Aural Rehabilitation in Audiology and Speech-Language Pathology

Dr. Blaha: I know what [aural rehab] means to an audiologist, but I want to know what it means to a Speech-Language Pathologist (SLP) because we have different approaches. [SLP and audiology] are complementary, and I think audiology should avail itself of speech pathology more often for patients. From my perspective, when I talk about aural rehab, I am looking to use devices with patients. I'm thinking along the lines of amplification through a hearing aid or other type of personal sound amplifier. I'm also coaching patients on advocating for themselves to know when to modify the environment if noise levels are too high. How would you approach aural rehab from a SLP perspective?

Serianni: This is one of those areas where collaboration is the best practice for the outcomes of the patient and the patient's family. Much like audiologists, speech pathologists go from a patient or family-centered approach and look at how communication is being impacted by hearing. My understanding of aural rehab from an audiologist's perspective is improving hearing to enhance communication. Whereas SLPs are going to look at communication first to enhance what hearing is available to the patient. Much like our colleagues, we are going to do a full assessment to look at what the needs are of the client and their family and then create a plan of care to address the gaps in versus strengths versus challenges.

Dr. Blaha: There's a lot of research that says anyone getting amplification does better when they have some form of auditory training, but the majority of the time I feel like we're only utilizing it for patients that might have an implant, like a cochlear implant.

Serianni: Based on the outcomes of the assessment, we'll approach it from four different areas. One would be to assist in sensory management, like the equipment aspect, and instruction on some of the techniques or strategies that the patient can use. We're going to do training where we practice those strategies to enhance communication. Much like our colleagues in audiology, we spend a lot of time counseling the patient and the patient's family. This isn't going to be a quick fix, that isn't going to be what might be known as normal hearing, but improving the strengths the client has. Closing the gaps or the challenges is the goal and the outcome of the sessions.

Dr. Blaha: What I find is that a lot of times with audiology, the patient is expecting that the device itself can take over and improve the communication through its processing, its noise reduction and all of its accessories. But we can't take the patient's participation out of the scenario because it is — as its name implies — an aid. It is a tool that will enhance your function, but you still have a lot of cognitive things that need to happen. The hearing aid lets you detect the sounds, but after detection, the brain takes over, identifies, and determines if action needs to be taken and that is the hardest part. Having a coach is one of the best ways to rehabilitate auditorily.

Serianni: I think that's a good assessment, to start and look at the patient's speech, language and cognitive skills. If there were deficits before the hearing loss, it's certainly not going to get any better with a hearing loss, and that might need some coaching. The technology isn't a quick fix and I think that's when treatment kicks in. Sometimes we do have a very ready, willing and able client and it's just three or four sessions, but then again, we meet patients and their families that need a lot of support and we might see them for weeks to make sure that they are understanding the limitations of the technology. That’s where we kick in with the strategies and the environmental modifications that will help bridge the gaps between what we know works in the technology and what we can fix outside of the technology.

Dr. Blaha: There are certain aspects of hearing loss we are assessing when you're tested — we're looking at your hearing sensitivity you still have, that can be stimulated with amplification. But we also have to consider how much speech you can understand in that amplified scenario. When we are testing you, we are presenting speech materials to you at a level that we know should be able to be heard. Then we're looking at the percentage of information you can correctly repeat back. For some patients, given what is causing their loss, it may cause distortions because their sensory receptors are damaged and the nerve fibers are not functioning as well as they could be. The sound that gets up to the brain is not very clear. We can tell that by the amount of words you can correctly repeat. For some patients, even at amplified levels, they may hear less than 75%, less than 50%, and for some patients, it can be even less than 10% of the speech information. At that point, even if the aids are the top technology and have all of the features correctly engaging in environments, they will have a very limited ability to use the information. That's when going through aural rehab is almost critical. You can't leave that step out.

Serianni: That's where I see the collaboration coming in. The speech pathologist may come in with training techniques, coach the patient, and teach them how to modify the environment. I always talk about not having competing sound sources like the TV or radio. How do you access communication with your significant others or communication partners? For example, using contextual clues. I could say to Rebecca (Dr. Blaha) here, “Remember that one time…” and she might have no clue what I'm talking about, but my partner will know exactly what I'm saying because we had that experience together. There are strategies that we discuss with patients about building quality of life.

The example I usually give is attending a meal at a restaurant. We know that meals and celebrations are a big part of our culture. How do you manage attending an event or going to a restaurant in one of those extraordinarily noisy environments? We defer to our audiology specialists and promote hearing protection and avoiding those hazards as part of our counseling. Then finally, [asking ourselves], “How do we teach the patient to be a self-advocate? How do we get them to get the things that they need?” For example, they might be in a doctor's office and for whatever reason the office door is open and the doctor is providing critical information, but the noise from the hallway is competing. Coaching the patients to say, “Can you close that door so I can better attend to what you're saying and make sure I hear and understand the information you're giving me?”

Dr. Blaha: You could supplement that by asking for things to be in writing so you can review them afterward because I believe the statistic says we only remember about 25% of what is delivered auditorily, and even about half of that is incorrect information. Think about the restaurant scenario, with amplification because of the background noise. We're trying to have a conversation, but background noise is always something that will interfere. Being able to manage the background noise, but also think about how you're communicating. We hear this a lot where you just keep repeating the same thing over and over, but it might be the choice of word that you're using that’s confusing to the person. Maybe you can rephrase what you're saying. Sometimes the aural rehab is applied to the communication partner, the family member. We hear this a lot when patients say, “I'm trying to watch TV, but my wife wants to have a conversation so my attention is directed to two places.” They feel that it's unreasonable in some instances to have to mute the television or pause what they're doing because when they were younger, they were able to do both things at the same time. Auditory attention is something that doesn't stick around. It does decline with time.

Serianni: I love strategies. Make sure things are written down. In my household when dinner's ready, we shout at the top of our lungs, “come to the table” and our children hear us. But if you're in a situation where you're communicating, using those nonverbal communication supplements is going to fill in the gaps that are being missed. For example, you can look at the face and be able to tell the person is speaking about something very serious because they have their eyes turned down or their lips are a little bit more pursed. You get those contextual cues while you are filling in the missing sound gaps in the words that are being transponded through your hearing aid.

Dr. Blaha: We also always advocate for face-to-face communication. Even with amplification in place, a lot of times the expectation is that the microphone sensitivity will allow you to communicate at a fair distance. Most devices will have a maximum amplification range of about eight to 10 feet. If the person communicating to you is further than that, you may notice that there's a sound, but it won't have the clarity or information until that person comes closer to you. Then you could use some visual cues to fill in for any information that you're not hearing. Hearing aids do not restore all aspects of hearing. They will make some sounds louder as long as you have hearing that can accept it. For more severe losses, we may not have enough residual hearing to function that could benefit from a hearing aid. You may not have access to all of the information and therefore, getting as close as possible for the visual supplementation is critical.

Serianni: That's why we try to pull in families too, because we don't want the burden to be completely on the patient to be constantly saying, “You need to look at me, we need to be in the same room, turn your radio down.” I think that must be exhausting for our patients. If we can get the families on board, caregivers and other practitioners that are in the world of a person that has a hearing impairment, we have an opportunity to be successful in managing the hearing loss, while maintaining a positive quality of life.

Dr. Blaha: One thing that I've noticed over the years is that manufacturers of hearing aids will include some aural rehab coaching in the manufacturer's guidebook for the products. I've seen where they talk about learning to use your devices primarily in a quiet environment so that you can begin to acclimate to what's around you. The majority of the time what we're listening to is actually a noise, and so the first step is to just get your brain used to being stimulated, hearing the sounds and practicing identifying. One of my colleagues, likes to say, ‘triangulate.’ If you hear a sound you're not familiar with, stop and listen and determine, is it something that you recognize? If not, try to figure out where it's located and maybe move closer to that sound and consider that it could be the air conditioner that you haven't heard for a while or the microwave when it's cooking.

I've had family members with hearing aids as new users that didn't realize the microwave made a noise when it cooked because the light came on and the tray started turning and that's what they assumed was the cooking process — but it makes a noise. So, getting used to, and being open to that type of practice, it's a different experience, but it shouldn't be immediately assumed to be a negative experience. It's a difference and it's a training process to get the best benefit out of hearing aids and communication enhancement. If you go into it with an open mind and are willing to practice, you could even try reading out loud to yourself so that you can get used to the way voices will sound coming through your new devices. That is a basic form of aural rehab that you can do on your own at home. 

Serianni: In therapy, we look at the type of client before we decide which approach we're going to take. My research tells me there are two basic approaches to what we'll call auditory training, or as you said, getting used to the device and using it successfully. We could take a bottom-up approach, which is looking at finite units of communication and then building upon them; for example, starting at discriminating words and then building into shorter sentences into longer conversations. Starting with the smallest unit of communication and building up. Or we could take more of a top-down process, which is an approach that looks at the overall meaning of the communication and helps the communication partners fill in the gaps with those contextual cues. An example I usually give to describe the difference is in the world of sign language: we could use finger spelling, which is the word for word interpretation of the words that you want to say, spelled out with the finger alphabet, versus American Sign Language (ASL), which uses gestures to broadly describe concepts. Thinking about how you want to approach training, again, depends on the goals of the client and their family and really what we think is going to be the biggest bang for the buck.

We also use that training aspect to begin to practice what the communicator needs to understand the information and then respond to it. The old term was called lip reading. Now we call it speech reading because we don't just focus on what the mouth is doing to interpret what is being said. There's lots of information and who better than our population these days to know being post-pandemic, the masks are coming off. We now see full faces and we're understanding communication differently these days than really just looking at what we used to call 'smile eyes' because that's the part of the face we healthcare providers and people in general were focused on through the pandemic.