Aural Rehabilitation

rehabilitation

intervention designed for the reteaching of particular skills

Aural rehabilitation

the services and procedures for facilitating adequate receptive and expressive communication in individuals with hearing impairement

Aural rehabilitation (Boothroyd)

the reduction of hearing loss induced deficits of function, activity, participation, and quality of life through sensory management, instruction, perceptual training, and counseling

habilitations

intervention aimed at the initial development of skills and abilities

• i.e. peds — trying to gain the skills

impairment

refers to a physiological disorder of condition, cosmetic disfigurement, or anatomical loss affecting body systems, or a mental or psychological disorder

• i.e. damaged hair cells, 8th nerve degeneration, CHL could be otitis media, ossicular fixation, ossicular discontinuity

disbility

• physical or mental impairment that substantially limits one or more major life activities

• disadvantage or deficiency, especially a physical or mental impairment that prevents or restricts normal achievement

  • i.e. limits the ability to communicate, listen

what is JCIH

first established in 1969

• national committe that supports and guide the implementation of IDEA’s EL services

• early intervention services birth to 3 years old

  • representatives from professional organizations w/ interest in children w/ HL

Purpose of JCIH

• position statements on infant hearing

• preferred practice in early IC using electrophysiological measures

JCIH 1-3-6

• in 2000, JCIH recommended:

  • universal screening by 1 month of age

  • audiological and medical evals by 3 months of age

    • needed to be diagnosed by 3 months

    • tone pip ABR supplemented click ABR, use of high frequency tympanometry

  • intervention by 6 months of age

    • amplification 1 month following diagnosis

    • family-centered EHDI (early hearing detection and intervention) system with information about all intervention and treatment options

Other JCIH wants

• immediate access to high quality HAs, CIs, other ALDs

• monitoring of HL

  • recommended every month: if HL drastically changes

    • every 3 months until child is age 3

    • every 6 months after that

    • check for possible progression

• knowledgeable professionals

• informational systems to interface w/ electronic health records, measure outcomes & effectiveness at community, state, and federal lvls

standard of care JCIH

hearing evaluation every 3 months in the first 3 years of life and then every 6 months

_% of children w/ SNHL experience progression

20-50

1 in 7 children w/ __ HL will develop loss in the good ear

unilateral

effects of HL on speech and language w/o intervention for slight or unilateral HL

• may miss some consonants

• mild difficulty w/ auditory language learning, listening at a distance and in noise

effects of HL on speech and language w/o intervention for mild HL

• only hearing louder speech sounds

• difficulty with auditory learning

• some language/speech delays

• inattention

• baby is still talking and localizing to sound

effects of HL on speech and language w/o intervention for moderate HL

• hears almost no speech sounds at normal levels

• articulation differences

• language delay

• learning dysfunction related to language delays

• inattention w/ 50 dB HL

• flat, moderate HL can hear speech 50% of the time

effects of HL on speech and language w/o intervention for severe HL

• hears no speech sounds at normal levels

• very reduced speech intelligibility

• verbal language delay

• learning dysfunction related to language delay

• inattention to verbal communication

effects of HL on speech and language w/o intervention for profound HL

• hears no speech or other sounds

• little or no speech intelligibility

• little or no verbal language

• learning dysfunction related to language delay

• learns by visual cues or manually coded language systems

• inattention to verbal communication

language acquisition

depends upon early phonetic learning in baby’s native language

• neural connections created prior to 12 months of age (really 6 months w/ new research)

• supports the need for consistent HA use so phonemic contrasts can be obtained

What is IDEA?

public law that states: all handicapped children have available to them a free, appropriate public education which emphasizes special education and related services designed to meet their unique needs, ensure rights of children w/ disabilities and their parents/guardians are protects, assist the States and localities to provide education of all children w/ disabilities and assess and assures effectiveness of efforts to educate children

• APPROPRIATE ≠ OPTIMAL

  • schools may not be using latest tech

  • kids who qualify get IFSP or IEP plan

  • THE DISABILITY MUST IMPACT EDUCATION

    • HL is considered disability BUT if they’re not being impacted by education (low grades), won’t get equipment under IDEA, will get equipment under 504 plan

• covers birth to age 21

IDEA: EI Provision

• governs EI services for infants and todlers under age 3

• Part C

• All families of infants w/ any degree of permanent HL should be considered eligible for EI

• If have a CHL, not qualifying for EI services

  • Audiologist has to argue if permanent HL

  • Kid can eventually get treatment once school-age

Four Principles of EI

1. Services are family centered

2. services are developmentally supportive and promote children’s participation in their natural environments

3. services are comprehensive, coordinated, and team based

4. services based on the highest quality evidence that is available

Services are Family Centered

parents have greater role during therapy sessions/respect parents communication choice

services are developmentally supportive and promote children’s participation in their natural environments

both home based and center based intervention options should be offered

services are comprehensive, coordinated, and team based

team session are a valuable option

services based on the highest quality evidence that is available

shortage of qualified clinicians

the legal side of early intervention

• its the law — 2 working days

  • federal law requires reporting of any child age birth to three years that has been diagnosed w/ a significant HL (or other developmentally significant condition) to the local part C EI program, regardless of family financial status

IFSP individualized family service plan

• written family-centered process that assists the family and team members

• identify concerns, priority, and resources

• identify functional outcomes based on the child’s everyday routines and activities

• develop strats to achieve outcomes including supports, services, and community resources

Yoshinaga et al (1998)

children who were identified and amplified by 6 months of age demonstrated better receptive language skills on the Minnesota Child Development Inventory than children identified after 6 months of age

Primary Mission of Educational Audiology

• Mission: to support students w/ HL by facilitating equitable access to communication and learning

• Execution: promoting academic achievement and participation through advocacy and multidisciplinary collaboration

BOCES — Board of Cooperative Educational Services

• an intermediate unit between school districts and the state

CSE Committee on Special Education

holds meetings for students aged 5–21

LRE — Least Restrictive Environment

Mandated by both IDEA and Section 504

HAT — Hearing Assistance Technology

assessed and monitored by the audiologist

Compare the Foundation of IDEA vs. Section 504 (type of law, funding, lifespan)

Compare eligibility of IDEA vs Section 504 (criteria, requirement, documentation)

A student has a documented hearing loss but maintains a 4.0 GPA and shows no "adverse educational effect." Do they qualify for IDEA?

If they don’t qualify for IDEA, what could they qualify for instead?

• No. IDEA requires the disability to adversely affect educational performance.

• Alternative: They would likely qualify for Section 504, as hearing is a "major life activity" that is substantially limited.

Deafness

• A hearing loss so severe that linguistic processing through hearing is impaired, with or without amplification.

Hearing Impairment

A permanent or fluctuating impairment that adversely affects performance but is not included under "deafness".

Classroom Acoustic Realities

• Noise: Typical classrooms are noisy, with Signal-to-Noise (S/N) ratios ranging from –5 to +12 dB.

• Reverberation: Causes speech "smearing," which is particularly damaging to the perception of consonants.

• The Rule: Students with hearing impairment require a +15 dB S/N ratio for optimal perception.

Why does reverberation mainly affect consonants?

• Vowels are louder and longer.

• Their energy lingers (smears) in the room.

• That lingering energy masks the softer consonants.

• Since consonants carry much of speech clarity, speech understanding decreases.

Impact of Poor Acoustics on Learning

• Excessive noise and reverberation negatively impact learning to read and attention span.

• Persistence: Children give up more rapidly when material is difficult due to poor listening conditions.

Role of the Educational Audiologist (The "To-Do" List)

• Assessment: Evaluate hearing, assess HAT needs, and monitor hearing aid function.

• Environment: Identify acoustic barriers and suggest physical fixes, such as sealing gaps between walls and floors.

• Collaboration: Participate in CSE meetings, write reports, and provide in-service training for teachers.

ADA Titles

Title I ADA: Employers

Title II ADA:  state run places, state/federal

Title III ADA: Dr, Restaurants, public places that aren’t state run (AUDIOLOGY)

Title IV: Telephone and internet companies need to let callers w/ speech or hearing disabilities to talk, captioning services, any TV after 1990 needs captioning; telecommunication

Title V: misc

Compare the "Discordant Dysfunction Theory" to the role of IHC/OHC destruction in tinnitus severity. What is one test to show this in clinic?

• OHC damage > IHC damage

• ↓ inhibition in DCN

• ↑ spontaneous firing → tinnitus

• If BOTH IHC & OHC destroyed → ↓ tinnitus

• Test done to show this in clinic: OAEs

Why are the Limbic and Autonomic Nervous Systems considered the primary drivers of "suffering" in the Jastreboff model?

• Limbic = emotional expression and memory storage

• Autonomic = fight-or-flight stress response

• Negative emotional tag → attention → prevents habituation

Compare and Contrast: Habituation of Reaction vs. Habituation of Perception.

Reaction

• emotional response decreases

• occurs first

Perception

• awareness of signal decreases

• 12–24 months

• subconscious auditory pathway stops flagging it as relevant

Reaction BEFORE Perception

Define "Transparency" in a Remote Microphone HAT system and explain its clinical goal.

• 65 dB SPL to HA mic = 65 dB to remote mic

• Equal output from both HA and remote mic

• Goal: balanced listening (+15 SNR)

Procedure: Detail the two "Runs" required for HAT Transparency verification in a test box.

Run 1

• HA in box

• Remote muted

Run 2

• Remote in box

• HA outside

Average difference:
±2 dB

• calculation: the average difference at 750 Hz, 1 kHz, 2 kHz between run 1 and run 2 must be w/in ±2 dB

Why is it unnecessary to measure the MPO of a Hearing Aid when it is connected to a HAT system?

• MPO belongs to HA

• Remote automatic gain control (AGC) changes input

• False MPO

Differentiate between a "Device-Centered" vs. "Person-Centered" approach in the clinical process.

Device	PCC
Audiogram	Person — life context
Prescriptive Targets	Specific Communication Goals
Hearing aid	Participation
Technical Verification	Quality of life (hear grandson on phone)

Apply the "HEAR" Framework to an initial aural rehab consultation.

H
Hear story — open-ended questions to understand journey and readiness to change

E
Explore situations — specific environments where struggle

A
Articulate SMART goals — personalized goals (“I want to”…)

R
Review progress — measure against THEIR specific goals, not just word-rec

Why is the "Mixing Point" critical in Sound Therapy, and how does it differ from masking?

• Tinnitus still audible and perceived

• Noise + tinnitus mix

• NOT masking (masking covers tinnitus, removes brain’s chance to learn the signal is neutral)

• Promotes habituation

Case Scenario: A patient has bothersome tinnitus and a moderate bilateral sensorineural hearing loss. Assign the Jastreboff Category and determine the intervention.

• Tinnitus + HL: category 2

• Counseling

• Combination instrument (HAs + noise generators)

Hyperacusis vs Misophonia?

Hyperacusis

• volume problem

• painful

Misophonia

• trigger sound

• emotional reaction

Protocol: Describe the "SMART-PCC" requirements for writing effective rehabilitation goals.

Specific - to relationship/situation

Meaningful - to pt’s values

Achievable

Relevant - to IRL

Time-bound

PLUS

WRITTEN IN First person (I want to…)

What is "Third-Party Disability," and how is it addressed in Family-Centered Care?

Definition:
Family affected by patient's HL

Management:

• SOS-Hear

• Include family

• Teach communication strategies

Jastreboff Category 0

• Minimal impact

• Tinnitus not significantly bothersome

• No hyperacusis

• Brief counseling ± sound enrichment

Jastreboff Category 1

• Significant tinnitus

• Normal/near-normal sound tolerance

• Full counseling + low-level noise generators

Jastreboff Category 2

• Tinnitus + hearing loss

• Counseling + combination hearing aid/noise generator

Jastreboff Category 3

• Hyperacusis present

• Reduced sound tolerance is primary problem

• Counseling + very low-level generators

• Slow, graded increase

Define "Somatosound" and explain its relationship to the traditional term "Objective Tinnitus.

• Formerly "objective tinnitus"

• Physical sound source — generated from w/in body (vascular turbulence, muscle contractions)

• May be heard with stethoscope

• ≠ subjective tinnitus

Explain the "Conditioned Reflex Arc" in the context of tinnitus suffering.

Tinnitus + negative emotion
→ conditioned reflex
→ limbic + autonomic activation

TRT goal:
Break the conditioned reflex.

How is the Tinnitus Handicap Inventory (THI) specifically scored?

25 items

Yes = 4

Sometimes = 2

No = 0

0–100 range

20-point improvement from initial= clinically significant

What is the relationship between a patient’s tinnitus pitch match and the frequency of external sounds?

• The Rule: no clear frequency relation between the pitch matched by the patient and the frequency of external sounds.

• Clinical Significance: supports the neurophysiological model, suggesting tinnitus is a central phantom perception

Why can we NOT assume that an ideal SNR has been achieved just because a HAT system is connected?

• Different SPL input levels bc HAs and HAT microphones at different distances from sound sources

• Compression/Automatic Gain Control (AGC)

• Manufacturer differences — mixing HA and HAT brands

Why can increasing damage to the Inner Hair Cells (IHCs) sometimes DECREASE tinnitus?

• Discordant Dysfunction Logic: Tinnitus is driven by the difference in activity between dysfunctional OHCs and functional IHCs (disinhibition).

• Mechanism: If IHC damage increases to match the OHC damage level, the imbalance in the dorsal cochlear nucleus is reduced.

• Result: The abnormal neural activity becomes less pronounced because the "gap" in activity between the two systems is smaller.

• A clinical measure we can do to test Discordant Dysfunction: OAEs

What is "Disco Tinnitus," and what is its physiological cause?

• Definition: Temporary tinnitus associated with exposure to loud music.

• Physiological Cause: Loud sound causes a temporary disorganization of the cilia on the Outer Hair Cells.

• Recovery: These cells are temporarily disabled, but if not irreversibly damaged, the cilia return to their normal state after a few hours or days

Compare/Contrast: Objective vs. Subjective Tinnitus

• Objective (Somatosound): Has a mechanical/vibratory source in the body; can be heard by others; rare.

• Subjective: A "phantom" perception with no acoustic source; results from central neural activity; represents the vast majority of cases

Compare/Contrast: TRT Patient Category 0 vs. Category 1.

• Category 0: Tinnitus has minimal impact on life; no hyperacusis. Intervention: Brief counseling and environmental sound enrichment.

• Category 1: Significant tinnitus (bothersome); normal sound tolerance. Intervention: Full directive counseling and noise generators set at low levels

Compare/Contrast: Goal Setting in Device-Centered vs. Person-Centered Care.

• Device-Centered: Goals are clinician-defined and technical (e.g., "Improve word recognition scores by 20%" or "Increase wear time to 8 hours").

• Person-Centered: Goals are patient-defined and functional (e.g., "I want to hear my grandson on the phone without asking him to repeat")

Tinnitus Prevalence and TRT Timelines

• 10–15%: Percentage of adults experiencing chronic tinnitus.

• 20% (1 in 5): Percentage of those cases that are "clinically significant" (bothersome).

• 12–24 Months: Typical duration of a full TRT program to achieve habituation.

• 80%: Reported success rate for patients treated with TRT.

Clinical Protocol: Transparency Verification Frequencies.

• Calculation: You must calculate the average difference between Run 1 (HA only) and Run 2 (HAT active).

• Specific Frequencies: The average is taken at 750 Hz, 1000 Hz, and 2000 Hz.

• Pass/Fail Criteria: The average difference must fall between ±2 dB.

Clinical Protocol: TRT Follow-up Timeline.

• Initial: Evaluation and category assignment (60–90 min).

• Fitting: Device calibration if indicated.

• Follow-up intervals: Approximately 3, 6, 12, and 18 months

Protocol: Managing Hyperacusis in Category 3 Patients

• Priority: Hyperacusis is treated as the dominant issue over tinnitus.

• Sound Therapy Rule: Use very low-level noise generators.

• Progression: Implement a slow, graded increase in volume over time to desensitize the auditory system

TRT treatment timeline

• Initial evaluation

• Device fitting

• Follow-up (3, 6, 12, 18 months)

• Habituation (12–24 months)

What happens during each TRT stage?

• Evaluation: 60–90 min + category assignment

• Fitting: Noise generator/combination device

• Follow-up: 3, 6, 12, 18 months

• Habituation: Reaction → Perception