Trends in Amplification
Volume 11 Number 2
Adult Aural Rehabilitation:
What Is It and Does It Work?
Arthur Boothroyd, PhD
Adult aural rehabilitation is here defined holistically as
the reduction of hearing-loss-induced deficits of func-
tion, activity, participation, and quality of life through
a combination of sensory management, instruction,
perceptual training, and counseling. There is a tendency
for audiologists to focus on sensory management, aural
rehabilitation being seen as something done by some-
one else after the provision of hearing aids or cochlear
implants. Effective sensory management may, by itself,
lead to improved activity, participation, and quality of
life, but there is no guarantee that these outcomes will
H
earing loss acquired in adult life can have a
serious impact on quality of life. This impact
results primarily from deficits in the activi-
ties of speech perception and communication and
the limitations imposed by these deficits on partici-
pation in social interactions, in employment, in
leisure pursuits, and in the enjoyment of sound. The
goal of rehabilitation is to restore quality of life by
eliminating, reducing, or circumventing these deficits
and limitations.
This goal can be addressed through a combina-
tion of:
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 deal
both emotionally and practically with residual
limitations.
This concept of adult aural rehabilitation is
summed up in the following definition: the reduction
From San Diego State University, San Diego, California.
Address correspondence to: Arthur Boothroyd, Scholar in
Residence, San Diego State University, 2550 Brant St, San
Diego, CA 92101; e-mail: aboothroyd@cox.net.
June 2007 63-71
2007 Sage Publications
10.1177/1084713807301073
http://tia.sagepub.com
hosted at
http://online.sagepub.com
be automatic or optimal. In fact, there is often a dis-
connect between clinical measures of assisted auditory
function and self-assessed benefit. Costs associated
with a holistic approach can be minimized by bundling
as many as possible into the cost of hearing devices,
by taking advantage of computer-based perceptual
training, and by capitalizing on the benefits of group
counseling.
Keywords: hearing loss; aural rehabilitation; audio-
logic rehabilitation
of hearing-loss-induced deficits of function, activity,
participation, and quality of life through sensory
management, instruction, perceptual training, and
counseling.
This definition uses the terminology developed
by the World Health Organization (WHO) in its
generic attempts to conceptualize, classify, and describe
the impact of disease.1 An earlier classification sys-
tem2 used the terms impairment (what is missing or
not working properly), disability (the things that
could not be done because of the impairment), and
handicap (the negative impact of the disability on
quality of life). The emphasis was on the individuals
losses. The current language is more positive. We
speak of function, activity, and participation: the
emphasis is on the individuals assets.
Life With Hearing
In applying the WHO taxonomy to hearing and
hearing loss, it helps to add 1 more level at the
beginning and to separate the objective concept of
participation from the subjective concept of self-
perceived quality of life, giving 5 categories in all.
1. Anatomy and physiology: Physical and func-
tional integrity, including the integrity of the outer
ear, the middle ear, the cochlea, neural pathways to
63
64 Trends in Amplification / Vol. 11, No. 2, June 2007
the brain, and the brain itself. Our major concern is
with the status of the cochlea. With older subjects,
however, the integrity of neural structures becomes
increasingly significant.
2. Function: Basic perceptual capacity as meas-
ured in the clinic or research lab. This includes
threshold, dynamic range, frequency range, spectral
and temporal resolution, acoustic pattern discrimi-
nation, direction and distance perception, attention,
auditory working memory, processing speed, and
noise resistance.
3. Activity: The use of this capacitythe things
one wants or needs to do with hearing in the real
world. Examples include being alerted by sound,
monitoring the environment, recognizing and localiz-
ing events and deducing their significance, monitor-
ing and controlling ones own speech, and enjoying
auditory experiences. The activities of most concern,
however, are perceiving the speech of others and
engaging in spoken language communication.
4. Participation: The contribution of these
activities to daily life, including social interactions
and relationships, employment, leisure, learning,
control, and creativity.
5. Quality of life: Reflects self-assessment of
the current life experience and includes such things
as enjoyment, meaning, purpose, usefulness, value,
freedom of choice, and independence. Quality of life
is a moving target. It is influenced by function, activ-
ity, and participation, but is by no means completely
determined by them.
Targeting Hearing Loss
When considering hearing loss, our main anatomic
and physiologic concern is cochlear damage, includ-
ing disruption of structures, malfunction or loss of
hair cells, or both. Such deficits may, however, be
compounded by postsynaptic atrophy and other
effects of auditory deprivation. They may also be
compounded by the cognitive and processing diffi-
culties that can accompany aging.
Cochlear damage has direct and immediate
effects on most aspects of auditory function, includ-
ing sensitivity, resolution, discrimination ability, and
noise resistance. The deficits of function produce
deficits of activity, especially speech perception and
communication by spoken language. These last
deficits are seriously exacerbated by noise. Reduced
activity impacts participation, and deficits of partic-
ipation are reflected in quality of life.
The goal of aural rehabilitation, as defined here, is
to reduce or eliminate these various deficits and, as far
as possible, restore the individual to his or her preloss
state. One of the long-term goals of auditory research
is to restore cochlear function in humans through the
regeneration of functional hair cells along with their
neural connections.3 At the time of writing, regenera-
tion of hair cells in mammals, once thought to be
impossible, has been achieved, but functionality and
neural connectivity are still in question; it will be many
years before we see this work extended to humans.4 In
other words, we are currently unable to restore
cochlear integrity; however, the other 4 areas of deficit
can be targets for intervention.
Targeting Function
We address deficits of function through sensory
management. The basic tools are hearing aids and
cochlear implants, with the possible addition of
accessories such as FM microphones or assistive
devices such as amplified telephones. The immedi-
ate goals are to provide audibility of the sounds of
speech while preserving comfort and perceived
sound quality and to do so over as wide a range as
possible of talker spectrum, talker distance, talker
effort, and interfering noise and reverberation.
Improvement of auditory function should have a
positive impact on the activity of speech perception.
We cannot assume, however, that carryover to par-
ticipation and quality of life will be either automatic
or optimal, nor can we assume that there will be a
return to the preloss state. The immediate outcomes
of sensory management vary dramatically from indi-
vidual to individual. Differences between expecta-
tion and reality can result in a combination of
selective nonuse (wearing the device only in partic-
ular situations), complete nonuse, or continued
avoidance of situations in which the device might
offer benefit and learning opportunities. This last
point is critical. Many adults with acquired hearing
loss are looking not for a significant improvement of
function but for full restorationa cure. It is our
inability to meet this expectation that creates the
need for a holistic approach to adult aural rehabili-
tation that goes beyond sensory management.
Instruction is a key component of such an
approach. The immediate goal is for the adult with
the hearing impairment to become a knowledge-
able and effective user of the hearing device and
a knowledgeable and effective controller of the

communication context. All users of these devices
need to understand the nature of their hearing loss, the
potential benefits of hearing aids, cochlear implants,
and other hearing-assistance devices, as well as the lim-
itations of this technology. They need to learn how to
maintain and operate their devices effectively and to
deal with the associated inconveniences. And they need
to acquire insights into the factors that enhance or
limit communication together with techniques either
to avoid communication failure or to repair it. It is gen-
erally accepted, therefore, that sensory management
must be supplemented by instruction.
There is, of course, a difference between instruc-
tion and telling. Instruction has not occurred until
the client has learned. To facilitate learning, the
audiologist may need to provide not only verbal and
written materials but also demonstration and coach-
ing,5 and often, more than once.6,7 Note, also, that to
refer to this aspect of management simply as coun-
seling is potentially misleading, although informa-
tional counseling might be an appropriate term.
Targeting Activity
Deficits of auditory perception may be addressed
through perceptual training. The immediate goals
are to enhance auditory or auditory-visual percep-
tual skills, or both, especially the skills involved in
spoken language perception. The term auditory
training is often used in reference to this compo-
nent. All hearing aid or implant users need to learn
to deal with auditory sensations that are both impov-
erished and different from those experienced before the
hearing loss. Such learning can occur spontaneously
in the context of every day communication. There
are, however, individual differences in such things
as the amount of learning needed, the opportunities
for learning and the confidence to engage in them,
adaptability, perceptual speed, use of context, and
tolerance for error and embarrassment.
Formal perceptual training in an unthreatening
environment with high levels of success and feed-
back on performance increases time-on-task. If
this increases confidence and helps the client mod-
ify perceptual strategies, the expected outcomes are
faster learning and higher ultimate performance.
Any improvements in perceptual and communicative
skill are expected to translate into increased participa-
tion and improved quality of life. Once again, how-
ever, it is a mistake to assume that the generalization
will be either automatic or optimal.
Adult Aural Rehabilitation / Boothroyd 65
Targeting Participation
and Quality of Life
The principal mechanism for addressing deficits of
participation and quality of life is counseling. For the
present purposes, I am not including under this head-
ing the explicit knowledge that was covered under
instruction. Instead, I am referring to situations in
which persons with hearing loss can discuss and
come to terms with its impact on their everyday lives,
discuss their feelings about this impact, and explore
ways to address the practical, social, and emotional
consequences. The goal, in a sense, is to enhance par-
ticipation and quality of life despite residual deficits
of function and activity. Issues for discussion might
include relationships, employment, anger, shame, risk
tolerance, and perceived locus of control.8-11 Some
aspects of counseling can be informal and can occur
during sensory management, instruction, and percep-
tual training. Other aspects may require intervention
by personnel with appropriate expertise.
Training programs must provide budding audiolo-
gists with knowledge and skills in this area, including:
an understanding of, and sensitivity to, the
psychosocial issues surrounding acquired hear-
ing loss12;
appropriate interactive styles13;
the ability to recognize when there is a need for
services beyond their expertise and/or scope of
practice;
the realization that they do not treat hearing loss
in peoplethey serve people with hearing loss
(Figure 1).
Components of Aural Rehabilitation
The foregoing analysis classifies the process of aural
rehabilitation into 4 components:
1. Sensory managementto target and enhance
auditory function;
2. Instructionto increase the probability of posi-
tive outcome from sensory management;
3. Perceptual trainingto target activity, by sup-
plementing the learning opportunities provided
by everyday communication;
4. Counselingto target issues of participation
and quality of life that result from residual
deficits of function and activity.
Note that the definition offered at the beginning
of this article includes both the goals of adult aural
66 Trends in Amplification / Vol. 11, No. 2, June 2007
Figure 1. The 4 components of a holistic approach to adult aural rehabilitation.
rehabilitation and the processes just discussed. It is
not enough to define it in terms of only one of these.
Does It Work?
We now turn to the second question in the title of this
article: Does it work? In other words, how well do the
processes of sensory management, instruction, per-
ceptual training, and counseling meet the goals of
restoring function, activity, participation, and quality
of life in adults with acquired hearing loss?
Now we are in difficult terrain. Each major com-
ponent of intervention can involve many subcompo-
nents practiced with varying degrees of emphasis
and expertise. In a similar fashion, each goal can
have several subgoals. And outcome at each level is
influenced by numerous factors that may be beyond
the control of the rehabilitative personnel. These
factors include such things as the hearing-impaired
persons
motivation,
readiness,
expectations,
sense of entitlement,
personality,
adaptability,
perceived locus of control,
lifestyle,
function in other areas such as cognition, tactile
perception, and visual perception
auditory ecology,14
resources, and
support from significant others.
Clearly, the importance of these factors increases
as we move from function, through activity, to par-
ticipation and quality of life. A hearing aid may
improve auditory function, but it will not convert an
introvert into an extrovert or a grouch into an angel.
So the only sensible answer to the question
Does it work? is It depends. It depends on what
aspect of aural rehabilitation is being discussed, how
well it is being implemented, the goals being pur-
sued, the characteristics of the person being served,
and the suitability of the outcome measure in rela-
tion to the goals.
Outcome Measures
This last point cannot be overstressed. When assess-
ing the effectiveness of a particular aspect of inter-
vention, the choice of outcome measures must
reflect the goals of that intervention. When evaluat-
ing the benefits of instruction for new hearing aid
recipients, for example, nonreturn may be a suitable
outcome measure if the goal is to increase sales. It
is only a necessary but insufficient condition if the
goal is hearing aid use. And if the goal is to enhance
quality of life, then nonreturn may tell us nothing.

When providing perceptual training, perform-
ance on formal speech perception tests may be a
suitable outcome measure if the goal is to improve
speech perception in the clinic or laboratory. But if
the goal is to enhance communication in everyday
life, then improved speech perception scores in the
clinic or research lab may only be an encouraging
indicator.
Got Evidence?
For the moment, let us use the general goals sug-
gested in this presentation and the 4 components of
intervention. What is the evidence for the conclu-
sion that these components meet their goals?
Effectiveness of Sensory Management
There is ample evidence to support the conclusion
that, on average, sensory management enhances
auditory function. In other words, hearing aids and
cochlear implants give the typical adult user
improved access to information carried by the
sounds of speech. Moreover, the improved function
enhances the ability to perceive the speech of others
and to communicate by spoken language. Most of
the research studies on which these conclusions are
based were actually designed to compare hearing aid
processing or prescription strategies.15-17 The overall
benefit in terms of function and activity, regardless
of strategy, is clear.18 There is also evidence to sup-
port carryover to participation and quality of life.19
The conclusion that the provision of hearing aids
or cochlear implants leads to enhanced participation
and quality of life, however, is often assumed rather
than confirmed. Indeed, a common finding in the
case of hearing aids is of a relatively low correlation
between improved function, as measured in the
clinic or research lab, and self-perceived benefit and
satisfaction.20-23 Some of the variance in outcome not
explained by objective measures of function has been
shown to be attributable to cognitive ability and the
characteristics of the users auditory environment.14
It is important to note that hearing aids and
cochlear implants do not restore normal function.
Users may be given relatively full audibility of the
sounds of conversational speech, but deficits of
spectral and temporal resolution remain and their
severity varies from individual to individual. The
consequences of these deficits are present in quiet
but are particularly serious when listening to speech
Adult Aural Rehabilitation / Boothroyd 67
in noise. In the case of hearing aid users, deficits of
aided function are partially correlated with unaided
threshold.24
Presumably, this relationship exists because both
threshold and spectral-temporal resolution are
determined by the underlying cochlear pathology. In
the case of cochlear implants, the correlation
between assisted function and preimplant threshold
is weak or nonexistent. In this case, the critical fac-
tor can be assumed to be the effective number of
discrete channels of stimulation. This number
depends on the distribution of electrodes and their
proximity to independently stimulable neural tissue,
neither of which depend on the original cochlear
pathology. Whatever the mechanisms, unresolved
deficits of speech perception, especially in noise,
will obviously limit carryover to perceived benefit,
satisfaction, participation, and quality of life, espe-
cially if the users expectations greatly exceed reality.
Three techniques currently exist to address the
negative effects of noise on speech perception: digi-
tal noise-reduction, directional microphones, and
remote wireless microphones. These 3 options are
listed in ascending order of functional effectiveness
but descending order of convenience and accept-
ability.25-29 All have the potential to enhance func-
tion and activity when used as part of an effective
program of sensory management.
Effectiveness of Instruction
There is evidence to support the conclusion that formal
instruction in hearing aid and accessory management
leads to increased usage and, therefore, enhanced
function and activity when summed over time.7,30-34
Effectiveness of Perceptual Training
Perceptual training does not target function. Rather,
its goal is better use of that function through
enhancement of perceptual skill. There is certainly
evidence of improvement on formal speech percep-
tion tests.35,36 It is not always clear, however, how
much of this improvement reflects skills that are
generalizable to every day communication.37 And
carryover to participation and quality of life are usu-
ally assumed rather than measured. As with lan-
guage instruction, the full benefits of perceptual
training will not be observed until the learner spends
time using and refining newly acquired skills in a
meaningful, real-world context.
68 Trends in Amplification / Vol. 11, No. 2, June 2007
Figure 2. The evidence of effectiveness for 4 aspects of intervention argues in favor of a holistic approach to adult aural rehabilitation.
Effectiveness of Counseling
Counseling, as defined here, specifically addresses
participation and quality of life. There is evidence of
its effectiveness,38 but obviously, the outcomes will be
highly dependent on the characteristics of the person
with the hearing loss, rapport with the counselor, rap-
port with other participants (if group or couple coun-
seling), and the content of the program.39
A Holistic Approach
The comments in the previous sections are summa-
rized in Figure 2, where a check mark indicates evi-
dence of effectiveness. This analysis supports the
argument that optimal attainment of the goals of
adult aural rehabilitation, as defined here, is best
pursued by a holistic approach that includes the 4
components of sensory management, instruction,
perceptual training, and counseling. Clearly, however,
the relative importance of and the needed emphasis
on the 4 components will vary from adult to adult.
The holistic approach is not a novel concept.
Tye-Murray, for example defines the goals of adult
aural rehabilitation as to alleviate the difficulties
related to hearing loss and minimize its consequences.
She further describes the processes as including
. . . diagnosis and quantification of the hearing loss
and the provision of appropriate listening devices [plus]
communication-strategies training, counseling related
to hearing loss, vocational counseling, noise protec-
tion, . . . counseling and instruction for family mem-
bers . . . [and] less commonly, . . . speech perception
training, such as speechreading training.40 And the
term was used if not coined by Lesner and Krikos in
their 1995 text.41
Evidence-Based Practice
The word evidence appeared several times in the
foregoing analysis, which brings us to the concept of
evidence-based practice. Evidence-based practice
has been defined as the conscientious, explicit and
judicious use of current best evidence in making
decisions about the care of individual patients. The
practice of evidence-based medicine means integrat-
ing individual clinical expertise with the best avail-
able external clinical evidence from systematic
research.42
During the past 2 decades, the medical commu-
nity has developed techniques to promote and for-
malize evidence-based practice. At the time of writing,
these techniques are being applied in audiology.43,44
Note that the definition just borrowed does not deny

the importance of clinical experience and expertise,
but the idea is to go beyond personal beliefs and expe-
rience to validate or perhaps modify practice on the
basis of data from high quality clinical research. The
proof of the pudding is in the eating.
An important aspect of developing best practice
is not just to consult the research but also to evalu-
ate the quality of the evidence it provides. Several
writers have proposed a hierarchy of levels of evi-
dence.44
At the top are meta-analyses and systematic
reviews of the literature prepared according to strict
guidelines for inclusion and weighting. Next come
individual experiments designed with random assign-
ment of patients to conditions and the inclusion of
control treatments and conditions, together with
blinding of participants and experimenters. In the
field of audiology, randomization and blinding are
not always possible, but we should expect control.
Although weaker, evidence from prospective
single-subject studies can be useful, especially if they
include control or no-treatment conditions and are
replicated with a small sample. Less valuable are ret-
rospective case studies because of the absence of both
randomization and control.
The lowest level of evidence is expert opinion.
This does not mean that expert opinion is necessarily
of little value. Indeed, the opinion of the expert in
question may be based on a systematic review of the
literature. But we have always done it this way and
we have never done it this way are not acceptable as
evidence.
As audiologists seek high-quality evidence to val-
idate or improve practice, it quickly becomes clear
that such evidence is in short supply. There is a
pressing need for increased research effortand for
the training of clinical researchers to carry it out.
Efficiency
I have said nothing so far about the cost of a holistic
approach to adult aural rehabilitation. Individuals and
third-party payers are often willing to pay for hearing
aids and cochlear implants. After all, money is being
exchanged for a tangible device. But enhanced activ-
ity, participation, and quality of life are intangibles;
moreover, individualized instruction, training, and
counseling can be expensive. For this reason there is
interest, not just in demonstration of effectiveness
but also in efficiency, or cost/benefit ratio.
Adult Aural Rehabilitation / Boothroyd 69
In fact, there are ways to minimize the cost of the
approach to management being advocated here. Basic
instruction, for example, can be built into the cost of
a device, as is already done by some providers. Self-
administered computer-assisted, or significant-other-
assisted techniques may enhance perceptual learning
at low cost.35,36 Many of the goals of counseling can
be accomplished in groups.38 And audiologists can
develop the sensitivity and skills required to address
participation and quality-of-life issues and, perhaps,
reduce the need for therapeutic counseling. Although
holistic adult aural rehabilitation may be more costly
than simple hearing aid dispensing, the differences in
cost do not have to be enormous and may be justified
on the basis of improved outcomes.
Summary
Hearing loss acquired in adult life can have serious
and far-reaching consequences for the individual
concerned. There are deficits of auditory function
(the things one can do in the clinic, or research lab,
if asked), activity (the things one needs or wants to
do in every day lifeespecially communicate via spo-
ken language), participation (in social, vocational,
and avocational activities), and quality of life (self-
perceived). It is argued here that the ultimate goal of
adult aural rehabilitation is to eliminate hearing-
loss-induced deficits of activity, participation, and
quality of life. Sensory management in the form of
hearing aids, cochlear implants, and hearing assis-
tance technology can go a long way toward meeting
that goal by enhancing auditory function.
Such evidence as is available, however, suggests
that the goal is best met by a combination of sensory
management, instruction, perceptual training, and
counseling. Improvements of outcome will be
accompanied by increased costs. There are, how-
ever, opportunities for minimizing these costs by
including some of them in the purchase price of
hearing devices, by making use of computer-based
self-instruction, and by taking advantage of group
counseling. The need for high quality research to
justify and optimize a holistic approach to adult
aural rehabilitation is self-evident.
Acknowledgment
This article was presented as the Keynote Address at
the State of the Science conference on: Optimizing
70 Trends in Amplification / Vol. 11, No. 2, June 2007
the benefit of hearing aids and cochlear implants for
adults: the role of aural rehabilitation and evidence
for its success. Gallaudet University, Sep 18-20,
2006. The preparation of this work was supported by
NIDRR RERC grant #H1343E98 to Gallaudet
University.
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