Auditory Low Level Functions

Introduction to
Manfred Stoifl
Hearing Aid Acoustician (Honors), AAHA, Vienna,
Austria
2/20/2013

Overview
• Principals of Hearing and Hearing Loss
• Neural / Central Hearing Assessment
• Indication for AudioFitness Training
• Measuring Benefits
• Neural / Central H.L. in Children
• Validation.
2/20/2013

2/20/2013
Peripheral
Hearing
CentralAuditory
Functions
How Hearing Works
Principle

5
left
middle
ear
right
middle
ear
left
cochlea
right
cochlea
left
Monaural
processing
right
Monaural
processing
arrival time
difference
evaluation
binaural
activity
imaging
aural
activity
image
memory
auditory processes
comparison evaluation
aural
scene
memory
smell
activity
images
Other
sensory
activity
images
vision
activity
images
other high
level
processes
Ears Brainstem Auditory cortex Other
brain
areas
left
outer
ear
right
outer
ear
time
domain
frequency
domain
aural activity
image
aural
scene
meaning
enjoyment
action
level
difference
evaluation
How We Hear

6
Hearing Loss
Where
Functional
problem
Cause
Cochlear Brain
Physical Problem Hair Cell damage
Loudness
Frequency Discrimination
Language Discrimination
Hearing in Noise
Directional Hearing
Genetics
Age / Wear and Tear
Trauma
Diseases
Under utilisation
Treatment Hearing Aids / C.I. Low Level Function
Training
Test Audiometry
EFI-EFK test
Low Level Function Test
Sensory
Hearing Loss
Neural/Central
Hearing Loss
?
?
-
Principle

7
10 20 30 40 50 60 70 80
Age
Slow / Bad
Fast / Good
Time
Normal Aging
Accellerated degeneration due
to peripheral Hearing Loss
Central Auditory Processing
Lifecycle
ProcessingSpeed
Principle

8
Nach: Ptok-M: „Auditive Verarbeitungs- und Wahrnehmungsstörungen
und Legasthenie“, Hessisches Ärzteblatt 2/2000, S. 52-54
Low-level
Automatic extraction of basic acousitc features like
time and frequency resolution
Automatic exraction of phonetic cues for phonem
differenciation
Automatic identification and discrimination of
syllables in a language
Automatic recognicion of words and their
meanings 1. Order – without context
Metalanguage awareness to decode both the
syntax and prosody
Phonetic
Phonologic
Lexical-semantic
Morpho-syntactic
i / e / a / o / u
train (Transport) / train (practice)
I train my hearing with AudioFitness.
?
d/t g/k b/p
Auditory processing and
perception of speech
Principle

ASHA* (1996) defines APD as an observed
deficiency in:
Definition of Cental Hearing problem…
• Sound localization and lateralization
• Discrimination
• Pattern recognition
• Temporal aspects of listening
• Speech understanding in noise
Knowing whether a sound comes from
left / right / middle
How the sounds are organized in a word determines its
meaning
Lemonade / Menolade
Tsar / Star
Reserve / Reverse
The pattern of a sentence creates a specific meaning
I want to drive
to Kuala Lumpur tomorrow
(and not fly)
I want to drive
to Kuala Lumpur tomorrow(and not today)
Hearing the difference between
Bat / pat / hat / fat
* American Speech-Language Hearing Association
Principle

Common Signs of Central He problems
Talks or likes TV louder than normal
Unusually sensitive to sounds
Asks many extra informational questions
Confuses similar sounding words
Hears better when watching the speaker
Problems with rapid speech
Frequently misunderstanding instructions or questions
Porblems understanding in background noise
Problems with phonics or discriminating speech sounds
Frequently requests repetition.
Principle

Neural / Central Hearing
Assessment
2/20/2013

2/20/2013
Wahrnehmungs -Trennschärfe -Test
Teil 1 O n.a.* Teil 2 O n.a.*
Links Rechts Links Rechts
EFI O
EWI O
EDI O
EPI O
EWI O
ETI O
EPI O
EFI O
EBI O
EDI O
EGI O
EKI O
ETI O
EBI O
EKI O
EGI O
OEBI O
EPI O
EGI O
EKI O
ETI O
EFI O
OEWI O
EGI O
EPI O
EDI O
EKI O
EFI O
EDI O
EWI O
EBI O
ETI O
EKI O EFI O
EBI O ETI O
EPI O EWI O
EFI O EGI O
EWI O EBI O
EDI O EPI O
OETI O EKI O
EGI O EDI O
ETI O
O
EPI O
EDI O EKI O
EPI O ETI O
EBI O EDI O
EFI O
O
EGI O
EWI O
EGI O
EKI O
EBI O
EFI O
EWI O
C C C
% % %
Richtige Silben: /32 Richtige Paare: /16
PRS: PRS:
Perception-Separation
Accuracy Test by Warnke (EFI-EKI)

Possible results
Similar consonants like b-p, d-t, f-w,g-k,d-g, are being mismatched often. Pay
special attention to ensure right ones are being repeated
Most common mistake in the 2nd test is duplication. E.g. the client repeats
EWI-EWI instead of the correct EWI-EBI
Clients or Children with CAPD barely ever reach 13-16 correct nonsense
words or 10 correct pairs. The second test is specially designed to avoid the
use of compensation strategies
If the client achieves less than 10 correct word pairs in the second test, it is a
strong indication of Central Auditory and Automation deficiency as well as
Speech deficiency
Low score also strongly indicates that client might have problems
discriminating with Hearing Aids, especially in noise.
2/20/2013
Perception-Separation
Accuracy Test by Warnke (EFI-EKI)

• 8 tests
– Visual Order
– Order of sounds
– Directionality
– Reaction
– Pitch discrimination
– Tact
– Pattern discrimination
• Frequency
• Duration.
Assessment

Age specific Adult Reference Values
2/20/2013
Function
Reference Values (Training)
20 years
old
30 years
old
40 years
old
50 years
old
60 years
old
70 years
old
80 years
old
90 years
old
100
years
old
Order-v 24 ms 36 ms 48 ms 60 ms 72 ms 84 ms 96 ms 108 ms 120 ms
Order-a 46 ms 59 ms 72 ms 85 ms 98 ms 111 ms 124 ms 137 ms 150 ms
Bearing 20 µs 32 µs 43 µs 55 µs 66 µs 78 µs 90 µs 101 µs 113 µs
Pitching 7 % 10 % 13 % 15 % 18 % 21 % 24 % 27 % 29 %
Rhythm 170 ms 185 ms 200 ms 215 ms 230 ms 245 ms 260 ms 275 ms 290 ms
Reaction 609 ms 670 ms 731 ms 792 ms 853 ms 914 ms 975 ms 1036 ms 1097 ms
Sequence 20 ms 58 ms 96 ms 134 ms 172 ms 210 ms 248 ms 286 ms 324 ms
Duration 40 ms 56 ms 72 ms 88 ms 104 ms 120 ms 136 ms 152 ms 168 ms
Valuating results

16
Function
Target Values (Training)
Ideal
Results*20 years
old
30 years
old
40 years
old
50 years
old
60 years
old
70 years
old
80 years
old
90 years
old
100
years
old
Order-v 12 ms 18 ms 24 ms 30 ms 36 ms 42 ms 48 ms 54 ms 60 ms 12 ms
Order-a 23 ms 30 ms 36 ms 43 ms 49 ms 56 ms 62 ms 69 ms 75 ms 23 ms
Bearing 10 µs 16 µs 22 µs 28 µs 33 µs 39 µs 45 µs 51 µs 57 µs 10 µs
Pitching 4 % 5 % 7 % 8 % 9 % 11 % 12 % 13 % 15 % 4 %
Rhythm 128 ms 139 ms 150 ms 161 ms 173 ms 184 ms 195 ms 206 ms 218 ms 128 ms
Reaction 305 ms 335 ms 366 ms 396 ms 427 ms 457 ms 488 ms 518 ms 549 ms 305 ms
Sequence 10 ms 29 ms 48 ms 67 ms 86 ms 105 ms 124 ms 143 ms 162 ms 10 ms
Duration 20 ms 28 ms 36 ms 44 ms 52 ms 60 ms 68 ms 76 ms 84 ms 20 ms
Age specific long-term Adult Target Values
Valuating results

17
Age specific Pediatric Reference Values
Valuating results

18
Age specific Pediatric Target Values
Valuating results

Explanation
• The further results are away from Optimal Results the less
good clients Central Auditory Processing is Functioning
• If any Values are below age specific Reference Values
– Necessitates full assessment
– Training is very strongly recommended
– High probability that client will have some problems understanding speech
(with Hearing Aids)
• If any Values are below age specific Target Values
– Necessitates full assessment
– Training is strongly recommended
– Probably client will have some problems (with Hearing Aids) in certain
situations
• If any Values are below age specific Optimal Value
– Training is recommended
– Possibly client will have some problems (with Hearing Aids) in certain
situations.
Assessment

Indication for AudioFitness
Training?
2/20/2013

When he/she exhibits problems with:
• Sound localization and lateralization
• Discrimination
• Pattern recognition
• Temporal aspects of listening
• Speech understanding in noise
Knowing whether a sound comes from
left / right / middle
How the sounds are organized in a word determines its
meaning
Lemonade / Menolade
Tsar / Star
Reserve / Reverse
The pattern of a sentence creates a specific meaning
I want to drive
to Kuala Lumpur tomorrow
(and not fly)
I want to drive
to Kuala Lumpur tomorrow(and not today)
Hearing the difference between
Bat / pat / hat / fat
When is it necessary
for a Client to do AudioFitness Training?

If she/he has probems in one or more of the
following situations:
Talks or likes TV louder than normal
Unusually sensitive to sounds
Asks many extra informational questions
Confuses similar sounding words
Hears better when watching the speaker
Problems with rapid speech
Frequently misunderstanding instructions or questions
Porblems understanding in background noise
Problems with phonics or discriminating speech sounds
Frequently requests repetition.

2/20/2013
Perception - Separation - Test
Part 1 Part 2
Left Right Left Right
AFEE O AWEE O AKEE O AFEE O
ADEE O APEE O ABEE O ATEE O
AWEE O ATEE O APEE O AWEE O
APEE O AFEE O AFEE O AGEE O
ABEE O ADEE O AWEE O ABEE O
AGEE O AKEE O ADEE O APEE O
ATEE O ABEE O ATEE O AKEE O
AKEE O AGEE O AGEE O ADEE O
ABEE O APEE O ATEE O APEE O
AGEE O AKEE O ADEE O AKEE O
ATEE O AFEE O APEE O ATEE O
AWEE O AGEE O ABEE O ADEE O
APEE O ADEE O AFEE O AGEE O
AKEE O AWEE O AWEE O ABEE O
ADEE O ABEE O AKEE O AFEE O
AFEE O ATEE O AGEE O AWEE O
Correct Syllables: /32 Correct Pairs: /16
Wahrnehmungs -Trennschärfe -Test
Teil 1 O n.a.* Teil 2 O n.a.*
Links Rechts Links Rechts
EFI O
EWI O
EDI O
EPI O
EWI O
ETI O
EPI O
EFI O
EBI O
EDI O
EGI O
EKI O
ETI O
EBI O
EKI O
EGI O
OEBI O
EPI O
EGI O
EKI O
ETI O
EFI O
OEWI O
EGI O
EPI O
EDI O
EKI O
EFI O
EDI O
EWI O
EBI O
ETI O
EKI O EFI O
EBI O ETI O
EPI O EWI O
EFI O EGI O
EWI O EBI O
EDI O EPI O
OETI O EKI O
EGI O EDI O
ETI O
O
EPI O
EDI O EKI O
EPI O ETI O
EBI O EDI O
EFI O
O
EGI O
EWI O
EGI O
EKI O
EBI O
EFI O
EWI O
C C C
% % %
Richtige Silben: /32 Richtige Paare: /16
If she/he can not understand 100 % in an EFI-EKI Test

24
Function
Ideal
Results*20 years
old
30 years
old
40 years
old
50 years
old
60 years
old
70 years
old
80 years
old
90 years
old
100
years
old
Pitching 4 % 5 % 7 % 8 % 9 % 11 % 12 % 13 % 15 % 4 %
If her/his Low Level Function Speed is less than optimal.

25
If her/his Low Level Function Speed is less than optimal.

• The speed with which the brain is able to digest and
process visual & auditory information
• Ability to differentiate critical plosives b-d-g-k-t
• Spatial (directional) hearing
• Ability of differentiating vowels and decoding of voice
melody
• Ability to convert perceived auditory stimuli as fast as
possible into movements
• Identifying time of Phonemes (spoken) and graphemes
(reading)
• Ability to distinguish auditory sound patterns (sound
pictures) based on Frequencies and Duration.
2/20/2013
Low Level Automation Training

1. Visual Order Threshold..
– is the minimum time at which you can separate 2 visual stimuli
• This ability is very important for digesting written information
• Increase the speed with which the brain is able to digest and process
information.
2. Auditory Order Threshold..
– is the minimum time at which you can separate 2 auditory stimuli
• If it takes you too long, you may have difficulty differentiating critical plosives
b-d, g-k, or p-t from each other. Which results in difficulty understanding
spoken language.
3. Spatial (Directional) Hearing
– Is the minimum time difference at which you can localize a sound
• Allows correct training of spatial (directional) hearing.
– Very important to be able to perceive sounds and especially language selectively
» from different directions,
» to be able to assign them
» to ignore them as well.
4. Pitch Discrimination
– is the minimum difference between two tones
• vital ability for differentiating vowels and decoding of voice melody.
• extremely important for speaking as well as for understanding language.
We assess, and customer
trains 8 CAP task (1-4)

5. Rhythm
– fastest rhythm you can follow
• Ability to convert perceived auditory stimuli as fast as possible into
movements.
• very important for thinking, speaking and writing
• To train hemispheric coordination.
6. Auditory Choice Reaction
– separating two different tones and reacting as fast as possible
• Decisive for identifying time of Phonemes (spoken) and graphemes (reading).
• To react fast and focused to auditory stimuli without visual aid
7. Frequency Pattern Recognition..
– quickly and accurately resolve auditory patterns
• An important pre-requisite for the segmentation of the continuous stream of
auditory stimuli during speech identification and processing.
8. Duration Pattern Recognition..
– quickly and accurately resolve auditory patterns
• An important pre-requisite for the segmentation of the continuous stream of
auditory stimuli during speech identification and processing.
We assess, and customer
trains 8 CAP task (5-8)

HomeTraining
• Practice all 8
functions at home
for 30 min a day
• The Home Trainer
will store data in a data log
• Follow up assessment and
advice in weekly
• consultations.

Unique 2 Step Training Approach
• Practice
• Consolidation.
2/20/2013

32
t
Access Information
Task Latency Reply Confirmation
Great!
Quelle: Skinner-BF & Correll-W in „Denken und Lernen“, 1976
Confirmation
German Patent # 196 03 001
„System for supported training and learning“
Explanation: Mirror-Neurons
How practice works

• 6 -8 weeks
• Final low level function
assessment
• Baseline discrimination assessment
report
• Continue training alone to reach ideal values.
• Maintain reached goals by training
once weekly
• Move on to second stage training.
EndofTraining

Measuring benefits of
AudioFitness
2/20/2013

35
10 20 30 40 50 60 70 80
Age
Slow / Bad
Fast / Good
Target
Time
Level of optimal central auditory function
Normal Aging
Accellerated degeneration due
to peripheral Hearing Loss
Lifecycle
ProcessingSpeed

36
Function
Ideal
Results*20 years
old
30 years
old
40 years
old
50 years
old
60 years
old
70 years
old
80 years
old
90 years
old
100
years
old
Pitching 4 % 5 % 7 % 8 % 9 % 11 % 12 % 13 % 15 % 4 %
Age specific long-term Adult Target Values
Valuating results

37
Age specific Pediatric Target Values
Valuating results

Showing improvement in APHAB
Measuring benefits of
AudioFitness

Auditory Processing Problems
in Children

The dilemma…
"Hearing" related complaints
Standard assessment including
- Hearing threshold measurement
- Middle-ear evaluation
Amplification the
way we know it
?
Hearing thresholds
are shifted
Hearing thresholds
are "normal"

42
10 20 30 40 50 60 70 80
Age
Slow / Bad
Fast / Good
Time
Lifecycle
ProcessingSpeed

AdaptedfromJohnson 1996
The effect of distance and noise on
word recognition
Age Group Word recognition in quiet Word recognition in noise
close (1.8 m) far (7 m)
4 years 88.3% 67.0%
5years 94.3% 84.0%
6 years 98.0% 86.7%
Adults 99.3% 97.0%

Reverberation
Classrooms are noisy places
Background noiseDistance
Noise affects learning
for all children but is more
problematic for many children
with APD…

APD
3-5% of
all children
ADHD
4-12% of all
children
Learning difficulties
in children can result from
• Co-morbidity
• Overlap
• Causality
• Other
LD
5-10% of
all children

Validation
• 30 years on the Market
• Widely used in Germany and
Switzerland
• Numerous Publications

Current Clinical trials proof benefits of
Low Level Training
• Learning Disabilities
– Dyslexia
– ADD / ADHD etc…..
• Hearing “Problems”
– Normal Hearing
• Central Auditory Problems
• Hearing in Noise
– Hearing Impaired
• Hearing in Noise
• Adaptation to Hearing Aids.
2/20/2013

48
Low level functions and education
.
100 adults 20-70 years of age
Quelle: Katerji-D „Veränderungen der Low-Level-Funktionen im Erwachsenen-
alter“, Dissertation (2006), Medizinische Hochschule Hannover, U. Tewes
Grade High Colle. Univ
0
6
12
18
24
30
Pitch Discrimination
0
150
300
450
600
750
900
ChoiceReaction Time
0
30
60
90
120
Duration Pattern
0
15
30
45
60
75
V. Processing Speed
0
20
40
60
80
100
Aud. Proc. Speed
0
40
80
120
160
200
Frequency Pattern

Clinical Trail
Speech discrimination in Noise (144 adults)
6/21/2013 Manfred Stoifl
49
Hearing Impaired with
Hearing Aids
Normal Hearing without
Hearing Aids
with Training without Training

Clinical Trial
38 adults before and after LLF training
(average age 43.7 years)
Average performance at 25 years
Order Auditive
DurationReaction
PitchDirectionality
Sequence
Before After
Before AfterBefore After
Before After
Before After
Before After

Clinical Trial
Trail Making Test 60+ age group
51
Before Training
After Training
Besides Improvement in central auditory processing
it also resulted in improvement general cognitive
abilities.
We therefore recommend the
training for this age group.
TimeinSeconds

42 dyslexic children
52
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
Group A Group B Group C
Error rate reduction in %Error rate reduction in %
Group A was given lessons specially designed for dyslexics
Group B had Low-Level Training with the Brain-Boy
Group C had Low-Level-Training and Lateral-Training together
6.3 %
18.9 %
42.6 %

53
Hearing Treatment
Functional
problem
Why
Cochlear Brain
Physical Problem Hair Cell damage
Loudness
Frequency Discrimination
Language Discrimination
Hearing in Noise
Directional Hearing
Genetics
Age / Wear and Tear
Trauma
Diseases
Under utilisation
Treatment Hearing Aids / C.I. Low Level Training
Test Audiometry EFI-EFK test
APHAB
Low Level Function Test
Hearing Understanding
-
Main Location

Thank YOU
Any Questions?
2/20/2013

Auditory Low Level Functions

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