AJA
Research Article
A Questionnaire Survey of Current
Rehabilitation Practices for Adults
With Normal Hearing Sensitivity Who
Experience Auditory Difficulties
Tess K. Koerner,a Melissa A. Papesh,a,b and Frederick J. Galluna,b
Purpose: A questionnaire survey was conducted to collect
information from clinical audiologists about rehabilitation
options for adult patients who report significant auditory
difficulties despite having normal or near-normal hearing
sensitivity. This work aimed to provide more information
about what audiologists are currently doing in the clinic to
manage auditory difficulties in this patient population and their
views on the efficacy of recommended rehabilitation methods.
Method: A questionnaire survey containing multiple-choice
and open-ended questions was developed and disseminated
online. Invitations to participate were delivered via e-mail
listservs and through business cards provided at annual
audiology conferences. All responses were anonymous at
the time of data collection.
Results: Responses were collected from 209 participants.
The majority of participants reported seeing at least one
normal-hearing patient per month who reported significant
communication difficulties. However, few respondents
indicated that their location had specific protocols for the
treatment of these patients. Counseling was reported as
A
necdotal reports from audiologists have sug-
gested that it is not uncommon for clinicians to
encounter adult patients who report auditory
difficulties despite having clinically normal or near-normal
pure-tone hearing thresholds. Such anecdotes received
support from a recent large-scale review of the Department
of Veterans Affairs (VA) audiological data repository,
a
VA RR&D National Center for Rehabilitative Auditory Research,
VA Portland Health Care System, OR
b
Department of Otolaryngology - Head & Neck Surgery, Oregon
Health & Science University, Portland
Correspondence to Tess K. Koerner: Tess.Koerner@va.gov
Editor-in-Chief: Ryan W. McCreery
Editor: Kathy R. Vander Werff
Received March 12, 2020
Revision received June 10, 2020
Accepted July 13, 2020
https://doi.org/10.1044/2020_AJA-20-00027
738 American Journal of Audiology • Vol. 29 • 738–761 • December 2020 • Copyright © 2020 American Speech-Language-Hearing Association
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
the most frequent rehabilitation method, but results revealed
that audiologists across various work settings are also
successfully starting to fit patients with mild-gain hearing
aids. Responses indicated that patient compliance with
computer-based auditory training methods was regarded
as low, with patients generally preferring device-based
rehabilitation options.
Conclusions: Results from this questionnaire survey strongly
suggest that audiologists frequently see normal-hearing
patients who report auditory difficulties, but that few clinicians
are equipped with established protocols for diagnosis and
management. While many feel that mild-gain hearing aids
provide considerable benefit for these patients, very little
research has been conducted to date to support the use of
hearing aids or other rehabilitation options for this unique
patient population. This study reveals the critical need for
additional research to establish evidence-based practice
guidelines that will empower clinicians to provide a high
level of clinical care and effective rehabilitation strategies
to these patients.
which revealed that 10.12% of Veterans seeking help for audi-
tory complaints at the VA between 1991 and 2015 presented
with normal hearing thresholds (Billings et al., 2018). Simi-
lar findings have been reported across studies performed
in non-VA facilities (Hannula et al., 2011; Parthasarathy
et al., 2020; Spankovich et al., 2018; Tremblay et al., 2015),
indicating that this situation is not unique to the Veteran
population. A recent report further highlighted the scale
of this issue by estimating that out of 37.4 million U.S.
adults with self-reported hearing difficulties, approxi-
mately 25.3 million actually have normal audiometric
hearing thresholds (Edwards, 2020). Numerous research
studies have documented the potential for functional audi-
tory deficits in several normal-hearing (NH) populations,
including those with established lesions in the central ner-
vous system (Musiek et al., 2005), various neurological
Disclosure: The authors have declared that no competing interests existed at the time
of publication.
 disorders (Iliadou et al., 2013; Valadbeigi et al., 2014), and
the natural process of aging (Helfer & Vargo, 2009), as
well as individuals with exposure to noise (Kumar et al.,
2012; Spankovich et al., 2018), high-intensity blast waves,
jet fuel, and other types of solvents (Fuente et al., 2013, 2006;
Gopal, 2008; Tepe et al., 2020).
Recent research has focused on the auditory effects
of high-intensity blast exposure and mild traumatic brain
injury (TBI), also known as concussion. NH individuals
who have been exposed to high-intensity blast waves, with
or without an official diagnosis of TBI, are more likely
to have higher rates of self-reported auditory difficulties
and perform more poorly on various electrophysiological
and behavioral tests of central auditory processing com-
pared to age- and hearing-matched control participants
(Callahan & Storzbach, 2019; Gallun et al., 2012, 2016;
Kubli et al., 2018; Saunders et al., 2015). Blast-exposed
NH individuals may have measurable deficits on a range
of auditory tasks, including dichotic listening, temporal
resolution and pattern recognition (Gallun et al., 2012,
2016), sound localization and spatial hearing (Kubli et al.,
2018; Papesh et al., 2018), and speech understanding in
noise (Remenschneider et al., 2014). Similarly, recent in-
vestigations of patients with non-blast-related TBIs, such
as those related to falls, sports injuries, or motor vehicle
accidents, also reveal high instances of perceived auditory
deficits. It is estimated that between 61% and 87% of these
patients report persistent auditory concerns even when
their TBI is classified as “mild” in severity (Knoll et al.,
2019; Oleksiak et al., 2012). Results of behavioral and
electrophysiological examinations of patients with non-
blast-related TBI largely mirror the deficits found in pa-
tients with high-intensity blast exposure (Bergemalm &
Lyxell, 2005; Hoover et al., 2017; Knoll et al., 2019; Kraus
et al., 2017, 2016; Šarkić et al., 2019; Thompson et al.,
2018; Turgeon et al., 2011; Vander Werff & Rieger, 2017).
Furthermore, many of these deficits are measured years
following the initial injury, suggesting the potential for
chronic impairments (Gallun et al., 2016; Knoll et al.,
2019). While the exact cause of these auditory processing
difficulties is still unknown, it is thought that auditory
deficits likely arise due to focal or diffuse TBI-related
neural damage in auditory or nonauditory areas, includ-
ing the temporal and frontal lobes, the corpus collosum,
and the cerebellum (Gallun et al., 2012; Papesh et al.,
2018). Recent estimates provided by the Centers for Dis-
ease Control and Prevention indicate that the number of
TBIs is on the rise, with more than 2.5 million patients
seen in emergency rooms for TBI just in the year 2014
alone (Centers for Disease Control and Prevention, National
Center for Injury Prevention and Control, 2019). These
estimates, combined with the prevalence of other known risk
factors for auditory processing difficulties listed above,
highlight the staggering number of NH individuals that
are likely struggling with auditory deficits.
Despite evidence that auditory-related issues affect
many different NH patient populations, there are cur-
rently no standardized, evidence-based protocols for the
Koerner et al.: Survey of Rehabilitation Options for NH Patients
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
management of hearing and communication difficulties in
these individuals. While ongoing research currently seeks
to better understand the underlying causes of auditory and
speech processing issues in these populations, the number
of NH patients who are currently seeking out hearing health
care for their perceived communication difficulties under-
scores the need for more immediate intervention solutions.
Studies on potential auditory-specific interventions for these
patients have focused on two distinct options: (a) audi-
tory training programs and (b) device-based options such
as hearing aids and FM systems.
Auditory training programs aim to improve auditory
function through neural plasticity and learning. Programs
designed for clinical use are often classified as primarily
training bottom-up sensory processes (analytic training),
top-down cognitive processes (synthetic training), or a com-
bination of both (Sweetow & Palmer, 2005). Training pro-
grams can be administered during in-person, one-on-one
sessions between a patient and a clinician or via computer-
based programs that can be completed by a patient at
home, thus providing potential options for clinicians. A
wide variety of commercial programs are now available for
use that target functions ranging from frequency and pho-
neme discrimination to auditory attention and working
memory. Several studies have provided evidence that audi-
tory training can alter the neural encoding and perception
of speech sounds in NH adults (Kraus et al., 1995; Song
et al., 2012; Tremblay et al., 1997), though most research
on the efficacy of training programs in adult patients have
focused on those with hearing loss. For these patients,
most, though not all (Saunders et al., 2016), studies have
shown the potential for such programs to improve perfor-
mance on trained and untrained auditory tasks (Anderson
& Kraus, 2013; Burk & Humes, 2008; Miller et al., 2016;
Olson et al., 2013; Sweetow & Sabes, 2006), suggesting the
potential for the use of such programs to improve speech
understanding and communication in NH populations with
auditory difficulties. However, only a few studies have be-
gun specifically examining the effects of auditory training
on NH individuals with auditory processing difficulties. So
far, much of this research has been in children (Loo et al.,
2016; Sharma et al., 2012). To date, only one randomized
controlled trial has investigated the use of auditory training
on NH adult patients with reported auditory difficulties
(Saunders et al., 2018). Saunders et al. (2018) explored
the efficacy of a commercially available program called
the Brain Fitness Program of Posit Science (Posit Science,
2014) for improving auditory function on several tasks in
a group of previously blast-exposed NH Veterans. This
particular program aims to improve temporal processing
abilities, auditory memory, and sound discrimination abili-
ties by incorporating several different types of training
tasks targeting top-down and bottom-up processes. The
authors reported that use of this training program did not
result in any significant measurable improvements in any
auditory domains tested, including temporal resolution
or the perception of speech in noise. However, one reason
for the lack of any significant training effects may be what
739
 the authors characterized as low compliance with this reha-
bilitation option, such that the majority of study participants
completed less than 10 of the recommended 40 training
sessions over an 8-week period. Despite evidence from
previous studies that auditory training has the ability to
improve auditory processing abilities, results from Saunders
et al. (2018) suggest that any potential clinical benefits of
these programs may be limited by factors such as motiva-
tion to complete the recommended protocol.
In addition to assessing the effects of training on
auditory performance, Saunders et al. (2018) also assessed
the effects of a device-based rehabilitation option. Partici-
pants were provided with personal FM systems for use
during the 8-week study period. The authors reported that
these blast-exposed NH participants showed significant im-
provements in speech-in-noise perception when using the
FM systems. Furthermore, participants generally reported
significant subjective benefits when using the devices in
their daily lives, especially in situations that they previously
struggled in, such as listening in the classroom or while in
the car. These results provide some evidence that devices
aimed at improving the signal-to-noise ratio (SNR) of the
listening environment may be beneficial for at least some
individuals who report auditory processing difficulties
despite having normal audiometric hearing sensitivity. It
is also notable that there was a substantial difference in
compliance between FM systems and auditory training
as reported by Saunders et al. (2018), which is an important
consideration for clinical audiologists when choosing an
appropriate rehabilitation approach.
In addition to the use of FM systems, there is growing
interest in the potential for mild-gain hearing aids to im-
prove communication abilities in NH patients with auditory
difficulties. The thought is that providing a small boost of
amplification in combination with hearing aid processing
features, such as directional microphones and noise reduc-
tion algorithms, may simultaneously improve the audibility
of the auditory signal and increase the SNR to enhance
speech understanding and reduce listening effort. In addi-
tion to hearing aids, a number of personal sound amplifi-
cation products have recently been introduced and are
currently being marketed to people with essentially nor-
mal hearing as a way to improve hearing and speech un-
derstanding in noise, mostly by including noise reduction
algorithms and directional microphones (Bose Hearphones,
2019; Nuheara IQbuds BOOST, 2019). Though additional
studies exploring the efficacy of mild amplification for these
patients are greatly needed, available studies that have fo-
cused on NH adults with reported auditory difficulties,
including those with diagnosed auditory processing defi-
cits and/or a history of brain injury, suggest that these de-
vices hold promise (Kokx-Ryan et al., 2016; Roup et al.,
2018, 2020; Smart et al., 2007). For instance, a recent study
by Roup et al. (2018) provided mild-gain hearing aids to a
group of 17 NH adults with auditory difficulties, nine of
whom had a history of TBI. Subjective assessments and a
behavioral speech-in-noise measure were performed be-
fore and after a 4-week hearing aid trial. Following the
740 American Journal of Audiology • Vol. 29 • 738–761 • December 2020
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
trial, significant improvements were found in both perceived
hearing difficulties and performance on the speech-in-noise
task. These results mirror the findings of several individual
case studies of mild-gain hearing aids in NH adults with
measured auditory processing deficits, suggesting im-
provements in perceived and behaviorally measured audi-
tory performance (Roup et al., 2020; Smart et al., 2007).
However, it is notable that not all participants tested by
Roup et al. (2018) perceived benefit from the hearing aids.
In fact, the authors reported that two individuals indicated
that their symptoms were actually exacerbated by use of the
hearing aids, suggesting that use of mild-gain hearing aids is
not a panacea for rehabilitation in this patient population.
The research work described above provides initial
evidence that NH individuals who report significant auditory
issues may benefit from currently available auditory reha-
bilitation options. Although additional research is greatly
needed on the efficacy of these options and how various
patient-specific factors influence rehabilitation outcomes,
the present work is predicated on the idea that such research
would benefit from a better understanding of what reha-
bilitation options are being explored in real-world clinics
and whether audiologists feel that these solutions have
been successful for their patients. To this end, a question-
naire survey was conducted to gather information from
practicing audiologists across a wide range of occupational
settings regarding their current auditory rehabilitation
methods for this patient population and the successes and
failures of those efforts. Results from this questionnaire
survey will also provide an opportunity for a comparison
of whether practices tend to differ across clinical work
settings in the VA or Department of Defense (DoD) health
care systems compared to those in civilian sectors.
Method
Survey questions were developed based on informal
discussions with audiologists and a review of literature in-
cluding theoretical approaches to auditory rehabilitation.
The initial composite of questions was reviewed by a range
of content experts, including audiologists and research
scientists at the VA RR&D National Center for Rehabili-
tative Auditory Research and members of the VA/DoD
Auditory Processing Disorder Working Group, and revised
accordingly. An online questionnaire survey interface was
then created in Oregon Health and Science University’s
Research Electronic Data Capture, which is a secure web-
based research data collection and management system
with tools for creating, administering, and storing survey
data (Harris et al., 2009, 2019). The final questionnaire
survey consisted of several sections, including an introduc-
tion with questions about participants’ work settings and
patient populations followed by sections concerning hear-
ing aid fittings, the use of auditory training, and patient
follow-up. Since the intent of the questionnaire survey was
to gather data related to NH patients with reported speech
understanding and hearing difficulties, all questions specifi-
cally referred to this patient population. All survey questions

and additional details regarding participant response options
are provided in the Appendix. Participants were not re-
quired to respond to every question on the survey and were
instructed to skip sections if they did not perform a specific
type of rehabilitation. For example, participants could skip
the section on adult hearing aid fittings if they indicated that
they did not fit hearing aids on NH adults. Although the
survey included questions regarding the rehabilitation of
adult and pediatric patients, few respondents indicated see-
ing pediatric populations, and so responses to these ques-
tions were not further analyzed and are not reported here.
Potential respondents were notified of the online
survey via the following methods: (a) audiology e-mail
listservs within the VA and the DoD, (b) distribution of
business cards that provided a link and QR code to the
survey to attendees at professional audiology meetings and
conferences, and (c) inclusion of slides advertising the sur-
vey in presentations at professional audiology conferences.
All e-mails, business cards, or other forms of dissemination
requested that any practicing audiologist participate in the
questionnaire survey and also that recipients disseminate
it to colleagues who may have not previously received notice
of it. The questionnaire survey was open to participants
for a period of 4 months. No personal identifiable infor-
mation was collected from any of the participating audiol-
ogists, and no compensation was provided. This study
was reviewed and classified as exempt by the institutional
review board at the VA Portland Health Care System.
Statistical Analysis
To determine whether responses to particular survey
questions were dependent on whether respondents worked
in VA or DoD audiology clinics versus non-VA or non-
DoD audiology clinics, nonparametric chi-square tests with
α = .05 were used in R (R Core Team, 2014). Response
categories with estimated expected values of less than five
were removed from the analysis. When this practice re-
sulted in only one response category remaining for analy-
sis, a two-proportion z test was used. Chi-square analyses
were not completed for survey questions that allowed par-
ticipants to choose more than one option or response.
Table 1. Range of counts (and percentages) of responses for each
section of the questionnaire survey.
Section No. (%) of respondents
Introduction (13 questions) 142–208 (67.9–99.5)
Hearing Aids (11 questions) 104–110 (49.8–52.6)
Auditory Training (3 questions) 59–76 (28.2–36.4)
Patient Follow-Up (4 questions) 61–140 (29.2–67.0)
settings, incidence of patient encounters, the presence/absence
of specialists and protocols for auditory processing dis-
orders (APDs), and professional preference and patient
response to offered rehabilitation options. The majority of
participants who responded regarding their occupational
setting were audiologists who identified as working within
VA Medical Centers (n = 114), followed by those in private
practice (n = 25), non-VA hospitals (n = 20), and a range
of other settings such as otolaryngology clinics (n = 13),
DoD facilities or military hospitals (n = 13), and school/
educational locations (n = 9). The total number and per-
centage of respondents in each specific work setting are
provided in Table 2. When asked how often they encounter
patients who have communication difficulties despite
having normal or near-normal pure-tone hearing thresh-
olds, only one person reported that they never see this
type of patient, while nearly half of respondents reported
seeing between one and three such patients per month,
and an additional 23% of respondents reported seeing
four or more patients who fit this description per month
(Question 2; see Figure 1). Audiologists also reported
that many of these patients are dissatisfied after finding
out that they have clinically normal hearing thresholds
and are interested in rehabilitation options (Questions 3
and 12; see Figure 2). The majority of the respondents in-
dicated that they typically only serve adult patients (n = 139)
or a combination of adult and pediatric patients (n = 54),
while six participants reported serving only pediatric pa-
tients (Question 6). All subsequent results presented here
Table 2. Number (and percentage) of participating audiologists in
reported occupational settings in response to Question 1: “What is
your work setting?” (n = 208).

Results Occupational setting No. (%) of respondents

Survey questions were divided into four sections
Education/school setting 9 (4.3)
defined as Introduction, Hearing Aids, Auditory Training, ENT clinic 13 (6.3)
and Patient Follow-Up. The numbers of questions included Non-VA hospital 20 (9.6)
in each section and the numbers and percentages of respon- Nonresidential/outpatient clinic 4 (1.9)
dents completing questions within each section are pro- Private practice 25 (12.0)
VA Medical Centers 114 (54.8)
vided in Table 1. The complete survey is presented in the Other
Appendix. Overall, a total of 209 participants responded to DoD facility/military hospital 13 (6.3)
at least some portion of the survey. Nonprofit clinic 1 (0.5)
Research laboratory 1 (0.5)
University hospital 8 (3.8)
Introduction Questions
Note. ENT = ear, nose and throat; VA = Department of Veterans
Questions included in the introductory section of the Affairs; DoD = Department of Defense.
questionnaire survey evaluated factors such as occupational

Koerner et al.: Survey of Rehabilitation Options for NH Patients 741

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 Figure 1. Pie chart displaying the percentage of participant responses
to Question 2: “How often do you encounter patients who have
communication difficulties despite having normal or near normal
pure-tone hearing thresholds?” (n = 205).
focus specifically on questionnaire survey responses re-
garding the clinical care of adult patients.
For all questions related to rehabilitation recommen-
dations, respondents were specifically asked to reflect on
“adult patients who have normal hearing thresholds yet
have speech understanding/hearing difficulties.” The hearing-
related issues that audiologists rated as the most impor-
tant to address, the most frequently addressed, and the
easiest to address for this NH adult patient population are
presented in Table 3 (Question 11). Overall, respondents
rated the improvement of speech understanding followed
by the management of intolerance of noisy environments
as the most important and frequently addressed issues.
However, while clinicians indicated that speech under-
standing was the easiest to manage, tinnitus was ranked
Figure 2. Pie charts displaying the percentage of participant responses to (A) Question 3: “If you have encountered this type of patient in the
clinic, do you find that they are satisfied or dissatisfied with the appointment after finding out that they have clinically normal hearing thresholds?”
(n = 191) and (B) Question 12: “Do you find that these patients are interested in the treatment options you discuss with them?” (n = 142).
742 American Journal of Audiology • Vol. 29 • 738–761 • December 2020
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
as somewhat easier to address compared to intolerance
to noise.
Rehabilitation options offered to adults, as well as
respondents’ most preferred option for this patient popula-
tion, are presented in Table 4 (Questions 9 and 10). More
than 87% of respondents indicated that communication
counseling is offered to these patients, and nearly half in-
dicated that this is their preferred rehabilitation method.
This was followed by a preference for recommending hearing
aids, with or without FM systems. Participants also had the
option to select that they refer NH adults with auditory
difficulties to other professional specialties. When asked
to elaborate on where they refer patients, the majority of in-
dividuals reported that they refer to an APD specialist for
further testing. This result is consistent with the finding that,
when asked whether their clinics had an APD clinic or APD
specialist, approximately 66% of participants responded
that they did not, and 56% reported that their clinics did
not have an established APD protocol or model (Questions 6
and 7). Other referral sources noted by respondents included
speech-language pathology, otolaryngology, psychology,
and mental health. Participants also had the option to se-
lect “other” and to write in a response that was not provided
in the list of choices given. Several participants who elected
to write in a response to this selection mentioned that their
choices for rehabilitation depend on the needs and com-
plaints of the specific patient. Other participants mentioned
the use of a stepped, or tiered, type of approach in which
they start with counseling for effective communication strat-
egies, move to informal or formal auditory training as a
potential second option, and finally provide gentle ampli-
fication with a remote microphone or FM system for more
severe situations if the patient is still seeking out or in need
of additional management options at that point in time.
Hearing Aids
The questionnaire survey requested that participants
who fit hearing aids on NH adults with auditory difficulties
 Table 3. Number (and percentage) of responses to Questions 11a, 11b, and 11c.

11c. What hearing-related

11a. What hearing-related
issues do you think are the
most important to address
for these normal-hearing
adults? (n = 155)
Possible responses No. (%) of respondents
11b. What hearing-related
issues do you most frequently
attempt to address for these
normal-hearing adults?
(n = 153)
No. (%) of respondents
issues do you find are most
amenable to alleviation by your
preferred rehabilitation options
for these normal-hearing
adults? (n = 144)
No. (%) of respondents

Speech understanding 137 (88.4) 124 (81.0) 104 (72.2)

Intolerance of noisy environments 90 (58.1) 83 (54.2) 54 (37.5)
Tinnitus 63 (40.6) 71 (46.4) 61 (42.4)
Hyperacusis 28 (18.1) 17 (11.1) 9 (6.3)
Other 10 (6.5) 4 (2.6) 9 (6.3)

Note. Participants could select more than one response for each question. Total numbers of respondents for each question are provided
below each stated question.

answer a series of questions regarding details about their
hearing aid fitting procedures and thoughts on whether
their practices have been successful for this patient popu-
lation. Approximately 99% of responses indicated that
audiologists are fitting bilateral, open-fit, receiver-in-the-
canal hearing aids on these patients. There did not appear
to be an overall preference for a particular hearing aid
manufacturer, though responses indicated that Oticon,
Phonak, and ReSound were the three most commonly fit
hearing aid brands. In addition, the majority of partici-
pants (89.8%) responded that they most commonly fit high-
end devices in terms of technology level, as well as cost,
for this patient population.
Participants also had an opportunity to provide de-
tails about how they are programming and fitting hearing
aids on NH adult patients (Questions 15–20 and 24). Many
audiologists reported that they most often start program-
ming hearing aids by using the gain settings indicated by
prescriptive formulae. However, when given the opportunity
to include written comments regarding their fitting approach,
a number of audiologists reported that they typically start
with prescriptive gain targets but often provide about
5–10 dB additional insertion gain in mid to high frequencies
based on patient preference. In other words, audiologists
are finding that prescriptive formulae provide a good start-
ing point for fitting hearing aids on NH adults, but that
patient preference tends to dictate an additional boost in
gain. In addition, audiologists who provided additional
written responses noted that they minimize the maximum
power output of the devices for these NH patients. The
hearing aid processing features typically activated or pro-
vided for NH adults are shown in Figure 3 (Question 19),
with the most common being Bluetooth capabilities, followed
by directional microphones, volume control, and noise
reduction algorithms. Participants also reported commonly
providing both television and telephone streaming devices
for patients (Question 20), which is consistent with the
large proportion of respondents who reported utilizing

Table 4. Number (and percentage) of responses to Questions 9 and 10.

9. If you have encountered adults with normal

hearing thresholds who have difficulties
understanding speech, what is your preferred
rehabilitation strategy (please select
only one)? (n = 157)
Possible responses No. (%) of respondents
10. What types of rehabilitation options
do you offer for these adults (select
all that apply)? (n = 157)
No. (%) of respondents

Hearing aids 36 (22.9) 99 (63.1)

Remote microphone/FM system 14 (8.9) 85 (54.1)
Auditory training 7 (4.5) 49 (31.2)
Personal sound amplification products 0 (0.0) 26 (16.6)
Counseling 77 (49.0) 138 (87.9)
Referral 14 (8.9) 46 (29.3)
Other 6 (3.8) 0 (0.0)
None 0 (0.0) 7 (4.5)
Unsure 3 (1.9) 8 (5.1)

Note. Participants could only select one response for Question 9 and could select more than one response for Question 10. Total numbers
of respondents for each question are provided below each stated question.

Koerner et al.: Survey of Rehabilitation Options for NH Patients 743

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 Figure 3. Percentage of participant responses to Question 19:
“What hearing aid processing features have you activated/provided
for these adults (select all that apply)?” (n = 109).
Bluetooth technology for this patient population. In addi-
tion, although it was not a choice provided in the question-
naire survey, participants also wrote that they often provide
remote microphones to NH patients.
Details of responses regarding hearing aid retention
as well as efficacy and perceived benefits of hearing aids
for this patient population are provided in Figure 4 (Ques-
tions 21–23). Nearly half of respondents reported that more
than 75% of patients retain their hearing aids, with an
additional 14% indicating that more than half of their
clients do (see Figure 4A). However, the vast majority of
Figure 4. Percentage of participant responses to (A) Question 21: “How many of these adults keep the hearing aids?” (n = 109), (B) Question 22:
“Do you feel that these adults receive benefit from the hearing aids?” (n = 104), and (C) Question 23: “How do these adults with normal hearing
thresholds say that they benefit from the hearing aids (select all that apply)?” (n = 107).
744 American Journal of Audiology • Vol. 29 • 738–761 • December 2020
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
audiologists indicated that they believe these patients re-
ceive moderate to major benefit from hearing aid use (see
Figure 4B), with high proportions reporting improvements
in focus and attention, listening in noise, reduced fatigue, and
improvements in issues related to tinnitus (see Figure 4C).
Open-ended responses regarding clinician experiences with
fitting hearing aids in this patient population were gener-
ally quite positive (Question 24). However, a handful of
these comments also indicated that not all NH adults with
reported or measured communication difficulties may bene-
fit from mild-gain hearing aids and that there may be sub-
stantial variability in uptake and satisfaction across patients.
Selected quotations from this comment section are provided
in Figures 5 and 6.
Auditory Training
Participants who provide auditory training options
for NH patients were asked to answer several questions
about their protocol for auditory training and their success
with this approach. Of those respondents who indicated
that they provide auditory training, approximately 70% re-
ported that they suggest or provide computer-based audi-
tory training options over book-based or in-person training
options. Programs listed included, but were not limited to,
Listening and Communication Enhancement (Sweetow &
Sabes, 2006), Angel Sound (TigerSpeech Technology),
clEAR (Tye-Murray et al., 2012), and even the Hear
Coach (Starkey Hearing Technologies) listening games
application. In addition, several participants indicated
that they refer to a speech-language pathologist for reha-
bilitation with auditory training approaches. However, re-
sults showed that reported compliance with these training
methods is relatively low (Question 27; see Figure 7).
In addition, responses revealed that only approximately
4% of respondents indicated that their patients prefer
training-based rehabilitation over device-based approaches
(Question 29).
 Figure 5. Selection of quotations from participants that depict both positive and negative outcomes in regard to
fitting hearing aids on normal-hearing adults.

Patient Follow-Up patient (Questions 31b and 31a, respectively). Responses

Finally, participants were asked about their patient
follow-up practices for NH adults with auditory difficul-
ties. These responses are provided in Table 5 for situations
in which a rehabilitation option is and is not offered to a
revealed that a large proportion of these patients do not re-
ceive follow-up care unless initiated by the patient, though
approximately 72% of respondents indicated that they tend
to follow up with their NH adult patients about the same
amount as their patients with hearing loss (Question 31c).

Figure 6. Selection of quotations that depict audiologists’ perceptions of variability in success with the use of
hearing aids and the importance of normal-hearing adult patients’ willingness and motivation to use hearing
aids.

Koerner et al.: Survey of Rehabilitation Options for NH Patients 745

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 Figure 7. Pie chart depicting the percentage of participant responses
to Question 27: “How compliant are patients with sticking to the
recommended auditory training protocol?” (n = 59).
Lastly, participants were also asked how confident
they are that there are rehabilitation options that work for
NH adults with auditory difficulties (Question 30), to which
43% of respondents indicated a high level of confidence,
38% reported being neutral, and approximately 19% indi-
cated that they were not at all confident.
Comparison of Responses Across
Occupational Settings
Differences between military and civilian patient
populations could lead to differences in the numbers of
NH patients who report hearing difficulties and rehabilita-
tion options provided by clinicians reportedly employed
in VA and DoD locations (n = 127) compared to those in
non-VA/DoD settings (n = 81). However, the results of
chi-square analyses comparing responses provided by clini-
cians who reported working in either of these two occupa-
tional groups revealed no significant differences in these or
other factors probed by the questionnaire survey (see Table 6).
For those rehabilitation questions that allowed respon-
dents to choose more than one response option, clinicians
at VA/DoD locations reported similar rates of offered re-
habilitation options as their non-VA/DoD counterparts,
Table 5. Number (and percentage) of participant responses to Questions 31a and 31b.
31a. If you do not provide a rehabilitation option,
do you follow up with these adults?
(n = 121)
Possible responses No. (%) of respondents
Yes 24 (19.8)
No 15 (12.4)
Only if patient contacts the clinic 82 (67.8)
Note. Total numbers of respondents for each question are provided below each stated question.
746 American Journal of Audiology • Vol. 29 • 738–761 • December 2020
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
although higher percentages of the former group indicated
selecting high-cost and technology-level hearing aids com-
pared to the latter group (see Table 7).
Discussion
Using a questionnaire survey, this study gathered in-
formation about current audiological practices related to
NH patients who present with auditory complaints from
clinicians across a wide range of work settings. Our results
revealed that it is not uncommon for audiologists to en-
counter such patients and that the proportion of audiologists
who report seeing these types of patients is not dependent
on work setting (i.e., VA/DoD audiology clinics vs. civilian
health care settings; see Table 6). These results are consis-
tent with previous reports that have indicated a high preva-
lence of normal hearing thresholds in both civilians and
Veterans seeking hearing health care (Billings et al., 2018;
Hannula et al., 2011; Parthasarathy et al., 2020; Spankovich
et al., 2018; Tremblay et al., 2015). In addition, question-
naire survey results showed that common auditory com-
plaints from NH adult patients involve issues understanding
speech and intolerance of noisy environments (see Table 3),
which is consistent with previous literature reporting mea-
surable deficits in auditory domains, including speech per-
ception in noise, temporal resolution, and dichotic listening
abilities in various NH patient populations (Fuente et al.,
2013, 2006; Gopal, 2008; Helfer & Vargo, 2009; Kumar
et al., 2012; Musiek et al., 2005; Spankovich et al., 2018).
Taken together, these findings further reinforce the need
to develop specific clinical guidelines and protocols for
efficiently managing communication difficulties in these
NH individuals.
Audiologists reported that a large proportion of their
patients are dissatisfied after learning that they have normal
hearing sensitivity and that their NH adult patients are gen-
erally interested in learning about potential rehabilitation
options for their auditory difficulties. This suggests that au-
diologists should reconsider their practices and not assume
that further care is unnecessary after informing these pa-
tients that they have “normal hearing.” These patients
may not feel as if their needs have been met by standard
audiometric test batteries, and despite learning that they
have normal peripheral hearing sensitivity, they may still
31b. If you do provide a rehabilitation option,
do you follow up with these adults?
(n = 125)
No. (%) of respondents
58 (46.4)
7 (5.6)
60 (48.0)
 Table 6. Chi-square test statistics and corresponding p values to test associations between questionnaire survey responses and reported
occupational setting (VA/DoD audiology clinics vs. non-VA/DoD audiology clinics) for selected survey questions of interest.

Question χ2 p

2: How often do you encounter patients who have communication difficulties despite having normal or near normal 1.32 .52
pure-tone hearing thresholds?
3: If you have encountered this type of patient in the clinic, do you find that they are satisfied or dissatisfied with the 4.05 .13
appointment after finding out that they have clinically normal hearing thresholds?
7: Does your work setting have an APD clinic or APD specialist? 1.45 .23
8: Does your work setting have an APD protocol/model? 0.99 .32
9: If you have encountered adults with normal hearing thresholds who have difficulties understanding speech, what 0.00 1.00
is your preferred rehabilitation strategy (please select only one)?
12: Do you find that these patients are interested in the treatment options you discuss with them? 3.07 .21
21: How many of these adults keep the hearing aids?a 0.06 .81
22: Do you feel that these adults receive benefit from the hearing aids? 1.97 .16
27: How compliant are patients with sticking to the recommended auditory training protocol? 0.07 .96
30: How confident do you feel that there are rehabilitation options that work for these adults? 1.24 .54

Note. VA = Department of Veterans Affairs; DoD = Department of Defense; APD = auditory processing disorder.
a
Represents situation in which a two-proportion z test was used to test for differences in the proportion of respondents who indicated that
75%–100% of patients retain their hearing aids.

feel that their hearing difficulties are severe enough to war-
rant seeking out management options. This situation is well
described by a case study by Smart et al. (2007), which de-
tailed the story of an adult who sought out audiological
care after noticing hearing difficulties for several years.
Smart et al. reported that the patient’s initial audiological
evaluation revealed normal hearing thresholds and that
they were subsequently sent away with no explanation re-
garding their reported hearing difficulties. After struggling
for an additional year, the patient sought out re-evaluation
from an audiologist who decided to pursue APD testing,
which revealed that the patient had central auditory pro-
cessing deficits. Following counseling in communication
strategies, the patient continued to report difficulties that
were impacting daily life. She was then offered mild-gain
hearing aids with an FM system, which provided both sub-
jective and objective improvements in communication, espe-
cially in the classroom setting where the patient had been

Table 7. Percentage of participant responses across reported occupational setting (VA/DoD audiology clinics vs. non-VA/DoD audiology clinics)
to selected survey questions of interest that allowed participants to select more than one response option.

Question VA/DoD audiologists (%) Non-VA/DoD audiologists (%)

10. What types of rehabilitation options do you offer these adults

(select all that apply)?
Hearing aids 65.0 60.4
Remove microphone/FM system 54.4 54.7
Auditory training 19.4 54.7
Personal sound amplification products 17.5 15.1
Counseling 87.4 88.7
Referral 28.2 30.2
Other 0.0 0.0
None 5.8 1.9
Unsure 6.8 1.9
15. What types of hearing aids do you usually fit (select all that apply)?
Manufacturer
Oticon 60.8 67.7
Phonak 50.6 64.5
ReSound 68.4 45.2
Siemens 34.2 32.3
Starkey 24.1 32.3
Widex 7.6 29.0
Other 1.3 6.5
Cost/technology level
Low 1.3 51.6
Mid 3.9 71.0
High 96.1 74.2

Note. VA = Department of Veterans Affairs; DoD = Department of Defense.

Koerner et al.: Survey of Rehabilitation Options for NH Patients 747

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 having the most difficulty (Smart et al., 2007). This case
example highlights the importance of continuing to seek out
acceptable solutions for each and every patient who reports
significant communication problems and who is interested
in pursuing rehabilitation, regardless of their audiometric
thresholds, as there may be options available that can sig-
nificantly improve a patient’s function and quality of life.
Results from the current questionnaire survey revealed
that many audiologists do feel that, based upon their clini-
cal experience, there are rehabilitation options that may
help manage auditory and communication issues in NH
adults. While results showed that the majority of responding
audiologists are providing some form of rehabilitation for
these patients, almost 4.5% of responses indicated that, in
some cases, no intervention is being offered, and approxi-
mately 5% of responses indicated that, in some cases, the
audiologist is unsure of what to offer (see Table 5). Inter-
vention guidelines have been published by the American
Speech-Language-Hearing Association (2005) and the
American Academy of Audiology (2010) as resources for
clinicians working with patients who have APDs. These
documents provide basic information and recommendations
about the general use of personal FM systems, auditory
training, and counseling on environmental modifications
and compensatory strategies and represent useful resources
for audiologists who are interested in or are already pro-
viding rehabilitation options for their NH patients. How-
ever, as the results of the current study demonstrate, there
is a need for more comprehensive, evidence-based reha-
bilitation guidelines and individualized protocols for use
in the clinic. To establish these clinical protocols, larger
randomized controlled trials are needed in order to more
thoroughly understand how different rehabilitation op-
tions, including the use of mild-gain amplification, might
be effective in improving communication across different
individuals within this unique patient population. This
work collected important details regarding experiences
and feedback from clinical audiologists on the use and
success of different rehabilitation approaches for serving
NH adults with auditory difficulties. This information is
integral to the development of robust randomized con-
trolled trials to examine the efficacy of these rehabilita-
tion methods, such as the use of mild-gain amplification or
auditory training, and will help to guide future research in
this area.
Hearing Aids
Questionnaire survey results showed that many audi-
ologists are fitting low-gain hearing aids on NH adults
with auditory difficulties (see Table 4) and that most re-
spondents find them to be very effective for their patients
(see Figure 4). In general, the majority of participants
reported using hearing aid selection and fitting methods
similar to those described by Roup et al. (2018), which
were shown to reduce subjective reports of hearing diffi-
culty and improve speech understanding in noise in their
NH adult participants, including those with a history of
748 American Journal of Audiology • Vol. 29 • 738–761 • December 2020
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
TBI. These choices included bilateral, open-fit, receiver-in-
the-canal aids with directional microphones, noise reduc-
tion algorithms, and Bluetooth capabilities to allow for
use of accessories (see Figure 3). Amplification used by
Roup et al. (2018) provided 5–10 dB of insertion gain
for all participants between 1 and 4 kHz for soft and con-
versational level sounds, provided no gain for loud inputs,
and set the maximum power output so that it would not
exceed 100 dB SPL for any input.
A high proportion of respondents from the current
questionnaire survey reported that high-end hearing aid
devices are typically chosen for this patient population. It
is not surprising that approximately 96% of VA audiolo-
gists are fitting high-end devices, as they primarily have
premier-level hearing aids on contract with manufacturers
and are therefore not typically able to select lower- or mid-
level devices for their patients. In addition, Veteran pa-
tients do not have to pay out of pocket for these devices.
However, results showed that a high percentage (74.2%) of
non-VA/DoD audiologists are also fitting high-end devices
on NH adult patients (see Table 7). Comments from par-
ticipating audiologists revealed some indication for why
higher- or mid-level devices are being chosen for NH indi-
viduals. Several audiologists mentioned that higher-end
devices tend to have lower internal hearing aid processing
noise, which is less likely to be perceived by NH users.
Additional responses indicated that NH patients may be
more able to take advantage of additional features and
frequency bands for processing that are available in higher-
end devices than patients with hearing impairment. Simi-
larly, the number of responses from audiologists indicating
that expansion is often activated when fitting hearing
aids on their NH patients provided additional information
about a hearing aid fitting strategy that has not yet been
described in research on this topic. Expansion, the opposite
of compression, is used to limit the amplification of un-
wanted low-level inputs, such as environmental sounds or
even internal processing noise from the hearing aids. Taken
together, these responses showed that clinicians are recog-
nizing that their NH patients may perceive internal hearing
aid processing noise and find it undesirable and that they
are seeking out options for limiting the presence and per-
ception of that unwanted signal.
While many hearing aid processing features were
noted as being activated for this patient population, such
as noise reduction and directional microphones, the most
commonly reported feature was related to Bluetooth tech-
nology (see Figure 3). Research on rehabilitation options
for individuals with normal hearing and communication
difficulties has shown that devices that improve the SNR
of the listening environment can provide both subjective
and objective improvements in auditory abilities and com-
munication (Saunders et al., 2018; Smart et al., 2007). Re-
sults from this questionnaire survey suggest that clinical
audiologists are also noticing the benefit that these devices
provide patients, as many indicated activating Bluetooth
technology and providing remote microphones to patients
and devices to wirelessly stream TV and phone signals.
 Although responses indicated that the majority of Auditory Training
NH adults are keeping the hearing aids prescribed to them,
Fewer audiologists who participated in the question-
it is well known that ownership of hearing aids does not
naire survey indicated that they generally offer or prefer
necessarily indicate that an individual is using the hearing
to offer auditory training for their NH patients with com-
aids or finding them beneficial (Kochkin, 2007). However,
munication difficulties compared to device-based rehabilita-
responses from audiologists suggest that their patients are
tion methods (see Table 1). In fact, while auditory training
reporting major benefit from the hearing aids and that
approaches were reported as being offered by approximately
benefit is perceived through improved focus and attention,
31% of responding audiologists, only 4.5% reported that
reduced fatigue, as well as improved performance in noisy
this was their most preferred option (see Table 4). Partici-
environments and even improved issues related to tinnitus
pants indicated a wide range of computer-based programs
(see Figure 4). These findings are consistent with data from
when asked what kinds of auditory training options they
two clinical trials (Humes et al., 2019, 2017), which showed
offer their patients. However, while the literature on the
that individuals with self-reported hearing difficulties re-
use of auditory training for NH adults with reported com-
ceived similar amounts of hearing aid benefit regardless of
munication difficulties is limited (Musiek et al., 2004;
whether their audiometric hearing thresholds were categorized
Saunders et al., 2018), responses from the current question-
as “normal,” “mild,” or “moderate” (Humes, 2019). In an
naire survey suggest that NH adult patients are currently
open-ended response section of the survey, participating
not as successful with this rehabilitation approach com-
audiologists were asked to provide general comments re-
pared to device-based strategies. For instance, similar to
garding their hearing aid fitting procedures, experiences in
results from Saunders et al. (2018), participants in the cur-
fitting hearing aids in this patient population, or any other
rent questionnaire survey indicated that patient compliance
considerations that they would like to mention. While many
with training programs is generally quite low.
participants provided positive comments about how their
Auditory training systems that have used syllable-,
NH adult patients have been successful with the hearing aids,
word-, and sentence-level stimuli have been shown to be
not all of the comments provided by participants regarding
effective in improving both the neural coding and percep-
fitting hearing aids on this population were positive in na-
tion of speech across participants with normal or near-
ture (see Figure 5). Some comments suggested that success
normal hearing sensitivity (Kraus et al., 1995; Song et al.,
with this particular auditory rehabilitation option may be
2012; Tremblay et al., 1997). However, these benefits are
highly dependent on individual needs and motivation (see
limited if, in non-research settings, individuals do not feel
Figure 6). Similarly, although Roup et al. (2018) noted that
motivated or perceive enough benefit to spend time and
the majority of their NH participants had both subjective
effort on the training programs. Research focused on bet-
and objective improvements in communication and speech
ter understanding how different aspects of training programs
understanding at the end of their hearing aid trial, when given
can promote learning has suggested that programs re-
the choice to purchase the hearing aids after the research
quire active participation, immediate feedback, and varied
study, only three of the 17 participants chose to do so. Roup
stimuli that adapt to patients’ performance in increased
et al. (2018) reported that the participants who did choose
cognitive or sensory demands (Green & Bavelier, 2008). In
to purchase the aids were those who had the poorest perfor-
addition, as mentioned in critiques of the auditory training
mance on the pretest measures, noted significant improve-
program used by Saunders et al. (2018), programs must
ment while wearing the aids, and tended to wear the hearing
use reinforcement techniques that are age appropriate and
aids more than other participants. These results from Roup
motivating for the target user population. New developments
et al. (2018), as well as the comments from some of the audi-
aimed at gamifying training programs may overcome
ologists who participated in our questionnaire survey, sug-
some of the limitations of current computer-based training
gest that subjective hearing aid–related improvements in
protocols, as they tend to include these desirable game
communication abilities for some NH individuals may not
designs in addition to being entertaining and enjoyable
be significant enough to actually warrant purchasing or
(Deveau et al., 2015; Green & Seitz, 2015; Whitton et al.,
consistently using the hearing aids. Individual case studies
2014). For instance, a typical, repetitive speech discrimina-
reported by Smart et al. (2007) and Roup et al. (2020) also
tion task that is often employed in traditional auditory
noted reported and measured improvements in communi-
training programs may be enhanced by improved graphics,
cation and speech understanding with hearing aids and/or
an interesting story or common goal or puzzle that the
FM systems but did not note that their NH patients returned
user must complete, rewards for faster response times or
or did not use the hearing aids. However, patients in these
correct responses, and the progression to more difficult
studies had been actively seeking out treatment and were
levels leading to larger rewards.
likely highly motivated to explore and utilize different man-
agement options for their specific needs. In other words, simi-
lar to traditional individuals with hearing impairment who
consider using hearing aids (Hickson et al., 2014; Sawyer Counseling
et al., 2019), it is likely that a major indicator of success While counseling strategies were not a main focus
with hearing aids for NH individuals may be acceptance, of the questionnaire survey, participating audiologists re-
motivation, and willingness to use the devices. ported that they most commonly offer and most strongly

Koerner et al.: Survey of Rehabilitation Options for NH Patients 749

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 prefer counseling on effective communication strategies
for NH adult patients who report auditory difficulties. In
the previously discussed randomized controlled trial by
Saunders et al. (2018), all NH blast-exposed Veterans in
each treatment group received a 10- to 15-min one-on-one
session with an audiologist who went through brochures
on auditory processing and effective communication strate-
gies. Results of that study revealed that, while about 75% of
participants reported reading the brochures, less than
50% reported finding them useful or utilizing any of the
suggestions outlined during counseling. It may be that
practicing clinicians refine their counseling approaches to
be more effective with individual patients compared to the
methods used in the study by Saunders et al. (2018), which
may result in better outcomes for these real-world pa-
tients. Indeed, when given the chance to expand on their
responses to questions regarding offered and preferred
rehabilitation options, several audiologists reported that
their choices are actually highly dependent on the indi-
vidual needs of each NH patient and, similar to the case
study by Smart et al. (2007), that a stepped approach is
often used for management. In this stepped approach, an
NH patient might start by receiving counseling for effec-
tive communication strategies but may be encouraged to
return to the clinic if communication difficulties persist
after receiving counseling so that other options like audi-
tory training or even mild-gain hearing aids could be trialed.
One potential drawback of this strategy is that patients
may not return to the same clinic for additional help if
they continue to perceive difficulties after counseling be-
cause they feel frustrated with the outcome or feel as if
their needs have not been adequately met by the clinician.
Therefore, structuring counseling in such a way that a
“tiered” approach to rehabilitation is clearly discussed
with the patient may be a good consideration for this par-
ticular approach.
Limitations and Future Directions
An important consideration in the current study is
that questionnaire survey respondents comprised a conve-
nience sample rather than a random sample of audiolo-
gists. Therefore, it is likely that clinicians who more often
encounter NH adults with reported hearing difficulties
were more likely to complete the survey. Though this may
skew the results regarding how often the average audiolo-
gist encounters such a patient, these are specifically the
types of audiologists that we hoped to target to gather in-
formation related to current clinical rehabilitation practices
for this population.
Some potentially important facets of rehabilitation
for NH adults with reported hearing difficulties that may
be valuable to further investigations were not included in
this study. For example, it could be useful to know what
audiologists who suggest computer-based auditory training
programs tend to prefer about certain programs in terms
of specific features, tasks, or training designs and whether
patients who do comply with training programs show or
750 American Journal of Audiology • Vol. 29 • 738–761 • December 2020
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
report improved auditory performance following training.
It would have also been useful to gain information about
whether audiologists are noting any specific patient char-
acteristics that seem to predict success with a particular
method and which may lead them toward choosing between
training-based or device-based rehabilitation options for
individual NH patients. This information could be beneficial
to other clinical audiologists who are currently unsure of
what commercially available programs they should suggest
for certain NH patients with auditory concerns. Knowledge
gained from these types of questions may have informed
the design of future studies on the effects of auditory train-
ing in this clinical population by allowing researchers to
pinpoint certain features of training programs that are
liked by clinicians and NH patients, and which may poten-
tially contribute to improved posttraining communication
abilities.
In addition, while the clinical assessment or identifi-
cation of the underlying cause of patients’ auditory diffi-
culties was not a focus of the current questionnaire survey,
these types of questions could have provided useful infor-
mation about how different patient characteristics might
impact success with different management options. For ex-
ample, it could have been useful to gather information from
audiologists about how many of their NH patients typi-
cally have diagnosed auditory processing difficulties at the
time of intervention and whether a clinically measured def-
icit in this area impacts their choice of management plan.
It could have also been useful to gather information about
the prevalence of other related diagnoses that may contrib-
ute to reported auditory difficulties, such as a TBI, and
whether these diagnoses tend to impact patients’ success
with different rehabilitation methods. Future work in this
area should focus on how outcomes for different rehabili-
tation options may be differentially impacted by various
patient characteristics. This knowledge will be integral to
the development of more comprehensive and more individ-
ualized clinical rehabilitation guidelines for NH patients
with auditory difficulties.
It is important to note that detailed knowledge about
the amount of benefit and type of benefit that NH adult
patients receive from hearing aids is limited by the fact that
this information was not elicited from actual patients who
were using the hearing aids, but rather from their audiolo-
gists who were providing general responses in reference
to their NH patient population. For instance, it is difficult
to conclude how hearing aid technology level, activated
hearing aid features, or chosen hearing aid accessories re-
late to the amount or type of benefit that NH adults receive
from these devices using the data from this questionnaire
survey, particularly given that a substantial proportion of
audiologists reported providing follow-up only when initi-
ated by the patient. Additional surveys of patient satisfac-
tion with device-based interventions would help to provide
a fuller picture of the efficacy of these options in this pa-
tient population. Ideally, more comprehensive, large-scale
randomized controlled trials should be developed to assess
the effects of different hearing aid fitting strategies and
 processing features on auditory and speech communica-
tion across NH adults with hearing difficulties.
In addition, when given an open space to provide
comments, several participants mentioned that there is a
need for better outcome measures and validation tools to
assess success with rehabilitation options for NH patient
populations. Documenting patient benefit, or lack thereof,
with a particular rehabilitation method and ensuring that
any positive outcomes are maintained over time is para-
mount to providing well-rounded patient-centered care.
Therefore, in addition to being needed to assess the effects
of different rehabilitation strategies in future research
work, reliable validation tools are also needed in the clinic
for standard patient care. Ongoing research that focuses on
better understanding central processing mechanisms that
underlie speech understanding and auditory deficits in NH
individuals is integral to the development of new tools to
better identify and assess auditory processing and com-
munication difficulties in this unique patient population.
Future research in this area should focus on making these
tools clinically applicable so that both clinical audiologists
and researchers can efficiently and reliably measure and
document benefit with various rehabilitation methods.
Conclusions
This study aimed to gather information from clini-
cal audiologists about what types of auditory rehabilitation
options are currently being provided for adult patients
with normal peripheral hearing sensitivity who report sub-
stantial communication issues and whether these methods
have been successful. While this work did not specifically
request that participants provide their thoughts regarding
the cause of auditory difficulties in the NH patients they
typically serve, results suggest that some available auditory
rehabilitation methods may be useful for NH individuals,
including those with a history of TBI. Future work will
focus on the development of a large randomized controlled
trial aimed at examining the interaction of patient-specific
factors on the efficacy of auditory rehabilitation options
in NH adults with reported auditory issues. This will allow
for the development of more focused, evidence-based pro-
tocols for auditory rehabilitation in this population and
clinical candidacy guidelines for better predicting what
types of rehabilitation options may benefit various patient
populations.
Acknowledgments
Funding is provided by a VA Advanced Fellowship in
Polytrauma/Traumatic Brain Injury Rehabilitation Research to
T. K. Koerner. REDCap is supported by Oregon Clinical and
Translational Research Institute Grant UL1TR002369. We would
especially like to thank all of the audiologists who responded to
this questionnaire survey for their time and effort in helping us
complete this research study. We would also like to thank col-
leagues at the National Center for Rehabilitative Auditory Research
and the Department of Veterans Affairs/Department of Defense
Auditory Processing Disorder Working Group for providing
Koerner et al.: Survey of Rehabilitation Options for NH Patients
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
feedback and suggestions regarding early versions of the question-
naire survey questions.
References
American Academy of Audiology. (2010, August). American Acad-
emy of Audiology clinical practice guidelines: Diagnosis,
treatment, and management of children and adults with central
auditory processing disorder.
American Speech-Language-Hearing Association. (2005). Technical
report: (Central) auditory processing disorders. http://www.asha.
org/policy
Anderson, S., & Kraus, N. (2013). Auditory training: Evidence for
neural plasticity in older adults. SIG 6 Perspectives on Hearing
and Hearing Disorders: Research and Diagnostics, 17(1), 37–57.
https://doi.org/10.1044/hhd17.1.37
Bergemalm, P. O., & Lyxell, B. (2005). Appearances are decep-
tive? Long-term cognitive and central auditory sequelae from
closed head injury. International Journal of Audiology, 44(1),
39–49. https://doi.org/10.1080/14992020400022546
Billings, C. J., Dillard, L. K., Hoskins, Z. B., Penman, T. M., &
Reavis, K. M. (2018). A large-scale examination of veterans
with normal pure-tone hearing thresholds within the Depart-
ment of Veterans Affairs. Journal of the American Academy of
Audiology, 29(10), 928–935. https://doi.org/10.3766/jaaa.17091
Bose Hearphones. (2019). [Homepage]. https://www.bose.com/
en_us/products/wellness/conversation_enhancing_headphones/
hearphones.html#v=hearphones_black
Burk, M. H., & Humes, L. E. (2008). Effects of long-term training
on aided speech-recognition performance in noise in older
adults. Journal of Speech, Language, and Hearing Research,
51(3), 759–771. https://doi.org/10.1044/1092-4388(2008/054)
Callahan, M. L., & Storzbach, D. (2019). Sensory sensitivity and
posttraumatic stress disorder in blast exposed veterans with
mild traumatic brain injury. Applied Neuropsychology: Adult,
26(4), 356–373. https://doi.org/10.1080/23279095.2018.1433179
Centers for Disease Control and Prevention, National Center for
Injury Prevention and Control. (2019). TBI-related emergency
department visits, hospitalizations, and deaths. https://www.cdc.gov/
traumaticbraininjury/data/tbi-edhd.html
Deveau, J., Jaeggi, S. M., Zordan, V., Phung, C., & Seitz, A. R.
(2015). How to build better memory training games. Frontiers
in Systems Neuroscience, 8, 243. https://doi.org/10.3389/fnsys.
2014.00243
Edwards, B. (2020). Emerging technologies, market segments, and
MarkeTrak 10 insights in hearing health technology. Seminars
in Hearing, 41(01), 037–054. https://doi.org/10.1055/s-0040-
1701244
Fuente, A., McPherson, B., & Hickson, L. (2013). Auditory dys-
function associated with solvent exposure. BMC Public Health,
13(1), Article 39. https://doi.org/10.1186/1471-2458-13-39
Fuente, A., McPherson, B., Muñoz, V., & Pablo Espina, J. (2006).
Assessment of central auditory processing in a group of workers
exposed to solvents. Acta Oto-Laryngologica, 126(11), 1188–1194.
https://doi.org/10.1080/00016480600681585
Gallun, F. J., Diedesch, A. C., Kubli, L. R., Walden, T. C., Folmer,
R. L., Lewis, M. S., McDermott, D. J., Fausti, S. A., & Leek,
M. R. (2012). Performance on tests of central auditory process-
ing by individuals exposed to high-intensity blasts. Journal of
Rehabilitation Research and Development, 49(7), 1005–1024.
https://doi.org/10.1682/JRRD.2012.03.0038
Gallun, F. J., Lewis, M. S., Folmer, R. L., Hutter, M., Papesh,
M. A., Belding, H., & Leek, M. R. (2016). Chronic effects of
exposure to high-intensity blasts: Results on tests of central
751
 auditory processing. Journal of Rehabilitation Research and
Development, 53(6), 705–720. https://doi.org/10.1682/JRRD.
2014.12.0313
Gopal, K. (2008). Audiological findings in individuals exposed to
organic solvents: Case studies. Noise & Health, 10(40), 74–82.
https://doi.org/10.4103/1463-1741.44345
Green, C., & Bavelier, D. (2008). Exercising your brain: A review
of human brain plasticity and training-induced learning. Psy-
chology and Aging, 23(4), 692–701. https://doi.org/10.1037/
a0014345
Green, C., & Seitz, A. R. (2015). The impacts of video games on
cognition (and how the government can guide the industry).
Policy Insights from the Behavioral and Brain Sciences, 2(1),
101–110. https://doi.org/10.1177/2372732215601121
Hannula, S., Bloigu, R., Majamaa, K., Sorri, M., & Mäki-Torkko,
E. (2011). Self-reported hearing problems among older adults:
Prevalence and comparison to measured hearing impairment.
Journal of the American Academy of Audiology, 22(8), 550–559.
https://doi.org/10.3766/jaaa.22.8.7
Harris, P. A., Taylor, R., Minor, B. L., Elliott, V., Fernandez, M.,
O’Neal, L., McLeod, L., Delacqua, G., Delacqua, F., Kirby, J.,
& Duda, S. N. (2019). The REDCap consortium: Building an
international community of software platform partners. Journal
of Biomedical Informatics, 95, 103208. https://doi.org/10.1016/
j.jbi.2019.103208
Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N.,
& Conde, J. G. (2009). Research electronic data capture
(REDCap)—A metadata-driven methodology and workflow
process for providing translational research informatics sup-
port. Journal of Biomedical Informatics, 42(2), 377–381. https://
doi.org/10.1016/j.jbi.2008.08.010
Helfer, K. S., & Vargo, M. (2009). Speech recognition and tempo-
ral processing in middle-aged women. Journal of the American
Academy of Audiology, 20(4), 264–271. https://doi.org/10.3766/
jaaa.20.4.6
Hickson, L., Meyer, C., Lovelock, K., Lampert, M., & Khan, A.
(2014). Factors associated with success with hearing aids in
older adults. International Journal of Audiology, 53(Suppl. 1),,
S18–S27. https://doi.org/10.3109/14992027.2013.860488
Hoover, E. C., Souza, P. E., & Gallun, F. J. (2017). Auditory and
cognitive factors associated with speech-in-noise complaints
following mild traumatic brain injury. Journal of the American
Academy of Audiology, 28(4), 325–339. https://doi.org/10.3766/
jaaa.16051
Humes, L. (2019). Hearing loss severity and OTC hearing aids:
Larry Humes comments on article by Leavitt, Bentler & Flexer.
The Hearing Review. https://www.hearingreview.com/hearing-
products/hearing-aids/otc/letters-hearing-loss-severity-otc-
hearing-aids-larry-humes-comments-article-leavitt-bentler-
flexer
Humes, L. E., Kinney, D. L., Main, A. K., & Rogers, S. E. (2019).
A follow-up clinical trial evaluating the consumer-decides service
delivery model. American Journal of Audiology, 28(1), 69–84.
https://doi.org/10.1044/2018_AJA-18-0082
Humes, L. E., Rogers, S. E., Quigley, T. M., Main, A. K., Kinney,
D. L., & Herring, C. (2017). The effects of service-delivery
model and purchase price on hearing-aid outcomes in older
adults: A randomized double-blind placebo-controlled clinical
trial. American Journal of Audiology, 26(1), 53–79. https://doi.
org/10.1044/2017_AJA-16-0111
Iliadou, V. (Vivian), Apalla, K., Kaprinis, S., Nimatoudis, I., Kaprinis,
G., & Iacovides, A. (2013). Is central auditory processing dis-
order present in psychosis? American Journal of Audiology,
752 American Journal of Audiology • Vol. 29 • 738–761 • December 2020
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
22(2), 201–208. https://doi.org/10.1044/1059-0889(2013/
12-0073)
Knoll, R. M., Herman, S. D., Lubner, R. J., Babu, A. N., Wong, K.,
Sethi, R. K. V., Chen, J. X., Rauch, S. D., Remenschneider,
A. K., Jung, D. H., & Kozin, E. D. (2019). Patient-reported
auditory handicap measures following mild traumatic brain in-
jury. The Laryngoscope, 130(3), 761–767. https://doi.org/10.1002/
lary.28034
Kochkin, S. (2007). MarkeTrak VII: Obstacles to adult non-user
adoption of hearing aids. The Hearing Journal, 60(4), 24–51.
https://doi.org/10.1097/01.HJ.0000285745.08599.7f
Kokx-Ryan, M., Nousak, J. M., Jackson, J. C., DeGraba, T.,
Brungart, D. S., & Grant, K. W. (2016). Improved management
of patients with auditory processing deficits fit with low-gain
hearing aids [Paper presentation]. International Hearing Aid
Research Conference,, Lake Taho, CA, United States.
Kraus, N., Lindley, T., Colegrove, D., Krizman, J., Otto-Meyer, S.,
Thompson, E. C., & White-Schwoch, T. (2017). The neural leg-
acy of a single concussion. Neuroscience Letters, 646, 21–23.
https://doi.org/10.1016/j.neulet.2017.03.008
Kraus, N., McGee, T., Carrell, T. D., King, C., Tremblay, K., &
Nicol, T. (1995). Central auditory system plasticity associated
with speech discrimination training. Journal of Cognitive Neuro-
science, 7(1), 25–32. https://doi.org/10.1162/jocn.1995.7.1.25
Kraus, N., Thompson, E. C., Krizman, J., Cook, K.,
White-Schwoch, T., & LaBella, C. R. (2016). Auditory biologi-
cal marker of concussion in children. Scientific Reports, 6(1),
Article 39009. https://doi.org/10.1038/srep39009
Kubli, L. R., Brungart, D., & Northern, J. (2018). Effect of blast
injury on auditory localization in military service members.
Ear and Hearing, 39(3), 457–469. https://doi.org/10.1097/AUD.
0000000000000517
Kumar, U. A., Ameenudin, S., & Sangamanatha, A. V. (2012).
Temporal and speech processing skills in normal hearing in-
dividuals exposed to occupational noise. Noise & Health,
14(58), 100–105.
Loo, J. H. Y., Rosen, S., & Bamiou, D.-E. (2016). Auditory train-
ing effects on the listening skills of children with auditory pro-
cessing disorder. Ear and Hearing, 37(1), 38–47. https://doi.org/
10.1097/AUD.0000000000000225
Miller, S. E., Zhang, Y., & Nelson, P. B. (2016). Efficacy of
multiple-talker phonetic identification training in postlingually
deafened cochlear implant listeners. Journal of Speech, Language,
and Hearing Research, 59(1), 90–98. https://doi.org/10.1044/
2015_JSLHR-H-15-0154
Musiek, F. E., Baran, J. A., & Shinn, J. (2004). Assessment and
remediation of an auditory processing disorder associated with
head trauma. Journal of the American Academy of Audiology,
15(2), 117–132. https://doi.org/10.3766/jaaa.15.2.3
Musiek, F. E., Shinn, J. B., Jirsa, R., Bamiou, D.-E., Baran, J. A.,
& Zaida, E. (2005). GIN (Gaps-In-Noise) Test performance
in subjects with confirmed central auditory nervous system
involvement. Ear and Hearing, 26(6), 608–618. https://doi.org/
10.1097/01.aud.0000188069.80699.41
Nuheara IQbuds BOOST. (2019). [Homepage]. https://www.
nuheara.com/products/iqbuds-boost/
Oleksiak, M., Smith, B. M., St. Andre, J. R., Caughlan, C. M., &
Steiner, M. (2012). Audiological issues and hearing loss among
Veterans with mild traumatic brain injury. Journal of Rehabili-
tation Research and Development, 49(7), 995–1004. https://doi.
org/10.1682/JRRD.2011.01.0001
Olson, A. D., Preminger, J. E., & Shinn, J. B. (2013). The effect
of LACE DVD training in new and experienced hearing aid
 users. Journal of the American Academy of Audiology, 24(3),
214–230. https://doi.org/10.3766/jaaa.24.3.7
Papesh, M. A., Theodoroff, S. M., & Gallun, F. J. (2018). Trau-
matic brain injury and auditory processing. In M. Fagelson &
D. M. Baguley (Eds.), Hyperacusis and disorders of sound intol-
erance: Clinical and research perspectives (pp. 149–166). Plural.
Parthasarathy, A., Hancock, K. E., Bennett, K., DeGruttola, V., &
Polley, D. B. (2020). Bottom-up and top-down neural signa-
tures of disordered multi-talker speech perception in adults
with normal hearing. eLife, 9, Article e51419. https://doi.org/
10.7554/eLife.51419
Posit Science. (2014). BrainHQ San Francisco (CA). http://brainhq.
com
R Core Team. (2014). R: A language and environment for statistical
computing. R Foundation for Statistical Computing, Vienna,
Austria.
Remenschneider, A. K., Lookabaugh, S., Aliphas, A., Brodsky, J. R.,
Devaiah, A. K., Dagher, W., Grundfast, K. M., Heman-Ackah,
S. E., Rubin, S., Sillman, J., Tsai, A. C., Vecchiotti, M., Kujawa,
S. G., Lee, D. J., & Quesnel, A. M. (2014). Otologic outcomes
after blast injury: The Boston Marathon experience. Otology
& Neurotology, 35(10), 1825–1834. https://doi.org/10.1097/
MAO.0000000000000616
Roup, C. M., Post, E., & Lewis, J. (2018). Mild-gain hearing aids
as a treatment for adults with self-reported hearing difficulties.
Journal of the American Academy of Audiology, 29(6), 477–494.
https://doi.org/10.3766/jaaa.16111
Roup, C. M., Ross, C., & Whitelaw, G. (2020). Hearing difficulties
as a result of traumatic brain injury. Journal of the American
Academy of Audiology, 31(2), 137–146. https://doi.org/10.3766/
jaaa18084
Šarkić, B., Douglas, J. M., & Simpson, A. (2019). Peripheral audi-
tory dysfunction secondary to traumatic brain injury: A system-
atic review of literature. Brain Injury, 33(2), 111–128. https://
doi.org/10.1080/02699052.2018.1539868
Saunders, G. H., Frederick, M. T., Arnold, M. L., Silverman, S.,
Chisolm, T. H., & Myers, P. (2015). Auditory difficulties in
blast-exposed Veterans with clinically normal hearing. Journal
of Rehabilitation Research and Development, 52(3), 343–360.
https://doi.org/10.1682/JRRD.2014.11.0275
Saunders, G. H., Frederick, M. T., Arnold, M. L., Silverman, S.,
Chisolm, T. H., & Myers, P. (2018). A randomized controlled
trial to evaluate approaches to auditory rehabilitation for
blast-exposed veterans with normal or near-normal hearing
who report hearing problems in difficult listening situations.
Journal of the American Academy of Audiology, 29(1), 44–62.
https://doi.org/10.3766/jaaa.16143
Saunders, G. H., Smith, S. L., Chisolm, T. H., Frederick, M. T.,
McArdle, R. A., & Wilson, R. H. (2016). A Randomized con-
trol trial: Supplementing hearing aid use with Listening and
Communication Enhancement (LACE) auditory training. Ear
and Hearing, 37(4), 381–396. https://doi.org/10.1097/AUD.
0000000000000283
Sawyer, C. S., Armitage, C. J., Munro, K. J., Singh, G., & Dawes,
P. D. (2019). Correlates of hearing aid use in U.K. adults:
Self-reported hearing difficulties, social participation, living
situation, health, and demographics. Ear and Hearing, 40(5),
1061–1068. https://doi.org/10.1097/AUD.0000000000000695
Sharma, M., Purdy, S. C., & Kelly, A. S. (2012). A randomized
control trial of interventions in school-aged children with
auditory processing disorders. International Journal of Audi-
ology, 51(7), 506–518. https://doi.org/10.3109/14992027.2012.
670272
Koerner et al.: Survey of Rehabilitation Options for NH Patients
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
Smart, J. L., Kelly, A. S., Searchfield, G. D., Lyons, A. M., &
Houghton, J. M. (2007). Rehabilitation of adults with auditory
processing disorder and normal peripheral hearing: Two case
studies. Australian and New Zealand Journal of Audiology, 29(1),
53–59. https://doi.org/10.1375/audi.29.1.53
Song, J. H., Skoe, E., Banai, K., & Kraus, N. (2012). Training to
improve hearing speech in noise: Biological mechanisms. Cere-
bral Cortex, 22(5), 1180–1190. https://doi.org/10.1093/cercor/
bhr196
Spankovich, C., Gonzalez, V. B., Su, D., & Bishop, C. E. (2018).
Self-reported hearing difficulty, tinnitus, and normal audio-
metric thresholds, the National Health and Nutrition Exami-
nation Survey 1999–2002. Hearing Research, 358, 30–36. https://
doi.org/10.1016/j.heares.2017.12.001
Sweetow, R., & Palmer, C. V. (2005). Efficacy of individual audi-
tory training in adults: A systematic review of the evidence.
Journal of the American Academy of Audiology, 16(7), 494–504.
https://doi.org/10.3766/jaaa.16.7.9
Sweetow, R., & Sabes, J. H. (2006). The need for and development
of an adaptive Listening and Communication Enhancement
(LACETM) Program. Journal of the American Academy of
Audiology, 17(8), 538–558. https://doi.org/10.3766/jaaa.17.8.2
Tepe, V., Papesh, M., Russell, S., Lewis, M. S., Pryor, N., & Guillory,
L. (2020). Acquired central auditory processing disorder in
service members and veterans. Journal of Speech, Language,
and Hearing Research, 63(3), 834–857. https://doi.org/10.1044/
2019_JSLHR-19-00293
Thompson, E. C., Krizman, J., White-Schwoch, T., Nicol, T.,
LaBella, C. R., & Kraus, N. (2018). Difficulty hearing in
noise: A sequela of concussion in children. Brain Injury, 32(6),
763–769. https://doi.org/10.1080/02699052.2018.1447686
Tremblay, K., Kraus, N., Carrell, T. D., & McGee, T. (1997). Central
auditory system plasticity: Generalization to novel stimuli follow-
ing listening training. The Journal of the Acoustical Society of
America, 102(6), 3762–3773. https://doi.org/10.1121/1.420139
Tremblay, K., Pinto, A., Fischer, M. E., Klein, B. E. K., Klein, R.,
Levy, S., Tweed, T. S., & Cruickshanks, K. J. (2015). Self-
reported hearing difficulties among adults with normal audio-
grams: The Beaver Dam Offspring Study. Ear and Hearing, 36(6),
e290–e299. https://doi.org/10.1097/AUD.0000000000000195
Turgeon, C., Champoux, F., Lepore, F., Leclerc, S., & Ellemberg,
D. (2011). Auditory processing after sport-related concussions.
Ear and Hearing, 32(5), 667–670. https://doi.org/10.1097/AUD.
0b013e31821209d6
Tye-Murray, N., Sommers, M. S., Mauzé, E., Schroy, C., Barcroft,
J., & Spehar, B. (2012). Using patient perceptions of relative
benefit and enjoyment to assess auditory training. Journal of
the American Academy of Audiology, 23(8), 623–634. https://
doi.org/10.3766/jaaa.23.8.7
Valadbeigi, A., Weisi, F., Rohbakhsh, N., Rezaei, M., Heidari, A.,
& Rasa, A. R. (2014). Central auditory processing and word
discrimination in patients with multiple sclerosis. European
Archives of Oto-Rhino-Laryngology, 271(11), 2891–2896. https://
doi.org/10.1007/s00405-013-2776-6
Vander Werff, K. R., & Rieger, B. (2017). Brainstem evoked po-
tential indices of subcortical auditory processing after mild
traumatic brain injury. Ear and Hearing, 38(4), e200–e214.
https://doi.org/10.1097/AUD.0000000000000411
Whitton, J. P., Hancock, K. E., & Polley, D. B. (2014). Immersive
audiomotor game play enhances neural and perceptual sa-
lience of weak signals in noise. Proceedings of the National
Academy of Sciences of the United States of America, 111(25),
E2606–E2615. https://doi.org/10.1073/pnas.1322184111
753
 Appendix ( p. 1 of 8)
Questionnaire Survey of Audiologists

754 American Journal of Audiology • Vol. 29 • 738–761 • December 2020

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 Appendix ( p. 2 of 8)
Questionnaire Survey of Audiologists

Koerner et al.: Survey of Rehabilitation Options for NH Patients 755

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 Appendix ( p. 3 of 8)
Questionnaire Survey of Audiologists

756 American Journal of Audiology • Vol. 29 • 738–761 • December 2020

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 Appendix ( p. 4 of 8)
Questionnaire Survey of Audiologists

Koerner et al.: Survey of Rehabilitation Options for NH Patients 757

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 Appendix ( p. 5 of 8)
Questionnaire Survey of Audiologists

758 American Journal of Audiology • Vol. 29 • 738–761 • December 2020

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 Appendix ( p. 6 of 8)
Questionnaire Survey of Audiologists

Koerner et al.: Survey of Rehabilitation Options for NH Patients 759

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 Appendix ( p. 7 of 8)
Questionnaire Survey of Audiologists

760 American Journal of Audiology • Vol. 29 • 738–761 • December 2020

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 Appendix ( p. 8 of 8)
Questionnaire Survey of Audiologists

Koerner et al.: Survey of Rehabilitation Options for NH Patients 761

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 04/05/2024, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions