Auditory Profile-Based Hearing Aid Fitting: Self-Reported Benefit for First-Time Hearing Aid Users.

Background: Although hearing aids (HAs) can compensate for reduced audibility, functional outcomes and benefits vary widely across individuals. As part of the Danish 'Better hEAring Rehabilitation' (BEAR) project, four distinct auditory profiles differing in terms of audiometric thresholds and supra-threshold hearing abilities were recently identified. Additionally, profile-specific HA-fitting strategies were proposed. The aim of the current study was to evaluate the self-reported benefit of these profile-based HA fittings in a group of new HA users. Methods: A total of 205 hearing-impaired older adults were recruited from two Danish university hospitals. Participants were randomly allocated to one of two treatment groups: (1) NAL-NL2 gain prescription combined with default advanced feature settings ('reference fitting') or (2) auditory profile-based fitting with tailored gain prescription and advanced feature settings ('BEAR fitting'). Two months after treatment, the participants completed the benefit version of the short form of the Speech, Spatial, and Qualities of Hearing Scale (SSQ12-B) and the International Outcome Inventory for Hearing Aids (IOI-HA) questionnaire. Results: Overall, participants reported a clear benefit from HA treatment. However, no significant differences in the SSQ12-B or IOI-HA scores between the reference and BEAR fittings were found. Conclusion: First-time users experience clear benefits from HA treatment. Auditory profile-based HA fitting warrants further investigation.

Usability of the inductive tongue computer interface: Internet use, speaking, and drinking - evaluated by two users with disabilities.

Tongue computer interfaces have shown promising for both computer control and for control of assistive technologies and robotics. Still, evidence is lacking in relation to their usability resulting in speculations on their effectiveness for general computer use and their impact on other activities such as speaking, drinking, and eating. This paper presents the results of such a usability study performed with two individuals with tetraplegia. The results show a high acceptance of the Inductive Tongue Computer Interface with an average rating of 2.6 on a scale from 1 (normal) to 10 (unacceptable) and a low impact on speech after only 3 days of use.Clinical Relevance- This study emphasizes the applicability and adoptability of the Inductive Tongue Interface as a useful assistive technology for individuals with severe disabilities.

Difference in SII provided by initial fit and NAL-NL2 and its relation to self-reported hearing aid outcomes.

OBJECTIVE: The speech intelligibility index (SII) is used to quantify the audibility of the speech. This study examined the relationship between self-reported hearing aid (HA) outcomes and the difference in aided SII (SIIA) calculated from the initial fit (IF) gain and that prescribed as per the second generation of National Acoustic Laboratory Non-Linear (NAL-NL2). DESIGN: A prospective observational study. STUDY SAMPLE: The study included 718 first-time and 253 experienced HA users. All users had a valid real-ear measurement (REM) at three input levels (55, 65 and 80 dB SPL). RESULTS: The gain provided by IF was lower than NAL-NL2 at 55 and 65 dB SPL. IF gain exhibited reduced compression than NAL-NL2 as input levels increased from 55 to 80 dB SPL. On average, the SIIA provided by IF was significantly lower than that for NAL-NL2 at all input levels. The difference in SIIA between IF and NAL-NL2 at 80 dB SPL input level with 0 dB signal-to-noise ratio (SNR) turned out to be a predictor for self-reported outcome for first-time HA users. CONCLUSION: The study suggests that an SIIA close to that provided by NAL-NL2 at high input levels would be preferred to obtain a better self-reported outcome. .

A history of occupational noise exposure is associated with steep-slope audiograms and poorer self-reported hearing-aid outcomes.

OBJECTIVE: To investigate the effects of previous occupational noise exposure in older adults with hearing loss on (1) audiometric configuration and acoustic reflex (AR) thresholds and (2) self-reported hearing abilities and hearing aid (HA) effectiveness. DESIGN: A prospective observational study. STUDY SAMPLE: The study included 1176 adults (≥60 years) with bilateral sensorineural hearing loss. Pure-tone audiometry, AR thresholds, and responses to the abbreviated version of the Speech, Spatial, and Qualities of Hearing Scale (SSQ12) and the International Outcome Inventory for Hearing Aids (IOI-HA) questionnaire were obtained, along with information about previous occupational noise exposure. RESULTS: Greater occupational noise exposure was associated with a higher prevalence of steeply sloping audiograms in men and women and a 0.32 (95% CI: -0.57; -0.06) scale points lower mean SSQ12 total score among noise-exposed men. AR thresholds did not show a significant relation to noise-exposure status, but hearing thresholds at a given frequency were related to elevated AR thresholds at the same frequency. CONCLUSIONS: A noise exposure history is linked to steeper audiograms in older adults with hearing loss as well as to poorer self-reported hearing abilities in noise-exposed men. More attention to older adults with previous noise exposure is warranted in hearing rehabilitation.

Adapting to New Hearing Aids and Hearing Aid Adjustments in Adult Danish Users.

PURPOSE: This study was aimed at understanding the effect of time taken to adapt to the new hearing aids (HAs) and the timeline of HA adjustments performed over more than a year of rehabilitation on self-reported HA outcomes. METHOD: A self-report of the time it took to get accustomed to the new HAs and adjustment of the HAs during a year of rehabilitation collected from 690 HA users using a nonstandardized questionnaire were analyzed. The abbreviated version of the Speech, Spatial, and Quality of Hearing questionnaire and the International Outcome Inventory for Hearing Aids were used as the self-reported HA outcome. RESULT: Out of 690 participants, 442 (64%) got accustomed to HAs within 2 months. Ninety-one participants (13%) did not get accustomed to the HAs at all, out of which 74 (81%) were first-time HA users. Eighty-four participants (12%) did not receive any HA adjustments after their initial fitting, and 49 (7%) had their HAs adjusted four or more times during the 1 year of rehabilitation. Three hundred ninety (57%) participants got their HA adjusted only at the 2-month follow-up visit, showing the intent to adjust given an opportunity. The stepwise multiple linear regression results showed the significant impact of getting accustomed to the HA and having HA adjusted at multiple instances on the self-reported HA outcomes. CONCLUSION: This study showed the importance of getting accustomed to the HA and having a minimal number of adjustments to have a better long-term self-reported HA outcome.

Impact of hearing aid technology level at first-fit on self-reported outcomes in patients with presbycusis: a randomized controlled trial.

To provide clinical guidance in hearing aid prescription for older adults with presbycusis, we investigated differences in self-reported hearing abilities and hearing aid effectiveness for premium or basic hearing aid users. Secondly, as an explorative analysis, we investigated if differences in gain prescription verified with real-ear measurements explain differences in self-reported outcomes. The study was designed as a randomized controlled trial in which the patients were blinded towards the purpose of the study. In total, 190 first-time hearing aid users (>60 years of age) with symmetric bilateral presbycusis were fitted with either a premium or basic hearing aid. The randomization was stratified on age, sex, and word recognition score. Two outcome questionnaires were distributed: the International Outcome Inventory for Hearing Aids (IOI-HA) and the short form of the Speech, Spatial, and Qualities of Hearing Scale (SSQ-12). In addition, insertion gains were calculated from real-ear measurements at first-fit for all fitted hearing aids. Premium hearing aid users reported 0.7 (95%CI: 0.2; 1.1) scale points higher total SSQ-12 score per item and 0.8 (95%CI: 0.2; 1.4) scale points higher speech score per item, as well as 0.6 (95%CI: 0.2; 1.1) scale points higher qualities score compared to basic-feature hearing aid users. No significant differences in reported hearing aid effectiveness were found using the IOI-HA. Differences in the prescribed gain at 1 and 2 kHz were observed between premium and basic hearing aids within each company. Premium-feature devices yielded slightly better self-reported hearing abilities than basic-feature devices, but a statistically significant difference was only found in three out of seven outcome variables, and the effect was small. The generalizability of the study is limited to community-dwelling older adults with presbycusis. Thus, further research is needed for understanding the potential effects of hearing aid technology for other populations. Hearing care providers should continue to insist on research to support the choice of more costly premium technologies when prescribing hearing aids for older adults with presbycusis. Clinical Trial Registration: https://register.clinicaltrials.gov/, identifier NCT04539847.

The effect of hearing aid treatment on health-related quality of life in older adults with hearing loss.

OBJECTIVE: To investigate the effect of hearing aid (HA) intervention on long-term health-related quality of life (HRQoL) changes in first-time and experienced HA users using the 15D questionnaire. Secondly, the study explored the relationship between clinical parameters and changes in 15D scores. DESIGN: A prospective observational study. STUDY SAMPLE: The study population included 1562 patients (1113 first-time and 449 experienced HA users) referred for HA rehabilitation. All patients responded to the 15D at baseline, two months after HA fitting, and at long-term follow-up (698 ± 298 d). RESULTS: Among both first-time and experienced HA users, significant improvements in hearing-dimension (15D-3) score were observed at two-month follow-up which sustained at long-term follow-up. 15D total scores significantly decreased at long-term follow-up. Self-reported hearing abilities, word recognition scores, and HA use time were significantly and positively correlated to increased 15D. CONCLUSIONS: Both groups of HA users reported improved hearing-related QoL after HA treatment which sustained at long-term follow-up but the improvement in total 15D total score did not sustain for either group. The results suggest that HA intervention positively affects hearing-related QoL among older adults with hearing loss, and the findings support the use of 15D as a tool for the evaluation of HA treatment effects.

Self-Reported Hearing-Aid Use Patterns in an Adult Danish Population.

The retrospective reporting of users' hearing aid (HA) usage can provide insight into individualized HA usage patterns. Understanding these HA usage patterns can help to provide a tailored solution to meet the usage needs of HA users. This study aims to understand the HA usage pattern in daily-life situations from self-reported data and to examine its relationship to self-reported outcomes. A total of 1537 participants who responded to questions related to situations where they always took off or put on the HAs were included in the study. A latent class analysis was performed to stratify the HA users according to their HA usage pattern. The results showed distinct usage patterns in the latent classes derived for both scenarios. The demographics, socio-economic indicators, hearing loss, and user-related factors were found to impact HA usage. The results showed that the HA users who reported using the HAs all the time (regular users) had better self-reported HA outcomes than situational users, situational non-users, and non-users. The study explained the underlying distinct HA usage pattern from self-reported questionnaires using latent class analysis. The results emphasized the importance of regular use of HAs for a better self-reported HA outcome.

Value Propositions of Public Adult Hearing Rehabilitation in Denmark.

Objective: To obtain and evaluate detailed descriptions of potential value propositions as seen by adults undergoing hearing rehabilitation with hearing aids. Design: Semi-structured interviews with patients and audiologists, a literature search, and the inclusion of domain knowledge from experts and scientists were used to derive value propositions. A two-alternative forced-choice paradigm and probabilistic choice models were used to investigate hearing aid users' preferences for the value propositions through an online platform. Study sample: Twelve hearing aid users (mean age 70, range 59-70) and eleven clinicians were interviewed. A total of 173 experienced hearing aid users evaluated the value propositions. Results: Twenty-nine value propositions as described by patients, clinicians, and hearing care experts where identified, from which twenty-one value propositions were evaluated. Results of the pair-wise evaluation method show that the value propositions judged to be the most important for the hearing aid users were: "13. To solve the hearing problem you have", "09. Thorough diagnosis of the hearing", and "16. The hearing aid solution is adapted to individual needs", which are related to finding the correct hearing solution and to be considered in the process. The value propositions judged to be least important were: "04 Next of kin and others involved in the process", "26. To be in the same room as the practitioner", and "29. The practitioner's human characteristics", related to the involvement of others in the process and the proximity and personal manner of the practitioners.

On the change in Speech Quality and Speed with a Tongue Interface for Control of Rehabilitation Robotics - A Case report.

Previous studies have described inductive tongue computer interfaces (ITCI) as a way to manipulate and control assistive robotics, and at least one commercial company is manufacturing ITCI today. This case report investigates the influence of an ITCI on the speed and quality of speech. An individual with tetraplegia read aloud a short part of "The Ugly Duckling", a well-known story by Hans Christian Andersen, in her native language Danish. The reading was done twice, first with her own Removable Full Upper Denture (RFUD) and secondly with a copy of this RFUD with an integrated ITCI in the palatal area. A word count assesses the speed of 5 minutes of reading aloud, and the confidence of an automated transcription into text measures the quality. This study found no difference in the speed or quality of speech between two settings with or without an ITCI.

Eyes-Free Tongue Gesture and Tongue Joystick Control of a Five DOF Upper-Limb Exoskeleton for Severely Disabled Individuals.

Spinal cord injury can leave the affected individual severely disabled with a low level of independence and quality of life. Assistive upper-limb exoskeletons are one of the solutions that can enable an individual with tetraplegia (paralysis in both arms and legs) to perform simple activities of daily living by mobilizing the arm. Providing an efficient user interface that can provide full continuous control of such a device-safely and intuitively-with multiple degrees of freedom (DOFs) still remains a challenge. In this study, a control interface for an assistive upper-limb exoskeleton with five DOFs based on an intraoral tongue-computer interface (ITCI) for individuals with tetraplegia was proposed. Furthermore, we evaluated eyes-free use of the ITCI for the first time and compared two tongue-operated control methods, one based on tongue gestures and the other based on dynamic virtual buttons and a joystick-like control. Ten able-bodied participants tongue controlled the exoskeleton for a drinking task with and without visual feedback on a screen in three experimental sessions. As a baseline, the participants performed the drinking task with a standard gamepad. The results showed that it was possible to control the exoskeleton with the tongue even without visual feedback and to perform the drinking task at 65.1% of the speed of the gamepad. In a clinical case study, an individual with tetraplegia further succeeded to fully control the exoskeleton and perform the drinking task only 5.6% slower than the able-bodied group. This study demonstrated the first single-modal control interface that can enable individuals with complete tetraplegia to fully and continuously control a five-DOF upper limb exoskeleton and perform a drinking task after only 2 h of training. The interface was used both with and without visual feedback.

DNA methylation biomarkers in peripheral blood of patients with head and neck squamous cell carcinomas. A systematic review.

BACKGROUND: Head and neck squamous cell carcinomas (HNSCC) are often diagnosed in advanced stages. In search of new diagnostic tools, focus has shifted towards the biological properties of the HNSCC, and the number of different biomarkers under investigation is rapidly growing. OBJECTIVES: The objective was to review the current literature regarding aberrantly methylated DNA found in peripheral blood plasma or serum in patients with HNSCC and to evaluate the diagnostic accuracy of these changes. METHODS: The inclusion criteria were clinical studies involving patients with verified HNSCC that reported findings of aberrantly methylated DNA in peripheral blood serum or plasma. We systematically searched PubMed, OVID Embase and Cochrane Library. In addition to the search, we performed forward and backward chaining in references and Web of Science. The protocol was registered in PROSPERO: CRD42019135406. Two authors independently extracted data. The quality and the risk of bias of the included studies were assessed by the QUADAS-2 tool. RESULTS: A total of 1,743 studies were found eligible for screening, while ultimately seven studies were included. All studies were found to have methodological weaknesses, mainly concerning patient selection bias. The best individual marker of HNSCC was Septin 9 in plasma with a sensitivity of 57% and a specificity of 95%. CONCLUSIONS: None of the aberrantly methylated genes found in the retrieved studies are applicable as single diagnostic markers for HNSCC and the best gene-panels still lack diagnostic accuracy. Future studies may benefit from newer sequencing techniques but validation studies with well-designed cohorts are also needed in the process of developing epigenetic based diagnostic tests for HNSCC.

In Vitro Investigation of the Dependency Between Abutment Length and Implant Stability Quotient (ISQ) for Stability Measurements on Bone Anchored Hearing Implant Systems.

HYPOTHESIS: The investigation aimed at measuring the relation between abutment length and Implant Stability Quotient (ISQ) for stability measurements on two types of bone-anchored hearing implant systems. BACKGROUND: Measuring bone-anchored hearing implant stability using the ISQ has the inherent limitation that the measurement is dependent on the length of the abutment used on the implant. This dependency has not earlier been analyzed in depth. Therefore, ISQ measurements for different abutment lengths cannot be directly compared if a patient needs a change of abutment or when evaluating different patients in a scientific setting. METHODS: The dependency of ISQ on abutment length for Cochlear BI300 (Cochlear Nordic AB, Mölnlycke, Sweden) and Ponto Wide Implant (Oticon Medical AB, Askim, Swden) was measured using a temporal bone model and a plaster model. ISQ at abutment level was compared with the corresponding ISQ at implant level and results were analyzed by multiple linear regression. RESULTS: The ISQ dependency on abutment length was -3.5 ISQ/mm (95% CI: -3.7 to -3.4) (Cochlear BI300 implant) and -2.9 ISQ/mm (95% CI: -3.0 to -2.7) (Oticon Wide Implant). CONCLUSION: The dependency of ISQ on abutment length for two types of bone-anchored hearing implant systems has been established empirically. This knowledge enables clinicians to continue monitoring the ISQ for a patient after a change of abutment and enables researchers to compare ISQ between patients in a clinical study.

A high-resolution tongue-based joystick to enable robot control for individuals with severe disabilities.

Assistive robotic arms have shown the potential to improve the quality of life of people with severe disabilities. However, a high performance and intuitive control interface for robots with 6-7 DOFs is still missing for these individuals. An inductive tongue computer interface (ITCI) was recently tested for control of robots and the study illustrated potential in this field. The paper describes the investigation of the possibility of developing a high performance tongue-based joystick-like controller for robots through two studies. The first compared different methods for mapping the 18 sensor signals to a 2D coordinate, as a touchpad. The second evaluated the performance of a novel approach for emulating an analog joystick by the ITCI based on the ISO9241-411 standard. Two subjects performed a multi-directional tapping test using a standard analog joystick, the ITCI system held in hand and operated by the other hand, and finally by tongue when mounted inside the mouth. Throughput was measured as the evaluation parameter. The results show that the contact on the touchpads can be localized by almost 1 mm accuracy. The effective throughput of ITCI system for the multi-directional tapping test was 2.03 bps while keeping it in the hand and 1.31 bps when using it inside the mouth.

On the functional compartmentalization of the normal middle ear. Morpho-histological modelling parameters of its mucosa.

BACKGROUND: Middle ear physiology includes both sound pressure transmission and homeostasis of its static air pressure. Pressure gradients are continuously created by gas exchange over the middle ear mucosa as well as by ambient pressure variations. Gas exchange models require actual values for regional mucosa thickness, blood vessel density, and diffusion distance. Such quantitative data have been scarce and limited to few histological samples from the tympanic cavity (TC) and the antrum. However, a detailed regional description of the morphological differences of the TC and mastoid air cell system (MACS) mucosa has not been available. The aim of the present study was to provide such parameters. METHODS: The study included sets of three histological H&E-slides from 15 archived healthy temporal bones. We performed a comparison of the mucosa morphology among the following regions: (1) anterior TC; (2) inferior TC; (3) posterior TC; (4) superior TC; (5) MACS antrum; (6) superior MACS; (7) central MACS; (8) inferior MACS. RESULTS: Regions (1)-(3), situated below the inter-attico-tympanic diaphragm, had the largest proportion of high respiratory epithelium, cilia and loose lamina propria within the mucosa, as well as the thickest mucosa and the largest diffusion distance. Regions (6)-(8), situated above the diaphragm, had the thinnest mucosa, the shortest distance to the blood vessels, together with the largest proportion of flat epithelium and very few cilia. Regions (4)-(5), still supradiaphragmatic, had intermediary values for these parameters, but generally closer to regions (6)-(8). The blood vessel density and the proportion of active mucosa were not significantly different among the regions. CONCLUSION: Mucosa of regions (1), (2) and (3) represented a predominantly clearance-specific morphology, whereas in regions (4)-(8) it seemed adapted to gas exchange. However, the lack of statistically significant differences in blood vessel density and proportion of active mucosa indicated that all regions could be involved in gas exchange with the highest adaptation in the superior MACS. This pattern divides the middle ear functionally along the inter-attico-tympanic diaphragm rather than the anatomical division into TC and MACS.

[Workup and treatment of Eustachian tube dysfunction in adults].

Symptoms of Eustachian tube dysfunction are frequent and multiple. Therefore, clear definitions and diagnostic criteria are important in order to achieve appropriate patient flow. So far, there has been a lack of consensus on this subject, but the proposed definitions and diagnostic criteria in this review may aid to achieve this. Tubomanometry is a diagnostic tool to evaluate Eustachian tube function, and balloon dilation of the Eustachian tube can be a helpful treatment in patients with Eustachian tube dysfunction.

Speaking Ability while Using an Inductive Tongue-Computer Interface for Individuals with Tetraplegia: Talking and Driving a Powered Wheelchair - a Case Study.

This paper assesses the ability of speaking while using an inductive tongue-computer interface. Lately, tongue- computer interfaces have been proposed for computer/robotic interfacing for individuals with tetraplegia. To be useful in home settings these interfaces should be aesthetic and interfere as little as possible with the limited preserved functionality of individuals with tetraplegia. As tongue interfaces from an aesthetical point of view are preferred to be entirely intra-oral it is relevant to address their effect on speech. Here we show that reading more than 566 words while using an inductive tongue-computer interface results in a maximum sensor activation time of less than 0.6 s, which means that false activations can be avoided by a sensor dwell time of 0.6 s. Furthermore, we show that it is possible to speak while controlling a powered wheelchair with the inductive tongue computer interface.

Ocular albinism with infertility and late-onset sensorineural hearing loss.

Ocular albinism type 1 (OA1) is caused by mutations in the GPR143 gene located at Xp22.2. The manifestations, which are due to hypopigmentation, are confined to the eyes and optic pathway. OA1 associated with late-onset sensorineural hearing loss was previously reported in a single family and hypothesized to be caused by a contiguous gene deletion syndrome involving GPR143 and the adjacent gene, TBL1X. Here, we report on a family with OA1, infertility, late-onset sensorineural hearing loss, and a small interstitial Xp microdeletion including the GPR143, TBL1X, and SHROOM2 genes. In addition, we re-examined a patient previously described with OA1, infertility and a similar Xp deletion with audiologic follow-up showing a late-onset sensorineural hearing loss. Our results raise an intriguing question about the possibility for TBL1X (absence) involvement in this type of hearing loss. However, our study cannot claim a causative relationship and more convincing evidence is needed before the hypothesis can be accepted that TBL1X could be involved in late-onset sensorineural hearing loss and that ocular albinism with late-onset sensorineural hearing loss can present itself as a contiguous gene deletion/microdeletion syndrome. The finding of infertility in all affected male patients demonstrates that this deletion, including the SHROOM2 gene, may be a potentially causative X-linked genetic factor of male infertility.

Wireless intraoral tongue control of an assistive robotic arm for individuals with tetraplegia.

BACKGROUND: For an individual with tetraplegia assistive robotic arms provide a potentially invaluable opportunity for rehabilitation. However, there is a lack of available control methods to allow these individuals to fully control the assistive arms. METHODS: Here we show that it is possible for an individual with tetraplegia to use the tongue to fully control all 14 movements of an assistive robotic arm in a three dimensional space using a wireless intraoral control system, thus allowing for numerous activities of daily living. We developed a tongue-based robotic control method incorporating a multi-sensor inductive tongue interface. One abled-bodied individual and one individual with tetraplegia performed a proof of concept study by controlling the robot with their tongue using direct actuator control and endpoint control, respectively. RESULTS: After 30 min of training, the able-bodied experimental participant tongue controlled the assistive robot to pick up a roll of tape in 80% of the attempts. Further, the individual with tetraplegia succeeded in fully tongue controlling the assistive robot to reach for and touch a roll of tape in 100% of the attempts and to pick up the roll in 50% of the attempts. Furthermore, she controlled the robot to grasp a bottle of water and pour its contents into a cup; her first functional action in 19 years. CONCLUSION: To our knowledge, this is the first time that an individual with tetraplegia has been able to fully control an assistive robotic arm using a wireless intraoral tongue interface. The tongue interface used to control the robot is currently available for control of computers and of powered wheelchairs, and the robot employed in this study is also commercially available. Therefore, the presented results may translate into available solutions within reasonable time.

Error-Free Text Typing Performance of an Inductive Intra-Oral Tongue Computer Interface for Severely Disabled Individuals.

For severely paralyzed individuals, alternative computer interfaces are becoming increasingly essential for everyday life as social and vocational activities are facilitated by information technology and as the environment becomes more automatic and remotely controllable. Tongue computer interfaces have proven to be desirable by the users partly due to their high degree of aesthetic acceptability, but so far the mature systems have shown a relatively low error-free text typing efficiency. This paper evaluated the intra-oral inductive tongue computer interface (ITCI) in its intended use: Error-free text typing in a generally available text editing system, Word. Individuals with tetraplegia and able bodied individuals used the ITCI for typing using a MATLAB interface and for Word typing for 4 to 5 experimental days, and the results showed an average error-free text typing rate in Word of 11.6 correct characters/min across all participants and of 15.5 correct characters/min for participants familiar with tongue piercings. Improvements in typing rates between the sessions suggest that typing ratescan be improved further through long-term use of the ITCI.