Pharmacological Enhancement of Aural Habilitation in Adult Cochlear Implant Users

Analysis of Outcome Domains in Adult Cochlear Implantation: A Systematic Review

OBJECTIVES

To determine the breadth of outcome domains used in the reporting of adult cochlear implant surgery for the purpose of registry and quality measure development.

DATA SOURCES

Systematic review of randomized controlled trials.

REVIEW METHODS

In consultation with a medical librarian, search strategies were constructed to identify randomized controlled trials studying adults undergoing cochlear implantation. MEDLINE, EMBASE, Scopus, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and the Database of Abstracts of Reviews of Effects were searched from database inception to July 2015. Studies were evaluated for level of evidence and risk of bias with the Cochrane Collaboration's Risk of Bias Tool, and outcome domains were extracted from each study.

RESULTS

Of 4473 unique citations found, 8 studies were included in this review. All 8 trials were evidence level 1B. Risk of bias was low in 2 trials and high in the other 6. Reported outcome domains included speech perception in quiet and noise, speech tracking, quality of life, timbre perception, hearing preservation, vestibular function, electrode insertion technique, functional measures, functional imaging, fitting time, and tinnitus.

CONCLUSIONS

An analysis of randomized controlled trials studying cochlear implantation in adults yielded a wide spectrum of outcome domains. This is the first study to comprehensively describe the breadth of outcome domains in adult cochlear implantation. Validated instruments from these domains could be considered for potential inclusion as quality measures and registry use.

Pairing Speech Sounds With Vagus Nerve Stimulation Drives Stimulus-specific Cortical Plasticity

BACKGROUND

Individuals with communication disorders, such as aphasia, exhibit weak auditory cortex responses to speech sounds and language impairments. Previous studies have demonstrated that pairing vagus nerve stimulation (VNS) with tones or tone trains can enhance both the spectral and temporal processing of sounds in auditory cortex, and can be used to reverse pathological primary auditory cortex (A1) plasticity in a rodent model of chronic tinnitus.

OBJECTIVE/HYPOTHESIS

We predicted that pairing VNS with speech sounds would strengthen the A1 response to the paired speech sounds.

METHODS

The speech sounds 'rad' and 'lad' were paired with VNS three hundred times per day for twenty days. A1 responses to both paired and novel speech sounds were recorded 24 h after the last VNS pairing session in anesthetized rats. Response strength, latency and neurometric decoding were compared between VNS speech paired and control rats.

RESULTS

Our results show that VNS paired with speech sounds strengthened the auditory cortex response to the paired sounds, but did not strengthen the amplitude of the response to novel speech sounds. Responses to the paired sounds were faster and less variable in VNS speech paired rats compared to control rats. Neural plasticity that was specific to the frequency, intensity, and temporal characteristics of the paired speech sounds resulted in enhanced neural detection.

CONCLUSION

VNS speech sound pairing provides a novel method to enhance speech sound processing in the central auditory system. Delivery of VNS during speech therapy could improve outcomes in individuals with receptive language deficits.

Effects of L-dopa during auditory instrumental learning in humans

The dopaminergic neurotransmitter system is critically involved in promoting plasticity in auditory cortex. We combined functional magnetic resonance imaging (fMRI) and a pharmacological manipulation to investigate dopaminergic modulation of neural activity in auditory cortex during instrumental learning. Volunteers either received 100 mg L-dopa (Madopar) or placebo in an appetitive, differential instrumental conditioning paradigm, which involved learning that a specific category of frequency modulated tones predicts a monetary reward when fast responses were made in a subsequent reaction time task. The other category of frequency modulated tones was not related to a reward. Our behavioral data provides evidence that dopaminergic stimulation differentially impacts on the speed of instrumental responding in rewarded and unrewarded trials. L-dopa increased neural BOLD activity in left auditory cortex to tones in rewarded and unrewarded trials. This increase was related to plasma L-dopa levels and learning rate. Our data thus provides evidence for dopaminergic modulation of neural activity in auditory cortex, which occurs for both auditory stimuli related to a later reward and those not related to a reward.

Cochlear implants matching the prosthesis to the brain and facilitating desired plastic changes in brain function

The cochlear implant (CI) is one of the great success stories of modern medicine. A high level of function is provided for most patients. However, some patients still do not achieve excellent or even good results using the present-day devices. Accumulating evidence is pointing to differences in the processing abilities of the "auditory brain" among patients as a principal contributor to this remaining and still large variability in outcomes. In this chapter, we describe a new approach to the design of CIs that takes these differences into account and thereby may improve outcomes for patients with compromised auditory brains.

Norepinephrine homogeneously inhibits alpha-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate- (AMPAR-) mediated currents in all layers of the temporal cortex of the rat

The primary auditory cortex is subject to the modulation of numerous neurotransmitters including norepinephrine (NE), which has been shown to decrease cellular excitability by yet unclear mechanisms. We investigated the possibility that NE directly affects excitatory glutamatergic synapses. We found that bath applications of NE (20 microM) decreased glutamatergic excitatory post-synaptic currents (EPSCs) in all cortical layers. Changes in the kinetics of synaptic EPSCs, invariance of pair pulse ratio and of the coefficient-of-variation, together with the decrease of responses to pressure-application of AMPA (500 microM), indicated the postsynaptic nature of the adrenergic effect. Pharmacological experiments suggested that the NE-induced depression of EPSCs is caused by the activation of alpha1 adrenoceptors, PLC, and a Ca(2+)-independent PKC. We speculate that the decrease in temporal cortex excitability might promote a posterior-to-anterior shift in cortical activation together with a decrease in spontaneous background activity, resulting eventually in more effective sensory processing.

Technologic advances in aural rehabilitation: applications and innovative methods of service delivery

The level of interest in aural rehabilitation has increased recently, both in clinical use and in research presentations and publications. Advances in aural rehabilitation have seen previous techniques such as speech tracking and analytic auditory training reappear in computerized forms. These new delivery methods allow for a consistent, cost-effective, and convenient training program. Several computerized aural rehabilitation programs for hearing aid wearers and cochlear implant recipients have recently been developed and were reported on at the 2006 State of the Science Conference of the Rehabilitation Engineering Research Center on Hearing Enhancement at Gallaudet University. This article reviews these programs and outlines the similarities and differences in their design. Another promising area of aural rehabilitation research is the use of pharmaceuticals in the rehabilitation process. The results from a study of the effect of d-amphetamine in conjunction with intensive aural rehabilitation with cochlear implant patients are also described.

What matched comparisons can and cannot tell us: the case of cochlear implants

OBJECTIVES

To examine the conclusions and possible misinterpretations that may or may not be drawn from the "outcome-matching method," a study design recently used in the cochlear implant literature. In this method, subject groups are matched not only on potentially confounding variables but also on an outcome measure that is closely related to the outcome measure under analysis. For example, subjects may be matched according to their speech perception scores in quiet, and their speech perception in noise is compared.

DESIGN

The present study includes two components, a simulation study and a questionnaire. In the simulation study, the outcome-matching method was applied to pseudo-randomly generated data. Simulated speech perception scores in quiet and in noise were generated for two comparison groups, in two imaginary worlds. In both worlds, comparison group A performed only slightly worse in noise than in quiet, whereas comparison group B performed significantly worse in noise than in quiet. In Imaginary World 1, comparison group A had better speech perception scores than comparison group B. In Imaginary World 2, comparison group B had better speech perception scores than comparison group A. The outcome-matching method was applied to these data twice in each imaginary world: 1) matching scores in quiet and comparing in noise, and 2) matching scores in noise and comparing in quiet. This procedure was repeated 10,000 times. The second part of the study was conducted to address the level of misinterpretation that could arise from the outcome-matching method. A questionnaire was administered to 54 students in a senior level course on speech and hearing to assess their opinions about speech perception with two different models of cochlear implant devices. The students were instructed to fill out the questionnaire before and after reading a paper that used the outcome-matching method to examine speech perception in noise and in quiet with those two cochlear implant devices.

RESULTS

When pseudorandom scores were matched in quiet, comparison group A's scores in noise were significantly better than comparison group B's scores. Results were different when scores were matched in noise: in this case, comparison group B's scores in quiet were significantly better than comparison group A's scores. Thus, the choice of outcome measure used for matching determined the result of the comparison. Additionally, results of the comparisons were identical regardless of whether they were conducted using data from Imaginary World 1 (where comparison group A is better) or from Imaginary World 2 (where comparison group B is better). After reading the paper that used the outcome-matching method, students' opinions about the two cochlear implants underwent a significant change even though, according to the simulation study, this opinion change was not warranted by the data.

CONCLUSIONS

The outcome-matching method can provide important information about differences within a comparison group, but it cannot be used to determine whether a given device or clinical intervention is better than another one. Care must be used when interpreting the results of a study using the outcome-matching method.

Audiologic management of older adults with hearing loss and compromised cognitive/psychoacoustic auditory processing capabilities

The number and proportion of older adults in the United States population is increasing, and more clinical audiologists will be called upon to deliver hearing care to the approximately 35% to 50% of them who experience hearing difficulties. In recent years, the characteristics and sources of receptive communication difficulties in older individuals have been investigated by hearing scientists, cognitive psychologists, and audiologists. It is becoming increasingly apparent that cognitive compromises and psychoacoustic auditory processing disorders associated with aging may contribute to communication difficulties in this population. This paper presents an overview of best practices, based on our current knowledge base, for clinical management of older individuals with limitations in cognitive or psychoacoustic auditory processing capabilities, or both, that accompany aging.

Cortical plasticity and rehabilitation

The brain is constantly adapting to environmental and endogenous changes (including injury) that occur at every stage of life. The mechanisms that regulate neural plasticity have been refined over millions of years. Motivation and sensory experience directly shape the rewiring that makes learning and neurological recovery possible. Guiding neural reorganization in a manner that facilitates recovery of function is a primary goal of neurological rehabilitation. As the rules that govern neural plasticity become better understood, it will be possible to manipulate the sensory and motor experience of patients to induce specific forms of plasticity. This review summarizes our current knowledge regarding factors that regulate cortical plasticity, illustrates specific forms of reorganization induced by control of each factor, and suggests how to exploit these factors for clinical benefit.