Thanks go out to Peter Bloch, BA Hons, MSTAT, a qualified teacher of the Alexander Technique based in Manchester, England for writing this insightful article exclusively for Physical Therapy Web. Peter Bloch is a psycho-physical therapist. He has moderate hearing loss and comes from a family with severe and profound hearing loss. As well as teaching the Alexander Technique, he has developed a unique form of touch psychotherapy that can be particularly helpful for people with communication disabilities. You can visit his website for professional therapists for more information.
Why is an understanding of hearing loss important for physical therapists? There are many different causes of hearing loss, and some of these can occur at any age. However, there is a strong relationship between age and hearing loss. Many physical therapists spend much of their time working with older patients, amongst whom the incidence of significant hearing loss can be as high as 50%. Since the success of our work depends in large measure on effective communication, it is particularly important that we understand how best to approach these patients.
If you set aside about ten minutes to read and understand this brief article your clients with hearing loss will love you forevermore!
What does the healthy ear hear? The healthy human ear is able to able to detect sounds across a wide range of frequencies from about 20Hz to about 20,000Hz. Examples of low frequencies are a large organ pipe or a big drum and examples of high frequencies are the hiss in a music recording or the highest notes of a piccolo. What happens with hearing loss? Different types of hearing loss can affect hearing at different frequencies. However, by far the most common types of hearing loss affects the upper frequencies and this almost universally deteriorates with advancing age. Most people with hearing loss are able to hear low frequencies normally, with a gradual deterioration in hearing as the frequencies get higher. In what ways does hearing loss affect the understanding of speech?
You can skip this section if technical stuff makes your eyes roll!
The sounds of speech tend to be concentrated in the range between about 200Hz and 6,000Hz (the range from the ‘U’ sound in the woman’s name “Sue” to the ‘S’ sound in the same word). The average 70 year old will hear the “U” very well (at 200 Hz they can hear a sound which is little more than a whisper) but at the same age the “S” (at 6,000Hz) would need to be quite strong and clear to be heard (“People don’t speak clearly these days”). In the audiogram below, the shaded area shows at what frequencies and at what intensities (how loud) vowels and consonants are used in normal speech (the “speech banana”). The horizontal line at 0 dB represents the hearing of a healthy 18-year-old. The person who had these results from a hearing test will not be able to understand any parts of normal speech with their right ear (marked in red). For example, they would need a sound intensity of 80 dB more than someone with good hearing could hear in order to hear an “S”, but at normal speech intensities, it is spoken with only about 25 dB more. With their left ear (marked in blue) they will have no problem hearing the “U” sound, but could not hear a normal “S”. They will be left asking themselves whether you said sue, too, who or few – the basis of many good jokes about conversations with people with hearing loss! Even with good hearing aids this person would find it difficult to hear the “S” sound at normal intensities. The blue line is similar to the hearing of the average man of about 80. 
There’s a nice example of what people hear with different levels of hearing loss in this entertaining short film clip. In the movie, the area in blue represents the “speech banana” – it should be yellow! How can I communicate better with my hard of hearing clients? Since vowels are in the low frequencies, it is generally not helpful to speak more loudly. This is because speaking more loudly usually means making the vowels louder, which can already be heard perfectly well (“there’s no need to shout!”). Instead, you should concentrate on speaking more clearly by emphasising the consonants. You could try this now by saying the word “Sue” making the “S” fairly loud and the “U” normally loud. Now try the following sentence in the same way, emphasizing the letters in bold; “So good to see you Fred!”. For someone with moderate hearing loss, you would need to speak very clearly, but not excessively or strangely so. Remember that many people who wear hearing aids have severe hearing loss that is made effectively moderate with the assistance of their aids. For someone with unaided severe hearing loss (not uncommon in the very elderly), you would need to make the consonants very loud indeed in order to be understood.
This approach alone will be enough to resolve your communication difficulties with about 80% of your clients who have hearing loss.
What else can I do to help?
- Turn off background noises such as music, fans and machinery. These sounds make it much more difficult for the hard of hearing to understand speech.
- Face your client when you speak. Most people lip-read even if they think that they don’t. Try speaking silently into a mirror and say the words “face” and “pace”.
- Get closer. Sound intensity drops off rapidly with distance.
- If they still can’t hear you, suggest nicely that they wear their hearing aids. Until you have tried a hearing aid and know how difficult and even unpleasant it can be to use one, you should be nice to people who won’t wear their aids!
- For the very hard of hearing, consider getting a loop system. These feed your speech directly into the hearing aid of your client, greatly improving their ability to understand speech. They are simple to use and are no longer expensive.
Do these things, and your hard of hearing clients will experience you as considerate, interesting and skilled (which you probably are anyway). They may not even realise why!