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Hearing Journal:
doi: 10.1097/01.HJ.0000361844.96713.ac
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Connectivity: Early steps point the way toward wireless wonders to come

Bloom, Sara

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Sara Bloom is a frequent contributor to The Hearing Journal.

Increasingly, we are living in a wireless world. We can make and receive telephone calls while walking down a city street; we can listen to music while jogging in a park; we can e-mail, text, and compute anywhere from the airport to the zoo. No longer are we tethered to desks, phone booths, and electrical outlets. We are free to wander wirelessly through the array of electronics this world provides. Unless we wear hearing aids.

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For all too many consumers, wearing hearing aids precludes wireless clarity when using a digital mobile telephone or listening to music on an MP3 player or attending a concert or lecture or even watching a television program at home.

But what if hearing-impaired people could hear music, lectures, TV programs, and telephone conversation wirelessly through their own hearing aids—devices that are customized and programmed to amplify according to each person's individual hearing loss? Imagine moving through the day, from activity to activity, environment to environment, taking advantage of the latest generation of electronic devices without need for neckloops, headsets, or other such devices. We're not there yet, but the first steps have been taken. And based on research currently under way, the day of easy, wireless connectivity for wearers of hearing aids is coming.

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DIFFERING VIEWS ON THE ISSUE

Curiously, this is news of only modest import to most current hearing aid users. While some of the people interviewed for this article find the prospect of connectivity a wonderment, others seem content with the status quo. Arthur Boothroyd, PhD, scholar-in-residence at San Diego State University, describes the term “connectivity” as little more than a catchword. He identifies the driving force behind the idea as the manufacturers, not the users, of wireless-enabled products.

“Offering the promise of a wireless connection to various external devices may give manufacturers an edge over the competition,” says Boothroyd. But, he adds, that feature appeals to only a small segment of users—those who are interested in taking advantage of cutting-edge technology and have the dexterity to operate the tiny controls on multi-function hearing aids.

In contrast, Sergei Kochkin, PhD, executive director of the Better Hearing Institute (BHI), is passionate about connectivity and what it means for hearing aid users. “We need to start a revolution,” Kochkin asserts. “We need wireless technology in all key public buildings as well as pharmacies, churches, and drive-up service centers like dry cleaners and banks.” Kochkin's marketing research shows that, by and large, consumers are disappointed that their hearing aids fail to perform well in many situations where they want to hear well.

But with wireless connectivity, Kochkin predicts “double-digit growth” in the sale of hearing aids. While many manufacturers and dispensers believe that cosmetics is the major deterrent to hearing aid sales and acceptance, he says poor functionality is the real culprit. A wireless receiver in every hearing aid will “deliver the world by delivering sound from telephones, TVs, music players, and PA systems directly into hearing aids,” he says, adding, “Double the usefulness, double the sales.”

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CELL PHONE “BUZZ” TRIGGERED CONCERN

Many clinicians and manufacturers share Kochkin's vision. The solution is clear, but not yet at hand. It was compatibility problems between hearing aids and the digital cell phones that burst on the scene in the 1990s that was largely responsible for focusing attention on the connectivity issue. When the circuitry of digital hearing aids encountered interference from the radio frequency pulses generated by digital wireless telephones, it caused whistling, buzzing and other types of acoustic feedback in hearing aids that made it impossible for wearers to use these phones.

Largely as a result of pressure from the hearing aid industry and consumer groups, the Federal Communication Commission (FCC) issued a mandate in September 2006 that manufacturers of cell phones must offer handset models that meet the ANSI (American National Standards Institute) hearing aid compatibility (HAC) standard. Cell phones that receive an HAC rating of M3 or M4 have met or surpassed the standard. The higher the M-rating, the lower the radio frequency emissions level.

Some hearing aid manufacturers responded to the cell phone/hearing aid incompatibility problem by developing an intermediate relay or gateway device. It consists of a neckloop with a built-in medallion that receives the signal from a cell phone (or other electronic device, such as an MP3 player or television set), and relays it wirelessly to the user's hearing aids. The use of such devices can effectively address any existing fidelity problem between two digital devices. It does require an outlay of around $500 for the relay device, which for some products must be worn around the neck whenever the user wants to talk on a cell phone or listen to music or television.

Despite technological advances in overcoming hearing aid-cell phone incompatibility, dispensers still report that cell phone use by their hearing aid patients is a sometime thing. And, the older the person, the less interest he or she has is in gadgetry and advances in technology, says Barbara Prestano, AuD, of Peconic Ear Nose and Throat in Aquebogue and Southampton, NY. In many cases, she finds, “As long as the hearing aid amplifies sound and improves hearing in noise, older clients are satisfied with their aids.”

She adds, older clients who need to “connect” have learned to adapt, she says. “Sometimes, all it takes is a simple trick to help patients use a mobile phone. For instance, by positioning the receiver of a cell phone closer to the microphone of a BTE hearing aid rather than against the ear, reception improves.” Similarly, she says, by adjusting the volume controls on hearing aids, wireless music devices, and television sets, or by wearing a headset, people with hearing deficits can enjoy programming without disturbing others around them.

Figure. Barbara Pres...
Figure. Barbara Pres...
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On the other hand, says Prestano, “younger people and the influx of baby boomers—patients likely still to be in the work force or in school—are savvy about technology, and they want the easy connectivity that wireless communication offers. For them, we have relay products to make that possible.” What she likes about the relay between cell phones and hearing aids is that the device she uses routes the telephone signal to both ears, thereby improving word recognition over what the user gets by holding a cell phone to one ear or against the microphone of a hearing aid.

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THE BLUETOOTH PROTOCOL

Wireless communication today is largely tied to the Bluetooth protocol, which was introduced in 1994 as a way for devices to communicate wirelessly with each over short distances, e.g., using a mouse that is connected wirelessly to a keyboard, printing a document from a wireless connection to a computer, or using a headset or earpiece that is connected wirelessly to a mobile phone carried in a handbag, briefcase, or pocket.

So why not connect a mobile phone wirelessly to hearing aids? Or a television set or iPod? The answer to those questions is both simple and complex. The simple answer is to embed a Bluetooth chip in every hearing aid to facilitate a wireless connection to these audio devices. The complex answer is that the power requirements of the Bluetooth chip take up too much space to fit into a device small enough to enter an ear canal or fit comfortably behind the ear.

Manufacturers are working to overcome this obstacle, and it seems clear that the first to do so—or to come up with another protocol, perhaps an offshoot of an FM receiver—will provide a breakthrough technology that will excite dispensers and users and lift hearing aid sales.

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INHERENT PROBLEMS

Further miniaturization of the technology is only one of the challenges that manufacturers need to overcome. Another may be resistance by practitioners, the people who will be presenting the new, more sophisticated products to their patients. Many dispensers, particularly those who have been in the field for decades, are often less at ease than younger people with today's high-tech communication devices and may not fully inform their patients about what is available to them beyond amplification, says David Fabry, PhD, former chief of audiology at the University of Miami Medical Center who recently became managing director of AudioSync, a Starkey company. “The focus of product development must be on simplicity and ease of operation for clinicians as well as consumers,” he says.

Connectivity is not a new concept, Fabry points out. For decades, schools have used wireless FM systems as the primary communication link between teachers and students with hearing aids. Today's systems are more streamlined, he says, and certain bandwidths are FCC-dedicated for educational use, thereby providing secure transmission from classroom to classroom. But today, the idea of connectivity is associated with direct, wireless connections to iPods and cell phones. “Unfortunately, for the hearing aid user, that may be years away,” Fabry acknowledges. But it will come, he says.

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CONNECTING ONE-TO-ONE WITH ELECTRONICS

HJ contacted a number of the major hearing aid manufacturers for a report on the latest one-to-one connectivity products available to consumers.

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“Adaptive FM”

Pat Henry, director of government services, wireless, and pediatrics for Phonak USA, cites his company's advances in personal FM, notably what he calls “adaptive FM,” in which a transmitter measures ambient noise and automatically adjusts for optimum listening. Henry says that the Phonak personal adaptive FM system shows a 50% improvement in HINT scores over traditional FM systems.

Nevertheless, personal FM is not without problems. A personal FM system can be miniaturized sufficiently to be built into a BTE hearing aid, says Colleen Noe, PhD, chief of audiology and speech pathology services at the VA Medical Center in Mountain Home, TN, but its use requires considerable counseling, and the cost of the system is nearly as much as that of hearing aids. Working with lead investigator Theresa H. Chisolm, PhD, of the University of South Florida and others, Noe participated in a study comparing the use of FM by community-based adults vs. veterans. At the end of the 6-week trial period, community adults elected not to purchase the FM devices, whereas veterans, who did not have to pay, continued to use them even after a year. The group concluded that cost, not performance, was the deterrent to continued use by the community group.

Pat Henry agrees with Sergei Kochkin that greater functionality in hearing aids—however it is achieved—is the future, and he thinks the Bluetooth platform probably holds the most promise for connectivity options for hearing aid users. In that regard, Henry cites the success of the Phonak iCom interface, a relay or gateway device that can be used with certain models of Phonak hearing aids. The iCom is worn on a lanyard around the user's neck and receives a Bluetooth signal that the user's mobile telephone is ringing. When the user presses a button, the iCom streams the call wirelessly to the hearing aids. In addition to phone use, the iCom can connect hearing aids wirelessly to other devices. For instance, a user listening to music can switch to telephone simply by pushing a button on the iCom.

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The Streamer

Donald Schum, PhD, vice-president for audiology and professional relations at Oticon, Inc., says that his company was the first to address the wireless area, leading to the development of the Streamer—a Bluetooth-enabled neckloop that connects wirelessly to external devices, much like the Phonak iCom. Oticon has also introduced two other connectivity devices. One is a TV Box that connects to the audio output of any television, and then sends the signal wirelessly to the Streamer, which transmits the signal to the user's hearing aids. The other is a Home Phone Bluetooth Adapter that connects to any telephone—landline, analog, or digital—and sends the signal wirelessly to the Streamer, which transmits the signal to hearing aids.

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Relay works in the pocket

Thomas Powers, PhD, vice-president of audiology and professional relations for Siemens Hearing Instruments, Inc., points out that his company's BTE open fittings allow outside sound to enter the ear and mix with amplified sound. In instances of a mild hearing loss, the mix is acceptable, he says. Also, an open BTE allows fairly interference-free cell phone use, as long as the ambient sound isn't intrusive.

The Siemens Tek device operates similarly to other relay devices for connectivity to television, DVD players, cell phones, MP3 players, etc. The Tek can be worn as a neckloop or, uniquely, can be placed on a nearby table or in the user's pocket rather than around the neck. Powers explains that the remote connection is possible because the unit's antenna is not in the lanyard, but in the Tek device itself.

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Compression control seen coming

Francis Kuk, PhD, director of audiological services for the Widex Hearing Aid Company, predicts that the next frontier in connectivity will be compression control, enabling hearing aids to amplify quiet sounds more than loud sounds, Kuk anticipates that in the future, two hearing aids will be able to compare information and measure the incoming sound for optimum noise reduction and better compression control.

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“Better in the future”

Laurel Christensen, PhD, vice-president of research and development for the ReSound Group, disparages the relay solution to wireless connectivity. To her, the devices are not user-friendly, but instead entail a complex technological “pairing” in order to interact with any other electronics, and also require dexterity to operate the small buttons on the relay devices. She also questions the comfort and convenience of wearing a medallion on a neckloop all day, calling the devices “cumbersome.”

She says that baby boomers, who have grown up with high technology, may want such devices despite their extra cost. But older people, who make up the bulk of hearing aid users, do not have connectivity issues, she says, and on the whole have shown only cursory interest in cell phones, iPods, and the like. However, Christensen acknowledges that the first generation of digital hearing aids was not ideal, but pointed the way to the future. Similarly, “Connectivity will get better in the future,” she says. “Meanwhile, there are solutions for people who need to connect wirelessly right now.”

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A radio technology-based system

Tim Trine, PhD, chief technical officer for Starkey Laboratories, Inc., agrees with Christensen that the first generation of Bluetooth products has not been widely embraced. However, he says, hearing aid manufacturers and cell phone companies have made “huge strides” in solving the connectivity problems between the two entities, so that today, “the problem is not as big as it has been.”

Trine says that Starkey's response to connectivity is tied to the T2 feature in its S-series of hearing aids. The T2 uses the pulses of a touchtone phone to remotely control volume and memory and to transmit a signal from any cell or landline phone to a user's hearing aids. Now in development, he adds, is a wireless system based on radio technology, not the Bluetooth platform, that will transmit the signal from telephones and other external devices directly to hearing aids.

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CONNECTING IN LARGE-SPACE SETTINGS

Wireless connectivity in large spaces, such as theaters, lecture halls, and churches, is accomplished typically through one of three systems—FM, infrared, or induction loop:

* FM systems use radio broadcast technology and operate on frequencies assigned by the FCC. The speaker wears a transmitter microphone and the listener wears a receiver. The receiver transmits sound to headphones worn by the listener or to hearing aids either by direct audio input or through a wireless neckloop.

* Infrared systems transmit sound from the speaker to the listener by way of infrared light waves.

* Induction loop systems use an electromagnetic field to deliver sound. These systems can be installed in large public spaces or in any area of a private residence, typically a room with a television set. An induction loop wire is permanently installed and connects to a microphone used by the speaker (or to a TV set). The speaker induces a current in the wire, creating an electromagnetic field in the area. The hearing aid's telecoil picks up the electromagnetic signal and feeds the communication directly into the listener's hearing aids, where the volume control can be adjusted for personal comfort.

David G. Myers, PhD, a professor of psychology at Hope College in Holland, MI, has virtually wired that city, initiating the installation of induction loop systems in more than 300 venues. The induction loop technology is about 50 years old, Myers says, and hearing aids with a T-coil can take advantage of the wireless benefits without additional hardware. Myers states that more than 60% of new hearing aids are equipped with a T-coil, up from 30% a decade ago. But, he reports regretfully, many hearing aid wearers don't know how to use the feature and so miss out on the benefits of listening to public talks and performances through their own hearing aids.

Figure. David G. Mye...
Figure. David G. Mye...
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Myers recounts his own discovery of the value of T-coils. He purchased new hearing aids in 1999 equipped with a T-coil, even though he had no idea what it could do. A year later, during a trip to Scotland, he was having trouble understanding the public address announcements in an abbey he and his wife were visiting. He had noticed a sign at the entrance saying that hearing help was available, and he took a chance that perhaps the mysterious T-coil was somehow involved. At that moment, he experienced “an emotional epiphany,” he says. When he returned home to Michigan he became an activist for induction loop systems and telecoil-equipped hearing aids. Thanks to his and others' efforts, there are now loop systems in Holland's new convention center, the concourses and gate areas of the nearby Grand Rapids Airport, and many other facilities in the region.

Myers notes that induction loop systems have caught on in other states as well, including parts of New Mexico, Wisconsin, California, and New York. With support from federal stimulus money, hearing loops are now slated for installation in all New York City subway ticket booths, he says.

Echoing Sergei Kochkin, Myers contends, “By doubling the functionality of hearing aids, enabling them to serve as wireless loudspeakers that deliver customized sound, we can increase acceptance and use of hearing aids.”

Mark Ross, PhD, now retired from a distinguished career in academics and audiology research, still writes frequently about issues in hearing, including connectivity. In his view, Bluetooth, because of the intermediate step required for use with hearing aids, “is not ready for prime time.”

But, he says, by using the ANSI rating system for cell phones and hearing aids, hard-of-hearing people can pick a phone that works pretty well with their hearing aids.

Figure. Mark Ross...
Figure. Mark Ross...
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FINAL THOUGHTS

Wireless connectivity for hearing aid wearers still has far to go, in part because the popular Bluetooth technology currently requires too much power for today's hearing aids. Once that hurdle is surmounted—and it will be, according to experts interviewed for this article—many more hearing aid wearers will embrace the enormous benefits of connectivity.

In the meantime, it is important for hearing professionals to become well acquainted with the technology that now exists. Even if many of their patients are not yet interested in it, a patient who is prepared to reap the benefits of connectivity should not be denied the opportunity because a hearing care provider either is not fully informed on the topic or doesn't see a significant financial reward for the effort, as Mark Ross suggests may be a deterrent factor.

In addition, more clinicians need to become active advocates for hearing-impaired consumers in their communities, encouraging the installation of large-space listening systems in public buildings, as David Myers, among others, has undertaken in his hometown.

Connectivity is in its infancy, says David Fabry. In the future, it needs to be smaller, simpler, and easier.

© 2009 Lippincott Williams & Wilkins, Inc.

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