Audiologists may wonder why ice hockey and sailing matter when the bipartisan Over-the-Counter Hearing Aid Act of 2017, currently winding its way through the U.S. Congress, has the potential to dramatically restructure hearing health care. Yet the constant that will endure any industry upheaval is the commitment to providing innovative solutions to patients’ hearing care needs. Student and professional athletes, fitness buffs, and weekend warriors with hearing loss share a strong need to engage in sports and physical fitness while wearing their hearing aids. But is today's hearing health care caught up with the specific needs of hearing-impaired and physically active patients? With the onset of summer, it's timely to explore solutions and tools—from water resistance to connectivity—that may best serve these patients in leading active and healthy lives.
PATIENT-CENTERED CARE FOR SPORTS AND FITNESS
To start the game clock of care with patients, audiologists need to understand the role of sports and physical fitness in their patients’ lifestyle. Joseph Montano, EdD, director of audiology and speech language pathology at Weill Cornell Medical College, explained that “if someone plays tennis, and he or she is having difficulty hearing on the court, it's a part of his or her life I have to address.”
Asking patients open-ended questions form the backbone of patient-centered care (Hearing Journal. 2017;70:36). In contrast, questions that require a yes or no answer—such as, “Do you have any problem hearing in restaurants?”—limit insights into a patient's needs. “The patient answers yes or no, and the discussion ends there,” said Montano. “Unless you ask open-ended questions, you will not engage the patient in a dialogue.”
Audiologists often object that they lack the time to coach. “Get rid of the audiogram!” Montano responded. By that provocative declaration, he meant that audiologists should spend far less time talking about the audiogram and more time probing about the patient's needs.
The resulting dialogues with patients often reveal a need to participate in sports and stay physically fit despite the challenges associated with wearing hearing aids while engaging in physical activities.
DUST AND SAND
Cyclers who go off-road, gardeners who weed in dusty soil, and equestrians who ride outdoors all kick up dust. Beachgoers expose their hearing aids to sand. For these patients, experienced audiologists recommend selecting a hearing aid with the highest IP rating for protection from solids.
“I always ask the manufacturers, what's your IP rating? I'm really going to test that,” said 1st Lt. Patrick Pead, AuD, hearing program manager at Fort Leonard Wood Army. “In an operational training environment, there is dirt, sand, mud, small particulates like gunpowder residue, and flying debris from explosions. That all adds up to a lot of stress on the hearing aid.”
IP stands for Ingress Protection, with ingress meaning a place of access or an entrance. The IP rating has two digits: The first digit represents how immune the hearing aid is to ingress from solids such as dust and sand, and the second digit from liquids such as water (more on water resistance below).
One of Pead's recent patients was a female soldier with an untreated, bilateral, moderate-to-severe hearing loss. “She was the top performer in push-ups, sit-ups, and running, but she was having trouble hearing her instructor in the classroom and in outdoor training. That discouraged her, and she did not want to continue as a soldier,” Pead said. “We got her an open fit. My primary goal was for her to excel in the classroom.” Pead paused for a moment, then flashed a smile. “She ended up making it all the way through.”
Since the IP Rating is an independent standard monitored by the International Electrotechnical Commission (IEC), audiologists may use the rating to assure patients that they may safely expose their hearing aids to dust or sand. The behind-the-ear (BTE) aids and receiver-in-canal (RIC) aids in Table 1 and invisible-in-the-canal (IIC) hearing aids in Table 2 are dust-protected or dust-tight.
Runners, yoga practitioners, and basketball players subject their hearing aids to heavy sweating. Soami Santiago de Snyder, PhD, a professor at the University of Puerto Rico and clinical director of Instituto De Audiologia Avanzada, fits hearing aids with the highest IP Rating for liquids for athletes who sweat profusely. For one of her student-athlete patients who runs, Santiago de Snyder also prescribed a dehumidifier and a small sock over the hearing aid to absorb sweat.
All the hearing aids shown in Tables 1 and 2 are water-resistant. Starkey Hearing Technologies, for example, accomplishes water resistance “with inspiration from the water repellent phenomena found in plants, such as the lotus,” explained a company audiologist.
Water-resistant hearing aids provide protection from rain, sweat, or the occasional splash, but what about water activities such as boating or sailing? Oticon, Sonova, Starkey, and Widex spokespeople all firmly maintained that their hearing aids are not for use in any water activities. Sivantos, however, has a different perspective. Since all Signia BTE/RIC aids were “completely submerged in water up to three feet for 30 minutes” in a test environment, explained a company executive, “we are comfortable recommending our devices for boating, sailing, and strenuous sports.” ReSound and Earlens executives also confirmed that their hearing aids shown in Tables 1 and 2 may be worn for boating and sailing.
In addition to being water-resistant, some of the hearing aids shown in the tables offer direct connectivity to a mobile device, a feature particularly valued by the sports and fitness segment. The ReSound LiNX, for example, “allows for direct streaming with Made for iPhone connectivity and no intermediary device needed, turning these hearing instruments into wireless stereo headphones for music, audiobooks, calls, and more,” explained a company representative.
Audiologists question why the industry currently lacks a waterproof hearing aid, when waterproof versions of other electronic devices also powered by batteries, such as watches, have been available for years. The difference comes in the hearing aids’ battery door, explained a Sonova research executive. Over time, frequent use of the battery compartment wears down the hearing aid's seal against water. To achieve complete waterproofing, “the hearing instruments need to be better sealed, achieved with a rechargeable solution that is completely sealed,” he added.
HELMETS AND MOVEMENT
Hockey, lacrosse, and football players struggle when their helmets press uncomfortably on their BTE/RIC hearing aids or snag the wires connecting device to receiver. One solution audiologists employ is to fit athletes with in-the-canal (ITC) or even completely-in-canal (CIC) devices, as Montano did for a baseball player with mild hearing loss who was just starting college. “He really just wanted amplification for sports and his classes. We wound up getting him CIC technology,” Montano shared. “And he has expanded his use to social events like parties and dinners.”
However, in the case of Linda A. Vasile, AuD, of the Hearing Health & Wellness Center in Plantsville, CT, her patient was an 11-year-old boy who played ice hockey. “Since he was still growing, I wanted to go with BTE so I could just change the molds as he grew,” she explained. With the helmet's ear protection inconveniently covering the microphones on his hearing aids, the situation called for ingenuity. Vasile worked with the student's parents to have crescent moons cut out of the helmet's fiberglass, corresponding to the location of the aids’ external microphones. “He could hear his coach, but his ears were still protected,” she concluded.
A related patient difficulty is movement, such as the bouncing motion from running or sudden movements when dancing or playing basketball. Here again, ITC hearing aids are a useful solution. For patients who nonetheless prefer a BTE/RIC device, Vasile recommends a sweatband to hold the aids in place.
When Santiago de Snyder works with children, she often relies on a product called Huggie Aids, which attaches to the aid and loops around the ear. “They really help position the aid stably,” she said.
External microphones on BTE/RIC hearing aids can make wind sound like a small tornado, leaving sports enthusiasts such as cyclers, sailors, and sprinters feeling overwhelmed by the onslaught of sound. Audiologists may recommend an ITC device.
The next best solution is to include a program on the BTE/RIC hearing aid that manages wind interference, which all the aids in Table 1 offer. The Widex Beyond series, for example, “analyzes the sound from the two microphones in each hearing aid,” said a company audiologist, subtracting “the wind noise from the signal in the microphone.”
Earlens, a new hearing device company that offers a light-driven hearing aid, provides added protection against wind. Like the products of the six major hearing aid companies, the Earlens device scans for turbulent flows in the sound signal and reduces the gain associated with that portion of the signal. In addition, the photon processor, which looks and fits like a large BTE device, contains a “microfiber screen that provides a smooth surface for wind to pass over without turbulence,” explained a company audiologist.
Earlens is an option for audiologists who are in practice with an ENT physician. The product's lens, which vibrates based on received light signals, fits over the tympanic membrane like a contact lens over the eye and needs to be inserted by an ENT physician in a 15-minute procedure.
Athletes often strain to hear their coaches, who stand on the side of the field or the ball court. One such patient was a high school girl who played varsity baseball whose outfield position was far from the coach. Her audiologist, Thumper Johnson, from Mid-Kansas Ear, Nose, and Throat Associates, fitted this student athlete with a streamer, and the coach wore the microphone device around his neck during practices and games. “This gave her the ability to hear her coach give directions,” Johnson said. “I put streamers on almost everybody,” she added. “It gives my patients connectivity in so many situations.”
Many patients who exercise maintain a strong identity of themselves as active and fit, in direct opposition to stereotypes that people with hearing loss are sedentary. IIC hearing aids, therefore, have a special appeal for the sports and fitness segment of the market. Table 2 lists suitable IIC devices.
Fit is one of the primary hurdles for an audiologist recommending an IIC. “Typically, small ears that have a narrow ear canal and strong bends are more challenging,” advised an executive from Phonak U.S. However, with the company's new Virto B-Titanium's shell half as thin as traditional shells, the product's fit rate has increased by 64 percent from previous generations of IICs.
Oticon reported a fit rate of 70 percent for its Alta 2 Pro if the aid does not contain wireless capability. An Oticon manager explained that the easiest ear to fit has “a reasonable opening of the ear canal and a long canal with nice definition of the first and second bend. A canal that is too curvy may be difficult to make as a true IIC. Canals that are too straight will have issues with retention.”
Although not listed in Table 2 because it is a CIC, Sivantos’ Silk merits mention because it is off-the-shelf and doesn't require a custom fit. “A silicon sleeve, which comes in three sizes, clicks onto the back of the hearing aid,” explained a company representative. “You can squeeze the sleeve, which makes for a snug fit.”
Also not included in Table 2 because it does not have an IP rating is the Phonak Lyric, an extended wear device, which sits deep in the canal. Patients may exercise and shower wearing the device.
Although swimmers may need to tread water for a while until the industry produces a waterproofed hearing aid, the current advances in hearing technology, along with patient-centric solutions, hold promise in empowering people with hearing impairment to enjoy active lifestyles.