Includes the following article: The Need for Aural
Rehabilitation in Today's Dispensing Practice Part
II Questions may be submitted online through the "Reader
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The Need for Aural Rehabilitation in Today’s Dispensing
Practice
(PartII)
By Max Stanley Chartrand
(This is the second in a three-part series authored by
M.S. Chartrand.)
In Part I of this series published in the
January-February 2000 issue of The Hearing Professional,
we discussed the prevalence of severely hearing impaired
(SHI) patients within the Hearing Instrument
Specialists's practice, and introduced a true "total
communication concept" with which to supplement the
communicative needs of SHI patients who need more than
amplification alone.
Indeed, though these patients constitute only about 15
percent of the average practice patient base, they also
comprise the most challenging group to satisfy with
amplification (Aural Rehab Concepts, 1997). Part of the
challenge is that expectations exceed the ability of
such damaged cochleae to efficiently process sound no
matter how much amplification is used.
THE HEARING PROFESSIONAL
Hence, many SHI sufferers experience diplacusis,
critical bandwidth distortion, extreme loudness growth
abnormalities and severely limited functional dynamic
ranges. These are dimensions usually little understood,
and even less frequently assessed, by both patients and
hearing care professionals. But they are real and may
significantly limit the effectiveness of hearing
instrumentation as the sole strategy for many SHI
patients.
This segment will concern itself with some of the
non-amplification compensation strategies available to
the patient, which may require active promotion by their
Hearing Instrument Specialists. It is not, however, a
complete or exhaustive exposition on the topic, by any
means, but an introduction and review of some of the
most proven approaches.
Visual Compensation Modes
The most obvious human sense to supplement a marked lack
of audition is vision. The human mind has an amazing
ability to compensate for critical sensory shortcomings
(via the diencephalon or "homunculus"), allowing one to
compensate in lieu of the more appropriate sense. Hence,
the blind are known for developing extraordinary
auditory and spatial mapping abilities to^compensate for
their lack of vision.
The same may be said of the deaf in developing superior,
almost uncanny, visual and vibrotactile abilities.
Visual compensation strategies such as speechreading,
gestures, facial expressions and signing can be
essential considerations in visually compensating for a
severe hearing impairment.
Speechreading
Probably no other sensory compensation strategy for SHI
patients should be stressed more than speechreading. Up
to 40 percent of speech communication clues may be
discerned through speechreading alone. Of course, that
means that 60 percent of verbal communication may still
be absent, making speechreading only a supportive or
secondary communicative strategy. Coupled with
amplification, the SHI patient can achieve total
communication (Shimon, 1992). However, the utilization
of speechreading skills exclusive of audition (without
amplification) can hamper one in developing good
listtning skills (Dodd and Burnham, 1988). Therefore,
speechreading should be considered an adjunct toórather
than replacement ofóthe auditory function for SHI
patients.
Basic skills in speechreading are easily developed over
time by both post-linguistic children and adults alike
(Hardman et al, 1993). Resources in speechreading
include several excellent videotape programs, books,
and, of course, volunteer and professional community
courses. Every specialist should survey the resources
available to their patients within their community. If
resources are not readily available, the specialist may
desire to provide such services through the auspices of
their private practice. Here are a few resources to
consider:
Local speechreading classes/instructors-The Alexander
Graham Bell Association will provide a list of
speech-reading instructors throughout the United States.
Con-
tact A. G. Bell Association, 3417 Volta Place, N.W,
Washington, D.C., 20007, or call 202.337.5220.
Self-help resourcesóConsumer organizations such as Self
Help for Hard of Hearing Persons (SHHH) and publications
such as Hearing Health magazine offer information and
materials for hearing impaired persons and
professionals.
In-office speechreading programóAn in-house program may
easily be developed at the hearing aid office by setting
up a room with a VCR and color monitor for viewing from
a library of videotaped lessons on speechreading. (This
would, incidentally, also be an excellent place for
display of assistive listening devices (ALDs).) SHI
hearing aid users may be assigned weekly private
sessions as part of their aural rehabilitation program,
which is included in the purchase of new hearing
instruments.
Contextual, Circumstantial Compensation
The utilization of contextual and circumstantial clues
over actual word discrimination is auditory closure. In
this way, the severe and severe-to-profound patient is
able to put together whole words, phrases and even
sentences derived from incomplete auditory clues. This
assists in maintaining spontaneity in conversation. Here
are a few examples of arriving at whole meaning out of
missed key words (easily misunderstood words are in
parentheses):
When two people greet each other, the one responding
says, "I'm doing vine (fine)."
In talking about an obstacle to completing a task, the
speaker explains, "I tried in pain (vain), to get the
door open."
When going to the store, his wife's request was, '"Would
you please pick up ten pound(s) of apple(s)?"
The time/temperature recording on the phone said, "The
time is ten-seven-ty (seventeen)."
In the punchline of a joke, "...when the boss found out,
boy, did he get the kink ship (pink slip)!"
By considering the time of day, circumstances, persons
involved and relationship to each otheróweather, purpose
of the activity, momentary matters affecting the spirit
of things, and surrounding environmentóthe impaired
person may "fill in the gaps" much more readily.
Spontaneity, again, is the key. Most human communication
revolves around spontaneous action and reaction, give
and take, questions and answers, a stated opinion and a
response and a greeting and its return.
Visual and Peripheral Awareness
A game that is sometimes played at parties presents a
good way to increase one's visual awareness. The group
is divided into pairs and instructed to notice
everything they can about that person (clothing,
hairstyle, facial expression, etc.). After about 10
seconds of studying each other, they are to look away
and name 10 items they remember about the other's
appearance. An object lesson from this simple game is to
increase awareness of things about the other person that
would normally be overlooked. In actuality, one is
increasing their comprehension or cognitive awareness.
Another important practice is to extend one's peripheral
vision (or "side vision"). Since the ears of the
deficient hearing system are no longer the "safety
radar" they should be, the eyes are able to compensate a
great deal by increasing their peripheral awareness of
activities and objects around them (Chartrand, 1999). An
exercise: Practice following one's own hand as far as
possible until out of view. To do this, hold the hand
directly in front of the face and then swing the hand
over to the side, almost out of the range of visibility.
Looking straight ahead, one should be able to note
location of the hand until it is about 80-95 degrees
azimuth.
Next, practice by making a mental list of things seen,
in detail (colors, shapes, names, etc.), at the
periphery of one's sight range. The increase of this
ability will provide greater safety, better spatial
mapping and, consequently, fewer surprises.
Using the Whole Body in Tactile Compensation
Many parts of the human body are particularly useful as
a tactile sensory interface: the feet for detecting
ground movement; the arms and legs resting against
furniture or guard rails; the back against the back of a
chair; the cheek-bones and sinuses for vibrations in the
open air; the teeth, via trimgeminal and facial nerves,
can detect slight vibrations; and the fingers against a
speaker or other resonating surface. By redirecting
one's attention to vibrotacrile information one can
develop a keen ability to perceive and utilize such
information in conjunction with auditory clues.
Currently, there are some credible theories about the
vibrotactile receptors of the human body, especially in
the ultra-hearing frequencies (above 20KHz). It is
expected that more will be learned in the future, and
that new technologies will develop that will enable the
hearing impaired and deaf to more effectively utilize
this little understood communicative route.
Development of Tactile Compensation
Apart from acoustic reception, the human ear is
extremely receptive of tactile information, especially
at the tympanicplexus, a virtual consortium of
interconnecting motor and sensory neurons located in the
center portion of the tympanic membrane (TM). Upon first
blush, this detour from the usual auditory pathway of
sound transmission may seem unuseful, but user
experience and reports tells us volumes, especially
among cochlear implant users who continue to wear a
hearing aid in their non-implanted ear.
An effective approach to counseling may help the SHI
hearing aid user who has a sharp precipitous loss with
little or no residual hearing after 1KHz. Such an
individual may be alarmed, after the fitting of new
instruments and all the promises (expectations) raised
by advertising claims that they are still unable to hear
the squeak of a rusty door hinge, the squeal of the
car's fanbelt, or the coach's whistle at a ballgame.
There are many situations in which it would
be enormously helpful to be aware of such signals
without actually "hearing" them. The specialist, then,
must help the patient develop "tactile awareness." The
sequence and dialogue of this counseling approach may
consist of the following example.
Patient: After I received my new hearing aids, I went
home expecting to hear things I haven't heard in a long
time. But I was disappointed to find out that I could
not hear the squeaking door hinge my wife had been
trying to get me to fix for months.
Specialist: Well, then, you'll need to learn to use your
tactile sense to "hear" such sounds since your hearing
threshold is completely off the chart in the high
frequencies. What I'd like you to do is tell me if you
hear this sound. (The specialist then produces a pulsing
2KHz signal @ 60dB via the bone oscillator which should
resonate against another surface, the test tabletop).
Now, tell me, do you hear that?
Patient: I hear nothing. What should I be hearing?
Specialist: OK, now I'd like you to close your eyes and
concentrate. See if you don't "feel" a tickling or
slight vibratory pulsation on your eardrum. (The pulsed
signal is given again, allowing the patient sufficient
time to note the pulsation.)
Patient: I feel something, a fine vibration going like
this (describes sound by moving finger in rhythm with
pulsation). Is that the sound you're talking about?
Specialist: Yes, it is. What you must learn to do is
begin to "feel" the sounds you cannot hear. This will
take time and practice, as well as focus, but it can be
done.
Imagery Compensation
This concept in aural compensation is a little more
elusive to describe, for it involves utilizing
substitution to fill the gaps where actual speech
discrimination is absent. This is particularly helpful
in cases where complete aural correction is not
possible. Imagery compensation allows the individual to
utilize such expressive clues as:
Voice InflectionóWhen a question is asked, the voice
tends to rise in pitch. More importantly, the ending of
the question is left "hanging," begging for a return
answer by virtue of suspension. The answer, then, tends
to pick up at the level of pitch where the question left
off, making its meandering trail back to the starting
pitch for finality. In music this is comparable to
starting the question at the tonic (I) and ending the
question on the dominant (V).
Then, the answer begins at the dominant (V) and ends at
the tonic (I) to show finality.
Voice inflection often belies the meaning behind the
words, the uncertain statement inflected like a question
(i.e., I'm not going to the show?), a pseudo-gratuitous
question, which sounds more like a stern warning than a
question (i.e.. You think you're something, don't you?}.
By noting the rise and fall, the nuances of coloration
and social ambiance, the listener will receive valuable
clues through voice inflection that will help complete
the auditory information accompanying it.
Elimination and DeductionóBy taking each missing word
and supplanting in its place several possibilities, the
listener may "piece together" the whole message in its
broader context. Example: "Today, we're going to (meet)
(eat) (visit) (talk) at Luby's." Similar to a "multiple
choice" test, the SHI individual may develop an
intellectual form of compensation.
A good practice while listening to a lecture or speaker
is to take written notes. Write down what you "think"
was said, analyze it and then make corrections only as
the need becomes apparent. When in doubt, ask a normal
hearing individual near you to help fill in the missing
words or concepts.
By redirecting one's attention to vibrotactile
information one can develop a keen ability to perceive
and utilize such information in conjunction with
auditory clues.
Syllabic MatchingóThis involves the same mental
acrobatics found in solving crossword puzzles, except
that one is finding the word with proper number of
syllables or phonemes. The fact that three syllables
could be heard in the word "processor" indicates that
the word was not protest, protect, or prospect which
have only two syllables. However, it could have been
protector, professor, prospector or hairdresser, each of
which has three syllables. Since the topic is food
making, processor would be the logical choice. By
narrowing the possibilities and using substitution, one
may come closer to correct communication.
TimbreóEach word, or combination of words, presents
various inflections of "brightness," such as in the
major musical chord, and "darkness," as in the minor
chord. The word "ate" is certainly brighter sounding
than, say, "art." The "long vowels" provide brighter
intonation than the "short vowels" and darker
"diphthongs." The fluctuation between bright and dark
syllables, if noticed, will begin to display an
identifiable coloration that may be associated with
certain words and expressions. If one were to analyze
the spectral content of vowel sounds in speech, they
would find distinct and measurable differences in the
harmonic frequencies, both at the fundamental level and
at each formant.
Notice the changes of timbre in the following sentence
as it is spoken aloud: "Today is the day (bright timbre)
for all good men and women to come (darker timbre) to
the aid of their nation (bright again)." The fluctuation
of bright and dark timbre would then provide another
auditory clue.
Consonant/Vowel Structure: While some words literally
ricochet with fricatives and plosives, others are just
as characteristic with their liquids and vowels. Witness
the distinctive contrast between the words "certificate"
and "lullaby," or "racketeer" and "animal." Through
focused awareness and practice the individual begins to
associate these consonantal structures and coloration
with the words themselves. In fact, this mathematical
and rhythmical approach, coupled with logic and context,
will enable the user a greater measure of speech
understanding through imagery and substitution.
Summary
This installment of the series involved a review of
visual and nonauditory coping strategies that are
available to the severely hearing impaired. Some of
these are developed out of necessity by the patient,
without specialized counseling. But to achieve maximal
benefit, it is incumbent upon dispensing professionals
to become well-grounded in these principles so that they
may direct the rehabilitative process of their patients,
and to connect them with community services that
otherwise might not ever be utilized.
References
Aural Rehabilitation Concepts, Study of the severely
hearing impaire population in the U.S., Gainesville, TX
(1997).
Chartrand, M. S., "Transcranial or Internal CROS
fittings," The Hearing Journal, September (1991).
Chartrand, M. S., Hearing Instrument Counseling, 2nd
ed., Livonia, MI:
International Institute for Hearing Instruments Studies
(1999).
Dodd, B. and Burnham, D., "Processing speechreading
information," Volta Review, 90, pp. 45-60 (1988).
Hardman, M. L. et al.. Human Exceptionally: Society,
School and Family, Boston: Allyn and Bacon, pp. 231-309
(1993).
Shimon, Debra A., Coping with Hearing Loss and Hearing
Aids, San Diego: Singular Publishing Group (1992).
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