Introduction to the special issue on perception and production of sounds in the high-frequency range of human speecha).

The frequency range audible to humans can extend from 20 Hz to 20 kHz, but only a portion of this range-the lower end up to 8 kHz-has been systematically explored because extended high-frequency (EHF) information above this low range has been considered unnecessary for speech comprehension. This special issue presents a collection of research studies exploring the presence of EHF information in the acoustic signal and its perceptual utility. The papers address the role of EHF hearing in auditory perception, the impact of EHF hearing loss on speech perception in specific populations and occupational settings, the importance of EHF in speech recognition and in providing speaker-related information, the utility of acoustic EHF energy in fricative sounds, and ultrasonic vocalizations in mice in relation to human hearing. Collectively, the research findings offer new insights and converge in showing that not only is EHF energy present in the speech spectrum, but listeners can utilize EHF cues in speech processing and recognition, and EHF hearing loss has detrimental effects on perception of speech and non-speech sounds. Together, this collection challenges the conventional notion that EHF information has minimal functional significance.

Corticomuscular Coherence in Children with Unilateral Cerebral Palsy: A Feasibility and Preliminary Protocol Study.

Objective This study assessed the feasibility of corticomuscular coherence measurement during a goal-directed task in children with unilateral cerebral palsy while establishing optimal experimental parameters. Methods Participants (Manual Ability Classification System levels I-III) completed a submaximal isometric goal-directed grip task during simultaneous electroencephalography and electromyography (EMG) acquisition. Results All participants (n = 11, 6 females, mean age 11.3 ±2.4 years) completed corticomuscular coherence procedures. Of the 40 trials obtained per extremity, an average of 29 (n = 9) and 27 (n = 10) trials were retained from the more- and less-affected extremities, respectively. Obtaining measurement stability required an average of 28 trials per extremity. Conclusion Findings from this work support the feasibility of corticomuscular coherence measurement in children with unilateral cerebral palsy. Acquiring 28 to 40 corticomuscular coherence trials per extremity is ideal. The experimental parameters established in this work will inform future corticomuscular coherence application in pediatric unilateral cerebral palsy.

Telehealth in PM&R: Past, present, and future in clinical practice and opportunities for translational research.

Telehealth refers to the use of telecommunication devices and other forms of technology to provide services outside of the traditional in-person health care delivery system. Growth in the use of telehealth creates new challenges and opportunities for implementation in clinical practice. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) assembled an expert group to develop a white paper to examine telehealth innovation in Physical Medicine and Rehabilitation (PM&R). The resultant white paper summarizes how telehealth is best used in the field of PM&R while highlighting current knowledge deficits and technological limitations. The report identifies new and transformative opportunities for PM&R to advance translational research related to telehealth and enhance patient care.

Burnout and Wellness Strategies Used by Academic Physiatry Programs: An Analysis and Perspective From the AAP Chairs Council.

ABSTRACT: Physiatrists are at elevated risk of burnout, a work-related exhaustion syndrome resulting from chronic stress associated with emotionally draining work demands. The high reported rate of burnout in physical medicine and rehabilitation led the Association of Academic Physiatrists Chair Council to convene a workgroup to address burnout among academic physical medicine and rehabilitation physicians. The council recognizes that leaders of departments are accountable for all organizational stakeholders, including faculty, trainees, and staff. Department leaders are expected to understand and effectively manage the drivers of burnout among stakeholders. The workgroup identified several opportunities, including identifying and disseminating effective burnout mitigation across US academic medical center physical medicine and rehabilitation programs. As a result, in 2019, a work group conducted a survey of US academic physical medicine and rehabilitation program leaders to ascertain the use of strategies for reducing physician burnout. With the aim of identifying, educating, and advancing the development of effective interventions to address burnout among academic physical medicine and rehabilitation departments, the Association of Academic Physiatrists Chair Council advocates for increased education and utilization of effective strategies aimed at promoting physician well-being across organizational levels (national, organizational, work unit, and individual).

Wellens syndrome: An important consideration in patients with chest pain.

ABSTRACT: Coronary artery disease (CAD) is the number one cause of death in the United States, and it is estimated that every 40 seconds one person experiences a heart attack. Among patients with chronic CAD, many will experience a potentially fatal complication known as acute coronary syndrome (ACS). Wellens syndrome is a rare form of ACS that indicates critical left anterior descending coronary artery occlusion and can be identified by its characteristic T-wave patterns on ECG. This syndrome also may go unrecognized by clinicians because of a lack of familiarity with the ECG findings. This article describes the Wellens ECG pattern and its significance in patients with chest pain.

Telehealth: Opportunities to Improve Access, Quality, and Cost in Pediatric Care.

The use of telehealth technology to connect with patients has expanded significantly over the past several years, particularly in response to the global coronavirus disease 2019 pandemic. This technical report describes the present state of telehealth and its current and potential applications. Telehealth has the potential to transform the way care is delivered to pediatric patients, expanding access to pediatric care across geographic distances, leveraging the pediatric workforce for care delivery, and improving disparities in access to care. However, implementation will require significant efforts to address the digital divide to ensure that telehealth does not inadvertently exacerbate inequities in care. The medical home model will continue to evolve to use telehealth to provide high-quality care for children, particularly for children and youth with special health care needs, in accordance with current and evolving quality standards. Research and metric development are critical for the development of evidence-based best practices and policies in these new models of care. Finally, as pediatric care transitions from traditional fee-for-service payment to alternative payment methods, telehealth offers unique opportunities to establish value-based population health models that are financed in a sustainable manner.

The peak height insertion gain (PHIG) method for quantifying acoustic feedback in hearing aids.

Hearing aids are commonly fit with ear canals partially or fully open-a condition that increases the risk of acoustic feedback. Feedback limits the audiometric fitting range of devices by limiting usable gain. To guide clinical decision making and device selection, we developed the Peak Height Insertion Gain (PHIG) method to detect feedback spikes in the short-term insertion gain derived from audio recordings. Using a manikin, 145 audio recordings of a speech signal were obtained from seven hearing aids. Each hearing aid was programmed for a moderate high-frequency hearing loss with systematic variations in frequency response, gain, and feedback suppression; this created audio recordings that varied the presence and strength of feedback. Using subjective ratings from 13 expert judges, the presence of feedback was determined and then classified according to its temporal and tonal qualities. These classifications were used to optimize parameters for two versions of the PHIG method based on global and local analyses. When specificity was fixed at 0.95, the sensitivity of the global analysis was 0.86 and increased to 0.95 when combined with the local analysis. Without compromising performance, a clinically expedient version of the PHIG method can be obtained using only a single measurement.

Hearing Aid Technology to Improve Speech Intelligibility in Noise.

Understanding speech in noise is difficult for individuals with normal hearing and is even more so for individuals with hearing loss. Difficulty understanding speech in noise is one of the primary reasons people seek hearing assistance. Despite amplification, many hearing aid users still struggle to understand speech in noise. In response to this persistent problem, hearing aid manufacturers have invested significantly in developing new solutions. Any solution is not without its tradeoffs, and decisions must be made when optimizing and implementing them. Much of this happens behind the scenes, and casual observers fail to appreciate the nuances of developing new hearing aid technologies. The difficulty of communicating this information to clinicians may hinder the use or the fine-tuning of the various technologies available today. The purpose of this issue of Seminars in Hearing is to educate professionals and students in audiology, hearing science, and engineering about different approaches to combat problems related to environmental and wind noise using technologies that include classification, directional microphones, binaural signal processing, beamformers, motion sensors, and machine learning. To accomplish this purpose, some of the top researchers and engineers from the world's largest hearing aid manufacturers agreed to share their unique insights.

Telehealth: Improving Access to and Quality of Pediatric Health Care.

All children and adolescents deserve access to quality health care regardless of their race/ethnicity, health conditions, financial resources, or geographic location. Despite improvements over the past decades, severe disparities in the availability and access to high-quality health care for children and adolescents continue to exist throughout the United States. Economic and racial factors, geographic maldistribution of primary care pediatricians, and limited availability of pediatric medical subspecialists and pediatric surgical specialists all contribute to inequitable access to pediatric care. Robust, comprehensive telehealth coverage is critical to improving pediatric access and quality of care and services, particularly for under-resourced populations.

The relationship between ipsilateral cochlear gain reduction and speech-in-noise recognition at positive and negative signal-to-noise ratios.

Active mechanisms that regulate cochlear gain are hypothesized to influence speech-in-noise perception. However, evidence of a relationship between the amount of cochlear gain reduction and speech-in-noise recognition is mixed. Findings may conflict across studies because different signal-to-noise ratios (SNRs) were used to evaluate speech-in-noise recognition. Also, there is evidence that ipsilateral elicitation of cochlear gain reduction may be stronger than contralateral elicitation, yet, most studies have investigated the contralateral descending pathway. The hypothesis that the relationship between ipsilateral cochlear gain reduction and speech-in-noise recognition depends on the SNR was tested. A forward masking technique was used to quantify the ipsilateral cochlear gain reduction in 24 young adult listeners with normal hearing. Speech-in-noise recognition was measured with the PRESTO-R sentence test using speech-shaped noise presented at -3, 0, and +3 dB SNR. Interestingly, greater cochlear gain reduction was associated with lower speech-in-noise recognition, and the strength of this correlation increased as the SNR became more adverse. These findings support the hypothesis that the SNR influences the relationship between ipsilateral cochlear gain reduction and speech-in-noise recognition. Future studies investigating the relationship between cochlear gain reduction and speech-in-noise recognition should consider the SNR and both descending pathways.

Pediatrician Attitudes Toward and Experiences With Telehealth Use: Results From a National Survey.

BACKGROUND: The American Academy of Pediatrics 2015 policy statement on telehealth proposed that telehealth could increase access to high-quality pediatric care and that pediatricians should work to reduce barriers to telehealth for their patients. However, little is known about pediatricians' experiences with and attitudes toward telehealth. METHODS: Data from a nationally representative survey of American Academy of Pediatrics postresidency US member pediatricians in 2016, restricted to respondents providing direct patient care (n = 744; response rate = 48.7%). Survey collected information on experience with telehealth in the previous 12 months, perceived barriers to telehealth incorporation, and conditions under which nonusers would consider using telehealth. In addition to descriptive statistics, we used multivariable logistic regression to examine characteristics associated with any telehealth experience in the past 12 months. RESULTS: Fifteen percent of pediatricians reported any telehealth use in the 12 months prior to the survey. The most commonly reported barriers to telehealth adoption were insufficient payment and billing issues. Multivariable regression models indicated that pediatricians in rural areas, the West, and subspecialists were most likely to report telehealth use, and identifying barriers was negatively associated with telehealth use. Among nonusers, over half indicated they would consider adopting telehealth if they were paid for the visits. CONCLUSION: Telehealth is considered an important health care delivery mechanism, but only 15% of pediatricians in 2016 reported having used telehealth. Reducing barriers will be instrumental in promoting future telehealth adoption. Many barriers have been reduced during the response to COVID-19, and the impact of these policy changes will need further study.

The S-SH Confusion Test and the Effects of Frequency Lowering.

Purpose Frequency lowering in hearing aids can cause listeners to perceive [s] as [ʃ]. The S-SH Confusion Test, which consists of 66 minimal word pairs spoken by 6 female talkers, was designed to help clinicians and researchers document these negative side effects. This study's purpose was to use this new test to evaluate the hypothesis that these confusions will increase to the extent that low frequencies are altered. Method Twenty-one listeners with normal hearing were each tested on 7 conditions. Three were control conditions that were low-pass filtered at 3.3, 5.0, and 9.1 kHz. Four conditions were processed with nonlinear frequency compression (NFC): 2 had a 3.3-kHz maximum audible output frequency (MAOF), with a start frequency (SF) of 1.6 or 2.2 kHz; 2 had a 5.0-kHz MAOF, with an SF of 1.6 or 4.0 kHz. Listeners' responses were analyzed using concepts from signal detection theory. Response times were also collected as a measure of cognitive processing. Results Overall, [s] for [ʃ] confusions were minimal. As predicted, [ʃ] for [s] confusions increased for NFC conditions with a lower versus higher MAOF and with a lower versus higher SF. Response times for trials with correct [s] responses were shortest for the 9.1-kHz control and increased for the 5.0- and 3.3-kHz controls. NFC response times were also significantly longer as MAOF and SF decreased. The NFC condition with the highest MAOF and SF had statistically shorter response times than its control condition, indicating that, under some circumstances, NFC may ease cognitive processing. Conclusions Large differences in the S-SH Confusion Test across frequency-lowering conditions show that it can be used to document a major negative side effect associated with frequency lowering. Smaller but significant differences in response times for correct [s] trials indicate that NFC can help or hinder cognitive processing, depending on its settings.

Effects of noise and reverberation on speech recognition with variants of a multichannel adaptive dynamic range compression scheme.

Objective: Adaptive compression methods in hearing aids have been developed to maximise audibility while preserving temporal envelope modulations. Increasing the number of channels may improve listening comfort for loud sounds. However, the effects of this on speech recognition in different environmental conditions are unknown. This study evaluated the effects of different channel architectures and adaptive compression properties on speech recognition in noise and reverberation. Design: Sentences were mixed with steady or modulated noise at three signal-to-noise ratios (SNRs). These were processed with and without reverberation and amplified with four proprietary adaptive compression methods or linear amplification. Study sample: 36 listeners with mild to moderately-severe hearing loss. Results: Adaptive compression improved speech recognition over linear amplification to a small extent, with no significant differences among methods using 4 or 24 channels or a combination thereof. These effects remained across the different background noise and reverberation conditions. Conclusions: Increasing the number of channels does not negatively affect speech recognition in noise and reverberation when adaptive compression is used. If future research shows that increasing the number of channels improves listening comfort for loud sounds, these results indicate that adaptive compression methods with as many as 24 channels are viable options for hearing aids.

Listening Effort and Speech Recognition with Frequency Compression Amplification for Children and Adults with Hearing Loss.

BACKGROUND: Nonlinear frequency compression (NFC) can improve the audibility of high-frequency sounds by lowering them to a frequency where audibility is better; however, this lowering results in spectral distortion. Consequently, performance is a combination of the effects of increased access to high-frequency sounds and the detrimental effects of spectral distortion. Previous work has demonstrated positive benefits of NFC on speech recognition when NFC is set to improve audibility while minimizing distortion. However, the extent to which NFC impacts listening effort is not well understood, especially for children with sensorineural hearing loss (SNHL). PURPOSE: To examine the impact of NFC on recognition and listening effort for speech in adults and children with SNHL. RESEARCH DESIGN: Within-subject, quasi-experimental study. Participants listened to amplified nonsense words that were (1) frequency-lowered using NFC, (2) low-pass filtered at 5 kHz to simulate the restricted bandwidth (RBW) of conventional hearing aid processing, or (3) low-pass filtered at 10 kHz to simulate extended bandwidth (EBW) amplification. STUDY SAMPLE: Fourteen children (8-16 yr) and 14 adults (19-65 yr) with mild-to-severe SNHL. INTERVENTION: Participants listened to speech processed by a hearing aid simulator that amplified input signals to fit a prescriptive target fitting procedure. DATA COLLECTION AND ANALYSIS: Participants were blinded to the type of processing. Participants' responses to each nonsense word were analyzed for accuracy and verbal-response time (VRT; listening effort). A multivariate analysis of variance and linear mixed model were used to determine the effect of hearing-aid signal processing on nonsense word recognition and VRT. RESULTS: Both children and adults identified the nonsense words and initial consonants better with EBW and NFC than with RBW. The type of processing did not affect the identification of the vowels or final consonants. There was no effect of age on recognition of the nonsense words, initial consonants, medial vowels, or final consonants. VRT did not change significantly with the type of processing or age. CONCLUSION: Both adults and children demonstrated improved speech recognition with access to the high-frequency sounds in speech. Listening effort as measured by VRT was not affected by access to high-frequency sounds.

Acoustic and perceptual effects of amplitude and frequency compression on high-frequency speech.

This study investigated how six different amplification methods influence acoustic properties, and subsequently perception, of high-frequency cues in fricatives that have been processed with conventional full bandwidth amplification or nonlinear frequency compression (NFC)-12 conditions total. Amplification methods included linear gain, fast/slow-acting wide dynamic range compression crossed with fixed/individualized compression parameters, and a method with adaptive time constants. Twenty-one hearing-impaired listeners identified seven fricatives in nonsense syllables produced by female talkers. For NFC stimuli, frequency-compressed filters that precisely aligned 1/3-octave bands between input and output were used to quantify effective compression ratio, audibility, and temporal envelope modulation relative to the input. Results indicated significant relationships between these acoustic properties, each of which contributed significantly to fricative recognition across the entire corpus of stimuli. Recognition was significantly better for NFC stimuli compared with full bandwidth stimuli, regardless of the amplification method, which had complementary effects on audibility and envelope modulation. Furthermore, while there were significant differences in recognition across the amplification methods, they were not consistent across phonemes. Therefore, neither recognition nor acoustic data overwhelmingly suggest that one amplification method should be used over another for transmission of high-frequency cues in isolated syllables. Longer duration stimuli and more realistic listening conditions should be examined.

Power spectral entropy as an information-theoretic correlate of manner of articulation in American English.

While all languages differentiate speech sounds by manner of articulation, none of the acoustic correlates proposed to date seem to account for how these contrasts are encoded in the speech signal. The present study describes power spectral entropy (PSE), which quantifies the amount of potential information conveyed in the power spectrum of a given sound. Results of acoustic analyses of speech samples extracted from the Texas Instruments-Massachusetts Institute of Technology database reveal a statistically significant correspondence between PSE and American English major classes of manner of articulation. Thus, PSE accurately captures an acoustic correlate of manner of articulation in American English.

A Sequential Sentence Paradigm Using Revised PRESTO Sentence Lists.

BACKGROUND: Listening in challenging situations requires explicit cognitive resources to decode and process speech. Traditional speech recognition tests are limited in documenting this cognitive effort, which may differ greatly between individuals or listening conditions despite similar scores. A sequential sentence paradigm was designed to be more sensitive to individual differences in demands on verbal processing during speech recognition. PURPOSE: The purpose of this study was to establish the feasibility, validity, and equivalency of test materials in the sequential sentence paradigm as well as to evaluate the effects of masker type, signal-to-noise ratio (SNR), and working memory (WM) capacity on performance in the task. RESEARCH DESIGN: Listeners heard a pair of sentences and repeated aloud the second sentence (immediate recall) and then wrote down the first sentence (delayed recall). Sentence lists were from the Perceptually Robust English Sentence Test Open-set (PRESTO) test. In experiment I, listeners completed a traditional speech recognition task. In experiment II, listeners completed the sequential sentence task at one SNR. In experiment III, the masker type (steady noise versus multitalker babble) and SNR were varied to demonstrate the effects of WM as the speech material increased in difficulty. STUDY SAMPLE: Young, normal-hearing adults (total n = 53) from the Purdue University community completed one of the three experiments. DATA COLLECTION AND ANALYSIS: Keyword scoring of the PRESTO lists was completed for both the immediate- and delayed-recall sentences. The Verbal Letter Monitoring task, a test of WM, was used to separate listeners into a low-WM or high-WM group. RESULTS: Experiment I indicated that mean recognition on the single-sentence task was highly variable between the original PRESTO lists. Modest rearrangement of the sentences yielded 18 statistically equivalent lists (mean recognition = 65.0%, range = 64.4-65.7%), which were used in the sequential sentence task in experiment II. In the new test paradigm, recognition of the immediate-recall sentences was not statistically different from the single-sentence task, indicating that there were no cognitive load effects from the delayed-recall sentences. Finally, experiment III indicated that multitalker babble was equally detrimental compared to steady-state noise for immediate recall of sentences for both low- and high-WM groups. On the other hand, delayed recall of sentences in multitalker babble was disproportionately more difficult for the low-WM group compared with the high-WM group. CONCLUSIONS: The sequential sentence paradigm is a feasible test format with mostly equivalent lists. Future studies using this paradigm may need to consider individual differences in WM to see the full range of effects across different conditions. Possible applications include testing the efficacy of various signal-processing techniques in clinical populations.

Minimal Hearing Loss: From a Failure-Based Approach to Evidence-Based Practice.

PURPOSE: A representative sample of the literature on minimal hearing loss (MHL) was reviewed to provide evidence of challenges faced by children with MHL and to establish the need for evidence-based options for early intervention. METHOD: Research articles published from 1950 to 2013 were searched in the Medline database using the keywords minimal hearing loss, unilateral hearing loss, and mild hearing loss. References cited in retrieved articles were also reviewed. RESULTS: In total, 69 articles contained relevant information about pediatric outcomes and/or intervention for unilateral hearing loss, 50 for mild hearing loss, and 6 for high-frequency hearing loss. Six challenges associated with MHL emerged, and 6 interventions were indicated. Evidence indicates that although some individuals may appear to have no observable speech-language or academic difficulties, others experience considerable difficulties. It also indicates that even though children with MHL may appear to catch up in some areas, difficulties in select domains continue into adulthood. CONCLUSIONS: Evidence indicates significant risks associated with untreated MHL. Evidence also demonstrates the need for early intervention and identifies several appropriate intervention strategies; however, no single protocol is appropriate for all children. Therefore, families should be educated about the impact of MHL and about available interventions so that informed decisions can be made.

Nonlinear frequency compression: Influence of start frequency and input bandwidth on consonant and vowel recognition.

By varying parameters that control nonlinear frequency compression (NFC), this study examined how different ways of compressing inaudible mid- and/or high-frequency information at lower frequencies influences perception of consonants and vowels. Twenty-eight listeners with mild to moderately severe hearing loss identified consonants and vowels from nonsense syllables in noise following amplification via a hearing aid simulator. Low-pass filtering and the selection of NFC parameters fixed the output bandwidth at a frequency representing a moderately severe (3.3 kHz, group MS) or a mild-to-moderate (5.0 kHz, group MM) high-frequency loss. For each group (n = 14), effects of six combinations of NFC start frequency (SF) and input bandwidth [by varying the compression ratio (CR)] were examined. For both groups, the 1.6 kHz SF significantly reduced vowel and consonant recognition, especially as CR increased; whereas, recognition was generally unaffected if SF increased at the expense of a higher CR. Vowel recognition detriments for group MS were moderately correlated with the size of the second formant frequency shift following NFC. For both groups, significant improvement (33%-50%) with NFC was confined to final /s/ and /z/ and to some VCV tokens, perhaps because of listeners' limited exposure to each setting. No set of parameters simultaneously maximized recognition across all tokens.

Resolution of New Daily Persistent Headache After Osteopathic Manipulative Treatment.

New daily persistent headache is a refractory headache with an elusive cause and treatment. Limited available data suggest that abnormalities in the musculoskeletal system may increase vulnerability to this type of headache. Osteopathic manipulative treatment has been used successfully to manage primary headache disorders. In this case report, a patient with new daily persistent headache and severe somatic dysfunction had resolution of her pain after osteopathic manipulative treatment. This case suggests that osteopathic manipulative treatment may be useful in patients with this typically treatment-resistant disorder.