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Importance of REM

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I almost never say this, but in this case... search the forums. There's a bit of a holy war going on. Two recent very long threads on this very topic. Best to leave sleeping dogs lie.

Agree — this is probably among the top three topics already discussed in this forum.

In reply to @Westlechars

In short the answer is no. You cannot achieve the best performance from hearing aids without measuring how they're performing in your ear. That is the measurement part of real ear measurement: it's in the name. Anything else is guesswork and might achieve fair performance, but never maximum or best performance. Your audiologist is only as good as the tools they use. If they don't measure, then they're flying blind. They might not crash, but they don't know exactly where they're starting or going.

I’m not at all disagreeing with you, but if you have and then have adjustments made to your program after, aren’t you undoing the REM? (Assuming the REM is done well.)

@Louaberg said:

then have adjustments made to your program after, aren’t you undoing the REM? (Assuming the REM is done well.)

This is idea of -based fitting. At first, it makes good starting point (or lines of output).

Having that output checked, you are not blind regarding individual characteristics of ear canal and can make additional adjustments with more certainty that patient has at least provided audibility.

In reply to @Westlechars

@Westlechars said:

to their maximum ability

I agree with hearing potential, no.

But additionally, the clinician most likely to be able to get close to an optimal fit without is also the clinician who regularly does REM. Doing it regularly teaches you things about how hearing aids fit and perform in the ears both generally and specifically that clinicians who have never done REM simply don't know in a deep way. Once you've done it a few thousand times, you can more easily look at an ear, and how a hearing aid it fitting in an ear, and know where to adjust and by how much to get closer to target. You also have a better idea of what client complaints relate to what adjustments because you've seen it and measured it and listened to it.

Edited

In reply to @d_Wooluf

@d_Wooluf said:

Best to leave sleeping dogs lie.

oh, come on... I'll play.... again.

In my unprofessional opinion, the short answer is yes. It might just take a little longer to get there.

is not some magical thing that makes the sun shine brighter. It's just a tool to help close in on some fuzzy targets and changing goals.

edit: I meant to add a caveat.... I think that I tend to agree with my first audiologist who said something to the effect that REM is really only Necessary for young kids or others who can't communicate well enough. The patient has to be able to let the fitter know in which situations the aids aren't working well in.

...and I suppose clarification in what I meant bout changing goals. I really doubt that there is a single "one best" fitting or program. We're chasing a bullseye that is basically impossible to see.

@bradw said:

I think that I tend to agree with my first audiologist who said something to the effect that REM is really only Necessary for young kids or others who can't communicate well enough

Interesting. That assumes that the practioner can tell somehow who can and who can't communicate well enough. Not sure how they do that. I asked the guy who sold me my OPNs why he didn't do until I requested it. His answer was that it was because I was an experienced user. That made me feel inadequate because the only thing I knew is that I wasn't understanding what people were saying. I couldn't be more precise than that and I suspect that I still can't.

I'll just repeat what I said in one of the previous REM discussions. I don't get how an audiologist can factor in thousands of dollars worth of support into the price of the device then quibble at the fifteen minutes of their time that REM takes. At the very least it brings the fitting to a known evidenced-based state. Then, if the practitioner and client can work together to improve things from there, then great. I don't see how the final outcome is going to be worse for having spent that fifteen minutes.

In reply to @bradw

@bradw said:

In my unprofessional opinion, the short answer is yes. It might just take a little longer to get there.

Navigating without a map can get you to the same destination if you have eyes to see. But when you're blind and cannot see the landmarks but are relying solely on the words of someone else who also cannot see, the chances of achieving optimal performance are well below chance. Good luck to you!

Sounds like we're beginning to get some agreement and are coming together here. There is a relationship between the competency of the audiologist, the communication abilities of the patient, and the importance of . 2 outa 3 ain't bad.

Edited

In my time on the forum two groups have provided help when I need

Providers who have technical and business skills

experts

 

Do the DIY experts use ? I wonder. The equipment is costly

 

I didn’t follow the DIY path.

The provider who supplied my Phonak Audeo Paradise P90R hearing aids always used REM. Except for his last setup. He used Target to do a first fit. Then we parted company.

 

I think finding a skilled hearing aid provider is more important. If they use REM that’s even better

 

DaveL

In reply to @d_Wooluf

I agree. If my provider is going to charge me $6800 for a pair of Oticon Reveal 1s, and I can get the very same devices online for $3800 albeit with online fitting and programming, which I have serious doubts about the efficacy of that method, then my current provider should put the effort in to do . Especially so when their other locations do use it, just not the location I've been going to for years. Obviously, before I spend the sort of money they're asking, I'm going to insist on visiting one of their other locations(same town, in fact). I have no idea what percentage of the cost is support and how much is the cost of the aids, but if they can be purchased outright for a good 40%+ less, then that support should be top shelf, and it should include REM.

I've had audiologists fit my hearing aids using , and I've now been programming my own Phonaks for quite some time. My fittings work substantially better for me than the professionally fitted ones did.

I'm not arguing that REM has no value. It provides objective information about what the hearing aids are delivering in the ear. But measuring output against a prescribed target isn't necessarily the same as achieving the best listening experience for a particular individual.

One enormous advantage of DIY is the ability to experiment and make adjustments whenever I want. I can change a setting, listen for ten minutes or several days, and open my laptop to refine it again. No appointments, no trying to remember exactly what bothered me three days ago, and no attempting to describe a subtle acoustic problem to someone who isn't hearing what I'm hearing.

A recent example is the activation threshold for Phonak's Spheric Speech Clarity in noise. Target provides a setting ranging from 1 to 20, without making particularly clear what each increment represents or precisely how it affects the activation behavior. I experimented with several settings in actual listening environments before finding the one that worked best for me.

How realistically could I have accomplished that through a series of audiologist appointments, with or without REM?

My point isn't that objective measurements are useless or that everyone should program their own hearing aids. It's that a good fitting isn't necessarily a single event. For someone willing and able to learn the software and evaluate the results, ongoing DIY refinement can accomplish things that even a conscientious audiologist working within the usual appointment structure would find difficult to duplicate.

REM can tell you how closely a fitting matches a target. It can't, by itself, tell you whether that fitting is the one you'll ultimately prefer in everyday life.

In response to the last post, if it’s possible to and get good results, then great. My view is that I have found it difficult to get optimal results through DIY because it’s difficult to know whether adjustments are immediately successful, as the real world conditions are not immediately available to test them. This is another talking point, and I don’t want to digress, but the walk around costco or audiologist talking behind you, to test a fit, is a nonsense. Of course, audiologists say you have to go away, and then come back to make future adjustments, but there is no other kind of assessment that validates the various programs on offer.

Which leads me to . At least it has some scientific basis. Yes, it is not necessarily the final fit, but at least it captures a gain curve that should leave one with balanced amplification across low, mid and high frequencies. Every REM fitting I have had has always left me with a feeling that I have the right mix of those low, mid and high frequencies. Yes, some, particularly phonak REMs on have still felt underamplified, but to rectify this all frequencies were always upped in unison, ensuring the overall shape of the gain curve was not altered.

I would say that all of the aids I had fitted with REM led to better outcomes. I even remember mid range Oticons fitted with REM outperforming premium Phonaks that had not. But I am not questioning the judgement of any DIYers or audiologists who can program without REM.

In reply to @d_Wooluf

@d_Wooluf said:

Interesting. That assumes that the practioner can tell somehow who can and who can't communicate well enough. Not sure how they do that. I asked the guy who sold me my OPNs why he didn't do REM until I requested it. His answer was that it was because I was an experienced user. That made me feel inadequate because the only thing I knew is that I wasn't understanding what people were saying. I couldn't be more precise than that and I suspect that I still can't.

humm, I haven't ever wrapped my head around the "experienced user" variable in this. I'll have to ponder on that one more, but I suppose I kinda get it to a point

The thing is, you can form a sentence, and within a few seconds you can tell the audiologist that you're getting a little too much brushing noise from your hair rubbing on the left side. As an experienced user, maybe you've learned to tolerate a bit of that or put another way what might be a big deal vs to be expected. You might have some idea of what is possible with hearing aids vs what is not possible. You can easily give some examples of things that sound great, and of other things that just don't sound natural. You may not have all the technical jargon, but you can still get the point across....something sounds too "hot"...or too much treble, not enough bass...or when people pronounce S sounds it's way too hot.

Anyway, my point...and my original Audi's point, was that you can easily understand and communicate things. An 8-month old baby for example, or a "special needs" person just might not have the awareness of what to expect, or the vocabulary, or the willingness, or maybe the interest to even try to explain it. Imagine a severely autistic non-verbal patient, as another example. In those sorts of situations it seems plausible the is necessary. Maybe it's the only way to know!

@bradw said:

I haven't ever wrapped my head around the "experienced user" variable in this.

This is also one factor in adaptation. Everyone knows it takes a little bit of time to adjust to hearing aids. The situation you want to avoid is a patient who has 20% audibility and gets 60% audibility with hearing aids and thinks that that's great, when if their clinician had used they would have seen that they could get them to 80% audibility with a little bit of cheerleading and education on adaptation, or if the patient was really sensitive at least a bit higher than 60%. But without REM the clinician does not know what kind of audibility has been achieved and all they have the to go on is the patient saying that they are hearing better. And the patient is indeed hearing better, just not as well as they could.

 

I think fittings should be done by experience users, not by new users, and particularly not by new users who have been living with hearing loss for a considerable amount of time.

@Neville said:

I think DIY fittings should be done by experience users, not by new users, and particularly not by new users who have been living with hearing loss for a considerable amount of time.

I didn't fit that situation at all. First time hearing aid user and had hearing loss for many years before going the route. Thanks to a few of the pros and DIY I managed to learn how to program aids and ask good questions. Back then there was only a handful of those that could or would help.

As far as it's a no brainer to want it done. It's the only way to verify the sound from the aid is meeting prescription at the ear drum. Anything else is a guess, maybe an educated guess but still a guess. If a person doesn't like the results of REM it is most likely an acclimation issue.

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