Interview with Michael Piskosz, M.S., Global Audiologist, ReSound
Topic: ReSound Live™TS
CAROLYN SMAKA: Today I'm talking with Michael Piskosz from ReSound. Michael, can you tell me about your background and your role at ReSound?
MICHAEL PISKOSZ: I'm a Board Certified Audiologist. I did my undergrad at Syracuse University, and I got my Master's at the University of Washington. I began my career at the University of Miami as a clinical audiologist, and from there I worked in a private practice in Hollywood, FL. with a private ENT clinic. I then came to ReSound, and I've been with ReSound for 6 years now. I started with ReSound as a regional manager in New Zealand.
Now I'm part of the global audiology team that's headed by Dr. Laurel Christensen. I present ReSound product trainings and I also present at conferences and seminars. We work closely with R&D to take the technical explanations of how our products work and put that into audiology terms in order to train our product managers, sales reps, and customers so that our products can be fit most effectively.
SMAKA: Do you work with the whole product portfolio, or do you primarily focus on the ReSound Live™TS?
PISKOSZ: I have worked on the ReSound Live and dot² product families as well as ReSound X-plore and other hearing instruments, but for the past year I've been focused on ReSound Live™TS.
SMAKA: Okay, great. Can you start by giving an overview of ReSound Live™TS?
PISKOSZ: ReSound Live™TS is a combination product, meaning that it has both hearing instrument features and a tinnitus sound generator program in it as well. The hearing instrument portion is everything that you get in the ReSound Live 9: all the bells and whistles of a top-of-the-line product, which is what makes the ReSound Live™TS quite unique. With tinnitus solutions in the past, which typically were just noise generators or maskers, you always had to compromise on hearing aid technology.
Now with ReSound Live™TS, you not only get premium digital hearing instrument technology, but also the most flexible tinnitus solution package available. That flexibility is important for people who either just have tinnitus or just have hearing loss, and for people who come in and have both hearing loss and tinnitus as their main concerns.
SMAKA: You mentioned ReSound Live™ is a premium hearing instrument, and that ReSound Live™TS shares its features. Would you mind reviewing those features?
PISKOSZ: Sure. ReSound Live™ and ReSound Live™TS have 17 bands of Warp™ processing. Our Warp™ compressor has a fast processing speed that keeps the clarity of speech with very low levels of distortion. Other key features include our spectral subtraction noise reduction called Noise Tracker II, and several state-of-the-art directionality options including our Natural Directionality. With the Natural Directionality option, one ear is a monitor ear, which is an omnidirectional ear that allows you to monitor the environment around you, and the other ear is the focus ear, which is a fixed directional giving you the benefit of an improved signal-to-noise ratio. In addition to Natural Directionality, we have AutoScope Adaptive Directionality, which optimizes the directional performance in various environments by automatically narrowing or widening the directional beam. We also offer fixed directionality, with multiple fixed directional beamwidths. So as you can see, we have a very flexible directional package that allows the professional to customize and maximize the performance of the product.
In terms of feedback management, the digital feedback suppression integrates something new called WhistleControl™. This essentially acts as an emergency brake and acts more aggressively in dynamic situations, to step in and eliminate that feedback more effectively than anything we've had before.
SMAKA: What makes the tinnitus features the most flexible available?
PISKOSZ: The features within the tinnitus portion are equally as innovative. If you think of traditional tinnitus sound generators or maskers, typically you had a high-cut and low-cut trim pot, and you could essentially just bring the high frequencies and low frequencies down to shape the white noise. If your patient didn't prefer that, you were kind of stuck as there really wasn't much else you could do.
With ReSound Live™TS, you have low- and high-cut filters where you can adjust the white noise via the Aventa fitting software. By default this is a broadband noise because research shows that that is the most preferred and the most effective in terms of tinnitus treatment. However, if someone doesn't prefer the broadband noise, you can provide either more of a high-frequency or low-frequency emphasis. You also have the ability to center the noise at 2 kHz. So you've got much more flexibility with shaping the noise for your patient's needs via the fitting software.
In addition, ReSound Live™TS offers amplitude modulation, which will simply modulate the white noise to give the effect of the ocean waves or the tide coming in and out. There's been some data that show that for people who don't like a continuous noise, changing or adjusting that to some degree may be more comfortable and preferred. In other words, adding modulation can, for some people, give a more soothing perception of the white noise. This feature is also very flexible;you can adjust the amount of modulation and also the speed at which those modulations occur.
SMAKA: Michael, I know there are different approaches that may require different noise settings, i.e. I've heard the term "mixing point' used. What is the default level or starting point for setting the white noise?
PISKOSZ: You're correct - where to set the noise is dependent on the professional's particular approach or method and we don't recommend one method over another. Professionals have to use the method or approach they're most comfortable with and find most effective. With the Aventa software, you have a volume slider and you can adjust that in dB SPL. While the patient is wearing the instruments, you can simply turn that up until they start to hear the white noise, and go from there.
One common method is TRT, Tinnitus Retraining Therapy, which sometimes does talk about the mixing point. The mixing point is where the white noise of the tinnitus sound generator starts to blend with the actual tinnitus. You want to be careful, though, that you don't completely mask the tinnitus. If you mask the tinnitus, you never allow the brain to habituate to it, and with any type of treatment plan, you want the brain to learn to habituate to the tinnitus. If the person can't hear the tinnitus because you've masked it, then you never allow the brain to do that.
There are some newer strategies out there now like Progressive Tinnitus Management, called PTM. It has some similarities to TRT. It has a five-step hierarchical approach, whereas you take each step and then depending on the particular individual, you might go to the next step. There are other approaches as well that use a low level of effective masking.
In sound therapy the main goal is to decrease the contrast of the tinnitus to the background. For example, someone might say their tinnitus is worse in a quiet situation because there's nothing contrasting the tinnitus, so they can hear it very easily. Whereas if they go into a restaurant and there's' a lot of background noise, they typically will say that they don't hear the tinnitus as much because the contrast between the tinnitus and the background has been decreased.
Where you set the device is really up to the individual's needs and ReSound Live™TS is flexible enough to accommodate your approach to those needs. For example, you may want to start about 5 to10 dB above the threshold of the white noise. That means establishing the threshold of the white noise first, and then setting the noise about 5 dB -10 dB above that. Or, if you're using the mixing point method, then by all means, you can set this device using the mixing point.
SMAKA: Ok, it sounds like no matter how the clinician is inclined, based on their training or experience, the product is going to more than flexible enough to meet their needs.
PISKOSZ: Yes. It really gives you the option to set it up any way that you think is appropriate. Live™TS is a tool to be used for sound therapy, and sound therapy is a tool that's used in some forms of tinnitus treatment.
SMAKA: What other features make ReSound Live™TS unique?
PISKOSZ:One of the most unique features is something we call Environmental Steering. The Environmental Steering is based on the philosophy of our environmental optimizer, which is something that acts as an automatic hearing aid gain control. Depending on the listening environment, this hearing aid will make automatic gain changes that you, as the clinician, set with the individual.
We've carried this feature over to the tinnitus portion of Live™TS as well. If you activate Environmental Steering, the hearing instrument will determine what listening environment the person is in and will adjust the white noise accordingly. For example, if they're in a quiet situation, the white noise will stay at the level that you've set it. If the person goes into a speech environment, we obviously don't want the white noise interfering or masking any important signals like speech. In this case, the white noise will automatically decrease. Likewise, if the person goes into a really noisy situation that will naturally drown out or mask the tinnitus, it will recognize the noisy environment and bring down the level of the white noise even more. Then, if the person goes back into a quiet situation, it will automatically raise it back up, and so forth.
SMAKA: So the person always has the preferred volume level of the white noise at all times?
PISKOSZ: Exactly, and it also takes away the need for someone to always adjust the volume control. The more tinnitus sufferers have to play with a volume control, the more it may remind them of their tinnitus, and that's the last thing we ever want to do. We want to be able to take their focus away from the tinnitus.
Of course, the volume control option is still available if a patient would ever want it. Or, you can shut off Environmental Steering and let the algorithms from the hearing instrument do the work.
SMAKA: Very interesting. What kinds of research studies were done on this product?
PISKOSZ: We did two separate external trials that involved about 25 to 30 subjects, and these were independent global sites. I would call them expert tinnitus clinics, with professionals who really understand tinnitus and have been working with it for a number of years.
The trials lasted over six months and included five different clinic visits. Essentially we wanted to look pre and post Tinnitus Handicap Inventory (THI) scores, Tinnitus Reaction Questionnaire scores (TRQ), and we also looked at setting preferences. We wanted to get an idea of how people liked these instruments to be set up, and did they get benefit over the six-month time period. We saw in both studies a significant improvement in both THI and TRQ scores after the six months. We also got great information as to preferences for some of the features that I just mentioned.
SMAKA: When you go out and do customer trainings, what is the most common question that you get about ReSound Live™TS?
PISKOSZ: I'd say one of the most common is, "How long is it going to take to make people better?" And the answer to that is that a lot of people will never be cured from tinnitus. It will never go away, and what tinnitus management aims to do is to reduce their perception and reactions to it. If you look at TRT or PTM, at a minimum I would say that six months of treatment is needed. You can get out to 18 months to 2 years depending on what particular model you're using. But ideally, the ultimate goal is to get them independent of the counseling provided from the clinician so that they know how to react to their tinnitus, how to appropriately use sound enrichment and know how to better cope with it, so they do not always have to come back for a visit. But the tinnitus itself will most likely never go away.
SMAKA: Now, does that mean after that point some people would discontinue use of the sound generator? What is the goal?
PISKOSZ: The goal is to wean them off of the sound generator over time. At the end of the day, sound therapy in its simplest form is really just effective use of sound. The sound enrichment an individual uses can be as simple as turning on the radio, the TV, or a tabletop sound generator that is used at night. It could even be turning on a fan or opening up a window. Over time, you want the person to understand how to use sound to help decrease that contrast of the tinnitus. Ideally, we want them to gain control of how they react to their tinnitus, because how they react to their tinnitus will determine how much their tinnitus affects them.
It's very similar to pain. Two people can feel the exact same pain, but one person might say, "Okay, I've learned to live with it. It's there." The other person might think about it all the time, and to them, the pain is exacerbated and worsened, as compared to the first person.
With tinnitus, we may see two people who have tinnitus of the same pitch and loudness, but it's the perception of that tinnitus that determines whether it's a problem or not. With tinnitus management, we want to change the perception from tinnitus as a negative stimulus to a more neutral stimulus;therefore, the person doesn't react as negatively to it when they hear it.
SMAKA: Like you said previously, get the person's focus off the tinnitus.
PISKOSZ: Yes. Tinnitus is a sound that someone can hear. If they listen to it and focus on it over and over and over again, there are neural pathways that start to identify that tinnitus. Just like if we hear an ambulance, there's a neural pathway or identity that tells our brain, "Wait a second. This is an ambulance, this is important. I have to pay attention to it."
Tinnitus is the same thing. The more people focus and listen to it, the more those neural networks or those neural pathways strengthen. As this happens, people may start to recognize and identify their tinnitus even in background noise. We want to weaken or shift those neural networks away from the tinnitus and provide other stimuli that can sort of come in and take the place of it.
SMAKA: What styles are Live™TS available in, and what degree of hearing loss is it appropriate for?
PISKOSZ: It is available in standard BTEs, a receiver-in-the-canal model, and the full line of custom products: ITE, Half shell, ITC and CIC. With closed fittings, you can fit losses up to about 85 - 90 dB.
SMAKA: How long has ReSound Live™TS been available?
PISKOSZ: The product has been out since the beginning of the year. We've had some very, very good success with it. One thing I always like to point out is that any tinnitus product is only as good as the overall treatment plan that you're providing, which includes many components in addition to the device.
SMAKA: Where would you recommend that professional to get more training on tinnitus management?
PISKOSZ: A good place to start is the American Tinnitus Association (http://www.ata.org/). The University of Iowa's tinnitus conference that happens every September is a great resource, as are TRT Seminars from the Drs. Jastreboff. Plural Publishing has just launched the Progressive Tinnitus Management series of books, and there's a CD that goes along with it as well. There really is a lot of good literature and resources out there if you look for them.
SMAKA: That's good information. Thank you, Michael, for you time today. I learned a lot. It was really nice "virtually meeting" you!
PISKOSZ: Same here! Thanks, Carolyn.
For more information, please visit www.gnresound.com or the ReSound Web Channel on AudiologyOnline.