Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Volume 11 Number 2
June 2007 63-71
Adult aural rehabilitation is here defined holistically as be automatic or optimal. In fact, there is often a dis-
the reduction of hearing-loss-induced deficits of func- connect between clinical measures of assisted auditory
tion, activity, participation, and quality of life through function and self-assessed benefit. Costs associated
a combination of sensory management, instruction, with a holistic approach can be minimized by bundling
perceptual training, and counseling. There is a tendency as many as possible into the cost of hearing devices,
for audiologists to focus on sensory management, aural by taking advantage of computer-based perceptual
rehabilitation being seen as something done by some- training, and by capitalizing on the benefits of group
one else after the provision of hearing aids or cochlear counseling.
implants. Effective sensory management may, by itself,
lead to improved activity, participation, and quality of Keywords: hearing loss; aural rehabilitation; audio-
life, but there is no guarantee that these outcomes will logic rehabilitation
H
earing loss acquired in adult life can have a of hearing-loss-induced deficits of function, activity,
serious impact on quality of life. This impact participation, and quality of life through sensory
results primarily from deficits in the activi- management, instruction, perceptual training, and
ties of speech perception and communication and counseling.
the limitations imposed by these deficits on partici- This definition uses the terminology developed
pation in social interactions, in employment, in by the World Health Organization (WHO) in its
leisure pursuits, and in the enjoyment of sound. The generic attempts to conceptualize, classify, and describe
goal of rehabilitation is to restore quality of life by the impact of disease.1 An earlier classification sys-
eliminating, reducing, or circumventing these deficits tem2 used the terms impairment (what is missing or
and limitations. not working properly), disability (the things that
This goal can be addressed through a combina- could not be done because of the impairment), and
tion of: handicap (the negative impact of the disability on
quality of life). The emphasis was on the individuals
sensory management to optimize auditory function, losses. The current language is more positive. We
instruction in the use of technology and control speak of function, activity, and participation: the
of the listening environment, emphasis is on the individuals assets.
perceptual training to improve speech perception
and communication, and
counseling to enhance participation, and deal Life With Hearing
both emotionally and practically with residual
limitations.
In applying the WHO taxonomy to hearing and
This concept of adult aural rehabilitation is hearing loss, it helps to add 1 more level at the
summed up in the following definition: the reduction beginning and to separate the objective concept of
participation from the subjective concept of self-
From San Diego State University, San Diego, California. perceived quality of life, giving 5 categories in all.
1. Anatomy and physiology: Physical and func-
Address correspondence to: Arthur Boothroyd, Scholar in
Residence, San Diego State University, 2550 Brant St, San tional integrity, including the integrity of the outer
Diego, CA 92101; e-mail: aboothroyd@cox.net. ear, the middle ear, the cochlea, neural pathways to
63
64 Trends in Amplification / Vol. 11, No. 2, June 2007
the brain, and the brain itself. Our major concern is The goal of aural rehabilitation, as defined here, is
with the status of the cochlea. With older subjects, to reduce or eliminate these various deficits and, as far
however, the integrity of neural structures becomes as possible, restore the individual to his or her preloss
increasingly significant. state. One of the long-term goals of auditory research
2. Function: Basic perceptual capacity as meas- is to restore cochlear function in humans through the
ured in the clinic or research lab. This includes regeneration of functional hair cells along with their
threshold, dynamic range, frequency range, spectral neural connections.3 At the time of writing, regenera-
and temporal resolution, acoustic pattern discrimi- tion of hair cells in mammals, once thought to be
nation, direction and distance perception, attention, impossible, has been achieved, but functionality and
auditory working memory, processing speed, and neural connectivity are still in question; it will be many
noise resistance. years before we see this work extended to humans.4 In
3. Activity: The use of this capacitythe things other words, we are currently unable to restore
one wants or needs to do with hearing in the real cochlear integrity; however, the other 4 areas of deficit
world. Examples include being alerted by sound, can be targets for intervention.
monitoring the environment, recognizing and localiz-
ing events and deducing their significance, monitor-
ing and controlling ones own speech, and enjoying
Targeting Function
auditory experiences. The activities of most concern,
We address deficits of function through sensory
however, are perceiving the speech of others and
management. The basic tools are hearing aids and
engaging in spoken language communication.
cochlear implants, with the possible addition of
4. Participation: The contribution of these
accessories such as FM microphones or assistive
activities to daily life, including social interactions
devices such as amplified telephones. The immedi-
and relationships, employment, leisure, learning,
ate goals are to provide audibility of the sounds of
control, and creativity.
speech while preserving comfort and perceived
5. Quality of life: Reflects self-assessment of
sound quality and to do so over as wide a range as
the current life experience and includes such things
possible of talker spectrum, talker distance, talker
as enjoyment, meaning, purpose, usefulness, value,
effort, and interfering noise and reverberation.
freedom of choice, and independence. Quality of life
Improvement of auditory function should have a
is a moving target. It is influenced by function, activ-
positive impact on the activity of speech perception.
ity, and participation, but is by no means completely
We cannot assume, however, that carryover to par-
determined by them.
ticipation and quality of life will be either automatic
or optimal, nor can we assume that there will be a
Targeting Hearing Loss return to the preloss state. The immediate outcomes
of sensory management vary dramatically from indi-
When considering hearing loss, our main anatomic vidual to individual. Differences between expecta-
and physiologic concern is cochlear damage, includ- tion and reality can result in a combination of
ing disruption of structures, malfunction or loss of selective nonuse (wearing the device only in partic-
hair cells, or both. Such deficits may, however, be ular situations), complete nonuse, or continued
compounded by postsynaptic atrophy and other avoidance of situations in which the device might
effects of auditory deprivation. They may also be offer benefit and learning opportunities. This last
compounded by the cognitive and processing diffi- point is critical. Many adults with acquired hearing
culties that can accompany aging. loss are looking not for a significant improvement of
Cochlear damage has direct and immediate function but for full restorationa cure. It is our
effects on most aspects of auditory function, includ- inability to meet this expectation that creates the
ing sensitivity, resolution, discrimination ability, and need for a holistic approach to adult aural rehabili-
noise resistance. The deficits of function produce tation that goes beyond sensory management.
deficits of activity, especially speech perception and Instruction is a key component of such an
communication by spoken language. These last approach. The immediate goal is for the adult with
deficits are seriously exacerbated by noise. Reduced the hearing impairment to become a knowledge-
activity impacts participation, and deficits of partic- able and effective user of the hearing device and
ipation are reflected in quality of life. a knowledgeable and effective controller of the
Adult Aural Rehabilitation / Boothroyd 65
When providing perceptual training, perform- in noise. In the case of hearing aid users, deficits of
ance on formal speech perception tests may be a aided function are partially correlated with unaided
suitable outcome measure if the goal is to improve threshold.24
speech perception in the clinic or laboratory. But if Presumably, this relationship exists because both
the goal is to enhance communication in everyday threshold and spectral-temporal resolution are
life, then improved speech perception scores in the determined by the underlying cochlear pathology. In
clinic or research lab may only be an encouraging the case of cochlear implants, the correlation
indicator. between assisted function and preimplant threshold
is weak or nonexistent. In this case, the critical fac-
tor can be assumed to be the effective number of
Got Evidence? discrete channels of stimulation. This number
depends on the distribution of electrodes and their
For the moment, let us use the general goals sug-
proximity to independently stimulable neural tissue,
gested in this presentation and the 4 components of
neither of which depend on the original cochlear
intervention. What is the evidence for the conclu-
pathology. Whatever the mechanisms, unresolved
sion that these components meet their goals?
deficits of speech perception, especially in noise,
will obviously limit carryover to perceived benefit,
Effectiveness of Sensory Management satisfaction, participation, and quality of life, espe-
cially if the users expectations greatly exceed reality.
There is ample evidence to support the conclusion Three techniques currently exist to address the
that, on average, sensory management enhances negative effects of noise on speech perception: digi-
auditory function. In other words, hearing aids and tal noise-reduction, directional microphones, and
cochlear implants give the typical adult user remote wireless microphones. These 3 options are
improved access to information carried by the listed in ascending order of functional effectiveness
sounds of speech. Moreover, the improved function but descending order of convenience and accept-
enhances the ability to perceive the speech of others ability.25-29 All have the potential to enhance func-
and to communicate by spoken language. Most of tion and activity when used as part of an effective
the research studies on which these conclusions are program of sensory management.
based were actually designed to compare hearing aid
processing or prescription strategies.15-17 The overall
benefit in terms of function and activity, regardless Effectiveness of Instruction
of strategy, is clear.18 There is also evidence to sup-
port carryover to participation and quality of life.19 There is evidence to support the conclusion that formal
The conclusion that the provision of hearing aids instruction in hearing aid and accessory management
or cochlear implants leads to enhanced participation leads to increased usage and, therefore, enhanced
and quality of life, however, is often assumed rather function and activity when summed over time.7,30-34
than confirmed. Indeed, a common finding in the
case of hearing aids is of a relatively low correlation
between improved function, as measured in the
Effectiveness of Perceptual Training
clinic or research lab, and self-perceived benefit and Perceptual training does not target function. Rather,
satisfaction.20-23 Some of the variance in outcome not its goal is better use of that function through
explained by objective measures of function has been enhancement of perceptual skill. There is certainly
shown to be attributable to cognitive ability and the evidence of improvement on formal speech percep-
characteristics of the users auditory environment.14 tion tests.35,36 It is not always clear, however, how
It is important to note that hearing aids and much of this improvement reflects skills that are
cochlear implants do not restore normal function. generalizable to every day communication.37 And
Users may be given relatively full audibility of the carryover to participation and quality of life are usu-
sounds of conversational speech, but deficits of ally assumed rather than measured. As with lan-
spectral and temporal resolution remain and their guage instruction, the full benefits of perceptual
severity varies from individual to individual. The training will not be observed until the learner spends
consequences of these deficits are present in quiet time using and refining newly acquired skills in a
but are particularly serious when listening to speech meaningful, real-world context.
68 Trends in Amplification / Vol. 11, No. 2, June 2007
Figure 2. The evidence of effectiveness for 4 aspects of intervention argues in favor of a holistic approach to adult aural rehabilitation.
the importance of clinical experience and expertise, In fact, there are ways to minimize the cost of the
but the idea is to go beyond personal beliefs and expe- approach to management being advocated here. Basic
rience to validate or perhaps modify practice on the instruction, for example, can be built into the cost of
basis of data from high quality clinical research. The a device, as is already done by some providers. Self-
proof of the pudding is in the eating. administered computer-assisted, or significant-other-
An important aspect of developing best practice assisted techniques may enhance perceptual learning
is not just to consult the research but also to evalu- at low cost.35,36 Many of the goals of counseling can
ate the quality of the evidence it provides. Several be accomplished in groups.38 And audiologists can
writers have proposed a hierarchy of levels of evi- develop the sensitivity and skills required to address
dence.44 participation and quality-of-life issues and, perhaps,
At the top are meta-analyses and systematic reduce the need for therapeutic counseling. Although
reviews of the literature prepared according to strict holistic adult aural rehabilitation may be more costly
guidelines for inclusion and weighting. Next come than simple hearing aid dispensing, the differences in
individual experiments designed with random assign- cost do not have to be enormous and may be justified
ment of patients to conditions and the inclusion of on the basis of improved outcomes.
control treatments and conditions, together with
blinding of participants and experimenters. In the
field of audiology, randomization and blinding are
Summary
not always possible, but we should expect control.
Hearing loss acquired in adult life can have serious
Although weaker, evidence from prospective
and far-reaching consequences for the individual
single-subject studies can be useful, especially if they
concerned. There are deficits of auditory function
include control or no-treatment conditions and are
(the things one can do in the clinic, or research lab,
replicated with a small sample. Less valuable are ret-
if asked), activity (the things one needs or wants to
rospective case studies because of the absence of both
do in every day lifeespecially communicate via spo-
randomization and control.
ken language), participation (in social, vocational,
The lowest level of evidence is expert opinion.
and avocational activities), and quality of life (self-
This does not mean that expert opinion is necessarily
perceived). It is argued here that the ultimate goal of
of little value. Indeed, the opinion of the expert in
adult aural rehabilitation is to eliminate hearing-
question may be based on a systematic review of the
loss-induced deficits of activity, participation, and
literature. But we have always done it this way and
quality of life. Sensory management in the form of
we have never done it this way are not acceptable as
hearing aids, cochlear implants, and hearing assis-
evidence.
tance technology can go a long way toward meeting
As audiologists seek high-quality evidence to val-
that goal by enhancing auditory function.
idate or improve practice, it quickly becomes clear
Such evidence as is available, however, suggests
that such evidence is in short supply. There is a
that the goal is best met by a combination of sensory
pressing need for increased research effortand for
management, instruction, perceptual training, and
the training of clinical researchers to carry it out.
counseling. Improvements of outcome will be
accompanied by increased costs. There are, how-
ever, opportunities for minimizing these costs by
Efficiency
including some of them in the purchase price of
hearing devices, by making use of computer-based
I have said nothing so far about the cost of a holistic
self-instruction, and by taking advantage of group
approach to adult aural rehabilitation. Individuals and
counseling. The need for high quality research to
third-party payers are often willing to pay for hearing
justify and optimize a holistic approach to adult
aids and cochlear implants. After all, money is being
aural rehabilitation is self-evident.
exchanged for a tangible device. But enhanced activ-
ity, participation, and quality of life are intangibles;
moreover, individualized instruction, training, and Acknowledgment
counseling can be expensive. For this reason there is
interest, not just in demonstration of effectiveness This article was presented as the Keynote Address at
but also in efficiency, or cost/benefit ratio. the State of the Science conference on: Optimizing
70 Trends in Amplification / Vol. 11, No. 2, June 2007
the benefit of hearing aids and cochlear implants for 16. Mueller HG. Fitting hearing aids to adults using pre-
adults: the role of aural rehabilitation and evidence scriptive methods: an evidence-based review of effec-
for its success. Gallaudet University, Sep 18-20, tiveness. J Am Acad Audiol. 2005;16:448-460.
2006. The preparation of this work was supported by 17. Mueller GH, Bentler RA. Fitting hearing aids using clin-
ical measures of loudness discomfort levels: an evidence-
NIDRR RERC grant #H1343E98 to Gallaudet
based review of effectiveness. J Am Acad Audiol. 2005;
University.
16:461-472.
18. Larson VD, Williams DW, Henderson WG, et al.
References Efficacy of 3 commonly used hearing aid circuits:
acrossover trial. JAMA. 2000;284:1806-1813.
1. WHO. International Classification of Functioning, 19. Mulrow CD, Tuley MR, Aguilar C. Sustained benefits of
Disability, and Health (ICF). Geneva, Switzerland: hearing aids. J Speech Hear Res. 1992;35:1402-1405.
World Health Organization; 2001. 20. Nabelek AK, Tampas JW, Burchfield SB. Comparison of
2. WHO. International Classification of Impairments, speech perception in background noise with acceptance
Disabilities, and Handicaps. Geneva, Switzerland: World of background noise in aided and unaided conditions.
Health Organization; 1980. J Speech Hear Res. 2004;47:1001-1011.
3. Kros CJ. How to build an inner hair cell: challenges for 21. Bentler RA, Niebuhr JP, Getta CV, Anderson CV.
regeneration. Hear Res. In press. Longitudinal study of hearing aid effectiveness. II: sub-
4. White PM, Doetzlhofer A, Lee YS, Groves AK, Segil N. jective measures. J Speech Hear Res. 1993;36:820-831.
Mammalian cochlear supporting cells can divide and 22. Erdman SA, Demorest ME. Adjustment to hearing
trans-differentiate into hair cells. Nature. 2006;441: impairment II: audiologic and demographic correlates.
984-987. J Speech Hear Res. 1998;42:797-803.
5. Boothroyd A. Hearing aid accessories for adults: the 23. Humes LE, Halling D, Coughlin M. Reliability and sta-
remote FM microphone. Ear Hearing. 2004;25:22-23. bility of various hearing-aid outcome measures in a
6. Noe CM, McArdle R, Chisholm TH, et al. FM group of elderly hearing aid wearers J Speech Hear Res.
Technology use in adults with significant hearing loss. 1996;39:923-935.
Part I: candidacy. In: Fabry D, Deconde Johnson CD 24. Boothroyd A. Hearing aid accessories for adults: the
(eds). ACCESS: Achieving Clear Communication remote FM microphone. Ear Hear. 2005;25:22-33.
Employing Sound Solutions. Chicago, Ill: Phonak AG; 25. Bentler RA. Effectiveness of directional microphones
2004. and noise reduction schemes in hearing aids: a systematic
7. Chisholm TH, Noe CM, McArdle R, et al. FM technol- review of the evidence. J Am Acad Audiol. 2005;16:473-484.
ogy use in adults with significant hearing loss. Part II: 26. Surr RK, Walden BE, Cord MT, Olsen L. Influence of
outcomes. In: Fabry DA, Deconde Johnson CD (eds). environmental factors on hearing aid microphone pref-
ACCESS: Achieving Clear Communication Employing erence. J Am Acad Audiol. 2002;13:208-322.
Sound Solutions. Chicago, Ill: Phonak AG; 2004. 27. Walden BE, Surr R, Cord M, Edwards B, Olson L.
8. American Speech Language Hearing Assoc. Knowledge Comparison of Benefits Provided by Different Hearing
and skills required for the practice of audiologic/aural Aid Technologies. J Am Acad Audiol. 2000;11:540-560.
rehabilitation. ASHA Desk Reference. Vol 4. Rockville, 28. Walden BE, Surr RK, Cord MT. Real world performance
Md: ASHA; 2001. of directional microphone hearing aids. Hearing J.
9. Noble W. What is a psychosocial approach to hearing 2003;56:40-47.
loss? Scand Audiol. 1996;25(suppl 43):6-11. 29. Walden BE, Surr RK, Cord MT, Dyrlan O. Predicting
10. Stephens D. Hearing rehabilitation in a psychosocial hearing aid microphone preference in everyday listen-
framework. Scand Audiol. 1996;25(suppl 43):57-66. ing. J Am Acad Audiol. 2004;15:363-394.
11. Clark GJ. The audiology counseling growth checklist for 30. Chisolm TH, Abrams HB, McArdle R. Short- and long-
student supervision. Semin Hear. 2006;27:116-126. term outcomes of audiological rehabilitation. Ear Hear.
12. Clarkson MG, English KM. Counseling in Audiologic 2004;25:464-477.
Practice. Boston, Mass: Pearson Education Inc; 2004. 31. Abrams H, Hnath-Chisolm T, Guerreiro S, Ritterman S.
13. Luterman DM. Counseling Persons With Communication The effects of intervention strategy on self-perception of
Disorders and Their Families. Austin, Tex: Proe-Ed; 1996. hearing handicap. Ear Hear. 1992;13:371-377.
14. Gatehouse S, Naylor G, Elberling C. Benefits from hear- 32. Brooks D. Counseling and its effect on hearing aid use.
ing aids in relation to the interaction between the user Scand Audiol. 1979;8:101-107.
and the environment. Int J Audiol. 2003;42:S77-S85. 33. Northern J, Beyer DM. Reducing hearing aid returns
15. Maki-Torkko EM, Brorsson B, Davis A, et al. Hearing through patient education. Audiol Today. 1999;11:10-11.
impairment among adultsextent of the problem and 34. Chisholm TH, Noe CM, McArdle R, et al. FM technol-
scientific evidence on the outcome of hearing aid reha- ogy use in adults with significant hearing loss. Part II:
bilitation. Scand J Audiol Suppl. 2001:8-15. outcomes. In: Fabry DA, Deconde Johnson CD (eds).
Adult Aural Rehabilitation / Boothroyd 71
ACCESS: Achieving Clear Communication Employing Health Needs of Persons Who Are Late Deafened or Hard
Sound Solutions. Chicago: Phonak AG; 2003. of Hearing. Washington, DC: U.S. Dept. of Education,
35. Sweetow RW, Henderson Sabe J. The need for and NIDRR; 1997.
development of an adaptive listening and communication 40. Tye-Murray N. Foundations of Aural Rehabilitation. San
enhancement (LACE) program. J Am Acad Audiol. 2006; Diego, Calif: Singular Publishing Group; 1998.
17:538-58. 41. Lesner SA, Krikos PB. Audiologic rehabilitation: a holis-
36. Rubinstein A, Boothroyd A. The effect of two approaches tic approach. In: Krikos PB, Lesner SA (eds). Hearing
to auditory training on speech recognition by hearing- Care for the Older Adult. Boston, Mass: Butterworth-
impaired adults. J Speech Hear Res. 1987;30:153-160. Heinemann; 1995:21-58.
37. Sweetow RW, Palmer CV. Efficacy of individual auditory 42. Sackett DL, Rosenberg WM, Gray JA, Haynes RB,
training in adults: a systematic review of the evidence. Richardson WS. Evidence-based medicine: what it is
J Am Acad Audiol. 2005;16:494-504. and what it isnt. Brit Med J. 1996;312:7172.
38. Hawkins D. Effectiveness of counseling-based adult 43. American Academy of Audiology Task Force. Guidelines for
group aural rehabilitation programs: a systematic review the Audiologic Management of Adult Hearing Impairment.
of the literature. J Am Acad Audiol. 2005;16:485-493. Available from: www.audiology.org. Accessed Feb 27, 2007
39. Trybus R, Stika CJ, Goulder TJ. Final Project Report: 44. Cox R. Evidence-based practice in the provision of
Rehabilitation Research and Training Center on Mental amplification. J Am Acad Audiol. 2005;16:419-438.