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Plotting beyond the audiogram to the TELEGRAM, a new assessment tool

Thibodeau, Linda M.

doi: 10.1097/01.HJ.0000324407.72391.e9

Linda M. Thibodeau, PhD, is Associate Professor of Audiology at the University of Texas at Dallas.

Correspondence to Dr. Thibodeau at Advanced Hearing Research Center, Callier Centerfor Communication Disorders, UT Dallas, 1966 Inwood Road, Dallas, TX 78235.

People typically go to an audiologist or other hearing healthcare provider because they are having difficulty communicating—or a family member believes they are. Initially, the practitioner addresses the concern by conducting a routine audiologic assessment.

If a hearing loss is identified, the next consideration is possible medical intervention and/or amplification. There are many factors to consider in determining candidacy for amplification, including the degree of loss relative to communication demands, family support, acceptance of the loss, manual dexterity, and general health. In many cases, the use of hearing aids may reduce the communication difficulties.

However, communication may not truly be optimized if personal hearing aids are the only rehabilitative strategy tried. It is likely that in some circumstances hearing aids will not completely compensate for the loss of hearing. In such cases, other devices, techniques, and/or strategies must be considered. Although assistive listening devices (ALDs) or hearing assistance technology (HAT) typically refers to products other than personal hearing aids, recent technologic advances have resulted in these often being the same instrument. This consolidation has implications for the delivery of services to persons with impaired hearing.

The Preferred Practice Patterns (PPP) for the Profession of Audiology, developed by the American Speech-Language-Hearing Association (ASHA), serves as astandard to promote quality care to clients.1 Two of the 23 audio-logic practices discussed specifically address ALDs (20.0 Product Dispensing and 22.0 Assistive Listening System/Device Selection), while five deal with practices related to assessment for and use of ALDs.

Several factors may influence how thoroughly hearing professionals consider these alternative strategies. This article will relate four concepts that could have a significant impact on the benefits that persons with hearing loss receive from hearing technology. These concepts are: (1) a broader notion of what hearing technology may be helpful to the patient, (2) the integration of assistive technology with personal systems, (3) the effect on the dispensing process of standardizing evaluation techniques, and (4) the need for AuD programs to incorporate more experiences with technology beyond the hearing aid.

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The evolution of digital and wireless options will inevitably lead to a broader notion of what technology is available for persons with hearing loss. The array of possible devices can be placed along a continuum based on the hearing needs they address, from hearing soft speech in quiet to communicating in noise. If the focus is on hearing speech in quiet, then a hearing aid that restores audibility of sounds may be sufficient.

However, most persons with a hearing loss complain of difficulties at various points along this continuum, including hearing in noisy environments, and can benefit from additional technology that may be as simple as an external microphone coupled to a BTE hearing aid.2 Thus, to optimize the patient's communication ability, the entire continuum of assistive devices must be considered.

This notion is reflected in the growing use of the term “hearing assistance technology,” or HAT, in place of the traditional “assistive listening devices.” The latter implies a focus on devices that facilitate “listening,” whereas many devices that solve communication difficulties use a visual stimulus to convey the auditory message.

To illustrate the importance of considering the complete needs of an individual, let's consider an analogy. When you get your annual physical, would you be satisfied if the physician measured only your temperature and blood pressure and ignored cholesterol levels and cardiac function? Hopefully, a physician would take a more comprehensive approach. So, too, should the audiologist.

As technology continues to change and consumers grow more comfortable with it, audiologists need to broaden their attention along the continuum of assistive devices to consider items such as Bluetooth wireless technology. This arrangement provides a short-range wireless interface between devices such as a cell phone and an ear-level amplification device.

As HAT evolves to include more ear-level devices, practitioners may cease being so focused on the “left side” of the continuum and fitting just the hearing aid. They may pay more attention to the many ways in which the use of assistive devices may impact the selection and fitting of hearing aids, such as the need for multiple programs, coupling options, and t-coils with the appropriate orientation and strength.3

In fact, many useful features may be incorporated into the ear-level devices of the future to facilitate communication of many kinds. One can imagine ear-level devices having options for downloading music, listening to the radio, and getting weather and traffic reports. As the features on ear-level devices expand, consumers will want to be served by providers who are knowledgeable about the devices available and skilled in determining which ones will meet an individual's needs.

This broad approach to providing services that optimize communication can be facilitated by convenient access to valuable resources. One resource with information for professionals, consumers, and educators on technologic advances related to hearing devices is the SHHH National Center for Hearing Assistive Technology (NCHAT).4 This unique program offers an intensive regional training series on hearing assistance technology to selected SHHH members from specific states. The participants agree to provide outreach about assistive technology at the local level following the training. Outreach by people who may be actively using ALDs can be a significant asset to the professional who adopts this broad approach to addressing the needs of persons with hearing impairment.5

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Just as one would choose the physician who conducts a thorough physical examination, persons with communication difficulties are best served by a clinician who addresses their communication needs through coordination of technology in cost-effective and beneficial ways. This shift in thinking to the continuum of technology has been facilitated by advances in HAT. Not so long ago, hearing assistance technology was typically viewed as products for persons with hearing loss that didn't fit on the ear, e.g., vibrating alarm clocks, phone amplifiers, body-worn FM systems. However, now that FM receivers can be coupled to an ear-level hearing aid or cochlear implant, the distinction becomes less apparent.

It is to the consumer's advantage to have a single device that meets all their hearing needs rather than one for increasing signal intensity, another for telecommunication, and another for delivering alarm-type signals. Achieving this may require an ear-level device to deliver the information and a hand-held remote to control the operation of the various components. One such system is the Phonak FM system, which comprises a SmartLink transmitter and a Claro BTE hearing aid with an integrated FM receiver. In addition to the noise-reduction features of the digital processing, there is considerable improvement in the signal-to-noise ratio through multi-microphone arrays on the FM transmitters, such as the HandyMic or SmartLink by Phonak or the Lexis made by Phonic Ear. The use of multi-microphone arrays has resulted in significantly improved speech recognition and quality of life.6–8

Furthermore, the SmartLink transmitter comes equipped with Bluetooth technology, so when it's used with compatible cell phones, the signal is delivered directly to the hearing aid and processed with the optimal amplification. Such an instrument combines the benefits of FM technology for hearing speech more clearly in noisy environments with convenient access to the cellular phone and optimal amplification.

Although such systems offer great convenience, programming them for maximum benefit obviously requires taking more factors into consideration. For example, the flexibility of the FM receiver includes channel options as well as the FM advantage, or the relative levels of the signals from the FM transmitter microphone and the hearing instrument microphone. Depending on the output and gain of the instrument, one may need to adjust the FM receiver to obtain the optimal FM advantage.9 In addition to programming the gain and output of the hearing aid, the FM receiver may also be programmed by means of a Hi-Pro interface and specialized software.

While this integrated system is certainly a type of assistive device, it obviously requires audiologic knowledge and skills for proper fitting. As the technology advances further, opportunities to integrate devices will increase, as will the demands on the audiologist's expertise, particularly in interfacing ear-level FM systems with cochlear implants.10

Fortunately, FM manufacturers have provided new tools for the practitioner through online resources. Phonak's FM fitting guides contain information on various types of FM technology and allow practitioners to print customized guide sheets for a client's specific equipment. Phonic Ear's programming and verification guides have instructions on setting the gain and output of the FM receivers as well as steps for verifying these settings.

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In fitting either hearing aids or assistive technology, evaluation of the fitting has three components: (1) evaluation of the instrument itself, (2) evaluation of the user to determine which instrument to fit, and (3) measurement of the benefit the device provides to the user. Chisolm et al. have provided suggestions regarding the third component,11 so the first two will be addressed here.

Regarding evaluation of the instrument, manufacturers must provide elec-troacoustic information on hearing instruments according to ANSI S3.22. Just as with hearing instruments, audi-ologists also need precise information about the electroacoustic functioning of hearing assistance technology. Unfortunately, though, there is no accepted standard for evaluating hearing assistance technology or, specifically, FM systems. An ANSI committee has been addressing this topic for many years, but the complexity of the task and the rapidly changing technology have delayed completion of its work.

As Ross explains, evaluating the patient's need for assistive devices is also very important to successful treatment.12 However, this evaluation has not been a routine part of the audiologic assessment.

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Proposing the “TELEGRAM”

If we are to encourage audiologists to extend their service beyond the hearing instrument to meeting the hearing-impaired patient's overall communication needs, perhaps we need a new approach that suits their personality type. Audiologists, it seems, tend to be drawn to this field because of such traits as attention to detail, precise record keeping, and comfort with quantitative representations.

Therefore, a convenient new tool is proposed stemming from the questionnaire suggested by Mark Ross,12 that the audi-ologist can use with every client to facilitate a comprehensive assessment of communication needs. Let's give it a familiar, yet catchy, acronym, the TELEGRAM (Figure 1), that conveys the goal of improving communication across distances. This new assessment is to be performed following the routine plotting of the audiogram.

Figure 1

Figure 1

The TELEGRAM is intended to be a communication assessment that can also be plotted for efficient summarization. The acronym reflects the areas that must be considered: Telephone, Employment, Legal issues, Entertainment, Group Communication, Recreation, Alarms, and Members of the family. Obtaining information on the client's functioning in each of these areas will lead to recommendations for additional technology or information to maximize communication.

When provided with this convenient graphic form, which is analogous to the audiogram, the hearing professional who is comfortable with plotting details should find it easy to document the client's current functioning and determine areas of need. The practitioner may use symbols to indicate performance with or without amplification. Additional codes are provided at the bottom with room to add unique items for each client for specific situations.

To illustrate the use of the TELEGRAM, consider the example provided in Figure 2 for a retired man who has just been identified with a bilateral, moderate-to-severe sensorineural hearing loss. He has needs in the areas of phone communication and hearing at church, bingo games, and while volunteering at the hospital. He also needs several flashing smoke alarms in his house, because he can't hear the high-pitched signal of his current alarms. Because he lives alone, meeting this need is a high priority. He is interested in the concert series he used to attend regularly, but does not know what accommodations may be available in public places for persons with hearing loss.

Figure 2

Figure 2

For this individual, the audiologist may suggest a trial with an FM receiver integrated into a BTE aid in conjunction with a multi-microphone FM transmitter. Combining the audiogram with the TELEGRAM would allow the audiologist to explain the sensory loss along with providing a broad assessment of communication needs that may be addressed with assistive technology. Research into the validity of the TELEGRAM will be needed to support its future use as a clinical tool.

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If audiology is to make broader use of hearing assistance technology, the basic ideas behind this approach must be incorporated into professional training programs. These ideas have been promoted for many years, but with very limited success.12 Twenty-five years ago, Vaughn et al. argued that the advent of smaller hearing aids resulted in certain communication limitations and so it was imperative that more attention be focused on communication-centered environments and effective listener/talker devices.13 In 1982, the notion of an assistive device demonstration center was “an idea whose time had truly come.”14 In 1995, audiologists were encouraged to quit asking if they should provide ALDs, and start asking how to incorporate them into their service delivery.15

Yet, despite all these past efforts to help practitioners select specific assistive devices for patients,16,17 the lack of progress in this area suggests that greater effort must be directed toward developing the demonstration centers in the programs that train professionals to enter the field. AuD programs are ideally suited to offer the intensive training and practicum experience required to apply the emerging sophisticated technology to the comprehensive rehabilitative needs of persons with impaired hearing.

The AuD program at the University of Texas at Dallas (UTD) has two components designed to instill a broad model of communication assessment and rehabilitation. One is an assistive device center (ADC), where technology is demonstrated and sold. The other is the program's aural rehabilitation conference, in which the entire process, from sensory assessment through the providing of hearing aids and integrated assistive technology, is experienced in an intensive format.

The ADC, which is staffed by AuD students, brings several benefits to the AuD program at UTD. The center provides consultations, demonstrations, selection, and sale of various assistive devices to persons with hearing loss and their families. Except, perhaps, for the need to provide computer access, the specifics of establishing such a center have not changed significantly from the suggestions made a decade ago.15,18

The students gain hands-on experience with equipment and become familiar with the needs and lifestyles of adults with hearing loss. They develop important clinical skills because considerations of hearing, vision, cognitive function, and motor skills are all involved in recommending an appropriate assistive device.

The Summer Intensive Aural Rehabilitation Conference (SIARC) is a significant element of the AuD program at UTD.19 It is a blend of service delivery, student training, and community awareness in which participants experience cooperative learning in a social environment.

Students also perform complete audiologic assessments, hearing aid checks, and ALD assessments, and fit new hearing aid technology. The participants experience new technology in various social situations, including dinners, plays, and tours offered throughout the week.20 During the 1-week conference, the AuD students gain experience that might otherwise require several semesters of practicum.

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To optimize communication in persons with hearing loss, the audiologist must look beyond merely restoring audibility. As evolving technology allows multiple functions to be incorporated into ear-level hearing aids and cochlear implants, the practitioner needs expertise in evaluating the need for such advanced technology.

Perhaps a new format for assessment, such as the TELEGRAM, will allow audi-ologists to routinely consider the need for HAT in clinical practice. Ideally, intensive experience with this technology through rehabilitative conferences will result in consumers and professionals realizing its benefits far better than is possible through the limited trials in a traditional clinic format.

Finally, it is of utmost importance to incorporate these concepts into AuD training programs to ensure that the audiologist of tomorrow can truly make, as Mark Ross so eloquently put it, a “world of difference” for persons with impaired hearing.12

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1. American Speech-Language-Hearing Association: Preferred Practice Patterns for the Profession of Audiology. Rockville: MD, ASHA. 1997.
2. Schur K: The perceived benefit of an external microphone coupled to post-auricular amplification. J Acad Rehab Audiol 1999;32:85–97.
3. Lesner S: Candidacy and management of assistive listening devices: Special needs of the elderly. Int J Audiol 2003;42:2868–2876.
4. Self Help for Hard of Hearing People: Self help for Hard-of-Hearing National Center for Hearing Assistive Technology. S Bethesda, MD: SHHH, 2004; at
5. Wayner D: Integrating ALDS into a hearing aid practice. Hear J 2004;57(11):43–45.
6. Lewis S, Crandell C, Valente M, et al.: Study measures impact of hearing aids plus FM on the quality of life in older adults. Hear J 2003;56(2):30–33.
7. Lewis S, Crandell C, Valente M, Enrietto Horn J: Speech perception in noise: Directional microphones versus frequency modulation (FM) systems. JAAA 2004;15:426–439.
8. Nelson J, LaRue C, Barr-O'Rourke M: Personal FM systems offer consumers more than ever before. Hear J 2004;57(11):36–42.
9. Thibodeau L, Whalen H, Guillot, K: Fitting programmable behind-the-ear FM systems. Poster presented at the International Conference on Achieving Clear Communication by Employing Sound Solutions (ACCESS) Conference. Chicago, 2003.
10. Schafer E, Thibodeau L: Speech recognition abilities of adults using cochlear implants with FM systems. JAAA 2004; in press.
11. Chisolm T, McArdle R, Abrams H, Noe C: Goals and outcomes of FM use by adults. Hear J 2004;57(11):28–35.
12. Ross M: Hearing assistance technologies: Making a world of difference. Hear J 2004;57(11):12–17.
13. Vaughn GR, Lightfoot RK, Arnold LC: Alternative listening devices and delivery systems for audiologic habilitation of hearing-impaired persons. J Acad Rehab Audiol 1981;14:62–77.
14. Fellendorf GW: A model demonstration of assistive devices for hearing-impaired people. J Acad Rehab Audiol 1982;15:70–82.
15. Sandridge S, Lesner S: Practical considerations in providing assistive devices. J Acad Rehab Audiol 1995;28:68–77.
16. Garstecki DC: Considerations in selecting assistive devices for hearing-impaired adults. J Acad Rehab Audiol 1988;21:153–157.
17. Palmer CV, Garstecki DC: A computer spreadsheet for locating assistive devices. J Acad Rehab Audiol 1988;21:158–175.
18. Lesner S, Klinger M: Considerations in establishing an optimum assistive listening device center. J Acad Rehab Audiol 1995;14:60–67.
19. Thibodeau L: Summer Intensive Aural Rehabilitation Conference, 2003. At
20. Thibodeau L, Cokely C: Maximizing auditory rehabilitation training for clients, students, and faculty through SIARC: Summer Intensive Aural Rehabilitation Conference. Submitted to JAAA, 2004.
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