The definition of aural rehabilitation (AR), as well as the terminology used to describe the practice of AR, has varied and evolved over the years. Montano (2014) defined AR as
a person-centered approach to assessment and management of hearing loss that encourages the creation of a therapeutic environment conducive to a shared decision process which is necessary to explore and reduce the impact of hearing loss on communication, activities, and participations (p. 27).
Boothroyd (2007) defined AR as
the reduction of hearing-loss-induced deficits of function, activity, participation, and quality of life through sensory management, instruction, perceptual training, and counseling (p. 63).
Ross (1997) included in his definition of AR
any device, procedure, information, interaction, or therapy which lessens the communicative and psychosocial consequences of a hearing loss (p. 19).
The impact of hearing loss and/or related disorders on a person's quality of life, and the quality of life of their family/significant others, may be substantial. The AR process takes into account a person's interpersonal, psychosocial, and educational functioning, among other factors.
Aural rehabilitation is also referred to as audiologic rehabilitation, auditory rehabilitation, hearing rehabilitation, and rehabilitative audiology. Some terms are more commonly used to refer to services offered by audiologists, whereas some encompass services offered by audiologists and/or speech language pathologists (SLPs).
See the ASHA Practice Portal pages on Adult Hearing Screening, Central Auditory Processing Disorder, Hearing Aids For Adults, Hearing Loss - Beyond Early Childhood (addresses hearing loss in ages 5 through adulthood), and Tinnitus and Hyperacusis for more information.
Aural rehabilitation falls within the scope of practice of both audiologists and SLPs. Audiologists and SLPs often collaborate in the AR process.
Audiologists play a central role in the screening, assessment, diagnosis, and treatment of persons with hearing loss. The professional roles and activities in audiology include clinical services (diagnosis, assessment, planning, and treatment), prevention, advocacy, education, administration, and research. See ASHA's Scope of Practice in Audiology (ASHA, 2018).
Appropriate roles for audiologists include the following:
As indicated in ASHA's Code of Ethics (ASHA, 2016a), audiologists who serve this population should be specifically educated and appropriately trained to do so.
SLPs play a role in the screening, assessment, and rehabilitation of persons with hearing loss. Professional roles and activities in speech-language pathology include clinical services, prevention and advocacy, education, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016b).
Appropriate roles for SLPs include the following:
As indicated in ASHA's Code of Ethics (ASHA, 2016a), SLPs who serve this population should be specifically educated and appropriately trained to do so.
Interprofessional education (IPE) and interprofessional practice (IPP) are important considerations in the field of AR. Collaboration between audiologists, SLPs, and other professionals (e.g., psychologists, social workers, physicians) benefit the person receiving services and allow for improved outcomes. See ASHA's page on Interprofessional Education/Interprofessional Practice for more information on this topic.
AR truly begins during the first contact with the person seeking/receiving services and/or their family/significant others. Individualized person- and family-centered care is an approach to the planning, evaluation, and delivery of clinical services based on collaboration among the person receiving services, their family/significant others, and the clinical provider (Johnson et al., 2008). Inclusion and involvement of family/significant others in the AR process is important and may benefit the person receiving services in a variety of ways (Hull, 2005; Scarinci, Meyer, Ekberg, & Hickson, 2013).
Integral concepts of person- and family-centered care include the following (Johnson et al., 2008):
For more information, see the ASHA pages on Person- and Family-Centered Care, Person-Centered Care in Audiology, Family-Centered Practice, and Health Literacy; the ASHA Practice Portal page on Cultural Competence; and the Institute for Patient- and Family-Centered Care.
Goals of an AR assessment include identifying the impact of hearing loss and/or other auditory complaints (e.g., tinnitus, CAPD) on communication, activities, participation, interactions with communication partners, and quality of life. Assessment may be ongoing or periodic depending on the person's evolving needs and goals and the initiation of device use (e.g., hearing aids, cochlear implants). Assessment may result in a recommendation for a variety of AR options and/or referral to other professionals.
A detailed and individualized case history is taken with attention to the following factors:
See the ASHA Practice Portal page on Cultural Competence for more information regarding gathering a case history. A variety of hearing-related self-report tools are available (Bentler & Kramer, 2000; Bentler, Mueller, & Rickets, 2016, pp. 447–496; Cox, 2005; Erdman, 2001; Weinstein, 2015).
An AR assessment may include the following measures and/or tests, depending on the person's needs:
The World Health Organization (WHO) published the International Classification of Functioning, Disability and Health (ICF) in 2001 as a classification of health and disability based upon functional status. This classification system can be used to assist clinicians in establishing goals and in determining specific outcomes that can be measured through client report.
See the ASHA page on International Classification of Functioning, Disability, and Health (ICF) for more information.
The use of person- and family-centered care is now an area of focus in the development of an AR plan of care (Ekberg, Meyer, Scarinci, Grenness, & Hickson, 2015; Grenness, Hickson, Laplante-Levesque, & Davidson, 2014; Laplante-Levesque, Hickson, & Worrall, 2010; Meyer, Scarinci, Ryan, & Hickson, 2015). A person- and family-centered AR plan of care may include one or more of the following approaches:
Effective counseling in AR is paramount (Sweetow, 2018) and is applicable not only to hearing loss but also to related disorders (e.g., tinnitus, CAPD). Fundamental skills in counseling are important for the implementation of an individualized person- and family-centered AR plan of care (Hull, 2005; Jessen, 2015; Johnson, Jilla, & Danhauer, 2018). "By shifting the focus to our patients and attending to the actual reasons they seek audiologic intervention, the foundation on which to base relevant counseling emerges" (Erdman, 2009, pp. 190–191). See ASHA's resources on Person-Centered Care in Audiology.
Types of counseling in AR may include one or more of the following:
Topics of AR counseling may include but are not limited to
The AR provider may assist the person receiving services with maximizing the use of a current hearing device or guiding the process of selection and fitting for a new device. Instruction and demonstration will be provided for the most effective use of the sensory aid(s). Devices may include hearing aids, cochlear implants, other implantable devices, and/or assistive listening devices.
See the ASHA Practice Portal page on Hearing Aids for Adults for more information.
Another focus of an AR plan of care may be to inform the person receiving services and/or their family/significant others of environmental modifications that may be helpful for their specific hearing needs and then to support them in implementing these changes. Examples of these modifications include the following:
A vocational counselor may assist in defining and implementing specific accommodations and/or modifications for the workplace and educational settings.
Training is provided in a variety of areas and in selected modalities to maximize communication skills in environments relevant to the person receiving services. Training includes participation of the family/significant others, as appropriate. There are a variety of commercially available training programs and mobile applications that may be useful in an AR plan of care.
"Auditory training is a process designed to enhance the ability to interpret auditory experiences by maximally utilizing residual hearing" (Sweetow & Sabes, 2009, p. 267). The approach to auditory training may be analytic, synthetic, or a combination of both (Sweetow & Sabes, 2009). Auditory training may be provided in individual or group sessions and may involve the use of computer programs and mobile applications (Olson, 2015; Sweetow & Sabes, 2007). In some cases, auditory training may be part of an intervention plan for persons with normal peripheral hearing (e.g., CAPD, tinnitus). There are two main approaches to auditory training—analytic and synthetic—both of which are discussed below.
Communication skills training may range from improving articulation to managing conversation. Group AR may be helpful in this area (Hawkins, 2006). Areas of focus may include the following:
Speechreading refers to processing speech using visual information, such as movements of articulators, facial cues, and gestures. Including speechreading in an AR plan of care supports the idea that "cross-modal stimulation from optical and acoustic events contribute to multisensory enhancement in speech perception" (Lansing, 2014, p. 253). Training may be provided to both the speech reader (i.e., listener) and the communication partner (i.e., talker). For example, the speech reader may engage in perceptual practice activities while the talker learns to modify speech and use proactive behaviors to reduce miscommunications. See Wickware (2014) for a description of four approaches to speechreading training: analytic, synthetic, pragmatic, and holistic.
Sound therapy refers to the use of sound to relieve bothersome tinnitus. It uses strategies and products to mask, habituate, or neuromodulate perceived subjective tinnitus. Both wearable and nonwearable devices may be helpful. Tinnitus retraining therapy is an approach to intervention that includes both sound therapy and counseling.
See the ASHA Practice Portal page on Tinnitus and Hyperacusis for more information.
A person's progress in the AR process may be measured in several ways and may require documentation by more than one professional (i.e., audiologist and SLP). Outcomes may be tied to the ICF framework and may include measures related to functional progress, activities, and participation.
Examples of outcome measures may include
Outcomes and treatment progress may be documented in a variety of ways. For example:
See the ASHA page on International Classification of Functioning, Disability, and Health (ICF) for more information.
In addition to determining the optimal treatment options for each person receiving AR services, the provider also considers service delivery variables. Examples of variables that may affect treatment outcomes include format, provider(s), dosage, timing, and setting.
AR services provided by an SLP may be a Medicare-covered benefit as long as the services are medically reasonable and necessary to improve patient function and that a plan of care is approved by the treating physician.
The Social Security Act defines audiology services as "hearing and balance assessment services," limiting the ability for audiologists to bill the Medicare program for treatment. The law only applies to the ability to bill, not to the scope of practice of an audiologist. The limitation, therefore, is based on the coverage of the benefit. An audiologist may provide AR services to a Medicare beneficiary, but the beneficiary must understand that treatment services provided by an audiologist are not covered by the Medicare program.
Coverage of AR varies across individual health plans. Audiologists and SLPs need to review third-party payer contracts and have the patient provide documentation of their health plan's coverage.
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
American Speech-Language-Hearing Association. (1999). Joint audiology committee clinical practice statements and algorithms [Guidelines]. Available from www.asha.org/policy/.
American Speech-Language-Hearing Association. (2016a).Code of ethics [Ethics]. Available from www.asha.org/policy/.
American Speech-Language-Hearing Association. (2016b). Scope of practice in speech-language pathology [Scope of practice]. Available from www.asha.org/policy/.
American Speech-Language-Hearing Association. (2018).Scope of practice in audiology [Scope of practice]. Available from www.asha.org/policy/.
Bentler, R. A., & Kramer, S. E. (2000). Guidelines for choosing a self-report outcome measure. Ear and Hearing, 21, 37S-49S.
Bentler, R., Mueller, H. G., & Ricketts, T. A. (2016). Modern hearing aids: Verification, outcome measures, and follow-up. San Diego, CA: Plural.
Boothroyd, A. (2007). Adult aural rehabilitation: What is it and does it work? Trends in Amplification, 11, 63–71.
Cox, R. M. (2005). Choosing a self-report measure for hearing aid fitting outcomes. Seminars in Hearing, 26, 149–156.
Ekberg, K., Meyer, C., Scarinci, N., Grenness, C., & Hickson, L. (2015). Family member involvement in audiology appointments with older people with hearing impairment. International Journal of Audiology, 54, 70–76.
Erdman, S. A. (2001). How to select a self-assessment instrument: What is it you want to know and why? Perspectives on Aural Rehabilitation and Its Instrumentation, 9, 7–9.
Erdman, S. A. (2009). Audiologic counseling: A biopsychosocial approach. In J. J. Montano & J. B. Spitzer (Eds.), Adult audiologic rehabilitation (pp. 171–215). San Diego, CA: Plural.
Grenness, C., Hickson, L., Laplante-Levesque, A., & Davidson, B. (2014). Patient-centered care: A review for rehabilitative audiologists. International Journal of Audiology, 53(Suppl. 1), S60–S67.
Hawkins, D. (2006). Improving adult hearing care with counseling-based aural rehabilitation groups. In R. Seewald & C. Palmer (Eds.) Hearing Care for Adults 2006: Proceedings of the First International Adult conference (pp. 301–306) Chicago, IL: Phonak.
Hull, R. H. (2005). Fourteen principles for providing effective aural rehabilitation. The Hearing Journal, 58, 28–30.
Jessen, D. (2015). Aural rehabilitation in private practice. Perspectives on Aural Rehabilitation and Its Instrumentation, 22, 15–26.
Johnson, B., Abraham, M., Conway, J., Simmons, L., Edgman-Levitan, S., Sodomka, P., . . . Ford, D. (2008). Partnering with patients and families to design a patient- and family-centered health care system: Recommendations and promising practices. Bethesda, MD: Institute for Family-Centered Care and the Institute for Healthcare Improvement. Retrieved from http://www.ihi.org/resources/Pages/Publications/
Johnson, C. E., Jilla, A. M., & Danhauer, J. L. (2018). Developing foundational counseling skills for addressing adherence issues in auditory rehabilitation. Seminars in Hearing, 39, 13–31.
Lansing, C. R. (2014). Visual speech perception in spoken language understanding. In J. J. Montano & J. B. Spitzer (Eds.), Adult audiologic rehabilitation (2nd ed., pp. 253–276). San Diego, CA: Plural.
Laplante-Levesque, A., Hickson, L., & Worrall, L. (2010). Rehabilitation with older adults with hearing impairment: A critical review. Journal of Aging and Health, 22, 143–153.
Meyer, C., Scarinci, N., Ryan, B., & Hickson, L. (2015). "This is a partnership between all of us": Audiologists' perceptions of family member involvement in hearing rehabilitation. American Journal of Audiology, 24, 536–548.
Montano, J. J. (2014). Defining audiologic rehabilitation. In J.J. Montano & J.B. Spitzer (Eds.), Adult audiologic rehabilitation (2nd ed.; pp. 23–-35). San Diego, CA: Plural.
Olson, A. D. (2015). Options for auditory training for adults with hearing loss. Seminars in Hearing, 36, 284–295.
Ross, M. (1997). A retrospective look at the future of aural rehabilitation. Journal of the Academy of Rehabilitative Audiology, 30, 11–28.
Scarinci, N., Meyer, C., Ekberg, K., & Hickson, L. (2013). Using a family-centered care approach in audiologic rehabilitation for adults with hearing impairment. Perspectives on Aural Rehabilitation and Its Instrumentation, 20, 83–90.
Seal, B. C., Wilson, N., & Gaul, E. (2013, November). Speechreading 101. Course presented at ASHA Conference, Chicago, IL.
Shen, J., Anderson, M. C., Arehart, K. H., & Souza, P. E. (2016). Using cognitive screening tests in audiology. American Journal of Audiology, 25, 319–331.
Social Security Act §1861 (II). Retrieved from https://www.ssa.gov/OP_Home/ssact/title18/1861.htm
Sweetow, R. W. (2018). Why and how should graduate students in audiology be taught and trained in counseling. Seminars in Hearing, 39, 3–4.
Sweetow, R. W., & Sabes, J. H. (2007). Technologic advances in aural rehabilitation: Applications and innovative methods of service delivery. Trends in Amplification, 11, 101–111.
Sweetow, R. W., & Sabes, J. H. (2009). Auditory training. In J. J. Montano & J. B. Spitzer (Eds.), Adult audiologic rehabilitation (pp. 267–283). San Diego, CA: Plural.
Weinstein, B. E. (2015). What hearing impairment measures do not tell us—but self-report measures do. The Hearing Journal, 68, 26, 28, 32.
Wickware, A. (2014). The impact of speechreading programs on adults with hearing loss: Literature review. British Columbia, Canada: The Canadian Hard of Hearing Association. Retrieved from http://www.chha.ca/sren/NSRP_Literature_Review.pdf
World Health Organization. (2001). International Classification of Functioning, Disability and Health. Geneva, Switzerland: Author.
Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Aural Rehabilitation for Adults page.
In addition, ASHA thanks the members of the Working Group on Audiologic Rehabilitation whose work on the Technical Report was foundational to the development of this content. Members of the Working Group were Susan J. Brannen (monitoring vice president), Catherine Carotta, Catherine C. Clark, Sue Ann Erdman (chair), Charissa R. Lansing, Joseph J. Montano, Mary June Moseley, Richard Nodar (past monitoring vice president), David J. Wark, and Evelyn J. Williams (ex officio). Pamela L. Jackson and Mary Pat Moeller served as consultants.
The recommended citation for the Practice Portal page is:
American Speech-Language-Hearing Association (n.d.). Aural Rehabilitation for Adults (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Professional-Issues/Aural-Rehabilitation-for-Adults/.