Musical Perception of Cochlear

Implant Users as Measured by

the Primary Measures of
Music Audiation:
An Item Analysis1
Kate Gfeller

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Charissa Lansing
The University of lows
The University of Illinois at Urbana-Champaign

The purposes of this study were (a) to evaluate the Primary

Measures of Music Audiation (PMMA) as a test of musical
perception for postligually deafened adult cochlear imp/ant
(Cl) users; and(b) to report test outcome on the Rhythm and
Tonal subtests of the PMMA. Correlations between PMMA
scores and speech perception tasks were calculated. Sub­
jects were 34 postlingually deafened adults with CI experi­
ence. Subject performance on the PMMA was analyzed to
determine test usability and technical adequacy (reliability,
item discrimination, and difficulty) for this particular popula­
tion. Comparisons were made across two different implant
types (Nucleus and Ineraid devices) and across Rhythm and
Tonal subtests. The PMMA was found to be usable with
minor adjustments. No significant differences in accuracy were
found for the Rhythm or Tonal subtest across devices. How­
ever, CI (Nucleus and Ineraid) users were significantly more
accurate on the Rhythm than the Tonal subtest (p < .001).
The mean difficulty for the Rhythm subtest was 84.93, while
the mean difficulty for the Tonal subtest was 77.50. The mean
discrimination indices were as follows: Rhythm subtest, 18;
Tonal subtest, .28. The Tonal subtest contained a larger
number of items within the satisfactory range for item diffi­
culty and item discrimination. The strongest correlations be-

Kate Gfeller, Ph.D., RMT-BC, is Director of Music Therapy at the University

of Iowa, Iowa City, Iowa Charissa R. Lansing, Ph.D., is an Assistant Professor
in the Department of Speech and Hearing Science at the University of Illinois
at Urbana-Champaign.
1This project was supported in part by NIH Grant #CDR P01 NS20466,
Grant RR59 from the General Clinical Research Centers Program, Division of
Research Resources, NIH.
tween musical perception and speech perception were be­
tween the Tonal subtest and the speech perception measures
of phoneme identification (r = .45) and accent recognition (r
= .46).

According to Ries (1982), an estimated 16 million adults suffer

from hearing loss. Although hearing loss caused by damage or

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injury to the outer or middle ear structures may be corrected
by medical or surgical interventions, hearing loss caused by
damage or injury to the inner ear structures may not respond
to traditional medical interventions. In the case of profound
sensori-neural deafness (pure-tone average >95 dB HL), many
hair cells in the cochlea may be damaged or missing. In some
cases, although populations of hair cells are diminished, some
cochlear neurons survive. Often individuals with profound sen­
sori-neural deafness (profound “nerve deafness”) receive lim­
ited benefits from hearing aids.
Since the 1960s, more than 3,000 profoundly deafened in­
dividuals have obtained sensations of sound through the direct
electrical stimulation of surviving cochlear neurons (Cochlear
Implants, 1988). As a result of electrical stimulation, nerve im­
pulses travel along the auditory pathways to the cortex where
they are interpreted as meaningful sounds. These sounds have
been shown to aid speechreading (lipreading), awareness of
environmental sounds, and in some cases enable the profoundly
deaf individual to understand speech (Cochlear Implants, 1988).
This principle of directly stimulating the auditory system with
an electric current was first demonstrated nearly 200 years ago
by Alesandro Volta (1800), and with improvements in tech­
nology has been applied to the present day cochlear implant.
While several different types of implant devices exist, they
share the same basic components. An external microphone re­
ceives sound and converts it into an electrical signal. This signal
is sent to a signal processor that transforms the electrical signal
into a desired pattern and shape. This information is transferred
directly by wires through the skin or across the skin by inductive
coupling to a package of electrodes surgically implanted in the
inner ear. The electrodes excite the cochlear neurons of the
auditory nerve.
20 Journal of Music Therapy

Some cochlear implant systems extract individual speech fea­

tures from acoustic signals. One example of this type of system,
designed primarily to code speech information, is the Nucleus
multichannel cochlear implant (Blarney, Dowell, Clark, & Se­
ligman, 1978). In one speech processing strategy, the funda­
mental frequency, first and second format frequencies, and
relative amplitude of the signal are estimated. An electrical
signal is generated with a pulse rate corresponding to the fun­

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damental frequency (F0). For unvoiced sounds, the pulse rate
varies aperiodically around 98 Hz. This pulsatile signal se­
quentially stimulates two pairs of 21 electrode pairs implanted
in the cochlea. The electrode pairs are arranged to follow the
spatial (tonotopic) organization of the cochlea. The place of the
particular electrode pairs stimulated codes estimates of first and
second formant frequencies. The current level of the electrical
signal corresponds to the relative amplitude of the acoustical
signal.
In other cochlear implant systems, individual speech features
are not extracted and analog coding strategies are used instead.
One example of this type of system is the Ineraid multichannel
cochlear implant (Eddington, 1980). This system uses a bank
of four filters centered in different frequency regions to separate
the incoming acoustic signal. The output of each filter is am­
plitude compressed and then sent to one of four different in­
ternal cochlear electrodes.
The success with which CI users can speechread or recognize
speech and environmental sounds varies greatly. For example,
while most implant users experience assistance in speechread­
ing, some implant users are able to conquer more demanding
auditory tasks such as understanding speech over the telephone.
It is not fully understood why some implant users experience
greater success than others, but a number of factors are believed
to contribute to performance. The remarkable variability in
performance may be due, in part, to the differing physiological,
psychosocial, and cognitive characteristics of implant users. A
partial list of these characteristics includes: the length of time
of profound hearing impairment, the age of onset of hearing
impairment, the etiology of hearing loss, number and locations
of surviving neural populations, the individual’s educational
experience and learning styles, prior and concomitant use of a
Vol. XXIX, No. 1, Spring, 1992 21

hearing aid (in the opposite ear), differences in abilities to per­

ceive sound units, speechreading and communication compe­
tencies, coping behaviors, personality characteristics, and sup­
port of a significant other.
Although increased use of the CI has been fairly recent and
the total population of users relatively small, a substantial body
of information has been amassed concerning speech perception
of cochlear implant users. In contrast, present knowledge about

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musical perception of implant users is primarily anecdotal in
nature. Systematic investigation of perceptual accuracy for
structural elements of music (e.g., rhythm, melody) is limited
(Gfeller & Laming, 1990, 1991; McCandless, 1990).
Prior studies of musical perception of hearing impaired lis­
teners indicate that hearing loss has a significant negative impact
on both rhythmic and melodic perception (Darrow, 1979,1984,
1987; Ford, 1985; Gfeller, 1988; Klajman, Koldeg, & Kowalska,
1982; Rileigh & Odom, 1972; Sterritt, Camp, & Lippman, 1966).
However, these studies have investigated perception of school­
aged children with congenital or prelingually-acquired hearing
losses who use either personal hearing aids or vibrotactile de­
vices. Consequently, these studies with prelingually deaf chil­
dren cannot be generalized to music perception of cochlear
implant users who present postlingual profound bilateral hear­
ing loss.
Considering the relative recency of cochlear implant use, and
because this sensory prosthetic device has been designed pri­
marily to enhance verbal communication, it is little wonder that
the issue of music perception remains essentially unexplored.
However, a number of implant users have expressed interest in
listening to music again following implantation (Dorman, Bas­
ham, McCandless, & Dove, 1991; Gfeller & Lansing, 1990, 199l;
McCandless, 1990). Furthermore, since music is a prevalent art
form and social activity, better understanding of musical per­
ception by CI users may provide insights into issues of user
satisfaction in daily functioning. One of the first challenges in
this new area of investigation is the selection of appropriate test
measures and research methodology. Tests are required that
are suitable for the technical features of the device, and for the
individual abilities and characteristics of cochlear implant users,
many who have limited musical training.
22 Journal of Music Therapy

Therefore, the purpose of this study was (a) to evaluate the

effectiveness of the Primary Measures of Music Audiation
(PMMA) as a test of musical perception for post-lingually deaf­
ened adult cochlear implant users; and (b) to report test outcome
on the Rhythm and Tonal subtests of the PMMA. The following
questions were addressed:
1. Is the PMMA a usable test for musical perception for
cochlear implant users?

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2. What types of melodic and rhythmic errors are revealed
by the PMMA as most prevalent among implant users?
3. Is there a significant difference between Ineraid and Nu­
cleus CI users for musical perception as measured by the PMMA?
4. Do particular subject characteristics (length of profound
loss, musical background) have an impact on musical perception
by CI users?
5. How does perceptual accuracy on measures of music dis­
crimination compare with performance on speech recognition
tasks?
6. How does perceptual accuracy as measured by the PMMA
compare among populations of CI usersnormally
and hearing
children (Gordon, 1979). hearing impaired children using tra­
ditional hearing aids (Darrow, 1987), brain injured adults and
their matched control group (Hunter, 1989), and older adults
(Gibbons, 1983)?
7. Is the PMMA satisfactory in terms of technical adequacy
for testing CI users?
Method
Subjects
Subjects were 34 experienced multichannel cochlear implant
users (17 Nucleus and 17 Ineraid) scheduled for follow-up test­
ing in a large mid western medical center between December
1987 and January 1991. All volunteered to participate in ex­
change for information regarding their music perception skills.
Procedures for informed consent were followed. Subjects ranged
in age from 28 to 74 years (M = 53.88, SD = 14.52). Twenty
of the subjects were women.
Prior to implantation, all subjects displayed profound (pure­
tone average >95 dB HL) bilateral, postlingually acquired hear­
ing losses. None scored higher than 4% when a word identifi-
Vol. XX/X, No. 1. Spring, 1992 23

cation test (NU-6 word lists) was presented at 60 dB HL in the

sound field with appropriately fitted hearing aids. None un­
derstood more than 10% of the words from the auditory-only
presentation of the Iowa Sentence Without Context task from
The Iowa Phoneme and Sentence Test (Tyler, Preece, & Tye-
Murray, 1986).
Three subjects continued to use a hearing aid in the opposite
ear in addition to their implant outside of the formal testing

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situation. The subjects displayed a wide range of performance
in speech perception skills. Table 1 compares the Nucleus and
Ineraid user groups for age, duration of bilateral profound hear­
ing loss, musical training and listening habits, and specific speech
perception skills. T-tests indicated no significant differences
between the two device groups for any of these variables.

Test Instrument
Perception for complex melodic (tonal) and rhythm patterns
was tested using the Tonal and Rhythm subtests of the Primary
Measures of Music Audition (PMMA) (Gordon, 1979). This
standardized test of musical perception assesses ability to hear
differences in short tonal and rhythm patterns. Although this
test is normed on young children (grades K-3), the test author
maintains that musical aptitude, as assessed by the PMMA,
stabilizes around age nine (Gordon, 1979).
Each subtest (Tonal and Rhythm) of the PMMA consists of
40 electronically produced pairs of melodic or rhythmic pat­
terns respectively. A 1.5 second inter-stimulus interval separates
each member of the pair, and each of the 40 item pairs is
separated by a 5-second silence. The test uses a “same” or
“different” paradigm. Each melodic pattern in the Tonal subtest
contains from two to five notes ranging in pitch from C4 to F5.
The item pairs have equivalent rhythmic patterns; however,
those item pairs that are “different” vary on one or more notes
in frequency. The Rhythm subtest presents all stimuli at one
frequency (C5). Differences are in duration, proportion of the
rhythmic values, or accent. The PMMA has been used in testing
with a variety of populations, including hearing impaired chil­
dren (Darrow, 1987), adults with traumatic brain injuries and
a control group of adults ages 14-61 (Hunter, 1989), and older
adults (age 65 or older) (Gibbons, 1983).
Table 1
Subject Characteristics for Nucleus and Ineraid Subgroups

Mean 51.59 10.94 37 62 86.79 3.25 6.00 4.50

SD 15 01 10.27 14.55 14.31 3.42 200 1.86
SEM 3.64 2.49 3.53 3.58 .85 .50 47
Minimum 28.00 1.00 11.00 58.00 000 2.00 2.00
Maximum 74.00 35.00 60.00 100.00 10.00 800 8.00

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Ineraid (N =17)
Mean 56.18 14.12 27.91 79.27 4.24 5.53 3.88
SD 14.08 12.39 19.53 19 09 4.45 1.81 1.76
SEM 3.41 3.01 4.74 4.77 108 .44 .43
Minimum 32.00 1.00 0.00 37.50 000 2.00 2.00
Maximum 72.00 47.00 62.00 l00.00 15.00 8.00 8.00
DPD = duration of profound deafness (in years).
Phoneme = % correct on NU-6 Phonemes test.
Accent = % correct on Iowa Accenf Test.
Ml = total paints for participation in musical experiences.
M2 = paints assigned for enjoyment of music prior to hearing loss
M3 = points assigned for enjoyment of music following implantation

Musical background. In order to account for past training

and experience, each subject was interviewed concerning past
musical training and pre­ and post-implant listening habits.
Interview questions were adapted from Gaston’s (1957) Test of
Musicality, which includes a self-rated assessment of musical
experiences and attitudes. A cumulative point system was used
to quantify years of participation in a variety of musical ex­
periences and self-reported enjoyment of music. Interview ques­
tions chosen for this study included the extent of pre-implant
experience in music lessons, participation in music ensembles,
and music appreciation classes. Points were assigned for the
length of time spent in each activity.
Points were also assigned for the amount of time spent each
week listening to music before hearing loss and following im­
plantation. In addition, subjects rated musical enjoyment prior
to the onset of hearing loss and following CI use on a 4-point
Likert-type scale (strongly agree to strongly disagree to the
question, “I would describe myself as a person who enjoys music
a lot.“) Cumulative points ranged from 2 (low) to 15 (high) for
Vol. XXIX, No. 1, Spring, 1992 25

past training, 2 to 8 for pre-implant listening habits, and 2 to

8 for post-implant listening habits.
Speech perception performance.Two measures were select­
ed as indicators of auditory-only speech perception perfor­
mance with the implant. The Iowa Accent Test is from the
Iowa Phoneme and Sentence Test (Tyler et al., 1986). It consists
of four sentences, such as “Ray bought a big dog.” One content
word receives primary stress (accent). Each sentence is repeated

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six times. The subject sees a sentence on a computer monitor
touch screen and touches the word that was accented. The Iowa
recording of NU-6 Phonemes consists of 50 monosyllabic words
(150 phonemes) presented without a carrier phrase. The subject
repeats the stimulus word to the examiner after each presen­
tation.

Procedure
Each subject was tested individually in a small clinic room
of a speech and audiology clinic. Subjects were asked questions
about their musical background. Then the Rhythm and Tonal
subtests of the PMMA were played over a portable cassette tape
recorder (SONY Stereo Cassette-Corder CS-W30) in sound field
at most comfortable level of loudness (range of 65-84 dBA SPL).
Those subjects who used a hearing aid as well as a cochlear
implant were asked to use only their implant during testing. A
short break was taken between the two subtests.
The following analyses were computed for each subtest: mean
score, standard deviation, internal consistency (KR-20), split­
halves reliability, and standard error. Item difficulty and item
discrimination indices were calculated for each item. Item dif­
ficulty indicates the percentage of subjects who correctly re­
spond to the item (Nunnally, 1967). Therefore, the higher the
index, the easier the item. For tests intended to differentiate
among subjects, maximum differentiation can be achieved in
tests of moderate difficulty (i.e., when items are answered cor­
rectly by 50 to 80% of the group) (Technical Bulletin 17, 1991).
Item discrimination refers to the degree to which a particular
item discriminates high, middle, and low scoring subjects for
the entire test. Items that discriminate well among subjects have
a correlation of at least .20 (Nunnally, 1967).
The sample size (N = 34) for this item analysis is admittedly
26 Journal,Of Music Therapy

small. However, at present, a limited number of medical centers

are doing implantation, and the total number of implant users
is small. Therefore, an N of 34 is a reasonable sample size given
the current status of implant usage.
To evaluate the association between music perception per­
formance and subject characteristics, PMMA scores were cor­
related with age, duration of profound deafness (DPD), and
musical background (Ml, M2, and M3). The relationship be­

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tween music and speech perception performance was examined
by correlating the PMMA scores with the percentile correct on
the Iowa Accent Test and the Iowa recording of the NU-6
Phonemes.
Results
1. Is the PMMA a usable measure of musical perception for
cochlear implant users?
During the preliminary stages of research development, sev­
eral other standardized tests were reviewed and evaluated [i.e.,
Seashore Measure of Musical Talents (Seashore, Lewis, & Saet­
veit, 1960), The Musical Aptitude profile (MAP) (Gordon, 1965),
The Standardized Test of Musical Intelligence1961),
(Wing,
and Musical Achievement Tests (Colwell, 1969, 1970)]. These
tests were rejected because: (a) the test items proved too difficult
for implant users (as demonstrated in pilot testing); (b) the tests
were too lengthy for the time available; (c) test constructs were
not pertinent to this study; or (d) the test required formal mu­
sical knowledge, such as notation or technical vocabulary. In
addition, the use of recorded acoustic instruments (e.g., the
MAP) would have introduced an additional variable of timbre
to the task of rhythmic and melodic discrimination.
In contrast to the aforementioned tests, the PMMA provided
additional advantages. Unlike many standardized tests of mu­
sical achievement, it requires no formal musical training, such
as the ability to read musical notation or understand musical
terminology. The test has relatively simple instructions that can
be learned in a matter of minutes and requires only 40 minutes
for administration. This was of critical concern, since music
perception testing was only one of an extensive battery of tests
that the implant patients were required to complete during
their follow-up appointment at the hospital. Since many patients
Vol. XXIX, No. 1, Spring, 1992 27

resided in relatively distant regions of the country, financial,

time, and travel constraints made it impractical to schedule
additional testing sessions.
One difficulty with the recorded format of the PMMA was
the verbal prompt prior to each item pair: Each rhythmic or
tonal pair is preceded by the name of an object (e.g., “apple,”
“leaf”) and prompts of “first” and “second.” For CI subjects,
these auditory stimuli may be perceived as a part of the signal

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for the discrimination task. Therefore, a visual prompt had to
be provided for each item indicating when the item pair began.
Several practice items were used to clarify this procedure, and
all subjects were eventually able to determine which stimuli
constituted the target comparison. However, future testing would
benefit from the use of visual prompts only in the test format.
All subjects demonstrated understanding of the same-different
task and completed the test in approximately 40 to 60 minutes
including several short breaks to reduce effects of fatigue. In
short, this battery (with minor modifications of visual prompts)
was a usable measure for quantifying melodic and rhythmic
discrimination.
2. What types of melodic and rhythmic errors are most prev­
alent among implant users?
Overall, subjects demonstrated significantly greater accuracy
on the Rhythm than the Tonal subtest (p < .001). The mean
score for rhythmic accuracy was 33.97 (SD = 2.39) and for
tonal accuracy, 31.00 (SD = 4.14). Item analysis for item dif­
ficulty further demonstrated the differences between the two
subtests. The mean difficulty for the Rhythm subtest was 84.93,
while the mean difficulty for the Tonal subtest was 77.50. Since
the higher score indicates the greater ease of the item, it appears
that this Rhythm test was easier for this group of CI users than
was the Tonal test.
A closer analysis of errors indicated the types of items that
were of the greatest difficulty for CI users. Few items in the
Rhythm subtest proved to be of moderate or greater difficulty.
Items 9, 19, 21, and 29 ranged from .06 to .41 in difficulty.
Item 9 includes a contrast between five versus seven 16th notes
in one beat. The durational difference between the individual
notes may be beyond the present technical capabilities of the
implant for accurate detection. Item 19 includes only a small
28 Journal of Music Therapy

durational difference of one eighth note length at the end of

an otherwise identical item pair. Items 21 and 29 present iden­
tical 7 eighth note patterns, but metric accents are different.
Three additional items fell in the range of moderate difficulty
(50 to 80%). These included Items 2 (79%), 13 (71%), and 17
(76%).
The Tonal test had a greater number of items in the difficult
and moderately difficult range. Six items (19, 21, 24, 26, 29,

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and 32) ranged from 27 to 45% in difficulty. Nine items fit
within the moderate range of difficulty (6, 7, 12, 15, 30, 34, 35,
36, and 38). These items ranged from 64 to 79% for item dif­
ficulty. Those items of greatest difficulty presented an inverted
melodic pattern (i.e., b4-c5-b4/c5-b4-c5) or only one whole note
difference on one pitch in the pattern (i.e., g4-b4-c5/a4-b4-c4).
It is possible that the coding strategy of the implant requires
an interval larger than a whole note in order for CI users to
discriminate differences in pitch.
3. Is there a significant difference between Ineraid and Nu­
cleus CI users for musical perception? Table 2 indicates the
mean scores on the Tonal and Rhythm subtests for the Nucleus
and Ineraid users. T-tests revealed no significant differences
between the two device groups for either subtest. Both device
groups showed slightly higher level of accuracy on the Rhythm
than the Tonal subtest.
4. Do particular subject characteristics (age, length of pro­
found loss, musical background) have an impact on musical
perception as measured by the PMMA?
Spearman correlation coefficients were calculated to deter­
mine the relationship between performance on the two subtests
of the PMMA and subject age, duration of profound deafness
(DPD), musical training, and musical enjoyment pre­ and post­
implant. Table 3 summarizes the correlation coefficients for
these variables.
The data suggest a modest negative correlation between age
and accuracy on both the Tonal and Rhythm subtests of the
PMMA. This suggests that the age of the subject may be related
to musical perception. A moderate negative correlation was
found between tonal accuracy and length of profound deafness,
while a weak positive correlation was found between rhythmic
perception and length of profound deafness. Musical back-
Vol. XXIX, No. 1, Spring, 1992 29

TABLE 2
Performance on PMMA by Device

Mean 33.77 31.81 34.18 30.24

SD 2.49 3.35 2.35 4.74
SEM .60 .84 .57 1.15

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ground and enjoyment and accuracy on the PMMA were weak­
ly correlated. The strongest correlation, however, was between
the listening habits following implantation (M3) and tonal ac­
curacy (r = .28).
5. How do PMMA performance scores for music discrimi­
nation compare with performance on speech recognition tasks?
The correlation coefficients reported in Table 3 suggest a
weak correlation between Rhythm subtest scores and phoneme
identification. This is not surprising in that the auditory per­
ceptual demands for the two tasks are very different. To achieve
a high score on the Rhythm subtest, subjects must accurately
utilize temporal information (e.g., duration, proportion of
rhythmic values, or accent), since all stimuli are presented at
one frequency. While many CI users may accurately discrim­
inate temporal contrasts, their ability to use spectral (frequency
specific) cues varies. It is expected that most CI users who
achieve high scores on phoneme identification would also achieve
high scores on the Rhythm subtest. CI users who achieve low

Table 3
Spearman-rho Correlation Coefficients for subject Variables and Performance
on the PMMA

Rhythm -.26 .21 .07 .37 .27 .08 .14

Tonal - 30 -.39 .45 .46 .07 .20 .28
DPD = duration of profound deafness (in years).
Phoneme = % correct on NU-6 Phenemes test.
Accent = % correct on Iowa Accent Test.
Ml = total points for participation in musical experiences.
M2 = points assigned far enjoyment of music prior to hearing loss.
M3 = points assigned for enjoyment of music following implantation.
30 Journal of MUSIC Therapy

scores on the phoneme task, however, may accurately discrim­

inate temporal contrasts and also achieve high scores on the
Rhythm task.
Additionally, the correlation coefficients reported in Table 3
suggest a moderate relationship between the Rhythm subtest
and the accent recognition task. This is plausible since the accent
recognition test affords the CI users with temporally based cues,
such as changes in duration and amplitude, and fundamental

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frequency cues. The speaker may vary any combination of these
cues to signal that a given word in the utterance is emphasized.
Consequently, the accent recognition and the Rhythm subtest
make similar demands on the listener’s auditory perceptual
skills. Both require the listener to attend to temporally-based
cues. Performance may, however, be only moderately related
since the accent recognition task affords cues regarding changes
in fundamental frequency in addition to temporal cues.
Scores on the Tonal subtest were moderately correlated to
scores for phoneme identification. These results are not sur­
prising in that one would expect those CI users who achieve
high scores on the Tonal task typically to obtain some speech
understanding although their scores may vary. Similarly, those
subjects unable to discriminate among notes ranging in pitch
from C4 to F5 would typically present difficulties in identifying
many speech sounds.
The moderate correlation observed for the Tonal subtest and
accent recognition appears to reflect the trend of CI users who
accurately utilize frequency information and achieve high scores
on the Tonal test. These subjects typically experience little dif­
ficulty with the temporal cues afforded by the accent recog­
nition task. Performance may be only moderately correlated in
that some CI users who achieve low scores on the Tonal task
may be proficient in utilizing temporal cues and thus may
achieve high scores on the accent recognition task.
6. How does perceptual accuracy as measured by the PMMA
compare between CI users and other populations tested in prior
research?
Table 4 compares the mean scores on the two subtests for
the cochlea implant users, hearing impaired children in Grade
3, normally hearing children in Grade 3, adults with brain
injuries, normally hearing adults, and adults over age 65. It is
Vol. XX/X, No. 1, Spring, 1992 31

TABLE 4
PMMA Means and Standard Deviation for Comparative Studies

Tonal Rhythm
M SD SEM M SD SEM
CI Users
HI Children 31.00 4.14 2.29 33.97 2.39 1.76
Norms 23.25 2.82 1.60 25.25 5.65 380
Normal 34.60 3.35 1.30 29 40 3.99 1.60

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Adults 39.40 0.96 .73 36.25 1.35 .98
BI Adults 36.45 3.64 1.52 33.85 3.31 1.81
Older Adults 31.98 5.81 2.22 30.31 5.01 2.45
CI = Adult CI users.
HI Children = 3rd grade students with hearing impairments (Darrow, 1987).
Norms = 3rd grade students with normal hearing, normative data (Gordon,
1979)
Normal adults = normally-hearing control group of adults (Hunter, 1989).
BI adults = adults with brain injuries (Hunter, 1969).
Older adults = adults 65 years of age or older (Gibbons, 1983).

interesting to note that the greater accuracy on the Rhythm

subtest occurs only for CI users and HI subjects. All other pop­
ulations represented showed greater accuracy on the Tonal sub­
test. While the trend for Cl users is in the same direction as
that found in hearing impaired subjects using hearing aids, the
overall means for the hearing impaired subjects are lower than
that found for CI subjects.
In some instances, the CI users showed error patterns similar
to those reported for older adults and adults with brain injuries.
For example, melodic items with differences of a whole step
or less were often perceived inaccurately by CI users, older
adults, and brain injured adults (Gibbons, 1983; Hunter, 1989).
Normally hearing adults of a younger age, however, did not
demonstrate these same errors (Hunter, 1989).
In the rhythm subtest, CI users tended to miss items that
differed only in accent (i.e., Items 21 and 29). However, in
previous research, normally hearing listeners (control group,
non-brain injured) have also failed to distinguish the difference
between the two items (Hunter, 1989). Therefore, these two
items are not particularly helpful in identifying discrimination
of CI users as they differ from normally hearing listeners.
7. Is the PMMA a technically adequate test of musical per­
ception for cochlear implant users?
32 Journal of Music Therapy

TABLE 5
Reliability, Difficulty, and Discrimination Measures for the PMMA as Re­
ported in Prior Research

CI Adults .68 79 .28 775

HI Children NA .67 NA NA
Norms for Children NA .85 35 85

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Normal Adults* .41 NA NA NA
BI Adults* .83 NA NA NA
Older Adults* .85 .86 NA NA
Rhythm Subtest

CI Adults .44 .80 .18 84.93

HI Children NA 54 NA NA
Norms for Children NA .86 33 75
Normal Adults* .48 NA NA NA
BI Adults* .70 NA NA NA
Older Adults* .76 66 NA NA
*Authors report discrimination and difficulty indices by range and number
of items within arbitrarily determined cut-off points.
C1 = Adult C, users
HI Children = 3rd grade students with hearing impairments (Darrow, 1978).
Norms = 3rd made students with normal hearinc, normative data (Gordon.
1979).
Normal adults = normally-hearing control group of adults (Hunter, 1989).
BI adults = adults with brain injuries (Hunter, 1989)
Older adults = adults 65 years of age or older (Gibbons, 1983)

Table 5 provides information on the reliability, mean item

difficulty, and mean discrimination for each subtest with dif­
ferent populations. As can be seen, the internal consistency (KR­
20) of the Tonal subtest is higher than the Rhythm subtest for
CI users. The internal consistency of the Tonal subtest calculated
for CI users compares more favorably with the KR-20 coeffi­
cients found with other populations [normal adults, brain in­
jured adults (Hunter, 1989), and older adults (Gibbons, 1983)]
then does the internal consistency of the Rhythm subtest coef­
ficients calculated for CI users. The split-halves coefficients with
the CI users were relatively strong for both the Tonal and
Rhythm subtests.
Vol. XXIX, No. I, Spring, 1992 33

The mean difficulty (M = 77.5) for the Tonal subtest was

within the 50-80% difficulty range recommended for moderate
test difficulty. In contrast, the mean difficulty for normally
hearing children in the third grade (Gordon, 1979) reported in
published norms was 85%. Thirty-two of the individual 40 items
proved more difficult for the CI users than for third grade
children (normative data). The mean discrimination index (M
= .28) was above the base criterion suggested by Nunnally

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(>.20). Twenty-seven of the individual items had values of .20
or greater.
The mean difficulty (84.93) for CI users on the Rhythm
subtest was higher than that reported in normative data for
third grade children (M = 75). Only four of the individual items
proved of greater difficulty for CI users than for third grade
children (Gordon, 1979). The mean discrimination index (.18)
was below the .20 level suggested by Nunnally and well below
the .33 mean discrimination index reported for normally hear­
ing children. These difficulty and discrimination indices sug­
gested that the Rhythm subtest of the PMMA lacks the range
of difficulty ideal for testing post-lingually deafened adult coch­
lear implant users.

Discussion
This study included two primary tasks: (a) an evaluation of
the effectiveness of the PMMA as a test for determining rhyth­
mic and melodic perception of CI users, and (b) an examination
of rhythmic and melodic accuracy by 34 adult CI users. The
PMMA was readily administered (with minor adaptations) to
all 34 subjects, despite differences in age, musical background,
and speech perception performance with the implant. However,
the relative ease of the Rhythmic subtest, along with the low
discrimination scores, suggest that the Rhythm subtest in its
original form (Gordon, 1979) is less than ideal for CI users.
Given the time constraints in testing this population, future
research might be based on those items that help to discriminate
high­ and low-scoring users most effectively.
These preliminary data indicate that the Nucleus and Ineraid
cochlear implants are more effective in facilitating perception
of rhythmic as opposed to melodic information. While one
34 Journal of Music Therapy

might postulate that the Rhythm subtest is simply an easier test

than the Tonal subtest, the data reported for normally hearing
adults do not support that notion. Furthermore, anecdotal re­
ports of CI subjects indicated greater ease in understanding
rhythmic rather than melodic components of music. For ex­
ample, subjects would often indicate that they could easily
follow the “beat” in music, especially musical styles with a
simple and predominant beat such as country western music.

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However, they also indicated that the melody and harmony
were more difficult to ascertain, especially with unfamiliar songs
or styles of music.
It is curious to note the negative correlation between length
of profound deafness and tonal perception compared with the
slight positive correlation between length of profound deafness
and rhythmic perception. Perhaps this might be explained by
extant research trends regarding musical perception by hearing
impaired listeners using traditional hearing aids (which was the
case for the majority of the CI users prior to implantation).
Research indicates that individuals with significant hearing loss
have greater accuracy in rhythmic than melodic tasks (Darrow,
1987). Furthermore. in cases of profound hearing loss, a hearing
aid provides little more than tactile information about the tem­
poral patterns of sound. Tactile information in general is more
effective in providing discrete temporally-based as opposed to
frequency-based information. Therefore, individuals with long­
term profound deafness may have, during their period of pro­
found deafness, relied primarily on rhythmic information as
opposed to pitch information. The lack of access to frequency­
based information may have deleterious effects on cognitive
organization and perception of melodic patterns, while the on­
going reliance on tactile, temporally-based information may
have contributed to awareness of rhythmic-type patterns of
speech and music.
The similarity of item errors between the CI adults and older
adults (Gibbons, 1983), along with the negative correlation be­
tween perceptual accuracy of CI users and advanced age, de­
serves some attention. These similarities might be explained by
either audiological or cognitive characteristics of older adults.
It is possible that some of the errors found in the older adults
(Gibbons, 1983) resulted from a distorted auditory signal. While
Vol. XXIX, No. 1. Spring. 1992 35

Gibbons did permit subjects to adjust the intensity of the stimuli

to a desirable level, this alone cannot ensure perceptual accu­
racy. For individuals with a sensori-neural loss, detection of a
signal may be improved by increasing its volume; however, the
signal would not become clearer. Furthermore, it is possible,
based on extant research regarding the hearing status of the
elderly, that unidentified or untreated audiological problems
existed among this group of subjects. For example, a 1980 study

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by Schow and Nerbonne of nursing home residents (the same
population as that tested in the Gibbons study) indicated that
as many as 86% of those evaluated had a hearing loss greater
than 26 dB HL; 48% had hearing levels greater than 40 dB HL.
Furthermore, only 7.6% of these potential candidates for am­
plification were aided. In a related study by Thibodeau and
Schmitt (1988), the authors evaluated hearing aids used by
persons in nursing homes and retirement centers. Seventy-two
percent of the hearing aids had problems that interfered with
adequate functioning. Of this group, 9% had aberrant fre­
quency responses and 21% had more than 5% distortion at one
or more frequencies. Since audiological screening was not re­
ported in Gibbons’ study, one cannot evaluate whether hearing
sensitivity may have contributed to the observed outcome.
The negative correlation between perceptual accuracy and
advanced age might also be explained by cognitive changes
occurring concomitant with the aging process that might influ­
ence perceptual accuracy. A number of the subjects in the CI
group were ages 55 or older. The level of cognitive functioning
varies among older adults, depending on health status and en­
vironmental factors (Davis, Gfeller, & Thaut, in press; Restak,
1988). Those adult subjects admitted into the cochlear implant
program were evaluated by a clinical psychologist. Participants
were required to demonstrate normal intellectual capability and
at least fourth grade reading skills. A set of visually presented
measures was administered to experimentally evaluate complex
and sequential pattern recognition. However, cognitive tests
may not have fully identified perceptual competency for stimuli
similar to that used in the PMMA.
Performances on the Rhythm and Tonal subtests and two
speech perception measures were not highly correlated. Mod­
erate correlations between the Tonal subtest and the two speech
36 Journal of Music Therapy

perception measures, however, suggest some similarities in au­

ditory perceptual demands on the listener. It is interesting to
note the higher accuracy level of CI users compared with hear­
ing impaired children using hearing aids and vibrotactile de­
vices. This finding, however, should not be viewed simplistically
as the obvious advantage of the implant over hearing aids.
Although the CI provides greatly improved audition for many
users, the information transmitted does not replicate normal

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hearing. For all practical purposes, cochlear implant users can
be considered a subgroup of individuals with hearing impair­
ments, and the CI is considered by some to be simply another,
albeit more sophisticated, form of sensory prosthetic hearing
device.
Why, then, are the scores of the CI adults well above those
of hearing impaired children using hearing aids and vibrotactile
devices? Several factors probably contribute to this difference.
The cochlear implant users were all adults, and may have per­
formed with greater attention and consistency than would young
children in a formal testing paradigm. Furthermore, all the
implant users were postlingually deafened, and in fact had
many years of hearing experience before their hearing loss. In
contrast, children with congenital or prelingual losses who com­
prised the subject sample for the Darrow study (1987) had little
auditory experience. Therefore, auditory perception may have
been hampered.
Data are not presently available for a comparison group (adult
hearing aid users with profound bilateral losses). Therefore,
interpretations regarding the relative merits of the implant for
these subjects compared with a hearing aid must be approached
with caution. However, in preliminary studies comparing chil­
dren using implants to those using traditional hearing aids, the
implant users have shown a wider range of perceptual accuracy
than have the hearing aid users; furthermore, the overall mean
score for small samples of implant users was well above that of
hearing aid users (Gfeller, Laming, Fryauf-Bertschy, & Hurtig,
1990). It is possible that the potential for accurate musical per­
ception by profoundly deaf children using cochlear implants is
greater than that of profoundly deaf children using hearing
aids.
Vol. XXIX, No. 1, Spring, 1992 37

Conclusions
At present, empirical data regarding musical perception by
cochlear implant users are scarce. Exploration of this issue will
be facilitated through the availability of usable and technically
adequate measures. Based on our data using the original form
of the PMMA, it appears that rhythmic and melodic elements
of music are differentially accessible to cochlear implant users.
However, actual perceptual accuracy for both tests is similar

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for the Nucleus and Ineraid devices.
Our data, however, also point up some limitations of the
original test format of the PMMA. These include the use of
auditory prompts that complicate the testing process and items
that are less than ideal with regard to difficulty and discrimi­
nation. Evaluation of a revised PMMA that uses visual prompts
only and consists of selected items is currently in progress. In
addition to evaluation of a revised format of the PMMA, further
tests of musical perception for CI users fitted with advanced
processing schemes (Mini-Med, Nucleus multipeak processing,
etc.) should he studied as they become available.

References
Blarney, P. J,, Dowell, R. C., Clark, G. M., & Seligman, P. M. (1978). Acoustic
parameters measured by a formant-estimating speech processor for a mul­
tiple-channel cochlear implant. ]ournal of the Acoustical Society of Amer­
ica, 82, 38-47.
Colwell, R. (1969). Music achievement tests 1 and 2. Chicago: Follett Edu­
cational Corporation.
Colwell, R. (1970). Music achievement testy 3 and 4. Chicago: Follett Edu­
cational Corporation.
Cochlear Implants. National Institutes of Health Consensus Development Con­
ference Statement (Vol. 7 [2]). (1988, May). Bethesda, MD: US Department
of Health and Human Services.
Darrow, A. A. (1979). The beat reproduction response of subjects with normal
and impaired hearing. Journal of Music Therapy, 16, 91-98.
Darrow, A. A. (1984). A comparison of rhythmic responsiveness in normal and
hearing impaired children and an investigation of the relationship of rhythm
responsiveness to the suprasegmental aspects of speech perception. Journal
of Music Therapy, 21, 48-66.
Darrow, A. A. (1987). An investigative study. The effect of hearing impairment
on musical aptitude. Journal of Music Therapy, 24, 88-96.
Davis, W. B., Gfeller, K. E., & That, M. H. (in press). Music therapy: An
introduction to theory and practice. Dubuque, IA: Wm. C Brown Pub­
lishers, cp. 6.
36 Journal of Music Therapy

Dorman, M. F., Basham, K., McCandless, G., & Dove, H. (1991). Speech
understanding and music appreciation with the ineraid cochlear implant.
The Hearing Journal. 44(6), 34-37.
Eddington, D. K. (1980). Speech dis
crimination in deaf subjects with cochlear
implants. Journal of the
Acoustical Society of America,68, 865-891.
Ford, T. A. (1985). The effects of musical experiences and age on the ability
of deaf children to discriminate complex tones. Unpublished doctoral
dissertation, The University of North Carolina
Gaston, E. T. (1957). Test of musicality.Lawrence,KS:Odell’s Instrumental
Service.

Downloaded from http://jmt.oxfordjournals.org/ at AMTA Member Access on January 1, 2017

Gfeller, K. E. (1988, April). A comparison of hearing aids and tactile aids in
facilitating accuracy of profoundly deaf children on the rhythm subtest
of the PMMA. Paper presented at the MENC National Conference, In­
dianapolis, IN.
Gfeller, K. E & Laming, C. R. (1991) Melodic, rhythmic, and timbral per­
ception of adult cochlear implant users. Journal of Speech and Hearing
Research, 34, 916-920.
Gfeller, K. E., & Laming, C. R. (1990, June). Discrimination and pleasantness
ratings of musical stimuli for adult multichannel cochlear implant users.
Paper presented at the Second International Cochlear Implant symposium,
Iowa city, IA
Gfeller, K. E Laming, C. R., Fryauf-Bertschy, H., & Hurting, R. (1990, No­
vember). Rhythmic perception by hearing-impaired children using OS­
sistive devises. Paper presented at the Annual Conference of the American
Speech-Language and Hearing Association, Seattle, Washington.
Gibbons, A. C. (1983). Primary measures of music audiation scores in an
institutionalized elderly population. Journal of Music Therapy, 20, 21-29.
Gordon, E. E. (1979). Primary measures of music audiation. Chicago. G.I.A.
Publications.
Gordon, E. E. (1965). Musical aptitude profile. Boston: Houghton Mifflin.
Hunter, B. (1989). A comparison o/the Seashore rhythm test and the primary
measures ofmusic audiation for auditory discrimination assessment in
traumatic brain-injured patients. Unpublished doctoral dissertation, The
University of Kansas.
Klajman, S.,Koldeg, E., & Kowalska, A. (1982). Investigation of musical abilities
in hearing-impaired and normal-hearing children. Folia Phoniatrica, 34,
229-233
McCandless, G. (1990, June). Music, environmental sound recognition and
user satisfaction with a multi-channel implant. Paper presented
cochlear
at the Second International Cochlear Implant Symposium, Iowa City, IA.
Nunnally, J (1967). Psychometric theory. New York: McGraw-Hill Book Com­
pany
Restak, R. M. (1988). The mind. New York: Bantam Books, cp. 3, 65-104.
Ries, P. W. (1982). Hearing ability of persons by sociodemographic and health
characteristics. United States Vital Statistics, Series 10, 140, DHHS Pub.
No. (PHS) 82-1568. Public Health Services, Washington, DC US Govt.
Printing Office.
Vol. XXIX, No. 1. Spring. 1992 39

Rileigh, K. K., & Odom, P. B. (1972). Perception of rhythms by subjects with

normal and deficient hearing. Developmental Psychology, 7, 54-61.
Schow, R. L., & Nerbonne, M. A. (1980). Hearinglevels among elderly nursing
home residents. Journal of Speech and Hearing Disorders, 45, 124-132.
Seashore, C E , Lewis, L., & Saetveit, J, G. (1960). Seashore measures of
musical talents. New York: The Psychological Corporation.
Sterritt, G. M., Camp, B W , & Lippman, B. S. (1966). Effects of early auditory
deprivation upon auditory and visual information processing. Perceptual
and Motor Skills, 23, 123-130.
Technical Bulletin 17 (1991, January). lowa City, IA: The University of Iowa

Downloaded from http://jmt.oxfordjournals.org/ at AMTA Member Access on January 1, 2017

Evaluation and Examination Service
Thibodeau, L. M., & Schmitt, L. (1988). A report on condition of hearing aids
in nursing homes and retirement caters. Journal of the Academy of
Rehabilitative Audiology, 21, 99-112.
Tyler, R. S., Preece, J P., & Tye-Murray, N. (1986). Iowa phoneme and
sentence test [Laser video disc]. Iowa City: The University of Iowa, De­
partment of Otolaryngology.
Wing, H. D. (1961). Standardized tests of musical intelligence. The Mere,
England: National Foundation for Educational Research.