Audacity Issue 4 by Audacity magazine

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Audacity ...a British Society of Audiology Publication issue 4 August 2014 ................................

Online access

28 Psychoacoustics and beyond

w ne

bsa

website

www.thebsa.org.uk

A trip to Bangladesh

explores new ideas

60 New website for the BSA www.thebsa.org.uk

resources .................................

audacity@thebsa.org.uk www.thebsa.org.uk

British Society of Audiology KNOWLEDGE | LEARNING | PRACTICE | IMPACT

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Editorial

elcome to the 4th edition of Audacity. We are one year old and maturing nicely. The publication of this issue coincides with the BSA annual conference in Keele. Organised for a second year by David Furness and his team, we hope that all attendees at the conference have a rewarding and stimulating time and return to their clinics or research and educational centres with renewed enthusiasm for hearing science. At the conference there will be presentations that include psychoacoustics. Is psychoacoustics like Marmite for you? Do you love it or loathe it? If you are in the latter camp then Chris Plack’s excellent introduction to psychoacoustics in Research Round-up and its use in interesting and highly relevant research projects will, I am sure, be your time of conversion. Chris also describes how combining psychoacoustic and electrophysiological techniques can lead to insights that would not be possible with either technique alone. The Featured Articles section has two contributions that focus on how patients think about their hearing condition and what their emotional requirements are.Teresa Czajka argues that audiology professionals have a key role in supporting the emotional needs of patients, which can help to minimise the impact of hearing loss and balance disorders and ensure successful rehabilitation with improved outcomes. In her article, Lucy Handscomb focusses on the role of thinking in tinnitus which is now considered to be a central component of tinnitus distress. The impact of hearing loss on cognitive decline is also covered within Featured Articles. Piers Dawes examines the evidence that hearing aid use could have an important role in reducing disability, and this may be important in the context of cognitive impairment. In their article in the Clinical Catch-up Section, Ruth Brooke and her colleagues from Leeds argue that “moderate-medicalisation” may be the way forward for NHS hearing aid services. Their article is thought provoking and timely:- it is supported by the recent

Martin O’Driscoll Editor-in-Chief On behalf of the editorial team E: martin.odriscoll@cmft.nhs.uk

publication from the International Longevity Centre UK of the ‘Commission on Hearing Loss’ www.ilcuk.org.uk which is critical of the over medicalised nature of hearing services. Within this issue, Kevin Munro delivers his final message as Chairman. Kevin has had the vision and drive to make a significant positive impact to the BSA during his time in office and he was instrumental in the formation of this publication. The editors congratulate him on his many achievements and we wish him well for the future. Our next Chairman is Huw Cooper and we look forward to working with him and receiving his first message that will be published in the December edition. The editors thank all those who contributed to this edition. Please look out for the interactive pdf that will be available soon. Also visit our section on the new BSA website www.thebsa.org.uk

from the editor

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Contents 3

meet the editorial team...

Editorial Martin O’Driscoll

Chairman’s Message Kevin Munro

SIG Segment information and updates from BSA Special Interest Groups Section Editor: Martin O’Driscoll / E: martin.odriscoll@cmft.nhs.uk

Martin O’Driscoll E: martin.odriscoll@cmft.nhs.uk

Knowledge Learning Practice Impact information and updates from the BSA Professional Practice Committee (PPC) and the Learning and Events Group (LEG) Section Editor: Rachel Booth / E: rachel.booth@cmft.nhs.uk

Featured Articles expert writing about topical areas in audiology Section Editors: Martin O’Driscoll / E: martin.odriscoll@cmft.nhs.uk Rachel Booth / E: rachel.booth@cmft.nhs.uk

Rachel Booth E: rachel.booth@cmft.nhs.uk

Research Round-up a spotlight on major ongoing research projects in the Audiology community worldwide. Section Editor: Rachel Hopkins / E: rachel.hopkins@cmft.nhs.uk

Dion Jones E: dion.jones@cmft.nhs.uk

Lunch & Learn a summary of the latest bite size online seminars for you to get your teeth into! Section Editor: Shahad Howe / E: shahad.howe@cmft.nhs.uk

Audacity is published by: The British Society of Audiology 80 Brighton Road, Reading, RG6 1PS, UK. E: audacity@thebsa.org.uk | W: www.thebsa.org.uk Design: Pinpoint Scotland Ltd

E: audacity@thebsa.org.uk

Jenny Griffin E: jenny.griffin@cmft.nhs.uk

W: www.thebsa.org.uk

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welcome to

Audacity ....a British Society of Audiology Publication

meet the editorial team...

38 Ear to the Ground a guide to all things Ear-related in the mediaâ&#x20AC;Ś Section Editor: Dion Jones / E: dion.jones@cmft.nhs.uk

44 Ear Reach find out about the latest charity and humanitarian work going on within audiology, both in the UK and abroad, with some opportunities for you to get involved. Section Editor: Jenny Griffin / E: jenny.griffin@cmft.nhs.uk

Rachel Hopkins E: rachel.hopkins@cmft.nhs.uk

48 Clinical Catch-up Short articles on relevant clinical topics Section Editor: Rachel Hopkins / E: rachel.hopkins@cmft.nhs.uk

54 Hearsay News from Regional Groups and BSA Members Section Editor: Danny Kearney / E: danny.kearney@cmft.nhs.uk

Shahad Howe E: shahad.howe@cmft.nhs.uk

Essentials Key information for the membership Section Editor: Danny Kearney / E: danny.kearney@cmft.nhs.uk

Danny Kearney E: danny.kearney@cmft.nhs.uk The British Society of Audiology publishes Audacity as a means of communicating information among its members about all aspects of audiology and related topics. Audacity accepts contributions, features and news articles concerning a wide range of clinical and research activities. Articles typically emphasise practical rather than theoretical material. Audacity welcomes announcements, enquiries for information and letters to the editor. Letters may be in response to material in Audacity or may relate to professional issues. Submissions may be subject to editorial review and alteration for clarity and brevity. Please email audacity@thebsa.org.uk for further information. Audacity is published in April, August and December. Contributions should preferably be emailed to: audacity@thebsa.org.uk or sent to; The Editor, Audacity, 80 Brighton Road, Reading, RG6 1PS. Views expressed in Audacity do not necessarily reflect those of The British Society of Audiology, or of the editors. The Society does not necessarily endorse the content of advertisements or non-Society documents included with their mailings.The Society reserves the right to refuse to circulate advertisements, without having to state a reason.

W: www.thebsa.org.uk

E: audacity@thebsa.org.uk

Julie Reading E: julie.reading@cmft.nhs.uk

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chairman’s message

Chairman’s Message Transforming BSA: progress means new challenges Sir James Jones, donated part of his estate (around £4 million in today’s money) to the University of Manchester in order to: (1) establish the first university-based programme for teachers of the deaf, and (2) undertake research into childhood deafness.

Kevin J Munro Chairman

The origins of international paediatric audiology can be traced to the death of a young man one hundred years ago. Ellis Llwyd Jones (1874-1918), son of a prominent businessman in the Manchester cotton industry, had been deaf since birth. Ellis insisted on joining the British army during World War One but was barred from active duty because of his deafness and, instead, worked in a canteen. In 1918 he caught a serious illness, possibly typhus, and was invalided back to Britain. He died in February of that year. He left no will when he died but his father,

Irene Rosetta Goldsack 1883 - 1959

In 1919, Irene Rosetta Goldsack was appointed as the first lecturer in deaf education. In 1920, Alexander William Gordon Ewing enrolled in her one-year Diploma programme. One assumes that Irene Goldsack and Alexander Ewing had much in common, both professionally and personally, because they married the following year. This was the start of a formidable partnership in the history of paediatric audiology and deaf education. Irene Ewing was awarded an OBE in 1947 and Alexander Ewing was knighted in 1958, both for their services to audiology and deaf education. The Ewings were responsible for the fundamental principles of paediatric audiology: (i) procedures for hearing assessment in preschool children, (ii) involving the family in intervention programmes, and (iii) recognising the importance of early identification and intervention.To the Ewings, ‘early’ intervention meant ‘preschool’ intervention. With the advent of the new-born screening programme (NHSP), rolled out across England 10 years ago, the age that hearing aids are prescribed and fitted to

Alexander William Ewing 1897 - 1980

Sir Alexander and Lady Irene Ewing: a formidable partnership in the history of paediatric audiology and deaf education

chairman’s message

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chairman’s message

7 Importance of early involvement of family

Importance of early id & intervention

Procedures for hearing assessment in babies & children

Ewing legacy: the fundamental concepts of paediatric audiology

infants has been drastically reduced. Prior to the introduction of NHSP, the typical age that hearing aids were prescribed and fitted was around 15-18 months: this has now been reduced to 2-3 months (Sally Wood, personal communication). This reduction in age is outstanding; however, progress means new challenges. For example, challenges for: • • •

Families, when there is little behavioural evidence that the infant is receiving benefit educational professionals, who provide family support, and health care professionals, who prescribe hearing aids with limited assessment data

Despite the challenges associated with NHSP, few, if any, individuals would deny that it has been an unqualified success. Although on a much smaller scale, the transformation of BSA represents tremendous progress but this too has brought challenges.

‘The transformation of BSA represents tremendous progress but this too has brought challenges’ Evidence of progress The progress of BSA has been guided by our first annual action plan, which covered the 12 month period to June 2014. The idea behind the Action Plan was very simple: we would identify and list our priorities for the coming 12 months so that we would move forward with purpose. Otherwise, it might be all too easy to drift and drown on the day-today activities of running the Society. We have used the Action Plan as a tool to help us work strategically and to use our time most efficiently. In June of this year, we reviewed the Action Plan along with the individual plans for each of our committees and Special Interest Groups (SIGs).

In no particular order, examples of recent successes from the first Action Plan include the: 1. 2.

new BSA website, coordinated by Nicci Campbell new Audacity magazine for members, edited by Martin O’Driscoll 3. new Hearing and Cognition SIG, led by Piers Dawes 4. new Electrophysiology and Hearing SIG, led by Siobhan Brennan 5. new Learning Events Group, led by Melanie Ferguson 6. new ‘Lunch and Learn’ eSeminars and ‘Lightning Updates’, led by Shahad Howe 7. new position of Operations Manager (currently being advertised) 8. refreshed ‘BSA Advisory Role’, led by John Day 9. additional Recommended Procedure and Good Practice documents, led by Paul James 10. adoption of Social Media, led by Helen Pryce and Charlotte Turtle 11. resurrection of BSA North, led by Kath Lewis 12. increased advisory role e.g., an invitation to act as a commissioner for the International Longevity Centre-UK report on age-related hearing loss; steering committee of GENERATE which will identify the UK research priorities for ENT and audiology; policy evaluation of AQP for MONITOR

Council members reviewing the annual plan and identifying the next priorities

chairman’s message

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chairman’s message

8 I am sincerely grateful to Council for their contribution to our recent achievements. The drive required to bring about these changes is a reflection of what Daniel Pink calls ‘intrinsic motivation’: the reward and pleasure from succeeding at the task (Pink, 2011). Some of the new developments are captured in the BSA pyramid of activities, shown below. By making our progress transparent, a process that is long overdue, you have been able to monitor our successes and failures. Only the most ungenerous of individuals could deny that Trustees have made outstanding progress over a relatively short period of time. However, success can be dangerous. A quotation that is attributed to Andrew Grove (author and scientist) reads as follows: Success breeds complacency and complacency breeds failure.

the format and structure of the annual conference, and engaging with membership. These challenges, and more, will require the Trustees to maintain strategic vision, to articulate this clearly to you, and to work relentlessly towards a sustained transformation to BSA. And, of course, we should accept that Trustees are human and will sometimes make mistakes while taking ‘healthy risks’. The smart thing to do (although it is much more difficult than it sounds) is to learn from the mistakes of others before we are confronted with similar challenges ourselves (Weinzimmer and McConoughey, 2013).

Success breeds complacency and complacency breeds failure

The smart thing to do is to learn from the mistakes of others before we are confronted with similar challenges ourselves

(Andrew Grove)

(Weinzimmer and McConoughey)

Challenges The recent successes of the Trustees have taken place in the context of significant challenges to the Society. Over the past few years there has been: (1) unprecedented and sustained upheaval to the administrative support team, (2) significant changes in membership of Council, and (3) strong pressure to contain, if not reduce, costs. Against this backdrop, there are ongoing challenges associated with articulating the ‘Unique Selling Point’ (USP) of BSA, completing the transformation to an engaged and proactive organisation, addressing concerns about

Future developments The Trustees are working towards the Action Plan for the coming 12 month period.The activities associated with publicity and communications will continue to expand and will likely include an increase in our Social Media presence, expanded support and benefits to new members and greater public involvement. We will extend our interface and networking activities by working in partnership with other organisations and professional bodies, and we will implement the BSA ‘dating agency’ that was suggested (and received with much enthusiasm) at the Innova-

ACTION PLAN Pyramid of BSA activities and structures

ADVISORY AND ADVOCACY WEBSITE

INTERNATIONAL JOURNAL OF AUDIOLOGY AUDACITY LEARNING EVENTS GROUP

RECOMMENDED PROCEDURES AND CLINICAL GUIDANCE SPECIAL INTEREST GROUPS

TRUSTEES OPERATIONS MANAGER ADMINISTRATIVE SUPPORT TEAM

chairman’s message

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chairman’s message

9 tion Forum, September 2013. Our global health activities will increase with a visit to Accra, Ghana, in order to provide advice on what is required to secure a self-sustaining education and training programme in audiology. We will also honour our commitment to increasing public engagement and social responsibility.

and exhibitors at most annual conferences. Andy has shown tremendous loyalty and dedication to BSA and we have relied on his creativity, knowledge and humour. My thanks also go to Nick Thyer who stood down from his role as Trustee earlier this year.

As well as the strategic developments listed above, there are a number of operational changes in hand including implementation of periodic reviews of our Special Interest Groups and committees, the development of a member’s Charter that articulates our values and aspirations (e.g., what is expected of members, what is expected of Trustees and what we will achieve together) and a more detailed role description for Trustees who have seen their workload increase in recent years. A major development will be the appointment of an Operations Manager.This appointment has been agreed by Council and signed off by Graham Sutton, our new Treasurer. I have discussed the role of the Operations Manager in several of my previous articles but, in summary, the Operations Manager will: develop the national and international profile of the Society, implement our annual Action Plan, meet annual targets for growth in membership and advertising income, and engage our stakeholders.

Welcome to Graham Sutton who has returned to the BSA as our Treasurer. At the Annual General Meeting in September, Huw Cooper will replace me as Chairman and Liz Midgley will become the new Vice Chair. I wish them well.

The ‘take home’ message I have been reviewing the ‘epistles’ I have written whilst being your Chairman. The six ‘take-home’ messages are that we need to: 1. articulate our ‘unique selling points’

BSA: omnipotent or impotent (Winter 2012)

2. develop and pursue a clear strategy

Carried by the current or moving with purpose (Spring 2013)

3. engage more with you and our partners

BSA and you: let’s get engaged (Summer 2013)

4. differentiate operational and strategic activities

Connect, communicate and contribute (Winter 2013)

5. embrace our strength in diversity

UK and BSA: what has held them together (Spring 2014)

6. recognise our substantial progress and acknowledge the challenges

Transforming BSA: progress means new challenges (Summer 2014)

After 20 years of service, Andy Reid stands down from his numerous roles within BSA

I have found the challenges of Chairman to be absorbing, relentless and rewarding. I appreciate the kindness and support of my colleagues and family for allowing me the freedom to undertake my BSA activities. I am looking forward to spending more time with all of them- until the itch of a new challenge becomes irresistible. As Helen Keller said: Life is either a daring adventure or nothing. And a final comment to our trusty and hardworking Council: be respectful of your role but do not be daunted. Why stop at good when you could make BSA great?

My best wishes,

And finally… On behalf of Council, I offer my sincere thanks to Andy Reid who has come to the end of his term of office. Andy has been actively involved in BSA for 20 consecutive years: Honorary Secretary (1994-2007); Chairman of the Programmes Committee (2007-2010) and Treasurer (2010-2014). During this time, he organised several annual conferences (1993 and 2002) and he has been our liaison officer with our sponsor members

Kevin J Munro kevin.munro@manchester.ac.uk Manchester June 2014 References Pink DH. (2011). Drive: the surprising truth about what motivates us. Edinburgh: Canongate. Weinzimmer LG, McConoughey J. (2013). The wisdom of failure: how to learn the tough leadership lessons without paying the price. San Francisco: Jossey-Bass.

chairman’s message

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SIG segment

SIG Segment Information and updates from BSA Special Interest Groups

BSA Special Interest Group

BSA Electrophysiology Special Interest Group Siobhán Brennan, Chair, Electrophysiology SIG

Auditory electrophysiology is a rapidly developing and multifaceted field. Following the cessation of the NHSP Clinical Advisory Group, it was clear that there continues to be a need for support for clinicians carrying out electrophysiological diagnostics for babies following the newborn hearing screen. Additionally it was recognised that there was a need to extend this work to include protocols for electrophysiological work with both adult and paediatric groups beyond the newborn period. To this end the BSA Electrophysiology SIG was formed. The first meeting was held on 27 May 2014 in Sheffield. This meeting focused on the remit and boundaries of the group.Themes emerged and areas identified where there appears to be limited support for clinicians in electrophysiological assessment. It was agreed however that scoping is required to identify the extent of existing knowledge in some areas so they can be built upon effectively.There was also a consensus that the group is not in a position to be a general forum for advice to clinicians

SIG segment

on specific cases. The goal of working closely with other SIGs to build on their expertise and avoid duplicating work was raised. Actions were then planned for the short and medium term. The aims of the EP SIG are to: • Carry out horizon scanning with respect to new developments in the field and identify areas where clinical evaluation of new techniques is required • Maintain and develop the existing NHSP test protocols and guidance (subject to agreement with the BSA Education Committee) • Provide guidance on the introduction of new or novel techniques into clinical practice • Identify areas of research need • Provide study days. It is hoped that the multidisciplinary aspect of the group will be extended so that expertise can be drawn from a range of perspectives on these techniques. The next meeting of the group will be held during the 2014 BSA conference.

For any further information please contact the group Chair, Siobhán Brennan, via email: siobhan.brennan@sth.nhs.uk

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SIG segment

11 BSA Adult Rehabilitation (ARIG) Special Interest Group Lucy Handscomb, Chair, Adult Rehabilitation (ARIG) SIG

Following our lightning update in the spring, we are delighted to be able to announce the very first ARIG event! We have secured a slot at the BSA conference in which ARIG will host a discussion forum with the title ‘Who defines rehabilitation?’ There is much talk about ‘patient choice’ and ‘patient-centred care’, but we want to really explore these concepts and their influence on both clinical practice and research.The idea of the session is to bring clinicians and researchers together to discuss their views, learn from each other and make plans for collaboration. In a series of round-table discussions – facilitated by experts in aural rehabilitation – we will focus on the topics of shared decision making, facilitating change and using outcome measures. The aim of the session is for participants to leave with a plan of action. This might be an agreement to share resources, to try out something

new and feed back to each other or to collaborate on a research project. We hope to see many of you there! Our other major plan is to conduct a survey of UK audiology services (NHS and private) to get a clearer idea of what’s really going on in terms of adult rehab. With all the current and impending changes to audiology provision, we feel it’s really important to know what the current picture is, where the gaps and inequalities are, what clinicians are concerned about and what people are doing which could serve as examples of best practice. We want to do a really good job of this, and are planning to get an experienced survey designer on board. We have just heard that our application for a BSA grant to enable us to do this has been successful! Please look out for more news of this project over the next couple of months, and make sure your department doesn’t miss out on the opportunity to contribute as it’s really important for the survey to be fully representative.

More information about ARIG and its members is available on the fantastic new BSA website.

BSA Auditory Processing Disorder (APD) Special Interest Group Pauline Grant, Chair, Auditory Processing Disorder (APD) SIG

Our main news is that both the APD Position Statement and the Management Guidelines for APD are currently being updated (thanks to Dave Moore & Nicci Campbell who are leading on this). Both documents will be available on the website as soon as possible.

Also, new information leaflets for adults and children will shortly be published on the website. Printed versions will also be available. Our main focus for the coming year is ‘Getting the message out there’ and so SIG members will be offering training to multiprofessional groups – with a particular focus on Education and enabling teachers to understand and meet the needs of children with auditory processing difficulties. In addition, a Family Awareness Day is planned for March 2015 – which Phonak has kindly offered to support – and the possibility of an ‘APD Road Show’ is under discussion.

SIG segment

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SIG segment

12 BSA Cognition in Hearing Special Interest Group Piers Dawes, Chair, Cognition in Hearing SIG

The new BSA special interest group in hearing and cognition recently turned one year old. The aim of the SIG is to promote research in and raise awareness of new developments on cognitive issues in hearing science, assessment and intervention. Here is a list of what the SIG has achieved so far: • Publicity for the SIG and its aims. After the founding meeting, a summary of the SIG’s aims was distributed to all individuals who expressed an interest in the SIG, chairs of other SIGs and the BSA council. The development of the SIG was outlined on a poster presented at the 2nd International Conference on Cognitive Hearing Science for Communication (16–19 June, Linköping, Sweden). A special event for clinicians and researchers describing the new SIG was held at the BSA Annual Conference (4–6 September 2013, Keele). Johanna Barry and Scott Richards represented the SIG at a conference stand and most of the management committee of the SIG attended. Helen Henshaw authored an article for the BSA Audacity magazine that introduced the new SIG to BSA members and described its aims. Piers Dawes also gave an online ‘Lightning update’ to introduce the new SIG (December 2013). • A web page for the SIG. The new BSA web page has information on the SIG, along with a description of its goals and an invitation to contribute. • Christian Fullgrabe and Clare Howard have developed a survey to identify issues related to cognition and hearing that are of relevance to the clinical community.The survey has been piloted with clinical audiologists and revised according to feedback received.The survey will be carried out over summer 2014, with results published in Audacity and used to inform planning of future SIG events at the next SIG meeting at the BSA annual conference (September 2014). • A discussion ‘white paper’ on “Listening effort and fatigue: what exactly are we measuring? A British Society of Audi-

SIG segment

ology Cognition in Hearing Special Interest Group” along with commentaries by leading experts in the field has been accepted for publication by the International Journal of Audiology, and will appear within the next few weeks. • A lunch and learn seminar by Dr Ariane LeplanteLevesque from Eriskholm on perceptions of age and cognitive status on hearing help-seeking (October 2013). Dr Leplante-Levesque also provided a written summary of her presentation, which was carried in Audacity issue 3 (April 2014). • An Audacity article by Dr Andrea Pittman from the University of Arizona on “Hearing loss, hearing aids and the business of childhood” which appeared in Audacity issue 3 (April 2014). • A BSA Twilight series meeting on “Hearing and Cognition: Updates in Research and Clinical Implementation” was held on 7 November 2013 in Birmingham, organised by Melanie Ferguson. An introduction was given by Scott Richards from the SIG. Speakers included Dr Douglas Beck from Oticon Inc, who spoke on issues in cognition and audition, Professor Sven Mattys from York University, speaking on cognitive demands of listening in adverse conditions and Dr Helen Henshaw from the NIHR Nottingham Hearing Biomedical Research Unit, who spoke about the benefits of auditory and cognitive training to real-world listening. Future Plans The survey of clinicians to identify areas related to hearing and cognition of particular interest will be completed over summer 2014. Survey results will be published in Audacity and will be used to plan future SIG activities. Please complete the survey when you receive it! We would welcome any new members for the SIG, and welcome any contributions or suggestions for Audacity articles and lunch and learn presentations on topics related to hearing and cognition. The SIG committee will meet at the annual BSA conference to discuss plans for 2014–15. Anyone will be welcome to attend and offer suggestions. Piers.dawes@manchester.ac.uk

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SIG segment

13 BSA Balance Interest Group (BIG) Special Interest Group Debbie Cane, Chair, Balance Interest Group (BIG) SIG

The Balance Interest Group has been hard at work organising its biennial conference: ‘Balance testing past, present and future’. This year it will be at the UCL Ear Institute in London on 7 November 2014. We have put together a varied programme of both lectures and hands-on practical workshops which we hope will appeal to clinicians of all levels of experience.There will also be a chance to see the latest in balance testing and rehabilitation equipment from manufacturers. We are delighted to welcome a truly multi-

disciplinary faculty with representation from ENT, Neurology, AV medicine, Audiology and Academia. We very much hope as many of you as possible will be able to join us. The BPPV testing protocol is nearing completion and we hope this will be on the BSA website for comment in the next few months. Please also look at the new BIG section on the BSA website. Recommendations for material to upload, e.g. BIG members research and interesting research papers, will always be well received. Please email me at Debbie.cane@royalberkshire.nhs.uk with your suggestions. In addition we are compiling a list of emails of professionals interested in balance function testing and rehabilitation.This is to help share practice and to gain others’ opinions on complex patients. If you have not asked to receive information from BIG then please email me and I will add you to the list.

BSA Balance Interest Group Conference, 7 November 2014, Ear Institute, UCL, Preliminary program: Balance testing – Past, Present & Future Program time 08:30-9:30 09:30-10:00 10:00-10:30 10:30-11:00 11:00-11:20 11:20-11:50 11:50-12:20 12:20-13:30 13:15-13:30 13:30-14:15 14:15-15:15

15:15-15:55

15:55-16:55

16:55-17:00

Lecture / Activity REGISTRATION Heroes & Villains in Balance testing Postcode lottery for dizzy patients? Advances in testing – there’s more to the ear than the Horizontal SCC! Coffee break Children have balance systems too – testing can be child’s play Vestibular regeneration & Otoprotection (the future) LUNCH & POSTERS & PARALLEL SESSIONS ALLOCATION BSA BIG AGM MEETING Lecture demonstration ‘The best use of 15mins with your patient – clinic testing in a nutshell’ Choice of 2 out of 3 Workshops arranged over 2 parallel sessions: Parallel session 1: 14:15-15:15 Parallel session 2: 15:55-16:55 Workshops session 1 Workshop 1: Hands-on practice of clinic tests with smaller groups Workshop 2: cVEMPs and oVEMPs Workshop 3: VR on a shoe string Sponsored demonstration session Innovative test equipment – vHIT & Virtual Reality (GNotometrics, Biosense, Interacoustics) + Poster session & Coffee Choice of 2 out of 3 Workshops arranged over 2 parallel sessions: Parallel session 1: 14:15-15:15 Parallel session 2: 15:55-16:55 Workshop 1: Hands-on practice of clinic tests with smaller groups Workshop 2: cVEMPs and oVEMPs Workshop 3: VR on a shoe string CLOSING STATEMENT, POSTER PRIZE & FEEDBACK

Speaker Dr Diego Kaski Dr Andrew Wilkinson Dr Jas Sandhu Dr Veronica Kennedy Professor Andy Forge

Dr Peter West

Dr Peter West, Albert Coelho, Katy Morgan Paul Radomskij, Dr Jas Sandhu, Dr Ghada Al-Malky Debbie Cane, Dr Richard Rutkowski

Dr Peter West, Albert Coelho, Katy Morgan Paul Radomskij, Dr Jas Sandhu, Dr Ghada Al-Malky Debbie Cane, Dr Richard Rutkowski Debbie Cane

SIG segment

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knowledge learning practice impact

Knowledge Learning Practice Impact BSA Professional Practice Committee (PPC) Paul James MSc Chief Audiologist NHS Clinical Leadership Fellow Chair PPC E: Paul.James@uclh.nhs.uk or p.james1@nhs.net or ppcadmin@thebsa.org.uk

We have been very busy over the last few years getting our house in order and learning to work better as a team. Unfortunately, despite a promising start against Italy, we still managed to turn in the worst World Cup performance since 1958. So England isn’t successful at football. No real news there. What we are great at however, is producing national guidance and protocols and the Professional Practice Committee (PPC) continues to work with the Special Interest Groups to produce excellent documents on behalf of the British Society of Audiology. These documents are reliable, dependable and internationally respected; so if you want to support the work of a team, why not try the Professional Practice Committee rather than the England football squad? In the International Arena, Dr Daniel Rowan, Past-Chair of the committee, was invited to speak at the 2nd Arab Hearing Health Conference at the Dead Sea in Jordan, which is organised by the Advanced Arab Academy of Audiology (4A). This is a new organisation formed in 2012 and covers the whole region. He was invited to talk about the work of the PPC and education in audiology in the UK. 4A will be in discussion with the BSA Chair and there may be a potential for joint meetings or adoption of our protocols in future, as decided by the Chair and Council. Moreover, the international profile of the BSA remains high. We remain active on our work to achieve NICE accreditation (see previous PPC updates) and are making good

progress. Our Short Courses sub-committee is also busy. Having a stamp of approval from as highly a respected organisation as the BSA is clearly of value to course providers and offers some assurance to potential students that the course meets our minimum standards. Our documents are available on the new BSA website under “Resources”. The keen-eyed of you will have spotted that the final version of the “Visual Reinforcement Audiometry for Infants Recommended Procedure” will be out soon. As I type, the “Recommended Procedure for Vestibular Assessment – Eye Movement Recordings” is out for consultation. As always, a big “thank you!” to everyone who takes the time to help us with the consultation process. On the website, a link to the Professional Practice Committee can be found under “Groups”. We are always looking for ways to improve our page and tailor it to your needs and we would welcome any feedback from you particularly on things like what you would like to see on our page that isn’t there, or how we can make it better. We would like the site to be the point of reference for all audiologists and easy to navigate.To give feedback either follow the links on the page or email ppcadmin@thebsa.org.uk. At the BSA Conference this year we invite you to hear more about what we do as a committee and how you can get involved. The work we do is incredibly rewarding and not only improves the quality of care for our patients, but also helps improve the working lives of all audiologists – including you!

TO JOIN THE BSA PPC

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So come along, get involved, and help us improve audiology! We do still have some vacancies for the committee, so if you want to get involved or want to nominate a BSA member who you think should be involved, or just want further information about us, please contact us on ppcadmin@thebsa.org.uk and we’ll be happy to help.

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15 BSA Learning and Events Group Update Mel Ferguson Learning and Events Group Lead E: melanie.ferguson@ nottingham.ac.uk

Since the formation of LEG last summer there has been increasing activity and co-ordination on the BSA events front. One new development has been the BSA Journal Club (JC). This was recently revived (the first one was held previously in Cambridge a few years ago), and a very successful 2nd JC was held in Nottingham in May.The JC reviewed three journal articles on Adult Hearing Screening with each paper led by an invited tutor (Cherilee Rutherford, Lorraine Gailey, John Day). The informal, friendly atmosphere led to all the attendees, tutors and organisers participating in a very stimulating, lively and enthusiastic discussion of each paper. Not only was it informative and educational, it was fun! (for more details, see articles in this edition). A repeat JC on Adult Hearing Screening will be held at the BSA Annual Conference at Keele. LEG intends to run the JC twice a year in at least two different locations across the UK for each subject to maximise accessibility to members. The next JC will be on another hot topic, Dementia and Hearing. On the theme of accessibility, and following from the wellattended Twilight Series evening meeting on Hearing and Cognition held in Birmingham in November, the second meeting was held in Manchester in June on the ever developing and exciting field of implantable devices. Speakers from clinical and research organisations covered a range of surgical, scientific and clinical updates. The meeting saw lots of networking and a healthy discussion, chaired by Martin O’Driscoll. Roll on the next Twilight meeting, which is being planned for towards the end of the year. There are a couple of SIG events planned. PAIG’s 14th annual 2014 conference on conductive hearing loss, held this year in Birmingham for a change, is imminent at the time of writing (though long gone for all the many readers who will be making this article a must-read!). BIG has been superorganised, with a full programme for their biennial conference held in November already arranged and on the BSA website with five months to go.The BIG conference includes both talks and workshops and if BIG’s conference is anything as good as their organisational abilities, this should be great! There are a few other meetings being planned, one of which is an econference currently being scoped. LEG members recently got a tour around the iCohere conference facilities, which looks a promising platform.

Lunch and Learn e-seminars continue with contributions from increasingly high profile speakers. The antipodean influences from earlier this year remain unabated with Wayne Wilson from Queensland University stepping in graciously at the last minute to cover an unforeseen circumstance and an autumn date with Harvey Dillon from the National Acoustic Laboratory, Sydney. The ‘to invite’ list is looking good. And for up-to-date news from the BSA, the lightning updates just keep on coming. There’s even one on BSA events. The Annual Conference to be held at Keele University in September, will be almost upon us by the time this edition is published.The conference committee, ably led by local organiser Dave Furness, has engaged in some forthright exchanges in our bid to ensure the conference meets the needs of attendees from both clinical and research communities, which comprise, rather surprisingly, roughly 50:50 BSA members and BSA non-members. There are some excellent invited speakers who will contribute as either keynote speakers or as part of the ‘From Hair Cells to Hearing’ and Biobank symposia. To ensure that attendees get the most out of the highly valued poster sessions, which are the main event for many attendees, there has been a considerable effort expended to ensure substantial dedicated poster time with limited competition from parallel sessions. BSA special interest groups (APD, ARIG, BIG and the PPC) all have sessions, which range from oral presentations to interactive group activities. So like a house party, the organisers have laid on the place, the entertainment (i.e. the programme) and invited some great guests - to make this a swinging event, (in hearing science and clinical terms of course) the rest is up to those who attend. Finally, for an event that deserves a special mention, we’d like to congratulate Shahad on the birth of her lovely little girl. For all the details of upcoming events, go to the fabulous new BSA website (www. thebsa.org.uk).

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Some thoughts about thinking in tinnitus CD

Author and Correspondence Lucy Handscomb, MSc Chair, BSA Adult Rehab Interest Group UCL Ear Institute and NIHR Nottingham Hearing Biomedical Research Institute Correspondence: UCL Ear Institute, 332 Gray’s Inn Road, London, WC1X 8EE E: l.handscomb@ucl.ac.uk Take home message Our current understanding of tinnitus distress sees thinking as crucially important, but not enough is understood about what and how tinnitus patients think. As clinicians who work with tinnitus patients, it’s not an issue we can ignore.

If you have been to any kind of tinnitus course over the past 7 or 8 years, you probably have at least a passing familiarity with Laurence McKenna’s cognitive model of tinnitus [1]. My familiarity with it is more than passing, as it is the topic of my PhD. As its name suggests, the lynchpin of this model is cognition. If you were to make a 3D model of the diagram below out of cardboard and string (as I have considered doing while in student procrastination mode) and then completely detach the ‘negative automatic thoughts’ box, the rest would collapse in a satisfying heap. Cognition is seen as a large part of the problem and changing it is a crucial part of the solution. But how much do we actually know, in an empirical sense, about how and what people think about their tinnitus? The answer is, rather little. Back in 1998, an Australian psychology team developed a Tinnitus Cognitions Questionnaire with 26 items drawn from things people said when asked what thoughts they had about their tinnitus [2]. There are 13 positive and 13 negative items. In their validation of this questionnaire, Wilson and Henry (1998) identified some of the most common negative thoughts to be:

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“I think – why me? Why do I have to suffer this horrible noise?”, “nobody understands how bad the noise is” and “I can’t enjoy what I’m doing because of the noise.” However, for no good reason, this questionnaire has not been picked up and used by researchers since its development, and so we really know nothing about whether similar thoughts are common amongst different clinical populations. We know even less about overall thinking style. Interestingly, Wilson and Henry found the positive and negative subscales of their questionnaire to be unrelated, suggesting that the absence of negative thoughts does not necessarily imply the presence of positive thoughts. There is some other work which indicates that having ‘accepting’ thoughts about tinnitus is linked to lower levels of distress, but it is still unclear whether active acceptance is necessary [3]. One thing I’m really keen to find out in the course of my PhD research is whether those people who have tinnitus but aren’t bothered by it have positive, accepting thoughts about it, or just don’t think about it much at all. More recently, three research teams have investigated the concept of cata-

strophising amongst people with tinnitus, which is defined as exaggeratedly negative thinking [4-6]. “This tinnitus is going to stop me from concentrating on my work” might be a negative thought while “this tinnitus is going to ruin my whole life” is a catastrophic one. Somewhat unhelpfully, each team created its own measure of catastrophising rather than pooling resources, but all of them found a correlation between catastrophic thinking and either tinnitus distress or poorer quality of life. More specifically, Cima et al. [4] also found a link between catastrophising and selective attention, suggesting that overly negative thinking may lead people to focus on their tinnitus more, kicking off the vicious cycle all of us who work in tinnitus are so familiar with. What this work doesn’t show us, however, is whether thoughts have to be overly negative in order for this to happen, or whether more run-of-themill gloomy thinking will do. Despite these unanswered questions, it seems reasonably clear that thinking does play a part in tinnitus distress. An important question for clinicians, then, is what do we do about it? Those who, like me, were brought up in the era of Tinnitus Retraining Therapy were taught the rather comforting notion that you didn’t really have to do anything about it at all. ‘Demystification’ of tinnitus was allimportant; once the neurophysiological model was fully understood and sound therapy switched on, the subconscious brain could be left to get on with the process of habituation and whatever negative thoughts there were would dissipate on their own. However, while a better understanding of tinnitus can be transformative for some, I have seen enough patients who say things like “I know tinnitus isn’t anything dangerous, but I just can’t stop thinking about it!” to

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17 Figure 1: A cognitive model of tinnitus distress. (McKenna, 2010)

Selective attention and monitoring

Arousal and distress

beliefs Distorted perception of tinnitus

Negative automatic thoughts (NATs) safety behavious

Tinnitus detection

Tinnitus-related neuronal activity

know that for many, it is not enough. It does appear that addressing thoughts directly is an important part of successful therapy. Henry and Wilson measured changes in thinking specifically (using a pre- publication version of their Tinnitus Cognitions Questionnaire) in people who had followed either a ‘cognitive restructuring’ group programme or a course of tinnitus education [7]. They found that only the cognitive restructuring group experienced reductions in negative thinking, indicating that learning techniques for thought modification is more effective than simply understand-

ing tinnitus better and letting thoughts take care of themselves. Other, more recent studies [8] have also shown Cognitive Behavioural Therapy (CBT), which centres around modifying distorted and unhelpful thoughts, not only to be effective in reducing tinnitus distress but more effective than other types of therapy such as tinnitus education, information and yoga (although it is hard to separate the relative benefits of addressing the ‘C’ (Cognition) and the ‘B’ (Behaviour); more work is needed here.) This is all well and good, but how do we as non-psychologists (let’s face it, most

of us who work with tinnitus patients aren’t psychologists and don’t even have ready access to psychology services) deal with the tricky issue of what’s going on in someone else’s mind? As a sometime clinician I admit to being relieved on several occasions to encounter a nice, hefty distortion I could immediately correct (“No! Your tinnitus isn’t going to make you go totally deaf!”) but daunted by discussing the more nebulous halftruths that negative thoughts more often are. The fear of following the patient down a negative spiral from which we cannot help them emerge is always there. However, we can at least encourage our patients to notice their thought patterns and be aware of some of the common cognitive distortions that go on (‘all or nothing’ thinking, setting higher standards for oneself than for others, etc) even if we do not feel well equipped to tackle them head on. My clinical impression is that simply having more awareness of the way in which thoughts can influence feelings about tinnitus is a helpful first step. We can also perhaps impart some of the wisdom that comes from mindfulness meditation, which teaches ‘your thoughts are not facts, they are not you’ [9].The beauty of this approach is that, rather than engaging with negative thoughts, patients are encouraged to disengage with them, to simply observe them and let them pass. When we feel our own skills and training to be inadequate, we could perhaps make better use of the increasing number of self-help resources available – books and websites – which teach cognitive skills and mindfulness, either in general or for tinnitus specifically. A recent review found active self-help programmes for tinnitus to be more effective than no intervention and, in

“Over the decades, the role of thinking in tinnitus has risen from being an irrelevance, to a peripheral issue, to a central component of tinnitus distress.”

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18 some cases, as effective as intervention involving clinician contact [10]. While this may at first be a depressing message for clinicians (what’s the point of me?) how much more effective could we be if all our work were supported by a remote expert whom our patients could call upon whenever they liked? Even better, we could train to become CBT or mindfulness practitioners ourselves, as some tinnitus clinicians have already done, acquiring useful life skills for themselves along the way.

References 1.

McKenna L. 2010. A Cognitive Therapy Model of Tinnitus Distress. 4th International TRI Tinnitus Conference. Dallas, USA. 2. Wilson P and Henry J. Tinnitus cognitions questionnaire: development and psychometric properties of a measure of dysfunctional cognitions associated with tinnitus. International Tinnitus Journal, 1998;4:22-30. 3. Schutte NS, Noble W, Malouff JM and Bhullar N. Evaluation of a model of distress related to tinnitus. International Journal of Audiology, 2009;48:428-32. 4. Cima RFF, Crombez G and Vlaeyen JWS. Catastrophizing and Fear of Tinnitus Predict Quality of Life in Patients With Chronic Tinnitus. Ear and Hearing, 2011;32:634-641. 5. Weise C, Hesser H, Andersson G, Nyenhuis N, Zastrutzki S, Kroner-Herwig B and Jager B. The role of catastrophizing in recent onset tinnitus: Its nature and association with tinnitus distress and medical utilization. International Journal of Audiology, 2013;52;177-188. 6. Kleinstauber M, Jasper K, Schweda I, Hiller W, Andersson, G and Weise C. The Role of Fear-Avoidance Cognitions and Behaviors in Patients with Chronic Tinnitus. Cognitive Behaviour Therapy, 2013;42:84-99. 7. Henry J and Wilson P. The psychological management of tinnitus: comparison of a combined cognitive eductional program, education alone and a waiting list control. International Tinnitus Journal, 1996;2:9-20. 8. Martinez-Devesa P, Perera R, Theodoulou M and Waddell A. 2010. Cognitive behavioural therapy for tinnitus. Cochrane Database of Systematic Reviews. 9. Williams M. Teasdale J, Segal, Z and Kabat-Zinn J. 2007. The mindful way through depression, London, Guilford. 10. Greenwell K, Sereda M, Coulson N, El-Refaie A and Hoare DJ. 2014. Self-help interventions for tinnitus: a systematic review of techniques and effects. 11th International Tinnitus Seminar. Berlin, Germany.

Over the decades, the role of thinking in tinnitus has risen from being an irrelevance (cochlear models) to a peripheral issue (neurophysiological model) to a central component of tinnitus distress (cognitive model). While- as is often the case in tinnitus- research lags behind ideas, the evidence we do have and our collective clinical experience supports the notion that thinking plays an important part in tinnitus distress. We need to understand it better and we need to know how to act on it. We have to keep thinking about thinking.

Audacity

...a British Society of Audiology Publication issue 4 August 2014 ................................

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Can hearing aids prevent cognitive decline and dementia? CD

Author and Correspondence

Figure 1. Future projections of the number of UK adults with dementia (from www.alzheimers.org.uk)

Dr Piers Dawes University of Manchester E: piers.dawes@ manchester.ac.uk

Dr Piers Dawes is a lecturer in Audiology at the University of Manchester. Dr Dawes's background is in experimental psychology. He is interested in the cognitive aspects of hearing, and his research interests include hearing loss, auditory processing and developmental psychology from childhood to old age, auditory plasticity, hearing genetics and developmental disorders. Dr Dawes is the chair of the BSA Cognition in Hearing Special Interest Group, which aims to promote research in and raise awareness of new developments on cognitive issues in hearing science, assessment and intervention. Please feel free to contact Dr Dawes if you would like to be involved in the special interest group.

Dementia is characterised by memory loss, mood changes and problems with communication and reasoning. Dementia has a profound negative impact on the individual and their family and friends. There is presently no cure. Dementia is strongly associated with age and is quite common; 1 in 25 people aged 70-79 years has dementia, and this rises to 1 in 6 people aged over 80 years. With an aging population, the number of people with dementia in the UK is set to rise from 800,000 in 2012 to 1,700,000 by 2051 (Figure 1). Dementia currently costs the UK £23 billion annually, including care to the value of £8 billion

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provided by family members and partners. Dementia is clearly a cause for concern, and recent scientific and public policy reviews have identified treatment and prevention of dementia as a priority. Hearing and cognition Of particular interest to the field of audiology is the possibility that treating hearing loss may help prevent cognitive decline and dementia. The link between sensory and cognitive functioning has long been the subject of research interest; the father of psychometrics, Sir Frances Galton (1822-1911) investigated associations between hearing, vision and cognitive function in over 9,000 participants [1]. The topic was revisited several more times during the 20th century, and the 1990s produced a surge of interest stimulated by the 1994 publication of data from the Berlin Study of Aging [2]. This study showed age-related declines in cognitive ability and sensory (hearing and vision) loss in a sample of older

adults aged 70 to 103 years. Age-related declines in sensory function were strongly correlated with age-related declines in cognitive function, with 94.7% of variance accounted for. Even after accounting for age, sensory function was associated with 12.6% of age-independent variance in cognitive ability (in other words, at any age, sensory function was positively associated with cognitive function).The authors concluded that the link between sensory and cognitive functioning may provide a window into the study of cognitive aging. There has recently been another surge of interest, with publications showing correlations between hearing loss, cognitive function and the risk of developing dementia [3-6]. Cascade or common cause? The two main hypotheses that seek to explain the association between hearing loss and cognitive decline are the ‘common cause’ and ‘cascade’ models (Figure 2). In the common cause model

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21 Figure 2. Cascade and common cause hypotheses

Cascade Model Sensory deprivation Cognitive decline

Hearing loss

Social isolation & lack of stimulation

Common cause model

Hearing loss Age-related changes in the nervous system Cognitive decline

[2], the association is due to age-related changes in the nervous system affecting both sensory and cognitive function. In the cascade model [7], hearing loss impacts on cognition. The impact of hearing loss may be directly via a reduced flow of auditory information to the brain producing insufficient or imbalanced stimulation, adversely impacting on cognition. Alternatively, the impact of hearing loss on cognition may be indirect, via social withdrawal and the resultant lack of cognitively stimulating social interaction. Social isolation is independently associated with cognitive decline, and hearing loss is associated with social isolation. It therefore seems plausible that the impact of hearing loss on cogni-

tion may be via social isolation. The common cause and cascade models are not mutually exclusive, and both may contribute to cognitive decline. On balance however, the ‘common cause’ model appears to be more convincing. There are several challenges for the cascade model. Firstly, the trajectory of age-related cognitive decline begins in the second decade of life. It is not plausible that average levels of age-related hearing loss would be severe enough in people aged in their 20s to contribute to cognitive decline via deprivation or social isolation. Secondly, cognitive decline and hearing loss share similar environmental and

lifestyle-related risk and protective factors. Healthy Mediterranean-type diet, exercise, low/moderate alcohol consumption and non-smoking are all associated with a reduced risk of cognitive decline and a reduced risk of hearing loss. A parsimonious explanation is that cognitive decline and hearing loss share risk factors because these risk factors impact on a common underlying causal process(es). Thirdly, there is the problem of selective focus on hearing and interpretation of correlational data. Vision, smell and taste show associations with cognitive function similar to hearing (for example [8]). Any ‘cascade’ type effect of deprivation on cognitive function may therefore be multi-sensory, and not particularly related to hearing impairment. A focus only on hearing may give the possibly erroneous impression that hearing impairment plays an especially important role in cognitive decline. Age-related cognitive declines are correlated with declines muscle strength, skin elasticity, cardiovascular capacity and bone density. One may argue that hearing impairment could contribute to cognitive decline on the basis of correlational data showing an association. However, it would be equally logical to argue that reduced skin elasticity contributes to cognitive decline on the basis of similar correlational data. The problem is that most studies examining associations between hearing and cognition have been correlational. With this methodology, one is not able to make definite conclusions about the causal nature (if any) of the association. Either the common cause or the cascade models are able to explain the association between hearing loss and cognitive decline in correlational studies. Other study designs are required to test

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22 exactly which model provides a more convincing explanation for the association. A strong test of the cascade model would be to conduct an intervention study examining the impact of hearing aid use on cognitive decline. If hearing loss contributed to cognitive decline, one would expect that hearing aid use would reduce cognitive decline via ameliorating the auditory deprivation and/or social isolation subsequent to hearing loss. Unfortunately, most studies that have examined the impact of hearing aid use on cognition have used very short timescales [9]. The longest timescale (examined prospectively in a published study) to date has been 1 year [10]. Agerelated cognitive declines are very gradual. It is unlikely that age-related cognitive declines (or the impact of hearing aid use on cognitive decline) would be observable in studies with durations of less than 5 years. Ideally, one would conduct a randomised controlled trial of hearing aid use, with cognitive performance measured over a timescale of 5 years or longer. Besides the challenges of selective drop out and practice effects that dog longitudinal studies of cognitive aging, the practical, financial and ethical challenges of

conducting such a study are significant. The study would be ethically challenging because one would be required to withhold hearing aids for several years from people that could benefit from them. One alternative is to examine cognitive outcomes in existing longitudinal data sets that contain information about hearing, cognition, hearing aid use and potential confounding variables. Long-term cognitive outcomes and hearing aid use Professor Karen J. Cruickshanks and colleagues at the University of Wisconsin and I recently modelled long-term cognitive outcomes associated with hearing aid use in two longitudinal data sets; the Epidemiology of Hearing Loss Study (EHLS) [11] and the Beaver Dam Offspring Study (BOSS). EHLS is an older-aged population-based cohort while BOSS is a middle-aged cohort comprised of the adult children of the participants in EHLS. In the EHLS cohort, we examined cognitive outcomes at 5 years and 11 years from baseline. We hypothesised that among those with clinically significant levels of hearing loss, hearing aid users would have better cognitive outcomes than non-hearing aid users. In an analysis controlling for age, sex and severity of hearing loss, there was no

difference between hearing aid users and non-users on a battery of standardised cognitive tests or the Mini Mental State Exam. There were no differences in the rate of self-reported concerns about memory or doctor-diagnosed Alzheimerâ&#x20AC;&#x2122;s disease. These findings do not support a robust effect of hearing aid use in preventing cognitive decline or dementia. Encouragingly, hearing aid users did have reduced levels of hearingrelated disability. Summary Overall, â&#x20AC;&#x2DC;common causeâ&#x20AC;&#x2122; seems to be a more satisfactory explanation for the association between hearing loss and cognitive decline. In this model, hearing loss is a marker of increased likelihood of cognitive decline and dementia, rather than a being a strong causal agent. Hearing aid use may not impact on the biological processes underlying cognitive decline and dementia. However, hearing aid use could have an important role in reducing disability, and this may be particularly important in the context of cognitive impairment. Unlike pharmacological interventions which aim at improving cognitive impairments by slowing or reversing the underlying pathology, hearing aids may be valuable because they reduce disability and improve quality of life in older age. This is a very worthwhile aim.

References 1.

Galton F. Inquiries into Human Faculty and Its Development. 1883, London: Macmillan.

Lindenberger, U and Baltes PB. Sensory functioning and intelligence in old age: a strong connection. Psychology and aging, 1994;9(3): 339.

Lin FR, et al. Hearing loss and incident dementia. Archives of Neurology, 2011;68(2):214.

Lin FR, et al. Hearing loss and cognitive decline in older aduts. JAMA internal medicine, 2013;173(4): 293-299.

Gallacher J, et al. Auditory threshold, phonologic demand, and incident dementia. Neurology, 2012;79(15):15831590.

Gurgel RK, et al. Relationship of Hearing Loss and Dementia: A Prospective, Population-Based Study. Otology & Neurotology, 2014;35(5):775-781.

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Birren JE. The psychology of aging. 1964, Oxford, England: Prentice Hall. 8. Schubert CR, et al. Odor identification and cognitive function in the Beaver Dam Offspring Study. Journal of clinical and experimental neuropsychology, 2013;35(7):669-676. 9. Kalluri S, and Humes LE. Hearing technology and cognition. American journal of audiology, 2012;21(2):338. 10. van Hooren SAH, et al. Does cognitive function in older adults with hearing impairment improve by hearing aid use? International journal of audiology, 2005;44(5):265-271. 11. Cruickshanks KJ, et al. Prevalence of Hearing Loss in Older Adults in Beaver Dam, Wisconsin The Epidemiology of Hearing Loss Study. American Journal of Epidemiology, 1998;148(9):879-886.

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Emotional aspects of hearing loss and inner ear disorders – why mental health and wellbeing matters and how patients can be supported in audiology departments

Author and Correspondence Teresa Czajka, Mental Health Promotion Specialist, Health and Wellbeing Service, Manchester Mental Health and Social Care Trust Correspondence: Wythenshawe Offices, 1 Stancliffe Rd, Sharston, Manchester, M22 4PJ Tel: 0161 946 9446 E: teresa.czajka@mhsc.nhs.uk Take home message Poor mental health and wellbeing is common in people with hearing impairments and those living with vestibular disorders. Audiology professionals have a key role in supporting the emotional needs of patients, which can help to minimise its impact ensuring successful rehabilitation, improved outcomes and quality of life.

Do you know someone who has experienced poor mental health and wellbeing? You most probably do. In the UK general population, 1 in 6 adults and nearly 1 in 10 children, experience common mental health problems at any one time. At least 1 in 4 adults will experience a mental health problem in the course of a year, making this a common problem affecting many of us at some time in our lives [1]. How does this compare to the patients seen in audiology departments? There is some evidence that suggests patients using audiology services are at increased risk of poor mental health and wellbeing. Tinnitus is associated with a higher occurrence of depression than in the general population [2]. Approximately 60% of people with tinnitus had significant levels of low mood, worsening the

perception of the condition, making it more difficult to cope with [3]. Link (2005) reported that rates of depression amongst deafened individuals were almost five times higher than the national average, with anxiety levels at nearly two and a half times higher [4]. Why should this be the case? Taking hearing loss as an example, hearing affects every facet of our lives. Its loss can have a devastating effect on relationships, school, work and social life. It can have a detrimental effect on selfesteem, confidence and our personal identity. Like any loss, it can take time to come to terms with this and requires a period of adjustment. Often likened to a bereavement or grief reaction, this can lead to emotional responses such as denial, fear, anger, and sadness. It may be beneficial for practitioners to consider

where someone is, in their journey in coming to terms with their deafness / hearing loss. It is very important to acknowledge this as a real loss and patients should be supported to work through this. Our mind and body are strongly linked together, with each affecting the other. An example of this close relationship between the mind and body is the ‘FightFlight’ mechanism. This alarm system keeps us safe from harm.Triggered when feeling threatened it prepares the body to fight or run away. It means that thoughts and feelings can affect the body physically.Those same physical symptoms can in turn influence our thinking, our emotions, and behaviour. In vestibular problems, emotions can increase the likelihood of dizziness due to the body’s autonomic nervous system response. Misinterpretations of bodily sensations as dangerous can maintain anxiety and fear of falling via what is known as a vicious circle. Individuals often find themselves caught in a vicious circle, which can not only maintain the distress experienced but also exacerbate certain inner ear problems. For example, figure 1 illustrates someone living with tinnitus and how it is impacting negatively on their thoughts, feelings, behaviour and body through physical symptoms. A shared understanding of an individual’s experiences can be gained using this cognitive behav-

“It is important that the emotional and psychological needs of patients are recognized and addressed.” featured articles

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25 What is going on in your life at the moment? I have tinnitus and it’s there all the time and I can’t deal with it

Figure 1 illustrates the vicious circle of someone experiencing tinnitus (based on reference [5])

“I can’t cope with this” “I’ll go mad”, “I’ll never sleep”

Thoughts

Physical

What are you feeling in your body? Tense, churning stomach, palpitations, tinnitus louder, tired because I can’t sleep

ioural therapy approach commonly used by CBT therapists and self-help materials.This is known as the five areas model (for more information visit www.fiveareas.com). This can be helpful for both patient and practitioner in understanding what is driving and maintaining the vicious circle and can be a starting point towards positive change. Importantly, an intervention anywhere within the five areas can break the vicious circle, thereby replacing it with a virtuous circle. Emotional distress and poor mental health and wellbeing can impede rehabilitation efforts and clinical management.Thus, Audiology professionals have an important role to play in supporting the psychological needs of patients. This

What is going on in your life at the moment? I feel dizzy and lightheaded a lot of the time and I don’t know why

Figure 1 illustrates the vicious circle of someone experiencing dizziness / balance problems

How does that make you feel? worried, angry, frustrated, sad

What thoughts go through go your mind?

Situation

Behaviour

holistic, biopsychosocial approach is recommended by the British Society of Audiology Practice Guidance (2012) [6]. Therefore, it is important that emotional issues are identified and addressed where possible. How you can help Be psychologically aware. It is important to recognise when patients are experiencing distress, poor mental health and wellbeing or are perhaps stuck in a vicious circle. Listening, acknowledging and validating their experience, supporting and signposting to other sources of support can lead to improved outcomes for the patient. This may include returning to their GP for further assessment or referral into mental health services. A number of options are

Feelings

What do you do when you feel like this? Preoccupied with it and find it hard to distract myself, avoid noise, drink alcohol to help sleep

available, which may also include some of the following: Peer support groups. Meeting others who have been through similar experiences may be a helpful source of support. Information signposting patients to local groups or national organisations should be made available. Self-help. Making use of self-help booklets provides patients the opportunity to help themselves, whilst being supported by audiology professionals. Examples of available guides can be viewed and in most cases downloaded at www.ntw. nhs.uk/pic/selfhelp/ or www.mhim.org.uk/ resource_library.html. It may be helpful to consider what mental health and wellbeing resources are available to you locally.

How does that make you feel? worried, afraid, sad

What thoughts go through go your mind? “I’m going to fall” “What use am I to anyone”

Thoughts

Physical

What are you feeling in your body? Tense, palpitations, dizzy

Situation

Behaviour

Feelings

What do you do when you feel like this? Avoid going out, rely on others to accompany me

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26 Online websites offer self-help programmes in relation to low mood, anxiety, and dealing with stresses of life generally. These include www.moody gym.anu.edu.au and www.ecouch.anu. edu.au. Living life to the full www.llttf.com contains an online course using the five areas approach discussed previously, in addition to self-help resources, which individuals or services can access and purchase. Relaxation exercises. Tinnitus or vestibular problems are often exacerbated during periods of anxiety or stress.Therefore, it may be beneficial for patients to learn and practice techniques to manage stress and anxiety. Simple exercises such as controlled breathing and progressive muscle relaxation may lessen the perceived intrusiveness and distress caused, whilst promoting a better night's sleep. Free downloadable relaxation exercises can be found at www.mentalhealth.org.uk/help-information/podcasts. Psychological services. For those patients experiencing significant distress and

impact on life, access into psychological therapies should be considered. As discussed earlier cognitive behavioural therapy (CBT) aims to explore how individuals think, feel, and respond to their situation, often replacing unhelpful thinking and behaviour with more effective strategies. It can also involve learning how to manage anxiety and anxiety related physical sensations.This does not provide a cure but can make conditions appear less bothersome. A review by Martinez-Devesa et al. [7], found that CBT had a positive effect on individuals' ability to cope with tinnitus and its associated depression. Ultimately, there may be less perceived impact on daily activity, a regaining of sense of control, improved mental health and wellbeing and quality of life. It is recommended that departments make themselves aware of local mental health services and referral routes into psychological therapy services, if psychological support is not available within audiology service provision. Visit

http://www.iapt.nhs.uk/services/ for links to a directory of increasing access to psychological therapies (IAPT) services. Types of therapies on offer and waiting times will vary, as there is often high demand for these services. Audiology departments may wish to consider undertaking training as part of their continuing personal development in order to better support patients' emotional needs. In Manchester, such training is available to all front line staff (www.goodhealth-manchester.nhs.uk/ training). Audiology professionals who feel this would be helpful within their roles should ascertain what is available in their locality. Poor mental health and wellbeing is common in the deaf/hearing impaired and those living with vestibular disorders. Audiology professionals have a key role in supporting the emotional needs of patients, which can help to minimise its impact ensuring successful rehabilitation, improved outcomes and quality of life.

References

Websites

www.fiveareas.com www.ntw.nhs.uk/pic/selfhelp/ www.mhim.org.uk/resource_library.html www.ecouch.anu.edu.au www.moodygym.anu.edu.au www.llttf.com www.iapt.nhs.uk/services/ www.goodhealth-manchester.nhs.uk/ training

3. 4.

6. 7.

Adult Psychiatric Morbidity in England â&#x20AC;&#x201C; 2007, Results of a household survey. Available at http://www.hscic.gov.uk/pubs/psychiatricmorbidity07 Holmes S & Padgham N. Review Paper: more than ringing in the ears: a review of tinnitus and its psychosocial impact. Journal of Clinical Nursing, 2009;18:2927-37. Daugherty JA. The latest buzz on tinnitus, The Nurse Practitioner, The American Journal of Primary Health Care, 2007;32(10):42-7. LINK (2005) HIDDEN LIVES. The psychological and social impact of becoming deafened in adult life. A collaborative research project between the LINK Centre for Deafened People and the University of Greenwich Summary report, September 2005 http://www.hearinglink.org/document.doc?id=100LINK(2005)HIDDENLIVES. The psychological and social impact of becoming deafened in adult life. A collaborative research project between the LINK Centre for Deafened People and the University of Greenwich Summary report, September 2005 http://www.hearinglink.org/document.doc?id=100 Williams CJ & Garland A. A cognitive behavioural therapy assessment model for use in everyday clinical practice. Advances in Psychiatric Treatment, 2002;8:172-9. BSA (2012) Practice Guidance. Common principles of rehabilitation of adults with hearing and /or balance related problems in routine audiology. Martinez-Devesa P, Perera R, Theodoulos M & Waddell A. Cognitive behavioural therapy for tinnitus (review). The Cochrane Collaboration.

featured articles

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research round-up

Psychoacoustics and beyond What is psychoacoustics and why is it useful?

Author and Correspondence Professor Chris Plack, Ellis Llwyd Jones Professor of Audiology Correspondence: School of Psychological Sciences The University of Manchester Manchester, M13 9PL Email: chris.plack@manchester.ac.uk

Psychoacoustics is the psychological or behavioural study of hearing – behavioural in the sense that the participant is required to make a physical response to the sounds that are played to them. As the name suggests, psychoacoustic research determines the relation between the physical stimuli (sounds) and the sensations produced in the listener. By determining this relation, we can investigate how the auditory system processes sounds. For example, we can determine how our ability to separate out the frequency components of sounds is related to physiological processes in the inner ear, and how these are affected by hearing loss. Research that could be categorised loosely as psychoacoustics has been conducted for over a century, although it is thought that the word ‘psychoacoustics’ was first coined by T W Forbes when he described the secret research his team was conducting in the United States during World War II. The purpose of the research was to investigate, among other things, the potential of acoustic weapons! Fortunately, psychoacoustic research today has much more benign aims. As well as being the main tool for investigating the normal function of the human auditory system, psychoacoustic research is also largely focussed on understanding and mitigating the effects of hearing loss. There are also important applications in areas such as telecommunications, sound reproduction, and acoustic design. For example, the MP3 coding used in personal musical players is based on psychoacoustic research. Psychoacoustic techniques In a psychoacoustic experiment, participants are asked to make a response based on sounds that are played to them over headphones, loudspeakers, or in the case of cochlear implant research, electrical signals that are transmitted to the implant. These experiments usually take place in sound-attenuating booths to isolate the participant from external noise.There are broadly speaking two different types of measurement that we can make.

research round-up

A happy participant performing a psychoacoustic experiment in a sound-attenuating booth. The participant is looking through the window in the booth at a computer monitor which displays a virtual ‘response box’ that indicates to the participant if they made the correct response. The participant makes responses by pressing keys on a computer keyboard.

First, we can ask the participant to make a subjective response corresponding to the perceived magnitude of some aspect of the sound. For example, the participant might give a judgment of the loudness of a sound, of the pleasantness of a musical chord, or of the direction of a sound source. In the case of loudness, the participant might be asked to rate a sound by giving a number, or by choosing a category (for example, very soft, soft, moderately loud, loud, or very loud). Tasks such as these allow us to estimate the internal sensation corresponding to physical quantities such as level, frequency, spatial location, and so on. In addition to being of practical use, these measurements help us understand how the physical aspects of sounds are represented in the auditory nervous system. Second, we can ask the participant to discriminate (i.e. to detect a difference) between two or more sounds, or between a sound and silence in the case of measurements of absolute hearing threshold such as pure tone audiometry. For example, on each trial of an experiment, participants might be presented successively with two brief sounds. By pressing a button on a response box or a key on a computer keyboard, they are asked

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Sound stimuli for a typical trial in a gap-detection experiment. The participant is asked to pick the time interval containing the sound with the brief temporal gap (inter two in this case). The position of the gap would be randomly allocated to the first and second sounds on individual trials.

to determine which one contains a brief temporal gap, which one has the higher frequency, or which one contains a particular sound feature such as a pure tone. The order of the stimuli is randomised so that participants cannot get the right response just by pressing the same button every time. This is an example of a two-interval, two-alternative forced-choice task, because there are two observation intervals in which stimuli are presented, and the participant is forced to choose one of these. It is possible to have any number of observation intervals and alternatives. Three-interval, three-alternative is also popular, with the participant picking which of three sounds is different or the ‘odd one out’ (again, the interval containing the ‘correct’ stimulus would be randomised). Discrimination tasks are often accompanied by feedback after every trial, perhaps by a light on the response box or computer screen, indicating whether or not the response was correct. Feedback helps the participant learn the cues in the sound to which he or she needs to attend to achieve good performance. The mathematics of detecting differences between stimuli were described by Dave Green and John Swets in the 1960s in their work on ‘Signal Detection Theory’. The idea is that the ability to detect a difference between sensory stimuli is limited by variability, or ‘noise’, in the neural representation of the stimuli in the brain. So that sometimes, by chance, the ‘correct’ sound might produce less neural activity than the ‘incorrect’ sound, and the participant will chose the wrong

interval. The greater the physical difference between the sounds (the more they differ in level, for example) the less likely this is to happen, and the higher the probability that the participant will make the correct decision. Discrimination tasks allow us to measure the just-noticeable difference between two sounds. This is often done using an adaptive technique in which the task is made harder the more correct responses are made and easier the more incorrect responses are made. A popular example of this is the two-down, one-up procedure, in which the task is made harder for every two consecutive correct response and easier for every one incorrect response. Suppose we wanted to find the smallest detectable level of a pure tone in the presence of an interfering or ‘masking’ noise. We might use a two-interval, two-alternative task, in which one interval contains the noise and one interval contains the noise plus

the tone. Initially, the tone would be set at a level at which it is easily detectable so that the participant would pick the interval with the tone almost every time. However, every two successive correct responses would cause the level of the tone for the next trial to be reduced by, say, 2 dB. Eventually, the participant would not be able to detect the tone and he or she would pick the wrong interval. Then the level of the tone would be increased and performance would improve. Over a block of trials, a plot of the level of the tone against trial number (an adaptive track) would show that the level of the tone varied up and down around the threshold of discrimination as the participant’s responses varied from correct to incorrect. By averaging the level of the tone at the turnpoints or reversals in the track (changes in direction of the track from decreasing to increasing tone level, and vice versa), we can obtain a threshold value for the tone in the noise. Masking tasks such as these are very powerful. By measuring how the smallest detectable level of the tone changes as we vary the characteristics of the noise we can determine the limitations of the ear’s ability to perceptually separate sounds based on frequency, time, or direction in space. These experiments can be used to produce accurate computational models of the basic processing of sounds by the auditory system, and can also be used to investigate how hearing loss affects these abilities.

A typical adaptive track, showing the level of a tone in noise as a function of trial number. The participant’s response on each trial is indicated by a tick (correct) or cross (incorrect). For every two consecutive correct responses, the level of the tone is decreased, making the tone harder to detect. For every incorrect response, the level of the tone is increased, making the tone easier to detect. As the experiment progresses, the level of the tone oscillates around threshold (defined, for example, by 70.7% correct responses). Threshold is indicated by the horizontal dashed line.

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30 Beyond psychoacoustics: investigating the neural basis of auditory perception The results of psychoacoustic experiments could, in principle, be affected by any physiological processing from the sound entering the ear to the finger press or other behavioural response from the participant. Although we can carefully design experiments to probe different aspects of auditory processing, psychoacoustics is still a somewhat indirect measure of the basic physiological mechanisms. I was extremely fortunate to have arguably the best training in psychoacoustics available, working in the laboratories of such luminaries as Brian Moore, Neal Viemeister, and Bob Carlyon. However, in recent years I have strayed somewhat from this noble path. About ten years ago I started a longterm collaboration with Deb Hall (now Director of the Nottingham Hearing Biomedical Research Unit) investigating the representation of pitch in the auditory brain using neuroimaging (fMRI) techniques. Shortly afterwards, a collaboration with Ravi Krishnan from Purdue University led to my interest in electrophysiological techniques; in particular, the use of human electroencephalography to measure the ‘frequency-following response’. This measure reflects the synchronised firing patterns of neurons in the auditory brainstem, and is thought to reflect neural coding of the temporal characteristics of sounds. I have come to realise that combining psychoacoustic techniques with more direct measures of neural activity can lead to important new insights. In particular, we can determine more precisely what aspects of neural processing underlie auditory sensations, and gain a deeper understanding of the function of the human auditory system. Research at Manchester Below I have summarised some of the projects currently conducted by our group at Manchester. These brief descriptions should give a flavour of how we are combining psychoacoustic and electrophysiological techniques to

research round-up

provide new insights into the physiology of normal and impaired hearing. These projects represent just a part of audiological research at Manchester, and in particular the reader is referred to Kevin Munro’s recent Audacity article on the work of the Ewing Auditory Research Team for examples of some of the other projects currently running at Manchester. Details of our projects are also available on our website: http://www.psych-sci.manchester.ac.uk/ audiologyanddeafness/research/

‘…combining psychoacoustic techniques with more direct measures of neural activity can lead to important new insights’ 1. Hidden hearing loss Hearing is usually assessed using the pure tone audiogram, which measures the sensitivity of the ear to quiet sounds at different frequencies. However, striking results from recent experiments in rodents have shown that exposure to loud noise can lead to a permanent loss of auditory nerve fibres without affecting sensitivity to quiet sounds permanently. This type of damage has been called ‘hidden’ hearing loss because it is not measurable using standard clinical procedures. Despite having little effect on threshold sensitivity, such neural damage may impair discrimination of sounds at everyday sound levels, such as speech and music. With funding from a five-year Medical Research Council Programme Grant, we are combining psychoacoustic and electrophysiological techniques to measure the characteristics and perceptual effects of the neural loss caused by noise exposure. We are testing young listeners with clinically normal hearing who have different degrees of exposure to recreational noise, such at nightclubs and live music events. For example, we are using psychoacoustic measures of the ear’s ability to detect the rapid temporal fluctuations of sounds, and

comparing these findings to measures of neural temporal coding using the frequency-following response. We are also relating these ‘basic’ abilities to more realistic ‘real-world’ tasks such as speech perception and music perception. In this way, we are able to gain a clearer insight into how the neural loss due to noise exposure affects hearing ability. Since millions of people in the UK are routinely exposed to noise levels similar to those used in the animal studies, hidden hearing loss could be a major public health issue. Our research could have a significant impact on how we measure hearing ability in the clinic, and how we monitor and control exposure to environmental noise. The research may also pave the way for interventions such as directional hearing aids, drug therapies, and stem-cell therapies, to improve the hearing ability of listeners with hidden loss. This work is carried out by Garreth Prendergast, Karolina Kluk-de Kort, Kevin Munro, and Chris Plack at Manchester, in collaboration with Deb Hall from the Nottingham Hearing Biomedical Research Unit, Sue Francis from the University of Nottingham, and Mike Heinz and Ann Hickox from Purdue University.The work is supported by the Medical Research Council. 2.The effects of occupational noise exposure on hearing In a related study, we are investigating the effects of noise exposure in a factory. We are using psychoacoustic techniques to measure cochlear function and speech perception, and electrophysiological techniques including the auditory brainstem response and frequency-following response to measure neural function. In preliminary results we have found that occupational noise exposure can produce deficits in speech identification in background noise despite normal hearing sensitivity as measured by the audiogram. If confirmed, this would be a concrete example of hidden hearing loss, and may imply that noise exposure regulations

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The author in his misspent youth, contributing to hidden hearing loss.

need to be re-evaluated to protect workers from the damaging effects of occupational noise.

often catastrophic effects of diabetes on visual function are well documented. However, the effects of diabetes on hearing are uncertain. One reason for the uncertainty is that any neural damage due to the condition may not be reflected in the audiogram, and hence may be yet another manifestation of hidden hearing loss. We are using our battery of psychoacoustic and electrophysiological techniques to characterise the effects of diabetes on neural function, and on speech perception. Our results may lead to new ways to diagnose and monitor the effects of diabetes on hearing. This work is carried out by Arwa Aljasser, Kai Uus and Chris Plack.

This work is carried out by Andy King and Chris Plack, with support from the Medical Research Council, and the Eriksholm Research Centre.

5.The neural basis of musical consonance Certain combinations of musical notes (for example, a ‘perfect fifth’ chord) produce a pleasing sensation of resolution and stability. These combinations are said to be ‘consonant’. Other combinations sound unpleasant and unstable (for example, a ‘tritone’ chord), and are said to be ‘dissonant’. Our research aims to determine the physiological basis of these perceptions. So far in this research we have shown that individual differences in consonance perception are related to individual differences in neural coding of the temporal fluctuations of sounds as measured using the frequency-following response. This is good evidence that musical consonance is dependent on the ability of neurons to represent the temporal properties of sound waveforms.The study is a great example of how combining psychoacoustic and electrophysiological techniques can lead to insights that would not be possible with either technique alone. We have also found recently that consonance perception deteriorates with age, and, crucially, that this deterioration is associated with a reduction in neural temporal coding, again suggesting a link between the two.

4. Diabetes and hearing loss Diabetes is a debilitating condition, known to cause widespread damage to the peripheral nervous system. The

This work is carried out by Olly Bones, Ravi Krishnan (Purdue) and Chris Plack, with support from the Economic and Social Research Council.

This work is carried out by Daphne Barker, Richard Baker, and Chris Plack. The work is supported by Action on Hearing Loss and the Colt Foundation. 3.The effects of age on hearing It is well know that hearing deteriorates with age, reflected by an elevation in audiometric thresholds (particularly in the high-frequency region). However, as for hidden hearing loss due to noise exposure, it is becoming apparent that aging is associated with a deterioration in the neural representation of sounds that is not reflected in the audiogram. Using psychoacoustic techniques, we have shown that aging impairs the ability of listeners to use detect differences in the arrival times of sounds at the two ears, independently of any effects on auditory threshold. This indicates that aging is associated with a decline in the precise temporal coding that the brain needs to determine the direction of sound sources.

Research at Lancaster I have recently started a 50% post in the Department of Psychology, Lancaster University. Our work in Lancaster focuses on more ‘basic’ science; understanding the normal function of the auditory system. However, there are also clinical implications to this research. 6. Auditory perceptual learning Performance on many psychoacoustic tasks improves with practice. But what are the neural mechanisms underlying the improvements in performance, and what are the factors that determine whether one individual improves more than another? In earlier work we showed that training on psychoacoustic pitch discrimination leads to an increase in the accuracy with which neurons represent the temporal characteristics of sounds, as measured by the electrophysiology frequency-following response. In follow-up work, we are examining some of the factors that influence learning. It is thought that sleep is important for the consolidation of memories, and we are trying to determine if this applies to auditory learning, and which sleep stages are important for consolidation. We are also examining the effects of age on the ability to learn new auditory tasks. The work has potential implications regarding how we help users of hearing aids and cochlear implants adapt to their devices, and potentially for targeted training strategies intended to improve hearing ability for people with a hearing loss. This work is carried out by Sam Carcagno (Lancaster), Penny Lewis (Manchester) and Chris Plack, with support from a grant from Lancaster University. Interested in reading more about psychoacoustics? Moore, B.C.J. (2012). An introduction to the psychology of hearing. 6th Edition (Emerald, London). Plack, C.J. (2013).The sense of hearing. 2nd Edition (Psychology Press, Hove). Acknowledgements Our research is funded by the Medical Research Council, the Economic and Social Research Council, Action on Hearing Loss, the Colt Foundation, the Eriksholm Research Centre, and Lancaster University.

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Research training – funding opportunities CD

Author and Correspondence Dr Heather Fortnum Associate Professor and Reader in Hearing Research, Lead for Postgraduate Training

Correspondence: National Institute of Health Research Hearing Biomedical Research Unit Ropewalk House Nottingham NG1 5DU Email: heather.fortnum@nottingham.ac.uk

There has never been a better time for non-medical clinicians to train as health researchers. The National Institute for Health Research (NIHR) offers a range of training opportunities from Masters courses right through to Professorships.The NIHR also manages, for Health Education England, a Clinical Academic Training Pathway specifically designed for nurses, midwives and the Allied Health Professions (AHPs) with training opportunities at Masters, Doctoral and Post-Doctoral level. A diagram of the opportunities (see below) can be accessed at: http://www.nihrtcc.nhs.uk/2013 TCC Career Pathway.ppt These scheme AHPs include speech and language therapists but not, as yet, audiologists. They and non-clinicians would need to

research round-up

apply through the ‘All Professions’ route. To promote these opportunities, the NIHR has developed a cohort of passionate and proactive researchers working both individually and as a group to act as NIHR Academic Training Advocates for the nonmedical clinical professions who wish to begin or continue a research career and I am the nominated NIHR advocate for Audiology and Speech and Language Therapy.The advocate role is an evolving one but we are encouraged to speak at professional meetings, encourage researchers in our field to pursue research and to be a general cheer leader for a clinical academic career. The first NIHR Research Career meeting took place in London in March and had nearly 600 applicants for 150 places – a fantastic response. It was a free event and the speakers, from a range of non-medical clinical professions, offered pragmatic advice on how to start a research career. Clear themes emerged from the meeting – the need to be resilient, to find a mentor, to network and to research a topic you have a passion for. Short films of the meeting speakers can be accessed at http://www.ccf.nihr.ac.uk/Pages/NIHRTrainees. aspx – take a look and be inspired! We are discussing plans to run the event again in London and the possibility of smaller events outside London. If you are interested in finding out more about support for a research career please visit the trainee page on the NIHR website: http://www.ccf.nihr.ac.uk/Pages/NIHRTrainees.aspx. If you have further questions or you would like to talk about the opportunities please feel free to contact me.

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lunch and learn

Lunch and Learn CD

Facilitators and Correspondence

Shahad Howe Clinical Scientist, Manchester Royal Infirmary

Christopher Cartwright Professional Marketing Manager, Phonak

Roulla Katiri Chief Audiologist, Mater Misericordiae University Hospital, Dublin

E: Shahad.howe@cmft.nhs.uk

E: Chris.cartwright@phonak.com

E: rkatiri@mater.ie

BSA Lunch and Learn eSeminars An exciting series of online presentations covering current topics of interest and clinically relevant research findings in Audiology and related professions, free of charge to all BSA members and non-members.

Recent bites

Coming up on the menu

These and other earlier seminars are available to access at www.thebsa.org.uk and http://www.phonaknhs.co.uk/news/news-archive/. You may need to request connection through Firewalls with your local IT department for your first eLearning experience.

To go live on the first Monday of every month for access by the emailed link, via the BAA or Audiology Northwest England Facebook pages, or archived at www.thebsa.org.uk and http://www.phonaknhs.co.uk/news/news-archive/. You may need to request connection through Firewalls with your local IT department for your first eLearning experience.

May 2014

APD: Lessons from history

Theory of mind and importance of overhearing › Lyndsey Allen,

› Wayne Wilson, The University of Queensland, Australia

The Ear Foundation

Tinnitus in Children: Practice Guidance

June 2014

› Rosie Kentish,

Clinical feasibility and accessibility of recording infant obligatory cortical evoked potentials in the soundfield; results from first 55 infants › Prof Kevin Munro,

Consultant Clinical Psychologist, Nuffield Hearing & Speech Centre, RNTNE

The University of Manchester

Auditory Training & Cognition › Helen Henshaw,

July 2014 The Complexities of Listening and Understanding in Children with Minimal / Mild Hearing Loss › Dawna Lewis Boys Town National Research Hospital in Omaha, Nebraska

Research Fellow National Institute for Health Research Nottingham Hearing Biomedical Research Unit

If you would like to contribute a seminar, have any queries or would like regular email updates, please email one of the facilitators above.

lunch and learn

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lunch and learn

Aided CAEPs: bridging the gap between prescribing hearing aids to infants and obtaining reliable behavioural assessment data

This short communication is based on the on-line BSA Lunch and Learn seminar by Professor Kevin Munro on 2nd June 2014. The recording is available at www.thebsa.org.uk

Success means new challenges There is growing interest in using cortical auditory evoked potentials (CAEPs) to supplement established paediatric assessment procedures. This interest is fuelled, at least in part, by the success of the national Newborn Hearing Screening Programme (NHSP) in England. Prior to the introduction of NHSP (around 10 years ago) the typical age that hearing aids were prescribed and fitted to infants with permanent childhood hearing impairment was around 15 months. Currently, the typical age at hearing aid prescription and fitting is 2-3 months of age. Despite the undoubted success of NHSP, this progress means new challenges. There are challenges for: • families, when there is little behavioural evidence that the infant is receiving benefit • educational professionals, who provide family support, and • health care professionals, who prescribe hearing aids based on limited assessment data Frequency-specific auditory brainstem responses (ABRs) are used when prescribing hearing aids to infants. ABRs provide an accurate prediction of hearing thresholds but: • behavioural thresholds often deviate from the predicted thresholds by 10 dB, and occasionally 20 dB (Stapells, 2011) • in cases of a severe hearing loss, there may be no measurable ABR but this does not mean that an appropriately prescribed hearing aid will not provide benefit (Stelmachowicz, 2008) • middle ear disease and concomitant medical problems can complicate interepretation of the ABR (Stelmachowicz, 2008) • the ABR is typically absent in some populations e.g., auditory neuropathy (Rousch et al., 2011)

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Bridging the gap There is an interval, or gap, of around 6 months between prescribing and fitting hearing aids at 2-3 months of age and obtaining reliable behavioural assessment data at a developmental age of 7-9 months. Families are enthusiastic about supplementing established asessment procedures with new techniques, including aided CAEPs, since a response to a speech-level stimulus would motivate and reassure them to persevere with using the hearing aids when there is limited behavioural evidence of benefit. In addition, audiologists will be alerted when the current hearing aid prescription is inappropriate and if it is necessary to expedite alternative strategies including frequency lowering devices or referral for a cochlear implant assessment. A potential way forward The use of CAEPs to supplement existing procedures is not new. As long ago as 1967, Rapin and Graziano reported using aided CAEPs to verify the physiological detection of sound in a hearing-impaired child. There have been a number of recent studies that have investigated the detection of CAEPs in infants (e.g., Chang et al, 2012;Van Dun et al., 2012). Both of the studies reported that CAEPs could not be detected in around 30% of cases when the stimuli were predicted to be audible. However, both studies used relatively small samples of children who were tested at an older age than our 2-7 month target age, and it is unclear if the testers were experienced at conducting CAEPs measurements. Verifying the physiological detection of sound As a precusrsor to a large-scale study of aided CAEPs in hearing-impaired infants, we have been carrying out a study investigating the clinical feasibility (test duration and completion rates), response detection and acceptability of this procedure in normal hearing children. So far we have tested around 80 infants (developmental age 4 to 39 weeks) who have passed newborn hearing screening and there are no concerns about their hearing. For the purposes of this preliminary study, we used the commerically available HEARlab, primarily because it: (i) provides information about residual noise/SNR and (ii) includes an automated response detection algorithm. The three short-duration stimuli on the HEARlab, /m/, /g/ and /t/, are derived from running speech and differ from each other in terms of spectral and temporal characteristics.The procedure involves the infant sit on the parent/caregivers lap, facing a loudspeaker in a set-up that does not look too dissimilar to visual reinforce-

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ment audiometry. The stimuli are presented at 65 dB SPL. Our test protocol involves two runs of 75 stimuli, each presented at a rate of around 1/s. Completion rate So far, the test completion rate is greater than 95%: three infants could not be tested because they were not in the correct behavioural state (two were restless and one was asleep). Test duration The typical test duration is 26 mins (range 17-89 min) with around 13 minutes spent preparing the child and 13 minutes collecting data. Response detection So far, response detection has been based on visual detection, of each of the two runs of 75 sweeps, by an expert examiner. Detection of a response to one or both sweeps is recorded as a response. A response has been obtained to at least one stimuli in 100% of infants. Responses to /g/, /t/ and /m/ were detected in 96%, 88% and 80% of infants, respectively. We have yet to combine the two sweeps into one grand average or compare against the automated response detection algorithm. Grand average CAEP to /m/, /g/ and /t/ left middle and right panel, respectively.

Grand average CAEP to /m/, /g/ and /t/ top middle and bottom panel, respectively.

Parents perspective Parents are invited to complete an online rating scale within one week of data collection.There are eight questions enquiring about various aspects of the test procedure including the test environment, the distress to the infant and the ability to keep the infant in the correct state of attention. Each question is rated from 1 (most favourable) to 8 (least favourable). So far, the mean score is less than 2.5 for each question and most are rated less than 1.5. The parents perspectives have also been explored in a qualitative study using semi-structured interviews. The responses have been extremely encouraging but we have yet to determine if this translates to parents with hearing-impaired infants.

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Electrode location: vertex or forehead? In terms of ease of use in a clinical setting, there may be merit in recording between electrodes on the forehead and mastoid instead of the more traditional vertex-mastoid combination. Our preliminary findings suggest that there is a slight reduction in signal-to-noise ratio (SNR) when using the forehead. If this finding remains when we have completed all the data collection, it suggests that a greater number of sweeps will be required when using a forehead location to give an equivalent SNR as the vertex-mastoid location. This time trade-off may, or may not, be acceptable in the clinical setting. Acknowledgements The study was funded by a strategic investment grant from Central Manchester University Hospitals NHS Foundation Trust to Kevin Munro, Ruth Nassar, Suzanne Purdy, Martin Oâ&#x20AC;&#x2122;Driscoll, Rachel Booth, Iain Bruce and Kai Uus. It was facilitated by the Manchester Biomedical Research Centre and the Greater Manchester Comprehensive Local Research Network. The study was supported by the NIHR Wellcome Trust Clinical research facility.

References 1. Chang H-W, Dillon H, Carter L,Van Dun B,Young S-T.The relationship between cortical auditory evoked potential (CAEP) detection and estimated audibility in infants with sensorineural hearing loss. International Journal of Audiology, 2012;51:663-70. 2. Rapin I, Graziani LJ. Auditory-evoked responses to normal, brain damaged and deaf infants. Neurology, 1967;17:88194. 3. Stapells DR (2011). Frequency-specific threshold assessment in young infants using the transient ABR and the brainstem ASSR. In R.C. Seewald and A.M. Tharpe (eds.), Comprehensive handbook of pediatric audiology (pp.409448). San Diego: Plural Publishing Inc. 4. Stelmachowicz P, Hoover BM, Lewis DE (2008). Progress means new challenges: Current issues in paediatric amplification. In RC Seewald & JM Bamford (eds). A sound foundation through early amplification 2007. StĂ¤fa, Switzerland: Phonak AG, pp161-72. 5. Roush P, Frymark T,Venediktov R, Wang B. Audiologic management of auditory neuropathy spectrum disorder in children: a systematic review of the literature. American Journal of Audiology, 2011;20:159-70. 6. Van Dun B, Carter L, Dillon H (2012). Sensitivity of cortical auditory evoked potential detection for hearing-impaired infants in response to short speech sounds. Audiology Research, 2012;2:65-76.

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Take home message The short test duration, high completion and detection rates and the good scores on the acceptability questionnaire suggest that the sound field CAEP procedure may be feasible and acceptable for use in infants within the clinical setting. We are now planning a large-scale study with hearing-impaired children.

High completion rate

High response detection

Acceptable test duration

Acceptable to parents

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Coming up:

Wayne Wilson The University of Queensland Australia

APD: Lessons from history In 2009, Jerger (2009, p. 10) eloquently surmised the controversies surrounding auditory processing disorder (APD) by stating “APD means different things to different people”. He argued this was due (at least in part) to three historical approaches having been taken to APD: 1. the audiological approach, which is based on the concept of brain injury, 2. the psychoeducational approach, which is based on the concept of a set of primary (discrete) auditory abilities and 3. an approach based on the possible impact APD could have on language acquisition and learning. In this presentation I will argue that that a further three approaches can now be added: 4. an approach based on the requirement that APD be modality specific (Cacace & McFarland, 2013), 5. an approach based on the defining feature of APD being a deficit in auditory attention (Moore et al., 2010), and 6. an approach based on abandoning attempts to define APD in favour of managing the presenting listening difficulties (Dillon et al., 2012). While all six approaches to APD contain strengths and weaknesses, attempts to determine which approach would best serve persons with APD are confounded by the high likelihood that these different approaches are identifying different people.

Tinnitus in Children: Practice Guidance Tinnitus in children is a relatively neglected area, from both a research and clinical perspective.Yet prevalence studies suggest that tinnitus is a surprisingly common experience in children (Sheyte and Kennedy 2010). Whilst the majority are untroubled by it, for some, tinnitus causes distress, and affects their lives both at home and at school. Tinnitus can impact upon sleep, concentration and psychological wellbeing (Kentish et al 2000).

Rosie Kentish Consultant Clinical Psychologist, Nuffield Hearing & Speech Centre, RNTNE, Gray’s Inn Road

Helen Henshaw Research Fellow, National Institute for Health Research Nottingham Hearing Biomedical Research Unit

The BSA “Tinnitus in Children: Practice Guidance” is intended for a range of professionals including audiologists, medical professionals,, hearing therapists, teachers of the deaf, psychologists and mental health professionals. It offers a practical and child friendly approach to the assessment and management of tinnitus in children, with the aim of enabling others to develop their clinical skills in Paediatric Tinnitus. Key recommendations from the Practice Guidance will be presented in this lecture, together with some suggestions for child friendly interview techniques, and age-appropriate ways to explain tinnitus to children.

Auditory Training & Cognition Dr Henshaw is a chartered research psychologist with an interest in the cognitive mechanisms underlying memory and attention for perceptual (auditory and visual) stimuli. Helen began her translational research career at NIHR Nottingham Hearing Biomedical Research Unit in September 2009, working alongside clinical and academic colleagues in the Habilitation for Hearing Loss team.Their research aims to evaluate novel interventions for adults with hearing loss and those who communicate with them. Current projects aim to evaluate the benefits of; auditory and cognitive training, effective patient education, patient motivation and enhanced patient–clinician relations, to help alleviate difficulties associated with hearing loss. At the BRU, Helen has developed expertise in presbycusis (age-related hearing loss), adult aural rehabilitation, perceptual learning, auditory training, working memory training, and audiological and cognitive assessment of adults with hearing loss. Helen’s current research spans health service delivery, research priority setting, clinical trials, the development and assessment of novel interventions, and systematic literature reviews. Helen is a member of the British Society of Audiology (BSA) and the recently formed BSA Special Interest Group on Cognition in Hearing, the Association for Research in Otolaryngology (ARO), an Associate of the Higher Education Academy (HEA) and a Chartered Member of the British Psychological Society (CPsychol) Cognitive Section.

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Ear to the ground for all things ear-related in the media In this issue, Ear to the Ground will include a roundup of relevant stories that have appeared in the media in recent months. This edition includes the big news coming out of North Staffordshire CCG concerning hearing aid provision, as well as some lighter pieces about Van Gogh's ear, a dog who has learned sign language and much more... Amanda Hall's Twitterarty piece this edition looks at the activity of the Audiology community and perspectives on recent conferences that have taken place.

North Staffs Proposals As I’m sure most of those in the Audiology community will be aware, the big story in the media recently has been the suggestion by North Staffordshire Clinical Commissioning Group to cut funding for NHS hearing aids to patients with mild or moderate hearing losses. Quotes attributable to Dr David Hughes from the CCG insist that “this is not yet a formal consultation, but a chance for local residents to give their views”. Details of the proposals and meetings to discuss them are available from the North Staffordshire CCG website at http://www.northstaffsccg.nhs.uk/news-and-events/north-staffordshireclinical-commissioners-urge-public-to-help-shape-local-plans-for-hearing-aid-services-2348/. Unfortunately, these meetings will have already taken place by the time this edition goes to press. The story has been covered by most of the British media outlets, and more details can be found at each of their websites. The proposals have also sparked segments on several news programmes, including BBC Breakfast, 5Live and Daytime. Several organisations, including professional bodies and charities, have raised concerns about the proposals. Read some of the briefings at these sites: http://www.sense.org.uk/content/north-staffordshire-consultation-provision-hearing-aids http://www.tinnitus.org.uk/Northstaffs http://www.actiononhearingloss.org.uk/get-involved/campaign/hearing-aid-cuts.aspx http://www.thebsa.org.uk/stop-cuts-nhs-hearing-aids http://www.baaudiology.org/indexphpnews/news-home

An ATTRACTive prospect The Daily Mail recently reported the case of an actor who has undergone implantation of Cochlear’s BAHA Attract. The article focuses on the advantages of the Attract compared to its percutaneous brother, but the acoustic disadvantages of the newer device are ignored, giving the article an unbalanced feel. The article also implies that the Attract makes conventional BAHAs obsolete, which is misleading to the reader. There is a thorough guide to the patient’s journey, and the benefits are clear for this patient, giving the piece some feel-good factor. See the article at http://www.dailymail.co.uk/health/article-2673245/ Magnet-skull-beats-deafness-gives-hearing-hope-thousands.html

Van Gogh's final masterpiece The BBC News website recently reported on an art installation in a German museum, with some ear-related interest. A replica of Van Gogh's ear has been made by artist Diemut Strebe, using genetic material from a descendant of the Van Gogh family. The ear is being kept alive in case containing a nutrient solution. The artist plans to display the piece in New York later in the year. Read the article at http://www.bbc.co.uk/news/entertainment-arts-27667422

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39 CI baby An article on the BBC News website discussed the youngest child in the UK to be implanted with bilateral cochlear implants. Evie Smith was three months and three days old when she had her first implant, with the second following around seven weeks later. She was implanted so early because of ossification in the cochlea following pneumococcal meningitis in her first week following birth. Her devices were switched on at St Thomas' NHS Hospital in London, and her parents were reported to be delighted seeing her stir to the sound of a drum banging. The article is informative yet understandable for a lay reader. Read Evie's story at http://www.bbc.co.uk/news/health-26894812

Inattentional deafness Speech and Language Therapist Fiona Barry wrote an interesting article in the Telegraph recently on what she terms 'inattentional deafness'. She explains that this term describes an inability for a child to hear if they are focussed on complex visual stimuli. She points out the difficulty that this can cause in a classroom environment, particularly for children with speech, language and communication difficulties. A whole host of tips are offered for parents and teachers to help reduce inattentional deafness at home and at school. Read the article and Fiona's recommendations at http://www.telegraph.co.uk/education/educationadvice/10880108/ Inattentional-deafness-wont-listen-or-cant-listen.html.

Musical ears The Independent described a recent German study from Occupational Health and Environmental Medicine which claims that musicians are four times more likely than the general public to develop a hearing loss. They also found that musicians were 57 percent more likely to develop tinnitus. These stats come from insurance data from 7 million people, which may have some bias as musicians are probably more likely to claim for hearing loss or tinnitus than the general public. However, the authors' call for ear protection to be given to musicians seems sensible for anyone working in such a noisy environment. Read the Independent's report at http://www.independent.co.uk/life-style/health-and-families/ health-news/professional-musicians-four-times-more-likely-to-go-deaf-9308020.html.

BSL inspiration Ayesha Gavin tells her inspiring story of overcoming her profound hearing loss to become a teacher specialising in British Sign Language and Deaf Awareness in an article in the Guardian. Ayesha now runs her own BSL teaching company, Ayesha Communications, and explains the steps she went through to achieve this goal. Her story raises awareness of BSL as a language separate from English and can act as a guide for young profoundly deaf adults who are considering a career in teaching. Read Ayesha's story at http://www.theguardian.com/teacher-network/ teacher-blog/2014/jun/15/deaf-people-aspiring-teacher-rights

Sounds of a cochlear implant Professor Michael Dorman of Arizona State University has shared a video with the Telegraph, demonstrating software that recreates speech as heard by a cochlear implant user. In the video Prof Dorman explains how he has experimented with sound and some of their current research looking at using sound crescents to test patient performance in noise. It is only a short video with a couple of examples, but may be a useful counselling tools for the families of those with cochlear implants, to better understand their relativeâ&#x20AC;&#x2122;s experience. The video can be viewed at http://www.telegraph.co.uk/health/10848586/ What-the-world-sounds-like-with-a-cochlear-implant.html

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40 Vestibular rehabilitation explained While on the topic of video clips from foreign media, Indianapolis based TV station Wish TV recently aired a segment with Dr Scott Sanders and Stephanie Ford, in which they introduce vestibular rehabilitation. The 5 minute video is a succinct and easy introduction to vestibular rehabilitation aimed at those with no audiological background. Ms Ford demonstrates the three senses that contribute to balance with a modified CTSIB technique. Dr Sanders has previously explained on TV about BPPV, and this video can also be found on the website. One slightly melodramatic moment in the video - "balance problems lead to injury and death" â&#x20AC;&#x201C; might raise some eyebrows, however VR specialists will rejoice to hear patients dissuaded from using a certain anti-emetic drug as a long term solution. See the video at http://wishtv.com/2014/06/11/vestibular-rehab-for-dizziness-vertigo-and-imbalance

Sign of the Dog An interesting video clip appeared on the Daily Mail's website recently, courtesy of Australia's 9 News. The segment is about a deaf Great Dane called Hurley who was rescued by the RSPCA and has subsequently been taught sign language. Hurley demonstrates his ability to sit and lie in response to sign, though he does become a little excitable when 9 News' intrepid reporter has a go! According to the report, the RSPCA are currently looking for a home for Hurley, though by the time this comes to print, one will undoubtedly have been found for him. See the video at http://www.dailymail.co.uk/video/news/video-1100871/ Hurley-deaf-Great-Dane-learns-sign-language.html

Motion Sickness Glasses A novel solution to motion sickness has been described in an article in the Telegraph recently. A farmer from Norfolk has designed glasses which are opaque on one side, which he claims has cured his motion sickness on planes, trains and in cars. His idea was also featured on the TV programme, Make Me a Millionaire, and has reportedly attracted interest from Lloyd's Pharmacy. Reducing the complexity of visual stimuli may help patients with visual vertigo, though I think it will be some time before we are recommending opaque glasses in the vestibular rehabilitation clinic! Read about the glasses at http://www.telegraph.co.uk/news/newstopics/howaboutthat/10807674/ Sunglasses-could-put-an-end-to-travel-sickness.html

Breaking the Silence This final piece was brought to my attention by a couple of Audiologists venting their frustrations at inaccuracies via social media. BBc One's daytime serial drama, Doctors, recently aired an episode in which two patients received Cochlear Implants, but with differing attitudes. The episode successfully highlighted the importance and the identity of the Deaf community, but was overshadowed by some unrealistic outcomes with the implants! Unfortunately, to the best of my knowledge, the episode is not currently available to view, as it is no longer on the iPlayer. However, you can read the precis of the episode at http://www.bbc.co.uk/programmes/b046pczl.

Donâ&#x20AC;&#x2122;t forget that any piece that appears on a news website can be commented on or shared via social media, allowing the reader to add their voice to a debate and pass the story to friends and colleagues.

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Twitterarty @HallAmandJ introduces you to the audiology Twitter community

Twitter can be very useful for keeping up to date on conferences. By following conference hashtags or conference twitter accounts, you can catch up on the highlights in real time without being there. Some recent tweets from Audiology conferences around the UK and further afield…

#HEAL2014 – Hearing Across the Lifespan Conference, June 2014, Italy

#PAIG2014 – Paediatric Audiology Interest Group Meeting on Conductive Hearing Loss, July 2014, UK

#BAAConference2013 – British Academy of Audiology Conference Nov 2013, UK

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@HaldSIG – Hearing and Learning Disability Special Interest Group Meeting on Hearing and Down Syndrome, June 2014, UK

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43 #BSAconference – British Society of Audiology conference, Sept 2013, UK

New website launched www.thebsa.org.uk

Healthcare Hashtag Project To search for other healthcare conferences and conversations on twitter, have a look at the Healthcare Hashtag Project: http://www.symplur.com/healthcare-hashtags

The new website allows for online registration for new members and renewal of membership for current members. You can Facebook and Tweet us – or reach us in more traditional ways.

We are there for you – on your ipad, notebook or computer, in a format that is quick and easy to access.

Some of the key elements of the new website are: • The BSA Chairman’s message

Tips for conference organisers and those live-tweeting at conferences If you’re organising a conference, assume there will be live tweeting by the audience unless you specifically ask them not to.

• Online access to electronic versions of BSA publications • Easy and free access to BSA Policies and Procedures • Easy access to our very popular recorded Lunch & Learn and Lightning Updates • Direct access and updates on the work of the BSA Special Interest Groups • Information about conferences and events

Let everyone know in advance the hashtag for your conference. If you’re live-tweeting, use the hashtag so that others can follow any tweets relating to the conference. If you’re presenting at a conference, tell the audience your twitter name so they can cite you in their tweets. If you’re tweeting, make sure you credit tweets appropriately.

• Information about global outreach projects • Job adverts and information and links to organisations.

British Society of Audiology KNOWLEDGE | LEARNING | PRACTICE | IMPACT

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Smiles, tears, cows, chaos and colour: a trip to Bangladesh CD

I was very nervous seeing the first patient, as I had no experience working with analogue hearing aids. Thankfully I had the specification sheets and training from colleagues before I left. I saw over 24 patients and each had a remarkable story.

Author and Correspondence Tanjinah Ferdous, Audiologist at St. George’s Hospital, London E: Tanjinah.Ferdous@stgeorges.nhs.uk Tanjinah.Ferdous.09@alumni.ucl.ac.uk

Author with her grandmother

Acknowledgements This trip would not have been possible without the audiology departments at St Mary’s Hospital, Charing Cross Hospital and St George’s Hospital. Thank you. Also, gratitude is extended to my wonderful cousin, Farhat Jannal Adil, for her translation during the entire trip.

Going back to Bangladesh for the first time since I was eight years old felt like I was going back as a different person. Rather than for a family holiday, this trip took on a different purpose. The journey was unexpected, as my grandmother became ill and we rushed to visit her in the summer of 2013 for a couple of weeks. Having just graduated in Audiology from UCL, my passion for the profession was flourishing, and I realised that this was also an opportunity to do some charity work. My aim was to help those in need of hearing aids but unable to access the care they require due to the very pricey healthcare system in Bangladesh (the mere concept of free hearing aids startled the locals).

In the very few days I had to plan the trip I was overwhelmed by generous donations from three London hospitals; St Mary’s Hospital, Charing Cross Hospital and St George’s Hospital. Donations included all of the essential items to set up a small audiology clinic. The first day in my home city of Sylhet brought back all the memories of my childhood visits. The humidity, the vibrant colourful chaos, tiktiki lizards running along the walls, and the sight of cows strolling casually on the road as I ride past on a very fragile looking ricksaw. After a family reunion at my grandparents’ house, I began my work. With all the donations I set up a makeshift clinic in my grandparents’ back garden.

Donations from three London hospitals

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Nineteen-year-old Nayeem was last seen by SAHIC (Society for Assistance to Hearing Impaired Children in Bangladesh) in 1999, but had not had his hearing checked nor was he given amplification. His hearing test revealed a bilateral severe to profound sensorineural hearing loss. He grew up with no hearing rehabilitation and his family had given up. Of the devices I had brought with me the BE52 hearing aid seemed the most appropriate. I used a temporary earmould made with impression material and took another impression for a permanent earmould, to be posted to him later. Seven-year-old Mahdi was an inspiration. An amazing, cheerful soul, who had suffered from meningitis as a baby but had not received the appropriate care in time. As a result he was left with a bilateral severe to profound sensorineural hearing loss, with his speech being severely impaired. Despite this he never stopped smiling, and seeing him communicate via sign language was incredible, bringing tears

Audiology clinic in grandparents' garden

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45 Earmould fitting

Adjusting settings of an analogue hearing aid

Hearing aid user with son

Performing pure tone audiometry

Making an earmould from impression material

Thank you for hearing machine' message

Father communicating with son

7 year old Mahdi

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46 received a phone call saying half a dozen people were waiting to be seen at my grandparents’ home. So the work continued throughout the night, with some patients staying over as it was too late for rickshaw services. This seemed daunting, yet the atmosphere was energising.There is no denying that countless challenges were faced: the electricity cutting out, the intense heat, no soundproofing to block the moaning of cows in the fields nearby. However, when conditions weren’t great my cousins and I would visit our local tea garden where I remember playing as a child. The peace and serenity there was breathtaking.

to my eyes. He made me recognise how fortunate we are in the UK to have services that urgently care for children with meningitis. Between seeing patients I began researching audiology in Bangladesh. I visited the Sylhet Women’s Medical College for advice on where to go, and was greeted by Bonnie, a final year medical student. She kindly offered to take me to the Ibn Sina Hospital, the largest public hospital in the city. As we arrived we were introduced to the well-respected ENT specialist, Dr. Sadee. We discussed how audiology is practiced in the county, the prevalence of BPPV in the community and the treatments used. He feels “the support for audiology is very poor in Bangladesh”.There is clearly a need for audiological equipment and support in maintaining existing equipment - audiologists were still using OAE machines past their calibration date. However not only is technology essential, but so is a refreshing knowledge update. It is well known that there are highly effective positioning manoeuvres that have made BPPV the most successfully treatable cause of vertigo. However, perhaps we take this knowledge for granted. A few of the doctors I met would prescribe vestibular suppressants for a classic case of BPPV, and were not confident using the simple, effective treatment of the Epley manoeuvre. Dr. Sadee suggested visiting an organisation called Ear Care. Not knowing what to expect I turned up unannounced in the evening. There were dusty diagrams of the ear arranged on the walls with ageing calendars from hearing aid manufacturers. I enquired about their hearing aids, the cost, the fitting procedure and the experience of the audiologists, and received very confusing responses. One thing that did become clear was that audiologists working there received only a few days of training, and I was astounded by the extortionate prices of their hearing aids. The Rexton Arena 1P hearing aid was being sold for 11,250 taka, equivalent to £88. A lot of money, considering this was one of the poorest parts of the city. On the way back from Ear Care I

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Dr. Sadee, ENT specialist at Ibn Sina Hospital

Audiometer protected from dust

'Echocheck' - OAE Screener

Recording tymps on a young child

At Usmani Hospital I interviewed several ENT doctors who kindly took time out of their busy schedules, with waiting queues so long that security was needed! I spent a day with the team, giving me the opportunity to speak with them about their views on audiology in the country. They each expressed the dire need to have an established audiology service that could benefit all, not just the wealthier minority. They recommended a visit to Dhaka, the capital and largest city, as they felt the services in Sylhet were extremely poor. After a seven hour sleeper cabin ride I reached Dhaka, a compellingly different place to Sylhet. Dhaka is a congested, but thriving and colourful metropolis, home to around 18 million people. It is the most developed part of the country, and suffers from the challenges of poverty, pollution and overpopulation. I headed to the HiCare Centre (the Society for Education and Care of Hearing Impaired Children in Bangladesh), the first facility I visited where there was a recognisable audiology system in place. Before leaving London I was fortunate to liaise with Monica Tomlin

Rexton hearing aid, sold for 7000 taka (=£54)

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47 MBE who established the HiCare Centre, which includes 10 Schools and 4 hearing centres across Bangladesh. It was uplifting to see classrooms full of children, the majority hearing aid wearers, all with a sincere and contagious eagerness to learn. A young timid boy sitting at the back of the classroom grabbed my attention, and told me he had lost his hearing aid but his parents were unable to pay for a replacement. Thankfully, we were able to do a hearing test and provide him with a hearing aid. His face lit up, especially when given two boxes of batteries. The Chief Executive of HiCare, Ashraf Khan, made it clear that their service is lacking in many ways and they would welcome training to advance the service. He also noted that a multi-disciplinary approach to audiology has yet to be established. Along with his colleague Kaniz Fatema, a Chief Audiologist, we briefly discussed earmould venting, as they had a few questions regarding this aspect of hearing aid fitting. I left an audiometer at HiCare, a kind donation from my colleague Patrick Schwab, as

well as all the remaining stock that I had brought. I was privileged to meet such incredible people who were so full of gratitude for things that we often take for granted. We all know the NHS gets criticised at times but we are undoubtedly blessed to have amazing free audiological services; a system that is a dream to the people of Bangladesh. The entire experience has had a profound effect on me. I set out with the idea that if I could just help one person, it would all be worth it. It was moving to see so many villagers waiting to see such an inexperienced young person. Considering my minimal experience, I am sure every single one of you reading this could offer so much more. My great hope is that one day the Bangladeshi people will have the means to independently establish the audiology services they desperately deserve. However, until this day, I urge anyone with the interest to make a trip and share their resources and knowledge.You donâ&#x20AC;&#x2122;t need years to plan it, just pack your bags and go.

ENT team at Osmani Hospital

Classroom teaching

Young boy proud of his hearing aid

Replacement of lost hearing aid

Keya & Naim, unable to maintain tuition fees of hearing impaired school

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NHSP Quality Assurance Programme: the impact on audiology services CD

Authors and Correspondence Sally Wood MSc CS, Clinical Scientist (Audiology), Newborn Hearing Screening Programme England

Participation in QA has been a significant workload for audiologists and so it is essential that we feed back the findings and cumulative knowledge from the QA activity to the audiology community.This article summarises the main findings from all four cycles of QA activity.

Summary of findings

Graham Sutton MA PhD CS, Clinical Scientist (Audiology), formerly of Newborn Hearing Screening Programme England

Christine Cameron MSc CS, Clinical Scientist (Audiology), Newborn Hearing Screening Programme Centre. (retired)

Introduction The Newborn Hearing Screening Quality Assurance Programme (NHSP QA) began in 2006 shortly after full implementation of universal newborn hearing screening in England, and finished in 2013 following the completion of the 4th cycle.The aim was to assess performance against the NHSP quality standards (which incorporated the MCHAS guidelines) that cover the whole care pathway from initial screen to identification of a permanent childhood hearing loss and referral for management, medical investigations and early intervention. There was a clear rationale for this approach since there is arguably little benefit in early screening if follow-on services are not of appropriate quality. Between 2006 and 2013 there were four cycles of quality assurance; on each occasion audiology departments have completed questionnaires on their services, and submitted evidence in the form of local protocols, audits, ABR traces and case studies. In the first two rounds all departments were visited by the QA peer review team; in later rounds a selection of departments was visited. After each round departments were given a report outlining (amongst other things) assessments against the Quality Standards, acknowledgement of good practice and recommendations for service improvement.

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The outcomes of the first QA identified serious shortcomings in a number of paediatric audiology departments, with excellent practice evident in only a minority. Examples of the issues identified were: • ABR testing that was unsafe to the point where services were suspended • parents waiting several days to see a doctor to be given the outcome of the initial ABR because the audiologist was not allowed to give the information • hearing aids fitted to a flat ‘safe’ audiogram irrespective of the actual ABR thresholds • hearing aid fitting without real ear measurement • distraction testing used as the only behavioural test of hearing • audiological assessment carried out in rooms that did not meet national standards • few written protocols with the result that the service and care families received was heavily dependent on the knowledge and views of the individual clinician Although the message was often painful to hear many departments were able to use the recommendations in their QA reports to make the case for improved facilities, resources and training. Training courses were initiated by the Programme centre, NDCS and others (e.g. ABR refresher days, Early Amplification, Family Friendly Practice, Sharing the News) and some departments used these recommendations as an impetus for change.

Qua

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So now seven years later the view looks more promising but with much work still remaining.The self-assessment questionnaires and case studies submitted as part of cycle 4 show that:• Families are told the outcome of the diagnostic test on the day and nearly all audiologists/clinicians who do this have attended a course on Sharing The News

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49 • Most paediatric habilitation departments use VRA as the preferred behavioural test, with many clinicians having attended training courses. Bone conduction and insert phones are available in all departments (although still not always used routinely) and VRA is now often started at 6-7 months rather than 9-10 months • The majority of departments report that RECDs are routinely measured prior to hearing aid fitting. However there is little evidence of their systematic measurement following the initial fitting • The quality of ABR testing and interpretation has improved with increased adherence to national guidelines; there are still some departments with considerable improvement to make. • The value of external review of ABR is now generally accepted and is established in some areas. However the rigour of the process varies considerably. • Many paediatric services continue to operate in unsuitable rooms with little or no sound treatment, particularly in community settings • There is little evidence of systematic evaluation of hearing fitting, or use of outcome measures Much of the hard work to change clinical practice has been undertaken by individual clinicians and teams. The beneficiaries of this improvement in clinical practice are the children identified with PCHI and their families. An important underlying issue is the need for specific training for audiologists working in paediatrics. All too often newlyqualified audiologists have had to acquire skills from other members in the department, who may themselves have never undertaken formal training in paediatric audiology. There is an obvious need for better clinical leadership to drive some of these improvements. Most of the areas for improvement are not new-they have been identified and discussed in the literature for many years.

Maintaining and enhancing quality in the future The importance of maintaining quality and engaging in peer review is recognised in the recently published service specification for Newborn Hearing Screening1 which states (section 3.1) that:Regardless of the service delivery model, all babies with a screen positive outcome should be referred to audiology and seen for the initial appointment within four weeks of referral. Audiology services should adhere to national specifications and participate in a peerreview process of ABR and the NHS IQIPS initiative. The challenge for any quality assurance system is to use a rigorous process that includes an examination of clinical practice as well as examining processes and procedures. Self-assessment responses and evidence of safe and robust procedures and failsafe processes may be seen as key elements of a QA process. However, by themselves they may not be sufficient to assure the quality of a service.

Consider two examples. Consider a service which has a robust means of referral from screening to audiology with evidence of high attendance at a diagnostic appointment within the recommended target time and good failsafe checks. These processes may be nearperfect, but if the method of carrying out and interpreting the ABR test is not robust the service is of questionable value. Consider a service where the clinicians are pleasant, polite and explain the results carefully. The waiting room is pleasant and comfortable and a nursery nurse is available to play with siblings. Such a service is likely to rate highly on parent satisfaction surveys. However if the ABR testing is not scientifically robust the service is of questionable value. Parent satisfaction is an important element of QA but is only part of the picture. Parents are not in a position to assess the scientific and technical quality of the assessment that has been carried out on their child and parent satisfaction measures are not a substitute or surrogate for proper assessment of these aspects.

Hence to assess quality it is essential to look at the fundamental aspects of clinical services. In the 4th cycle of QA we requested two detailed case studies selected for the purpose by an unbiased member of the QA team according to pre-determined criteria. These were hugely informative in enabling the QA team to review the quality of clinical care. However in the final analysis the only people who can improve the quality of audiology services are audiologists. As audiologists we need to be robust in leading quality improvement in our services and arguing for the resources we need to achieve this.

Summary reports for cycle 4 of the QA have just been published in the public domain and can be found at http://hearing.screening.nhs.uk/siteqareports

References 1. Public health functions to be exercised by NHS England. Service specification No.20 NHS Newborn Hearing Screening Programme. Nov 2013. www.gov.uk/dh

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NHS hearing-aid services: some ideas to modify medicalisation and decrease stigma CD

Authors and Correspondence Dr Ruth Brooke Lecturer in Audiology University of Leeds

Dr Ted Killan Lecturer in Audiology University of Leeds

Dr Peter Morrall Senior Lecturer in Health Sociology University of Leeds

Take home message This article suggests that modifying the medicalised and olderage oriented sub-culture of NHS HA services will improve earlier access and reduce stigma of hearing loss and hearing aids.

The effects of age-related hearing loss are well known and include negative impacts on emotional, social, and physical wellbeing [1,2]. The use of optimally fitted hearing aids (HAs) is crucial in counteracting these effects. Anecdotal reports from NHS HA services indicate that the typical age of an individual presenting for assessment for first time HA fitting is 70 to 75 years old. However, many individuals experience symptoms for several years prior to seeking help [3] and this has remained the case despite changes to service delivery and improvements in technology [4]. Recently there have been calls for earlier provision of HAs to individuals who are fifty to sixty years old [4,5] in order to provide earlier benefit, facilitate acclimatisation and HA management and, potentially, reduce the risk of developing dementia in later life [4,6].

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Age-related Stigma Much research has been undertaken to investigate the reasons behind the reluctance of hearing impaired individuals, particularly these ‘younger patients’, to seek help, be provided with, or use a HA and a number of factors have been identified including cost, perceived lack of benefit and denial of hearing loss [7,8]. However, one disincentive that is often reported is the stigma, both real and perceived, associated with hearing loss and the use of HAs [5,9]. Stigma is used to describe an attribute that is demeaning and can lead to experiences of rejection, isolation, interpersonal and institutional discrimination, and what sociologist Erving Goffman describes as a ‘spoiled identity’ [10]. Stigma can affect all aspects of the hearing loss continuum (including acceptance, whether to be assessed, the type of HA selected, and when and where HAs are worn) and is related to three interrelated experiences: alterations in selfperception, vanity, and ageism i.e. the negative perceptions of growing old (e.g. cognitive decline, disability, reduced ability to function in society) [5,9,11]. This age-related stigma will be felt most acutely by fifty-to-sixty year olds who are still actively engaged in their work and careers and otherwise feel fit and well; they do not “feel old”. Therefore, to improve HA uptake and achieve the espoused benefits linked with earlier HA use, an important step is to identify practical strategies to breakdown the negative associations between hearing loss, HAs and ageing.

“Moderate-medicalisation”: A proposed way forward To breakdown these negative associations we suggest changes to the current “older-age-oriented” and medical sub-culture of NHS HA services in order to make them less medicalised (i.e. based around medical ideas of what is normal or abnormal [12]) and more appealing to fifty-to-sixty year olds. We argue the approach required is similar to what we identify as the “moderate-medicalisation” of optometry services undertaken some thirty years ago, wherein services were freed from the policies and protocols associated with being located in hospitals and were able to adopt high-street retail influences. This has seen glasses shift from being undesirable medical devices to being fashion accessories worn by people of all ages. In arguing for these changes we stress that we are not proposing privatisation or decommissioning of NHS HA services for mild to moderate hearing loss.

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51 In the UK an individual seeking intervention for hearing loss must visit their GP in order to obtain a referral to a NHS audiology service. This requirement, in addition to the subsequent hospital-based audiology appointments, increases the amount of time spent within medicalised environments, and may therefore reinforce the belief that having a hearing loss is a sign of ageing and illness. To reduce the amount of time patients are in a medical environment (and overcome any barriers that occur as a result of this) thought could be given to shortening the patient pathway by allowing direct access to audiology services, as also suggested by Dawes et al. [4]. The medical sub-culture typical of hospitals is immediately apparent to patients in the waiting areas and the treatments rooms. For example, wipe clean chairs and hand cleaning gel dispensers are ubiquitous. Similarly, some departments require their audiologists to wear white tunics that are synonymous with caring for people who are ill. Whilst infection control is an important consideration and the use of hand gel is important in this regard, wipe clean chairs and tunics are arguably unnecessary given audiologists are rarely exposed to bodily fluids. The wearing of suitable but personally chosen

work and with modern technology. HA advertisements could also be used more effectively, within waiting areas and treatments rooms, to highlight benefits for all age groups and could positively reinforce HA use by not always emphasising the discreetness of the device. Further, we feel it would be beneficial for prospective users to be able to view and try on a range of hearing devices and associated accessories and suggest that this is made possible in the waiting room. Following a case history and hearing test, individuals who would benefit from amplification are customarily shown a typical selection, or a single example of, beige, brown or grey HAs prior to their fitting. The assumption is often made that the HA should blend in with skin tone or hair colour, so that it is discreet. Little or no time is available for the client to discuss or try out different colours or designs in front of a mirror. We propose that the approach to being fitted with a HA should be more individualised, in a similar way to how people with poor vision are able to choose between wearing contact lenses or glasses, and further, what model of glasses to wear. Having had the opportunity to view and try HAs in the waiting room, clients will be better placed to make an informed choice

Is “moderate-medicalisation” the way forward for NHS hearing aid services? attire would go some way to support the creation of a less medicalised environment. Similarly, within the treatment rooms the walls often display, if anything, medically related information (e.g. posters regarding the anatomy of the auditory system, or protocols for the audiologists to follow), and there is a large amount of technical and medical equipment (required to programme modern HAs) on display. Thought could be given to the environment so that less emphasis is given to the clinical and medical nature of the appointment. The old-age-oriented sub-culture is also immediately apparent to patients. Simple changes, with the aim of making the department less elderly focused, might include making waiting areas more contemporary with consideration to colour schemes, the addition of some stylish chairs and sofas, magazine choices appealing to both a younger and older readership and access to the internet. The latter may be particularly pertinent in promoting earlier access by a younger demographic who are still working and may wish to work whilst waiting for their consultation. Waiting areas often contain myriad information, on noticeboards and as leaflets, regarding health and growing old e.g. regarding mobility, illnesses associated with age and social support for the elderly. Whilst we recognise these are relevant and important to a large proportion of patients, we suggest that increased information pertinent to a younger client is equally emphasised e.g. information regarding use of HAs at

regarding their HAs. Future cohorts of fifty to sixty year olds will be used to the sight of futuristic designed devices clearly observable in people’s ears (e.g. hands free mobile phones, personal listening devices). Thus, whilst some individuals may still choose a discreet model of HA, some may opt to make a bolder statement. A further aspect which could easily be addressed and one which has been shown to affect attitudes is language [13]. Anecdotal evidence shows the language used in association with audiology services, be it written or spoken, is often unimaginative and medical. Changes which may have a positive impact would be to routinely call the ‘patient case history’ an ‘interview’ and to refer to patients as ‘clients’. Although both words have similar definitions, ‘patient’ is only used in medical spheres whereas ‘client’ is used in other arenas and thus, may be less associated with illness and frailty. Further, when discussing HAs an approach similar to that used when describing modern technology could be used, with HAs called by their commercial names such as “Aero”, “Spirit” or “Halo” (a relatively new device co-developed by the ultra-fashionable Apple and Starkey). These names are chosen by the manufacturers following extensive market research and are synonymous with the futuristic-sounding names given to fashionable modern technology, such as the iPad Air. Finally, because the negative perceptions associated with the

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52 above sub-culture will be reinforced during each return visit to the department (or local health centre), it would be preferable to clients (and departments from an economic perspective) if repeat visits could be minimised. As an example, consideration should be given to alternative methods of battery dispensing such as placement of vending machines in areas that are easily accessed and not associated with health such as supermarkets and newsagents. Final thoughts In this article we have presented some ideas aimed at changing the medical and old-age-oriented sub-culture of NHS HA services to what we have called “moderate-medicalisation”. It is envisaged these modifications would decrease stigma associated with hearing loss and facilitate earlier access. Again, we stress that our argument is for a modified NHS HA service (in terms of its sub-culture) and not a call for privatisation. We also appreciate that, whilst some of these ideas represent small changes, others would require substantial financial investment and major policy change. However, this should not limit their inclusion in any future debates regarding improving services. We are also aware that, as well as positive outcomes, de-medicalisation may lead to negative consequences. It is therefore important that future research is undertaken to explore the potential benefits of “moderatemedicalisation” to NHS HA services.

References 1. Dalton DS, Cruickshanks KJ, Klein BE, Klein R, Wiley TL & Nondahl DM. The impact of hearing loss on quality of life in older adults. Gerontologist 2003;43:661-8. 2. Gopinath B, Wang JJ, Schneider J, Burlutsky G, Snowdon J, McMahon CM, Leeder SR & Mitchell P. Depressive symptoms in older adults with hearing impairments: the Blue Mountains Study. J Am Geriatr Soc 2009;57:1306-8. 3. Davis AC. The prevalence of hearing impairment and reported hearing disability among adults in Great Britain. International Journal of Epidemiology 1989;18:911-17. 4. Dawes P, Fortnum H, Moore DR, Emsley R, Norman P, Cruickshanks K, Davis A, Edmondson-Jones M, McCormack A, Lutman M & Munro K. Hearing in middle age: a population snapshot of 40- to 69-year olds in the United Kingdom. Ear Hear 2014;35:e44-51. 5. Wallhagen MI. The stigma of hearing loss. Gerontologist 2010;50:66-75. 6. Lin FR, Ferrucci L, An Y, Goh JO, Doshi J, Metter EJ, Davatzikos C, Kraut MA & Resnick SM. Association of hearing impairment with brain volume changes in older adults. NeuroImage 2014;90:84-92. 7. Knudsen LV, Oberg M, Nielsen C, Naylor G & Kramer SE. Factors influencing help seeking, hearing aid uptake, hearing aid use and satisfaction with hearing aids: a review of the literature. Trends Amplif 2010;14:127-54. 8. McCormack A & Fortnum H. Why do people fitted with hearing aids not wear them? Int J Audiol 2013;52:360-8. 9. Preminger JE & Laplante-Lévesque A. Perceptions of age and brain in relation to hearing help-seeking and rehabilitation. Ear Hear 2014;35:19-29. 10. Stigma: notes on the management of spoiled identity. Erving Goffman. Publ Simon & Schuster, 1963 11. Hickson L & Meyer C. Improving uptake and outcomes of hearing aid fitting for older adults: what are the barriers and facilitators? Int J Audiol 2014;53 Suppl 1:S1-2. 12. Morrall P. 2009. Sociology and Health: An Introduction Routledge. 13. Young ME, Norman GR & Humphreys KR. The role of medical language in changing public perceptions of illness. PLoS One 2008;3:e3875.

In the next issue of Audacity Whatever happened to ASSRs?

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Journal Club: What do the papers say? Article by Rachel Card & Annie Woolley, STP Trainees, Nottingham University Hospitals & University of Manchester Photography by Simon Unwin, Prinicpal Audiologist, Betsi Cadwaladr University Health Board

Screening Tools Boatman et al, 2007, How Accurate Are Bedside Hearing Tests?, Neurology, Vol. 68, pp. 1311-1314 Presented by Dr Cherilee Rutherford Effectiveness of Screening Yeuh et al, 2010, Long-Term Effectiveness of Screening for Hearing Loss: The Screening for Auditory Impairment - Which Hearing Assessment Test (SAIWHAT) Randomised Trial, Journal of the American Geriatrics Society, Vol. 58, pp. 427-434 Presented by Dr Lorraine Gailey Economic Evaluation of Screening Morris et al, 2012, An Economic Evaluation Of Screening 60- to 70Year-Old Adults for Hearing Loss, Journal of Public Health, Vol. 35, No. 1, pp. 139-146 Presented by Mr John Day

Tools for Evidence-Based Quality Assessment The STARD (STAndards for the Reporting of Diagnostic accuracy studies) initiative aims to improve the accuracy and completeness of reporting of studies of diagnostic accuracy, to allow readers to assess the potential for bias in the study (internal validity) and to evaluate its generalisability (external validity). The STARD statement consists of a checklist of

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Adult Hearing Screening The BSA Learning Events Group recently held the first in a new series of Journal Clubs at NIHR Nottingham Hearing Biomedical Research Unit. The focus for the event was Adult Hearing Screening. As organiser, Jane Wild had selected a range of articles covering different aspects of the screening process (see panel). Each article was summarised by the presenter and a group discussion followed considering its strengths and weaknesses. Interestingly, none of the articles were published in audiology journals, which gave delegates an insight into the way that hearing research is undertaken by and presented to non-audiology professionals. It was really pleasing to see that hearing screening was being considered in high impact journals in the fields of Neurology, Gerontology and Public Health. The first article by Boatman and colleagues aimed to evaluate the sensitivity and specificity of a screening test battery that could be completed with minimal equipment at a patient's bedside, compared with pure tone audiometry. This included listening for a watch tick, rubbing fingers, whispered speech and Weber and Rinne tuning fork tests in combination with a self-assessment questionnaire. The results were compared to a pure tone average of 0.5, 1 and 2kHz.The study was limited by the lack of test standardisation and the use of only one tester but highlighted the poor sensitivity of these tests as well as the misuse of tuning fork tests to screen for hearing loss. The authors concluded that further studies are required to investigate the potential for the use of pure tone screeners and OAEs in future. Cherilee also introduced the group to some useful tools to help readers to evaluate similar papers (see panel). Yueh and colleagues presented a well considered paper assessing whether American veterans who were screened with a tone emitting otoscope and questionnaire were significantly more likely to use hearing aids one year following the screen than either controls or those who were screened with only one test. This population is of particular interest to those working in the NHS as veterans are eligible for free audiology services. Around three quarters of the participants thought that they might have a

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25 items and recommends the use of a flow diagram which describes the design of the study and the flow of patients. Further details are available from www.stardstatement.org The QUADAS (QUality Assessment Tool for Diagnostic Accuracy Studies) was developed with funding from the Health Technology Assessment Programme and has been recommended for use by the Cochrane Collaboration, the National Institute for Health and Clinical Excellence and the Agency for Healthcare Research and Quality. Further details are available from www.bris.ac.uk/quadas Further Reading Wong & Hickson, 2012, EvidenceBased Practice in Audiology: Evaluating Interventions for Children and Adults with Hearing Impairment, Plural Publishing, San Diego, CA, USA

Student Perspective Students attending an event such as this with more experienced professionals can understandably feel some apprehension; 'Will I understand the papers?', 'What if I'm asked something I don't know?'. However, these concerns were not to be realised. The small size of the group made it easier to have the confidence to give your opinion and each person's input was equally welcome and valued and everyone had something to learn. Some of the key benefits for us were •Developing our critical appraisal skills. •Gaining confidence to voice our ideas. •Gaining a greater understanding of an important and current topic in Audiology. •Meeting with colleagues from all areas of the field, including clinicians, researchers and academics. These skills are directly linked to a number of our learning outcomes and will definitely impact our future

hearing loss.This perhaps reflects the risks of noise exposure amongst veterans, and the recruitment method of voluntary enrolment attracting those who had concerns about their hearing.The authors found the greatest prevalence of hearing loss (confirmed by pure tone audiometry) in the group that was screened with both the tone emitting otoscope and questionnaire. However, the rate of hearing aid use in this group was only 7.4%, which perhaps suggests a need for alternative rehabilitation strategies. Although it may be more challenging, it may be more effective to screen for hearing disability, rather than hearing loss, as Knudsen and colleagues (2010) showed that self-reported hearing disability to be the only positive predictor of hearing aid uptake, use and satisfaction. Delegates certainly saw predictors of non-use as an area for further investigation. The third paper by Morris and colleagues described an economic evaluation of hearing screening and many delegates found it to be the most difficult to digest. The authors used terms such as the incremental cost-effectiveness ratio (ICER), dominance and QALY (Quality Adjusted Life Year) and tools such as scenario analysis and Markov models that would be familiar to those working in public health, but certainly had delegates turning to the sheet of definitions helpfully provided by John. Although challenging, it is important for audiologists to be able to understand this type of study both in order to evaluate their validity and because this evidence will be important to agencies such as the National Screening Committee who influence whether adult hearing screening is implemented in the UK. The authors concluded that a screen using a one stage audiometric test targeting bilateral hearing loss of at least 30 dB HL in adults aged 60-70 years would be cost-effective. The authors also suggested that almost double the current number of patients currently fitted via GP referral would obtain hearing aids if screening were introduced, impacting on a lot of lives. Although the modelling approach has limitations, the authors considered and, where possible, provided a rationale for their decision on figures such as the rate of hearing aid take-up. Delegates then discussed the option of direct access to audiology services, perhaps including a screen in the initial appointment, as an option between the current system of GP referral and the proposed system of screening evaluated in the paper. The feedback from other delegates echoed our own views and showed that, in addition to finding the Journal Club to be a valuable learning experience, they appreciated the relaxed and informal atmosphere and were surprised by how much fun they had at the event! Going Forward Following the success of this Journal Club, the LEG organisers plan to take the format forward with biannual events hosted in different regions of the UK. Adult Hearing Screening will be discussed again at the BSA Conference in September. There are also plans for a future focus on Dementia and Hearing Loss, with invited experts from other professions. If you would like to see the Journal Club come to your area or there is a topic that you would be keen to discuss, please get in touch!

A Participant’s View by Nighat Kalsoom BSA Journal Club Review My name is Nighat Kalsoom and I graduated last year from the Audiology BSc programme, I work at Derby Hospitals NHS Foundation Trust. When I saw the advert on the BSA website for a journal club I thought it would be a fantastic opportunity to continue my professional development by discussing a topic that I felt was very current. It also sounded like a good way to enhance my ability to critique papers

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practice; gaining confidence in identifying the strengths and weaknesses of the design of other studies will be invaluable when conducting our own research and the breadth of papers has illustrated the importance of building links with our colleagues in other disciplines. Overall, we would recommend future events to other students who are keen to better understand the evidence for our practice.

alongside more experienced colleagues. I was not disappointed in the least. At the journal club I met with professionals with many years of experience in research and although I had the least experience I was not made to feel inadequate – so thank you all. We discussed how to set up a journal club as a way to keep training and practice current within your own department or organisation. This is easy to do; someone from your department/organisation with some or little research experience can choose three papers from different journals on a similar topic, which will then be discussed amongst staff so they can be critiqued using a critical appraisal form (which can be found on the internet). As a learning tool this can be priceless. From my experience I would definitely recommend attending the BSA’s bi-yearly Journal club, which will also be one of the events offered at the annual conference in Keele in September.

Getting engaged in the North West Getting Engaged… There are some great venues in the North West to get engaged. If you are thinking a ‘down on one knee enduring love’ type of engagement, that’s not quite what we’ve been talking about at BSA NW. Instead for the North West regional BSA Group it is public engagement we’ve been getting excited about! At our winter regional meeting around 30 members met up to discuss what public engagement means to us at BSA NW and to see if there was anyone who might be interested in working on some local “PE” projects.

Tracey Adams, MPhys MSc CAC Audiological Support Specialist, Cochlear Europe Middle East & Africa E: tadams@cochlear.com Cochlear Europe Limited, 6 Dashwood Lang Road, Bourne Business Park, Addlestone, Surrey, KT15 2HJ, UK

What unique contributions can BSA bring to PE projects? The British Society of Audiology stands for evidence based practice, linking science knowledge to education and multidisciplinary working. Using these key principles we felt that any PE projects we worked on should target -

KNOWLEDGE LEARNING PRACTICE IMPACT

Reaching Out… One of our first discussions was around who it was we could reach out to. Who are our “public”? School children or young people? Adults or seniors? Or a particular demographic of the population? We had a good discussion around this and one of the target groups we decided we’d love to reach in the region were young people at risk of hidden hearing loss. Talking Topics…. Next the fun bit! Breaking up into smaller groups, we quickly came up with some

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57 really creative ideas to make up a long list of projects. Each group explained their ideas to the meeting and after refreshments we summarised our discussion and agreed our next steps. An email vote to all our NW members followed the meeting to allow everyone, even those that couldn’t attend, to choose our favourite projects. We came up with our short list of 3 topics, but here is the long list – which would you have voted for? • Create a phone App “How old are your ears?” promoting hearing care awareness. • Football in the Community project for hearing impaired children. • Have an MSc student competition to develop You Tube clips on Audiology. • Highlight hearing health to young people at Music Events. • Campaign Schools on inclusion hearing/balance in PSE/Citizenship classes. • Encourage school careers officers to include Audiology (and other Healthcare Sciences). • Develop resources to give talks at University of the 3rd Age, luncheon and other clubs. • Link up with Museums/Galleries to coordinate projects on hearing and balance.

Working together… All North West BSA members were invited to join the working party and the result was a small but willing band of volunteers who met to discuss the short list. We looked at how achievable each topic really was and they were adapted accordingly in order to set some achievable short, medium and long term goals to get started on. Rob Johnson talks us through the Macclesfield Children’s Audiology Sports Day Event

Host Your Own Event… If you are interested in hosting your very own Sporting Event for Hearing Impaired Children, you can find a full description of the event, a step by step break down of the things you need to do as well as templates ready for you to edit with your own local details: • Letter to Parents including Application/Consent Form • Attendance List • Poster or Newsletter Adver

Sports in the Community for Hearing Impaired Children The Macclesfield Football Project took place in November with 8 children (aged 7-12) and their and parents. The project was financially supported by Community Sports Trust in partnership with Macclesfield Football Club. The children had 45 minutes of football coaching and then attended a home match. They had an announcement at the game and the children provided a guard of honour to the players entering the pitch. This event was highlighted in the Macclesfield Town Match Program and later the local paper and the Trust Newsletter published articles on the event.

All of this can be found on our new NW Public Engagement website. Please let us know if you’re planning an event – we’d love to hear about it. BSA NW Next Steps… Our next key goal is to work on a project to raise awareness of hearing loss and hearing aids through the “University of the Third Age” who have indicated an interest in the project so we think that there would be plenty of opportunities to deliver talks at these types of meetings. For more details on the University and its activity in the UK please see their website http://www.u3a.org.uk/

Progress to date… Our short term project was to develop a Sport in the Community project for hearing impaired children. A highly successful event had already been run by colleagues in the Macclesfield Audiology department in collaboration with Macclesfield Town Football Club. We felt that it would be really useful to develop a template so that other Audiology Departments and BSA Regional groups could use the same idea with their local sports clubs. These templates are now completed and you can download all the information to help you run your own version of the event locally, quickly and easily! Just follow this link: www.thebsa.org.uk/public-engagement/public-engagement-resources/

We’ve also been busy looking at whether there is a need to develop hearing / balance information for use in schools. A questionnaire was given to teachers to find out what types of resources they might be interested in receiving – the most requested format was for Practical Demo Ideas, especially on ‘How We Hear’ and ‘How we Balance’. Our next goal is to work on a “Lesson in a Box”. Our group plans to meet three times a year and we are keen to expand our working party. Members have approached some patients to join and would like to encourage any of our BSA members in the NW to get in touch! Links/resources… www.PublicEngagementBSANW.com

●

www.u3a.org.uk/

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Twilight Meeting on Implantable Devices Another successful Twilight Meeting was held in the North West region this time on Thursday 26th June. The topic was on the ever developing and exciting field of implantable devices. Our ENT colleague Mr Mark Fenton kicked off with surgical perspectives on implantable devices and talked us through the Manchester Royal Infirmary experiences of Bone Anchored Hearing Aid implantations as well as transcutaneous devices. He then moved on to cochlear implantation and the significance of electrode insertion depth for low frequency hearing preservation to improve patient outcomes.

Roulla Katiri, MSc Twilight Meeting Coordinator Audiologist Mater Misericordiae University Hospital Dublin, Ireland E: rkatiri@mater.ie

Dr Bob Carlyon took over to share his experiences on performing clinical trials and outcome studies in the cochlear implantees population. He walked us through theoretical reasons on why certain psychoacoustic changes may or may not help with outcomes and highlighted the importance of overcoming experimental biases when translating research outcomes and correlating results to the clinical setting. Finally Catherine Killan shared her vast clinical audiological experiences in the field of paediatric implantations at the Yorkshire Auditory Implant Service and discussed the use of clinical spatial listening testing. She then walked us through her well equipped clinical toolkit to test the paediatric population using the Crescent of Sounds to aid effective patient management, parents counselling and developing staff's clinical experiences. A very healthy discussion was lead at the end by the chair of the meeting Dr Martin O'Driscoll and the floor contributed their experiences to link lab work to clinic. The meeting proved once more a brilliant setting for networking between clinicians, medics, researchers and students.Thanks to our generous exhibitors delegates were informed on new product developments by Advanced Bionics, MedEl and Oticon Medical. We are looking forward to future Twilight Meetings which are always bringing new perspectives to our research and clinical thinking!

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New BSA Website In line with the dynamic and forward-thinking work of the BSA, we decided that the time had come to have a leading website that is the first port of call for Audiology. The new BSA website went live on Monday, the 16th June 2014. An email was sent to all members with a new username and link for setting up a new password, which allows access to members-only sections. Some of the key elements of the new website are:

Nicci Campbell, BSA Advisor Associate Professor/Principal Audiological Scientist University of Southampton Email: N.G.Campbell@soton.ac.uk

• The BSA Chairman’s message which provides a regular update on the work of the BSA and new developments, both nationally and internationally, in the field of Audiology • Online access to electronic versions of BSA publications such as Audacity and the International Journal of Audiology • Easy and free access to BSA Policies and Procedures, outlining best practice based on current evidence • Easy access to our very popular recorded Lunch & Learn and Lightning Updates, keeping you informed of latest developments from the comfort of your own desk • Direct access and updates on the work of the BSA Special Interest Groups and news of their publications and international collaboration • Information about conferences and events, with easy online registration for BSA events Informa tion and updates about research grants, prizes and awards • Information about global outreach projects, projects within the community and information for the public Old to new • Job adverts and information and links to organiwebsite sations and our sponsors The new website allows for online registration for new members and renewal of membership for current members. You can Facebook and Tweet us – or reach us in more traditional ways. We are there for you - on your ipad, notebook or computer, in a format that is quick and easy to access.

Visit the BSA website at www.thebsa.org.uk We look forward to hearing from you.

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Essentials Council Members / Meeting Dates Officers Prof Kevin Munro – Chairman Dr Huw Cooper – Vice Chairman Dr David Baguley – Immediate Past Chairman Prof David Furness – Secretary (ESP) Mr Andrew Reid – Treasurer Elected Trustees Dr Michael Akeroyd Mr Peter Byrom Mr Chris Cartwright Mr John Day Dr Heather Fortnum (RFSCo) Dr Sebastian Hendricks (PAIG) Dr Martin O’Driscoll (Audacity) Ms Helen Pryce

Dr Nick Thyer Ms Tracey Twomey (PPE) Council Advisors Ms Siobhan Brennan (EAP) Dr Nicci Campbell (BSA New Website) Miss Debbie Cane (Chair, Balance Interest Group) Mr David Canning (PA Interest Goup) Professor Adrian Davis (IJA Council Representative) Dr Piers Dawes (Interim Chair, Cognition and Hearing) Mrs Mel Ferguson (Coordinator Learning & Events Group) Ms Pauline Grant (Chair, Auditory Processing Disorders) Ms Lucy Handscomb (Chair, Adult Rehabilitation Interest Group) Mr Paul James (Chair, Professional Practice Committee) Ms Kathryn Lewis (BSA North) Mr Jason Smalley (Webmaster) Miss Charlotte Turtle (New Members Representative) Dr Peter West (IJA Council Representative)

BSA Meeting Dates for 2014 Wednesday 3rd September - Annual Conference, Keele Tuesday 9th December - University of Manchester (TBC) Council from 11.00am to 4.30pm Housekeeping Meetings Dates Tuesday 12th August Thursday 23rd October The above meetings will be held at the BSA Admin Office Professional Practice Committee Meeting Dates Monday 22nd September Monday 24th November Hearing and Balance UK Meeting Dates Wednesday 16th October

Meeting dates and venues may be liable to change... essentials

For further information, please contact BSA Admin Office Tel: 0118 966 0622 Fax: 0118 935 1915 Email: bsa@thebsa.org.uk Web: www.thebsa.org.uk

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Essentials Examination Passes The following students have passed accredited BSA courses over recent months:

BSA Certificate in Otoscopy & Impression Taking (Adults & over 5â&#x20AC;&#x2122;s) (Audio-Training) Lynne Standen Fred Jackson Luke Grainger Jenny Ware

Luke Mynott Craig Roberts Jacci Davies Ryan Birch

Ellie Jones Helen Maiden April Naylor Joshua Knight

BSA Certificate in Industrial Audiometry (Audio-Training) Georgios Stavrinos Meryl Cochrane Craig Roberts

Kenneth Reed Kathryn Phillips Bob Macdonald

Alistair Bromhead Bernard Masters

BSA Certificate in Basic Audiometry & Tympanometry (Community Audiology, Dublin) James Paul Stewart Leah Harnett Tom Barrett Deirdre O'Connor Orla Smith Catherine Lowe Catherine Brien Robert Murphy Irene Moffat Darina McGuirk Brigid Fitzpatrick Ann-Marie Coyle Geraldine Kavanagh Bernadette O'Brien May McBride Elizabeth Brosnan Norma Browne Una Donohoe Geraldine Trant Helena Allen Fiona Devereux Joan Giller

Ann O'Connell Elizabeth Cullen Elizabeth Ward Brian Redahan Deirdre Murray Bridie Martin Linda Hayes Sarah O'Malley Adrian Kelly Lucy McClean Josephine Devlin Agnes Flynn Margaret Harkin Pamela Austin Mary Naughton Edel O'Connor Ann-Marie Dillon Jerome Ryan Caitriona Cologhan Mary Murphy Paul McKenna Essie Jennings

Congratulations to all candidates Details of all accredited course providers, together with information on providing accredited courses, are available from the BSA office and via the BSA website www.thebsa.org.uk. The BSA also retains a list of delegates who have completed accredited courses.

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Ann O'Gara Gemma Healy Marie O'Connell Seosaimhin Kidney Sinead Taff Ann Byrne Maura McCarthy Edel Kelleher Stella Murray Nicola McMahon Anita Ennis Anne O'Malley Rosemary McDonnell Helen Whelan Joe Quinn Edel Frawley Angelika Wiesmann Muriel O'Mahoney Edith O'Regan Claire Joyce Elaine Kehilly Phil Fitzgerald

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Essentials Sponsor Members The partnership with Sponsor members of the British Society of Audiology (BSA) is of fundamental importance to the Society. As the largest multidisciplinary society concerned with hearing and balance in the UK, the BSA seeks to include commercial colleagues and organisations in its mission to promote knowledge, research and clinical practice in these areas. Being a Sponsor member places an organisation in close dialogue with senior members of the BSA, supporting meetings and publications. The outworking of this are yearly meetings between the Officers of the BSA and the Sponsor members to share information and perspectives on the strategic direction of the BSA. Sponsor members have direct input to the Programmes Committee, and their input is especially valued in the organisation of meetings and supporting exhibitions, these being a crucial element of successful events.

ACOUSTIC METROLOGY LIMITED Manufacturers of VRA systems. Repair service of Audiometers, tympanometers and acoustics instruments. E: info@a-met.com W: www.a-met.com

INDUSTRIAL ACOUSTICS COMPANY LTD World leader in the design, supply and installation of high performance, state-of-the-art of Audiometric Rooms. E: info@iac-acoustics.com W: www.industrialacoustics.com/uk

SIEMENS HEARING INSTRUMENTS LIMITED Leader in the provision of digital hearing systems to the NHS and private hearing aids dispensers. E: info-hearingaids.shi.ukhealthcare@ siemens.com

AMPLIVOX LIMITED Amplivox provides a range of audiological products and services that combine innovation and reliability E: n.court@amplivox.ltd.uk W: www.amplivox.ltd.uk

OTICON LIMITED Oticon designs and manufactures both hearing solutions for adults, and specialized paediatric instruments. E: info@oticon.co.uk W: www.oticon.co.uk

SPECSAVERS Specsavers is largest provider of the free NHS digital hearing aids and 60% of its 17.3m customers in the UK are from the NHS. W: www.specsavers.co.uk

AUDITDATA LIMITED Auditdata provides office management systems for hearing clinics, innovative audiometry fitting systems, and hearing instrument testing. E: uksupport@auditdata.com W: www.auditdata.com

OTODYNAMICS LIMITED Otodynamics Ltd. pioneered OAE screening 25 years ago and sells a wide range of OAE screening and diagnostic instruments and makes in-house research and development its top priority E: sales@otodynamics.com W: www.otodynamics.com

STARKEY LABORATORIES LIMITED Provides information throughout the world about hearing loss, hearing aids and different types of hearing professionals. E: sales@starkey.co.uk W: www.starkey.co.uk

BIOSENSE MEDICAL LIMITED Biosense Medical supply specialist equipment for use in Audiology, Vestibular and Balance, Neurophysiology, Pressure Measurement, Human Movement and Biomechanics W: www.biosensemedical.com

PHONAK UK Phonak offers latest product information, an interactive content about hearing and a specific children section W: www.phonak.com

THE TINNITUS CLINIC The Tinnitus Clinic is the leading provider of the latest evidence-based tinnitus treatments in the UK. W: www.thetinnitusclinic.co.uk

ECKEL INDUSTRIES OF EUROPE LIMITED Eckel supply, design and install hemi (semi) and anechoic chambers. Further applications offered include Audiology Rooms and Suites. E: general@eckeleurope.co.uk W: www.eckeleurope.co.uk

PURETONE Limited Manufacturers of quality digital and analogue hearing aids, tinnitus management systems. E: info@puretone.net W: www.puretone.net

P C WERTH LIMITED PC Werth supplies calibrate and service the UKâ&#x20AC;&#x2122;s leading range of instruments for every diagnostic and audiology need. E: sales@pcwerth.co.uk W: www.pcwerth.co.uk

GUYMARK UK LIMITED Guymark is a distributor of GSI audiological equipment, Vivosonic ABR equipment and Micromedical Technologies balance equipment E: sales@guymark.com W: www.guymark.com

GN RESOUND LIMITED ReSound is part of GN ReSound Group, one of the worldâ&#x20AC;&#x2122;s largest providers of hearing instruments and diagnostic audiological instrumentation E: iinfo@gnresound.co.uk W: www.gnresound.co.uk

THANK YOU FOR THE VALUABLE SUPPORTS

www.thebsa.org.uk

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Essentials Audacity Advertising rates ADVERTISING RATES : 2014 - 2015 Combined Career Opportunity

Sponsors Non-Sponsors Half A4 colour Full A4 colour

£325 £545

Full A4 in Audacity + Web listing + Bulk Email (commercial) Half A4 in Audacity + Web listing + Bulk Email (commercial) Full A4 colour in Audacity (unlimited words) + web listing Half A4 colour in Audacity (unlimited words) + web listing Quarter A4 colour (200 words) + web listing

£495 £845

Special Positions Full A4 Colour Outside Back Cover Full A4 Colour Inside Front Cover Inside/Outside Cover Sponsors ONLY Technology Update per issue

£915 £845 £215 £230

Flyer insert in Audacity Single A4 (flyer provided) Single A4 (B/W printed by BSA)

£645 £895

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2014 - AUDACITY PUBLICATION SCHEDULE

For further details, please contact the BSA Admin Office by email: bsa@thebsa.org.uk or Tel: 0118 966 0622