Aaron Moberly - Profile on Academia.edu (original) (raw)

Papers by Aaron Moberly

Otology & Neurotology, 2016

Hypothesis-Adding a low-frequency acoustic signal to the cochlear implant (CI) signal (i.e., bimo... more Hypothesis-Adding a low-frequency acoustic signal to the cochlear implant (CI) signal (i.e., bimodal stimulation) for a period of time early in life improves language acquisition. Background-Children must acquire sensitivity to the phonemic units of language to develop most language-related skills, including expressive vocabulary, working memory, and reading. Acquiring sensitivity to phonemic structure depends largely on having refined spectral (frequency) representations available in the signal, which does not happen with CIs alone. Combining the lowfrequency acoustic signal available through hearing aids with the CI signal can enhance signal quality. A period with this bimodal stimulation has been shown to improve language skills in very young children. This study examined whether these benefits persist into childhood. Methods-Data were examined for 48 children with CIs implanted under age 3 years, participating in a longitudinal study. All children wore hearing aids prior to receiving a CI, but upon receiving a first CI, 24 children had at least one year of bimodal stimulation (Bimodal group), and 24 children had only electric stimulation subsequent to implantation (CI-only group). Measures of phonemic awareness were obtained at second and fourth grade, along with measures of expressive vocabulary, working memory, and reading. Results-Children in the Bimodal group generally performed better on measures of phonemic awareness, and that advantage was reflected in other language measures. Conclusions-Having even a brief period of time early in life with combined electric-acoustic input provides benefits to language learning into childhood, likely due to the enhancement in spectral representations provided.

Laryngoscope, Oct 27, 2017

Objective: To evaluate diagnostic concordance of a synchronous telemedicine otolaryngology clinic... more Objective: To evaluate diagnostic concordance of a synchronous telemedicine otolaryngology clinic with use of currently available technology. Study Design: Prospective. Methods: Patients in a rural otolaryngology clinic were enrolled in a pilot telemedicine clinic. To assess system fidelity, an on-site and remote (consulting) otolaryngologist conducted simultaneous patient evaluations using streaming telecommunication technology for all aspects of the clinical encounter, including high-definition examination and endoscopic images. Both physicians and patients were blinded and diagnoses recorded. Post-encounter physician surveys and an original patientcentered TeleENT Satisfaction Questionnaire (TESQ) were used to assess overall satisfaction. Results: Twenty-one patients were enrolled consecutively. Visual technology was found acceptable in all cases, and audio technology was acceptable in 20 of 21 encounters. Patient satisfaction was 96%, and patients felt comfortable using a telemedicine system in the future. Encounters were not significantly longer than traditional encounters. Physician diagnostic agreement was found in 95% of cases, and the consulting physician indicated that all encounters provided sufficient history, examination, and high-quality images to generate an accurate diagnosis, order additional workup, and/or make an appropriate referral. Conclusion: A synchronous otolaryngology telemedicine clinic is comparable to a standard clinic in terms of diagnostic concordance and patient satisfaction when using streaming technology and high-definition images. Using telemedical technology may be a viable way to increase otolaryngology access in remote or underserved areas. With system validity now established, future studies will assess the feasibility of using trained on-site physician extenders (nurse practitioners or physician assistants) to conduct in-person patient encounters with remote otolaryngologist support.

Otology & Neurotology, Dec 1, 2021

Hypotheses: Significant variability persists in speech recognition outcomes in adults with cochle... more Hypotheses: Significant variability persists in speech recognition outcomes in adults with cochlear implants (CIs). Sensory (''bottom-up'') and cognitive-linguistic (''topdown'') processes help explain this variability. However, the interactions of these bottom-up and top-down factors remain unclear. One hypothesis was tested: top-down processes would contribute differentially to speech recognition, depending on the fidelity of bottom-up input. Background: Bottom-up spectro-temporal processing, assessed using a Spectral-Temporally Modulated Ripple Test (SMRT), is associated with CI speech recognition outcomes. Similarly, top-down cognitive-linguistic skills relate to outcomes, including working memory capacity, inhibition-concentration, speed of lexical access, and nonverbal reasoning. Methods: Fifty-one adult CI users were tested for word and sentence recognition, along with performance on the SMRT and a battery of cognitive-linguistic tests. The group was divided into ''low-,'' ''intermediate-,'' and ''high-SMRT'' groups, based on SMRT scores. Separate correlation analyses were performed for each subgroup between a composite score of cognitive-linguistic processing and speech recognition. Results: Associations of top-down composite scores with speech recognition were not significant for the low-SMRT group. In contrast, these associations were significant and of medium effect size (Spearman's rho ¼ 0.44-0.46) for two sentence types for the intermediate-SMRT group. For the high-SMRT group, top-down scores were associated with both word and sentence recognition, with medium to large effect sizes (Spearman's rho ¼ 0.45-0.58). Conclusions: Top-down processes contribute differentially to speech recognition in CI users based on the quality of bottom-up input. Findings have clinical implications for individualized treatment approaches relying on bottom-up device programming or top-down rehabilitation approaches.

Emerging Relations among Cognitive Constructs and Cochlear Implant Outcomes: A Systematic Review and Meta‐Analysis

Otolaryngology-Head and Neck Surgery, Jun 27, 2023

ObjectiveHearing loss has a detrimental impact on cognitive function. However, there is a lack of... more ObjectiveHearing loss has a detrimental impact on cognitive function. However, there is a lack of consensus on the impact of cochlear implants on cognition. This review systematically evaluates whether cochlear implants in adult patients lead to cognitive improvements and investigates the relations of cognition with speech recognition outcomes.Data SourcesA literature review was performed following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. Studies evaluating cognition and cochlear implant outcomes in postlingual, adult patients from January 1996 to December 2021 were included. Of 2510 total references, 52 studies were included in qualitative analysis and 11 in meta‐analyses.Review MethodsProportions were extracted from studies of (1) the significant impacts of cochlear implantation on 6 cognitive domains and (2) associations between cognition and speech recognition outcomes. Meta‐analyses were performed using random effects models on mean differences between pre‐ and postoperative performance on 4 cognitive assessments.ResultsOnly half of the outcomes reported suggested cochlear implantation had a significant impact on cognition (50.8%), with the highest proportion in assessments of memory & learning and inhibition‐concentration. Meta‐analyses revealed significant improvements in global cognition and inhibition‐concentration. Finally, 40.4% of associations between cognition and speech recognition outcomes were significant.ConclusionFindings relating to cochlear implantation and cognition vary depending on the cognitive domain assessed and the study goal. Nonetheless, assessments of memory & learning, global cognition, and inhibition‐concentration may represent tools to assess cognitive benefit after implantation and help explain variability in speech recognition outcomes. Enhanced selectivity in assessments of cognition is needed for clinical applicability.

Verbal Learning and Memory Following Cochlear Implantation

Over the last 50 years, results of free-recall experiments using categorized word lists have prov... more Over the last 50 years, results of free-recall experiments using categorized word lists have provided detailed information about how subjects encode, store, and retrieve words from memory and how they control their attentional resources and develop organizational strategies to optimize verbal learning and memory. The basic experimental methodology is now well understood and has been used to develop several clinical instruments that are routinely used by neuropsychologists to assess verbal learning and memory disorders in a range of clinical populations. This chapter summarizes three new studies that used the California Verbal Learning Test (CVLT) with deaf children and adults who received cochlear implants. In addition to the “primary measures” of immediate free and cued recall, the CVLT also provides several “process measures,” such as repetition learning, primacy and recency effects, proactive (PI) and retroactive interference (RI), semantic, serial and subjective clustering, short- and long-delayed free and cued recall, response intrusions, and recognition memory. The study of verbal learning and memory represents a new approach to understanding variability in speech recognition and spoken-language outcomes following implantation and provides new knowledge about the elementary cognitive processes that form the core building blocks of word recognition, lexical access, and spoken-language understanding.

Quality of Life Outcomes Reported by Patients and Significant Others Following Cochlear Implantation

American Journal of Audiology, Sep 3, 2020

Purpose This study tested the hypotheses that both patients receiving cochlear implants (CIs) and... more Purpose This study tested the hypotheses that both patients receiving cochlear implants (CIs) and their significant others (SOs) would demonstrate improvements in perceived hearing handicap over time following cochlear implantation and that the SOs would demonstrate delayed patterns of perceived improvement compared to the patients who directly experienced the changes in hearing function provided by the CI. Method A study sample of 19 pairs of postlingually deafened adult candidates with CIs and their SOs answered questions about the patients' hearing handicap. Patient- and SO-reported scores were obtained preoperatively and at 1, 3, and 6 months after CI activation. The study hypotheses were tested using linear mixed-effects models. Results Patients and SOs independently reported improvements on self-reported hearing handicap measures at 1, 3, and 6 months post CI activation compared to preoperatively. Correlations between patient- and SO-reported scores were significant at all intervals; however, the asynchrony between pairs at 1 month postactivation was greater in magnitude compared to the other intervals. Conclusions Findings support the hypotheses of the study. Results should inform future clinical practice and research to guide the expectations of patients and their SOs as they adjust to hearing with a CI and experience various benefits and challenges over time.

Automated video summarization and label assignment for otoscopy videos using deep learning and natural language processing

Tympanic membrane (TM) diseases are among the most frequent pathologies, affecting the majority o... more Tympanic membrane (TM) diseases are among the most frequent pathologies, affecting the majority of the pediatric population. Video otoscopy is an effective tool for diagnosing TM diseases. However, access to Ear, Nose, and Throat (ENT) physicians is limited in many sparsely-populated regions worldwide. Moreover, high inter- and intra-reader variability impair accurate diagnosis. This study proposes a digital otoscopy video summarization and automated diagnostic label assignment model that benefits from the synergy of deep learning and natural language processing (NLP). Our main motivation is to obtain the key visual features of TM diseases from their short descriptive reports. Our video database consisted of 173 otoscopy records from three different TM diseases. To generate composite images, we utilized our previously developed semantic segmentation-based stitching framework, SelectStitch. An ENT expert reviewed these composite images and wrote short reports describing the TM's visual landmarks and the disease for each ear. Based on NLP and a bag-of-words (BoW) model, we determined the five most frequent words characterizing each TM diagnostic category. A neighborhood components analysis was used to predict the diagnostic label of the test instance. The proposed model provided an overall F1-score of 90.2%. This is the first study to utilize textual information in computerized ear diagnostics to the best of our knowledge. Our model has the potential to become a telemedicine application that can automatically make a diagnosis of the TM by analyzing its visual descriptions provided by a healthcare provider from a mobile device.

Partial Resection in Microsurgical Management of Vestibular Schwannomas

JAMA otolaryngology-- head & neck surgery, Sep 1, 2017

Observation, stereotactic radiosurgery, and microsurgical resection comprise the conventional arm... more Observation, stereotactic radiosurgery, and microsurgical resection comprise the conventional armamentarium in the management of vestibular schwannomas (VSs).1 The potential to “cure,” as opposed to control tumor growth, is unique to microsurgical resection. Progress in neuroimaging, permitting more accurate surveillance and refinement of stereotactic radiosurgery, along with a priority shift toward minimizing morbidity, has made partial tumor resection (PTR) attractive as an alternative to gross total resection (GTR). For most patients with VSs, we strive to achieve a GTR. In our practice, judicious use of PTR, in particular near total resection (NTR), is reserved for imminent compromise of facial nerve functional integrity or in cases where a safe GTR is deemed unlikely for reasons related to patient stability or very large tumor size. Below we discuss some of the considerations that inform this position.

Considerations for Integrating Cognitive Testing Into Adult Cochlear Implant Evaluations—Foundations for the Future

JAMA otolaryngology-- head & neck surgery, May 1, 2021

International Journal of Pediatric Otorhinolaryngology, May 1, 2019

be related to the imaging type and diagnostic criteria used, the patients included, the source of... more be related to the imaging type and diagnostic criteria used, the patients included, the source of the identified patents, and the overall population of patients studied.

Journal of The American Academy of Audiology, 2020

Background: Adults with cochlear implants (CIs) are believed to rely more heavily on visual cues ... more Background: Adults with cochlear implants (CIs) are believed to rely more heavily on visual cues during speech recognition tasks than their normal-hearing peers. However, the relationship between auditory and visual reliance during audiovisual (AV) speech recognition is unclear and may depend on an individual's auditory proficiency, duration of hearing loss (HL), age, and other factors. Purpose: The primary purpose of this study was to examine whether visual reliance during AV speech recognition depends on auditory function for adult CI candidates (CICs) and adult experienced CI users (ECIs). Study Sample: Participants included 44 ECIs and 23 CICs. All participants were postlingually deafened and had met clinical candidacy requirements for cochlear implantation. Data Collection and Analysis: Participants completed City University of New York sentence recognition testing. Three separate lists of twelve sentences each were presented: the first in the auditory-only (A-only) condition, the second in the visual-only (V-only) condition, and the third in combined AV fashion. Each participant's amount of ''visual enhancement'' (VE) and ''auditory enhancement'' (AE) were computed (i.e., the benefit to AV speech recognition of adding visual or auditory information, respectively, relative to what could potentially be gained). The relative reliance of VE versus AE was also computed as a VE/AE ratio. Results: VE/AE ratio was predicted inversely by A-only performance. Visual reliance was not significantly different between ECIs and CICs. Duration of HL and age did not account for additional variance in the VE/AE ratio. A shift toward visual reliance may be driven by poor auditory performance in ECIs and CICs. The restoration of auditory input through a CI does not necessarily facilitate a shift back toward auditory reliance. Findings suggest that individual listeners with HL may rely on both auditory and visual information during AV speech recognition, to varying degrees based on their own performance and experience, to optimize communication performance in real-world listening situations.

Otology & Neurotology, Feb 1, 2018

Hypothesis-As a result of their hearing loss, adults with cochlear implants (CIs) would selfrepor... more Hypothesis-As a result of their hearing loss, adults with cochlear implants (CIs) would selfreport poorer executive functioning (EF) skills than normal-hearing (NH) peers, and these EF skills would be associated with performance on speech recognition tasks. Background-EF refers to a group of high order neurocognitive skills responsible for behavioral and emotional regulation during goal-directed activity, and EF has been found to be poorer in children with CIs than their NH age-matched peers. Moreover, there is increasing evidence that neurocognitive skills, including some EF skills, contribute to the ability to recognize speech through a CI. Methods-Thirty postlingually deafened adults with CIs and 42 age-matched NH adults were enrolled. Participants and their spouses or significant others (informants) completed well-validated self-reports or informant-reports of EF, the Behavior Rating Inventory of Executive Function -Adult (BRIEF-A). CI users' speech recognition skills were assessed in quiet using several measures of sentence recognition. NH peers were tested for recognition of noise-vocoded versions of the same speech stimuli. Results-CI users self-reported difficulty on EF tasks of shifting and task monitoring. In CI users, measures of speech recognition correlated with several self-reported EF skills. The present findings provide further evidence that neurocognitive factors, including specific EF skills, may decline in association with hearing loss, and that some of these EF skills contribute to speech processing under degraded listening conditions.

Otology & Neurotology, May 14, 2020

Hypotheses: Adult cochlear implant (CI) outcomes depend on demographic, sensory, and cognitive fa... more Hypotheses: Adult cochlear implant (CI) outcomes depend on demographic, sensory, and cognitive factors. However, these factors have not been examined together comprehensively for relations to different outcome types, such as speech recognition versus quality of life (QOL). Three hypotheses were tested: 1) speech recognition will be explained most strongly by sensory factors, whereas QOL will be explained more strongly by cognitive factors. 2) Different speech recognition outcome domains (sentences versus words) and different QOL domains (physical versus social versus psychological functioning) will be explained differentially by demographic, sensory, and cognitive factors. 3) Including cognitive factors as predictors will provide more power to explain outcomes than demographic and sensory predictors alone. Background: A better understanding of the contributors to CI outcomes is needed to prognosticate outcomes before surgery, explain outcomes after surgery, and tailor rehabilitation efforts. Methods: Forty-one adult postlingual experienced CI users were assessed for sentence and word recognition, as well as hearing-related QOL, along with a broad collection of predictors. Partial least squares regression was used to identify factors that were most predictive of outcome measures. Results: Supporting our hypotheses, speech recognition abilities were most strongly dependent on sensory skills, while QOL outcomes required a combination of cognitive, sensory, and demographic predictors. The inclusion of cognitive measures increased the ability to explain outcomes, mainly for QOL. Conclusions: Explaining variability in adult CI outcomes requires a broad assessment approach. Identifying the most important predictors depends on the particular outcome domain and even the particular measure of interest.

Intraoperative Electrocochleography: A Window Into Endolymphatic Hydrops in a Patient With an Endolymphatic Sac Tumor

Otology & Neurotology, Apr 1, 2017

Intraoperative electrocochleography (ECochG) provides valuable information regarding inner ear fu... more Intraoperative electrocochleography (ECochG) provides valuable information regarding inner ear function during surgical procedures. Here, we report findings from ECochG collected at three time intervals during the management of a patient with symptoms of inner ear hydrops. A 38-year-old man with an endolymphatic sac tumor who demonstrated classic Ménière&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s symptoms. Endolymphatic shunt, tumor biopsy, and definitive resection of an endolymphatic sac tumor. Intraoperative ECochG measurements at three time intervals, using frequency-specific tone bursts and clicks. Across time intervals, the amplitude of ECochG summation potential (SP) responses decreased for tone bursts of all frequencies. On the other hand, the SP response to the click stimulus, and the ratio of the SP to action potential (AP), basically remained unchanged across time points. Results suggest that the absolute amplitude of the SP response to frequency-specific tone bursts may be more sensitive to inner ear hydrops than the traditionally used SP/AP ratio as a response to click stimuli.

Laryngoscope, Nov 10, 2020

Objectives/Hypothesis: With the increasing emphasis on developing effective telemedicine approach... more Objectives/Hypothesis: With the increasing emphasis on developing effective telemedicine approaches in Otolaryngology, this study explored whether a single composite image stitched from a digital otoscopy video provides acceptable diagnostic information to make an accurate diagnosis, as compared with that provided by the full video. Study Design: Diagnostic survey analysis. Methods: Five Ear, Nose, and Throat (ENT) physicians reviewed the same set of 78 digital otoscope eardrum videos from four eardrum conditions: normal, effusion, retraction, and tympanosclerosis, along with the composite images generated by a SelectStitch method that selectively uses video frames with computer-assisted selection, as well as a Stitch method that incorporates all the video frames. Participants provided a diagnosis for each item along with a rating of diagnostic confidence. Diagnostic accuracy for each pathology of SelectStitch was compared with accuracy when reviewing the entire video clip and when reviewing the Stitch image. Results: There were no significant differences in diagnostic accuracy for physicians reviewing SelectStitch images and full video clips, but both provided better diagnostic accuracy than Stitch images. The inter-reader agreement was moderate. Conclusions: Equal to using full video clips, composite images of eardrums generated by SelectStitch provided sufficient information for ENTs to make the correct diagnoses for most pathologies. These findings suggest that use of a composite eardrum image may be sufficient for telemedicine approaches to ear diagnosis, eliminating the need for storage and transmission of large video files, along with future applications for improved documentation in electronic medical record systems, patient/ family counseling, and clinical training.

Ear and Hearing, Jul 1, 2016

Objectives-Formant Rise Time (FRT) and Amplitude Rise Time (ART) are acoustic cues that inform ph... more Objectives-Formant Rise Time (FRT) and Amplitude Rise Time (ART) are acoustic cues that inform phonetic identity. FRT represents the rate of transition of the formant(s) to a steady state, while ART represents the rate at which the sound reaches its peak amplitude. Normal hearing (NH) native English speakers weight FRT more than ART during the perceptual labeling of the /bα/-/wα/ contrast. This weighting strategy is reflected neurophysiologically in the magnitude of the mismatch negativity (MMN) -MMN is larger during the FRT than the ART distinction. The present study examined the neurophysiological basis of acoustic cue weighting in adult cochlear implant (CI) listeners using the MMN design. It was hypothesized that individuals with CIs who weight ART more in behavioral labeling (ART-users) would show larger MMNs during the ART than the FRT contrast, and the opposite would be seen for FRT-users. Design-Electroencephalography (EEG) was recorded while twenty adults with CIs listened passively to combinations of three synthetic speech stimuli: a /bα/ with /bα/-like FRT and ART; a / wα/ with /wα/-like FRT and ART; and a /bα/ wa stimulus with /bα/-like FRT and /wα/-like ART. The MMN response was elicited during the FRT contrast by having participants passively listen to a train of /wα/ stimuli interrupted occasionally by /bα/ wa stimuli, and vice versa. For the ART contrast, the same procedure was implemented using the /bα/ and /bα/ wa stimuli. Results-Both ART-and FRT-users with CIs elicited MMNs that were equal in magnitudes during FRT and ART contrasts, with the exception that FRT-users exhibited MMNs for ART and FRT contrasts that were temporally segregated. That is, their MMNs occurred significantly earlier during the ART contrast (~100 ms following sound onset) than during the FRT contrast (~200ms). In contrast, the MMNs for ART-users of both contrasts occurred later and were not significantly separable in time (~230 ms). Interestingly, this temporal segregation observed in FRT-users is consistent with the MMN behavior in NH listeners. suggest that listeners with CIs who learn to classify phonemes based on formant dynamics, consistent with NH listeners, develop a strategy similar to NH listeners, in

Discussing Age-Related Hearing Loss and Cognitive Decline With Patients

JAMA otolaryngology-- head & neck surgery, Sep 1, 2019

Laryngoscope, Jun 14, 2019

Journal of The American Academy of Audiology, Apr 1, 2020

Background Objective speech recognition tasks are widely used to measure performance of adult coc... more Background Objective speech recognition tasks are widely used to measure performance of adult cochlear implant (CI) users; however, the relationship of these measures with patient-reported quality of life (QOL) remains unclear. A comprehensive QOL measure, the Nijmegen Cochlear Implant Questionnaire (NCIQ), has historically shown a weak association with speech recognition performance, but closer examination may indicate stronger relations between QOL and objective auditory performance, particularly when examining a broad range of auditory skills. Purpose The aim of the present study was to assess the NCIQ for relations to speech and environmental sound recognition measures. Identifying associations with certain QOL domains, subdomains, and subitems would provide evidence that speech and environmental sound recognition measures are relevant to QOL. A lack of relations among QOL and various auditory abilities would suggest potential areas of patientreported difficulty that could be better measured or targeted. Research Design A cross-sectional study was performed in adult CI users to examine relations among subjective QOL ratings on NCIQ domains, subdomains, and subitems with auditory outcome measures. Study Sample Participants were 44 adult experienced CI users. All participants were postlingually deafened and had met candidacy requirements for traditional cochlear implantation. Data Collection and Analysis Participants completed the NCIQ as well as several speech and environmental sound recognition tasks: monosyllabic word recognition, standard and high-variability sentence recognition, audiovisual sentence recognition, and environmental sound identification. Bivariate correlation analyses were performed to investigate relations among patient-reported NCIQ scores and the functional auditory measures. Results The total NCIQ score was not strongly correlated with any objective auditory outcome measures. The physical domain and the advanced sound perception subdomain related to several measures, in particular monosyllabic word recognition and AzBio sentence recognition. Fourteen of the 60 subitems on the NCIQ were correlated with at least one auditory measure. Conclusions Several subitems demonstrated moderate-to-strong correlations with auditory measures, indicating that these auditory measures are relevant to the QOL. A

Otology & Neurotology, Oct 1, 2018

Hypothesis: For experienced adult cochlear implant (CI) users who have reached a plateau in perfo... more Hypothesis: For experienced adult cochlear implant (CI) users who have reached a plateau in performance, a clinician-guided aural rehabilitation (AR) approach can improve speech recognition and hearing-related quality of life (QOL). Background: A substantial number of CI users do not reach optimal performance in terms of speech recognition ability and/or personal communication goals. Although self-guided computerized auditory training programs have grown in popularity, compliance and efficacy for these programs are poor. We propose that clinician-guided AR can improve speech recognition and hearing-related QOL in experienced CI users. Methods: Twelve adult CI users were enrolled in an 8-week AR program guided by a speechlanguage pathologist and audiologist. Nine patients completed the program along with pre-AR and immediate post-AR testing of speech recognition (AzBio sentences in quiet and in multi-talker babble, Consonant-Nucleus-Consonant words), QOL (Nijmegen Cochlear Implant Questionnaire, Hearing Handicap Inventory for Adults/Elderly, and Speech, Spatial and Qualities of Hearing Scale), and neurocognitive functioning (working memory capacity, information-processing speed, inhibitory control, speed of lexical/phonological access, and nonverbal reasoning). Pilot data for these 9 patients are presented. Results: From pre-AR to post-AR, group mean improvements in word recognition were found. Improvements were also demonstrated on some composite and subscale measures of QOL. Patients who demonstrated improvements in word recognition were those who performed most poorly at baseline. Clinician-guided AR represents a potentially efficacious approach to improving speech recognition and QOL for experienced CI users. Limitations and considerations in implementing and studying AR approaches are discussed.