research that live and recorded music listening can be quite different so may need tackling separately (or with separate programs and strategies). Live music can be substantially louder and harder to modify (you can turn the volume down or up when listening at home!) whereas you may not even be able to move seats in a live venue. 7. And what about hearing aid settings? We will be producing a more detailed clinical guide but some simple measures are listed here: Ensure there is no feedback or loudness discomfort when playing or singing. Let your client sing in clinic or bring their instrument if possible, this can take a matter of minutes and allows a ‘realistic’ trial of the aid for how they actually want to use it. Make changes to music in a separate program and always give a volume control and a wide volume range. Remove any active sound management such as feedback management, wind noise reduction as much as you are able to. Increase MPO so long as loudness tolerance is not exceeded For players/singers, use an ‘instrument to frequency chart’ (see our website) to explain to clients where their hearing loss is in relation to the range of their voice or instrument. 8. How can I deal with occlusion for singers or players? This is a problem that crops up fairly often; a few simple solutions can be helpful. Try to give less occluding fittings where possible by using open fits or adapting earmoulds. Don’t forget deep canal fittings and shortening vents, these are often forgotten but can be very effective. For mild-moderate loss, have they tried removing aids? For some people this is fine as the sound levels are sufficient for them to hear the instrument well given it is close to them – this is more often the case than we would think. A quick occlusion check in clinic can be done

by asking your client to say ‘a’ as in father and ‘i’ as in ‘beet’ with the aids in and turned on. If the ‘i’ is louder there is a significant occlusion effect. Consider altered seating positions when performing – this can work well for singers and some performers in small groups but is not always possible. Lastly, try monaural aiding rather than binaural, occlusion is more noticeable with binaural fittings. Where occlusion can’t be resolved by earmould adaptations this can reduce the amount of occlusion experienced whilst still providing amplification to monitor voice or instrument. 9. What about hearing protection? Haven’t we been telling people to turn music down to avoid tinnitus and NIHL? Yes this is a difficult topic for music. We do advise discussing NIHL and noise protection with people wanting to listen to music with a hearing loss. Professional musicians can obtain specialist advice through help musicians UK (https://www.helpmusicians.org.uk/) and there will be a wider rollout of their scheme to provide specialist ear protection for working musicians over the next year. Our website has a section on hearing aids and hearing protection and will have more resources and links as it develops. There are a wide range of sound level meter apps now so people can use their phone to give a good estimate of when noise levels are too loud and you need to take action. 10 So is the project finished now? We planned carefully for our project to provide long term support for hearing aid users. Our website has funding for the next ten years and we have organisations in place that are keen to work with us to raise awareness further. We have a final clinical project that has 20 NHS clinical sites subscribed to it to gather even more data via our web survey so keep tabs on www.musicandhearingaids.org and watch this space.


clinical catch-up

43

Integrative medicine for persistent dizziness or tinnitus. CD

Author and Correspondence Joey Remenyi MClinAud, MaudSA (CCP), BA (Psych), ACT/CBT (cert), Registered Senior Yoga Teacher

Joey is a vestibular audiologist specialising in neuroplasticity for vertigo and tinnitus. She is also the founder and director of Seeking Balance Australia www.seekingbalance.com.au

Neuroplasticity is a subtle process that our sensory impairment clients need education and support to go through. Their body has changed. Their confidence has likely dropped. Their self-belief will alter. And after rigorous investigations it is possible that they have been told: “There is nothing more we can do”. And, as you all know, there is truth in this. We can’t do neuroplasticity for them. Our role is to refer clients a process so that they can re-set the mapping of their inner world. However, this takes commitment, belief and desire. One of the biggest barriers clients have to recovery is not believing that it is possible. Your clients may have been disheartened by trying exercises or talk therapies that haven’t addressed the root concern or isolated persistent symptom patterns.

ly with their condition. Your clients will need to begin a process of exploring the many aspects of integrative neuroplasticity. There are plenty of free resources available that you can refer to. Know where your therapeutic limits are and be careful what information or ‘strategies’ you offer clients. For developing your own clinical skills in this arena, you can undertake intensive plasticity training to acquire practice in the therapeutic process for persistent symptoms. Trust that your client will find the support that they need, at the right time that they need it. Encourage them to keep learning and looking. It is not your job to do the work for them, but rather to provide reassurance and encourage them to start a self-study process.

You as a health professional might feel ‘stuck’ and unsure yourself if recovery of persistent symptoms is possible- in which case, you are affirming the client’s doubt. Doubt feeds chronic stress patterns, inhibits plasticity and contributes to persistent symptoms.

I have had clients referred to me by an audiologist three years before they felt ready to start a recovery program. They needed to go through three years of symptoms, before they were ready to open up and become curious about neuroplasticity. Others are ready immediately.

So what can you do about it? Education, encouragement and referral. Guide them toward specific support program like ROCK STEADY or a specialised therapist who works specifical-

Becoming ready to implement change is an important part of the process. If this takes years, that is okay. You have done your part by making the initial suggestion, offering hope and making the refer-

ral. You can’t rush them- as frustrating as this can feel to everyone involved. Readiness is essential. Clients with persistent symptoms of vertigo or tinnitus go through deep changes among various interconnected neural systems.

Aspects of integrative neuroplasticity: Physical: movement, diet, medication, surgery, behavioural habits, daily posture, tension release, sexuality, sleep. Mental: thoughts, doubts, worries, ideas, internal dialogue, speech, and voicing. Emotional: autonomic nervous system patterning and reactions (anxiety, depression, frustration, anger, joy, relief, safety, calm, self-soothing) Spiritual: beliefs, dreams, creativity, vision, belonging, community, values, purpose, meaning, self-relationship.

We all have deep neural patterning within us that create our perception of reality. When these templates suit us, it feels good! However when our neural templates change, as happens with sensory impairment, it can feel very unfamiliar and unwanted.

clinical catch-up


clinical catch-up

44 Many clients will say: “I just know that something isn’t right… but I don’t know what it is and the tests can’t explain it.” Clients are searching for a way to feel at ease in their body again; to feel connected; and to reset their reactions to their body sensations. However too often they are offered devices, tests, medications, generic exercises or nothing at all. The 12-week self-study program called ROCK STEADY can guide clients through this subtle process. They learn how to create new sensory perception pathways at home, at their own pace. They go through it. It is via this self-study process that the persistent symptoms of vertigo or tinnitus tend to resolve. By kindly bringing conscious awareness to very old patterns, we create new ones. For clients with chronic symptoms, there will often be a pattern of self-judgment and inner critique that is becoming heightened and problematic. They will need access tools to sort this out, daily. Neurons fire, wire and re-map for every thought, sensations, feeling, movement, word, idea, belief, or insight- 24/7. Everything within us is mapped within neural networks. What you can do: Encourage your clients to learn about neuroplasticity and what is possible. Direct them to empowered recovery stories for people with persistent and chronic symptoms (resources below). Plant the seed and inspire them to seek resources for their own recovery. Let them know that they can learn to do this at home, with a self-study program. It is a personal process. Your clients need support and reassurance to learn about harnessing which sensory pathways are useful and which sensations are no longer useful. It is a subtle yet profound process. The human body is more than capable of rewiring and resetting itself. This process of recovery and adaptation is different for everyone. The underlying

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Where to send clients: Where to send clients: www.seekingbalance.com.au

www.seekingbalance.com.au

Refer clients to the FREE Resources + STARTER KIT for: • > 8 hours of audio streaming about neuroplasticity for vertigo and tinnitus. • Recovery case studies • Videos, audios and pdfs guiding them to begin and gentle home program • Community, belonging and motivation • Symptom tracker score to monitor progress • Audio-vestibular specific information • Closed Facebook group: ROCK STEADY for vertigo and tinnitus • Mindfulness and self-kindness prompts For clients with significant vertigo/tinnitus concerns: Consider recommending the full ROCK STEADY self-study process. Honour that your client may not feel ready and support them to move towards the idea of neural healing. Encourage them to look at the 12-week program, case studies and 97% benefit rate. Help them to believe in themselves- recovery is a commitment.

process is either conscious or unconscious neuroplasticity.

skills so that they can create their own recovery program? If not, why not?

Clients learn to replace the fixation upon symptom outcomes with being open and curious to the reality of what is unfolding in the here and now. They begin to create the outcomes they want, consciously feeling them moment-to-moment. Replacing wishful thinking, blame and persistent worry.

• How do you offer your clients with persistent symptoms hope?

We can’t say how long it will take for the brain to rearrange its balance templates or to filter out tinnitus pathways. But we know that it can happen and for many people it does happen. I teach people how to consciously do it. What role do you play in your clients’ recovery process? • Do you encourage your clients to begin exploring integrative neuroplasticity? • Are you making assumptions that your client can’t do it or can’t afford it? • Do you empower your client to learn

Further reading • Various articles: https://www.seekingbalance.com.au/research-articles/ • The Brain That Changes Itself: Book by Norman Doidge • Full catastrophe living: Book by Jon Kabat-Zinn


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How the use of British Society of Audiology recommended procedures for audiometry and measurement of uncomfortable loudness levels can lead to discomfort for patients with tinnitus and/or hyperacusis. CD

Authors and Correspondence

Professor Brian C.J. Moore Department of Psychology, University of Cambridge, Downing Street, Cambridge CB2 3EB

Dr. Hashir Aazh Audiology Department, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, GU2 7XX Correspondence: Dr. Hashir Aazh Tinnitus & Hyperacusis Therapy Specialist Clinic, Audiology Department, Royal Surrey County Hospital, Egerton Road, Guildford, GU2 7XX E: mail: hashir.aazh@nhs.net

Patients seeking treatment for tinnitus and hyperacusis are usually assessed via personal interviews with a trained audiologist, by asking them to complete a variety of standardised questionnaires, by conducting pure-tone audiometry (PTA), and via the measurement of uncomfortable loudness levels (ULLs). PTA provides a measure of the weakest sounds that can be detected for tones with different frequencies. In contrast, ULLs provide a measure of the sound intensity above which tones with different frequencies become uncomfortably loud. Both are measured in units called “decibels hearing level” (dB HL), where 0 dB HL is the weakest sound that can be detected by young people with no known hearing problem. For normal-hearing people without hyperacusis, the average ULL across the audiometric frequencies is about 100 dB HL (Sherlock and Formby, 2005). However, for a person with hyperacusis, the across-frequency average ULL is usually 77 dB HL or below (Aazh and Moore, 2017a). In extreme cases of hyperacusis, ULLs can be as low as 10 dB HL (Aazh and Moore, 2017c). Such low ULLs raise the possibility that some patients will experience discomfort during routine audiometry and measurement of ULLs. The proportion of patients for whom this might happen was assessed in a recent study by Aazh and Moore (2017b). The study was based on 362 consecutive patients who attended a National Health Service audiology clinic for tinnitus and/ or hyperacusis rehabilitation. PTA was conducted using the procedure recommended by the British So-

ciety of Audiology (BSA) (2011a) for frequencies of 0.25, 0.5, 1, 2, 3, 4, 6, and 8 kHz. According to this procedure, once the threshold has been determined at a given frequency, the initial level when assessing the threshold for the next frequency should be “at a clearly audible level (e.g. 30 dB above the adjacent threshold” (p. 11), but never more than 80 dB HL. An experience of discomfort during PTA was deemed to be present when a test tone with a given frequency presented at 30 dB above the threshold for an adjacent frequency exceeded the ULL at the test frequency for at least one of the measured frequencies. Remarkably, the results showed that discomfort would have occurred for 21% of the patients. The incidence of discomfort would have been reduced to 10%, 2.7%, and 0.8% if the starting level had been 20 dB above, 10 dB above, or at the same level as the threshold for the adjacent frequency, respectively. ULLs were also measured using the BSA recommended procedure (British Society of Audiology, 2011b). According to this, the audiologist should “Start testing at 60 dB HL or at the subject’s hearing threshold level for that ear at that frequency, whichever is highest, unless otherwise indicated (Section 2.2)” (p.7). An experience of discomfort during measurement of ULLs was deemed to be present if the starting level of 60 dB HL exceeded a patient’s ULL for at least one of the measured frequencies. Discomfort would have occurred for 24% of the patients using this criterion. The incidence of discomfort would have been reduced to 3.6% if the starting lev-

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46 el had been reduced to 30 dB HL and to 0.5% if the starting level had been reduced to 15 dB HL. Given the high prevalence of anxiety and stress in patients seeking help for tinnitus and hyperacusis, it is very important to ensure that any evaluation procedures do not lead to any unnecessary discomfort. If discomfort is experienced, this might trigger further anxiety and stress, leading to worsening of the symptoms and to possible loss of trust in the audiologist. This in turn might reduce the effectiveness of any therapy performed by the audiologist after the initial evaluation. To avoid discomfort during PTA, Aazh and Moore (2017b) suggested using an initial level of 0 dB HL at the starting frequency of 1 kHz and setting the level for subsequent frequencies to be equal to the level at threshold for the previous-

ly tested frequency. To avoid discomfort during measurement of ULLs, they recommended that the starting level for a given test frequency should be equal to the measured audiometric threshold at that test frequency and that levels above 80 dB HL should not be used. References 1. Aazh, H., Moore, B. C. J., 2017a. Factors related to Uncomfortable Loudness Levels for patients seen in a tinnitus and hyperacusis clinic. Int. J. Audiol. (in press). 2. Aazh, H., Moore, B. C. J., 2017b. Incidence of discomfort during pure-tone audiometry and measurement of uncomfortable loudness levels among people seeking help for tinnitus and/ or hyperacusis. Am. J. Audiol. (in press). 3. Aazh, H., Moore, B. C. J., 2017c. Prev-

alence and characteristics of patients with severe hyperacusis among patients seen in a tinnitus and hyperacusis clinic. J. Am. Acad. Audiol. (in press). 4. British Society of Audiology, 2011a. Pure-tone air-conduction and bone-conduction threshold audiometry with and without masking: Recommended procedure, British Society of Audiology, Reading, UK. 5. British Society of Audiology, 2011b. Recommended procedure: Determination of uncomfortable loudness levels, British Society of Audiology, Reading, UK. 6. Sherlock, L. P., Formby, C., 2005. Estimates of loudness, loudness discomfort, and the auditory dynamic range: normative estimates, comparison of procedures, and test-retest reliability. J. Am Acad. Audiol. 16, 85-100.


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Facilitating shared decision making in tinnitus. CD

Author and Correspondence Helen Pryce MSc, PD(Health) Senior lecturer in Audiology, School of life and Health Sciences, Aston University, Aston Triangle, Birmingham, B47ET E: h.pryce-cazalet@aston.ac.uk Shared decision making is a core feature of evidence-based healthcare and its practice. The NHS mantra ‘no decision about me without me’ if a familiar phrase to many clinicians but the actual practice of shared decision making is often harder to achieve. The basic tenet of shared decision making is that where there is more than one clinical option available to manage a health condition (including doing nothing) – then the patient has an active role in deciding which clinical option best fits their individual values and preferences. Within audiology there are a large number of clinical guidelines and practice documents to inform practitioners. These derive evidence from population averages to determine what on the whole works for whom on the whole. No guidelines tell us how to help this individual patient in these individual circumstances. All too often we end up with clinician determined decisions about patient care or breakdowns in communication with ‘heart-sink’ patients. Clinicians may do their utmost to do evidence-based practice and get the right answer to bestow upon the patient. Unless they incorporate patient values and preferences they risk ‘silent misdiagnosis.’ This phrase ‘silent misdiagnosis’ describes how one can unwittingly cause significant harm to quality of life by misdiagnosing - not the original condition – but what the patient wants to do about the condition. Rarely do patients with silent misdiagnosis bother us – they become dissatisfied, possibly seek help elsewhere and remain ‘silent’, leaving us unaware that we have

failed in any way. Hand on heart most of us can reflect on scenarios where this may have been the case. The patient who didn’t return for follow up. The patient who constantly complained. The patient who went home and never used the hearing aid again… Happily there is an alternative The British Tinnitus Association have strategic aims to support and represent the tinnitus community. They funded my research team to undertake work to identify patient preferences for tinnitus treatments, describe how decisions are currently made in clinical settings and finally to design a decision aid to facilitate shared decision making in tinnitus. This decision aid can enable both patients and clinicians to work from consistent information. Put simply it can help a clinician practice shared decision making if they are willing. To practice shared decision making in tinnitus care we propose clinicians focus on the following: Build a relationship This is a bedrock of all change. We need to trust, believe and value our clinicians. They earn trust belief and value by being explicitly interested in us. That means not looking at computer screens, paperwork or anything else. Full and undivided attention is a great starting point. Open questions are what you need. Great listeners are amongst the most efficient case history takers in the world. Just try talking on one subject to an interested person uninterrupted for two minutes and you’ll see for yourself.You cover vast

amounts of information. By all means check facts afterwards, but be present and fully attend to what people are telling you. Even if it makes you uncomfortable. Even if you can’t fix it. Even if you don’t like it. You will do more good than you realise. People seek help more often to be heard and validated than to be fixed, honest. In this relationship it is straightforward to negotiate that you will make a decision together. Present choices There are always choices in tinnitus. There are always choices in hearing loss. Your preferences as a clinician are important to acknowledge but it is more important to hear what your patient prefers. They will be living with the consequences of the decision made, not you. This is where the decision aids available really help. They are freely available to down load and can be posted out to a patient before they meet with you so that they can consider them with their family and friends. The decision aids we have developed meet the international consensus for decision aid standards because both the options and the frequently asked questions are derived from evidence. They are structured not just to present some options but to weigh up pros and cons for them. There are important differences between those who would like group support, those who would like a device and those who would like counselling or talking therapies. The decision aid helps people decide on the approach that

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48

TINNITUS CARE OPTIONS

The tinnitus decision aid Use this decision aid to help you and your healthcare professional(s) talk about evidence based tinnitus care options. If you have a hearing loss as well, see the Hearing loss: hearing technology options Option Grid www.optiongrid.com

Frequently asked questions

Will this option mean I hear my tinnitus less or cure it?

What does this do to tinnitus?

How does this approach help tinnitus?

How do I access this option?

Can I choose more than one option?

Options for tinnitus care Understanding tinnitus

Understanding tinnitus may not make it go away, but getting a better grasp of tinnitus can mean that you notice it less.

Tinnitus is often made worse by worrying about what it is and what it means. Understanding tinnitus and what influences it can help you manage tinnitus better.

Making sense of the causes of tinnitus and what keeps people noticing it, can help people cope with tinnitus. Most people find discussing tinnitus information with an Audiologist or Hearing Therapist is helpful. You can get tailored advice from your Hearing Therapist or Audiologist. Your GP can refer you to these services. The British Tinnitus Association produce clear information on all aspects of tinnitus. Yes

Talking therapies Following talking therapy, some people don’t hear tinnitus as much. Whilst some people may find that they hear it just as much, others often describe their tinnitus as becoming less bothersome.

Tinnitus is often made worse by higher levels of stress, and talking therapies can help by reducing stress. Talking therapies also focus on changing how you respond to tinnitus. You learn to change how you think and act and how much attention you give to it.

Using sound

Group support

Some people find playing sound through various devices helps them hear the tinnitus less. Sound is unlikely to make your tinnitus go away completely. If you have hearing loss and tinnitus some people find hearing aids can help reduce awareness - see the Hearing loss: hearing technology options Option Grid. Tinnitus is influenced by other sounds around you. By listening to external sounds, you’re likely to hear your tinnitus less. It can be helpful to focus your attention onto another sound.

Some people find it helpful to put Talking therapies have been shown to a radio on in the background when they come into a quiet setting. reduce distress caused by tinnitus. People who have talking therapy for tinnitus can find that they notice it less.

There are different types of talking therapies. You can access this type of help from a psychologist, therapist or even online.

Others may use relaxing sounds to help get to sleep at night. Various devices and apps are available for this.

An Audiologist or Hearing Therapist can advise on this. Your GP can arrange a referral.

Talk to your GP about referral. Yes

Yes

This probably won’t mean that you hear your tinnitus less, but sharing experiences can be supportive, especially in helping you to understand tinnitus and feel less alone. This may mean that you notice tinnitus less.

Groups can help people find support from others. People swap ideas about what helps them with their tinnitus.

Many people find it helpful to meet others who are in the same position. Groups provide information and support. Groups are unlikely to make tinnitus go away but understanding that you are not alone might help. The British Tinnitus Association have information on tinnitus groups in the UK. Alternatively your local audiology service may be able to guide you to a group. Yes

Editors: Helen Pryce, Elizabeth Marks, Sarah Swift, Melanie Ward, Amanda Hall, Rachel Shaw, Beth-Anne Culhane, Jean Straus, Katie Chilvers. The British Tinnitus Association. Registered charity no: 1011145

suits them best. Our research found a really important role for the clinician here. Patients described really wanting curated information, tailored for them. They wanted someone to bounce their thoughts about management off. This is where clinicians can shine! Make the decision in partnership The decision making is then the integration of the preferences and values the patient holds coupled with the expertise of the clinician. In practice this can mean have a conversation in which a thought experiment tries out the various options. What would it involve in practice to seek talking therapy in your area? How does someone access a group? What’s the commitment in time, travelling, cost etc? These finer points are discussed in this phase of the decision. Resources Look out for the BTA you tube channel for films on how to engage in shared decision making. The decision aid for tinnitus is available at www.tinnitus.org.uk/decision-aid

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For hearing loss we have the hearing loss option grid http://optiongrid.org/option-grids/grid-landing/27 Both these decision aids were developed in accordance with the consensus on international decision aid standards (IPDAS), (Elwyn 2009). That means that they went through iterative development with input from many patients, experts in the field, clinicians and researchers. They have been through user testing procedures and readability testing (Pryce et al, 2016; Pryce et al 2017 – in review). Look out for films appearing on the British tinnitus Association youtube channel where we will demonstrate how small changes in practice can have a big effect in practice. References • Tinnitus decision aid, editors Helen Pryce, Elizabeth marks, Sarah Swift, Melanie Ward, Amanda Hall, Rachel Shaw, Beth-Anne Culhane, Jean Straus, Katie Chilvers on behalf of The British Tinnitus Association www.tinnitus.org. uk/decision-aid

• Hearing Loss Option Grid, editors Amanda Hall, Helen Pryce, Elizabeth Clark, Ariane Laplante-Lévesque, Melanie Ward, Lucy Handscomb, Kelly Tremblay, Marie-Anne Durand, Glyn Elwyn. http://optiongrid.org/pdf/grid/ grids/27/27.en_us.1.pdf • Elwyn, G., O’Connor, A.M., Bennett, C., Newcombe, R.G., Politi, M., Durand, M.A., Drake, E., Joseph-Williams, N., Khangura, S., Saarimaki, A. and Sivell, S., 2009. Assessing the quality of decision support technologies using the International Patient Decision Aid Standards instrument (IPDASi). PloS one, 4(3), p.e4705. • Pryce, H., Hall, A., Laplante-Lévesque, A. and Clark, E., 2016. A qualitative investigation of decision making during help-seeking for adult hearing loss. International journal of audiology, 55(11), pp.658-665. • Pryce, H., Durand, M.A., Hall, A., Shaw, R,L, Culhane, B.A., Swift, S.,Straus, J., Marks, E., Ward, M., Chilvers K., The development of the decision aid for tinnitus. In review.


The future is now: with Sprint™ and TeleCare.

Sprint, a new innovation for NHS audiology services with an evidence* based workflow, has just raised the innovation bar even higher. The TeleCare web portal allows the audiologist to manage patient profiles, evaluate progress and communicate with patients, even allowing for fine tuning to the Sprint hearing aids remotely. The new myHearing App transforms how patients manage and maintain their Sprint hearing aids, placing them right at the centre of the fitting process. TeleCare and myHearing App provide: • Instant text, voice and video communication between patient and audiologist

• Instant access to educational reference materials**

• Daily satisfaction ratings utilising easy to use emojis

• Auditory training modules which can be

TeleCare ready.

customised for individual patients

For the patient this means better communication with the audiologist and greater satisfaction with their hearing aids and less visits to the clinic. For audiologists this means improved patient outcomes and greater efficiency with reduced follow ups in the clinic. For more information, please contact your Sivantos NHS Audiologist or call Sarah Banks at Sivantos on 01293 423703 to discuss booking a meeting on how Sprint & TeleCare can work for you.

Hearing Systems

www.bestsound-technology.co.uk * Please email sarah.banks@sivantos.com to receive a summary of the evidence ** Booklet versions are also available

Sivantos Limited is a Trademark Licensee of Siemens AG | © Signia GmbH 2018 | JN9071


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Basic science research in Audiology at Manchester CD

Author and Correspondence Dr Garreth Prendergast Manchester Centre for Audiology and Deafness E: garreth.prendergast@manchester.ac.uk

A (very) brief history The University of Manchester will soon celebrate 100 years of being a leader in the field of audiology teaching and research. Since Irene and Alexander Ewing began lecturing practitioners on how to best tutor and develop deaf children in 1919, the department has maintained a strong international reputation for developing, improving and delivering audiology provisions and services.The early 1990s saw Professor John Bamford drive forward Evidence-Based Practice, which led to the department running numerous well-respected audiology courses, remaining a world-leader in training teachers of the deaf, and conducting high-quality basic science research. All of these themes remain strong within today’s department, which recently re-badged itself as the Manchester Centre for Audiology and Deafness (ManCAD). Types of Research Research is often considered as falling into three distinct categories; basic, translational and applied science. To the lay person “basic” science has the unfortunate misnomer of sounding as though it is the science which is straight-forward and simple. However, basic science is the process whereby we seek to discover the or define the unknown. It forms the bedrock of all the other scientific endeavours which eventually lead to concrete changes in the real-world, which affect the experience and treatment of a patient. Basic science aims to better understand a phenomenon, process, or behaviour with no other end-goal beyond finding out something that we do not currently know. For many people who study human behaviour, especially when there are direct health implications, there is often a desire to then move on to translational research. Translational research is when the research aims seek to define the scope of potential applications and to define what might feasibly become a usable, practical output. The final step is then to apply this research in the com-

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munity or clinic. Recent examples of how Manchester has led and shaped applied hearing-healthcare research include the development and implementation of universal newborn hearing screening and modernisation of children’s hearing aid services in the NHS. For the remainder of this article I would like to focus on current, and future, basic science research themes at ManCAD. The Effect of Noise on “Normal” Hearing A number of projects are looking at the effects of noise-exposure on our hearing, and whether sub-clinical listening deficits can be turned into clinically relevant, observable symptoms. Professor Chris Plack is the lead investigator on a five-year grant (£1.2 million) funded by the Medical Research Council, to study cochlear synaptopathy in humans. Cochlear synaptopathy describes the physiological process whereby synapses between inner hair cells and auditory nerve fibers are destroyed, which leads to a degradation in the information transmitted by the auditory nerve. Cochlear synapses are known to decrease in number as part of the natural ageing process, but this also occurs as a result of over-exposure to high intensity sounds. This loss of synapses has been shown to affect the processing of supra-threshold sounds rather than sounds presented around absolute threshold. As a result, cochlear synaptopathy is also termed “hidden hearing loss” because its presence is not identified by our standard diagnostic tool: the audiogram. To-date, the ManCAD study shows that performance on a range of behavioural and electrophysiological tasks is not predicted by the amount of noise an individual has exposed themselves to over the lifetime. Work on this topic continues, with planned projects investigating whether the first, intensive exposures encountered are demonstrably harmful, or whether the rate of decline of the auditory system with age is related to the amount of previous lifetime noise exposure. Related projects include that of PhD student Hannah Guest (funded by an Action of Hearing Loss studentship from the Marston Family Foundation), who is looking at how lifetime noise exposure, tinnitus and impaired speech intelligibility relate to listeners with normal audiometric function. Dr Samuel Couth is working on a project funded by the Colt Foundation which looks at the hearing-health of a group of musicians. By tracking the hearing of an individual over a number of years, it may be possible to identify the best method of first detecting subtle changes in hearing sensitivity. Such work has potentially serious health implications for people who rely on their hearing for their job, the very nature of which ensures they are often exposed to sounds that are potentially harmful.


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51 All of these research projects are largely conducted using listeners with good audiometric sensitivity and would be characterised as having “normal” hearing.These projects aim to develop cutting edge methodological tools which have the potential to be developed into a diagnostic protocol with good clinical utility. Noise-induced hidden hearing loss is relatively well characterised in a range of different rodents, and the physiological changes which occur are dramatic and irreversible. Numerous laboratories world-wide are actively researching how this mechanism might manifest in the human listener and the extent to which such a process presents a hearing-healthcare issue. Our understanding of how intense noise exposures affect the auditory system remains incomplete and, by challenging how best we can define normal hearing, these research projects aim to identify the scope and aims of tomorrow’s translational research projects. There remains a strong basic science research theme of considering hearing difficulties that are not well-characterised by pure tone audiometry and ManCAD researchers are working hard to contribute to improving our understanding of these difficulties. How Do Hearing and Dementia interact? Our hearing, along with other sensory functions such as vision, decline as we age. As we live longer, cognitive decline, most commonly in the form of Alzheimer’s disease, affects a large proportion of the population. The burden to healthcare of dementia is vast, but our understanding of how best to detect it and intervene remains rudimentary. Furthermore sensory impairment, such as hearing loss, as a result of ageing often occurs in conjunction with cognitive decline. However it remains unclear if the sensory impairment is a contributing factor to the rate of cognitive decline or if cognitive decline in fact precedes the loss of hearing acuity and possible is a cause of the hearing impairment. Alternatively, the rate of both sensory and cognitive decline with age may be regulated by other factors rather than the two having a direct causal link. What is clear is that our understanding of how these processes interact and influence each other is limited and we need to better understand the key factors if we are to better detect and treat these two impairments, as they become increasingly prevalent in an ageing population.

Manchester Biomedical Research Centre Biomedical Research Centres (BRC) are funded by the National Institute for Health Research and are formed via leading NHS Trusts and Universities. The aim is to drive innovation in the diagnosis and treatment of ill-health and therefore a key component is to fund basic science research which is conducted with a clear ambition to progress to translational and applied research. There are different themes within each BRC and the Manchester BRC (established in April 2017 with an award of £28 million) has a Hearing Health theme. The Hearing Health theme spans the prevention, diagnosis and treatment of hearing loss and combines a wealth of expertise by building a team including clinicians, engineers, audiologists, psychologists, geneticists and neuroscientists. The specific research areas include minimising the risk of hearing impairment and looking at a genetic solutions to hearing loss. There is also a strong focus on developing and optimising the diagnosis of hearing problems, the effectiveness of hearing aid solutions and the outcome measures of hearing loss. These research areas are long-term, ambitious projects which seek to use basic science discoveries to drive forward the next decade of translational and applied hearing-health research. The BRC is in its early stages, with the first six months dedicated to building infrastructure and support staff. Throughout 2018 more PhD students and research associates will be appointed to begin tackling the big issues in these defined research areas and the projects will continue to develop and grow. The aim is to use the Manchester Hearing Health BRC to grow the critical mass of researchers in audiological sciences and to continue the basic, translational and applied scientific research into hearing impairment that Manchester as been associated with for so long. As we approach a century since the establishment of research into hearing impairment at Manchester, it is fitting that basic science research remains a core focus of the department. ManCAD continues to grow in size, strength and influence in the teaching and research of audiology and deafness. Under the guidance of Professor Kevin Munro, ManCAD is well-placed to begin its second century of being a world leader in understanding, treating and managing hearing impairment throughout the lifespan and from a number of different perspectives.

Dr Piers Dawes is a co-investigator on the SENSE-Cog project, which is a multi-million pound grant funded by the EU Horizon 2020 initiative in which a broad range of academics from different disciplines and European institutions combine with partners in industry to investigate these multi-factorial relationships between disease states. The aims of the project are to explore the relationship between hearing, vision and cognition in a large cohort of older volunteers and to then begin developing new tools and approaches based on these investigations. Economic, management, and patient-centred approaches are combined to produce new assessments and interventions which will hopefully change the way in which complex, co-occurring impairments are identified and treated.

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52

National Institute for Health Reseach (NIHR) Nottingham Biomedical Research Centre CD

Author and Correspondence Professor Deborah Hall Deputy Director NIHR Nottingham Biomedical Research Centre E: deborah.hall@nottingham.ac.uk

Mild-to-moderate hearing loss (Associate Prof Melanie Ferguson) This research area will improve the quality of life for adults with mild-to-moderate hearing loss by developing new knowledge and clinical strategies that overcome listening and social participation difficulties arising from hearing loss. We are evaluating novel technological and patient-centred interventions that give maximum benefit to those who experience hearing loss. We are also working to identify the most important outcomes for hearing loss interventions and how best to measure them.

Nottingham boasts a cadre of established world-leading hearing scientists and clinical researchers. Around 50 staff and postgraduate students are supported by the National Institute for Health (NIHR) Nottingham Biomedical Research Centre. Since 2008, we have established a successful programme of translational research that directly links to discovery science funded by the Medical Research Council. Collaborations extend to all corners of the globe, and are particularly enhanced by several multi-million pound awards from the European Union.

Severe-to-profound hearing loss (Associate Professor Padraig Kitterick) Our research examines the benefits of cochlear implantation in individuals who have acquired a profound deafness in one ear but still have access to some residual hearing in the other ear. We are also examining the potential benefits of combining electric hearing from a cochlear implant with an acoustic hearing aid in patients who have very little remaining hearing in their non-implanted ear. Benefits might extend to alleviating tinnitus as well as improving hearing.

Our shared vision is to create new knowledge to alleviate the burden of disability arising from hearing-related problems. We achieve this by actively collaborating with hearing healthcare practitioners to drive progress in seven research areas:

Tinnitus and hyperacusis (Associate Prof Derek Hoare) No single management strategy is effective for every patients and so our work examines strategies for long-term management. We will establish clinical efficacy and cost-effectiveness

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53 of audiology-delivered counselling, hearing aids for adults with hearing loss and tinnitus, and an e-health self-management programme. Clinical hearing sciences (Prof David Baguley) We are investigating hearing loss, balance and tinnitus associated with platinum-based chemotherapy, looking at how often this occurs, how severe and burdensome the symptoms are, whether it is possible to predict who will develop these symptoms, and how people can best be treated and supported. Our aim is to support early identification of those survivors of cancer who are likely to develop ongoing difficulties as a result of auditory symptoms, and to shape optimised and timely interventions. Objective measures (Associate Prof Douglas Hartley) We are developing imaging methods for measuring auditory sensorineural plasticity using novel brain imaging techniques, and methods currently applied in other sensory domains. We are applying these techniques to address patient-centred questions about impairment and treatment. We are also integrating these findings with knowledge of animal models of network processing and cortical plasticity. Outcome measures for clinical trials (Prof Deborah Hall) This research area will deliver evidence-based recommendations on what should be outcome measures to drive up the quality and value of clinical trials. “Outcomes” refer collectively to those aspects of the condition that are chosen to assess how well the treatment has worked and the corresponding instruments for measuring them. We have started with tinnitus (see COMiT initiative below) and have also initiated a project on single-sided deafness in adults (CROSSSD study). Magnetic resonance imaging in humans (Dr Katrin Krumbholz) By bringing together physicists with expertise in magnetic resonance imaging at the University of Nottingham, physiologists and ENT surgeons and audiologists, we are addressing important clinical questions about brain reorganisation after hearing loss, deafness and tinnitus. Toward a global consensus on outcome measures for clinical trials in tinnitus. The COMiT initiative In 2014, the EU funded a network of tinnitus experts to help drive progress in the field by bringing together academic, clinical, patient-centred and commercial sectors, for 4 years. This network calls itself the TINNET (TINnitus NETwork, http:// tinnet.tinnitusresearch.net/). Although there is no direct funding for research activity, five working groups were established to develop standards on clinical practice, clinical trials, genetic studies, neuroimaging, and multi-centre data collection. For the past 4 years, Prof Deborah Hall, lead for the hearing and deafness theme NIHR Nottingham BRC has been chair of the working group focused on standards for outcome measurement in clinical trials, with co-chair Dr Alain Londero who is an ENT consultant at the Hôpital Européen Georges-Pompidou,

Paris (http://tinnet.tinnitusresearch.net/index.php/2015-10-2910-22-16/wg-5-outcome-measurement) [1,2]. The group has 46 members from 17 EU countries, and has closely worked together through face-to-face meetings, teleconferences and e-communications. The group’s ambition is to answer the fundamental question: ‘How to do good clinical research to find effective treatments for adults with chronic subjective tinnitus?’ using evidence-based methods for reaching consensus among a wide range of stakeholders. We know that different people have very different ideas about what is the most important aspect of tinnitus to reduce or improve when deciding if a treatment for tinnitus has worked or not. But we also know that clinical trials of tinnitus treatments would be more effective if all studies across the UK and around the world measured the outcomes of a tinnitus treatment in the same way. Examples of outcomes include tinnitus loudness using a psychophysical matching procedure, or the ability to concentrate, sense of control, or impact on work, all measured using questionnaires. A Core Outcome Set (COS) is a list of critically important outcomes which form a minimum set of assessments that should be measured and reported in every clinical trial. A COS would mean that investigators must report on the same core outcomes, whilst remaining free to collect and explore other outcomes too. Ideally, these COS should be of importance to patients as well as health professionals, and outcome instruments should be reliable, validated, and responsive to treatment-related change [1,2]. Tinnitus treatments themselves are quite diverse and so in recognition of this COMIT is developing three COS’s for sound-based, psychology-based, and pharmacology-based treatment strategies. If the same COS were used and reported for each family of intervention strategies then, for example, results from Nottingham could be easily compared with results from London or Berlin. And results collected today could be easily compared with results collected in the future. To create the final COS for tinnitus will take many years of careful research (set out in a roadmap [3]). The research roadmap extends beyond the duration of the TINNET award that ends in Spring 2018. So the group has created a distinct identify for its work and has called itself the COMiT initiative (Core Outcome Measures in Tinnitus). The aim of COMiT is that same as the TINNET working group; to improve the quality of future clinical research by identifying a minimum standard for assessing how a tinnitus treatment has worked, and proposing standards for how they should be measured. COMiT published its first research study in 2016 [4]. This systematic review of journal articles and clinical trial registrations found that over 60 different aspects of tinnitus and over 130 different tinnitus measurement methods had been reported in the past 10 years of clinical trials. Clearly this lack of consensus shows that there is work to be done to create a minimum standard. COMiT has now just completed its second research study [5]. The starting point for this study was a long list of all the different aspects of tinnitus, developed with patient input. Three separate online consensus surveys were completed to identify how sound-, psychology- and drug-based

research round-up


research round-up

54 tinnitus treatments should be commonly assessed before and after treatment [5]. In each survey, the same list was given to all participating international tinnitus experts (people with lived experience of tinnitus, healthcare practitioners, researchers, commercial representatives and funders of tinnitus research) and they were each asked to rate which outcomes they felt were critically important when deciding if a treatment for tinnitus has worked. A wide range of people completed the online survey based on their experience with one or more of these treatment types. Overall, we succeeded in involving the global tinnitus community with over 600 people taking part from over 40 countries worldwide. Thank you for all your support! From each online survey, participants agreed on between 17 and 24 different tinnitus-related problems to recommend to researchers for assessing in a clinical trial. From a practical point of view however, these numbers are too many for investigators to measure in a clinical research study. So, survey participants were invited to attend one of three consensus workshops (one for each treatment type). About twenty participants – people with lived experience of tinnitus and a range of professionals representing the different stakeholder groups – took part in each workshop to discuss the findings. They agreed that the list of recommended tinnitus assessments should be reduced to a more manageable number, creating a minimum set that will become international standards to be used in research.This minimum set was selected those attending the workshops on the basis that assessments are: i) directly relevant to patients with tinnitus, to the healthcare professionals giving the treatment, and to the researchers designing the trial, ii) directly relevant to how the treatment is supposed to be working, and iii) are expected to be very sensitive to change during the treatment. Although the three online surveys and workshops for soundbased, psychology-based and drug-based tinnitus treatment were all completed separately, everyone taking part in the COMIT’ID study agreed that tinnitus intrusiveness is important and critical to measure. Over 85% of participants said that tinnitus intrusiveness was important, no matter which type of tinnitus treatment is being tested and no matter which stakeholder group was asked. Tinnitus intrusiveness describes the state of noticing the sound of tinnitus is there and it is invading your life or your personal space. Here are the other core assessments that our stakeholders recommend to investigators. These are our minimal reporting standards which will enable findings to be compared across studies. Investigators will always be free to add other assessments to their clinical trial design, if they wish. Our next steps will be to define exactly what each of the assessments means to the community so that we can make recommendations on how they should be measured. Future efforts will therefore be pairing these selected outcome domains with suitable outcome instruments.

research round-up

Acknowledgements Stay informed: @hearingnihr @COMITIDStudy The COMiT initiative has been funded by the Biomedicine and Molecular Biosciences European Cooperation in Science and Technology (COST) Action framework (TINNET BM1306), Action on Hearing Loss, British Tinnitus Association, National Institute for Health Research References 1. Hall DA (2017) Designing clinical trials for assessing the effectiveness of interventions for tinnitus. Trends in Hearing 21: 1-12. doi: 10.1177/2331216517736689 2. Londero A, Hall DA (2017) Call for an evidence-based consensus on outcome reporting in tinnitus intervention studies. Front. Med. 4:42. doi: 10.3389/fmed.2017.00042 3. Hall DA, Haider H, Kikidis D, Mielczarek M, Mazurek B, Szczepek AJ, Cederroth CR (2015) Towards a global consensus on outcome measures for clinical trials in tinnitus: report from the first international meeting of the COMiT initiative 14 November 2014, Amsterdam, The Netherlands. Trends in Hearing 19: 1–7.doi: 10.1177/2331216515580272 4. Hall DA, Haider H, Szczepek AJ, Lau P, Rabau S, Jones-Diette J, Londero A, Edvall NK, Cederroth CR, Mielczarek M, Fuller T, Batuecas-Caletrio A, Brueggemen P, Thompson DM, Norena A, Cima RFF, Mehta RL, Mazurek B (2016) Systematic review of outcome domains and instruments used in clinical trials of tinnitus treatments in adults. Trials 17:270. doi: 10.1186/s13063-016-1399-9 5. Fackrell K, Smith H, Colley V, Thacker B, Horobin A, Haider HF, Londero A, Mazurek B, Hall DA. (2017) Core Outcome Domains for early phase clinical trials of sound-, psychology-, and pharmacology-based interventions to manage chronic subjective tinnitus in adults: the COMIT’ID study protocol for using a Delphi process and face-to-face meetings to establish consensus. Trials 18(1):388. doi: 10.1186/ s13063-017-2123-0. Sound-based treatments

Psychology-based Treatments

Drug-based treatments

tinnitus intrusiveness

tinnitus intrusiveness

tinnitus intrusiveness

ability to ignore

tinnitus acceptance

tinnitus loudness

concentration

mood (including feelings of anxiety and depression)

quality of sleep

negative thoughts and beliefs

sense of control

sense of control


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55

From cochlea to cortex and from cells to cognition: discovery research in hearing and deafness at the UCL Ear Institute CD

Authors and Correspondence

Jennifer F Linden E: j.linden@ucl.ac.uk

Jonathan E Gale E: j.e.gale@ucl.ac.uk

Since its inception in 2005, the Ear Institute at University College London (UCL) has become a leading centre for auditory research in Europe. In partnership with the Royal National Throat Nose and Ear Hospital (RNTNEH), the UCL Ear Institute constitutes the UK’s largest grouping of scientists interested in hearing and deafness. The Ear Institute was born out of a partnership between basic and clinical scientists, who collaborated to obtain Wellcome Trust funding for an new institute at UCL incorporating the previous Institute of Laryngology and Otology and School of Audiology. From the beginning, the UCL Ear Institute’s mission has been to generate scientific discoveries and clinical breakthroughs in hearing and deafness and to train a generation of future leaders in our field. The UCL Ear Institute’s research ethos is exemplified by the work of three of the Institute’s founding members: Professor David Kemp, who discovered otoacoustic emissions; Professor Andrew Forge, who discovered that mammalian vestibular sensory cells can regenerate; and Professor Jonathan Ashmore, who discovered that outer hair cells drive cochlear amplification. Building upon this great tradition, discovery science at the Ear Institute is world-leading in its scope and impact. Examples of our research strength include: •

A recent bibliometric analysis of biomedical and health research in England 2004-2013 (RAND, 2015) found that UCL had the highest percentage of Highly Cited Publications in all subject areas related to hearing research, including Deafness and Hearing, Audiology and Speech-Language Pathology, and Experimental Psychology and Neuroscience.

In REF2014, UCL ranked at the top for research power and intensity in all areas related to hearing research (Clinical Medicine and Psychology, Psychiatry and Neuroscience).

Since the UCL Ear Institute was established in 2005, it has attracted over £35M in external grants from UK research councils, European funding agencies, charities and industry, including the recent award of £2.7M for a “Deafness and Hearing” translational research theme within the UCL Hospitals National Institute for Health Research Biomedical Research Centre (UCLH NIHR BRC).

Central to the UCL Ear Institute’s success is its commitment to interdisciplinary and collaborative research. The discovery science research teams at the UCL Ear Institute span all levels of the auditory system. Scientists working in fields as diverse as human genetics, biophysics, cell biology, human cognition, computational neuroscience, physiological acoustics, and speech processing come together to create a genuinely collaborative research environment in the Institute. Major research facilities – including electron and confocal microscopes, acoustic isolation booths, DNA sequencers and electrophysiology equipment – are shared by multiple laboratories and accessible to any Ear Institute scientist with appropriate training. Regular seminar series attended by all Ear Institute scientists cover topics ranging from the genetic mechanisms of susceptibility to hearing loss to the cognitive principles of auditory scene analysis. The common thread is a shared mission: to understand the auditory system from cochlea to cortex and from cells to

research round-up


research round-up

56 cognition, and to develop transformative treatments for hearing problems. Here, we outline a few of the key questions driving discovery science research at the UCL Ear Institute, highlighting the collaborative themes that tie together the work of multiple research groups. How does the ear work? Structure and function are inseparable in the ear. For example, the convolutions of the pinna in the outer ear contribute to sound localisation, and the ossicular chain in the middle ear enables transmission of sound vibrations from air into the cochlear fluid.The cochlea is perhaps the best example of the interplay between structure and function, with its mechanical separation of sound frequencies along the basilar membrane, transduction of sound vibrations by the inner hair cells, and amplification of sensitivity to quiet sounds via the outer hair cells. The research groups led by Professors Joerg Albert, Jonathan Ashmore, Andrew Forge, and Drs Daniel Jagger and Torsten Marquardt study the fundamental biophysical and biological mechanisms that underlie sound detection in the ear. Why do auditory sensory cells not regenerate in mammals? Loss of hair cells in the cochlea, due to aging and/or noise exposure, is one of the primary causes of hearing loss in humans. In humans as in other mammals, once auditory sensory cells are lost, they do not regenerate. However, auditory sensory cells can regenerate in birds and reptiles. The Forge laboratory and the research groups led by Professor Jonathan Gale and Dr Nicolas Daudet seek to understand the processes of repair and regeneration in the inner ear, to determine why mammalian auditory sensory cells do not regenerate and how regeneration might be triggered in order to cure sensorineural hearing loss. Why does age-related hearing loss happen, and how might it be prevented? Hearing loss is a common consequence of aging. However, the extent of hearing loss differs greatly between individuals of the same age, even when their history of noise exposure is similar. The normal

research round-up

function and survival of cells and tissues in the cochlea during aging depends on preservation of mechanisms for normal maintenance (“homeostasis�) in the inner ear. The research groups of Dr Sally Dawson and Dr Ghada Al-Malky along with the Albert and Gale laboratories investigate the genetic factors that confer susceptibility to hearing loss and the biological pathways involved in survival and protection of cells and tissues in the inner ear. How does noise exposure affect the ear? Exposure to loud noise can cause loss of auditory hair cells and a concomitant increase in hearing thresholds. In recent years it has become clear that even levels of noise exposure that do not cause loss of hair cells can damage the synaptic contacts between hair cells and auditory nerve fibres, affecting transmission of sound signals into the brain. The Ashmore, Dawson, Forge, Gale and Jagger laboratories and the research group of Dr Nicholas Lesica study the mechanisms of noise-induced cochlear damage and the means by which it might be prevented. How does hearing loss affect the brain? Cochlear damage is not the only cause of hearing problems during aging or following noise exposure. Loss of auditory nerve input to the brain drives longterm changes in brain circuitry, which can themselves cause hearing problems. For example, tinnitus is thought to arise when auditory brain areas over-compensate for loss of auditory input and become hyper-excitable. Most patients with tinnitus have some hearing loss, and the frequency of the phantom sound perception correlates with the frequency range of hearing loss. Research groups led by Dr Roland Schaette, Professor Jennifer Linden and Dr Peter Keating as well as the Lesica laboratory study these and other consequences of hearing loss for the auditory brain. Why is it so difficult to understand speech in a noisy environment? Listening to conversation in a loud restaurant or classroom is one of the most

difficult auditory tasks that humans perform. Adults with age-related hearing loss and children with developmental disorders have exceptional difficulty understanding speech in noisy environments, and this difficulty cannot be fully explained in terms of problems in the ear. Brain mechanisms are critical for perception of speech in noise. The research groups led by Dr Jenny Bizley and Professor Maria Chait, along with the Linden, Lesica, Schaette, Keating and Marquardt laboratories, investigate mechanisms of speech-in-noise perception in the auditory brain. What is the difference between hearing and listening? Eavesdropping at a cocktail party might be impolite, but it is also an impressive demonstration of the remarkable human ability to attend to particular sounds in a complex acoustic environment. The auditory cortex and other structures in the auditory brain respond very differently to attended versus unattended sounds. However, the brain mechanisms of auditory attention are still poorly understood. The Chait, Bizley, Linden, Lesica and Keating laboratories study the differences between passive hearing and active listening. How do we translate new discoveries into new treatments? Accurate and complete answers to the basic science questions listed above have the potential to transform treatment of hearing problems, improving productivity and quality of life for audiology patients. Clinical academics at the UCL Ear Institute play a critical role in ensuring that the potential clinical benefits of discovery research are fully realised. Professor Shakeel Saeed, Director of the RNTNEH and Head of the Medicine and Clinical Trials group at the Ear Institute, leads Ear Institute projects related to his surgical specialty of cochlear implants. Professor Anne Schilder, an international authority on evidence-based clinical trials in audiology and ENT medicine, heads the national clinical trials centre evidENT and oversees clinical trials of novel treatments for hearing loss, nose and throat problems. Professor Martin


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57 Birchall is a world-leading authority on laryngology, and has pioneered the use of stem cells and tissue engineering for treatment of ENT disorders. Professor Doris-Eva Bamiou is an expert on auditory processing disorders, auditory neuropathy and stroke, and heads specialist clinics for these conditions as well as international research projects devoted to development of new treatments. Dr Hannah Cooper, an audiologist, studies neurodevelopment of children with hearing loss and the use of assistive technologies to improve outcomes for them. All Ear Institute clinical academics and their teams collaborate with the discovery scientists to ensure that discoveries

in the lab can become treatments in the clinic as quickly as possible. These efforts are now supported by ~ÂŁ2.7M funding from the UCL/UCLH NIHR BRC Deafness and Hearing Theme (led by Professor Schilder), which was established in 2017 to support development of transformative new treatments for hearing problems. The UCL Ear Institute welcomes enquiries from potential PhD or MDRes students interested in either discovery science, clinical research or projects that encompass both of these. Funding opportunities for PhD/MDRes students, for example through the UCLH NIHR BRC Deafness and Hearing Theme, are

advertised on the Ear Institute website when available. The Ear Institute also invites applications for the MRes in Sensory Systems, Technologies & Therapies, a research-intensive one-year programme designed to prepare students for pursuing PhD-level research. For students interested in advancing their understanding for clinical practice, the Ear Institute offers highly regarded MSc, PGDip or PGCert degrees in Advanced Audiology, Audiological Science, Audiological Science with Clinical Practice, or Otology and Audiology. For details of all programmes, see www.ucl.ac.uk/ear/study.

research round-up


ear to the ground

58

Ear to the ground

for all things ear-related in the media This issue of Ear to the Ground begins with a recent study, which further supports the link between dementia and hearing loss. The importance of early identification of a hearing impairment is raised in a BBC news article and tinnitus and recreational noise exposure once again make the headlines. The Poppy Appeal last November contributed towards an equipment fund for veterans to assist with hearing and communication devices and the plight of Teachers of the Hearing Impaired in England has been highlighted as funding cuts take effect. The latest research in the mechanism of tinnitus and genetic hearing loss are mentioned along with the latest Audiology news from the world of ‘Twitter’ and coverage from the BSA conference.

Addressing Hearing Loss is once again highlighted in recent Dementia research looking at lifestyle changes to help reduce the effects of this debilitating health condition. Gill Livingstone from University College London is lead author on a recent study to identify factors which contribute to brain health and so help to reduce cognitive decline and the onset of dementia. Dementia is on the increase with a worldwide aging population and this article in the Independent highlighted that in Britain alone, the number of people with the degenerative brain condition will soar from around 850,000 to two million by 2051. Links with hearing loss and dementia have been noted in previous studies but this recent work highlights the strength of the link and how important early identification of hearing loss and habilitation is. “A cognitively rich environment is one where you are using your brain as much as possible. It is an environment which makes you think, listen to several other people during group conversation, and then respond to them in an appropriate way. This is considered to be a cognitively challenging task and one where an individual with an unaddressed hearing loss will have difficulty”. For further information please read the full article: http://www.independent.co.uk/news/health/dementia-cases-preventable-third-education-hearing-loss-lancet-university-college-london-a7849561.html

Why you should get your hearing checked? An interesting article on the BBC news website discussing prevalence of hearing loss in the general population. Over 40% of people over 50 years of age have some degree of hearing loss. This increases to 70% in the over 70’s. Unaddressed, hearing loss can lead to social isolation and depression. This article highlights the need to address hearing loss at an earlier stage through visiting the GP surgery for referral to Audiology. Good to again raise public awareness of the need to seek early intervention and the benefit that amplification via hearing aids can provide. . http://www.bbc.co.uk/news/health-42620387

ear to the ground


ear to the ground

59 How likely are you to get tinnitus from clubbing? I don’t know about you but my clubbing says are well and truly over. However, for many people regular attendance at clubs and gigs is a large part of their social life. This recent article in ‘The Independent’ highlights the risk faced by music lovers who expose their hearing to potential noise damage. Over 600,000 people in the UK suffer with tinnitus. Noise exposure for a minimum of 15 minutes at over 100dB can be enough to put someone ‘at risk’ of this. Interestingly there are wide intra-subject variation with some people being more susceptible than others to the effects of noise exposure. Taking regular breaks from the noise and limiting exposure can help reduce the risk of developing a long term problem. http://www.independent.co.uk/arts-entertainment/music/features/tinnitus-hearing-damage-clubbing-how-likely-causeshow-to-prevent-a8152276.html

Remember Remember the 5th of November: Money raised from the Poppy Appeal contributes to the Veteran Hearing Fund. Living with hearing loss is a major problem for around nine million people in the UK, according to the Disability Resource Centre. Of these, 300,000 are ex-servicemen and women, according to a piece of research carried out by the Royal British Legion in 2014. Another way of looking at this is that veterans under the age of 75 are three and a half times more likely to suffer from hearing problems than the rest of the British population. The Veteran Hearing Fund provides funding for technical support in the form of ‘state of the art’ hearing aids, streaming equipment and specialist tinnitus masking devices. http://www.independent.co.uk/news/long_reads/remembrance-sunday-poppy-seller-service-hearing-loss-deafness-tinnitus-veterans-armed-forces-a8043041.html

Educational Support for Deaf Children in England in Complete Disarray The number of Teachers of the Deaf (ToDs) has been cut by 14% in England over the past 7 years. Over this time, the number of children requiring the support of a ToD has risen by 31%. Consortium for Research into Deaf Education (CRIDE) carries out an annual survey of ToD provision and found that existing ToDs are near to retirement, which will further exacerbate the problem. In some areas, one ToD is responsible for as many as 100 pupils. In response, the Government claims that an extra £223m of funding for special educational needs (no specific mention of hearing-impaired children) has been given to councils, and cites figures that show that the proportion of hearing-impaired pupils achieving 5 GCSEs at grades A to C is at a “record high”, but there is no mention of how this compares to pupils without hearing impairments. https://www.theguardian.com/society/2018/jan/08/educational-support-for-deaf-children-in-england-in-complete-disarrayhow-to-prevent-a8152276.html

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Don’t forget that any piece that appears on a news website can be commented on or shared via social media, allowing the reader to add their voice to a debate and pass the story to friends and colleagues.

ear to the ground


ear to the ground

60 Tinnitus Treatment Tackles Underlying Mechanisms Medscape reported on a study published in Science Translational Medicine by researchers at the University of Michigan. The study relates to the role of the dorsal cochlear nucleus, a part of the brain which integrates auditory input from the cochlea with somatosensory input from the head and neck. The study used 20 human participants in a double-blinded, sham-controlled, crossover clinical study. Bimodal stimulation was used; simultaneous presentation of sound via headphones and somatosensory stimulation of the skin via electrodes on the cheek or neck, designed to affect the activity of fusiform cells in the cochlear nucleus. Researchers found that daily 30 minute treatments with bimodal stimulation was associated with a significant reported decrease in tinnitus loudness, and reduced mean overall scores on the Tinnitus Functional Index (TFI) questionnaire. No improvement was seen with the sham treatment (Sound stimulation only). However, participants selected for the study were required to have a somatosensory component to their tinnitus, i.e. be able to alter their symptoms by clenching the jaw, sticking out the tongue or turning the neck. Thus the treatment may not be as effective for patients without a somatosensory component. The authors of the study are now reportedly moving ahead with a larger scale clinical trial, to obtain further data on the effectiveness of the treatment. https://www.medscape.com/viewarticle/891318

Breakthrough for genetic hearing loss as gene editing prevents deafness in mice The Guardian reported on a study led by Professor David Liu from Harvard University, published in the journal Nature, who developed a genome editing technique to treat a dominantly inherited type of generic deafness. The technique targets the gene Tmc1, using gene editing technology, an RNA molecule can be attached to a protein called Cas9. This can then be injected into the cochlea of neonatal mice, and the Cas9 protein will guide the RNA molecule to the dominant allele associated with causing deafness present on the TMC1 gene. The RNA molecule will then attach to and effectively disrupt the allele. The study showed that mice with the mutant Tmc1 gene who received this treatment showed better survival rates for hair cells within the cochlea, lower ABR thresholds and enhanced startle responses to sound when compared with untreated mice who had the mutant Tmc1 gene. This suggests that this gene therapy technique could potentially be applied to treat some types of autosomal dominant hearing loss. The team plans to trial the therapy further in larger animals, prior to consideration of trials in humans. https://www.theguardian.com/science/2017/dec/20/breakthrough-for-genetic-hearing-loss-as-gene-editing-preventsdeafness-in-mice https://www.nature.com/articles/nature25164

Join us on Twitter @BSAudiology1 ear to the ground


ear to the ground

61 The BSA embarked on its first e-conference in December and in this edition we explore the conference from the twitter perspective; you can find these yourself using the handle #BSAeConf. At the same time, twitter itself embraced change with an increase to 280 characters per tweet. For our featured profile, we share the resources and support from experts brought to you by the Ida Institute.

The e-conference brought a fantastic array of international speakers and current topics to the comfort of your own computer, wherever in the world you were. Laura Turton @LauraFromTheBSA . 13 Sep 2017 Speakers and topics for the @BSAudiology1 #BSAeConf ow.lu/5pBW30f8pAS

Twitterarty Sarah Bent @HearingDementia, updates on and attempts to demystify the audiology Twitter community known as #audpeeps

BritishSocAudiology @BSAudiology1 . 4 Dec 2017 ‘Impulsive noise is much more dangerous than lower levels of continuous noise leading to #tinnitus and hyperacusis.’ #RichardTyler #BSAeConf #liveevent BritishSocAudiology @BSAudiology1 . 4 Dec 2017 Siobhan Brennan asks our panel #BryanPollard #RichardTyler whether measurement of uncomfortable loudness levels is appropriate with people with hyperacusis. #BSAeConf BritishSocAudiology @BSAudiology1 . 4 Dec 2017 ‘Dont over protect your ears and Listen to low levels of noise’ should be studied as 2 independent factors in #hyperacusis’ #BryanPollard.’ #BSAeConf #liveevent

Niels Søgaard Jensen @NielsSJensen . 6 Dec 2017 Inspirational #BSAConf talk on “aging well” by Kathy Pichora-Fuller. Mentioned interesting study (done together with @henda52), which looked into the connections between #age, #hearingloss, #cognitionsm and #socialwithdrawal. What mediates what? pic.twitter.com/JIM2CdFdJU Niels Søgaard Jensen @NielsSJensen . 4 Dec 2017 One of the cons of eConferences is the lack of photo opportunities! :-) But I’m sure @HarveyDillon3 liked not having to travel around the world to make a 20min presentation fo the first data from ambitious large-scale study, addressing a very interesting question! #BSAeConf

The interactive sessions gave an opportunity to pose questions to the speakers live, then carry on discussing the issues in the forum afterwards. BritishSocAudiology @BSAudiology1 . Dec 2017 ‘It is critical to comprehend a persons total 24 hours of noise exposure given the safe average.’ #BryanPollard #BSAeConf #liveevent

Niels Søgaard Jensen @NielsSJensen . 5 Dec 2017 @padraig_hearing talks about benefits of bimodal hearing during #BSAConf live event. BritishSocAudiology @BSAudiology1 . 6 Dec 2017 ‘The goal of a therapist is that your client no longer needs you’ Joey Remenyi #BSAeConf #SelfCare #Onlinetools seekingbalance.com.au

BritishSocAudiology @BSAudiology1 . 6 Dec 2017 ‘Rather than being symptom focus you need to decide what’s important for the person with chronic dizziness’ #BSAeConf #LiveEvent Joey Remenyi Sophie England @BSAudiology1 . 6 Dec 2017 ‘Inspiring live panel with Debbie Cane & Joey Remenyi highlight of a great eConference! @BSAudiology1 #BSAeConf

ear to the ground


ear to the ground

62 Our featured #audpeep for this issue is the Ida Institute, whose twitter feed brings the latest news, articles and opportunities from the Institute for clinicians and researchers across Audiology.

The tools and approaches are welcomed by clinicians and researchers internationally: Dr. Tom Goyne @tomgoyne . 29 Nov 2017 If there’s one thing I could change about audiology, it would be this. Too many audiologists think they’re taking this approach, and they aren’t. Ida Institute @IdaInstitute Research has shown that an empathetic, person-centered approach leads to better clinical outcomes: bit.ly/2j1yKBH

AudiologyOnline @audiologyonline . 4 Dec 2017 Ear Foundation study confirms benefits of @Idainstitute’s My World Pediatric Counseling tool: bit.ly/2hQBBjo

Ida Institute @IdaInstitute . 27 Nov 2017 Do you want to implement more person-centered approaches into your practice? are you worried it will be too time-consuming? We talked to audiologists who say PCC can save you time in your appointments: bit.ly/2jrlGVA Ida Institute @IdaInstitute . 13 Dec 2017 We interviewed Lisa Kovacs from @HandsandVoices about how to support teens who are deaf or hard of hearing: bit.ly/2jrlGVA Ida Institute @IdaInstitute . 20 Dec 2017 Three people with hearing loss share how personcentered care made a difference in their rehabilitation in our new ethnographic films: bit.ly/2jVzxEv Ida Institute @IdaInstitute . 29 Dec 2017 We’ve hosted a number of webinars on @audiologyonline to introduce our tools. Learn more about our presentations, including our most recent one on helping kids and young adults with transitions: bit.ly/2g22bBF Ida Institute @IdaInstitute . Jan 12 A study by the @EarFoundation show that our Telecare for Teens and Tweens tool can help your young clients come preparted to appointments or serve as a starting point for group discussions: bit.ly/2Cq5lmS Ida Institute @IdaInstitute . Jan 16 Ida lab assistant Selma knows that a key to successful communication is to make sure you have your communication partner’s attention before you start talking.

David Maidment @DavidWMaidment . 21 Dec 2017 Replying to @Idainstitute Our projects assessing the feasiblility and effectiveness of the @Idainstitute Telecare Tools are coming along nicely @hearingnihr @Mel_Ferguson1 @hlh1 @Eithne_H CROSSSED Study @CROSSSD . 27 Dec 2017 As clinicians, are we #confident in using #motivationaltools such as @Idainstitute described by @Mel_Ferguson1 @DavidWMaidment et al @hearingnihr in #IJA tandfonline.com/doi/full/10.31... to #establishexpectations #SSE #hearingloss @HearingLosshour #engagement #hearingaiduser #feasibility The Hearing Journal @HearingJournal . Jan 18 Study Confirms Benefits of Ida Institute’s Pediatric Counselling Tool ow.ly/85KH30hzhiD via @EarFoundation @Idainstitute #hearingloss #healthcare

The latest from Ida is a new research fund, with the call closing in March 2018. Don’t miss out: Ida Institute @Idainstitute . Jan 9 Our Research Committee is currently accepting applications for our 2018 grant. We’ll be awarding up to $10,000 USD for projects on tinnitus, telehealth, or using Ida tools for educational purposes: bit.ly/2p510ZH HearingHealthMatters @HearingHealthM . Jan 16 Researchers, did you hear? @Idainstitute makes grants available, up to $10K USD. #audpeeps

Ida Institute @IdaInstitute . Jan 17 Amongst our current group of moderators, we have Priya Carling (@Kent_Hearing) leading discussions on client motivation. Read her introductory post here: bit.ly/2mldphN

ear to the ground

Ida Institute Announces Availability of Research Gr... NAERUM, DENMARK -- The Ida Institute Research Committtee announced that they are accepting proposals for research projects investigating outcomes of the use hearinghealthmatters.org


Small, light and comfortable.

The Nucleus 7 Sound Processor is the world’s smallest and lightest behind-the-ear sound processor and offers up to 50% longer battery life , offering a more comfortable hearing experience for even the smallest ears. ®

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Parents and carers can have peace of mind by monitoring their child’s hearing performance with the Nucleus Smart App. Find out how Nucleus 7 Sound Processor can benefit your patients at:

www.cochlear.com/uk/nucleus7

In a recent clinical trial,

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of users rated the Nucleus 7 Sound Processor as comfortable to wear. 3

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References 1. Cochlear Limited. D1190805. CP1000 Processor Size Comparison. 2017, Mar; Data on file. 2. Cochlear Limited. D1140877. Battery Life and Power Consumption Comparison between CP1000, CP900 Series and CP810 Sound Processors. 2017, Mar; Data on file. 3. Cochlear Limited. D1182081. CLTD 5620 Clinical Evaluation of Nucleus 7 Cochlear Implant System. 2017, Mar; Data on file. Please seek advice from your medical practitioner or health professional about treatments for hearing loss. They will be able to advise you on a suitable solution for your hearing loss condition. All products should be used only as directed by your medical practitioner or health professional. Not all products are available in all countries. Please contact your local Cochlear representative. Cochlear, Hear now. And always, HearYourWay, Nucleus and the elliptical logo, are either trademarks or registered trademarks of Cochlear Limited. The Nucleus 7 Sound Processor is compatible with iPhone 7 Plus, iPhone 7, iPhone 6s Plus, iPhone 6s, iPhone 6 Plus, iPhone 6, iPhone SE, iPhone 5s, iPhone 5c, iPhone 5, iPad Pro (12.9-inch), iPad Pro (9.7-inch), iPad Air 2, iPad Air, iPad mini 4, iPad mini 3, iPad mini 2, iPad mini, iPad (4th generation) and iPod touch (6th generation) using iOS 10.0 or later. The Nucleus Smart App is compatible with iPhone 5 (or later) and iPod 6th generation devices (or later) running iOS 10.0 or later. Apple, the Apple logo, FaceTime, Made for iPad logo, Made for iPhone logo, Made for iPod logo, iPhone, iPad Pro, iPad Air, iPad mini, iPad and iPod touch are trademarks of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc., registered in the U.S. and other countries. Information accurate as of July 2017. © Cochlear Limited 2017. D1265625 ISS2 SEP17


Audacity Issue 11  

Audacity is the publication of the British Society of Audiology

Audacity Issue 11  

Audacity is the publication of the British Society of Audiology

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