Patient client counseling & aural rehab

PATIENT/CLIENT COUNSELING &
AURAL REHABILITATION
 It has always been difficult to describe an
audiogram to a patient/client using the
relative terms of mild, moderate, severe, and
profound hearing loss.
 These are all relative terms, as they would
relate to deafness.

 No one can actually simulate total deafness,
so why should we be using these relative
terms when describing a patient/client’s
audiogram to them?
 Most patient/clients are in their denial stage
of hearing loss when they first have their
audiogram explained to them.
 They can easily perceive the terms mild and
moderate as “not that bad”, and continue
suffering hearing loss!

 As Hearing Instrument Specialists, we must
present to our patient/clients a more
accurate portrayal of their hearing
condition.
 After all, electro acoustic stimulation via
hearing instruments simply does not
“correct” the hearing loss. It only stimulates
the remaining ability of their damaged
auditory system.
 Their hearing loss is permanently gone!

Patient/client counseling exercise:
1. Draw a “normal” undamaged dynamic range
“hearing ability” box onto an audiogram.
2. Mark horizontal lines at 0db and 100dbHL,
attach the horizontal lines with vertical lines
at 250hz and 6Khz.
3. Plot the patient/client’s thresholds within this
box.
4. “Shadow” or “X”-out the area of the box where
no hearing ability could be measured.

 The non-shadowed area within the box
represents the patient/client’s remaining
hearing ability (the hearing the
patient/client has left).
 The shadowed area is permanent hearing
loss—gone forever—cannot be “restored”!

 This information can be presented as a bad
news—good news type of scenario:
 Bad news as finding permanent hearing
damage.
 Good news being the amount of residual
hearing ability which can successfully be
electroacoustically stimulated.

 Counseling the patient/client regarding the
permanency of the hearing loss, results in
the patient/client taking “ownership” and
becoming more proactive in “taking care” of
their residual hearing ability.
 The patient/client will become more willing
to move over to your side, and listen to your
professional suggestions regarding
appropriate methods for each ear’s care.

 Our goal for the hearing impaired is
“normal” hearing ability.
 However, realistic expectations based on the
patient/client’s defined residual hearing
ability, should be our basis for counseling
and aural rehabilitation--not their
permanent hearing loss or, even worse, a
ridiculous comparison to a normal hearing
person’s abilities.

 Realistic expectations of electro acoustic
stimulation as applied to each
patient/client’s residual auditory ability
result in more satisfied patient/clients.
 To achieve this goal of realistic
patient/client expectations, Hearing
Instrument Specialists must recognize the
following:

First: recognize the digital hearing
instrument paradigm in custom electro
acoustic fitting methodology.
 Due to the implementation of new digital
hearing instrument technology, new
assessment tools and methodologies should
be integrated/implemented.

Second: Fitting digital hearing instruments
using analog fitting methods and rules, equals
“digitized analog” fittings.
 This failure to fully implement new digital
algorithms results in less than optimum
hearing instrument performance for the
patient/client.

Third: Consistent methodology in the custom
electro acoustic fitting of digital technology.
 This will result in greater patient/client
satisfaction, reduced return rates, and
greater market penetration. Ref. Kochkin
Feb. ’03 Hearing Review

Fourth: With the appropriate use of digital
hearing instrument technology, the
patient/client’s UCL should never be exceeded!
 Loudness discomfort levels can now be
measured in-situ with many digital hearing
instruments. This test should always be
performed.
 Assuring output response limits are
appropriately established by frequency is
absolutely essential.

Fifth: Patient/clients reject fittings based
upon the output of their hearing
instrument(s).
 The old standard electroacoustic amplifier
rules (input plus gain equals output), still
apply to digital hearing instrument fittings.

Sixth: Reduced stimulation of the
patient/client’s residual auditory ability can
result in: 1) poorly perceived sound quality,
2) poor ability to understand words clearly,
3) continued auditory deprivation.
 When at all possible, it is very important
that the dynamic range of speech
information be preserved within the residual
auditory capacity of each ear.

Seventh: Kneepoints & compression ratios
should not be based upon an audiogram using
arbitrary normative data.
 Kneepoints & compression ratios should be
determined based upon supra-threshold test
results for each ear--for each patient/client.
 You have then achieved a true custom
electro acoustic fitting and a satisfied
patient/client!

 Identifying and Stimulating the Auditory
Residual Area (ISARA), is the custom
fitting technique for maximizing the
remaining capabilities of the auditory
system to both 'hear' and 'understand'.
 The ISARA technique may involve, 'warble
tones' at frequency, speech noise, or in situ
measures to assist in defining the threshold,
as well as, the supra-threshold levels of each
ear’s dynamic range.

 The concept of fitting the residual auditory
area accurately, requires that we begin with
a method termed: Residual Auditory Area
Mapping (R.A.A.M.).
 This map is unique to each individual ear,
and incorporates each facet of the “diamond
like” surface that is sound.

 If the full benefit of the hearing instrument
is to be embraced by the patient/client, the
R.A.A.M. methodology requires accurate--
individual measurement.
 Residual auditory area mapping can be
accomplished using either pure tones under
headphones, insert earphones, in situ
audiometry (to include both threshold and
supra threshold data).

 The residual auditory area mapping
(RAAM) method permits us to create a 'full'
and complete sound without exceeding the
individual's loudness discomfort level.
 Further, the sound 'floor' is the
patient/client's own MCL, below which, the
sound has only limited utility.

PLEASE NOTE: Patient/client
counseling is not the time to 'dazzle' with
'techno-babble' or recite a pedantic
mantra about the mysteries of the
'treasured' audiogram, for all of its
'magic'.

Patient/client counseling should involve
realistic hearing/communication
expectations based upon tests which
reveal the residual hearing ability of each
ear!

 With today’s digital hearing instrument
technology, we can approach 'filling' that
residual auditory area and we can
approximate the perception of "fullness".
 This adds character to 'spoken voices' and
'richness to music'.
 And results in a “realistic” and satisfied
patient/client.

Patient client counseling & aural rehab

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