If you ask hearing healthcare providers if they provide aural rehabilitation, a resounding number will answer in the affirmative. And yet, data indicate that less than 20 percent of new amplification users—and less than 10 percent of experienced users—receive any form of aural rehabilitation beyond the provision of hearing aids (MarkeTrak VIII: Hearing Review 2010;17:12-34http://www.hearingreview.com/2010/04/marketrak-viii-the-impact-of-the-hearing-healthcare-professional-on-hearing-aid-user-success/). Moreover, fewer than five percent are provided with formal retraining opportunities.
Perhaps a misguided belief that supplying hearing aids and basic counseling equals aural rehabilitation accounts for this incongruity. In reality, nearly everything we do as hearing healthcare providers constitutes aural rehabilitation, including counseling, the furnishing of hearing aids and assistive listening devices, the use of communication strategies, group therapy, and auditory training.
The utilization of aural rehabilitation beyond hearing aids remains low despite the evidence arguing for its inclusion in clinical practice. Steps can be taken to increase its usage, with new and better tools for aural rehabilitation on the horizon.
Aural rehabilitation can be broadly defined as the attempt to enhance the ability of people with hearing loss to communicate. Hearing is but one element of communication ability. In addition to hearing, a passive function, there is listening, an active process requiring intention and attention. Communication is the bidirectional transfer of information, meaning, and intent. Use of proper communication strategies can shape both hearing and listening.
Hearing aids affect hearing but do not directly influence listening or communication. In addition, cognitive decline, which is experienced by many, if not most, of our patients, particularly those who are elderly, must be considered in any full rehabilitation effort.
Aural rehabilitation typically is delivered in a group, individualized face-to-face, or home-based format. The advantage of group therapy is that it is cost-effective and can provide social and emotional benefits when facilitated properly. The limitation is that content is not individualized. This drawback can be rectified with face-to-face therapies, which, unfortunately, are not cost-effective.
Another solution is home-based treatments, which are becoming increasingly popular via web or mobile applications. These programs can incorporate auditory training, a process designed to enhance the ability to interpret auditory experiences by maximally utilizing residual hearing and communication strategies. The table on page 12 includes a representative list of commercially available programs.
Ample evidence shows that physiological changes occur as a result of training. While the available evidence supports efficacy, it does not produce unanimous or indisputable conclusions regarding the efficiency of individual auditory training, meta-analyses have indicated (J Am Acad Audiol 2005;16:494-504http://www.audiology.org/sites/default/files/journal/JAAA_16_07_08.pdf; PLOS ONE 2013;8:e62836http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0062836).
These analyses concluded that: less than five percent of published studies on auditory training meet rigorous evidence-based criteria; for those that do, auditory training resulted in improved performance for trained tasks; and although significant generalization of learning was shown to untrained measures of speech intelligibility, cognition, and self-reported hearing abilities, with retention of learning demonstrated post-training, improvements were variable and relatively small.
While the gains in speech recognition are relatively modest, the practical benefits may be larger than suspected. Consider, for example, that even a 1-dB reduction in signal-to-noise ratio has been credited with a six percent to eight percent improvement in sentence recognition. Off-task measures such as the Quick Speech in Noise (QuickSIN) test may show group averages in excess of 3 dB and double-digit percentage improvements for people using certain training protocols.
Perhaps the evidence that should be most compelling to hearing healthcare professionals dispensing hearing aids, however, are the studies indicating that training is significantly correlated with increased communication confidence (HJ Dec. 2010 issue, pp. 17-24http://journals.lww.com/thehearingjournal/Fulltext/2010/12000/The_Communication_Confidence_Profile__A_vital,_but.4.aspx), reduced listening effort (J Am Acad Audiol 2013;24:214-230http://www.ingentaconnect.com/content/aaa/jaaa/2013/00000024/00000003/art00007), and a lower hearing aid return rate of four percent versus 13 percent (HJ Aug. 2007 issue, pp. 32-35http://journals.lww.com/thehearingjournal/Fulltext/2007/08000/Software_based_auditory_training_program_found_to.5.aspx).
REASONS FOR INFREQUENT USE
Only the most skeptical audiologist would deny the likelihood that therapy beyond the use of wearable amplification benefits patients. Unfortunately, most audiologists do not offer or prescribe these additional therapies, and most patients do not ask for, or even wish to participate in, additional rehabilitation. There are many possible reasons for this reluctance.
- Boring to administer: Many audiologists, including this author, were initially attracted to the profession by the glamour and promise of technology and are underwhelmed by the tedium of plotting lesson plans and spending hours in individualized therapy. Now, however, the bulk of auditory training can be conducted via computer programs that include not only adaptive training to optimize individual learning rates, but also automatic scoring.
- Too time-consuming: Since the bulk of training is done via computer, there is no need for the professional to spend significant time in the training phase—with the exception, of course, of providing initial instructions, occasional monitoring, and follow-up counseling. Establishing the protocol and collecting materials for auditory training and group aural rehabilitation are no longer onerous tasks for the provider, as numerous materials are available via the web.
- Not convinced by the data supporting aural rehabilitation: Clinicians may have the unsubstantiated view that modern technology is sufficient and negates the need for additional auditory training. Published studies on auditory training often are poorly controlled or lack adequate sample size. Uncertainties regarding the optimal training parameters may contribute to the absence of belief in the value of therapy.
- In addition, there are questions about which outcome measures are most essential. For example, while many have used speech intelligibility, what about subjective measures such as the Hearing Handicap Inventory for the Elderly (HHIE) or the Communication Confidence Profile (CCP)? After all, a lack of confidence contributes to social withdrawal, and isn't that one of the primary restrictions we want to lift from our patients? And, when speech measures are used, shouldn't they approximate reality by employing sentence-length material and multi-talker babble as opposed to steady-state noise?
- Reluctance to ask patients to spend more money or time: Given the substantial cost of hearing aids, adding the relatively small additional monetary expenditure for auditory training and aural rehabilitation may seem insignificant to patients, or the cost can be included in the bundled pricing structure. Asking the patient to spend more time in the rehabilitation process is a somewhat trickier issue. When audiologists are not convinced the training will help, they may be reluctant to ask the patient to participate in what could become a frustrating task. However, requesting patient participation in even more difficult, and sometimes uncomfortable, rehabilitation programs such as physical therapy post-surgery is commonplace and well-accepted.
- Discussion of aural rehabilitation in clinical practice typically occurs at the tail end of a hearing aid fitting, when the hearing healthcare professional is running short on time, and the patient is running short on patience. Thus, the impression often conveyed to the patient is that anything beyond the use of hearing aids is an afterthought or an option rather than a vital part of the process. This impression also is reflected by the fact that aural rehabilitation is usually covered in the final chapter of audiology textbooks.
- Lack of reimbursement: This is an extremely valid concern. It is ironic that speech–language pathologists may be reimbursed under Medicare for audiologic rehabilitation using CPT 92507 but audiologists, due to their classification as diagnosticians, cannot. Changing this policy requires a concerted effort by the major professional associations.
GETTING PATIENTS ON BOARD
Even if audiologists recognized the importance of providing auditory therapy, there is still the task of convincing patients to participate. Many patients believe that they have spent enough money on products and professional services. Thus, they acquire the common, but unrealistic, expectation that the responsibility for success rests solely with the hearing aids and the expertise of the clinician.
This belief is a primary reason why expectations, which tend to be based on the product and thus carry no responsibility for active participation by the patient, should be replaced by goals, which have a rehabilitative foundation and require the patient's active participation.
In this author's biased opinion (see disclosure), probably the most widely used auditory training program currently available is Listening and Communication Enhancement (LACE), the online or software-based program that also includes exercises focusing on auditory memory and cognitive processing speed (J Am Acad Audiol 2006;17:538-558http://www.ingentaconnect.com/content/aaa/jaaa/2006/00000017/00000008/art00002?token=005a18be05c06e03383a4b3b25702e7b462424382d3b2b675d2a726e2d58464340592f3f3b57b6488634b07bb3).
LACE utilizes an adaptive training algorithm so that the difficulty level is near the user's skill threshold and training proceeds at the patient's optimal pace. Studies have confirmed the positive effects of LACE both in terms of improved speech understanding in noise and communication confidence.
Clinical data from over 3,000 individuals taking LACE training, however, indicated that adherence, defined as completion of at least half of the recommended number of auditory training sessions, was less than 30 percent (J Am Acad Audiol 2010;21:586-593http://www.ingentaconnect.com/content/aaa/jaaa/2010/00000021/00000009/art00007). As disheartening as this compliance rate appears, even cochlear implant users have lower than expected adherence to training regimens, despite the severity of their communication problems.
In general, compliance increases if patients are given clear and understandable information about their condition and progress, instructions and treatment routines are simplified as much as possible, systems are in place to generate treatment and appointment reminders, and, whenever possible, family members or friends are involved.
Hearing healthcare professionals need to devise methods appropriate for their particular business models to incentive patients. Possibilities include providing free batteries, discounts, and other propositions.
Perhaps most important in terms of increasing usage, however, is the manner in which the professional discusses aural rehabilitation. Surgeons do not recommend physical therapy post-surgery as an option. They make it clear to the patient that physical therapy is an integral part of the remedial process.
Hearing healthcare professionals need to be just as forceful and persuasive in their recommendations. We must consider auditory training and other non-hearing-aid components of aural rehabilitation to be of equal importance to prosthetics, and we must convey that belief clearly and decisively to our patients.
WHAT THE FUTURE HOLDS
A number of improvements are being made to current products, and exciting new projects are being developed. These efforts have the potential to significantly increase the benefit and use of aural rehabilitation.
For example, in addition to enhanced video content, the most recent version of LACE incorporates weekly testing of objective outcome measures, such as the QuickSIN, and subjective measures, such as the Hearing Handicap Inventory for the Elderly and the Communication Confidence Profile.
There also is a clear movement in the direction of creating therapies that are more gamelike for patients.
Read My Quips is an adaptive speech-in-noise training program that includes both auditory and visual information from the speaker. The speaker presents sentence-level stimuli in a video format. The trainee then identifies portions of the stimuli and enters solutions into a crossword-like puzzle.
Nancy Tye-Murray, PhD, and her colleagues at Washington University in St. Louis are creating a program based on principles of learning and memory. Their strategy is that training must be engaging. The program, which can be run on a computer or handheld device, emphasizes principles of meaningful play, positive and negative feedback, ease of learning, and reward systems. One of the most exciting aspects of this venture is that a version permitting training with stimuli spoken by a patient's frequent communication partner is being developed. It is hoped that the program will be available later this year.
Spoken language may not be the only stimuli used for aural rehabilitation and auditory training. Scientists at Northwestern University are pursuing research establishing the benefit of nonspeech training materials, particularly music, for aural rehabilitation. The Hearing Journal Editorial Advisory Board member and Hearing Matters columnist Nina Kraus, PhD, and colleagues have shown that music training can lead to better processing of speech in the auditory brainstem and cortex, as well as superior understanding of speech in noise (J Neurosci 2009;29:14100-14107http://www.jneurosci.org/content/29/45/14100.full).
RESEARCH LEADS THE WAY
The popularity of brain-training programs continues to increase. Programs such as Lumosity, Fit Brains, and BrainHQ from Posit Science enjoy widespread usage.
Our challenge is to attain similar acceptance and popularity for auditory training. To do so, a number of improvements to current programs should be considered, such as the development of mobile apps; incorporation of videos, animation, and graphical interfaces; and creation of more exciting and enjoyable training protocols.
There is a great need for better diagnostic and prognostic assessments. Computerized training may not be feasible for every patient. It is currently not possible to predict outcomes based on initial data. Therefore, clinical expertise and experience, as well as information obtained from counseling, are important when deciding who should participate in computerized aural rehabilitation.
Many unresolved questions remain:
- What are the best training parameters and modes?
- What sequences of specific inputs will change the brain in desired ways?
- Will training generalize to real-life experiences?
- Will training improve the acceptance of hearing aids?
- Will results be magnified when training is introduced in conjunction with the introduction of or changes to amplification?
- When should auditory training be offered—before hearing aid fitting, during the hearing aid trial, or after the trial?
- Will training last over extended time periods?
- And, perhaps most important to convincing audiologists and patients about the efficacy of auditory training, what are appropriate outcome measures, and how should success be measured? Certainly, group mean data do not reflect individual variation in improvements from auditory training. Should success be defined by on-task improvement, generalized speech recognition performance, subjective communication confidence (J Am Acad Audiol 2010;21:586-593http://www.ingentaconnect.com/content/aaa/jaaa/2010/00000021/00000009/art00007), or quality of life?
To find these answers, we must conduct multisite studies with adequate control groups and large sample sizes. Research must lead the way to acceptance that hearing aids are one, but not the only, component of aural rehabilitation.
EXAMPLES OF COMMERCIALLY AVAILABLE AUDITORY TRAINING PROGRAMS
- Group Rehabilitation Online Utility Pack (GROUP) and other resources from the Ida Institute idainstitute.comhttp://www.idainstitute.com/
- Active Communication Education (ACE)
- Learning to Hear Again (Hear Again Publishing) bit.ly/Hear-Againhttp://www.bit.ly/Hear-Again
- Listening and Communication Enhancement (LACE; Neurotone) neurotone.comhttp://www.neurotone.com/
- Read My Quips (Sense Synergy) sensesynergy.comhttp://www.sensesynergy.com/
- Seeing and Hearing Speech (Sensimetrics) seeingspeech.comhttp://www.seeingspeech.com/
- Angel Sound (TigerSpeech Technology and Emily Shannon Fu Foundation) angelsound.tigerspeech.comhttp://angelsound.tigerspeech.com/
- Speech Perception Assessment and Training System (SPATS; Communication Disorders Technology) bit.ly/SPATS-CDThttp://bit.ly/SPATS-CDT
Author disclosure: Dr. Sweetow is codeveloper of LACE and has a financial interest through the University of California, San Francisco, and Neurotone.