Virtual LGHA Fitting: Beyond Traditional Real Ear Measurement (REM) Verification
Note to Non-Clinician Readers:
I wrote this article mainly for clinicians, since it talks about how virtual fittings are done and how we make sure they’re both safe and effective. I recently shared it with a researcher, and I wanted to put it here too so it’s clear it comes from me. More importantly, I want to be transparent about the work I’m doing, because even though it’s written for professionals, it’s really about making care more accessible for kids and adults with auditory processing challenges.
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Abstract
Traditional Real Ear Measurement (REM) is inadequate for low-gain hearing aid (LGHA) fitting in normal hearing populations with auditory processing difficulties. Virtual fitting protocols using functional assessment tools deliver superior outcomes while maintaining safety standards. This evidence-based approach should replace outdated verification requirements that barrier access to care for underserved populations.
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The Problem: REM’s Irrelevance for Normal Hearing Populations
Real Ear Measurement (REM) verifies acoustic output but misses the point entirely for normal hearing populations. Standard prescriptive formulas like NAL-NL2 assume hearing loss requiring threshold compensation, irrelevant when thresholds are normal.
Key limitations:
• No valid targets exist for normal audiograms with processing difficulties
• Static testing in quiet with adaptive features disabled doesn’t reflect real-world use
• Stops at the eardrum while processing happens in the brain
Research from Kuk et al. (2008) established that LGHA benefits stem from enhanced signal-to-noise ratio (5-15 dB gain) and reduced cognitive load, not audibility restoration. A 2024 study of 256 hearing aid users confirmed REM provides no meaningful improvement over modern fitting software for mild amplification cases.
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The Precedent: FM Systems Set the Standard
Standalone FM systems are routinely prescribed without REM for normal hearing populations with APD, providing 10-20 dB SNR enhancement. These assistive listening devices bypass strict fitting requirements due to their proven safety profile.
Why LGHAs deserve equal treatment:
• Similar gain levels (5-15 dB vs 10-20 dB)
• Comparable safety (92-93 dB SPL maximum output)
• Superior technology (RIC vs “garden hose” slim tubing)
• Professional oversight (virtual monitoring vs basic setup)
If FM systems are safe for over-the-counter use without verification, LGHAs with professional virtual oversight should be equally acceptable.
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The Solution: Functional Assessment Over Static Verification
Modern virtual protocols assess what matters: real-world function.
Core Assessment Battery
• Speech-in-noise testing (QuickSIN, BKB-SIN): Captures primary patient complaints
• Dichotic listening: Reveals brain-level processing efficiency in 3.5 minutes
• Expanded ANL with effort scaling: Shows not just tolerance limits but collapse patterns
• Temporal processing: Gap detection predicts long-term satisfaction
• Fatigue curves: Dynamic testing during peak/trough periods reveals true needs
Safety Protocols
• Gain ceilings (10-15 dB maximum)
• MPO limits (92-93 dB SPL for normal hearing)
• Real-time monitoring via Noah Link Wireless
• Emergency reversion capabilities
• Professional oversight throughout
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Why LGHA Integration Beats Standalone FM
Customizable FM integration in LGHAs addresses complex needs that standalone systems cannot:
For Misophonia & Hyperacusis
• Frequency-specific compression softens painful pitches
• Active noise reduction masks triggers while preserving speech
• Pink noise programs for gradual desensitization
• FM’s open domes allow unprocessed triggers through
For ADHD, Autism, Dyslexia & APD
• Preserves spatial awareness (FM centralizes sound, causing disorientation)
• User control for emotional regulation (toggle FM on/off)
• Multi-environment functionality (social, media, classroom)
• Superior sound quality through RIC technology
Clinical Example
Sarah, 12, has autism and APD. Standalone FM helps in class, but overwhelming cafeteria noise triggers meltdowns. LGHA with integrated FM allows her to toggle FM off during lunch while maintaining noise reduction and spatial awareness. Virtual fitting enabled iterative adjustments for comfort without clinic visits.
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Evidence Base: Virtual Protocols Deliver Results
Recent research validates virtual fitting effectiveness:
• D’Onofrio & Zeng (2022): Comprehensive teleaudiology review shows comparable outcomes to in-person care
• Büyükkal & Çelikgün (2023): Remote fitting technology significantly improves hearing aid satisfaction
• Military studies: 92.3% LGHA success rate in normal hearing populations with self-reported difficulties
Functional measures outperform static verification:
• QuickSIN scores correlate strongly with patient satisfaction and daily function
• Gap detection thresholds predict long-term hearing aid satisfaction with medium effect sizes
• Acceptable Noise Level (ANL) shows 68-91% accuracy in predicting successful hearing aid use
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Addressing Counterarguments
“Virtual fitting could miss acoustic issues”
→ Modern fitting software achieves better target matching than REM for mild amplification. Functional testing reveals real-world problems REM cannot detect.
“Patient compliance concerns without supervision”
→ Data logging and remote monitoring provide more oversight than traditional fit-and-release protocols. Emergency support exceeds in-clinic availability.
“Safety risks from overamplification”
→ LGHA gain levels (5-15 dB) are lower than OTC FM systems (10-20 dB). Multiple safety protocols prevent overamplification.
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Regulatory Reform: Prioritizing Outcomes Over Procedures
Current REM mandates reflect outdated assumptions:
• Virtual technology was primitive
• Assessment tools were limited to basic audiometry
• Professional oversight in remote settings was impossible
• Target populations had traditional hearing loss
Modern reality demands updated standards:
• Evidence-based fitting without REM shows comparable outcomes
• ASHA and AAA guidelines support teleaudiology when outcomes are equivalent
• Professional competency matters more than specific procedures
Specific Reform Recommendations
For Clinicians:
• Adopt validated virtual assessment batteries (QuickSIN, expanded ANL)
• Implement fatigue-based dynamic testing protocols
• Use functional measures as primary outcomes
For Researchers:
• Prioritize long-term LGHA outcome studies
• Develop standardized virtual fitting protocols
• Validate predictive models for LGHA success
For Regulators:
• Redefine “verification” to include functional metrics
• Allow virtual fitting for low-gain applications
• Focus on patient safety and outcomes, not procedural compliance
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The Ethical Imperative
Restricting virtual fitting denies care to underserved populations:
• Rural communities lacking specialized services
• Patients dismissed despite normal audiograms and legitimate complaints
• Neurodivergent individuals needing customized approaches
• Families unable to travel for frequent adjustments
When virtual protocols deliver superior functional assessment, enhanced safety monitoring, and better patient outcomes, regulatory barriers become ethically indefensible.
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Future Directions
Technology Development
• AI-assisted programming based on functional test results
• Environmental adaptation through real-time acoustic analysis
• Physiological monitoring integration (pupil response, cortical measures)
• Predictive modeling for LGHA success
Professional Standards
• Specialized training programs for virtual LGHA fitting
• Certification requirements for normal hearing amplification
• Standardized outcome measures for virtual fitting success
• Quality assurance protocols for remote care
Research Priorities
• Randomized controlled trials comparing virtual vs traditional fitting
• Long-term safety data for remote LGHA applications
• Cost-effectiveness analysis of virtual care models
• Pediatric-specific virtual fitting protocols
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Call to Action
The audiological profession stands at a crossroads. We can cling to outdated verification methods that barrier access and miss functional deficits, or embrace evidence-based virtual protocols that serve underserved populations with superior outcomes.
For patients with normal hearing thresholds and legitimate auditory difficulties, advanced virtual fitting protocols represent not just an acceptable alternative, but the superior standard of care.
The choice is clear: prioritize real-world function over static verification, expand access over procedural compliance, and embrace innovation over tradition.
The future of audiology is virtual, functional, and patient-centered. It’s time our regulations caught up.
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Key Takeaways
REM is irrelevant for normal hearing populations with processing difficulties
FM system precedent justifies virtual LGHA fitting without verification
Functional assessment predicts outcomes better than static verification
LGHA integration provides superior care over standalone FM systems
Virtual protocols deliver comparable safety with better access
Regulatory reform should prioritize outcomes over outdated procedures
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References
American Academy of Audiology. (2013). Clinical practice guidelines: Remote microphone hearing aids for children and youth from birth to 21 years. Author.
American Speech-Language-Hearing Association. (2020). Telepractice and COVID-19: Frequently asked questions. Retrieved from https://www.asha.org/.../telepractice-and-covid-19.../
Beck, D. L., & Le Goff, N. (2017). Hearing aids, listening effort, and fatigue. Hearing Review, 24(2), 34-36.
Büyükkal, F., & Çelikgün, B. (2023). The effect of remote fitting technology on hearing aid satisfaction. Egypt Journal of Otolaryngology, 39(1), 83. https://doi.org/10.1186/s43163-023-00447-7
D’Onofrio, K. L., & Zeng, F. G. (2022). Tele-audiology: Current state and future directions. Frontiers in Digital Health, 3, 788103. https://doi.org/10.3389/fdgth.2021.788103
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