Audacity Issue 13

Audacity ...a British Society of Audiology Publication

issue 13 March 2019 ...................................

07 UK Survey on outcome measures used in NHS Adult rehabilitation... “...we should consider goal setting as an integral part of clinical care”

18

Anne Olson Goal setting for Adult Aural rehabiliation...

24

Audiology in Nepal: Demons in my ears...

44 Chris Plack Cochlear synaptopathy in humans: recent...

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3 As usual, the BSA Today section includes updates from a number of BSA Special Interest Groups (SIGs); the Professional Guidance Group (PGG), the Online Learning Group (OLG) and the Conference Group (CG). A special plug for the article written by Mel Ferguson and Anne Olsen based on the work by ARIG, summarising the results from the recent Outcome Measures survey completed by UK NHS audiology services.

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

Welcome to the 13th Edition of Audacity.

We’ve been busy working on this edition over the Christmas and New Year period, much of which now seems like a distant memory. This is the BCUHB team’s 4th edition and I’m really pleased to let you know that we’ll be carrying on for another four editions making the Spring 2021 edition our last one. We’re really enjoying being the editorial team but think that after four years, it will be the right time to hand over to another team. I know it’s a long way away but if you think your team would be interested in taking over ready for the Autumn 2021 edition, and want to know more about how it all works, then please get in touch.

Research Round-Up includes some really interesting articles related to Cochlear Synaptopathy in Humans; the cortical and cognitive mechanisms of gait; and the use of functional neuroimaging methods to investigate crossmodal plasticity in deafness. And of course, don’t forget to take a look at what’s happening around the World in Ear Globe and in the media and on social media in Ear to the Ground.

We’re continuing to pursue the option of an online interactive version of Audacity. We’re planning to circulate a survey to the membership shortly to get your views.

Please keep an eye out for that survey, we’d welcome feedback from as many members as possible to ensure any changes we make are in line with what the membership want.

I’d just like to take the opportunity to thank the Audacity team for their hard work in putting together what I think (and hope you will agree) is another great edition.

Enjoy!

So what do we have within Edition 13?

Once again we have two great featured articles. Anne Olsen’s article: Goal Setting for Adult Aural Rehabilitation describes why goal setting matters for patients and what we can do to implement goal setting more fully within our clinical practice. Piers Dawes gives an update on the work of the SENSE-cog project, which through a number of ‘work packages’, is aiming to improve mental well-being for elderly Europeans with sensory impairment.

We’ve got a number of brilliant articles within the Clinical Catch Up section. The Top Ten Qs this time is related to Ecological Momentary Assessment (EMA), the author Barbra Timmer, summarises this as ‘capturing real-world experience of hearing difficulties and benefits’. As John Day says in his introduction to this article, this is a ‘likely game changer for Audiological rehabilitation’.

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Editor in Chief Welcome

4

Contents 3

Editor in Chief’s welcome

6

Chair’s welcome / Obituary - Mr Bruce Rowe

7

Expert writing about topical areas in audiology

Ear Globe – audiology around the world

31

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

Featured Articles

24

Ted Killan / Gareth Smith

BSA Today

18

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.

44 Research Round-up

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

51 Ear to the Ground

A guide to all things Ear-related in the media

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.

contents

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

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Ear to the ground

Ear to the ground

Ear to the ground

www.thebsa.org.uk Clinical Catch-up

Research Round-up

Research Round-up

audacity@thebsa.org.uk Section Editor Sophie Wareham, Clinical Scientist

Clinical Catch-up

Section Editor Beverly Soden Principal Audiologist

Section Editor Suzanne Tyson, Senior Chief Audiologist

Section Editor Sueann Meyer, Senior Clinical Scientist

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

Section Editor Susan Boon, Chief Audiologist

Section Editor Susannah Goggins, Principal Clinical Scientist

Clinical Catch-up

Section Editor Amber Roughley STP trainee

BSA Today Section Editor Rebecca Anderson, Clinical Scientist

Section Editor Sarah Bent, Principal Clinical Scientist

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Section Editor Shanelle Canavan, STP trainee

Section Editor Simon Wierzbicki, Associate Audiology Practitioner

Editor in Chief

Section Editor Stephanie Greer, Pre-Registration Clinical Scientist

Section Editor Matthew Evans, Principal Clinical Scientist

Section Editor Jenny Townsend, Principal Clinical Scientist

Section Editor Emily Dennis Audiologist

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

5

Meet the team

Research Round-up

Featured articles

Ear Globe

Ear Globe

Ear Globe

Next issue of Audacity September 2019

www.thebsa.org.uk

Research Round-up

meet the team

chair’s welcome / obituary

6 Dr Ted Killan PhD CS (Audiology) Chair Audiological Science and Education (ASE) Group Lead & Deputy Head of Specialist Science Education Department (SSED) LICAMM, Faculty of Medicine & Health University of Leeds

Chair’s Message - March 2019 Due to the timescales involved in compiling an issue of Audacity, whilst you will be reading this in March, I wrote this message at the start of January. As was done by the Roman god Janus (for whom January is named), it is customary at this time to both reflect on the past year as well as look forward to the year ahead (Janus is often depicted as having two faces – one facing backward and the other looking forward). Being respectful of customs, I thought I would do the same…

In February 2018, BSA hosted a joint conference with the BAA and BSHAA. This was an extremely positive event, reflecting the increased eagerness for closer collaborative working within the audiology sector. Around the time you are reading this, the second joint conference will have been held, where plans for unification within our sector will have been discussed. I am keen that in 2019 BSA will play a major role in these important developments.

Throughout 2018, our SIGs continued to deliver on a range of important initiatives. For example, working closely with PGG (led by Donna Corrigan) a range of new and revised guidance has been produced. In 2019 SIGs will also work closely with BSA’s Online Learning Group (led by Sara Coulson) to create world-class learning resources for BSA members. Council have recently agreed investment to develop the online platform for these resources and in doing this we hope to see much needed improvements to our website.

BSA continues to have a significant influence on national policy by contributing to a number of important consultations (e.g. NICE guidelines on adult hearing loss and cochlear implant referrals), and our social media team has been working hard to raise our profile on a number of platforms. If you don’t already, please follow BSA on Twitter.

In 2019 we plan to introduce a BSA Fellowship Scheme that will allow members to apply to have their contributions to the field of audiology recognised through the use of post-nominal letters. Please keep an eye out for news about this initiative.

We also hosted our second innovative eConference in December (many thanks to Siobhan Brennan and the conference group) and are excited about plans for our physical annual conference to be held in June 2019 (by the time you read this plans will be well advanced and you have probably already booked your place!)

So, as you would expect there is a lot going on and we are always keen to hear from members who are keen to get more involved.

Please get in touch and help make 2019 another successful year for BSA.

Obituary - In Memory of Mr Bruce Rowe FRSH FSHAA written by: Gareth Smith

Mr Bruce Rowe

18th July 1943 – 23rd November 2018 Bruce started his audiology career as a hearing aid technician in 1963, joining Scrivens at the age of 20. In 1967 he formed his own practice and in the same year gained Fellowship of the Society of Hearing Aid Audiologists.

This commitment to practice and the profession continued, with Bruce holding various Chair positions within the BSA and for other agencies and societies. He was a founder member of the National Hearing Aid Museum. He was awarded the Ruth Spencer Prize in 1987.

Between 1992 – 1994, Bruce became Chairman of the BSA, as the first Chair-

chair’s welcome / obituary

man from the private sector, and was awarded Honorary Life Membership of the BSA in 2010.

Bruce was diagnosed with skin cancer 10 years ago shortly after retirement.

Lung cancer developed some years later.

He has 6 children and 12 grandchildren ranging from 6 to 24, and enjoyed life living on a farm in the High Peaks surrounded by sheep, pigs, hens, ducks, cats and his German Shepherd dog called Arthur.

Bruce was a passionate musician with the release of a charity album planned for this year with his band Spontaneous.

The final words go to Bruce: “Enjoyment is the key to success”

BSA Today

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BSA Today UK Survey on Outcome Measures used in NHS Adult Rehabilitation Services Melanie Ferguson NIHR Nottingham Biomedical Research Centre E: Melanie.Ferguson@nottingham.ac.uk

Dr Anne Olson University of Kentucky, USA E: Anne.Olson@uky.edu

Background In 2016, the BSA Adult Rehabilitation Interest Group (ARIG) produced Practice Guidance on the ‘Common Principles of Rehabilitation for Adults in Audiology Services’1 that reported on the current evidence-base and best practice relating to adult audiology services. This provided “core principles for promoting a patient-centred, collaborative and reflective approach to rehabilitation”. The importance of, and increasing need, to use patient-reported outcome measures (PROMS) to demonstrate clinical- and cost-effectiveness of audiology services to commissioners, against the current backdrop of cuts to services, was highlighted. Currently, there are numerous PROMS that relate to device interventions (e.g. hearing aids and cochlear implants), as well as non-technical interventions (e.g. support groups, communication strategies)2. Both PROMs (e.g. Glasgow Hearing Aid Benefit Profile) and patient-reported experience outcomes (PREMS, e.g. satisfaction with services) were indicated as a requirement in the NHS England commissioning framework for hearing services3, and the Welsh and Scottish government’s Quality Standards for Adult Hearing Rehabilitation Services4. This was alongside the need for other outcome measures to assess how hearing impacts comorbidities, such as dementia, loneliness and social isolation5.

But what outcomes are actually measured, when, how and why, in audiology services? And are they used by departments, trusts, health boards, and healthcare commissioners? To address these questions, and to better understand current practice patterns in the UK relating to outcomes, the BSA ARIG developed a UK online survey to obtain a

national picture on how PROMS are used. The information from this survey will be used to form the basis of the development of an Outcome Measures Toolkit for Adult Rehabilitation.

Survey Development and Delivery The survey was developed by ARIG members. A previous survey on adult rehabilitation (AR), carried out in 2015, had asked about services more generally, with a few questions on outcome measures6. However, that survey was specific to individuals, and in the current survey we wanted to assess the national landscape from a service viewpoint. The survey was delivered in two ways. The initial freedom of information (FOI) request went to clinical commissioning groups and health boards with a view for data to be collected at a trust/hospital level. Following a limited response rate, the survey was emailed to 1 or 2 (if possible) named hearing healthcare professionals in Audiology services who were in senior positions. The survey questions were mainly closed, but with some open-ended questions. Data were treated as confidential and all reported results are anonymized. The survey took approximately 10-15 minutes to complete.

The survey comprised four sections: 1) demographics for each participating service, 2) outcome measures for individual patients, 3) outcome measures for service evaluation, and 4) provision of PROMS data beyond the service.

The second survey included some additional questions asking about new developments in measuring outcomes (i.e. ecological momentary assessment, EMA) and emerging technologies (e.g. personal sound amplification products, PSAPs).

Invitations were emailed to named individuals in 170 audiology services, with the majority working in NHS Trusts and health boards. Data from both surveys were merged, and duplicate responses from the same service were removed.

The first survey (FOI) was sent in September 2017 (n=27 responses). The second, almost identical, survey (direct email) was sent in May 2018 (n= 66 responses). The total response rate (55%) exceeded expectations, with a total of 93 completed surveys, covering England, Scotland and Wales. The vast majority of respondents (89%) worked in the NHS or a health board, with 4% representing independent practitioners (missing response=7%).

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8 Results A full report on the survey will be made available online in the next few months. We present some of the key findings here. PROMs were used by the majority of services (85%). Assessment of patients’ needs was achieved primarily through interviews (patient, 24%; significant other, 16%) and individual management plans (20%), with 32% using more formal assessment questionnaires (32%). Similarly, the majority of respondents (90%) reported that they assessed readiness and motivation to take-up interventions, primarily through clinical interview with patients (50%) and discussion with significant others (21%); 20% used a questionnaire, of which 12% used a published PROM, and 7% used the Ida Institute Motivation Tools.

The what?

The PROMs used are shown in Figure 1. The main PROMs were the Glasgow Hearing Aid Benefit Profile (GHABP), Client Orientated Scale of Improvement (COSI) and the Glasgow Hearing Aid Difference profile (GHADiffP). All of those who used the GHADiffP also used the GHABP. Despite the Glasgow questionnaires being implemented into patient management systems following the Modernising Hearing Aid Service programme in the early 2000s, nearly as many services now use the COSI. However, only around two-thirds (68%) of those who responded reported that they found the tools satisfactory for the purpose of measuring outcomes. For complex patients, 77% of those who responded reported that they used additional outcome measures to assess interventions for tinnitus (e.g. Tinnitus Handicap Inventory, Hospital Anxiety and Depression Scale), single-sided deafness (e.g. Speech Spatial and Qualities of Hearing), severe-to-profound hearing loss, and other complex cases (e.g. COSI for Significant Others).

services (4%) evaluate PROMs over the longer-term (>6 months). This is problematic when establishing the longterm effectiveness of interventions such as hearing aids7 and interventions to support hearing aid use8.

Figure 2. Duration after intervention that the PROMS are collected.

Respondents could check all that apply (no. responses=108).

The why?

The reasons why PROMs were used are shown in Figure 3.

The majority of responses (71%) suggest that service providers primarily use PROMs for ‘value added’ reasons (i.e. enhance care, track outcomes, plan appointment, and improve service) rather than simply because they are required to do so (16%), or to justify resources (7%).

Three service providers reported that they do not use any outcome measures because they find them of limited benefit. Open-ended responses reported that non-use of PROMs was related to clinical capacity issues, perception of limited value, and too time-consuming. In addition, they reported that discussion with patients of greater value (faceto-face or phone follow-up). Although these numbers are small, it is likely that in those services that did not respond to the survey, a greater percentage would not use PROMs, and it is likely that these reasons would also explain why they did not use them.

Figure 1. Tools used to measure individual patient outcomes. Respondents could check all that apply (no. responses=134).

The when?

Figure 2 shows the time-point when PROMs are administered. Three-quarters of outcomes (74%) are measured within the first four months following intervention. Very few

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Figure 3. Reasons for using PROMS. Respondents could check all that apply (no. responses=323).

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9 Use of PROMs outside Audiology Only two-thirds of respondents answered the question “Are you required to provide PROMs outside of your service?”. Of these, just over half (55%) were required to provide summaries of PROMs. The majority reported to a commissioner (31%), with 21% reporting to the directorate (11%) or executive board (10%). Of those who reported their outcomes data to commissioners, half (50%) did not know how the data were used. Reasons for how commissioners used the data were for monitoring contracts (21%), improving services (10%), determining who provides the service (9%), and payment for services (8%). This suggests that outcomes should be shared with more commissioners to promote the value and benefits of audiology services, and greater clarity for why and how they are used is needed.

Looking to the future Most (77%) reported that they might or would be willing to contribute to a national database of outcome measures.

There was also substantial interest (82%) in a practical outcome measures toolkit. One of the new developments in measuring outcomes is a method known as ecological momentary assessment (EMA). EMA involves repeated measures of an individual’s current opinions, experiences and behaviours measured in real-time, in everyday life and environments9 (see Barbra Timmer’s article in this edition).

Surprisingly, one-third (33%) reported being aware of EMA as an outcome measurement method, which was higher than expected. There was, however, a substantial interest in this method (81%) for the future measurement of patient outcomes. We anticipate that with the increasing use of smartphones to operate hearing aids and other devices such as PSAPs, EMA will become a major method of obtaining patient outcomes, experiences and preferences in the future.

dependent sector) in order to obtain a consensus on how technological developments with different service delivery models (e.g. over-the-counter, direct-to-consumer) will impact hearing healthcare provision in the UK.This will help inform, and better prepare, UK hearing healthcare professionals to adapt to the ever-changing technological landscape.

Summary Key findings from the BSA ARIG survey show widespread use of PROMs in UK audiology services. The GHABP and COSI are the most common PROMs, which are primarily used to enhance and provide added value to patient care.

Far fewer services use PROMs to inform commissioners about the effectiveness of their services. PROMs are typically measured in the short term post-intervention (1-4 months), and there is a lack of longer-term outcomes. This survey is probably the most informative data that we have on the use of outcome measures in audiology, as the response rate was higher than typically seen in online surveys at 50%. However, we do need to be mindful that those services that did not respond may have a less positive view on the use of PROMs Only a minority of services report that they are required to provide PROM data to commissioners. This suggests that commissioners may benefit from nationally developed guidance on the use of PROMs within contracts and interpretation of performance, to help assure delivery of cost effective health care. Finally, the use of smartphone technologies is likely to change the way PROMs and hearing device interventions are used in the future.

The full report will be able online by mid-2019. This survey along with some ongoing work to identify key aspects of the main PROMs (e.g. psychometric properties, how to use and score PROMs, use in patient care and service evaluation) will form the basis of the BSA ARIG’s Outcome Measure Toolkit.

Acknowledgments Many thanks to the BSA ARIG members who contributed to the development, delivery and data collection for this survey (Jane Wild, Judith Bird, Laura Turton, Elaine Clifford, Sarah Hughes), and to John Day for his helpful comments.

Finally, there are many developments in listening devices coming onto the market, such as PSAPs, ‘hearables’ and smartphone-connected hearing aids10,11. Although only two-thirds responded to the question about awareness of these new and emerging technologies, awareness with those was high (n=89%), as was interest in learning more about these technologies (78%). We are currently obtaining views from hearing healthcare professionals (NHS and in-

References 1. BSA. Common principles of rehabilitation for adults in audiology services. Reading: British Society of Audiology;2016.

2. Granberg S, Dahlström J, Möller C, Kähäri K, Danermark B. The ICF Core Sets for hearing loss-researcher perspective. Part I: Systematic review of outcome measures identified in audiological research. Int J Audiol. 2014;53(2):65-76.

3. NHS England. Commissioning Services for People with

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10 Hearing Loss: A Framework for Clinical Commissioning Groups. United Kingdom2016.

4. Welsh Government. Quality standards for adult hearing rehabilitation services: the assessment and rehabiltiation tool. 2016.

5. Heffernan E, Habib A, Ferguson M. Evaluation of the psychometric propertis of the Social Isolation Measure (SIM) in adults with hearing loss. Int J Audiol. 2019;Early Online:1-8.

6. Ferguson M, Coulson N, Handscomb L, Brassington W, Downes B. A national survey of adult rehabilitation practice in UK audiology services. BSA Grow: Library; Adult Rehab - Key Commissioning Evidence. 2015. https://www.thebsa.org.uk/about/bsa-grow/.

7. Ferguson MA, Kitterick P, Chong L, Edmondson-Jones M, Barker F, Hoare D. Hearing aids for mild to moderate hearing loss in adults Cochrane Database of Systematic Reviews. 2017(9 ).

8. Barker F, Mackenzie E, de Lusignan S. Current process in hearing-aid fitting appointments: An analysis of audiologists’ use of behaviour change techniques using the behaviour change technique taxonomy (v1). Int J Audiol. 2016;55(11):643-652.

9. Timmer BH, Hickson L, Launer S. The use of ecological momentary assessment in hearing research and future clinical applications. Hearing Research. 2018.

10. Maidment DW, Barker AB, Xia J, Ferguson MA. A systematic review and meta-analysis assessing the effectiveness of alternative listening devices to conventional hearing aids in adults with mild-to-moderate hearing loss. Int J Audiol. 2018;57(10):721-729.

11. Maidment D, Ali Y, Ferguson M. Applying the COM-B model to assess the usability of smartphone-connected listening devices in adults with hearing loss. J Am Acad Audiol. In Press.

SIG update Balance Interest Group (BIG) Andrew Wilkinson Balance Interest Group (BIG) E: andrew.wilkinson@uhbristol.nhs.uk

The Balance Interest Group (BIG) continues to forge ahead with a dynamic and enthusiastic multidisciplinary team. We are very fortunate to have expertise with a broad scope of disciplines pertinent to all aspects of vestibular/balance assessment, management, rehabilitation and research. This includes: audiologists and clinical scientists (with backgrounds in both Audiology and Medical Physics), Neurology, Physiotherapy, the academic sector, and the Meniere’s Society (Registered Charity).

The team have been very busy in recent months putting the final touches to Recommended Procedures (RPs) (including updates) and other papers.These have included: a major rewrite of the Recommended Procedure for Calorics (submitted); a comprehensive RP on Vestibular Evoked Myogenic Potentials (combined document covering both cervical and ocular procedures, lead by Paul Radmoskij); a Guidance Document on Vestibular Rehabilitation (submitted, lead by

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Amanda Male (Physiotherapy) and Debbie Cane (Lecturer/ Clinical Scientist), and work with Amy Lennox (University of Manchester) on procedures for v-HIT (head impulse testing).

Committee member, Dr Diego Kaski and his team from Neurology at Imperial have submitted an excellent article on postural control that appears in this edition of Audacity.

Some of the BIG committee members are due to stand down, and so by the time you read this an advertisement will have gone out to BSA to advertise for one or more new members for the team. I am due to stand down as Chair in April 2019, so this will probably be the last update you hear from me, although I hope to be able to continue to contribute to BIG in whatever ways I can. Ciao! Andrew.

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

www.thebsa.org.uk

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11 Adult Rehabilitation Interest Group (ARIG) Jane Wild Adult Rehabilitation Interest Group (ARIG) E: Jane.Wild@wales.nhs.uk

ARIG are really pleased to have welcomed three new members since our last update in Audacity. Wendy Trump, Lorraine Lewis and Jo Herrod attended their first ARIG meeting in October. They will be initially focusing on our #inspiringaudiologists tag line and considering ways that we can promote all that is great about adult rehabilitation.

We also continue to make good progress in our other areas of focus: Outcomes measure survey As we reported last time, the online survey had a good response rate. Results have been evaluated and we’re really pleased that a report is included as an article within this edition of Audacity.

Conference Group (CG) Gemma Crundwell Conference Group (CG) E: gemma.crundwell@addenbrookes. nhs.uk

After many years as BSA Conference Group Lead, Siobhan Brennan stepped down from this role at the end of 2018.

She leaves a big hole in the conference team and will be much missed. There are now five of us on the conference team – Gemma Crundwell (Conference Group Lead), Prof Manohar Bance, Joanne Deane, Tamara Lamb, and David Maidment; but we are looking for more members!

December saw the 2nd BSA E-Conference ‘Global Brilliancy’. This innovative approach to conferencing allowed delegates to access a variety of topics given by eminent speakers from around the world – all from the comfort of their own PC. Following feedback from the inaugural event the conference ran for the whole of December. We will use feedback from this year’s conference to make the 2019 conference programme event better! A big thank you goes to Jacqueline McCafferty and the rest of the fitwise team for their invaluable help coordinating this event.

We’d like to thank Anne Olsen for her support with this piece of work and her contribution to ARIG whilst she was in the UK on secondment. ARIG are planning to stay in touch with Anne and look at how we can work together and link to similar groups in the USA. Outcome measures toolkit We are continuing to work on the outcome measures toolkit. The toolkit will provide information on key aspects of the most commonly used outcome measures, and how they are to be used. It’s envisaged that the toolkit will be the ‘go-to’ place for adult rehab outcomes in the UK. Sound Practice - http://bsa-soundpractice.org.uk/ We are still working on the Beta version of the website. We are in discussion with web designers as to the best approach for further development and hope to be able to make the changes needed ready for further promotion at the BSA conference in the summer.

If you are interested in registering or uploading a scheme to showcase innovative work you are doing, then please take a look.

As always, please continue to stay in touch with what ARIG are doing and keep a look out for our tag line #inspiringaudiologists.

2019 promises to be the year of collaborative conferences starting with the joint BSHAA/BAA/BSA event ‘Hearing: a sense of purpose’ on the 25th March. This event is quickly followed on the 5th April by the second ENT UK & BSA Global Health meeting. Most excitingly on the 5th June the BSA will be hosting a one-day face to face event which will be free for members. The programme hopes to provide something of interest for both researchers and clinicians using a combination of keynote talks and grand round clinical series.

The BSA conference group is looking for more members to help plan and organise conference events, if you would be interested or want to find out more please contact me at the email above.

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12 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

We are delighted to welcome 3 new members to our APD SIG steering committee, who bring considerable expertise to our group. They are: • Ansar Ahmmed: Consultant Paediatric Audiovestibular Physician at the Lancashire Teaching Hospitals NHS Foundation Trust • Nehzat Koohi: Clinical Scientist (Audiology) at the University College London Hospitals (UCLH) Neuro-otology Department and Honorary Lecturer at the University College London (UCL Ear Institute) • Stuart Whyte: Educational Audiologist at the University of Southampton, immediate Past President of the British Association of Teachers of the Deaf (BATOD) and the current Chair of the UK Children’s Radio Aid Working group.

We would also like to thank Tony Sirimanna (Consultant Audiological Physician) for the tremendous contribution he has made to both the field of APD in the UK and our APD SIG. He is one of the founding members the APD SIG and a past chair. He set up the APD Service at Great Ormond Street Hospital and has seen and helped hundreds of children and their families. He is retiring but has accepted our invitation to serve on the APD SIG Reference Group. We wish him happiness in his new ventures.

We are currently working on a number of exciting projects.

This includes two new ‘whitepapers’; one about APD in children and the other APD in adults. This follows on from the success of our first ‘whitepaper’; a discussion document with an international set of commentaries from researchers around the world. It served as a catalyst for a fundamental reconsideration of APD internationally; promoting evidence-based practice [Reference: Moore, D.R., Rosen, S., Bamiou, D-E., Campbell, N., & Sirimanna, T. (2013). Evolving concepts of developmental auditory processing disorder (APD): A British Society of Audiology APD Special Interest Group ‘white paper’. International Journal of Audiology, 52, 3–13].

We are collaborating with the UK Children’s Radio Aid Working group in improving access to technology for children with both hearing loss and APD. We are in the early stages of developing an evidence-based BSA guidance document on the use of assistive listening devices for individuals with APD. A new online APD resource, initiated by British Association

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of Teachers of the Deaf (BATOD), will be launched early in 2019. The aim of the new Auditory Processing Disorder (APD) in Children MESHGuide is to provide those interested in APD with the most up-to-date research evidence, presented in an easily accessible way, and thereby promote excellence in the support and care provided to children with APD. The target audience is professionals, funders, parents, children with APD and the general public. It aims to promote a high standard of research and evidence-based care and encourage both international and multi-disciplinary collaboration. A number of the members of our APD SIG were invited to be authors.

We are currently collating a list of APD Services in the UK to make available on the BSA website. Please contact me (n.g.campbell@soton.ac.uk) if you would like us to add your service and contact details to the list.

For more information about APD and to access the BSA APD Position Statement & Practice Guidance 2018 please visit the BSA website http://www.thebsa.org.uk/bsa-groups/ group-apdi/ BSA APD SIG: Ansar Ahmmed, Nicci Campbell (Chair), Pauline Grant, Nehzat Koohi, Stuart Rosen (Vice Chair) and Stuart Whyte BSA APD SIG Reference Group: Doris Bamiou, Dave Moore, Tony Sirimanna

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

We are busy in the process of organising the second joint global health conference with ENT UK which will be held in London on the 5th April 2019. The conference will offer a range of speakers from both the UK and internationally involved in global health related to hearing loss and ENT. We had great success last year with our first ever conference and receiving positive feedback from delegates, so we’re working on making our second one better again. For information about the programme and how to register please visit https:// www.entuk.org/events/773 - we look forward to seeing you there!

In addition, the GO SIG have met again in February to look over the work that has been achieved so far and make plans for 2019 and beyond and will update on our plans on the BSA website.

BSA Today

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

Since the last update the TH SIG have revised the BSA ‘Recommended procedure for measuring uncomfortable loudness levels’, and drafted a ‘Recommended procedure for fitting combination hearing aids for tinnitus’. Both documents, and the draft BSA ‘Practice guidance on tinnitus in adults’, will be going through review and member consultation during 2019. We have also produced a set of materials that will form a BSA online learning module on tinnitus.

Next the SIG are turning their attention to hyperacusis. Priorities will be informed, in part, by the results of the BSA and Action on Hearing Loss-funded James Lind Alliance Hyperacusis Priority Setting Partnership. This project led to the identification of priority research questions on various aspects of hyperacusis including assessment, management, and healthcare delivery. The Top 10 priorities, published in the Lancet, were 1. What is the most effective treatment approach for hyperacusis in children?

2. What is the prevalence of hyperacusis in a general population and other specific populations (e.g. people with

Online Learning Group (OLG) Sara Coulson Online Learning Group (OLG) E: sara.coulson@dmu.ac.uk

Over the course of the autumn, BSA Grow has focused on patient centred care. It is so important to combine an accurate diagnosis with an understanding of the individual’s physical, social and psychological needs, in order to tailor their rehabilitation plan.

Bert Meijers, project manager at the IDA institute, provided learning on tools available to support children and teenagers with hearing loss. These tools are free for clinicians to use with their patients. The recordings are available in the Library/IDA Institute Resources of the BSA Grow website.

autism, mental health issues, learning disabilities, hearing loss)?

3. Are there different meaningful types of hyperacusis?

4. What is the essential knowledge/training required for health professionals to appropriately refer or effectively manage hyperacusis?

5. Which treatment approaches are most effective for different types or severities of hyperacusis?

6. Is hyperacusis due to physical or psychological issues or is it a combination of both?

7. Which psychological therapy (e.g. counselling, Cognitive Behavioural Therapy, mindfulness) is most effective for hyperacusis?

8. What management approach for hyperacusis is most effective for adults/children with autism?

9. What is the best way of using sound in therapy for hyperacusis?

10. Which self-help interventions are effective for hyperacusis?

There is important work to do to understand the current landscape of hyperacusis care in the NHS. SIG members will be leading on a number of projects including a Delphi review to identify a consensus clinical definition of hyperacusis, so do look out for opportunities to participate.

Finally, we are delighted to welcome two new members to the SIG – Amanda Casey (Aston University) joined the steering group, and Joy Rosenberg (Mary Hare) joined the reference group.

In November BSA Grow promoted patient centred care and mental health. There are a number of short recordings from experts on dementia and cognitive impairment, post-traumatic stress disorder, and depression and anxiety.

These are in the Library/Lunch and Learn Archive.

Finally, David Maidment, Research Fellow at the NIHR Biomedical Research Centre, discusses individual patient motivation as a factor in successful adoption of hearing aid technology. His presentation can be found in the Library/Lunch and Learn Archive.

The BSA Grow website is set for a makeover, so please look out for our new look site. We intend to launch with some guidance on changes to recommended procedures later in the year - REM, bone conduction testing, tinnitus guidance - so there will be some very useful information coming out.

BSA Today

BSA Today

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

so please read these new procedures to maintain up to date practice. The EP SIG Steering Group will be circulating tips and advice from the new procedures to EP SIG members in early 2019.

A number of other procedures and practice guidelines are in the pipeline for public consultation including; • Recommended Procedure for Auditory Brainstem Response (ABR) testing for post newborn and adult • Recommended Procedure for ABR testing in babies

I would like to start by welcoming Dr Michelle Foster as the vice chair of the EPSIG. Michelle is very active in the revision of a number of the BSA Recommended Procedures and Practice Guidance documents the group are working on.

Two documents released as BSA approved procedures in early January 2019, having been through external peer review, public consultation and approval by BSA council in late 2018 are; • Recommended Procedure for Cochlear Microphonic Testing • Recommended Procedure for Assessment and Management of ANSD in Young Infants) They reflect updated practice and knowledge in these areas

• Practice Guidance on principles of external peer review of auditory electrophysiological measurements.

So please watch out for these and we would welcome your feedback.

Progress continues with the revision of the ‘Guidelines for the early audiological assessment and management of babies referred from the newborn hearing screening programme’. The ASSR sub-group met recently and good progress was made in defining the scope of the ASSR recommended procedure.

If you are interested in developing your expertise and skills in electrophysiology work why not join the EP SIG as a member, just e-mail me at the contact above; membership is open to all BSA members.

ENT UK and BSA are collaborating again this year for the second Global Health Meeting, which will be held on Friday 5th April 2019 at the Wesley Euston Hotel & Conference Venue, London.

After the great success of the Global Health Meeting in 2018, ENT UK and BSA will, come together to discuss important Global Health issues related to hearing loss and ear disease. It will be a superb and unique networking event for both delegates and exhibitors.

Feedback and evaluation from the 2018 conference: 98% of delegates rated the event as ‘excellent’ or ‘good’

We’d love to see you there!

Please go to https://www.entuk.org/ events/773 to view the programme and to register!

BSA Today

This central London location is easily accessible with excellent travel links, with Euston Station conveniently located close by.

BSA Today

15 Practice Guidance Assessment Guidelines for the Distraction Test of Hearing, Recommended Procedure Assessment and Management of Auditory Neuropathy Spectrum Disorder (ANSD) in Young Infants and Recommended Procedure Cochlear Microphonic Testing will all be presented to BSA Council in December 2018 for final approval and will therefore be published shortly after.

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

How to reference a BSA document If you wish to cite a document in your work please use the following format:

2018 has been a busy year for the PGG, with many brand new documents having completed much of the creation process and on track for publication early in 2019. There are currently 25 documents in process and as you will have seen there has been a constant stream of consultations over the Summer and Autumn, a trend set to continue well into 2019 as we already have the next 6 months of consultations mapped out which will include Recommended Procedures for Auditory Brainstem Response (ABR) Testing in Babies, Practice Guidance Principles of external peer review of auditory electrophysiological measurements, Practice Guidance Behavioural Observational Audiometry and Recommended Procedure The Caloric Test to name just a few.

BRITISH SOCIETY OF AUDIOLOGY, (Year of publication), Full title of document. [Online]. Available from: insert web link.

[Accessed date] An example would be: BRITISH SOCIETY OF AUDIOLOGY, (2018), Recommended Procedure Pure-tone air-conduction and bone-conduction threshold audiometry with and without masking. [Online]. Available from: https://www.thebsa.org. uk/wp-content/uploads/2011/04/Recommended-Procedure-Pure-Tone-Audiometry-August-2018.pdf [Accessed 01/12/2018]

The updated Recommended Procedure for Pure tone air and bone conduction threshold audiometry with and without masking and have been published so please make sure that you review the document paying particular attention to what is now recommended for the testing of bone conduction.

Please look out for social media notifications letting you know of new public consultations and the final publication of documents.

What documents are in process?

A summary of documents within the review/creation process at the moment: Type of document

Total number

2019

Under review

Current

Proposed new

Recommended Procedures

19

10

9

0

Practice Guidance

19

13

3

3

Accreditation

6

2

4

0

0

1

0

0

2

0

25

19

3

ANNUAL CONFERENCE Position Statement 1

Wednesday 5th June 2019 Policy Stadium, Wolverhampton 2 Molineux Totals

47

2019 ANNUAL CONFERENCE

Wednesday 5th June 2019 Molineux Stadium, Wolverhampton

BSA Today

BSA Today

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

Joy Rosenberg

Karen Willis

As a group we have agreed a change in meeting formats, we are now moving to an annual face-to-face working day and three further online meetings a year. Our first was in January 2019, with our annual face-to-face working day which included achieving excellent results from a committee meeting in the morning, and with interest group members beavering away at agreed projects in the afternoon.

We have decided to reinvigorate our advisory group and agreed it is very important to have wider input into committee issues where possible, tapping into exponential years of collective experience represented in Paediatric Audiology, Education of the Deaf and other related professionals of the BSA. Our advisory group members agree to be available by email to give an opinion if merited and do not attend meetings or have project obligations, if you are interested in becoming part of this advisory group please contact the BSA. We have been busy with documentation; the Distraction Test practice guidance document is now complete and on the BSA website, and the Behavioural Observation Audiometry practice guidance is in final proof read stage and will be due out soon. This year we will begin the review of the Visual Reinforcement Audiometry protocol.

PAIG’s BSA Grow e-learning module (‘Value of Educational Audiology Role’) has now been published with many thanks to the BSA Online Learning Group and chair for their com-

BSA Today

mendable efforts at re-establishing contact and arranging the launch. As a beneficial resource to clinical audiologists, the module raises awareness of the bridging role of educational audiologists between clinic, school and home which can optimise hearing aid fittings and reviews.

We have brainstormed ideas for future focus and the direction PAIG would like to take in the coming year. We concluded that we would aim for increased conference presence, such as at Deaf Children Now: Changing Conversation which is being held in Manchester in June this year and at the BSA conference, also in June. We also suggested the need for a document to give guidance to paediatric audiology departments regarding surveillance of at-risk children. Our next idea was to collect and collate best practice examples from clinical and education sources about partnership working, family centred care and linking listening life.

If you have examples, please get in touch.

We have fielded responses to paediatric audiological enquiries to the BSA. These have included queries about programmable brain shunts, noise protection for babies and VRA protocol. Provision of radio aids for 0-2 year olds was discussed in response to a letter from British Association of Educational Audiology requesting support and providing a rationale for an NDCS campaign for national funding agreements. We agreed with its factual presentation and endorse such an effort.

Thanks for reading and if you think there is anything that the PAIG should be working on then please pass your ideas onto the BSA. We look forward to seeing you at the BSA conference in June.

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.

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18

Goal Setting for Adult Aural Rehabilitation CD

Author and Correspondence Dr Anne Olson, PhD, CCC/A Audiologist University of Kentucky Correspondence address: Room 124J Wethington Building, 900 South Limestone Street, Lexington, Kentucky, 40536-0200, USA E: aolso2@uky.edu

The following is a summary from a recently presented talk from the December 2018 BSA e- conference titled Goal Setting for Adult Aural Rehabilitation that was presented by Anne D. Olson, PhD. Goal setting for adults with hearing loss is a core principle of Aural Rehabilitation that is recognized by the British Society of Audiology.The purpose of this article is to describe goal setting, why it matters for patients and what we can do as clinicians to more fully implement goal setting in our everyday clinical activity.

Michie and colleagues (2013) have defined goal setting as the “setting or agreeing on a goal defined in terms of the behaviour to be achieved”. This definition is particularly useful because it focuses on goal setting in terms of behaviours that people want to change. It also implies that goal setting is a mutual process, emphasising the joint responsibility between patient and clinician in goal setting.

Many of us set goals each new year, despite the fact that an estimated 80% of resolutions fail to become a reality. This inability to reach our intended goals is referred to as the “intention-behaviour gap” (Faries, 2016). The idea here is that there is a disconnect between our planned goal and what we actually do.

There are several ways that this intention-behaviour gap is relevant to audiology. First, we know that approximately one in six adults has a hearing loss. However, most people with hearing loss postpone acquiring amplification for almost a decade and only one-third of adults who needs a hearing aid actually owns one (Scholes et al, 2018). Furthermore, of those who do have a hearing aid, many do not know how to use them or do not use them at all. This lack of use, or sub-optimal use is quite similar to our inability to lose weight after the holidays. Therefore, we should be mindful of this intention- behavior gap in relation to hearing loss.

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One way to address a behaviour intention gap is to engage in goal setting with clients. While much of the research about goal setting has been done in the private business sector (Locke and Latham, 2003) there has also been some investigation within rehabilitation settings (Levack et al, 2006; Epton et al 2017, Rose et al 2017). Collectively these studies have shown that goal setting has the potential to change behaviour (Locke and Latham, 2003; Levack et al, 2006), especially when goals are specific and difficult (Epton et al, 2017). Patient outcomes are improved in adults with acquired disabilities (Levack et al 2006), particularly when they are established face to face and adequately challenging (Epton et al, 2017). Furthermore, goal setting enhances patient autonomy, so that they are more able to self-manage their chronic conditions. This is important for persons with hearing loss as we know that hearing loss worsens with age. Lastly, by setting goals it allows us to readily assess outcomes and readily demonstrate the impact of rehabilitation to commissioners. Together, these are fairly compelling reasons about why we should consider goal setting as an integral part of clinical care.

Good goals have key characteristics. Many people may be familiar with the concept that goals should be constructed using the SMART (Duran, 1981) framework. SMART is a simple mnemonic to recall important key characteristics of goals (S= Smart, M = Measureable, A = Attainable, R= Realistic (or relevant) and T= Timely). Using this framework when writing goals, decreases the likelihood of setting unclear goals such as “I want to hear better”. For example, rather than say “I want to improve my running”, a more targeted goal would be “I want to reduce my mile run time by 8 seconds over the next 3 months”.The initial, generic goal clearly does not follow the SMART principles and the latter goal does.

“...we should consider goal setting as an integral part of clinical care” Two systematic reviews conducted (Levack et al, 2006) (Rose et al, 2017) looked at the effectiveness of goal planning in clinical populations. The take home message is that there is good evidence documenting improved patient performance when goal setting is used in rehabilitation settings. Most importantly, findings were strongest when specific and challenging goals were established.This finding should cause audiologists to pause and consider how we might be able to better implement goal setting in our daily practice. A recent BSA sponsored Adult Rehabilitation Interest Group (ARIG) survey (2017-2018) queried 93 audiologists throughout the UK about goal setting practice by asking: “how do you typically assess patient needs leading to goal setting?” Responses indicated that 60% of audiologists in

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19 the UK use informal approaches to goal setting, such as clinical interview, individual management plan (IMP) and discussions with significant others. This suggests that the current practice patterns lend themselves nicely to developing more systematic formal goal setting approaches.

One way to readily include goal setting conversation in the clinic is through the use of the Client Oriented Scale of Improvement (COSI) (Dillon et al 1997). This tool was designed to develop goals that can be discussed during the interview approach. The form is blank, so that goals discussed with the client can be individually tailored to their needs. There is a list of common communication difficulties to help facilitate discussion and goals.

Goals are then recorded and ranked in order of importance.

Clients then self-assess their ability to perform the chosen goal.

After intervention, goals can be re-evaluated to determine progress. The idea is that if goals are specific and individually tailored, people are typically more satisfied with their care, and achieve better outcomes. One potential limitation of the COSI is that it could be overwhelming for clients who do not fully understand the complexity of the rehabilitation process.

Bornman and Murphy (2006) believed that one barrier to goal setting in the clinic was that clients do not understand the rehabilitation process.They examined goal setting in a clinical setting for adults with long term conditions. To address this knowledge gap about the rehabilitation process, they adopted a visual approach to facilitate discussion with clients and developed a tool called Talking Mats. They showed that by sharing a visual diagram of topics that reflected activities of daily living, this was effective for facilitating goal setting in adults with disabilities. Such an approach could also be useful in audiology clinics for clients with hearing loss. A visual representation of typical communication problems related to hearing loss is provided in Figure 2 and is modeled after the Bornman and Murphy approach.

The purpose of this illustration is to facilitate discussion with

clients about goal setting using descriptive icons rather than text. Providing a diagram of typical communication difficulties may readily trigger conversation so that clients might be more specific in generating goals for communication deficits.

Figure 2. A visual representation of typical problems related to hearing loss that incorporate the communication difficulties from the Client Oriented Scale of Improvement (COSI). The purpose of the tool is to facilitate discussion with clients about goal setting.

A currently available tool to ensure that patients understand the complexity of steps in the auditory rehabilitation process is to refer to an auditory skills hierarchy (link - http://mshaonline.org/wp-content/uploads/2015/07/Auditory-Skills-Checklist. pdf).This is a useful resource that provides detailed descriptions of the several levels that are involved in auditory skill development. These steps begin at level one (awareness of environmental signals) and extend up to level ten (auditory only comprehension of connected speech). Referring to a hierarchy during goal setting, may help ensure that clients set challenging goals at an appropriate level. To use this hierarchy, consider the case of a 25-year old female client who was recently received a cochlear implant. She has a history of a pre-lingual onset (age 2 years) severe sensorineural hearing loss. She states that her goal is to have a conversation with her German grandmother on the phone. The auditory skills necessary to accomplish her goal can be described as an open set speech recognition without visual cues, consistent with the highest auditory skill on the hierarchy. From anecdotal clinical experience, we know that this goal will be unrealistic as a starting point and will require significant time before this skill could be developed. Given her duration of deafness it is unclear if she will in fact develop this ability. To help her understand the process, an audiologist can refer to the Auditory Skills Hierarchy, and visually illustrate for the her that there would be several levels of auditory skill

Activities and participation

Figure 2

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20 acquisition needed to accomplish before acquiring the ability to speak with her grandmother on the phone. The hierarchy would also provide a roadmap of suggested goals that would be important to acquire first such as closed set speech recognition without visual cues.

In summary, the present article summarises tools that can be used in the clinic to formally and systematically address goal setting in the clinic. Implementing any of the goal setting approaches discussed here, will potentially narrow the intention-behaviour gap. While additional research is needed to provide evidence for this in audiology settings, the current research about goal setting discussed here is strong and provides core principles that can be applied to our audiological settings.

References 1. Bornman, J and Murphy, J (2006) Using the ICF in goal setting. Clinical application using Talking Mats Dis Rehab: Asst Tech, June 1(3): 145 – 154.

2. Dillon H, James, A, Ginis, J (1997). Client oriented scale of improvement (COSI) and its relationship to several other measure of benefit and satisfaction provided by hearing aids. J Am Acad Audiol 8: 27-43.

3. Duran, G (1981). There’s a S.M.A.R.T way to write management’s goals and objectives. Management Rev 70 (11) 35-36.

4. Epton T, Currie S, Armitage C (2017). Unique effects of

setting goals on behavior change: Systematic review and meta-analysis. J Consult and Clin Psychol 85(12) 1182-1198.

5. Faries, M (2016) Why we don’t “just do it”: Understanding the intention-behavior gap in lifestyle medicine. Am J Lifestyle Med 10(5).

6. Levak WM, Taylor K, Siegert RJ, Dean SG, McPherson KM, and Weatherall M. (2006) Is goal planning in rehabilitation effective? A systematic review. Clin Rehabil 20(9) 739-755 7. Locke and Latham (2002). Building a practically useful theory of goal setting and task motivation. A 35-year odyssey.

Am. Psychol. 87:497-505.

8. Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, Eccles MP, Cane J, Wood, CE (2013) The Behavior Change Technique Taxonomy of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann. Beh Med 46(1) 81-95.

9. Rose A, Rosewilliam S, Soundy A, (2017). Shared decision making within goal setting in rehabilitation settings; A systematic review. Pt Educ Counsel 100 65-75.

10. Scholes S, Biddulph J, Davis A, Mindell J (2018). Socioeconomic difference in hearing among middle aged and older adults; Cross section analyses using the Health Survey of England. Br Med J Open 8e019615. Doi:10.1136/bmjopen-2017-019615.

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21

The SENSE-cog project to improve mental well-being for elderly Europeans with sensory impairment CD

Author and Correspondence Dr Piers Dawes Correspondence address: Manchester Centre for Audiology and Deafness NIHR Manchester Biomedical Research Centre University of Manchester, Oxford Road, Manchester M13 9PL E: piers.dawes@manchester.ac.uk

Figure 1. SENSE-cog project partner sites

Seven in ten Europeans over the age of 65 live with sight or hearing problems and over two-thirds live with depression or dementia. Both cognitive and sensory problems are under-identified and under-treated. There is therefore a ‘crucible of multi-morbidity’, where sensory and cognitive impairment interact to impact the mental health and well-being of older people. But there is also an opportunity to improve mental well-being outcomes by effective prevention, identification and treatment of hearing and vision problems. The SENSE-cog project addresses this opportunity.

SENSE-cog (https://www.sense-cog.eu/) is funded by the European Commission’s Horizon 2020 programme. SENSE-cog involves 27 investigators from academic, clinical and industrial partners across 7 EU countries and the USA (Figure 1). SENSEcog is led by Professor Iracema Leroi and Dr Piers Dawes from the University of Manchester.

impairment [3], and positive impacts of hearing (hearing aids) [4] and vision (cataract surgery) [5] on cognitive decline. A key focus is understanding why hearing and vision impairments are markers of risk for cognitive decline and dementia.

Health economic analyses concluded that co-morbid sensory and cognitive impairments are associated with increased health care utilisation costs, as well as identifying potential economic benefits of addressing sensory impairments [6].

‘Assessment’ involves developing and validating screening tests for cognitive impairment that are suitable for people with hearing or vision impairment. Commonly used cognitive screening

The project has 5 substantive work packages: The ‘Exploration’ work package involves modelling associations between hearing and vision impairment and sensory interventions on mental well-being outcomes. This work package makes use of existing longitudinal data sets that have information about hearing, vision and mental well-being.

Key findings so far are: identification of retinal markers for dementia risk [1], trajectories of cognitive decline according to patterns of hearing/vision impairment (Figure 2 [2]), associations between affective well-being outcomes and hearing/vision

Figure 2: Trajectories of cognitive decline according to patterns of hearing and vision impairment (from Maharani et al. 2018, Age and Aging)

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22

The SENSE-cog kick-off meeting in Manchester, February 2016

tests rely on good sensory function. Sensory impairments may be mis-identified as cognitive impairment, or the severity of cognitive impairment may be over-estimated due to the impact of sensory factors on currently used cognitive tests [7].

The hearing and vision-independent cognitive tests developed in this work package will be freely available to clinicians across Europe, and will help ensure people receive appropriate and timely diagnoses and management.

“there is an opportunity to improve mental well-being outcomes by effective prevention, identification and treatment of hearing and vision problems” The ‘Intervention’ work package involves development and evaluation of a sensory support intervention for people with dementia [8]. Addressing remediable sensory impairment offers a promising low risk, inexpensive and effective non-pharmacological approach to improve quality of life outcomes for people with dementia and their loved ones [9].

Finally, an ‘Involvement’ work package centres on consulting people with lived experience of cognitive and/or sensory impairment on all aspects of the research [8]. A network of patient panels across 5 clinical sites in Manchester, Nice, Athens and Cyprus received research awareness training to support their involvement in the research, and meet regularly to provide input to the research.

Although the future participation of UK researchers in European research is uncertain, SENSE-cog is on track to be completed in December 2020. Longer life expectancies and ageing European populations mean that it is vital that these extra years of life are healthy and productive ones. SENSE-cog will provide practical information on addressing sensory impairment to ensure a happy and healthy old age for European citizens.

References 1. Mutlu, U., et al., Association of Retinal Neurodegeneration on Optical Coherence Tomography With Dementia: A Popula-

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tion-Based Study. JAMA neurology, 2018. 75(10): p. 12561263.

2. Maharani, A., et al., Visual and hearing impairments are associated with cognitive decline in older Americans, Britons and Europeans. Age and Ageing, 2018. 47(4): p. 575-881.

3. Cosh, S., et al., The association amongst visual, hearing, and dual sensory loss with depression and anxiety over 6 years: The Tromsø Study. International Journal of Geriatric Psychiatry, 2017.

4. Maharani, A., et al., Longitudinal relationship between hearing aid use and cognitive function in older Americans. Journal of the American Geriatrics Society, 2018.

5. Maharani, A., et al., Cataract surgery and age-related cognitive decline: a 13-year follow-up of the English Longitudinal Study of Ageing. PloS one, in press.

6. Palacios, D.L. and B. Gannon, Health care utilisation amongst older adults with sensory and cognitive impairments in Europe.

Health Economics Review, in submission. 7(1): p. 44.

7. Pye, A., et al., Screening tools for the identification of dementia for adults with age-related acquired hearing or vision impairment: A scoping review. International Psychogeriatrics, 2018.

8. Miah, J., et al., A protocol to evaluate the impact of involvement of older people with dementia and age-related hearing and/ or vision impairment in a multi-site European research study.

Research Inovlvement and Engagement, 2018. 4(44).

9. Dawes, P., et al., Interventions for hearing and vision impairment to improve outcomes for people with dementia: A scoping review. International Psychogeriatrics, 2018.

Take home message: The SENSE-cog project is a UK-led pan-European collaboration to improve mental well-being outcomes for European citizens by addressing hearing and vision problems.

ear globe: audiology around the world

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Audiology in Nepal Demons in my ear - Stories of ear disease in the Nepalese Himalaya CD

Author and Correspondence I’m sitting in a small house in the Himalayas, it is already dark outside. An open fire in front of me is burning and smoke is all over the room. An older lady is cooking “Dhido”, a local food, in a pan on the fire. She doesn’t seem bothered, but my eyes are burning and I feel discomfort breathing as I listen to her tell me a story. A story about ear disease and where she believes it comes from: Sandra Eisner BSc in Speech and Language Therapy and Audiology from Austria; MSc Student with Queen Margaret University of Edinburgh I’m currently supporting a local NGO (NELHOS) in organizing and running Ear and Hearing Care Awareness Programs in local schools of Sankuwashaba District (Northeast Nepal)

“Once there was a person suffering from ear disease and ear pain. But it was actually a demon couple living in this ear. They’ve built their house inside and had 5 sons. The person tried everything to treat his ear disease, but nothing really worked. So, he approached the local Lama who finally had a brilliant idea. They put different green leaves around the affected ear and performed sounds with their drums right in front of the ear. Inside, the demons thought it must be summer and they finally can go outside but somehow weren’t sure. So, they sent their oldest son to look. He went outside and saw green leaves and heard sounds like rain and thunder. He went back and reported to his parents. They were still not convinced and sent one son after the other. All of them told the same: green leaves, rain and thunder. The demon mother finally had a look as she just couldn’t believe it. And she as well saw the green leaves and heard the rain. She was finally convinced and the whole family left the ear and the patient was without ear disease or pain.”

E: sandra.eisner@gmx.at I am an Austrian trained Audiologist/Speech and Language Therapist living and working in Nepal. I was a volunteer at a new specialist ear center in Western Nepal for three years and now I am living with my husband in a mountainous area of Eastern Nepal. Nepal is a landlocked country located between India and Tibet/China. It is a developing country still recovering from a civil war which officially ended with a peace agreement in 2006, and is prone to frequent natural disasters, like earthquakes and landslides. Geographically, the country can be divided into 3 areas: the lowland plains in the south, the middle hill region and the high Himalayan regions in the north. There are also many socio-economic, cultural and ethnic divisions. The northern part of Nepal is primarily inhabited by indigenous Tibetan ethnic people groups such as Sherpa, Lowa or the Singsa Lhomi. They share similar beliefs and traditions, are usually Buddhists and speak Tibeto-Burmese languages (Wikipedia 2018).

Most of them have never heard of terms such as ‘middle ear infection’, ‘audiology’ or ‘hearing aids’. They are unaware of the

ear globe: audiology around the world

consequences of ear disease and hearing loss and the impact these have on an individual; for instance how hearing loss affects language learning, future education and employment, or how a foul-smelling ear stigmatizes, and reduces a girl’s chance of getting married. The people don’t know what can be done, or how they can prevent and treat ear disease and hearing loss.

They mainly trust local medicines and approach the local priest if health problems occur.

“So, they first treat their diseases at home with herbal medicines available locally, or through local religious practices” Health care services in Nepal are provided in primary, secondary or tertiary government facilities, in private clinics or through various non-governmental organizations, with most of

ear globe: audiology around the world

25 them concentrated in urban areas. Provision of ear and hearing care services is unsatisfactory with only a few districts offering specialized services (Central Bureau of Statistics 2014). Ear Aid Nepal (EAN), a UK charity, was established to reduce the impact of ear disease and hearing loss and support local health care institutions and training. They work closely with the International Nepal Fellowship (INF) and helped to build, set up and now run the Ear Center at Green Pastures Hospital (GPH) in Pokhara. EAN is a UK charity promoting good ear health in Nepal and treating people with ear disease and/or hearing loss through various projects; in particular by fundraising, professional networking, teaching, research and connecting volunteers. One goal is to reach out to the community in areas with limited access to specialized health care facilities, provide ear health education and primary health care (Ear Aid Nepal 2018).

I’m on my way up to Chepuwa which is a small village in the Eastern part of Nepal (Sankuwashaba District). They told me it’s near the Tibetan border and must be beautiful.

But all I can think of at the moment is how on earth I will make it up there. We took a bus from Kathmandu to Khandbari (district headquarters). It took us 28 hours to get there. My google maps app says it is approximately 400km. After a good nights sleep in a beautiful hotel we took another vehicle, a Jeep, which is now bringing us up to Gola, a small town. And from there we’ll walk. We’ll walk for 2 days, up and down the mountains.

Nepal, with its mountainous terrain, insufficient infrastructure and limited health care facilities is generally home to traditional medicine. There is one healer for every 100 people, using herbal medicines, mineral substances, animal materials or other methods to treat patients. Knowledge is passed on orally and depends on local customs, available resources, spirituality and religious beliefs. Communities often believe that diseases are caused by evil spirits, or moreover, that a certain god or evil spirit is disappointed with the patient, who must have done something wrong. So, they first treat their diseases at home with herbal medicines available locally, or through local religious practices. If seriously ill, the patient or his/her family would approach a local Buddhist priest (Lama) who would perform a certain sacrifice (mainly animal sacrifice). This is meant to satisfy the spiritual world, bringing back peace with human beings. The last step would be seeking help at a local health post, when already seriously ill and potentially irreversible consequences may already be present (Kunwar et. al 2010).

A local health post worker in Lingam (Sankuwashaba District, East Nepal) re-

“Ear disease and hearing loss are major public health issues worldwide, but numbers are unevenly and unequally distributed with prevalence rates being especially high in developing countries such as Nepal.” ports that ear disease and hearing loss are among the most prevalent complaints patients present with at his clinic. Ear disease and hearing loss are major public health issues worldwide, but numbers are unevenly and unequally distributed with prevalence rates being especially high in developing countries such as Nepal. Not only does ear disease and hearing loss significantly impact an individual’s life, it also has an economic impact on a country. Unaddressed hearing loss is believed to pose a cost of 750 billion international dollar annually, so it should be addressed adequately and public health strategies should target prevention, screening and early intervention (World Health Organization 2017, World Health Organization 2018).

Since January 2018, I’ve been working with NELHOS (Nepal Lhomi Society), a local NGO. They are running a small health post in Lingam, a remote town in the North East Himalayas, near Chepuwa. Our aim is to provide quality services to the local community, to raise awareness about prevention and treatment of common diseases and connect with specialized centers for referral when necessary.

The local community has a unique health-related belief and behaviour system which is based on and shaped by their

Figure 1: A local health post worker from the “Jhyambe Mengang Clinic” is raising awareness about ear and hearing care at the government school of Chepuwa, Sankuwasabha District

ear globe: audiology around the world

ear globe: audiology around the world

26 religious beliefs and practices. Although health care facilities are available and accessible, people don’t seek treatment or advice at the clinics. How can they be reached and how can health-related behaviour be changed and transformed?

the clinic asking for ear syringing or with other questions

First step is to reach out to the people and community and talk about ear disease and hearing loss. And this is what we’re doing. We’re going out to communities and schools to talk about ear disease and hearing loss, their consequences and the importance of regular check-ups.

need further diagnosis and treatment. We are developing

Up to now we have visited 3 local schools, developed some outreach material and started cleaning ears, as smoke and dust are contributing to ear wax accumulation. We even had family members of the school children coming into References 1. EAR AID NEPAL (EAN), 2018. About us. [online]. [viewed 27 June 2018]. Available from: https://www.earaidnepal.org 2. KUNWAR, R.M., SHRESTHA, K.P., BUSSMANN, R.W., 2010. Traditional herbal medicine in Far-west Nepal: a pharmacological appraisal. Journal of Ethnobiology and Ethnomedicine. Vol. 6, no. 35.

3. WIKIPEDIA, 2018. Nepal. [online]. [viewed 27 June 2018].

Available from: https://en.wikipedia.org/wiki/Nepal 4. WORLD HEALTH ORGANIZATION (WHO), 2018.

Addressing the rising prevalence of hearing loss [online]. [viewed 27 June 2018]. Available from: http://apps.who.

related to their ears. Our small team was very encouraged by that and we could see how our education is reaching beyond the people who came. Our goal is to continue with these awareness programs and identify children who telemedicine and smart phone options to aid diagnosis and referral with the Ear Center in Pokhara (EAN, INF).

I believe that one of the keys to successfully address the burden of ear disease and hearing loss in developing countries such as Nepal is teaching local health post workers, educating the community and raising awareness as well as connecting health care facilities together. int/iris/bitstream/handle/10665/260336/ 9789241550260eng.pdf?sequence=1&ua=1 5. WORLD HEALTH ORGANIZATION (WHO), 2017.

Global costs of unaddressed hearing loss and cost-effectiveness of interventions – A WHO Report [online]. [viewed 27 June 2018]. Available from: http://apps.who.int/iris/bitstream/handle/10665/254659/ 9789241512046-eng.pdf?sequence=1 Website List: Nepal Lhomi Society (NELHOS): www.nelhos.abvalley.com Ear Aid Nepal (EAN): www.earaidnepal.org International Nepal Fellowship (INF): www.inf.org

Figure 2: Chepuwa, a remote village in the Northeast of Nepal, is inhabited by the Singsa Lhomi which is a Tibetan ethnic people group in Nepal. It takes 4-6 days to reach that village.

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ear globe: audiology around the world

27

Hear the World Foundation Employee Engagement for Children with Hearing Loss: Gain while you Give CD

Author and Correspondence Elena Torresani Director Hear the World Initiative Sonova AG Laubisruetistrasse 28, 8712 Staefa, Switzerland E: elena.torresani@sonova.com

80 percent of people with hearing loss live in low to middle income countries. Audiologists in these countries are rare; therefore most people do not have access to audiological or medical care. Against this background, Sonova, leading provider of hearing solutions, founded the non-profit Hear the World Foundation in 2006. An important pillar of the foundations support is the commitment and expertise of employees of the Sonova Group. These employees volunteer and provide help for disadvantaged people, particularly children with hearing loss in low-income countries. Their engagement often changes the lives of children towards a better future. Nadja Laible, one such audiologist with Sonova, volunteered for a project dedicated to children in Haiti.

Founded in 2006 by Sonova, the leading provider of hearing solutions, the Hear the World Foundation supports disadvantaged people with hearing loss around the world and gets involved in hearing loss prevention. The foundation focuses particularly on projects for children with hearing loss, enabling them to develop to their fullest potential. Since its establishment, the non-profit Swiss foundation has supported over 90 projects all around the world with funding, hearing aid technology and expertise.

with hearing loss and engages in prevention and education. Audiological care for children in countries with poor healthcare is the focus of its commitment as well as building sustainable local capacities by passing on know-how in audiology. Sonova employees are enthusiastic about the program: ever since the foundation started its volunteering program in 2013, the team has received applications exceeding available projects. Nadja was one of the lucky ones who was invited to volunteer abroad for a week.

Volunteers are the heart of the foundation program. We couldn‘t achieve the great results we have without the commitment of Sonova employees from all over the world.

When Nadja embarked on a trip to the Caribbean in May 2018, her big suitcase did not contain heaps of sunscreen and good books for a relaxing holiday; instead, it was filled with otoscopes, medication, hearing aids and other medical equipment. Nadja, an audiologist at Phonak in Stuttgart/Germany is one of many hearing care professionals who had applied for the employer engagement program by Sonova’s Hear the World Foundation.

Excited to be accepted for a project in Haiti, Nadja felt this would be an opportunity to use her expertise to provide hearing care for people with hearing loss and in particular, children in need. Sonova supports every volunteer who participates in the foundation’s projects abroad by covering all travel expenses and by giving two additional paid days of leave.

Tropical climate, Caribbean beaches, Haiti appears to be the “picture-perfect” island, however, Haiti is also one of the poorest countries in the world. Its approximately 11 million inhabitants live on an average income of about $813 GDP per capita/ year according to the United Nations and suffer from poor medical care. Children with untreated hearing loss are among those hit the hardest. They are referred to as “bébés” and are thought to be mentally disabled.

The Hear the World Foundation envisions a world where everyone enjoys the gift of hearing and therefore lives a life without limitations. The foundation supports people in need

Hearing loss: A major problem in low-income countries Haiti is only one out of many low-income countries where hearing loss is prevalent and audiologists are scarce. Due to the

ear globe: audiology around the world

ear globe: audiology around the world

28 lack of hearing professionals and technical equipment, hearing aids as well as audiological and medical care are beyond the grasp of most families. According to the World Health Organization (WHO), 466 million people worldwide are affected by hearing loss and among them 34 million children. Around half of these cases could have been avoided by taking preventive measures. Fewer than 1 in 40 people who need a hearing aid have one.

For children in particular, the consequences of poor hearing care can be devastating and children with untreated hearing loss have few prospects in low-income countries. When they have difficulty learning to speak they are often excluded from Audiologist Nadja Laible travelled to Haiti to support the Hear the World Foundation society and hidden away by their families.

They cannot attend normal schools which jungle. Hundreds of people were waiting for the Hear the reduces their chances of receiving education and developing at World team”, Nadja recalls. “One family even walked through an appropriate rate for their age. In some countries, children the forest for four hours in the heat of the day to have their with hearing loss may also be at increased risk of physical, social, children examined. In many cases it was sufficient to clean the emotional and sexual abuse. children’s ears thoroughly from wax and objects such as small #HearHaiti: Help on the ground for children with hearing loss crawling animals, beans or pearls. As a result, many children In Haiti, Nadja and 13 other Sonova volunteers from the USA were able to hear better immediately although many boys and and Canada worked hard to give children the gift of hearing: In girls also suffered from untreated otitis media, some of which a children’s home in Haiti’s capital Port au Prince, the volunteers had resulted in hearing loss. The volunteers provided them conducted hearing tests, fit hearing aids, carried out check-ups with hearing aids – for the children, this was more than just on children who had already received treatment, and repaired a technical device. “When we give those children professional faulty devices. audiological care, we can enable them to lead independent lives and give them a better future”, Nadja explains.

During their stay, the volunteers headed to a school in a remote area in central Haiti, in Hinche, to examine and treat hundreds Volunteers make a difference of children’s ears in cooperation with a German non-profit orVolunteers like Nadja are at the heart of the foundation program and Hear the World could not achieve the great results ganisation. “It was an adventurous five-hour journey into the without the commitment of Sonova employees worldwide. The foundation donates hearing technology, financial resources and professional expertise whilst the hearing care professionals from the group regularly travel as volunteers to support project partners all over the world. They train local professionals, carry out hearing screenings, fit hearing aids as well as care for those children who have already been fitted, repairing hearing aids if necessary. The key element of the volunteering program is building local capacity and raising the level of education.

Training local professionals and creating a network is key so that the local population is not dependent on foreign specialists who are only able to offer transient Can you hear me? Nadja is testing the hearing of a Haitian girl using a smartphone app. support. The creation of qualified and

ear globe: audiology around the world

ear globe: audiology around the world

29 prospective local jobs is a welcome and encouraging consequence of the program.

To learn more about the Hear the World Foundation’s work worldwide, please visit www.hear-the-world.com.

Many of Sonova’s 14,000 plus employees actively support the Hear the World Foundation by contributing their time, skills and knowledge to its worldwide projects. Most say that the experience of volunteering gives them the purpose they have been looking for when choosing a career in hearing care in the first place.To date, more than 1,000 employees have performed over 10,000 hours of voluntary work in projects or through active participation in fundraising events. The Foundation has already supported more than 90 projects in 39 countries on six continents, primarily for the benefit of children with hearing loss, in order to allow them to develop at an appropriate rate for their age. In 2017 alone, 25 projects in 26 countries were supported with funding, hearing aid technology and expertise, primarily in Central and South America, Africa and Asia.

References • Olusanya, B. O., Neumann, K. J., & Saunders, J. E. (2014).

The global burden of disabling hearing impairment: a call to action. Bulletin of the World Health Organization, 92(5), 367-73.

“It makes me so proud to be a part of this team,” says Nadja.

“It is an incredibly rewarding feeling to see children laugh when they hear their own voice for the first time. I see my profession in a new light, and realize how much of a difference I can make”.

Nadja is sure that this was not her last trip with the Hear the World Foundation.

• World Health Organization Data, https://www.who.int/ news-room/fact-sheets/detail/deafness-and-hearing-loss, retrieved December 13 2018.

Take home message and why the article is of interest to professionals in audiology: 34 million children worldwide are affected by hearing loss. The Hear the World Foundation envisions a world where everyone enjoys the delight of hearing and therefore lives a life without limitations. Volunteers from the Sonova group support people in need with hearing loss and engage in prevention and education.

Check out: www.hear-the-world.com

ear globe: audiology around the world

2019

FRIDAY

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A selection of in-depth workshops, focusing on clinical and business excellence BSHAA AGM Informal reception and exhibition preview

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Exhibition with technology, business and career hubs Full education agenda with keynote speakers – boost your professional development with the latest research, clinical and business best practice

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31

Top Ten Qs: Ecological Momentary Assessment – capturing real-world experiences of hearing difficulties and hearing aid benefit This article describes a likely game changer for Audiological rehabilitation and is a thought provoking read. It would provide a good topic for a discussion within teams engaged in research and clinical practice.

Although the article describes the approach of Ecological Momentary Assessment applied to Audiological rehabilitation, a quick search for the term reveals that the approach has been used in psychology research since the 1940s. EMA has been implemented using low-tech paper-and-pencil journals in previous hearing aid outcome research. What has changed more recently and described well in this article is the potential offered by technology (smartphone/apps) as a more accessible tool to gather such information. Similar applications are also reported in other disciplines such as behavioural medicine.

The article explains the research use and thoughts on potential clinical use of EMA. It will provide readers with a good overview of the potential of EMA as an additional dimension to outcome measurement and source of information to guide their efforts, beyond conventional retrospective self-reports. As with other survey and outcome measurement tools there is potential to use in cohorts of patients as well as individuals. Regarding the latter, it should complement well any approach to tailor interventions to meet the patient’s individual needs. This topic should be of interest to researchers and those developing hearing aid technology. However, as a clinician, I am particularly interested to consider how clinical applications might progress in rehabilitative audiology and beyond. I can see that the application of this approach will take off in Audiology.

John Day

CD

Author Barbra Timmer, PhD Adjunct Senior Research Fellow School of Health and Rehabilitation Sciences The University of Queensland Brisbane, Australia Senior Scientist Sonova AG E: b.timmer@uq.edu.au 1. Other than being a mouthful, what is Ecological Momentary Assessment?

Ecological Momentary Assessment, or EMA, is a technique that involves regularly surveying individuals about their experiences, as they are experiencing them, in real time and at multiple times per day. For our research projects, that meant asking our participants to tell us about their listening activity, the acoustic environment and how they felt they were hearing while they were in their everyday listening situations. You may have heard it called ‘experiential sampling’.

2. So it’s kind of a listening diary?

In a way yes, but rather than using paper-and-pencil, we used an app on a smartphone to gather this information. This meant we

could see the time and day the surveys were completed. We asked our participants to complete a survey while they were in a listening situation at least 3 times per day for 2 or 4 weeks (depending on the study) and using a smartphone meant we could build in alerts to remind them to fill in a survey.

3. Can’t we just ask these questions when we see our patients in the clinic?

There are many self-report questionnaires available in audiology that ask about hearing difficulty, how hearing impacts an individual’s activity and participation, or to measure hearing aid outcomes. While many of them are easy to use, these traditional self-report measures ask about an individual’s memory of select listening situations, including situations that may not be common or relevant for them. EMA captures data in the individual’s natural environments, in situations important to them and it doesn’t require memory of a situation as the surveys are done in real time.

4. I’m not sure if patients can really give us a lot of useful information about the acoustic environment.

We weren’t too sure either so we tested this. In one of our studies, we compared the subjective ratings of noisiness with an ear-worn classifier and there was good correlation between the two. We also asked them questions about the location, such as how big the room was and if there was carpeting. From this we could build quite an accurate picture of the acoustic

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32 environment.

for their patient and set up outcome goals around those.

5. So what information does EMA give that our current approaches don’t give?

Using EMA in our studies meant that we collected a lot of valuable data. We also found we could get information about self-reported hearing performance beyond speech understanding. For example, to get a bigger picture of how our participants were experiencing their hearing, we also asked them about their listening effort, their listening enjoyment and how hampered they felt by their hearing difficulty. This gave us interesting insight in how this group of participants (older adults with mild hearing impairment) rate their hearing performance. In over 1100 surveys, they typically rated speech understanding to be 75% or 100% but to reach that level of understanding, they expended considerable listening effort. So for this group, any solution provided by their audiologist had to address not only intelligibility but also help to reduce the effort required to listen effectively.

9.

6. How would you know if you’ve achieved that?

We used EMA. We asked a group of participants to complete surveys on an app for 1 week before fitting them with hearing aids and then they continued to complete the same surveys for 2 weeks while they wore their hearing aids. From comparing the baseline survey answers given without hearing aids versus the surveys completed with hearing aids, we saw that hearing aids did indeed improve speech understanding but also reduced listening effort, increased listening enjoyment and participants felt their communication was less negatively affected by their hearing difficulties.

7. Couldn’t you have just asked them?

Yes we could have but we would have gathered only general impressions. We know from our previous research that for adults with mild hearing impairment, there are typically large individual variations in how their hearing impairment impacts their communication. So generalised questionnaires may not be sufficiently sensitive as an outcome measure for solutions for mild hearing impairment. Using EMA we could see in which listening situations the hearing aid was making a difference for each individual participant and in which hearing performance dimension. One participant for example showed only little benefit from the hearing aid in terms of improved speech understanding when talking to 1 or 2 speakers, but significant improvement in terms of listening effort and enjoyment in that situation.That’s a great outcome that a standardised questionnaire may not have picked up.

8. That’s OK for research, but I don’t think my patients want to complete 3 surveys a day for weeks.

Many patients will not, but we hope that in the future, EMA can be tailored to be better suited as a clinical tool. We’d like to see an app suitable for any smartphone that your patients can use to note down their hearing difficulties whenever they experience them. This could give the audiologist personalised information about the listening situations that are a challenge

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I’d really prefer something that tells me how they’re doing with their hearing aids.

Well, the same app could also be used to record positive or negative experiences with their hearing aids. That could provide useful tips for the audiologist to fine tune their hearing aids. For example, if the app showed that speech understanding was good but effort was still high even with hearing aids, the audiologist could consider increasing the strength of the noise cancellation feature in the hearing aid. The app could be set up to alert you when there were repeated instances of negative experiences so you would know when it is time to see your patient again. And this app could be used with any intervention, not only hearing aids but also for communication/auditory training.

10. OK, I like the sound of EMA. What’s next?

We will continue our EMA studies and collaborate with others too, as we’ve seen the value it brings to hearing science and research. If you’re interested in knowing more about EMA, see the references below. We’re sure it won’t be long before EMA will find its way into clinical practice, giving audiologists access to real-world information about their patient’s relevant situations.

The beauty of tools like these is that they support audiologists in providing patient-centered care as well as will help patients in self-management of their hearing impairment.

References 1. Timmer, B. H. B., Hickson, L., & Launer, S. (2015). Adults with mild hearing impairment: Are we meeting the challenge? International Journal of Audiology, 54(11), 786-795. doi: 10.3109/14992027.2015.1046504.

2.

Timmer, B. H. B., Hickson, L., & Launer, S. (2017). Ecological momentary assessment: Feasibility, construct validity and future applications. American Journal of Audiology, 26(3S), 436-442. doi: 10.1044/2017_AJA-16-0126.

3.

Timmer, B. H. B., Hickson, L., & Launer, S. (2018). Do Hearing Aids Address Real-World Hearing Difficulties for Adults With Mild Hearing Impairment? Results From a Pilot Study Using Ecological Momentary Assessment. Trends in Hearing, 22, 2331216518783608. doi: 10.1177/2331216518783608.

4.

Timmer, B. H. B., Hickson, L., & Launer, S. (2018). The use of ecological momentary assessment in hearing research and future clinical applications. Hearing Research, Early online. doi: 10.1016/j.heares.2018.06.012.

Acknowledgments This article presents research supported by a PhD studentship provided by Sonova AG. Thanks to PhD supervisors Professor Louise Hickson, School of Health and Rehabilitation Sciences, The University of Queensland, and Adjunct Professor Stefan Launer, School of Health and Rehabilitation Sciences, The University of Queensland and Senior VP Science & Technology, Sonova AG.

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The effect of Madsen ‘Accuscreen New’ equipment settings on the referral rate of babies undergoing newborn hearing screening CD

Authors and Correspondence Christine Cane, Newborn Hearing Screening Manager, Norfolk & Norwich University Hospital

Ian Nunney, Statistician, University of East Anglia

Christopher Fazakerley, Regional Screening Manager, GN-Otometrics

John E FitzGerald, Consultant Clinical Scientist, Newborn Hearing Screening Team Leader, Norfolk & Norwich University Hospital activity from the hearing nerve and parts of the brainstem is recorded to indicate hearing status from three small sensors placed on the baby’s head and neck.

Abstract AABR hearing screening was performed at the Norfolk and Norwich University hospital using the Algo 3i until 2015 when it was replaced by the Accuscreen New. It was noticed that, for those babies who had an AABR, the referral rate to diagnostic hearing assessment increased from approximately 20% of AABR cases to 40%. Two features of the Accuscreen New were investigated (the ‘Fast Refer’ feature and an increased test time) to assess if these factors influenced the referral rate in young babies (<48hours old). The Fast Refer and an increased test time in this age group did not influence the referral rate.

However an improved pass rate was observed by testing babies from Day 2 after birth so as a result of the study the local policy was changed to not to perform AABR testing on babies at day 0 or day 1and this achieved a referral rate from AABR testing to audiology diagnostic testing back to 20%.

Introduction Newborn hearing screening has been established within England for over 14 years. The screening pathway can involve two different tests, the otoacoustic emission test (OAE), and the automated auditory brainstem response test (AABR). In the OAE test a clicking sound is played into the ear and a sound is recorded from a healthy ear to indicate good hearing. For those babies who do not pass the OAE after two attempts, they go on to have the AABR test where sound stimuli are played in to the ear via soft headphones placed over the baby’s ears and

At the Norfolk and Norwich University hospital the Algo 3i was used for many years for AABR with a typical referral rate of approximately 20% of babies undergoing AABR testing (7% for bilateral and 14% for unilateral referrals for 175 completed AABRs performed on babies screened in May and June 2014) .

In March 2015 the Accuscreen New was introduced to record AABRs (approved by the NHS Newborn Hearing Screening Programme (NHSP), Public Health England and used widely across the UK) and a significant increase in referral rate to approximately 40% was observed (20% for bilateral and 22% for unilateral referrals for 140 completed AABRs on babies screened in May and June 2015). After referral to Audiology for diagnostic testing most of these babies were found to have satisfactory hearing. The impact of the increased referral rate caused increased delays on diagnostic testing within Audiology and also led to unnecessarily increased parental anxiety in relation to the hearing of their new born baby.

Possible reasons for the increased referral rate were considered; 1. It was possible that the initial increase in referral rate was due to screening staff being unfamiliar with the equipment and this resulting in fewer Clear Response (CR) outcomes.

2. It was possible that the initial increase in referral rate was due to the average age of the baby at testing with the Accuscreen New being less than that in the Algo 3i sam-

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34 ple of babies as evidence shows AABR screening failure rates decrease with postnatal age over the first 48 hours (although exact failure rates depend upon the screening protocol used). Johnson et al, (2018) found that 13.3% of screened babies failed at <24 hours versus 3.8% at ≥48 hours (P < .0001). Sensorineural hearing loss (SNHL) was diagnosed in 18.6% of infants who failed their final screening at ≥48 hours compared with 2.8% of those whose final screening occurred earlier (P = .03). They concluded that failure rates were minimised by delaying AABR screening in the first 48 hours. Van Dyk (2015) showed a progressive decrease in screen referrals for AABR with increasing age. The referral rate of ears for infants screened after 24 hours was significantly lower than for those screened before 24 hours. She found that for infants screened within 12 hours of birth, the AABR referral rate per ear was 51.1% and for those tested after 48 hours post birth it was 3.2% per ear, with an average age at testing of 57 hours post birth. Shortly following birth, babies may not have an aerated middle ear and amniotic fluid may be retained in the ear canal or middle ear so more babies are likely to have a ‘conductive hearing loss’.

3. It was noted that the Accuscreen New ran for considerably less time than the Algo 3i (often only for a few minutes against up to 40 minutes for the Algo 3i) and sometimes for less than a minute before the refer decision was made by the system. This was due to the ‘Fast Refer’ function on the Accuscreen New, an algorithm that makes a decision on the likelihood of a CR occurring by looking at the level of the current signal. It was hypothesised that the shorter test time for the Accuscreen New to refer a patient was the reason for the increased referral rate from newborn hearing screening to audiological investigation.

Aim The aim of this study was to identify if the following factors could explain the difference in referral rates from the AABR screen; 1. screener familiarity with the new equipment 2. difference in the average age of the baby when tested between the Algo 3i group compared to the Accuscreen New group.

3. the Fast refer function and shorter test time of the Accuscreen New when testing young babies (less than 96 hours old).

Methodology To assess the influence of screener familiarity Screener familiarity with the new equipment was investigated by utilising the evidence based phenomenon that age at testing influenced referral rates. Age at testing was delayed to more than 48 hours to assess if this reduced the AABR referral rate and then age at testing was reduced to less than 48Hours to see if the referral rate increased again. If the referral rate increased again it would rule out screener familiarity as the fundamental reason for the increased referral rate and implicate age

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at testing as being at least a contributory factor.

To identify if a difference in age between the Algo 3i data and Accuscreen New data accounts for the difference in referral rate The age at testing for babies using the Algo 3i for referrals in May/ June 2014 was compared to the age at testing for babies referred using the Accuscreen New in May / June 2015. This avoided any fluctuations in referral rates due to seasonal fluctuations.

To assess the effect of equipment settings The effect of the equipment settings on the Accuscreen New were assessed by undertaking a prospective randomised comparative study using a ‘standard’ Accuscreen New and a modified Accuscreen New (the ‘evaluation’ device). A protocol was developed and agreed with the equipment suppliers (Otometrics) and the NHSP Programme centre. Otometrics supplied a modified Accuscreen New with the Fast refer disabled and equipment test time set to continue for up to a maximum of 20 minutes if no response was obtained sooner.

The ethical issues regarding this study were presented to the UK National Health Service (NHS) National Research Ethics Service for approval. Local approval was then obtained from the Research and Development Department of the Norfolk & Norwich University Hospital NHS Foundation Trust (Protocol ID: 214416 Version 1.5 Date:16/05/2017).

Babies were prepared for the AABR screen as normal (sensors and headphones attached to the baby’s head) and tested twice, once with the standard equipment, once with the evaluation equipment, by qualified hearing screeners. Test order was randomised (by drawing the type of equipment to use first from a hat). Sensors and headphones remained in place for both tests, only the connection to the test equipment was changed (to minimise disturbance to the baby). Any baby that did not pass the hearing screen by the standard equipment was referred for diagnostic testing in Audiology according to the normal NHSP pathway.

The inclusion criteria were babies undergoing newborn hearing screening under the care of the Norfolk & Norwich University Hospital NHS Foundation Trust (NNUH), who required AABR testing as part of their newborn hearing screen up to 96 hours old. Babies who did not require an AABR test as part of their newborn hearing screen or who were older than 96 hours old were excluded.

It was not possible to blind testers from which equipment they were using.

Recruitment and Consent Appropriate information about the study was given to parent(s) and written informed consent was obtained.

Data Collection The screen outcome (CR or NCR) was recorded from both systems in 172 ears (86 babies), along with the gender, gestational age at birth and age at testing and the state (whether set-

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35 tled or not) of the baby. The electrode impedance was also recorded. The hearing outcome for babies referred to Audiology was noted.

Data analysis A two tailed students t-test was used to assess whether or not there was a statistical difference in age at testing using the Algo 3i and Accuscreen New and a paired two tailed students t-test was used to see if there was a statistical difference in impedance (at nape of neck, at forehead and impedance balance) between the standard and evaluation equipment.

McNemarâ&#x20AC;&#x2122;s test was used to assess if there was a significant difference in referral rates between standard and evaluation equipment. The Kappa statistic was used to assess the level of agreement in referral rates for the standard equipment and the evaluation equipment. The Kappa statistic is interpreted as follows; 0.4 to 0.6 as moderate agreement, 0.61 to 0.8 as substantial agreement and greater than 0.81 as almost perfect agreement and given with the 95% lower and upper confidence limit.

Results The influence of screener familiarity Figure 1 shows the effect of changing the age of testing to assess whether screener familiarity with the new equipment was responsible for the increased AABR referral rate. For comparison the referral rate of the Algo 3i for January and February 2015 is shown when AABR testing was performed as soon as possible following birth. The Accuscreen New was introduced in March 2015 and used alongside the Algo 3i when the rise in referral rate was noticed. The Algo 3i was phased out of service by June 2015. Figure 1 shows the marked increased referral rate between the Algo 3i (18%) and Accuscreen New (43%) following the same policy of testing AABRs as soon as possible following birth (Jan/Feb and June- Aug respectively). In October and November AABR testing was delayed until Day 2 with a marked drop in referral rate (22%). In December 2015 testing from Day 1 was instigated with a corresponding rise in referral rate (34%).

Age analysis between the Algo 3i data and Accuscreen New data The average age (in days, where day 0 is the day of birth) at testing babies referred using the Algo 3i in May/June 2014 was 1.7days + 2.5 and the average age at testing babies referred using the Accuscreen New in May/June 2015 was 2.8 + 3.6, so the Accuscreen group were on average a day older than the Algo 3i group, but there was no significant differ-

Figure 1 Average Monthly AABR Referral Rates for 2015 for Algo 3i and Accuscreen New tested as soon as possible following birth and Accuscreen New tested from Day 2 and Day 1.

Figure 2. Test outcomes for the standard equipment and evaluation equipment.

Standard Accuscreen New

Evaluation Accuscreen New

Clear Response

47 (55%)

43 (50%)

Referrals (unilateral and bilateral)

39 (45%)

43 (50%)

P value

0.3458

Table 1. The number of patients passed or referred by the Standard and Evaluation Accuscreen New and the p value using McNemarâ&#x20AC;&#x2122;s test

ence in the age between groups (p = 0.090) and the median age at testing for both the Algo 3i and Accuscreen New was Day 1.

The Influence of Equipment Settings For the prospective study making a direct comparison between the standard Accuscreen New and the evaluation Accuscreen New (with the Fast refer disabled and increased test time before referral) the gestational age of babies at testing varied between 35 and 42 weeks, and age when tested following birth ranged from 4.5 and 53 hours with an average age at testing of 22 + 12 hours (mean + standard deviation).

A CR on both ears was obtained for 47 babies with the standard equipment and 43 babies with the evaluation equipment.Thirty-nine babies were

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36 the standard and evaluation equipment.

Figure 3. Bilateral ‘No Clear Response’ referrals by test time after birth for the standard and evaluation equipment

Figure 4. Unilateral referrals by test time after birth for the standard and evaluation equipment

Of the 39 babies referred from the standard equipment, 38 attended for Audiology assessment, 32 with an outcome of satisfactory both ears, 2 with an identified sensorineural loss in both ears, 2 with an identified sensorineural loss in one ear and 2 with a conductive temporary loss in one ear. I baby failed to attend two appointments offered. Of all the hearing losses identified at diagnostic testing from babies referred by the standard equipment, the evaluation equipment did not identify one of the conductive losses as No Clear Response (NCR), but identified all the other hearing losses identified at diagnostic testing.

The length of test time for the standard equipment varied between 00:16 and 07:15 minutes: seconds.

The length of test time for the evaluation equipment varied between 00:30 and 21:10 minutes: seconds. Of the 86 babies tested, 2 babies were slightly unsettled with both the standard and trial equipment (1 baby had bilateral NCR on the standard equipment and bilateral CR on the evaluation equipment, 1 baby had bilateral NCR on the standard equipment and unilateral NCR on the evaluation equipment). 3 babies were unsettled with the evaluation equipment (1 baby had bilateral CR on both the standard and the evaluation equipment, 1 baby had unilateral NCR on the standard equipment and bilateral CR on the evaluation equipment and 1 baby had bilateral CR on the standard wequipment and unilateral NCR on the evaluation equipment).

There was no significant difference in the impedance between the standard equipment and evaluation equipment in either the forehead electrode (p = 0.7700), nape of neck electrode (p = 0.9006) or the impedance balance between the electrodes (p = 1).

Figure 5. Accuscreen New Screen Outcomes May and June 2018 (79 completed cases)

referred from the screen with the standard equipment (25 unilateral referrals and 14 bilateral referrals) and 43 babies were “referred” from the evaluation equipment (23 unilateral referrals and 20 bilateral referrals) (Figure 2).

There was no significant difference in referral rate between the standard and evaluation equipment, as shown in Table 1 (p = 0.3458). The overall agreement in referral had a kappa value of 0.5814 (0.4102, 0.7526) (lower and upper 95% confidence limit), showing moderate agreement between

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More babies tested at <12 hours were referred with a bilateral no clear response by the evaluation equipment than by the standard equipment (3 (11%) standard & 7 (26%) evaluation) (Figure 3). The number of babies <12 hours who referred with a unilateral no clear response was the same for both standard and trial equipment (8 (30%)) (Figure 4).

Kappa analysis was performed for the tests performed up to 24 hours after birth and after 24hours after birth. For testing within 24 hours of birth the Kappa value was 0.4091 (0.1465, 0.6717) and for testing after 24 hours it was 0.7619 (0.5662, 0.9576) showing moderate agreement and substantial agreement between the two pieces of equipment respectively.

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37 Discussion The reason for the increased referral rate on changing from the Algo 3i to the Accuscreen New cannot be completely attributed to lack of screener familiarity with the Accuscreen New as shown by the reduction in referral rate when babies were tested from day 2 onwards and an increase in referral rate again when they were tested from day 1 onwards (Figure 1). If the increase in referral rate had been entirely due to screener familiarity the December referral rate (Figure 1) would be expected to similar to that of January/February and not to have increased from October /November. However screener familiarity can not be ruled out entirely as the December referral rate is better than that of June/July/August.

The absence of a significant difference in age at testing between the cohort referred in May/June 2014 and May/June 2015 for the Algo 3i and Accuscreen New respectively demonstrated the increased referral rate for the Accuscreen New was not due to the age of testing between the two cohorts. However on close inspection of the referral rate day by day it was noted that for babies tested within the first 2 days (day 0 and day 1) 26% of cases tested with the Algo 3i and 52% of cases tested with the Accuscreen New were referred, so although overall there was no difference in the average age between the two sets of data, the referral rates within the age profile suggested the Accuscreen New referral rate was influenced by earlier testing more than the Algo 3i.

Results showed that disabling the ‘Fast refer’ function or increasing test time to a minimum of 20 minutes before ‘referring’ an ear did not influence the referral rate of the Accuscreen New. This suggests these functions are not responsible for the increased referral rate observed in the Accuscreen New compared to the Algo3i in babies less than 48 hours old. Given the test time is greatly reduced using the Fast Refer feature this is seen as an advantage enabling screeners to perform screening more quickly, thereby increasing screener efficiency and also potentially reducing parental anxiety, which can be caused by long test times.

It remains a matter of speculation as to why the Accuscreen New has a higher referral rate than the Algo3i in babies tested before Day 2. One possibility is the different stimulus type (the Algo 3i uses a click and the Accuscreen New uses a CHIRP), or whether the stimulus level between the two types of stimuli is comparable, but this is beyond the scope of this assessment.

Perhaps the greater levels of ear canal debris or lack of a fully aerated middle ear within the first few days following birth have a greater influence on any slight differences in stimulus between the systems thereby affecting test outcomes and that as these factors improve over time the pass rate improves and becomes more comparable.

The important thing is to have recognised the impact of the age of testing on the referral rate and as a result of this we have, from a local perspective, adapted our screening policy to avoid AABR testing within the first 2 days following birth to reduce referrals on to Audiology for diagnostic hearing assessment.This

has a number of advantages; 1. To reduce potential parental anxiety.

2. To minimise diagnostic audiology assessments and thereby reduce costs associated with this more time consuming and more expensive diagnostic test compared to a hearing screen performed by the screeners.

3. To enable Audiology to offer more choice to parents who do get referred and enable Audiology to meet the national Public Health England Key Performance Indicator NH2 target (To perform diagnostic audiology testing within 4 weeks of the screen referral).

The disadvantage is that some early discharge babies will not be offered an AABR screen prior to discharge that would have previously been tested on the ward. This will require an outpatient follow up screening test and will increase the demand for screening outpatient clinics.

Figure 5 shows the AABR outcomes in May and June 2018 with the new policy of not testing AABR at Day 0 or Day 1, which gave similar outcomes to the Algo 3i outcomes of May and June 2014, confirming the new policy has effectively reduced referral again back to those seen with the Algo3i.

Conclusion Disabling the ‘Fast refer’ function or increasing test time to a minimum of 20 minutes before ‘referring’ an ear does not influence the referral rate of the Accuscreen New. This suggests these functions on the equipment are not responsible for the increased referral rate observed in the Accuscreen New compared to the Algo3i. AABR testing using the Accuscreen New on babies at Day 2 or older gives an acceptable referral rate for diagnostic testing and this has been introduced locally. This has resulted in a referral rate of 20% from AABR testing to diagnostic audiology testing (average referral rate from January - June 2018).

Acknowledgements Thanks to Otometrics for adapting an Accuscreen New and loaning the equipment to enable this study to take place, to the hearing screening team at the Norfolk & Norwich University Hospital for conducting the study and to Sally Wood, Clinical Advisor – NHS Newborn Hearing Screening Programme, for her constructive comments in the preparation of this report.

References 1. Michelle Van Dyk (2015) Outcome with OAE and AABR screening in the first 48 hours – implications for newborn hearing screening in South Africa. Dissertation Dept. of Speech-Language Pathology and Audiology, Faculty of Humanities University of Pretoria 2. Johnson LC, Toro M, Vishnia E, Berish A, Mills B, Lu Z, Lieberman E. (2018) Age and Other Factors Affecting the Outcome of AABR Screening in Neonates. Hosp Pediatr.

Mar:8 3:141 - 147

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38

NICE guideline on adult hearing loss: where is the evidence?

Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK

Introduction The National Institute of Health and Care Excellence (NICE) guideline on Hearing Loss in Adults (NG98) was published in June 2018. The guideline provides recommendations for the assessment and management of adults with hearing loss.

It differs from guidelines produced by the British Society of Audiology and the British Academy of Audiology because of its reliance on systematic reviews and quality assessment of the evidence, along with economic modelling. The guideline provides important, practical messages based on evidence. The full guideline can be viewed at www.nice.org.uk/guidance/ ng98 but a short summary is provided by Ftouh et al (2018). This article is based on an invited presentation at the 2018 annual conference of the British Academy of Audiology.

Identifying clinical research questions Soon after the guideline was commissioned, stakeholders met to refine the

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Assessing the quality of the research evidence Each study outcome was assessed for quality using the following criteria: •

Risk of bias e.g., selection bias because of lack of randomisation or/ and blinding

•

Inconsistency e.g., different findings across the studies

•

Indirectness e.g., the study sample is

•

Imprecision e.g., small sample leading to wide confidence intervals

•

Publication bias e.g., over-estimate of effectiveness because of under-reporting of inconclusive outcomes

•

Other issues e.g., conflict of interest

NICE attach considerable importance to Randomised Control Trials (RCTs), where a sample from the population is randomised to the treatment and control groups, preferably blinded to both the participant and the researcher, in order to reduce any potential bias. Within hearing health care, there are few RCTs (for exceptions, see hearing aid study by Humes et al [2017] and tinnitus study by Sahlsten et al [2017]) ) and this immediately reduces the quality of the overall evidence. The quality of the evidence is graded from ‘high’ (i.e., high confidence that the true effect is close to the estimated effect) through to ‘very low’ (i.e., very low confidence that the true effect is close to the estimated effect). In the example above, the overall quality of the study outcomes was assessed as very low. In summary, there was insufficient evidence to determine if there are clinically important benefits of two versus one hearing aid. In addition, no relevant

Outcome

Intervention

➛

Manchester Centre for Audiology and Deafness, School of Health Sciences, University of Manchester, Manchester, UK, and

Identifying the clinical evidence After a process of identification, screening, and eligibility checks, studies that addressed the clinical research question were reviewed. In the example provided in Figure 1, this resulted in the identification of four relevant publications (Cox et al, 2011; Vaughan-Jones et al, 1993; Stephens et al, 1991; Erdman and Sedge, 1981)

not representative of the population

What is the clinical and cost effectiveness compared to one hearing aid

Comparison

of two hearing aids

for adult onset hearing loss with aidable hearing in both ears?

➛

Kevin J Munro, Ewing Professor of Audiology

key areas of interest where there was variation, and uncertainty, in current practice. The committee then developed the review questions, which were framed using the PICO format. The PICO acronym stands for population, intervention, comparison and outcome. The anatomy of one review question from the guideline, comparing unilateral versus bilateral hearing aid fittings, is shown in Figure 1.

➛

Authors and Correspondence

➛

CD

Population

Figure 1. The anatomy of a PICO-framed clinical research question

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39 economic evaluations were identified.

between none versus one hearing aid).

How is a recommendation made?

In the absence of high quality evidence, recommendations were based primarily on the views and opinions of the guideline committee. The considerations for making consensus-based recommendations include the balance between potential harms and benefits and the economic costs compared with the economic benefits. In this example, the committee confirmed that: (i) two ears are better than one, (ii) the NHS England commissioning framework highlights the potential benefits of two hearing aids, and (iii) the NICE cost threshold analysis revealed that two hearing aids are likely to be cost effective (because hearing aids are inexpensive to the NHS and the increase in health-related quality-of-life from one to two hearing aids need only be 1/20th of the difference

Summary of research recommendations For 50% of the research questions addressed in the guideline, there was either no evidence or the quality of evidence was assessed as low or very low (see Table 1). The quantity of studies that are identified in NICE guidelines varies greatly and for some topics e.g., pain management, there are many studies.

The quality of studies also varies greatly but, again, for some topics e.g., cardiovascular disease, there are examples of large studies of good quality.

When areas were identified for which good evidence was lacking, the committee included research recommendations based on national priorities, the importance to patients, potential impact to the NHS and ethical (and technical) feasibil-

ity. Research recommendations include identifying if hearing aids reduce dementia and the effectiveness of monitoring and follow-up.

Take home message The NICE guideline has undoubtedly increased the national profile of hearing loss. However, the evidence on which recommendations are based is limited in quantity and quality. There are ample opportunities for audiologists to be involved in studies that provide an evidence-base for clinical practice. For example, at the Manchester Centre for Audiology and Deafness and the NIHR Manchester Biomedical Research Centre (contact: kevin.munro@manchester. ac.uk) there are opportunities for you to: â&#x20AC;˘

Use your clinical experience to propose research questions

Table 1. A summary of the evidence for each of the 20 research questions

Topic

Number of studies

Quality of evidence

Who needs an accelerated referral?

0

n/a

Who requires a medical opinion?

0

n/a

Who needs referral for MRI?

7

Low/ v.low

Who might be missed with a hearing loss?

0

n/a

Benefit of early versus delayed management

1

v.low

Benefit of assessing communication hearing-related communication needs

0

n/a

Method of ear wax removal

12

Mostly low/ v. low

Setting for ear wax management

0

n/a

Treatment for sudden hearing loss

13

Mostly low/ v.low

Treatment administration routes for sudden hearing loss

11

Mostly moderate

What information/advice to support

11

Mostly low

Benefit of decision tools

0

n/a

Benefit of assistive devices

1

Low

Benefit of hearing aids

3

Mostly moderate

Benefit of two versus one hearing aid

4

v.low

Benefit of directional microphones

1

v.low

Benefit of noise reduction

0

n/a

Method used to monitor/follow-up

0

n/a

When to monitor/follow-up

0

n/a

Interventions to support hearing aid use

4

Mostly low/ v.low

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40 • •

Collaborate on a research study Apply for a short research ‘taster’ session • Work as a research audiologist • Undertake research training e.g., MRes in experimental medicine, PhD, and Higher Specialist Scientist Training A research-active workforce will enhance the reputation of the profession, as well as improve the lives of people with hearing loss.

Acknowledgement The guideline referred to in this article was produced by the National Guideline Centre for the National Institute for Health and Care Excellence (NICE). The views expressed in this article are those of the author and not necessarily those of NICE. The author is supported by the NIHR Manchester Biomedical Research Centre.

References 1. Cox RM, Schwartz KS, Noe CM, Alexander GC. 2011. Preference

6. Sahlsten H, Virtanen J, Joutsa J, Niinivirta_Jousta K, Loyttyniemi E, Johnasson R, Paavola J, taiminen T, Sjosten N, Salonen J, Holm A, Rauhala E, Jaaskelainen SK. (1997). Electric field-navigated transcranial magnetic stimulation for chronic tinnitus: a randomized placebo-controlled study. International Journal of Audiology, 56, 692-700.

for one or two hearing aids among adult patients. Ear and Hearing, 32, 181-197.

2. Erdman SA, Sedge RK. 1981. Subjective comparisons of binaural versus monaural amplification. Ear and Hearing, 2, 225-229.

3. Ftouh S, Harrop-Griffiths K, Harker M, Munro KJ, Leverton T. 2018. Summary of NICE guidance. British Medical Journal 361: k2219 doi: 10.1136/ bmj.k2219.

7. Stephens SD, Callaghan DE, Hogan S, Meredith R, Payment A, Davis AC. 1991. Acceptability of binaural hearing aids: a cross-over study. Journal of the Royal Society of Medicine, 84, 267-269.

4. Humes LE, Rogers SE, Quigley TM, Main AK, Kinney DL, Herring C. 2017. The effects of service-delivery model and purchase price on hearing-aid outcomes in older adults: a randomized double-blind placebo-controlled clinical trial. American Journal of Audiology, 26, 53-79.

8. Vaughan-Jones RH, Padgham ND, Christmas HE, Irwin J, Doing MA. 1993. One aid or two? – more visits please. Journal of Laryngology and Otology, 107, 329-332.

5. National Institute for Health and Care Excellence. 2018. Hearing loss in adults: assessment and management (NICE guideline NG98). 2018. www.nice.org.uk/guidance/ng98.

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41

Our Journey: Peer reviewing diagnostic balance in the West Midlands CD

Authors and Correspondence Karen Lindley, MSc Senior Clinical Scientist Clinical Lead, Adult Diagnostic Services.

Queen Elizabeth Hospital, Birmingham.

E: Karen.Lindley@uhb.nhs.uk Bernadette Parker, MSc Chair of the West Midlands Balance Peer Review Group: Consultant Clinical Scientist NHSP Team Leader Head of Centre for Hearing and Balance Disorders University Hospital, Coventry and Warwickshire.

E: bernadette.parker@uhcw.nhs.uk

2016 the group had set its terms of reference, aims and quality standards enabling services to present results for peer review.

Today the group has 13 member departments attending from as far as Stoke in the north, Hereford in the south, Kettering in the east and Shrewsbury in the west. The group meets quarterly for half a day, hosted at a central location; Queen Elizabeth Hospital, Birmingham. 75% attendance is expected.

Group Aims 1. Peer review diagnostic test results to agreed National Standards where available or agreeing, as a group, quality standards based on robust clinical evidence where no National Standard is available.

2. Debate and determine the non-medical clinical and professional view on vestibular patient assessment.

3. Provide non-medical clinical and professional support to group members in the area of vestibular diagnostics.

4. Improve links with universities to develop teaching and research.

5. Influence the progress of service modernisation both locally and nationally.

5 founding members, over 4 years of collaboration; today a group of 13 departments peer review balance testing.

Background In early 2014, Bernadette Parker, Consultant Clinical Scientist at University Hospitals Coventry and Warwickshire sent out a communication to regional Audiology services to determine if there was any interest in setting up a Regional Balance Peer Review group.

Having received an overwhelming positive response to this idea, an inaugural meeting took place on 22nd August 2014 at Queen Elizabeth Hospital, Birmingham to discuss the idea of developing a West Midlands Balance Peer Review Group. Lead clinicians who perform diagnostic vestibular assessments were invited to attend. The idea was met with enthusiasm.

Development During 2015 the group worked to distil the British Society of Audiology (BSA) Recommended Procedures1,2,3 relating to balance assessment into a set of quality standards and to develop quality standards for areas not covered by the BSA. By February

The quality standards were developed by the group to ensure each member department provides a high quality service delivery and interpretation of results for vestibular patients in the West Midlands. The standards outline the minimum expected to ensure that a patient receives a comprehensive diagnostic assessment.

Process At a peer review meeting balance assessment results are submitted for marking against the peer groupsâ&#x20AC;&#x2122; quality standards, the majority from the BSA recommended procedures pertaining to balance assessment. However, where standards were not available, for example, for video head impulse testing (VHIT), the group worked to define a set of quality standards to be referenced against. Departments who had good clinical experience of VHIT combined with robust clinical evidence which had been referenced in order for them run their VHIT procedure were used as the groups initial start point.

Diagnostic vestibular results to be submitted for peer review are selected on a rota basis by a group member. A couple of weeks prior to the meeting the results will be called for in the format: patient number in a given week, for example, the fourth patient seen in the second week of April. At the peer review meeting the anonymised results are analysed against the quality standards.

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42

Contraindications noted

Otoscopy and Tympanometry results noted

Spontaneous nystagmus checked with and without fixation with mental alerting

Direction, morphology and velocity noted for any spontaneous nystagmus

YES

YES

YES

YES

Order of irrigations recorded

Stimulation 30 seconds mental alerting

Minimum recording time post irrigation 60 seconds

YES

NO

Fixation after peak response for 5-10 seconds

Minimum recording time post fixation 5 seconds

Calorics Coventry

NO

YES

YES

Figure 1. Quality standards for caloric irrigations.

Once all the quality standards have been completed the department is given an overall outcome:Recall Patient Errors requiring improvement Good Quality Confirmed Figure 2. Outcome codes for peer review.

Learning & Improvement The results and comments from the peer review outcome are fed back to the balance teams at the member departments.

This feedback mechanism has shown to be a driver for facilitating the process of service modernisation. Through audits the quality and standard of services are monitored. Peer review outcomes can also for some, indicate areas that warrant a training input.

One clear advantage of the peer review group is that it offers support to member departments who want to make change but are struggling to do this alone. One department was unable to deliver a high quality diagnostic service within the existing time slot allocation. This was a direct result of additional testing required with the introduction of the BSA recommended procedure – vestibular assessment – eye movement recordings in 20153. In addition the team had also introduced VHIT. Additional time per full assessment would impact on waiting times so there was a reluctance to facilitate more test time. Having this comparative information in addition to some below par peer review outcomes, meant a significant increase in test time was successfully facilitated.

The peer review meetings facilitate the exchange of best practice, experience and knowledge. A strong networking group has been formed and along with reviewing results we encourage members to share their experiences of challenging cases.

Quality Peer review is mandatory as part of the Improving Quality in Physiological Services (IQIPS)4 process and participating in the

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balance peer review group satisfies this requirement. I believe that inter departmental peer review has a clear advantage for those departments who do not have a peer review within their own service. Inter-departmental review also has the potential to be a more robust method of peer review because the bias for a successful outcome when peer reviewing one’s own service is significantly reduced.

Future From the peer review groups inception in August 2014 to running successfully to date it is perhaps time to look to the future.

The Queen Elizabeth Hospital, Birmingham has a dedicated Audiology/Otology research group so the prospect of the peer review member departments participating in a multi-centre vestibular research project is a wonderful opportunity that we hope to exploit.

The future may hold more opportunities to work with local universities such as Aston University, The University of Birmingham and De-Montfort University.

The success of peer review for diagnostic balance testing leads us onto setting up a peer review of balance rehabilitation.This is likely however to be a more challenging project in the absence of any national guidance.

If you would like to learn more about our journey or if you are interested in joining our group we are happy to hear from you.

References 1. Recommended Procedure, Positioning Tests, British Society of Audiology, 2016.

2. Recommended Procedure,The Caloric Test, British Society of Audiology, 2010.

3. Recommended Procedure, Vestibular assessment: Eye Movement Recordings, British Society of Audiology, 2015.

4. UKAS: Physiological Services accreditation (IQIPS). www. ukas.com

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• Bluetooth audio streaming via easyTek and smartphone App compatible For more information, to receive a Contrast information pack or arrange your Contrast training – please contact your Sivantos Audiologist.

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The use of functional neuroimaging methods to investigate crossmodal plasticity in deafness CD

Authors and Correspondence

Jodie Davies-Thompson1,2,3, Ian Wiggins2, Olivier Collignon3,4 Douglas EH Hartley2 Affiliations: 1 Swansea University, School of Psychology, College of Human and Health Sciences 2

NIHR Nottingham Biomedical Research Centre, Division of Clinical Neuroscience, School of Medicine, University of Nottingham

3

Crossmodal Perception and Plasticity Lab, Centre for Mind/Brain Sciences, University of Trento, Italy

4

Institut de recherche en Psychologie (IPSY), Institute of Neuroscience (IoNS), Université catholique de Louvain (UcL)

Full reading list for this article available from our Research Round-Up editorial team British Sign Language (BSL) has had an interesting history. Use of sign language in the UK dates back to the 13th Century in which the Deaf Princess Joanna of Scotland was reported to have used interpreters. In 1567, a groom used signs during his marriage ceremony, and in the 1600s the manual sign alphabet became more publically known as a consequence of an anonymous published book on the BSL alphabet (‘Digiti Lingua’, 1698), and

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via education – Sir John Gaudy and Fram Gaudy became the first Deaf people to be educated using the manual alphabet and signs. In 1760, Thomas Braidwood opened the first (private) sign language school in Britain, which was soon followed by more and more residential schools being established, creating deaf culture and common signs, resulting in more people learning what was to become ‘British Sign Language’. However, the prosperity of sign language all changed when, in 1880, when a group of (primarily hearing) teachers of the Deaf met in Milan at the ‘2nd International Congress on Education of the Deaf ’.

During this now infamous meeting, the attendees voted to ban sign language and enforce oralism. This affected most of Europe, and the oral method of spoken language learning remained dominant for over 100 years. Deaf children were required to learn spoken language in deaf schools or attended mainstream schools where sign language was discouraged.

Fast-forward to the 21st century, and the consequences of oralism are still very much prevalent. Despite British Sign Language (BSL) being recognised as an official language (UK in 2003, Northern Ireland in 2004), and the Milan 1880 motion being overturned at a meeting in Vancouver (2010), many deaf children are still discouraged from learning sign language. The reason for this discouragement is complex; on a practical level, approximately 90% of deaf children are born to hearing parents, and hearing parents do not typically know BSL – this results in delays of deaf children learning BSL, typically until the age of 4-5years old when children receive educational support and/or attend sign language classes. Another reason for the delay in learning sign language comes from medical considerations.

Cochlear implants (CI) were becoming more and more common place, with the NHS in the UK performing CI surgery over the past 3 or 4 decades.

CIs have been extremely successful in restoring hearing in those who are either born deaf or become deaf. However CIs are not successful in everyone.

Previous studies have found that duration of deafness (Busby, Tong, & Clark, 1993) and age-at-onset (O’donoghue, Nikolopoulos, & Archbold, 2000; Sarant, Blamey, Dowell, Clark, & Gibson, 2001) of hearing loss play a vital role in how successful a CI is. Pre-linguistically (prior to language learning) deaf adults generally perform more poorly with a cochlear implant than post-linguistically deaf adults, whilst a long duration of deafness prior to implantation is generally detrimental to performance. Nonetheless, while some influential factors have been identified, including age-at-onset of hearing loss and duration of deafness, currently there is no accurate predictor of how well an individual will perform with a CI (Lazard et al., 2012).

Behavioural studies suggest that Deaf people are better at detecting visual motion (Bosworth & Dobkins, 2002), have enhanced peripheral vision (Bavelier, Tonmann, Hutton, Mitchell, Corina, Liu & Neville, 2000; Neville & Lawson, 1987; Proksch & Bavelier, 2002), are more sensitive to tactile stimulation (Levänen & Hamdorf, 2001), and are better on a variety of face tasks including remembering faces (Arnold & Murray, 1998) and distinguishing facial features (McCullough & Emmorey, 1997). How does deafness lead to such an enhancement in visual and tactile skills?

Since the development of neuroimaging techniques, researchers have begun to understand more about the capacity of the human brain to change following sensory loss. In blind individuals,

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45 functional magnetic resonance imaging (fMRI) studies show that visual cortex respond to a variety of auditory and tactile stimuli – so called ‘crossmodal plasticity’. For example, a part of the fusiform gyrus which typically responds to visually presented words (the visual word form area) instead responds to braille in blind braille readers (Reich, Szwed, Cohen, & Amedi, 2011). Further, in echolocators – individuals who learn to navigate their way around the world using a series of clicks and ‘echos’ – primary visual cortex responds to echos that depend on the location of the echo source, effectively creating an ‘echotopic map’ in visual cortex (Thaler, Arnott, & Goodale, 2011).

Such studies demonstrate examples of regions maintaining their function (i.e. reading, a spatial map of the world) but changing their sensory inputs (from vision, to touch or sound). In deaf individuals, so called ‘auditory’ cortex has been found to respond to vision. For example, previous fMRI studies have shown that parts of auditory cortex responds to visual motion (Finney, Clementz, Hickok, & Dobkins, 2003; Finney & Dobkins, 2001; Sadato et al, 2004; Shibata. 2007), while other studies have shown that Wernicke’s area – an area in superior temporal gyrus that responds to spoken speech – instead responds to sign language both in deaf individuals who sign, and in hearing signers (Fine, Finney, Boynton, & Dobkins, 2005; Nishimura et al, 1999; Petitto, Zatorre, Gauna, Nikelski, Dostie, & Evans, 2000).

These studies raises the question as to whether learning a visual language exerts pressure on so called ‘auditory’ cortex to respond to visual stimuli, which in turn leads to detrimental outcomes following CI. Specifically, if young children learn a visual language instead of a spoken language prior to receiving a CI, does this cause auditory cortex to respond to visual stimuli, and in turn causes ‘auditory cortex’ to be unable to rewire again and respond to auditory stimuli following the implant? This concern is, understandably, on the minds of audiologists and medical doctors while giving advice to parents of deaf children. One might be tempted to err on the side of caution and sug-

gest that parents do not teach their infant child sign language, for fear that this might promote visual responses in auditory cortex which may be detrimental if parents are intending to provide their child with a CI later on. And indeed, this advice is still, at times, given to parents of deaf children, resulting in delays of deaf children learning sign language. However, is this concern justified? One important issue is that it is unclear from these studies whether the response to vision occurs in early ‘auditory’ processing, such as Heslch’s gyrus, or whether it is the later auditory processing regions that are responding to vision. Do these early auditory processing regions actually respond to vision in Deaf adults who use BSL as their primary language?

In a new study, we used fMRI to present two forms of visual language – written words and signed words – to 12 congenitally Deaf individuals who use BSL as their primary means of communication.

We found no evidence of primary auditory cortex responding to either written words or signed words in deaf individuals.

In another study, we presented participants with low-level visual stimuli (black and white gratings), and again found no response in ‘auditory cortex’ to visual stimuli. Both these studies demonstrate that learning sign language does not lead to primary ‘auditory cortex’ becoming responsive to visual stimuli. Instead, we found that both written words, signed words, and low-level visual stimuli, activated later auditory processing regions, such as regions typically involved in language processing. Thus, we found no evidence that learning sign language exerts pressure on primary auditory cortex to respond to vision, and therefore no link between learning sign language and crossmodal plasticity of primary auditory cortex.

This therefore suggests that sign language usage may not be a contributing factor on primary auditory cortex’s ability to respond to auditory stimuli following a CI.

Another issue that arises, is what happens to the brain after an individual receives a CI? The theory that learning sign language may be bad for CI outcomes is based upon the idea that any crossmodal plasticity that occurs as a result of learning a visual language is maladaptive, and that it is difficult for auditory cortex to rewire a second time following the (re)introduction of hearing with a CI. Further, can a response to vision in auditory cortex predict CI outcomes?

Unfortunately, fMRI is not well suited to research involving CI users as it is unsafe for patients to enter the scanner after receiving their implant. In order to study how the brain reorganises in deaf individuals after hearing is restored with a CI, one can use other techniques such as functional near-infrared spectroscopy (fNIRS) which is fully compatible with a CI and is essentially silent, providing an opportunity for safe and repeated testing of CI recipients (Wiggins et al 2016).

In line with the fMRI results, fNIRS has been used to confirm that parts of socalled ‘auditory cortex’ respond to visual stimuli in deaf adults (Dewey et al 2015).

Anderson and colleagues (Anderson et al, under review) used fNIRs to show that greater responses to visual stimuli in ‘auditory’ cortex before cochlear implantation predicts poorer auditory speech understanding after implantation.

However, greater increases in responsiveness to visual stimuli after implantation is also predictive of better auditory speech understanding (Anderson et al, 2017). Subsequently, rather than thinking that cross-modal plasticity of auditory cortex is ‘maladaptive’, Wallace (PNAS 2017) suggested that new guidelines

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46 for those who are candidates for a CI should encourage, rather than discourage, experience and training with visual speech, such as lip-reading and sign language.

In sum, neuroimaging tecniques such as fMRI and fNIRS are useful tools for investigating crossmodal plasticity in deafness. These techniques have found that early auditory areas do not respond to vision in deaf British Sign Language users, and so far have found little evidence that learning a visual language such as sign language is detrimental to clinical outcomes following a CI. However, it is unclear whether the response to sign language and low level visual stimuli in later

(language) areas might lead to worse outcomes following cochlear implants.

Further studies may be helpful elucidate any potential links between the extent of cross-modal plasticity in later auditory areas and CI clinical outcomes.

Key Reading • Anderson, C. A., Lazard, D. S., & Hartley, D. E. (2017). Plasticity in bilateral superior temporal cortex: effects of deafness and cochlear implantation on auditory and visual speech processing.

Hearing research, 343, 138-149.

• Busby, P. A., Tong, Y. C., & Clark, G. M. (1993). The perception of temporal modulations by cochlear implant patients. The Journal of the Acoustical Society of America, 94(1), 124-131.

• Dewey, R.S. & Hartley, D.E.H. (2015).

Cortical cross-modal plasticity following deafness measured using functional near-infrared spectroscopy. Hearing Research, 325, 55-63.

• Lazard, D. S., Vincent, C., Venail, F., Van de Heyning, P., Truy, E., Sterkers, O., ... & Mawman, D. (2012). Pre-, per-and postoperative factors affecting performance of postlinguistically deaf adults using cochlear implants: a new conceptual model over time. PloS one, 7(11), e48739.

• O’donoghue, G. M., Nikolopoulos, T. P., & Archbold, S. M. (2000). Determinants of speech perception in children after cochlear implantation. The Lancet, 356(9228), 466-468.

Cochlear Synaptopathy in Humans: Recent Developments CD

in a quiet environment (Sergeyenko et al., 2013).

Author Chris Plack The University of Manchester and Lancaster University.

Full reading list for this article available from our Research Round-Up editorial team

The clinical audiogram is easy to obtain but is a poor measure of damage to the auditory system, and is a poor predictor of speech perception in noise, arguably the most debilitating perceptual deficit experienced by people with a hearing loss. A type of “sub-clinical” damage (i.e. damage that is not revealed in the audiogram) that has received much attention recently is cochlear synaptopathy. In a landmark study, Kujawa and Liberman (2009) found that mice exposed to 100 dB SPL noise for two hours experienced only a temporary elevation in threshold sensitivity (equivalent to a temporary audiometric hearing loss) but a permanent destruction of a large proportion of the synapses (connections) between inner hair cells and auditory nerve fibres.The disconnected nerve fibres subsequently degenerated, leading to a loss of about 50% of nerve fibres in affected frequency regions.

These results have been replicated in the macaque monkey, although the noise levels needed were higher than in mice, and the degree of synaptopathy was less, ranging from 12 to 27% (Valero et al., 2017). In rodent models, ageing is also associated with considerable cochlear synaptopathy, even for animals raised

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The implication of these studies is that noise exposure and ageing can cause widespread damage to the auditory nerve without affecting audiometric sensitivity. In other words, such damage may be “hidden” from standard hearing tests.The animal findings raise crucial questions for our understanding of hearing loss in humans, in particular: how prevalent is cochlear synaptopathy in humans, and is cochlear synaptopathy an important cause of listening difficulties?

Since the early animal results were published, a number of research groups around the world have sought to address these questions. With regard to the relation between noise exposure and synaptopathy, one approach has been to ask (typically young) participants with normal audiograms to estimate their past noise exposure, or to compare a group of participants with normal audiograms who engage in a particular noisy activity (e.g., firearm use) with those who do not. It is then possible to determine if noise exposure is related to a measure thought to be sensitive to synaptopathy. The “go-to” metric for many of these studies has been the amplitude of wave I of the auditory brainstem response (ABR), an electrophysiological potential that reflects activity in the auditory nerve. ABR wave I amplitude is strongly associated with synaptopathy in the animal models. The results of these human studies have been somewhat mixed. Although a few studies have reported a reduction in wave I amplitude in participants with more noise exposure (e.g. Bramhall et al., 2017), the majority of studies have found no clear relation (e.g.

Prendergast et al., 2017a). Furthermore, for young participants

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Figure 1. An illustration of the loss of synapses between inner hair cells in the cochlea and auditory nerve fibres that may occur as a result of noise exposure or ageing.

there is little evidence for a relation between noise exposure and listening tests such as speech perception in noise (Prendergast et al., 2017b;Yeend et al., 2017).These results do not suggest that noise-induced synaptopathy is a significant cause of listening difficulties in young adults with normal audiometric hearing, although some caution is appropriate: We may not yet have a sensitive measure of synaptopathy in humans, and self-report estimates of noise exposure are likely to be highly unreliable.

Another approach has been to select people with an established perceptual deficit, and ask if this deficit may be the result of synaptopathy. Tinnitus can occur in young people with normal audiometric thresholds, and this is associated with prior noise exposure. Some studies have shown a reduction in ABR wave I in these people compared to people without tinnitus, consistent with synaptopathy (e.g. Schaette and McAlpine, 2011), although other studies have failed to find an effect (e.g. Guest et al., 2017). There are also young people who have speech perception in noise difficulties despite normal audiometry. A reasonable hypothesis is that these individuals may have cochlear synpatopathy, although in a recent study we found no evidence for a reduction in wave I in these individuals compared to audiogram-matched controls (Guest et al., 2018).

The studies exploring the relations between synpatopathy and noise exposure, tinnitus, and listening difficulties, have tended to focus on young listeners with normal audiometric hearing, since measures of synaptopathy such as ABR wave I are affected by audiometric loss, making it difficult to disentangle the effects of synaptopathy from the effects of hair cell damage. In the macaque model, noise levels that produced a permanent threshold elevation, produced very high levels of synaptopathy (Valero et al., 2017). Hence, it is possible that people with a noise-induced audiometric hearing loss also have significant synaptopathy, and that this may be functionally significant. It is a considerable challenge, however, to separate synaptopathy from hair cell damage using the non-invasive measurement techniques that are available in humans.

The evidence for a relation between ageing and synaptopathy in humans is more robust. There is now direct histological evidence from a small number of human temporal bones that suggests that older people have reduced synapse counts (Viana

et al., 2015). Furthermore, there is convincing recent histological evidence from human temporal bones that as we age the proportion of auditory nerve fibres declines at a higher rate than the proportion of inner hair cells, consistent with cochlear synaptopathy (Wu et al., 2018). But while these results provide good evidence that synaptopathy is a consequence of normal ageing in humans, the effects of synaptopathy on perception are not yet clear. Ageing is associated with a number of changes to the auditory nervous system, including loss of nerve fibres, loss of the myelin sheath surrounding nerve fibres, and reductions in the inhibitory communications between neurons. All these are likely to impact on perception. Speech in noise performance is also known to be dependent on cognitive factors which also decline with age. It may prove difficult to isolate the effects of synaptopathy from all the other age-related declines.

To summarise, while the evidence for a relation between noise exposure and cochlear synaptopathy in humans is weak at present, there is now good evidence that synaptopathy occurs as a result of ageing. However, we do not have a clear understanding of the perceptual consequences of cochlear synaptopathy. It is still uncertain that synaptopathy is a major contributor to the listening difficulties experienced by older people. Understanding this relation is of crucial importance if we are to consider potential drug treatments for the condition, such as neurotrophins, that may restore the damaged synapses. We also need a diagnostic test that can identify synaptopathy on an individual basis.

Although the electrophysiological measures show good test-retest reliability, there is large variability between individuals due to factors such as head size, tissue resistance, and the alignment of the nerve cells that generate the response. As described earlier, there is also an influence of hair cell damage on these measures.

Without an understanding of these other sources of variability, it will be difficult to use these tests to produce a definitive diagnosis of synaptopathy. A different measure that may prove useful diagnostically is the middle ear muscle reflex (either the threshold for activation or the response amplitude). The reflex is thought to be driven by the nerve fibres that are affected by synaptopathy, and shows a good relation to synaptopathy in recent mouse studies (Valero et al., 2018). Some groups have started using this measure to test for the presence of synaptopathy in people with tinnitus (Wojtczak et al., 2017), and as a result of noise exposure and ageing, and it will be interesting to see how this line of research develops.

Key Reading • Kujawa, S.G., Liberman, M.C. 2009. Adding insult to injury: cochlear nerve degeneration after “temporary” noise-induced hearing loss. J Neurosci 29, 14077-85.

• Prendergast, G., Guest, H., Munro, K.J., Kluk, K., Leger, A., Hall, D.A., Heinz, M.G., Plack, C.J. 2017a. Effects of noise exposure on young adults with normal audiograms I: Electrophysiology.

Hear Res 344, 68-81.

• Wu, P.Z., Liberman, L.D., Bennett, K., de Gruttola, V., O’Malley, J.T., Liberman, M.C. 2018. Primary neural degeneration in the human cochlea: Evidence for hidden hearing loss in the aging ear. Neuroscience. https://doi.org/10.1016/j.neuroscience.2018.07.053.

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The neural art of walking - cortical and cognitive mechanisms of gait CD

Authors Patricia Castro Senior Audiologist and Research Assistant Imperial College London

Dr Diego Kaski Consultant Neurologist National Hospital for Neurology and Neurosurgery Honorary Senior Lecturer University College London Full reading list for this article available from our Research Round-Up editorial team

Think back to how you got to work today. Perhaps you walked to your car, or the nearest tube or train stop, or even walked all the way in. We are advised to take 10,000 steps a day to stay healthy, but many of us take for granted the complex neural pathways that allow us to walk from one place to another. Here we discuss the cortical contributions to gait, and the effects of emotion and cognition on balance performance.

Early studies of locomotion postulated that since walking is such an automatic activity, the cortical (conscious) contribution is likely minimal. Indeed, famous studies made with decerebrated cats showed that despite not having a cortex, these animals could walk with mesencephalic stimulation or even spontaneously if the lateral hypothalamic region was preserved (1,2).

However, such animals were observed to walk “robotically” with “non-goal directed” locomotion - they could move their legs, but this was far removed from everyday walking! Early evidence suggested that subcortical structures such as the caudate nucleus facilitated a “drive” for locomotion, hence providing evidence that gait is not merely a reflexive motor process (3,4).

Further, when the pyramidal tracts were disrupted bilaterally in cats, they were able to walk but could not perform skilled gait tasks such as walk on a narrow beam or horizontal ladder (5,6). Indeed, it is increasingly clear that skilled performance of gait necessitates knowledge of the orientation and movement of our body, an ability that could only be achieved through an

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integration of sensory afferent signals (e.g. vestibular, visual and proprioceptive) (7,8), to deliver a contextually appropriate efferent motor signal. Supplementary motor areas are closely involved in gait initiation and selection of motor programs for leg movements, but also have an important role in generating anticipatory postural adjustments necessary for everyday gait performance (9–11), and preparatory activity prior to gait initiation (12,13).

The degree to which cortical regions in the brain are recruited for gait depend upon a number of factors. For example, a novel or more skilled motor task such as walking backwards may require more cortical activity than normal forwards walking (14).

Furthermore, when a subject walks at a preferred speed, the cortex appears to have less contribution presumably needing less motor planning and more subcortical involvement. Any enforced change in preferred speed, then (whether faster or slower), generates greater cortical participation, and is typically more demanding for the individual (15). Such cortical influences on gait adaptation have been shown for a variety of locomotor tasks (16,17).

The specific cognitive influences upon gait have perhaps only recently begun to be unravelled. A number of imaging studies have shown an increase in metabolic activity in the prefrontal cortex (an area associated with attention), when performing skilled gait tasks compared to normal walking (18). The effects of cognition upon gait are perhaps most apparent in the elderly population. Indeed, it has been argued that gait should be considered a cognitive task in the elderly (rather than the automatic process we often assume) (19). It is no secret that gait declines with age, and this is often attributed to the consequence of age-related multifactorial balance affecting the afferent signals (visual loss, hearing loss, vestibular dysfunction, proprioceptive loss), biomechanical factors (osteoporosis, arthritis, muscular atrophy), and fatigue (20). Impaired cognition, or at least a change in cognitive reserve or resource allocation, are presumably also pertinent to gait impairment in the elderly. In support of this, the execution of a cognitive task in combination with a postural task (dual-tasking) significantly worsens gait performance, even in healthy participants (21–23). Given their every-day relevance, dual-tasks may be more sensitive in predicting fall risk than conventional posture and gait assessments. One example is the “Stop walking when talking” sign, used as a measure of dual-task performance. This sign can be observed when starting a conversation with someone while they are walking (about 100 or 200mts) and identifying if they stop walking in order to respond (24). This clinical observation is able to segregate older subjects into “stoppers” and “non-stoppers”; significant differences

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Figure 1: The relationship between instability and anxiety in younger and older healthy individuals. For the same degree of instability, the older individuals manifest greater degrees of anxiety.

in kinematic parameters, such as gait velocity and angular displacement in the roll plane have been observed between these two groups, even when employing a shorter version of the test (8mt walk, 1 question) (24–26). More importantly, “stoppers” have been shown to have a higher risk of falling compared to “non-stoppers” (25,26). The cognitive influences on gait are of particular concern in patients with dementia, in whom the fall risk is considerably greater, even in the absence of motor deficits. Cognitive decline is thus associated with decreased gait speed (27), and stride length and gait symmetry (19,28). Moreover, in patients with moderate to severe Alzheimer’s disease hippocampal volume is related to increase stride time variation (29).

Finally, recent evidence has highlighted the importance of anxiety upon postural control. Consider stepping onto an icy path; when subjects feel threatened, they generate adaptive motor patterns to maintain a stable posture (30–33). However, anxiety not only influences motor performance, but may also affect our perception of stability. Subjects can accurately match their subjective rating of objective instability (34), as is supported by our own data in both healthy young and older subjects (35).

However, our data also revealed a tight coupling between instability perception and task-related anxiety in this group of healthy individuals during a postural perturbation, and that this relationship is stronger with increasing age. In other words, the more postural sway that exists, the greater the perception of imbalance which in turn translates into greater anxiety perception, particularly in older subjects. Why should this be?

Increased postural sway may lead to greater postural anxiety, given the increased potential for falls. The relationship between perceptual instability and postural anxiety is likely strongest in the elderly, where the consequences of falling are greater (e.g. hip fracture etc.). This strong relationship could imply that the degree of anxiety may be influencing how we perceive our postural performance. Previous studies have also seen this relationship and therefore give anxiety an important role while elaborating our perception of instability (36). It has also been postulated that when performing a postural task, anxiety may

deplete cognitive resources required for postural control. Our findings then suggest that older subjects might not be able to drift their attention away from anxiety and are less able to focus on the relevant objective cues of stability. As a result, they feel more anxious when facing the same degree of instability when compared to young subjects (Figure 1). Additionally, when exposed for a second time to the same postural task, older people do not reduce their anxiety as do young people, suggesting their anxiety is not directly related to the novelty of the task but rather to the actual implied risk they feel while performing the task. Unfortunately, older people are constantly exposed to the risk of falling and therefore it is not surprising that they restrict their daily activities because of the fear of falling. The fact that emotional components are an important factor in balance and gait performance however opens potential novel therapeutic avenues to manage balance disorders in the elderly.

To summarise, we have seen how walking, previously thought to be an automatic and simple task is in fact an impressive neural feat, involving sensory, motor, cognitive, and emotional processes. Although often overlooked, it is important to consider the latter when assessing postural control, particularly in the elderly, in order to provide an accurate fall risk estimate and therefore prevent the future consequences of falls.

Key Reading • Hausdorff JM,Yogev G, Springer S, Simon ES, Giladi N. Walking is more like catching than tapping: gait in the elderly as a complex cognitive task. Exp Brain Res [Internet]. Springer-Verlag; 2005 Aug 28 [cited 2018 Dec 10];164(4):541–8. Available from: http://link.springer.com/10.1007/s00221-005-2280-3.

• Lundin-Olsson L, Nyberg L, Gustafson Y. “Stops walking when talking” as a predictor of falls in elderly people. Lancet [Internet]. Elsevier; 1997 Mar 1 [cited 2018 Dec 7];349(9052):617.

Available from: https://www.sciencedirect.com/science/article/pii/S0140673697240092?via%3Dihub.

• Carpenter MG, Frank JS, Adkin AL, Paton A, Allum JHJ. Influence of Postural Anxiety on Postural Reactions to Multi-Directional Surface Rotations. J Neurophysiol [Internet].

American Physiological Society; 2004 Dec [cited 2018 Apr 19];92(6):3255–65. Available from: http://www.physiology. org/doi/10.1152/jn.01139.2003.

• Castro P, Kaski D, Schieppati M, Furman M, Arshad Q, Bronstein A. Subjective stability perception is related to postural anxiety in older subjects. Gait Posture [Internet]. Elsevier; 2019 Jan 2 [cited 2019 Jan 3]; Available from: https://www.sciencedirect. com/science/article/pii/S0966636218304958?via%3Dihub.

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ear to the ground

51

Ear to the ground

for all things ear-related in the media In this Issue’s Ear to the Ground, we welcome new editor Simon Wierzbicki and say farewell to Sarah Canton. Articles recently have included an app for checking children’s hearing, hearing loss as a barrier to employment, and the benefit of hearing aids in reducing decline of dementia. In Twitterarty we explore the guidelines, books and articles recommended by the audiology community on Twitter.

New app developed by NAL to check children’s hearing ABC News Australia reported on the roll out of a new app which enables children from age 4 and up to test their own hearing. The app, Sound Scouts, has been developed by the Australian Department of Health, in conjunction with Harvey Dillon and the team at NAL. Released in 2017, children play a game within the app to test their hearing. The app is available on Apple and Android devices and has been designed to be usable without the need for clinician present, or calibrated equipment. Once the test has been completed, the app provides a report and guidance on the next steps to take if a hearing loss is indicated. The Australian government has allocated $4 million of funding to provide test sessions for 600,000 children aged 4-17. The project aims to provide an accessible hearing check to children across Australia, and has been particularly welcomed in remote areas, where access to health professionals is more restricted.

The app is available to download at www.soundscouts.com Full details of the app have been published in the IJA: Harvey Dillon, Carolyn Mee, Jesus Cuauhtemoc Moreno & John Seymour (2018) Hearing tests are just child’s play: the sound scouts game for children entering school, International Journal of Audiology, 57:7, 529-537 www.abc.net.au/news/2018-12-29/game-tests-children-for-hearing-loss-and-disorders/10637970

Hearing loss “a barrier to employment A recent survey of over 1,000 people by Action on Hearing Loss in Northern Ireland found that over half felt unfairly treated at work due to their hearing loss, and 44% did not disclose their hearing loss due to concerns that potential employers would not consider them fit for the job.

Clare Lavery from Action on Hearing Loss advised employers to act to prevent employees experiencing stress or bullying at work, saying “It’s inconceivable for anyone with another disability to be mocked at work, and that still happens for people with hearing loss or deafness”. She also feels employers need to be made aware that making the necessary adjustments in the workplace are often not costly, and in many cases can be as simple as changing where someone is positioned in the workplace, or having written notes taken at meetings. www.bbc.co.uk/news/uk-northern-ireland-45791132

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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

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52 Study finds that hearing aids can slow dementia “by up to 75% A recent study by a team at the University of Manchester led by Dr Asri Maharani and Dr Piers Dawes, has shown a link between uptake of hearing aids and a slower rate of age related cognitive decline. Data from the Health and Retirement Study in the USA was analysed, looking at episodic memory scores for 2,040 individuals age 50+, starting to use hearing aids for the first time between 1996-97 and 2014-15. Results showed the rate of decline in cognitive performance for individuals when they started to use hearing aids, compared to before using hearing aids, was reduced by 75%.

The same team also analysed data from 2,068 individuals who underwent cataract surgery, finding that the rate of decline in cognitive performance was reduced by around 50% Dr Piers Dawes was quoted as saying “It’s not really certain why hearing and visual problems have an impact on cognitive decline, but I’d guess that isolation, stigma and the resultant lack of physical activity that are linked to hearing and vision problems might have something to do with it.” https://www.telegraph.co.uk/science/2018/10/11/hearing-aids-slow-dementia-75-new-study-finds

Continuing Risk of Noise Induced Hearing Loss A recent article in Personnel Today magazine highlighted the continuing risk of noise induced hearing loss (NIHL) in the workplace. The article highlighted key risks as a lack of awareness about NIHL, especially among younger workers, poor training methods in the workplace, and the fact that fit testing for personal protective equipment (PPE) is not mandatory under current regulations.

The author recommended organisations provide individual fit-testing for all workplace PPE, this ensures staff can use the equipment correctly, as well as ensuring it fulfils its function.

In the future, technology may provide some answers, for example integrating communication devices within ear defenders to make PPE an integral and multi functional tool, or integration of miniature microphones within PPE to register residual noise, combined with software and cloud technology, providing the ability to monitor sound exposure in real time. https://www.personneltoday.com/hr/wake-up-to-hearing-loss-in-younger-workers

Join us on Twitter @BSAudiology1 Follow us on Twitter to keep up to date with BSA courses, meetings and conferences.

Find out about relevant events and conferences worldwide; as well as all the latest news from the world of audiology.

Get involved by sharing meeting photos and contributing to regular discussion points and surveys.

ear to the ground

ear to the ground

53

Twitterarty

In this edition of Twitterarty, we first focus on the tweets shared on guidelines relevant to Audiology. We also take a look at some books that have been published and shared by #audpeeps And for a featured profile, did you know that the International Journal of Audiology now has its own twitter feed? We show some interesting tweets over its first 2 months.

2018 was a significant year for the publication of new guidance, not least with the NICE guidelines on hearing loss produced. 2019 is so far proving to be just as busy: BritishSocAudiology @BSAudiology1 ´ 20 Nov 2018 New Document: Pure Tone air-conduction and bone-conduction threshold audiometry with and without masking is now published. thebsa.org.uk/wp-content/upl...#AudPeeps

BritishSocAudiology @BSAudiology1 ´ 18 Dec 2018 The National ENT Trainee Research network (INTEGRATE) is soon to launch a Delphi process to establish consensus on definition, diagnosis and outcome meansures for otitis externa. If you would like to be involved please contact gemma.crundwell@addenbrookes.nhs.uk #AudPeeps

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

What books are #audpeeps currently reading?

Laura Turton @LauraAudPeep Getting my teeth into this today #hyperacusis #CPD @DrDavidBaguley

SFAC @SFACmby Clever and funny book, and weaving mindfulness into the story is brilliant. Have now ordered the other books. I can see this as a tool in mindful practice, including tinnitus and hyperacusis. #audiology #tinnitus #hyperacusis #rabbitandbear

BritishSocAudiology @BSAudiology1 ´ 28 Dec 2018 The British Society of Audiology’s Professional Guidance Group are delighted to send out for Recommended Procedure for ABR Testing in Babies Please see our website for more details thebsa.org.uk/ pulbic-consult...#Audiology #AudPeeps #ABR #NHSP #Paedeatricaudiology

Brianna Young AuD @BYoungAuD ´ Jan 26 A little in flight reading on my first trip of the year to the Taastrup Denmark office. Kind of sad I only was introduced to the work of @simonsinek recently! #StartWithWhy #AudPeeps

BritishSocAudiology @BSAudiology1 ´ Jan 8 Important read: the NICE guidelines for Cochlear Implant candidacy has been updated #Audiology #cochlearimplants #cochlearimplant #hearing #audpeeps #ENTauds @NICEcomms

ear to the ground

ear to the ground

54 Our featured profile this issue is the new twitter feed for the International Journal of Audiology.

International Journal of Audiology @ijaonline #FlashbackFriday #MostRead @IJAlonline article is on improving #hearingaid use by Barker @VestibHealth, Atkins @LouAtkinsUCL & Lusignan @lusignan_s - 9392 views!

International Journal of Audiology @ijaonline Editorial #IJA board meeting at 34th World Congress of #Audiology with esteemed associate editors #proud #audpeeps

The link for this is: tandfonline.com/doi/full/10.3109/1499202 7.2015.1120894 #IJA #audiology #auralrehab #audpeeps

International Journal of Audiology @ijaonline Welcome Dr De Wet Swanepoel @dewetswanepoel! New editor-in-chief of #IJA @ijaonline #2019. BIG thanks to Dr Ross Roeser who remains as emeritus editor-in-chief. #audiology #audpeeps

International Journal of Audiology @ijaonline Check out #interesting #OpenAccess article by Pryce @ helenpryce and Chilvers in @ijaonline on role of thoughts & acceptance in #tinnitus.

International Journal of Audiology @ijaonline “Cognitive behavioural therapy associated with reduced The 1link for this is: tandfonline.com/doi/full/10.1080/1499202 BSA_A5_Landscape_Membership_Advert.V1.qxp_Layout 1 30/03/2017 12:14 Page #insomnia and distress for patients with #tinnitus 7.2018.1500041#audiology #newresearch Check out #EarlyOnline article in @ijaonline tandfonline. #audpeeps #IJA BSA_A5_Landscape_Membership_Advert.V1.qxp_Layout 1

SA_A5_Landscape_Membership_Advert.V1.qxp_Layout 1 30/03/2017 12:14 Page com/doi/full/10.10...#audiology #cbt1

British Society of Audiology British Society of Audiology Membership British Society ofOrganisational Audiology

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International Journal of Audiology @ijaonline 3 March 2019 is #WorldHearingDay - how many of our #audpeeps are hosting an event this year? Get a #grant from the @WHO’s Hearing Forum for your event.

Organisational Membership

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BSA_A5_Landscape_Membership_Advert.V1.qxp_Layout 12:14 Page 1 SA_A5_Landscape_Membership_Advert.V1.qxp_Layout 1 30/03/2017 12:14 Page 1 1 30/03/2017 Benefits of organisational

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RIGHT-HANDED VERSION

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FINGERSPELLING

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© 2018 LET’S SIGN BSL graphics Cath Smith - www.DeafBooks.co.uk - info@deafbooks.co.uk - on behalf of Gemma Crundwell, Audiologist, Cochlear Implant Centre, Cambridge

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