auditory low level functions

2/20/2013

Introduction to

Manfred Stoifl

Hearing Aid Acoustician (Honors), AAHA, Vienna, Austria

2/20/2013

Overview

• Principals of Hearing and Hearing Loss

• Neural / Central Hearing Assessment

• Indication for AudioFitness Training

• Measuring Benefits

• Neural / Central H.L. in Children

• Validation.

2/20/2013

2/20/2013

Peri

ph

eral

H

eari

ng

C

entr

al A

ud

ito

ry

Fun

ctio

ns

How Hearing Works P

rin

cip

le

5

left middle

ear

right middle

ear

left cochlea

right cochlea

left Monaural processing

right Monaural processing

arrival time difference evaluation

binaural activity imaging

aural activity image

memory

auditory processes

comparison evaluation

aural scene

memory

smell activity images

Other sensory activity images

vision activity images

other high

level processes

Ears Brainstem Auditory cortex Other brain areas

left outer

ear

right outer

ear

time domain

frequency domain

aural activity image

aural scene

meaning enjoyment

action

level difference evaluation

How We Hear

6

Hearing Loss

Where

Functional problem

Cause

Cochlear Brain

Physical Problem Hair Cell damage

Loudness Frequency Discrimination

Language Discrimination Hearing in Noise Directional Hearing

Genetics Age / Wear and Tear Trauma Diseases

Under utilisation

Treatment Hearing Aids / C.I. Low Level Function Training

Test Audiometry EFI-EFK test Low Level Function Test

Sensory

Hearing Loss

Neural/Central

Hearing Loss

?

?

-

Pri

nci

ple

7

10 20 30 40 50 60 70 80 Age

Slow / Bad

Fast / Good

Time

Normal Aging

Accellerated degeneration due

to peripheral Hearing Loss

Central Auditory Processing

Lifecycle

Pro

cessin

g S

peed

Principle

8

Nach: Ptok-M: „Auditive Verarbeitungs- und Wahrnehmungsstörungen

und Legasthenie“, Hessisches Ärzteblatt 2/2000, S. 52-54

Low-level Automatic extraction of basic acousitc features like

time and frequency resolution

Automatic exraction of phonetic cues for phonem

differenciation

Automatic identification and discrimination of

syllables in a language

Automatic recognicion of words and their

meanings 1. Order – without context

Metalanguage awareness to decode both the

syntax and prosody

Phonetic

Phonologic

Lexical-semantic

Morpho-syntactic

i / e / a / o / u

train (Transport) / train (practice)

I train my hearing with AudioFitness.

?

d/t g/k b/p

Auditory processing and perception of speech

Pri

nci

ple

ASHA* (1996) defines APD as an observed deficiency in:

Definition of Cental Hearing problem…

• Sound localization and lateralization

• Discrimination

• Pattern recognition

• Temporal aspects of listening

• Speech understanding in noise

Knowing whether a sound comes from

left / right / middle

How the sounds are organized in a word determines its meaning

Lemonade / Menolade Tsar / Star Reserve / Reverse

The pattern of a sentence creates a specific meaning

I want to drive to Kuala Lumpur tomorrow (and not fly)

I want to drive

to Kuala Lumpur tomorrow (and not today)

Hearing the difference between

Bat / pat / hat / fat

* American Speech-Language Hearing Association

Pri

nci

ple

Common Signs of Central He problems

Talks or likes TV louder than normal Unusually sensitive to sounds Asks many extra informational questions Confuses similar sounding words Hears better when watching the speaker Problems with rapid speech Frequently misunderstanding instructions or questions Porblems understanding in background noise Problems with phonics or discriminating speech sounds Frequently requests repetition.

Pri

nci

ple

Neural / Central Hearing Assessment

2/20/2013

2/20/2013

Wahrnehmungs -Trennschärfe -Test

Teil 1 O n.a.* Teil 2 O n.a.*

Links Rechts Links Rechts

EFI O EWI O

EDI O EPI O

EWI O ETI O

EPI O EFI O

EBI O EDI O

EGI O EKI O

ETI O EBI O

EKI O EGI O O

EBI O EPI O

EGI O EKI O

ETI O EFI O O

EWI O EGI O

EPI O EDI O

EKI O

EFI O

EDI O EWI O

EBI O

ETI O

EKI O EFI O

EBI O ETI O

EPI O EWI O

EFI O EGI O

EWI O EBI O

EDI O EPI O O ETI O EKI O

EGI O EDI O

ETI O O

EPI O

EDI O EKI O

EPI O ETI O

EBI O EDI O

EFI O O

EGI O

EWI O

EGI O

EKI O

EBI O

EFI O EWI O

C C C

% % %

Richtige Silben: /32 Richtige Paare: /16

PRS: PRS:

Perception-Separation Accuracy Test by Warnke (EFI-EKI)

Possible results

Similar consonants like b-p, d-t, f-w,g-k,d-g, are being mismatched often. Pay special attention to ensure right ones are being repeated

Most common mistake in the 2nd test is duplication. E.g. the client repeats EWI-EWI instead of the correct EWI-EBI

Clients or Children with CAPD barely ever reach 13-16 correct nonsense words or 10 correct pairs. The second test is specially designed to avoid the use of compensation strategies

If the client achieves less than 10 correct word pairs in the second test, it is a strong indication of Central Auditory and Automation deficiency as well as Speech deficiency

Low score also strongly indicates that client might have problems discriminating with Hearing Aids, especially in noise.

2/20/2013


• 8 tests

– Visual Order

– Order of sounds

– Directionality

– Reaction

– Pitch discrimination

– Tact

– Pattern discrimination

• Frequency

• Duration.

Ass

essm

ent

Age specific Adult Reference Values

2/20/2013

Function

Reference Values (Training)

20 years

old

30 years

old

40 years

old

50 years

old

60 years

old

70 years

old

80 years

old

90 years

old

100

years

old

Order-v 24 ms 36 ms 48 ms 60 ms 72 ms 84 ms 96 ms 108 ms 120 ms

Order-a 46 ms 59 ms 72 ms 85 ms 98 ms 111 ms 124 ms 137 ms 150 ms

Bearing 20 µs 32 µs 43 µs 55 µs 66 µs 78 µs 90 µs 101 µs 113 µs

Pitching 7 % 10 % 13 % 15 % 18 % 21 % 24 % 27 % 29 %

Rhythm 170 ms 185 ms 200 ms 215 ms 230 ms 245 ms 260 ms 275 ms 290 ms

Reaction 609 ms 670 ms 731 ms 792 ms 853 ms 914 ms 975 ms 1036 ms 1097 ms

Sequence 20 ms 58 ms 96 ms 134 ms 172 ms 210 ms 248 ms 286 ms 324 ms

Duration 40 ms 56 ms 72 ms 88 ms 104 ms 120 ms 136 ms 152 ms 168 ms

Valuating results

16

Function

Target Values (Training)

Ideal

Results* 20 years

old

30 years

old

40 years

old

50 years

old

60 years

old

70 years

old

80 years

old

90 years

old

100

years

old

Order-v 12 ms 18 ms 24 ms 30 ms 36 ms 42 ms 48 ms 54 ms 60 ms 12 ms

Order-a 23 ms 30 ms 36 ms 43 ms 49 ms 56 ms 62 ms 69 ms 75 ms 23 ms

Bearing 10 µs 16 µs 22 µs 28 µs 33 µs 39 µs 45 µs 51 µs 57 µs 10 µs

Pitching 4 % 5 % 7 % 8 % 9 % 11 % 12 % 13 % 15 % 4 %

Rhythm 128 ms 139 ms 150 ms 161 ms 173 ms 184 ms 195 ms 206 ms 218 ms 128 ms

Reaction 305 ms 335 ms 366 ms 396 ms 427 ms 457 ms 488 ms 518 ms 549 ms 305 ms

Sequence 10 ms 29 ms 48 ms 67 ms 86 ms 105 ms 124 ms 143 ms 162 ms 10 ms

Duration 20 ms 28 ms 36 ms 44 ms 52 ms 60 ms 68 ms 76 ms 84 ms 20 ms

Age specific long-term Adult Target Values

Valuating results

17

Age specific Pediatric Reference Values

Valuating results

18

Age specific Pediatric Target Values

Valuating results

Explanation

• The further results are away from Optimal Results the less good clients Central Auditory Processing is Functioning

• If any Values are below age specific Reference Values – Necessitates full assessment – Training is very strongly recommended – High probability that client will have some problems understanding speech

(with Hearing Aids)

• If any Values are below age specific Target Values – Necessitates full assessment – Training is strongly recommended – Probably client will have some problems (with Hearing Aids) in certain

situations

• If any Values are below age specific Optimal Value – Training is recommended – Possibly client will have some problems (with Hearing Aids) in certain

situations.

Ass

essm

ent

Indication for AudioFitness Training?

2/20/2013

When he/she exhibits problems with:

• Sound localization and lateralization

• Discrimination

• Pattern recognition

• Temporal aspects of listening

• Speech understanding in noise

Knowing whether a sound comes from

left / right / middle

How the sounds are organized in a word determines its meaning

Lemonade / Menolade Tsar / Star Reserve / Reverse

The pattern of a sentence creates a specific meaning

I want to drive to Kuala Lumpur tomorrow (and not fly)

I want to drive

to Kuala Lumpur tomorrow (and not today)

Hearing the difference between

Bat / pat / hat / fat

When is it necessary for a Client to do AudioFitness Training?

If she/he has probems in one or more of the following situations:

Talks or likes TV louder than normal Unusually sensitive to sounds Asks many extra informational questions Confuses similar sounding words Hears better when watching the speaker Problems with rapid speech Frequently misunderstanding instructions or questions Porblems understanding in background noise Problems with phonics or discriminating speech sounds Frequently requests repetition.


2/20/2013

Perception - Separation - Test

Part 1 Part 2

Left Right Left RightAFEE O AWEE O AKEE O AFEE O

ADEE O APEE O ABEE O ATEE O

AWEE O ATEE O APEE O AWEE O

APEE O AFEE O AFEE O AGEE O

ABEE O ADEE O AWEE O ABEE O

AGEE O AKEE O ADEE O APEE O

ATEE O ABEE O ATEE O AKEE O

AKEE O AGEE O AGEE O ADEE O

ABEE O APEE O ATEE O APEE O

AGEE O AKEE O ADEE O AKEE O

ATEE O AFEE O APEE O ATEE O

AWEE O AGEE O ABEE O ADEE O

APEE O ADEE O AFEE O AGEE O

AKEE O AWEE O AWEE O ABEE O

ADEE O ABEE O AKEE O AFEE O

AFEE O ATEE O AGEE O AWEE O

Correct Syllables: /32 Correct Pairs: /16




EFI O EWI O

EDI O EPI O

EWI O ETI O

EPI O EFI O

EBI O EDI O

EGI O EKI O

ETI O EBI O

EKI O EGI O O

EBI O EPI O

EGI O EKI O

ETI O EFI O O

EWI O EGI O

EPI O EDI O

EKI O

EFI O

EDI O EWI O

EBI O

ETI O

EKI O EFI O

EBI O ETI O

EPI O EWI O

EFI O EGI O

EWI O EBI O


EGI O EDI O

ETI O O

EPI O

EDI O EKI O

EPI O ETI O

EBI O EDI O

EFI O O

EGI O

EWI O

EGI O

EKI O

EBI O

EFI O EWI O

C C C

% % %


PRS: PRS:

If she/he can not understand 100 % in an EFI-EKI Test


24

Function


Ideal

Results* 20 years

old

30 years

old

40 years

old

50 years

old

60 years

old

70 years

old

80 years

old

90 years

old

100

years

old




Pitching 4 % 5 % 7 % 8 % 9 % 11 % 12 % 13 % 15 % 4 %





If her/his Low Level Function Speed is less than optimal.


25


If her/his Low Level Function Speed is less than optimal.

Introduction to

2/20/2013

• The speed with which the brain is able to digest and process visual & auditory information

• Ability to differentiate critical plosives b-d-g-k-t

• Spatial (directional) hearing

• Ability of differentiating vowels and decoding of voice melody

• Ability to convert perceived auditory stimuli as fast as possible into movements

• Identifying time of Phonemes (spoken) and graphemes (reading)

• Ability to distinguish auditory sound patterns (sound pictures) based on Frequencies and Duration.

2/20/2013

Low Level Automation Training

1. Visual Order Threshold.. – is the minimum time at which you can separate 2 visual stimuli

• This ability is very important for digesting written information • Increase the speed with which the brain is able to digest and process

information.

2. Auditory Order Threshold.. – is the minimum time at which you can separate 2 auditory stimuli

• If it takes you too long, you may have difficulty differentiating critical plosives b-d, g-k, or p-t from each other. Which results in difficulty understanding spoken language.

3. Spatial (Directional) Hearing – Is the minimum time difference at which you can localize a sound

• Allows correct training of spatial (directional) hearing. – Very important to be able to perceive sounds and especially language selectively

» from different directions, » to be able to assign them » to ignore them as well.

4. Pitch Discrimination – is the minimum difference between two tones

• vital ability for differentiating vowels and decoding of voice melody. • extremely important for speaking as well as for understanding language.

We assess, and customer trains 8 CAP task (1-4)

5. Rhythm – fastest rhythm you can follow

• Ability to convert perceived auditory stimuli as fast as possible into movements.

• very important for thinking, speaking and writing • To train hemispheric coordination.

6. Auditory Choice Reaction – separating two different tones and reacting as fast as possible

• Decisive for identifying time of Phonemes (spoken) and graphemes (reading). • To react fast and focused to auditory stimuli without visual aid

7. Frequency Pattern Recognition.. – quickly and accurately resolve auditory patterns

• An important pre-requisite for the segmentation of the continuous stream of auditory stimuli during speech identification and processing.

8. Duration Pattern Recognition.. – quickly and accurately resolve auditory patterns

• An important pre-requisite for the segmentation of the continuous stream of auditory stimuli during speech identification and processing.

We assess, and customer trains 8 CAP task (5-8)

Ho

me

Trai

nin

g • Practice all 8

functions at home for 30 min a day

• The Home Trainer will store data in a data log

• Follow up assessment and advice in weekly

• consultations.

Unique 2 Step Training Approach

• Practice

• Consolidation.

2/20/2013

32

t

Access Information

Task Latency Reply Confirmation

Great !

Quelle: Skinner-BF & Correll-W in „Denken und Lernen“, 1976

Confirmation

German Patent # 196 03 001

„System for supported training and learning“

Explanation: Mirror-Neurons

How practice works

• 6 -8 weeks

• Final low level function assessment

• Baseline discrimination assessment report

• Continue training alone to reach ideal values.

• Maintain reached goals by training once weekly

• Move on to second stage training.

End

of

Trai

nin

g

Measuring benefits of AudioFitness

2/20/2013

35

10 20 30 40 50 60 70 80 Age

Slow / Bad

Fast / Good Target

Time

Level of optimal central auditory function

Normal Aging

Accellerated degeneration due

to peripheral Hearing Loss


Lifecycle

Pro

cessin

g S

peed

36

Function


Ideal

Results* 20 years

old

30 years

old

40 years

old

50 years

old

60 years

old

70 years

old

80 years

old

90 years

old

100

years

old




Pitching 4 % 5 % 7 % 8 % 9 % 11 % 12 % 13 % 15 % 4 %





Age specific long-term Adult Target Values

Valuating results

37

Age specific Pediatric Target Values

Valuating results

2/20/2013




EFI O EWI O

EDI O EPI O

EWI O ETI O

EPI O EFI O

EBI O EDI O

EGI O EKI O

ETI O EBI O

EKI O EGI O O

EBI O EPI O

EGI O EKI O

ETI O EFI O O

EWI O EGI O

EPI O EDI O

EKI O

EFI O

EDI O EWI O

EBI O

ETI O

EKI O EFI O

EBI O ETI O

EPI O EWI O

EFI O EGI O

EWI O EBI O


EGI O EDI O

ETI O O

EPI O

EDI O EKI O

EPI O ETI O

EBI O EDI O

EFI O O

EGI O

EWI O

EGI O

EKI O

EBI O

EFI O EWI O

C C C

% % %


PRS: PRS:


Showing improvement in APHAB

Measuring benefits of AudioFitness

Auditory Processing Problems in Children

The dilemma… "Hearing" related complaints

Standard assessment including - Hearing threshold measurement - Middle-ear evaluation

Amplification the way we know it

?

Hearing thresholds are shifted

Hearing thresholds are "normal"

42

10 20 30 40 50 60 70 80 Age

Slow / Bad

Fast / Good

Time


Lifecycle

Pro

cessin

g S

peed

Adapted from Johnson 1996

The effect of distance and noise on word recognition

Age Group Word recognition in quiet Word recognition in noise close (1.8 m) far (7 m)

4 years 88.3 % 67.0 %

5 years 94.3 % 84.0 %

6 years 98.0 % 86.7 %

Adults 99.3 % 97.0 %

Reverberation

Classrooms are noisy places

Background noise Distance

Noise affects learning for all children but is more problematic for many children with APD…

APD 3-5% of all children

ADHD 4-12% of all children

Learning difficulties in children can result from

• Co-morbidity

• Overlap

• Causality

• Other

LD 5-10% of all children

Validation

• 30 years on the Market

• Widely used in Germany and Switzerland

• Numerous Publications

Current Clinical trials proof benefits of Low Level Training

• Learning Disabilities – Dyslexia

– ADD / ADHD etc…..

• Hearing “Problems” – Normal Hearing

• Central Auditory Problems

• Hearing in Noise

– Hearing Impaired • Hearing in Noise

• Adaptation to Hearing Aids. 2/20/2013

48

Low level functions and education

.

100 adults 20-70 years of age

Quelle: Katerji-D „Veränderungen der Low-Level-Funktionen im Erwachsenen-alter“, Dissertation (2006), Medizinische Hochschule Hannover, U. Tewes

Grade High Colle. Univ

0

6

12

18

24

30

Pitch Discrimination

0

150

300

450

600

750

900

ChoiceReaction Time

0

30

60

90

120

Duration Pattern

0

15

30

45

60

75

V. Processing Speed 0

20

40

60

80

100

Aud. Proc. Speed

0

40

80

120

160

200

Frequency Pattern

Clinical Trail Speech discrimination in Noise (144 adults)

6/21/2013 Manfred Stoifl 49

Hearing Impaired with

Hearing Aids

Normal Hearing without

Hearing Aids

with Training without Training

Clinical Trial 38 adults before and after LLF training

(average age 43.7 years)


Average performance at 25 years

Order Auditive

Duration Reaction

Pitch Directionality

Sequence

Before After

Before After Before After

Before After

Before After

Before After

Clinical Trial Trail Making Test 60+ age group


Before Training

After Training

Besides Improvement in central auditory processing it also resulted in improvement general cognitive abilities.

We therefore recommend the training for this age group. Ti

me

in S

eco

nd

s

42 dyslexic children


0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

Group A Group B Group C

Error rate reduction in % Error rate reduction in %

Group A was given lessons specially designed for dyslexics

Group B had Low-Level Training with the Brain-Boy

Group C had Low-Level-Training and Lateral-Training together

6.3 % 18.9 %

42.6 %

53

Hearing Treatment

Functional problem

Why

Cochlear Brain

Physical Problem Hair Cell damage

Loudness Frequency Discrimination

Language Discrimination Hearing in Noise Directional Hearing

Genetics Age / Wear and Tear Trauma Diseases

Under utilisation

Treatment Hearing Aids / C.I. Low Level Training

Test Audiometry EFI-EFK test APHAB Low Level Function Test

Hearing Understanding

-

Main Location

Thank YOU

Any Questions?

2/20/2013

auditory low level functions

Technology

overview principals

warnke efieki

correct pairs

common signs of central

correct ewiebiclients

correct word pairs

discrimination ofsyllables

correct nonsensewords