The Influence of Activities and Functional Social Support on Adult Cochlear Implant Outcomes

Objective: The objective of this study is to assess whether patient participation in specific activities and perceived social support correlate with speech perception following cochlear implantation. Setting: Tertiary referral hospital Methods: Adult cochlear implantation patients implanted in their poorer hearing ear between January 2019 and December 2020 completed the Functional Social Support Questionnaire (FSSQ) and a modified version of the Victoria Lifestyle Study-Activities Lifestyle Questionnaire (VLS-ALQ). Demographics, FSSQ score, and individual activities were correlated with implanted ear and binaural AzBio scores. Results: Twenty-three patients completed the survey and had at least 6 months of follow-up with appropriate speech perception testing. The average age at survey completion was 71.7 (SD, 9.1). Average pure-tone average in the contralateral ear was 70.1 (SD: 20) dB. The majority (N = 21, 91.3%) wore a hearing aid in the contralateral ear following cochlear implantation. Mean AzBioQuiet score improvement was 60.6% (range: 20%–99%) in the implanted ear and 42.6% (range: −2% to 67%) binaurally. Work-related social support correlated positively with improvement in the implanted ear (Pearson’s R = 0.473; 95% CI, 0.075-0.741; P = 0.023). Improvement in the implanted ear correlated positively with creative writing (R = 0.542; 95% CI, 0.167-0.780; P = 0.008), attending films (R = 0.448; 95% CI, 0.044-0.726; P = 0.032), going out with friends (R = 0.423; 95% CI, 0.013-0.711; P = 0.044) listening to audiobooks (R = 0.433; 95% CI, 0.025-0.717; P = 0.039), and public speaking (R = 0.468; 95% CI, 0.069-0.738; P = 0.024). Gains in binaural performance correlated positively with watching TV news (R = 0.819; 95% CI, 0.509-0.941; P < 0.001) and negatively with eating at restaurants (R = −0.532; 95% CI, −0.829 to −0.002; P = 0.05). Conclusions: Activities that provide intellectual stimulation and engage auditory faculties correlate with greater speech perception testing improvements in adult cochlear implantation patients.


exist regarding how patient-directed activities may influence outcomes.
There is no standard rehabilitation protocol for adult cochlear implantation recipients, and patients may benefit from specific recommendations to support postimplant performance.Patients sometimes elect formal auditory verbal therapy (AVT), utilize online resources (e.g., angelsound (4)), and/or pursue select activities with their new device (such as streaming audiobooks) (5).Further research into therapies and lifestyle guidance that support adult cochlear implantation rehabilitation remains an unmet need.While several studies have focused on pediatric outcomes, limited data are available examining AVT in adults (6,7).One study found that 10 AVT participants performed at the same level as 7 controls on speech recognition testing 3 and 6 months postimplantation.However, AVT participants partook in only 10 AVT sessions-potentially too few to detect a meaningful difference in outcomes, even with a larger sample size (8).Dornhoffer et al. (9) compared passive auditory training (e.g., audiobooks), AVT, and computer-based training in 72 adult cochlear implantation recipients.The use of any rehabilitation technique was associated with increased sentence recognition scores 3 months postimplantation, but the greatest improvements were seen following computer-based training.
While our understanding of the specific activities that assist in cochlear implantation rehabilitation is limited, more engaged patients appear to perform better.In one study of 23 adult cochlear implantation users, the highest scorers on speech perception were patients that intentionally sought out new auditory stimulation and expected that there would be a significant adaptation to their implant (5).Tang et al. (10) found relative to patients who lived alone, adult cochlear implantation recipients Objective: The objective of this study is to assess whether patient participation in specific activities and perceived social support correlate with speech perception following cochlear implantation.Setting: Tertiary referral hospital Methods: Adult cochlear implantation patients implanted in their poorer hearing ear between January 2019 and December 2020 completed the Functional Social Support Questionnaire (FSSQ) and a modified version of the Victoria Lifestyle Study-Activities Lifestyle Questionnaire (VLS-ALQ).Demographics, FSSQ score, and individual activities were correlated with implanted ear and binaural AzBio scores.Results: Twenty-three patients completed the survey and had at least 6 months of follow-up with appropriate speech perception testing.The average age at survey completion was 71.7 (SD, 9.1).Average pure-tone average in the contralateral ear was 70.1 (SD: 20) dB.The majority (N = 21, 91.3%) wore a hearing aid in the contralateral ear following cochlear implantation.Mean AzBio Quiet score improvement was 60.6% (range: 20%-99%) in the implanted ear and 42.6% (range: −2% to 67%) binaurally.Work-related social support correlated positively with improvement in the implanted ear (Pearson's R = 0.473; 95% CI, 0.075-0.741;P = 0.023).Improvement in the implanted ear correlated positively with creative writing (R = 0.542; 95% CI, 0.167-0.780;P = 0.008), attending films (R = 0.448; 95% CI, 0.044-0.726;P = 0.032), going out with friends (R = 0.423; 95% CI, 0.013-0.711;P = 0.044) listening to audiobooks (R = 0.433; 95% CI, 0.025-0.717;P = 0.039), and public speaking (R = 0.468; 95% CI, 0.069-0.738;P = 0.024).Gains in binaural performance correlated positively with watching TV news (R = 0.819; 95% CI, 0.509-0.941;P < 0.001) and negatively with eating at restaurants (R = −0.532;95% CI, −0.829 to −0.002; P = 0.05).Conclusions: Activities that provide intellectual stimulation and engage auditory faculties correlate with greater speech perception testing improvements in adult cochlear implantation patients.
who lived with another individual scored 20 points higher on AzBio tests.However, the benefits of socialization extend beyond speech perception: among post-lingually deafened cochlear implantation users, 36% of the variance in quality of life (assessed using the International Outcome Inventory-Cochlear Implants) can be explained by patient attitudes and support from others (11).These findings suggest realistic expectations, diverse auditory stimuli, and social interaction are associated with better outcomes.
Motivated to improve patient counseling by highlighting effective habits of successful cochlear implantation users, we sought to understand whether specific lifestyle activities and patients' self-assessment of their social network correlate with speech perception outcomes.We hypothesized that patients engaged in more lifestyle activities that encourage social interactions would perform better on AzBio sentence testing post-implantation.

METHODS
The study was approved by the Institutional Review Board (STU 2021-0209).A prospectively maintained cochlear implantation database was used to identify patients implanted between January 1, 2019 and December 31, 2020.Adult cochlear implantation recipients were recruited to complete questionnaires via email with survey links.The estimated time to participate in the study was 20 minutes.All patients were postlingually deafened and were encouraged to wear their implants at all waking hours.Counseling also emphasizes that implant benefits may not be perceived for several months.Patients are also informed of online exercises and offered external AVT resources.
Electronic health records were reviewed to extract demographics, pre-and post-implantation AzBio sentence scores (12), and operative details.Non-English speakers, and patients <18 years were excluded.Study data were collected and managed using REDCap (13,14).

Patient-Reported Activity Measures Victoria Longitudinal Study-Activities Lifestyle Questionnaire
Victoria Lifestyle Study-Activities Lifestyle Questionnaire (VLS-ALQ) is a 70-item questionnaire that assesses engagement in lifestyle activities in the preceding 2 years (15,16).Originally developed to assess how activity engagement affects cognitive decline, the VLS-ALQ surveys a broad range of social activities but intentionally overrepresents those that require knowledge and intellectual exertion.Each item is graded on a 9-point Likert scale ranging from "never" to "daily," with higher scores indicating higher activity engagement.We added 11 questions potentially relevant to cochlear implantation rehabilitation to the original VLS-ALQ (Appendix A).

Functional Social Support Questionnaire
Functional Social Support Questionnaire (FSSQ) is an 8-item questionnaire that assesses patient perceptions of social support (Appendix B) (17).Respondents indicate their level of satisfaction on a 5-point Likert scale, ranging from "much less than I would like" to "as much as I would like."Similar to the VLS-ALQ, the FSSQ is scored by summing the responses across all items.Higher scores indicate higher satisfaction.

Data Analysis
The primary outcome measured was postoperative speech perception improvement with AzBio sentence scores in quiet, obtained at least 6 months following activation.Speech perception was assessed in the implanted ear and binaurally.
Improvement was calculated by subtracting the score obtained during cochlear implantation evaluation from the highest postoperative AzBio score in quiet.Pearson's correlation coefficient (Pearson's R) was calculated to assess whether demographic variables (age, race, and gender), follow-up, total FSSQ score, and individual items from the VLS-ALQ were associated with speech perception outcomes.P-values <0.05 were considered significant.All analyses were performed using R version 4.1.10(R Foundation for Statistical Computing, Vienna, Austria).

RESULTS
A total of 154 cochlear implantation patients were emailed survey links, with 53 completed (34% response rate).Patients with less than 6 months of audiometric follow-up, lack of speech perception testing, programming at outside audiology centers, single-sided deafness recipients, and bilateral cochlear implantation were excluded, leaving 23 patients (60.9% male) for analysis.The average age at the time of survey completion was 71.7 ± 9.1 years.The majority (87.0%) of subjects were White.Most (91.3%) patients were implanted with lateral wall electrodes (Table 1).Fifteen (65.2%) met implantation criteria for either ear at evaluation, and 21 (91.3%)wore a hearing aid in the contralateral ear following implantation.

Patient-reported Activities and Speech Perception Outcomes in the Implanted Ear
Neither age at initial evaluation (R = -0.200;95% CI, -0.566 to 0.230; P = 0.359) nor the length of follow-up (R = 0.260; 95% CI, -0.170 to 0.670; P = 0.231) correlated with improvement in AzBio scores.While the total FSSQ score was not correlated (R = 0.376; 95% CI, -0.043 to 0.682; P = 0.077), higher responses to 1 question, "I get a chance to talk to others about problems at work or with my housework," correlated with improvement in ipsilateral AzBio scores (R = 0.472; 95% CI, 0.075-0.741;P = 0.022).Thus, patients who feel more supported at work performed better.
Pearson's correlation between VLS-ALQ responses and the postimplantation improvement in binaural AzBio Quiet are shown in Table 3.There was a strong positive correlation between watching TV news (R = 0.819; 95% CI, 0.509-0.941;P < 0.001) and improvement in AzBio scores.There was a strong negative correlation between eating at restaurants (R = -0.532;95% CI, -0.829 to -0.002; P = 0.050) and improvement in binaural AzBio scores.

DISCUSSION
To our knowledge, this is the first study to assess how patient-reported engagement in lifestyle activities correlates to cochlear implantation outcomes.Creative writing, attending films, going out with friends, public speaking, and listening to audiobooks correlated positively with improvement in the implanted ear, and watching TV news correlated with improvement in the binaural condition.While social engagements with friends influenced outcomes, functional social support (as assessed by the FSSQ; Appendix B) did not.This result suggests that actual participation in social activities-particularly those that engage auditory processing skills-rather than subjective feelings of social connection, are more important for improved speech perception outcomes following cochlear implantation.
Multiple explanations may account for the link between social engagement and improved cochlear implantation outcomes.It is possible that patients who are more active socially are healthier overall, allowing the time and energy needed for successful auditory rehabilitation.Additionally, if the relationship between social engagement and better speech perception outcomes is causative, perhaps social interactions employ cognitive resources in a manner that facilitates adaptation to hearing with cochlear implantation or engages resources that leads to improved outcomes.Social engagement might preserve gray matter volume in areas associated with sensory processing, language, and memory, which are shown to be associated with improved outcomes (18).Patients with more active social lives may also have greater cause to use their cochlear implantation and thus invest more heavily in adapting to them.Further study is needed to untangle the connection between socialization, cognitive aging, and adaptation to cochlear implantation.
Consistent with prior reports, participation in intellectually stimulating activities correlates with greater gains following cochlear implantation.Dornhoffer et al. (19) found the use of audiobooks is associated with increased improvement in speech perception and quality of life in adult cochlear implantation patients.Notably, verbal working memory, but not processing speed or intellectual capacity, predicts 6-month speech recognition AzBio scores, in adult cochlear implantation patients (20).Perhaps verbally/linguistically-intensive activities such as creative writing, public speaking, and listening to audiobooks support speech perception by strengthening verbal working memory.Surprisingly, the variables correlating with greater improvement in postimplantation binaural speech perception differed from the implanted ear.For example, watching TV news was positively correlated, and eating at restaurants correlated negatively with greater improvement in binaural speech perception.This discrepancy between the ipsilateral and binaural analyses could result from fewer available data for the binaural condition (binaural AzBio scores were available for 14 patients versus 23 for the implanted ear), which could skew results.
There are several limitations to our study.The retrospective nature of our study means it is subject to recall bias.Controlled trials are also needed to determine whether the relationships between activities and postimplantation speech perception scores are causative.While the VLS-ALQ inventories a range of activities, it is possible there are activities patients engage in to help them adapt to cochlear implantation that were not queried.We elected to not apply commonly used statistical approaches (e.g., Bonferroni or Benjamini-Hochberg Correction) to control for multiple comparisons, as these assume the individual items tested are independent of each other.We anticipated that patient involvement in certain types of similar activities would cluster together.Our sample size was also relatively small and lacked diversity, limiting statistical power and generalizability.Device use was also not available for most study participants and was not included in the analysis.Additionally, as the period over which patients were queried overlapped with the Coronavirus Disease 19 (COVID-19) pandemic, it is also likely that participation in work and leisure activities was curtailed in ways we cannot fully adjust for.Indeed, Knickerbocker et al. (21) found that adults implanted during the COVID-19 pandemic improved less between pre-operative and 6-month AzBio scores than those implanted just prior, likely due to reduced daily use and fewer social interactions.

CONCLUSION
Programs to support newly implanted cochlear implantation patients in reaching their aural rehabilitation potential are needed.Our results suggest that a deeper investigation into the kinds of social interactions patients have and an assessment of how they communicate during these interactions are worth pursuing.We found that creative writing, attending films, public speaking, and going out with friends positively correlated with improvements in speech perception in the implanted ear.Watching TV news positively correlated with, and eating out at restaurants negatively correlated with improvements in binaural speech perception.These findings highlight social and intellectual engagement as potential targets for cochlear implantation rehabilitation.

FUNDING SOURCES
Internal departmental funding was utilized without commercial sponsorship or support.

TABLE 1 .
Descriptive statistics and AzBio results for the 23 study participants

TABLE 2 .
Correlation between patient-reported lifestyle activities and improvement on AzBio in quiet in the implanted ear (n = 23) Significant correlations are bolded.