Robert W. Sweetow, PhD, is director of Audiology and professor of Otolaryngology at the University of California San Francisco (UCSF); Deborah Corti, MA, is hearing aid product line manager with Starkey Laboratories, Eden Prairie, Minn; Brent Edwards, PhD, is the executive director of the Starkey Hearing Research Center, Berkeley, Calif; Sheila T. Moodie, MClSc, is a research audiologist at the National Centre for Audiology in London, Ontario, Canada; Jennifer Henderson Sabes, MA, is a research audiologist at the UCSF Audiology Clinic.

Dispensing professionals need to consider the entire scope of patient needs—including expectations, listening behavior, and neural plasticity—as opposed to concentrating only on hearing thresholds, audiometric configurations, and the electroacoustic characteristics of hearing devices. Therefore, AR and AT are not simply “add-ons”; they’re essentials that should be employed throughout the client’s experience with your practice.

The reader might find the above to be a rather unlikely title, considering the fact that all of the authors are known for their commitment to the use of aural rehabilitation. Why then would we advocate that aural rehabilitation (AR) or auditory training (AT) should not be an add-on to hearing aid fitting procedures? Is this a misprint? Have the authors had a significant change of heart and mind?

The answer is no! The title is purposeful. It refers to the current state of affairs in our field: that most dispensing professionals—while fully aware of the limitations of hearing aids and the importance of counseling and education—may perceive AR and AT as optional add-on processes that occur after the hearing aid evaluation and fitting. To validate this conviction, look at practically any textbook or chapter on fitting of hearing aids and you will find the section on aural rehabilitation at the end of the book or chapter.

The consensus of this paper’s authors, and indeed, the entire group of participants at the summit, is that AR and AT are not add-on procedures, they are integral components of the holistic approach we should be providing our patients. As such, they should be introduced at the very outset of the process.

This is the main point we want to emphasize in this paper. If audiologists identify AR and AT as the dessert, rather than as part of the main course, they will have a difficult time overcoming the inertia that our profession has created regarding the order and level of importance of components to the overall rehabilitation of patients with impaired hearing.

Where’s the Evidence for AR and AT?

Before we describe the problems that must be overcome to render AR and AT as an integral part of the solution for patients rather than a mere afterthought, it is appropriate first to describe why we believe this is so important. Arthur Boothroyd, one of the participants at the Summit and a long-time advocate of AR, defines rehabilitation as the reduction of hearing-loss-induced deficits of function, activity, participation, and quality of life through sensory management, instruction, perceptual training, and counseling.1

The reader may recognize these areas as the terminology developed in 2001 by the World Health Organization in its attempt to conceptualize, classify, and describe the impact of disease.2 This taxonomy positively emphasizes patients’ assets rather than weaknesses, disabilities and handicaps, as was previously done. Boothroyd asserts that the goal of rehabilitation is to restore quality of life by eliminating, reducing, or circumventing deficits and limitations. He claims that for aural rehabilitation to be successful, four components should be addressed:

  • Sensory management to optimize auditory function;
  • Instruction in the use of technology and control of the listening environment;
  • Perceptual training to improve speech perception and communication; and
  • Counseling to enhance participation and address emotional and practical limitations.

Deficits of function are addressed via sensory management. The tools employed include hearing aids, cochlear implants, and ALDs (assistive listening devices). Of course, it is essential that the hearing impaired patient be a knowledgeable and effective user of technology (hearing devices), as well as be proficient in utilizing communication and repair strategies that assist in shaping the auditory ecology3 and acoustic environment. In addition, the listener must learn to positively impact the manner in which communication is occurring. Moreover, establishment of realistic expectations and an understanding of limitations at the start of the process, imposed by both technology and pathology, must be conveyed and accepted. Thus, clear, precise, and comprehensible instruction to the patient is vital.

Deficits of auditory perception may be addressed through perceptual or auditory training. The goals are to enhance the patient’s auditory and/or auditory-visual perceptual skills. Sweetow and Henderson Sabes4 emphasized that hearing is not the same as listening. While hearing aids are designed to address hearing, they do not necessarily convert a person into a good listener or communicator. Hearing aids and cochlear implants do not restore normal function. Even when conversational speech sounds are made audible, deficits of spectral and temporal resolution remain. Additionally, cognitive changes that occur with normal aging, including a reduction in speed of processing, and deficits in auditory working memory, can negatively impact communication in adverse environments.5-8

While some degree of spontaneous learning occurs for new hearing aid users, computerized training programs can bring formal perceptual training into nonthreatening environments, provide feedback to the trainee regarding progress, identify and modify perceptual and communication repair strategies, and build confidence. Some of the newer attempts at such training programs are LACE (Listening and Communication Enhancement),4 CASPER (Computer-Assisted Speech Perception Evaluation and Training),9 CAST (Computer Aided Speech-reading Training),10,11 and CATS (Computer Assisted Tracking Simulation).12

Support for individual AT was presented in an evidence-based review of the literature by Sweetow and Palmer.13 In addition, Hawkins14 presented an evidence-based review of the benefits gleaned from group-based AR. Formal instruction in hearing aid and accessory management leads to increased usage and, therefore, enhanced function and activity when summed over time.15,16 Evidence is also emerging clearly demonstrating that individuals completing either group-based AR17,18 or individual AT such as LACE19 have significantly lower return-for-credit (RFC) rates on new hearing aid purchases.

The principal mechanism for addressing deficits of participation and quality of life is counseling. Counseling may be divided into informational counseling, which can be considered part of the instruction discussed earlier, and emotional support, during which patients can explore their feelings, understand the impact of hearing loss on their everyday lives, and determine methods to address the practical, social, and emotional consequences of hearing loss.

Obstacles To Providing AR and AT

Despite these rather compelling arguments for initiating AR at the outset of the patient care process—not as an afterthought, but as an integral part of the rehabilitation process (just as integral, in fact as the use of prosthetic devices)—a number of questions remain. Among them are the following:

  • Why don’t audiologists and hearing care professionals routinely recommend AR and AT and introduce it at the beginning of the process?
  • Why might patients be reluctant to participate?
  • How can third-party payers be convinced of the importance of AR and AT?
  • Can AR be cost-effective?
  • What are the best methods for measuring outcomes from AR and AT?
  • Which outcome measures are relevant in assessing the success of AR and AT:
    • Listening effort?
    • Knowledge and use of communication and repair strategies?
    • Word or sentence recognition in noise?
    • Return for credit of hearing aids?
    • Motivation?
    • Self-assessed benefit and satisfaction?
    • Quality of life?
  • Do current approaches produce long-term effectiveness?
  • How can AR and AT be definitively demonstrated to generalize to the real world?
  • Is it the responsibility of the manufacturers to aggressively promote AR and AT?
  • Can and should the results of AR and AT be considered in the programming of hearing aids?
  • Should AT be done alone or with visual training?
  • Should AT be completed with dual tasks such as training with simultaneous talkers or by additionally taxing other sensory inputs and resources?
  • Do AR and AT provide benefit for all hearing aid wearers, and are there materials existing that would help predict who will benefit?

Summit Recommendations

The following recommendations are the result of the summit discussions:

  1. AR and AT should not be considered add-ons and should be integrated into the overall therapy plan at the outset of the process.
  2. A holistic, complete, and individualized therapeutic protocol should consist of the following processes, all of which are vital:
    • Diagnostics, including speech recognition in noise and assessment of the patient’s personality characteristics and motivation;
    • Hearing aid selection and fitting;
    • Instruction on hearing aid care and use and fine-tuning (employing data logging and objective/subjective outcome measures);
    • AR and/or auditory training AT;
    • Comprehensive counseling based on diagnostic findings, AR/AT results, and patient self-assessment.

    The sequence of the above processes is dependent on the needs of the patient.

  3. Efficacy, effectiveness, and efficiency of AR and AT programs must be studied using appropriate methodologies.20 Evidence-based research results need to be attained and reported to all stakeholders (audiologists, hearing aid dispensers, hearing aid and ALD manufacturers, policy makers, consumers, etc).
  4. The nature of evidence that it is important for hearing care professionals to incorporate AR may be different from that which is important to patients and to policy makers and regulating bodies. For example, improvement in listening performance and patient satisfaction is important to all groups, enhanced confidence is particularly important for the consumer, potential reduction in RFCs is important to dispensing professionals, and contributors to cost containment are important for third-party payers. Research should be conducted to provide such data for all groups.
  5. Methods need to be determined for translating rehabilitation procedures directly to the consumer in cases where AR cannot be fully incorporated in the audiologist’s practice.
  6. Cognitive factors may be one reason why we see a difference between real-world performance and clinical measures. Therefore, more research is needed regarding the contribution of cognitive factors and their integration into individual therapies (see the article by Cord et al).
  7. Reimbursement considerations must be addressed, and will be optimally resolved, only via an accumulation of evidence supporting the importance of including AR and AT.


In the words of Boothroyd, “We’re polishing the hubcaps rather than fixing the engine; what we are focusing on (hearing aids only) isn’t suitable to the demands of the task.” In other words, dispensing professionals need to consider the entire scope of the patients’ needs—including expectations, listening behavior, and neural plasticity—as opposed to concentrating only on hearing thresholds, audiometric configuration, and the electroacoustic characteristics of hearing devices.

Radical changes in technology are adopted eagerly and quickly by the industry, but radical changes in practice occur very slowly. Inertia is great and difficult to overcome for changes in practice. Audiologists and other hearing health care professionals must be convinced that it is in their best interest, as well as in the interest of the future of our profession, to transition from the long established paradigm of the hearing aid fitting toward a holistic, effective, efficient, and individualized therapy program.

Audiologists in particular must commit to the principle that AR is an integral part of a comprehensive plan for hearing health care; it is not an add-on or an option. It should be introduced at the outset and utilized as one of the main components of an overall rehabilitation and therapeutic plan that is based on the needs of each individual. As hearing care professionals, we should strive to ensure that all patients understand and agree on a comprehensive rehabilitation approach that addresses every one of their individual needs.

Aural rehabilitation was founded on a process-based system, says Mark Ross, PhD, in his article, “Aural Rehabilitation: Some Personal and Professional Reflections” from the HR archives, September 2001.


Two of the authors, Robert Sweetow and Jennifer Henderson Sabes, are developers of LACE and have a financial interest in Neurotone Inc, the company that produces this system.


  1. Boothroyd A. Adult Aural Rehabilitation: What is it and does it work? Paper presented at: State of the Science Conference on optimizing the benefit of hearing aids and cochlear implants for adults: the role of aural rehabilitation end evidence for its success; September 18-20, 2006; Gallaudet University, Washington, DC.
  2. World Health Organization (WHO). International Classification of Functioning, Disability, and Health (ICF). Geneva: WHO; 2001.
  3. Gatehouse S, Naylor G, Elberling C. Benefits from hearing aids in relation to the interaction between the user and the environment. Intl J Audiol. 2003;42,S77-S85.
  4. Sweetow R, Henderson Sabes J. The need for and development of an adaptive listening and communication enhancment (LACE) program. J Am Acad Audiol. 2006;17,538-558.
  5. Hickson L, Worrall L. Beyond hearing aid fitting: improving communication for older adults. Intl J Audiol. 2003;42,2S84-91.
  6. Pichora-Fuller MK, Souza PE. Effects of aging on auditory processing of speech. Intl J Audiol. 2003;42(Suppl 2):2S11-6.
  7. Pichora-Fuller MK. Cognitive aging and auditory information processing. Intl J Audiol. 2003;42(2):S26-32.
  8. Wingfield A, Tun PA. Spoken language comprehension in older adults: interactions between sensory and cognitive change in normal aging. Sem Hear. 2001;22:287-301.
  9. Boothroyd A. CASPER—Computer Assisted Speech Perception Evaluation and Training. Proceedings of the 10th Annual Conference of the Rehabilitation Society of North America; 1987:734-736; Washington, DC. Association for Advancement of Rehabilitation Technology.
  10. Gagné JP, Dinon D, Parsons J. An evaluation of CAST—computer-aided speechreading training. J Sp Hear Res. 1991; 34:213-221.
  11. Pichora-Fuller MK, Benguerel A. The Design of CAST—Computer aided speechreading training. J Sp Hear Res. 1991;34,202-212.
  12. Dempsey JJ, Levitt H, Josephson J, Porrazzo J. Computer-assisted tracking simulation (CATS). J Acoust Soc Am. 1992;92(2 Pt 1):701-710.
  13. Sweetow R, Palmer C. Efficacy of individual auditory training in adults: a systematic review of the evidence. J Am Acad Audiol. 2005;16:494-504.
  14. Hawkins D. Effectiveness of counseling-based adult group aural rehabilitation programs: a systematic review of the literature. J Am Acad Audiol. 2005;16,485-493.
  15. Chisolm TH, Abrams HB, McArdle R. Short- and long-term outcomes of adult audiological rehabilitation. Ear Hear. 2004;25(5):464-77.
  16. Brooks D. Counseling and its effect on hearing aid use. Scand Audiol.1979;8,101-107.
  17. Wayner DS. Aural rehabilitation adds value, lifts satisfaction, cuts returns. Hear J. 2005;12:30-8.
  18. Northern J, Beyer C. Reducing hearing aid returns through patient education. Audiol Today. 1999;11,10-11.
  19. Martin M. Reducing returns for credit. Paper presented at: American Academy of Audiology Audiology!NOW meeting; April 18-21, 2007; Denver.
  20. Gagné JP. What is treatment evaluation research? What is its relationship to the goals of audiological rehabilitation? Who are the stakeholders of this type of research? Ear Hear. 21(4):60S-73S.

Correspondence can be addressed to HR or Robert Sweetow: .