This article is the first in an occasional series contributed by Special Interest Division 7, Aural Rehabilitation and Its Instrumentation, highlighting the work of master clinicians in audiologic/aural rehabilitation. In this article, Mark Ross, professor emeritus, University of Connecticut, and a widely regarded audiologist who has hearing loss, revisits his seminal publication, "A Retrospective Look at the Future of Aural Rehabilitation," which appeared a decade ago in the Journal of the Academy of Rehabilitative Audiology. Ross responded to a series of questions:
- Do you think the provision of AR services has changed significantly since the publication of your article?
- Please comment on the impact of third-party reimbursement on AR services.
- Does the use of self-study auditory training and speechreading programs offer substantial benefit over individualized or group AR treatments?
- Do you believe most clinicians provide adequate hearing aid orientation services?
- If you were to re-write your article today, what would you add or change?
—Joseph Montano, Division 7 coordinator
In the 1997 article, "A Retrospective Look at the Future of Aural Rehabilitation," I pointed out that the profession had drifted from its founding purpose—audiologic/aural rehabilitation (AR). Much of this change was inevitable, indeed desirable, but as the audiology profession developed, much was left behind. I reviewed our profession and recommended at least one way—group hearing aid orientation programs—to get back on the AR track.
At first, professionals who worked with people with hearing loss focused on communication problems. The main ingredients of a rehabilitation program were speech reading and auditory training—despite the lack of objective evidence supporting their efficacy. AR was defined primarily in terms of speechreading and auditory training exercises. Commercial hearing aid "dealers" sold hearing aids, usually without any rehab program. Various non-profit centers carried out AR.
About 30 years ago, it was deemed ethical for audiologists to dispense hearing aids—based on the need for audiologists to ensure comprehensive AR services by participating in the entire fitting and post-fitting process. What happened instead was that audiologists emulated the system we criticized—now it was audiologists who sold the hearing aids. Any AR services focused on the hearing aids were—and to this day remain—rather haphazard.
I don't think much has changed in actual clinical practices since then. The primary focus still is on the fitting and purchase of the hearing aids. On the positive side, many more "intelligent" hearing aids have been developed, as has a more general awareness of many other types of hearing assistive technologies (e.g., various kinds of assistive listening systems and signaling and warning devices). Research also is emerging on various facets of the AR process, which was showcased in a 2006 AR conference at Gallaudet University.
The most promising new information is the rationale that links the emerging understanding of adult neural plasticity with evidence supporting the efficacy of auditory training procedures. The advent of the cochlear implant as a viable therapeutic option stimulated this effort. People obtaining cochlear implants, as well as professionals manning implant centers, are intensely motivated to enhance effectiveness. The centers are willing to provide follow-up AR services, with much of the cost paid by third-party reimbursement, while the recipients are eager to undergo follow-up training exercises.
However, it does not seem that professionals strongly encourage this training, even on a fee-for-service basis, while third-party reimbursement is not readily available for audiologists. Relatively few audiologists provide ongoing communication therapy, which would include traditional auditory training and speechreading. The current challenge is to provide ongoing AR in a cost-effective manner. Even "nonprofit agencies" are extremely budget-conscious now.
One important change is the current availability of home-based computer-controlled communication training programs. I commented 10 years ago that this area was potentially valuable. I discussed four such programs in the December 2005 issue of Hearing Loss; several others were reviewed at the Gallaudet AR conference. Such programs have yet to be widely adopted, although they are a valuable way to implement some AR procedures and can be cost-effective. The evidence, much of it reported at the Gallaudet conference, demonstrates that some people made significant improvements in auditory perception through the training program. However, my 1997 emphasis still holds: it is necessary for new hearing aid users or cochlear implant users to participate in a short-term group AR program as part of the post-hearing aid fitting process. Home-based, self-administered communication training programs can best be utilized to complement face-to-face encounters with a clinician and other clients.
The heart of the 1997 article was my recommendation for a short-term group hearing aid orientation program to be provided to all hearing aid users as a routine component of the selection process. A number of dispensing practices offer such a program. But evidently, many hearing aid users do not take advantage of the opportunity, even on a no-cost basis, to participate in a three- or four-session post-selection orientation program. I wonder how strongly clinicians tie the necessity of a follow-up program to dispensing hearing aids. Do they give people an easy choice out, thus implying that the orientation program is not crucial? Most people will accept the strong recommendation by their audiologist regarding participating in such a program; others, well, we can't win them all.
I have recently received a cochlear implant. After the surgery, I received four appointments for follow-up mapping. Although I'm doing well after just two appointments, I couldn't think of missing the other two. In addition to the mapping, listening training procedures are routinely recommended for implant users, and few reject this recommendation. While people with implants generally have a greater hearing loss than someone using hearing aids, what people hear through either device is equally important. Why should the type of follow-up care implant users receive not be available for hearing aid users as well?
What has clearly changed in the past decade is our knowledge base. What seems not to have changed is the actual application of AR procedures to people, beyond the provision of hearing aids and associated information (a crucial foundation of any AR program). At worst, the paucity of follow-up care reflects society's view about the significance of a hearing loss. It is not a high-priority condition, either in terms of public attitudes or public policy. Its impact on individuals is not widely understood; until that understanding changes, AR will remain one of the step-children of the audiology profession.