Interventions for Cochlear Implants and Associated Barriers in Occupational Therapy

Introduction

In 2019, 118,100 cochlear implant (CI) devices were implanted in adults and 65,000 in children.^[1]Estimates based on manufacturers’ voluntary reports of registered devices to the U.S. Food and Drug Administration, December 2019. Cochlear implants can help users to better perceive sounds such as loud, medium, and soft. They can also help users to make telephone calls, watch TV more easily, and music. All of these activities can be meaningful occupations in occupational therapy.

Success vs Rejection

How successful are they? Everyone’s hearing range is different and so the benefits they may get from cochlear implants may vary, from “near normal” to no hearing benefit at all. ^[2]FDA. (2022). Benefits and Risk of Cochlear Implants. Retrieved from https://www.fda.gov/medical-devices/cochlear-implants/benefits-and-risks-cochlear-implants Children also differ compared to adults who receive cochlear implants. Adults benefit immediately and continue to improve months after the initial tuning sessions and continue to improve for several years. Overall, children improve at a slower pace and require a lot of training.

The rejection rate is less than 0.2% of recipients. The cochlear implantation procedure also comes with its risks due to its use of general anesthesia, potential injury to the facial nerve, meningitis, CSF leakage, infection, vertigo attacks, tinnitus, taste disturbances, numbness around the ear, and localized inflammation.^[3]FDA. (2021). Benefits and Risks of Cochlear Implants. Retrieved from https://www.fda.gov/medical-devices/cochlear-implants/benefits-and-risks-cochlear-implants

Complications and Long-Term Impact

Aside from the surgical complications, issues specific to the implant include hearing sounds differently (including strange sounds), losing residual hearing, unknown effects affecting nerves, having the implant itself fail, not being able to upgrade to a better one in the future, not being able to have imaging done such as MRIs, and specific lifestyle changes.

Examples of lifestyle changes include setting off theft detection systems and metal detectors, being affected by radio waves such as cell phone uses, turning them off during airplane take-offs and landings, and other unpredictable interactions with technology.^[4]FDA. (2021). Benefits and Risks of Cochlear Implants. Retrieved from https://www.fda.gov/medical-devices/cochlear-implants/benefits-and-risks-cochlear-implants

In one study of the long-term outcomes in cochlear implant recipients from childhood, “Educational, vocational, and occupational level achieved by this cohort were significantly poorer compared with the German and worldwide population average.”^[5]Illg, A., Haack, M., Lesinski-Schiedat, A., Büchner, A., & Lenarz, T. (2017). Long-term outcomes, education, and occupational level in cochlear implant recipients who were implanted in … Reference List Another study reported that “Although all CI-users reported high satisfaction with their work, the correspondence between career aspiration and actual occupation was significantly lower for CI-users compared to normal-hearing peers.”^[6]Huber, M., Wolfgang, H., & Klaus, A. (2008). Education and training of young people who grew up with cochlear implants. International Journal of Pediatric Otorhinolaryngology, 72(9), 1393-1403.

Therapy Team

Therapies for children who receive cochlear implants include speech, aural rehabilitation, physical therapy, occupational therapy, early intervention, and counseling. In one study of families of children who received cochlear implants, 50% reported no obstacles to accessing therapies (and 50% did). The biggest barrier to therapies was insurance. As for the family, not everyone is potentially on board with this procedure, such as extended family.^[7]Wiley, S., Jahnke, M., Meinzen-Derr, J., & Choo, D. (2005). Perceived qualitative benefits of cochlear implants in children with multi-handicaps. International journal of pediatric … Reference List In this study, it is worth noting the method of communication pre-implant and post-implant.

As you can see, a good portion of the participants preferred to continue using sign language and/or behavior instead of strictly oral.^[8]Wiley, S., Jahnke, M., Meinzen-Derr, J., & Choo, D. (2005). Perceived qualitative benefits of cochlear implants in children with multi-handicaps. International journal of pediatric … Reference List This means that receptively, the cochlear implant may be helpful, but it does not necessarily mean they are able to communicate with those with normal hearing. Therefore, families would most benefit from a combination of methods of communication. For occupational therapists, they would benefit from learning how to sign for working with this population and their families.

‘‘everyone painted a rosy picture of what was going to happen. We did not really know about how much work it would take.’’

Theory of Rehabilitation

Occupational therapists can play an important role with those who receive cochlear implantation across the lifespan. Cochlear implants are a form of assistive device to address hearing impairment.^[9]Tomita, M., Mann, W. C., & Welch, T. R. (2001). Use of assistive devices to address hearing impairment by older persons with disabilities. International journal of rehabilitation research, 24(4), … Reference List Whether there are small or large, positive or negative improvements from the procedure, occupational therapists play a role in how patients perceive their world through the sensory input of hearing and vestibular function in their participation in everyday activities. The theory behind occupational therapy rehabilitation is the underlying mechanism of neuroplasticity after cochlear implantation. The auditory system is believed to be able to undergo extensive reorganization of external input during development.^[10]Zhang LI, et al. Disruption of primary auditory cortex by synchronous auditory inputs during a critical period. Proc. Natl. Acad. Sci. U S A. 2002;99:2309–2314. This is especially true for children before aged 3-4 years as they have shown higher scores in speech perception than those who are older.^[11]Svirsky MA, et al. Development of language and speech perception in congenitally, profoundly deaf children as a function of age at cochlear implantation. Audiol. Neurootol. 2004;9:224–233.^[12]McConkey Robbins A, et al. Effect of age at cochlear implantation on auditory skill development in infants and toddlers. Arch. Otolaryngol. Head Neck Surg. 2004;130:570–574.

Role of Occupational Therapy Post-Cochlear Implantation

• Tailoring therapy to the occupational profile of the client’s hearing and their personal contexts.
• Educating the strengths and limitations of current generation cochlear implants.
• Using a strengths model to promote engagement in meaningful occupations
• Being family-centered to provide support and referral to appropriate professionals.
• Supporting the child in academic attainment and better quality of life (school, play, leisure, ADLs, and sleep).
• Support the adult in attaining work and meaningful careers.
• Modifying the environment to maximize hearing and educating the client to problem solve how to manage their own dynamic environment.
• Developing better listening habits to maximize function:
  • Being close to the speaker.
  • Having conversations in quieter areas.
  • Placing and orienting oneself to one’s listening strengths.
  • Arriving early for better seating options.
  • Selecting locations that also have good lighting for sight of the speaker.
• Using assistive listening devices that connect to the CI where available, e.g., public venues, Bluetooth.
• Obtain see-through masks to provide to others who you will be having a conversation with; remind other speakers to speak slower instead of louder.^[13]Sorkin & Zombek. (2022). Tips for Overcoming the Challenges of Listening in Noise with a Cochlear Implant. The Hearing Journal: March 2022 – Volume 75 – Issue 3 – p 18,19 doi: … Reference List
• Educate the client on taking breaks from sensory environments, planning their trips, and how to manage unpleasant symptoms such as headaches.
• Educating clients on how to protect their residual hearing.
• Collaborating with clients to identify meaningful values and goals that are realistic.
• Providing means to assistive devices to train to hear such as podcasts and audiobooks.
• Implementing visual resources as a backup option such as Apps or writing down notes.
• Promoting meaningful occupations that train one’s hearing, e.g., listening to conversations, noise, music, movies, telephone conversations.^[14]Sorkin & Zombek. (2021). Optimizing Outcomes with a Cochlear Implant: Tips for Adults. The Hearing Journal: July 2021 – Volume 74 – Issue 7 – p 28 doi: … Reference List
• *Many of the OT interventions meant for hearing impairment also apply to those with CI.
• Provide interventions to manage mental health and psychosocial conditions.