Includes the following article: The Need for Aural
Rehabilitation in Today's Dispensing Practice Part
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The Need for Aural Rehabilitation in Today's Dispensing
Practice
(Part III)
By Max Stanley Chartrand
(This is the final installment of a three-part series.)
The question "What if these hearing aids don't work?" is
asked with the implication that there are no finite
limitations to correcting one's hearing loss; just
limitations in hearing aids. More often than not,
though, for the severely hearing impaired patient, the
question should be "What if I need more than hearing
aids to meet my needs?"
Of course, the informed answer is the application of the
appropriate assistive listening devices (ALDs) to fill
communicative/auditory gaps. In practice, however, it's
reportedly rare that assistive devices are even
recommended during the evaluative or counseling stages
of dispensing.
Whereas hearing instruments provide continuously
wearable auditory correction for all-around function, in
comparison to assistive devices they can perform poorly
in auditoriums, on the telephone and in other
communicative and signal-to-noise situations. This
points to an undeniable need for assistive devices to
complete the aural rehabilitative picture for those with
the more serious hearing losses. Poor signal-to-noise
ratio, distance and room reverberation come to the
forefront when weighing the benefits of hearing aids
versus ALDs in specific acoustic applications, the
latter providing the needed advantage.
Specialists should be well acquainted with all available
devices, their care, application and sources of supply.
Recent professional journals and other sources are
replete with information about currently available
devices. For that reason, we will provide only an
introductory treatment of the topic to acquaint
dispensing professionals with appropriate counseling
information as it pertains to ALDs.
Many Hearing Instrument SpecialistsÆ have ALD displays
in their offices. In some practices, a separate room has
been designated with a display of demonstration models.
Others keep a sampling of basic units in their
counseling or fitting room for demonstration when
needed. At the very least, most specialists will have
the catalogs of various sources of supply.
In addition to hearing aid and cochlear implant users,
the "culturally" deaf population, the immobile and those
with central auditory processing difficulties (such as
receptive aphasia) may also benefit from appropriate
assistive devices.
However, many specialists and audiologists do not
actively promote ALDs. Perhaps the principal reasons are
the relatively low margin of profit and a perceived
competitive factor to hearing aid amplification. There
are a number of important reasons for actively promoting
assistive devices into the financial model of a
profitable dispensing practice:
1. Supplementing hearing instruments and cochlear
implants with assistive devices can reduce
over-expectation and credit returns.
2. ALDs do not require the same level of evaluation,
counseling and adaptation as hearing instruments.
3. Patient and third-party loyalty will be enhanced by
offering a more holistic hearing service.
4. The severely impaired hearing aid user's lifestyle
and opportunities for growth will be enhanced.
These rehabilitative devices have enabled their users to
mainstream into society in ways that hearing aid
amplification and cochlear implantation cannot. It is
suggested that the specialist utilize a "Communicative
Assessment Form" to help determine the special and
individual needs of their severely impaired patients
and, where possible, to work with an aural
rehabilitation counselor who specializes in assistive
devices.
Following is a brief overview of some of the available
devices that may effectively supplement and extend the
usefulness of hearing instruments and cochlear implants.
Closed caption television (CC) has lifted many hearing
impaired individuals from virtual boredom and
frustration while watching television and movies to
joining with their normal hearing counterparts as part
of the audience. Far more effective than a hearing aid
for those with poor aided speech discrimination, the CC
decoder projects dialogue and pertinent subtext onto the
screen, while scrolling in relative synchronization with
the spoken message.
Since 1993, the Americans with Disabilities Act (ADA)
has mandated that every television set 13" or larger
sold in the US. must include a closed captioning
decoder. Some people may not be aware of this because
the option is programmed into the set-up controls. Too
often, severely hearing impaired patients do not use
this feature, or are unaware of its existence until
advised by their Hearing Instrument Specialist.
Infrared TV amplifiers provide an acoustic benefit for
the hearing impaired. The clarity, fidelity and
convenience of these wireless devices make them superior
considerations to external speakers for many hearing
impaired persons who still enjoy reasonable residual
hearing. The range of broad-cast is usually within 20 to
30 feet of the sound source.
Infrared reception is received in the direct visual
pathway of the transmitter, while the signal travels on
light waves within the room. Hence, some lighting will
be needed while viewing the television with the infrared
system or a disturbing "hissing" and/or distortion may
occur.
Recent commercially available infrared systems with
their attractive display materials, have made this a
profitable device for specialists to sell in their
waiting rooms. As patients enter for their appointments,
they are given a demo headset with which to watch a
hearing health-related video.
Often the receptionist the most active promoter these
devices, because of its ease of sale and continuous
demonstration in the waiting room. Infrared transmitting
and receiving sets are also available for wide-area
listening situations (see Figure 3).
Wireless frequency modulation (FM) auditory systems are
also invaluable for difficult listening situations, such
as in large auditoriums, church meetings, classrooms and
one-on-one conversations in noisy restaurants or while
traveling. Many churches, schools, amusement parks and
some theaters provide these devices to the public at no
charge, though too often they go underutilized by those
who need them.
Unique advantages of FM auditory systems are numerous.
Broadcast and reception range is much longer than
infrared, horizontally up to 1,000 feet, vertically by
several miles; it will transmit through most building
materials (except metal), and several channels can be
used simultaneously without cross-interference. Sound
quality can be very high fidelity (see Figure 4). FM
systems can be found in three user modes:
1. Personal FM auditory systems are used by individuals
who purchase an entire auditory kit containing the
microphone transmitter unit and a personal receiver. The
receiver unit is used either directly with an acoustic
coupler onto the ear, or by transmission through the
hearing aid with a neckloop, direct auditory interface
(DAI) or boot connection. Also available are ear-level
FM receiver units, usually as part of an amplification
array.
2. Large area and group listening systems are featured
in many schools, churches, auditoriums and some theaters
and amusement parks. In these cases, the transmitter is
usually built into a public address or large area
broad-casting system, while users simply check out the
receiver units for personal use. The availability of
various channels is very important in these systems,
especially when several broadcasts (or classrooms) are
using FM at once. Again, users may interface by direct
coupling, DAI or hearing aid boot.
3. FM classroom soundfield systems, although a recent
development, have proven to be helpful for a wide array
of students: hearing aid and cochlear implant users who
wish to be "mainstreamed" in the class room,
developmentally-delayed students (particularly those
with CAPD, ADD, or history of chronic OME) and normal
hearing students who must listen in poor acoustic
classroom settings.
Hardwired systems are simply hard-wired assistive
listening systems, which reduce the distance between
thespeaker and listener or teacher and student. For
years, hardwire systems were all that were available for
the hearing impaired, and then only in large area
listening situations such as auditoriums or chapels and
sometimes schools. Nearly all modern buildings have
replaced hardwired systems with wireless systems (i.e.,
FM, infrared). One reason these systems have fallen out
of favor with hearing professionals is because of their
lack of spectral and loudness growth functions. While
hardwire systems are probably adequate for those with
conductive losses or flat configurations, they certainly
leave much to be desired for the much larger number of
sensorineural losses. Additionally, they restrict the
user to a specific location and usually require the use
of bulky headphones.
Loop Systems are hard-wired systems that provide a
magnetic field or leakage that can be picked wirelessly
by a hearing aid user's induction telecoil. These, also,
are falling out of favor as few new structures today
accommodate induction loop systems. Besides being
severely limited in range, there have been reports of
electromagnetic interference in some buildings. In
regard to fidelity, the main drawback has been the very
limited F2 range of the hearing aid induction coil
itself, often topping out at 1.5-2.0KHz. Some of the
newer amplified telecoils (with pre-amp) show responses
near 4KHz. This is more acceptable, but is still quite
limited compared to the 10KHz sensitivity ranges of
their FM counterparts.
Loop induction technology gained in popularity in the
1950s in Europe and later came to the U.S. in the 1960s.
Consumer groups' recent push for telecoils on hearing
aids has caused a mini-revival of the technology;
however, fewer than 20 percent of hearing aids in use
today feature telecoils, generally for users of BTE and
some larger ITE products. Nearly always these are power
class instruments for more severe losses. Consumer
demand for smaller and less visible instruments has
caused a continuing decline in the number of telecoil
options offered. While the author, a hearing impaired
consumer himself, sympathizes with those who wish to
change current trends, the fact remains that FM is
taking over and loop systems are on their way out. As
far as telephone use, most mild and moderate users have
better sound reception through the newer acoustic
microphones and low-distortion amplifiers.
Special signal devices include flashing light alarm
clocks and flashing lamps for telephone calls, the
doorbell or even a knock at the door. These devices
serve to put the impaired individual in touch with the
signals around them. Several new devices that have
recently been introduced to the market involve multiple
signal devices, allowing the user to wear a box no
larger than a pager on their belt to be alerted of
knocks on the door, monitoring of the baby, ringing of
the telephone and, in some cases, built-in FM
communication or direct amplifier (see Figures 5 and 6).
Telephone amplifiers include built-in or add-on receiver
amplifiers, special ringers and frequency selectors to
accommodate various hearing loss configurations. Also,
there are user-operated amplifiers on pay telephones at
airports, hotels and other public places with high
levels of activity. Under the ADA, specific mandates
have been instituted that require a certain number of
amplified phones per standard public telephones. For an
individual at home or work, there are a host of add-on
or re- placement telephone devices to add low-distortion
amplification on the telephone. One often overlooked
piece of equipment is the speakerphone, designed to give
"hands free" utilization to the normal person but, more
importantly, to allow an increased and
lower-frequency acoustic signal for the hearing impaired
without feedback. Furthermore, the severe or profound
hearing impaired person may use an interpreter in calls
(lipreading, written messages, etc.) while using the
speaker phone, allowing for a "conference call" type
setting (see Figure 7).
Teletypewriter (TTY) or telecommunications device tor
the deaf (TDD) equipment is indispensable for those who
have little or no aidable speech discrimination. Just as
important to these patients are their State Relay
Services, which provide direct Relay Agent assistance
when calling normal hearing persons. More recently the
voice carry-over feature (VCO) was added, allowing the
patient to speak into the telephone while the agent
types the other party's end of the conversation via the
TDD monitor screen. The purpose of TDD Relay Services is
to provide the same level of telecommunications services
to the deaf and hearing impaired as that afforded their
normal hearing customers.
Today there are many local, state and federal programs,
including some private programs, that provide TDDs for
the deaf and their close family members either free of
charge or at reduced costs. Since 1985, there has been
an aggressive effort in some community organizations, in
co-operation with private telephone companies, to
install these devices in more homes and businesses
throughout the U.S. Moreover, it is becoming more
commonplace for many hearing and speech clinics to have
TTY/ TDD telephone numbers for their clientele. It is
strongly recommended that all ENT medical, audiology and
dispensing practices keep a TDD at their front desk, and
to advertise the availability of the device next to
their advertised phone number. Such wording may be
displayed in the following manner: 817.555.5555 (Voice/TDD).
A recent development with TDD technology involves the
new microprocessor models that provide printed text of
calls and interface with computers and other
communications devices. Most of these have internal
memory, instant conversion or translation of various TDD
baud rates and languages. One of the most popular
versions of the TDD is a small, compact TDD operating on
rechargeable or alka-line batteries.
The ADA mandates that all businesses and public
accommodations provide some way for effective
communication for the deaf. At hotels, US. federal
regulations require one "ADA Compliance Kit" for every
sixty hotel rooms. Foremost in that kit is the TDD. In
addition, they are to have a TDD at the front desk so
that deaf and hearing impaired guests may communicate
with hotel personnel and services. In many cases, it has
been reported that few hearing impaired individuals take
advantage of the mandated services. Therefore, it is
advisable for specialists to encourage their patients to
take advantage of these services. As in any other market
endeavor, services only rise to the level of demand if
there is indeed a demand.
Conclusion
The very essence of aural rehabilitation is the
empowerment of the hearing impaired individual to be
given opportunities and insights that will help them to
stretch higher, reach further and enlarge their vision.
By reaching beyond the apparent capabilities they will,
at a minimum, achieve the possible. This will take
constant encouragement from the specialist, loved ones
and other professionals.
it is imperative that the specialist customize the
program for each patient. Some individuals will need
assistive devices, some will not.
Furthermore, it is imperative that the specialist
customize the program for each patient. Some individuals
will need assistive devices, some will not. Some will
need to utilize tactile compensation, while others may
have to rely on speechreading as the only additional
consideration be- yond amplification. In customizing
each patient's hearing health care program, the
specialist will be acting more as an aural
rehabilitation counselor, and less as a commercial
hearing aid dispenser. This approach maximizes the
ultimate benefit of the caregiving.
References
Benoit, Robert, "Home use of FM amplification-systems
during the early childhood years," Hearing Instruments,
Vol. 40, No. 3, pp. 8-12 (1989).
Chartrand, M. S., From in-class surveys to more than
3000 hearing professionals attending the "Wholism in
Hearing Healthcare" series lectures, National Institute
for Hearing Instruments Studies, Livonia, MI (1992-94).
Chartrand, M. S., "The Unreported Story: Schools Still
Failing in Hearing Healthcare," Hearing Health,
May/June, pp. 12-13, 49 (1997).
Crandall, C. C., "Classroom Acoustics: A Failing Grade,"
Hearing Health, September/October, pp. 11-16, 59 (1998).
Kaplan, Harriet, "Assistive Devices for The Hearing
Impaired," The Hearing Journal, pp. 13-18, May (1987).
Lightfoot, R. K., and Vaughn, G. R., "Assistive
Listening Devices and Systems for Adults Who Are Hearing
Impaired," Aural Rehabilitation:
Serving Adults and Children, 3rd edition, R. H. Hull,
ed., San Diego: Singular Publishing, Inc., pp. 227-250
(1997).
Morris, B., "Assistive devices plus hearing aids: A
winning combination," Hearing Journal, March (1998).
Redmon, J., Survey in use of ALDs in the dispensing
practice, Unimax Hearing Instruments (1990).
Stach, Brad A., "Hearing Aid Amplification and Central
Processing Disorders," Robert E. Sandlin, ed.. Handbook
of Hearing Amplification, Volume II, Boston:
College-Hill Press, pp. 103-104 (1990).
Vaughn, G. R., "Bill of rights for listeners and
talkers," Hearing Instruments, no. 37, p. 8 (1986).
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