Includes the following article: The Need for Aural
Rehabilitation in Today's Dispensing Practice Questions
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THE NEED FOR AURAL REHABILITATION IN TODAY'S DISPENSING
PRACTICE
(Part I)
By Max Stanley Chartrand
(This is the first in a three-part series authored by
M.S. Chartrand.)
Almost always, those who require extended compensation
beyond amplification are moderately severe, severe,
severe-to-profound or profound patients. As a population
of the typical hearing instrument practice they comprise
approximately 15 percent of all patients. The most
debilitated portion of the population is in the
severe-to-profound and profound cases, comprising
approximately two percent of the typical practice's
patient base.
When hearing aid amplification alone becomes
increasingly limited in meeting the communicative needs
of these patients, other means of compensation increase
in value (see Figure 1). Moderate losses, for instance,
may require only a brief review of speechreading and
coping strategies, while those with moderately severe
losses may require numerous sessions of training in not
only speechreading and coping strategies, but
instruction in the use of assistive devices. Those on
the cusp between hearing aids and cochlear implant
candidacy may require the services of a speech
pathologist, deaf educator or speechreading trainer.
As cochlear implant candidacy criteria continue to
broaden, many of those struggling with hearing aids and
assistive devices today will be enjoying a new lease on
life with the near miracle of cochlear implantation
tomorrow.
In those cases, hearing aids continue to play an
important, albeit supportive, role. But the question is
asked, "Where did all of these new severe and profound
patients come from?" The truth is that they came from
the same hearing aid patients who were mild and moderate
cases only yesterday. Hence, the pool of those with the
worst forms of hearing impairment continues to grow
exponentially faster than our profession's ability ro
keep up.
To date, most adults with cochlear implants still wear a
hearing aid in the non-implanted ear, and utilize
assistive devices and coping strategies intensively to
complete their rehabilitation. There is, therefore, a
growing number of cochlear implant and hearing aid users
who need the continued services of a hearing health
specialist.
Prevalence of Those Needing Intensive Assistance
Out of the 28 million hearing impaired Americans, there
are 2.7 million severely and profoundly deafened
children and adults (see Figure 2). Of this population,
64 percent wear hearing aids, cochlear implants or
reside in the deaf community, as shown in Figure 3.
These are the open and shut cases of which none should
fall between the cracks of the current delivery system.
Also, there are many "shades of gray" losses (moderately
and moderately severe) which also need to be addressed
from a compensatory counseling standpoint. They, too,
can benefit from assistive technology and coping
strategies in addition to hearing aid amplification.
Aural Rehabilitation Counseling
Traditionally, aural rehabilitation has been the domain
of audiologists, but in recent years Hearing Instrument
SpecialistsÆ have become more involved as they guide
their patients through available avenues of compensatory
strategies and devices. However, it is not a blanket
assumption that Hearing Instrument SpecialistsÆ are also
aural rehabilitation counselors. Aural rehabilitation is
an integral facet of practice when the specialist plans
and prepares for the task. Continuous education and
training become critical requisites, whether obtained on
the job, through continuing education courses, by formal
study or through a combination of these.
Most long experienced specialists have evolved into
aural rehabilitation in the quest to meet the needs of
their patients whose hearing losses have grown
progressively worse over many years. This necessitates
working in accordance with other professionals who have
specialized skills in areas such as formal speechreading
training, communicative rehabilitation of stroke
victims, CAPD cases or cochlear implant use. In this
way, community hearing health care reams have evolved
nearly everywhere, driven by the rapidly growing number
of patients who need additional and intensive clinical
services that cannot be provided by any one
professional.
Needed: Caring Specialists
The most important qualification for the hearing health
specialist becoming involved in the rehabilitative
aspects of hearing correction is to care enough to do
the necessary research for each case where immediate
solutions are not available. This would mean that all
hearing instrument patients should be able to gain
access to those resources through their specialist. In
turn, patients- must be willing partners in the quest to
utilize all possible options to help them pick up where
hearing aids leave off. By adding compensatory services
to their dispensing practice, the specialist is
providing a total communication concept.
Total Communication Concept
The habilitative/rehabilkative philosophy of total
communication declares that a person has a right to have
information access through any means possible,
including:
Hearing aids
Cochlear implants
Assistive listening devices (ALDs)
Speechreading
Written language
Auditory closure
Gestures and facial expressions
Sign language
Fingerspelling
Every practitioner of hearing rehabilitation should
consider the total communication concept. Our reference
to total communication does not mean the restrictive
(non-oral/aural) philosophy of total communication held
by some, but instead an all-inclusive or holistic
approach in utilizing all forms of communication,
especially oral/aural.
Step One: Recognizing and Accepting Limitations
As in any rehabilitative situation, the first step in
conquering limitations is to recognize and accept them.
This entails a keen understanding of how hearing loss
affects one's life. The cause is essentially
transparent, but the effects are indeed real. Assessing
how these effects are impacting one's psychosocial
well-being is no time for masking over the truth. The
truth, in this case, needs to be dragged out into broad
daylight and carefully examined so the patient and their
loved ones can begin to move forward.
After all that can be done with amplification alone, the
specialist should direct attention toward
self-assessment of the limitations that remain
afterward. Following is an example of a case where the
user has a moderately sloping loss through the low
frequencies, a steeper drop in the mid-range frequencies
and no aidable hearing after 2KHz:
Mr. Jones, after all that can be done with the fitting
and adjusting of these instruments, you'll still have a
substantial hearing loss. The frequencies you'll be
missing are critical for two reasons. The first is in
speech understanding. Some of the softer consonant
sounds, which define words in the English language, will
be difficult to hear no matter how loudly you adjust
your volume control. The second is in understanding
speech while in noise. The masking effect of the
lower frequencies which you already hear will cause an
"upward spread of masking" covering some essential parts
of words. Following are some ways you can help this
situation.
1. First, you must realize the permanent auditory
limitations arising from your hearing loss. Hearing aids
are only part of your hearing solution. Since you have
no residual hearing after 2KHz. it is impossible to give
you hearing in that range with any hearing device.
You'll need to learn not to become frustrated in
critical listening situations. Trying too hard only
makes it more difficult.
2. You must develop better Speechreading skills. I will
help you locate Speechreading learning resources in your
community. They are often inexpensive or free. It will
take practice on your part, but will be of tremendous
help.
3. Whenever possible, try to limit communication in very
noisy places. Ask your visitor(s) to walk with you to a
quiet area. Furthermore, tell them that speaking loudly
does not help that amplifying or increasing the sounds
that you cannot hear will not improve your speech
understanding. Knowing that it is difficult for you to
function where you cannot easily see the person
speaking, consider lighting and distance.
4. When faced with a difficult listening situation, such
as in a telephone conversation from a public phone, make
the other party aware of your hearing loss and ask them
to have patience. Don't try to bluff your way through.
5. You may create a more functional environment for
yourself by obtaining several other items:
a. closed-caption or infrared listener on your TV
b. lower-pitched alarm clock and telephone ringer
c. FM auditory system for large area listening
d. distortion-free amplified telephone or low-frequency
emphasis speaker phone
e. In all future purchases such as automobiles,
recreational equipment, etc., think in terms of how you
can communicate in the noise created by these items.
Look for the lowest possible ambient noise levels.
(Note: A copy of the above dialog may be given the
client to read if that will assure better communication.
Too often a person with this type of loss has resorted
to nodding in agreement even though they miss many
essential points.)
By way of counseling in the above manner, patients will
realize greater success while framing expectations in a
more realistic light. They will also have a viable
format from which to accept and accommodate the
necessary limitations of their aurally corrected loss.
In Part II of this series, we will enumerate several
methods of compensation, the actual application of which
will depend upon the specific needs of each individual
hearing aid user.
References
Aural Rehabilitation Concepts, Study of the severely
hearing impaired population in the U.S., Gainesville, TX
(1997).
Busse, L., "When Hearing Aids Are Not Enough,"
continuing education course, Cochlear Corporation:
Englewood, CO (1996).
Chartrand, M. S., "The Unreported Story: Schools Still
Failing in Hearing Healthcare," Hearing Health,
May/June, pp. 12-13, 49 (1997).
Chartrand, M. S., Market Analysis: SHI, Englewood, CO:
Cochlear Corporation (1998).
Chartrand, M. S., Patient Care Course, Series I, a
continuing education course, Livonia, MI: National
Institute for Hearing Instruments Studies (1999).
Costello, E., Signing: How to Speak With Your Hands, New
York: Bantam Books, Inc. (1983).
Tye-Murray, N., Foundations of Aural Rehabilitation, San
Diego, CA:
Singular Publishing Group, Inc., pp. 2-14 (1998).
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