UBC Faculty Research and Publications

Noise and hearing loss in musicians Thom, Jadine; MacIntyre, Elaina; Winters, Meghan; Teschke, Kay; Davies, Hugh 2005-08-31

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              Noise and Hearing Loss in Musicians  August, 2005   Prepared for: Safety and Health in Arts Production and Entertainment (SHAPE) Suite 280 - 1385 West 8th Avenue Vancouver, BC V6H 3V9 Prepared by:  Jadine Thom, Elaina McIntyre, Meghan Winters,  Kay Teschke, Hugh Davies*  School of Occupational and Environmental Hygiene 2206 East Mall Vancouver, BC V6T 1Z3  *Corresponding author Noise and Hearing Loss in Musicians    Page 2 of 39  Executive Summary  This literature review was produced at the request of SHAPE, the association for Safety and Health in Arts Production and Entertainment.  SHAPE was concerned about noise exposure among arts and entertainment employees. An excellent lay publication Listen While you Work1 had been previously completed and so SHAPE asked us for a rigorous systematic review of the scientific literature for specific questions such as ?To how much noise are musicians exposed? Is there a hearing loss problem for musicians? What do we recommend that musicians and other entertainment professionals do to protect their hearing??  We conducted a systematic and comprehensive review of the peer-reviewed scientific literature with respect to hearing loss among musicians, exposure to noise, determinants of noise exposure, and methods for controlling those exposures. Details of the literature search are given in an appendix.  We found that both classical and rock musicians are at increased risk of developing noise-induced hearing loss and an associated disease, tinnitus, as a result of their exposure to music.   Musicians ? even classical musicians and choral singers ? can be exposed to very high, damaging levels of sound. Average levels between 80 and 100 dBA have been recorded for classical musicians, and 90-105 dBA for rock musicians. Peak levels can be higher still. Non-musicians who work in entertainment venues are also at increased risk.  Factors contributing to hearing damage include playing a ?loud? instrument; many wind instruments, including trombone, flute, piccolo French horn and clarinet are capable of producing sound over 100 dBA. Also, there is risk associated with sitting near loud instruments (especially in front of other loud instruments). Electronically amplified music can be much louder again. The risk of hearing loss increases with increasing duration of exposure, which includes not only performance, but also practice, and attending concerts (which may or may not be occupationally-related). Poor acoustical design of some venues may also result in increased noise exposure.  Despite these hazards, there are techniques that can be used to control exposure and help to prevent hearing loss. These may be behavioural (such as resting ones ears by avoiding loud noises outside of work), engineering-based (such as modifying the seating positions of loud instruments, or elevating speakers off of the floor), or various techniques (devices?) for ear protection, including many new models designed to reduce sound level without altering original sound quality. Certain barriers to implementing control measures are somewhat specific to musicians: the ability to retain sound quality while reducing sound level is paramount; there is a psychological aspect of not wanting to be                                                   1 Listen While you Work: Hearing Conservation for the Arts. Produced by Safety and Health in Arts Production and Entertainment, Vancouver, B.C. 2001  Noise and Hearing Loss in Musicians    Page 3 of 39   seen to have ?weak? hearing in business that is all about subtlety and nuance; and the risk of increasing risk of one hazard while reducing another, such as ergonomic strain from adjusting playing techniques.   Noise and Hearing Loss in Musicians    Page 4 of 39  Table of Contents   Executive Summary............................................................................................................ 2 Table of Contents................................................................................................................ 4 Why did we do this review?................................................................................................ 5 How much noise are musicians exposed to?....................................................................... 5 How do we define noise?............................................................................................ 5 What kinds of regulations are there for the noise at music venues?........................... 6 How loud are music venues? ...................................................................................... 7 Hearing loss in musicians - Is there a problem? ................................................................. 8 How well do classical musicians hear?....................................................................... 9 What about rock musicians?..................................................................................... 10 What about other people who work around music, like bar and club staff?............. 11 What factors increase the risk of noise-induced hearing loss in musicians? ............ 12 What do we recommend that you do to protect your hearing?......................................... 12 Changes to the environment or Technique ............................................................... 13 Hearing protection devices ....................................................................................... 14 Conclusions and Recommendations ................................................................................. 17 Acknowledgements........................................................................................................... 17 Appendix 1: Literature Search Strategy............................................................................ 21 Appendix 2: Literature Review Summary Tables ............................................................ 22 Table 1: Epidemiology Papers: Exposure and Health Outcome Papers....................... 22 Table 2: Exposure assessment papers........................................................................... 29 Table 3: Disorders other than noise-induced hearing loss............................................ 32 Table 4: Controls and preventive measures.................................................................. 33 Table 5: Papers not used for this review....................................................................... 35  Noise and Hearing Loss in Musicians    Page 5 of 39  Why did we do this review?  SHAPE (an organization created to address Safety and Health in Arts, Production, and Entertainment) asked the University of British Columbia to help investigate several questions related to the noise-related health and safety of musicians and other workers potentially exposed to loud music that fall under their mandate. These questions were:  1.  How much noise are musicians exposed to?  a.  How do we define noise? b.  What kinds of regulations are there for the noise at music venues? c.  How loud are music venues? 2.  Hearing loss in musicians: Is there a problem? a.  How well do classical musicians hear? b.  What about rock musicians? c.  What about other people who work around music, like bar and club staff? d.   What factors can increase the risk of noise-induced hearing loss in musicians? 3.  What do we recommend that musicians and other entertainment professionals do to protect their hearing? a.  Changes to the environment or behaviours b.  Hearing protection devices  A comprehensive literature search was performed using several scientific literature databases, and the references of gathered articles were also searched by hand for completeness. Please refer to Appendix 1 for further details about the search methodology. Appendix 2 contains tabular information on all of the papers that were reviewed, and includes Table 1 (Epidemiology), Table 2 (Exposure Assessment), Table 3 (Disorders Other Than Noise-Induced Hearing Loss), Table 4 (Controls and Preventive Measures), and Table 5 (Papers not used for this review, but may be of interest to the reader).  How much noise are musicians exposed to?  There are several unique reasons to be concerned about sound exposure and its effect on musicians? hearing. First of all, musicians? working hours are usually quite varied as compared to most employees, especially during performance weeks. Also, musicians spend a varied amount of time practicing, playing solo and as a member of different groups, and enjoying the music of others. One review article suggested that classical musicians play an average of 25 hours per week (Palin 1994), but this could vary widely from week to week, and from person to person.  How do we define noise?  As you probably know, sound has both pitch (frequency; which we quantify in units called Hertz) and loudness (amplitude; which we quantify in units called decibels,  Noise and Hearing Loss in Musicians    Page 6 of 39  abbreviated dB). Sound is produced by sources and we experience noise at our ear, if the sound is undesirable.   ?A-weighting? filters out some of the low-pitched sounds, because these do not contribute much to hearing loss. Therefore, exposures measured in dB will be somewhat higher than exposures measured in dBA, especially where there is a great deal of low-pitched sound.   Throughout this review, the loudness component of sound will be expressed in either decibels (dB) or A-weighted decibels (dBA). For reference, some common events with their corresponding sound levels are presented in Table 1.   Table 1: The sound pressure levels associated with different events (adapted from ?Listen While You Work?, by Kevin Sallows for SHAPE, 2001):  Approximate sound level (dBA) Sound source 45-55  Normal conversation at arm?s length 60-70  Piano played at moderate levels 75-85 Chamber music in a small auditorium 80 Telephone dial tone 90  Train whistle at 150 meters away 92-95  Piano played loudly 95  Subway train at 60 meters away 105-120  Amplified rock music at 1-2 meters away 120-137  Symphonic music peak 140  Jet engine at 30 meters away 150 Rock music peak   You may also recall that the scale that sound levels are measured on is logarithmic, such that for each increase of 3 dBA, the sound level is actually doubling, so 88 dBA is twice as loud as 85 dBA.  What kinds of regulations are there for the noise at music venues?  The regulatory limit for noise exposure in BC is 85 dBA, and this is set and enforced by the WCB (Workers? Compensation Board). This number is based on an 8-hour work day for which the average noise level is less than 85 dBA. If either the total duration of noise exposure or the level of noise exposure increases the other must decrease to prevent permanent hearing loss. The following table (Table 2) shows the maximum exposure times for different sound pressure levels:    Noise and Hearing Loss in Musicians    Page 7 of 39   Table 2: Maximum exposure times for different sound pressure levels Sound level (dBA)  Maximum Exposure Time 82 16 hours 85 8 hours 88 4 hours 91 2 hours 94 1 hour 97 30 minutes 100 15 minutes 103 7.5 minutes  How loud are music venues?  As you might imagine, the sound levels in a venue depend on a number of factors, such as the type of music being played, the number of musicians, types of instruments, amplification, and the design of the venue. The first detailed measurements of sound levels produced by musical instruments were reported in the early 1930?s (Lebo and Oliphant 1968). Review articles on the subject of sound measurements report varied levels, but one result is clear: rock, pop, jazz, and symphonic music ALL have the potential to produce sound levels well above the WCB 8-hour limit of 85 dBA.  In a study by Westmore & Eversden, sound levels reached 104 dBA, resulting in perceptible pain for some of the classical-musician subjects  (Westmore and Eversden 1981). Another researcher found that during practice time, there was an average sound level of 100 dBA for several different types of bands (Early and Horstman 1996), showing that performances aren?t the only dangerous times for a musician?s ears. In general, most researchers report sound levels of about 80-100 dBA (average, for the performance) for classical music (Arnold and Miskolczy-Fodor 1960; Lebo and Oliphant 1968; Axelsson and Lindgren 1981; Westmore and Eversden 1981; Jansson and Karlsson 1983; Szymanski 1983; Royster, Royster et al. 1991; McBride 1992; Sabesky and Korczynski 1995; Fisk 1997; Teie 1998; Laitinen, Toppila et al. 2003; Lee, Behar et al. 2003), with short-term peaks of up to 137 dBA (Westmore and Eversden 1981). Choirs have been reported to produce sound levels of about 100 dBA as well, which is important to know for professional singers and the musicians that may accompany them (Steurer, Simak et al. 1998).   For rock/jazz/pop music performances, the dynamic range of the music is somewhat less (i.e. ? once a rock song starts, there isn?t much variation in the sound level as compared to say, a symphony) (Hart, Geltman et al. 1987). This also means that rock music is on average louder, because there aren?t as many quiet spots in the arrangements (Gunderson,  Noise and Hearing Loss in Musicians    Page 8 of 39  Moline et al. 1997). The literature indicates that an average sound level during a rock performance is likely to fall between 90 and 105 dBA (Lebo and Oliphant 1968; Dey 1970; Gunderson, Moline et al. 1997; Jaroszewski, Fidecki et al. 1998; Henoch and Chesley 2000; Bray, Szymanski et al. 2004), with peaks up to around 150 dB (Hart, Geltman et al. 1987). As an interesting aside, there is a small body of literature on professional pannists (steel drum players); they can produce average sound levels of about 110 dBA with their drums (Griffiths and Samaroo 1995; Juman, Karmody et al. 2004).  So as one can see, there is a large potential for hearing damage to musicians. Average sound levels are often above the recommended safety level of the WCB, and peak levels are sometimes high enough to cause pain in listeners. This begs the question: are musicians more at risk for hearing loss, given all this exposure to loud noise? Hearing loss in musicians - Is there a problem?  Most people are aware that loud noises are bad for your ears, and might lead to hearing problems down the road. Since listening to music is a positive, pleasant, and desirable activity for many people, it may come as a surprise that music can have a negative effect on hearing too.   Work-related hearing loss is quite a different problem for those in the music industry than it is for industrial workers. Musicians and DJs regard themselves as having superior hearing, specially trained to detect nuance or tone, and consider that their hearing is their livelihood (Axelsson and Lindgren 1981; Early and Horstman 1996). A slight hearing loss that may not bother an industrial worker may cause difficulties for a musician. In addition, controlling musicians? exposures poses a different challenge than it does for other types of employees.  Even though sound levels can be exceedingly high at music venues, very few investigations on the hearing of musicians had actually taken place as of the early 1980?s (Axelsson and Lindgren 1981). An early study on the hearing of orchestral musicians at an opera house found that 42% of participants had hearing loss that was greater than expected for their age (Axelsson and Lindgren 1981). Many other studies, including both classical and pop musicians, have found similar results: musicians have worse hearing than would be expected based on their age (Lebo and Oliphant 1968; Westmore and Eversden 1981; Jansson and Karlsson 1983; Hart, Geltman et al. 1987; Ostri, Eller et al. 1989; Royster, Royster et al. 1991; Fearn 1993; Jaroszewski and Rakowski 1994; Jaroszewski, Fidecki et al. 1998; Eaton and Gillis 2002; Kahari, Zachau et al. 2003). Other researchers report no difference between musicians and other workers (Arnold and Miskolczy-Fodor 1960; Karlsson, Lundquist et al. 1983; Johnson, Sherman et al. 1985; McBride 1992; Kahari 2001); this difference in finding may be due to varying definitions of what constitutes hearing loss, difficulties in quantifying leisure noise exposure, or poor study quality (Sataloff 1991).   The general consensus in the literature suggests that hearing loss is a problem for musicians, and this varies across type of music played (i.e. ? rock or jazz or classical),  Noise and Hearing Loss in Musicians    Page 9 of 39  and type of instrument played (Palin 1994; Mikl 1995). It has been suggested that since sound pressure levels (SPL) produced by music can be (and often are) well above the recommended 85 dB, we have good reason to be concerned about musicians? hearing.   Another complaint from some musicians (but more typically of industrial workers) is a disease called ?tinnitus?, which is a permanent ringing in the ears caused by chronic exposure to loud noises (Axelsson and Ringdahl 1989; Axelsson and Prasher 2000; Lockwood, Salvi et al. 2001). More research needs to be done on the musician?s experience with this often highly debilitating disease. How well do classical musicians hear?  Estimates by several researchers on the incidence of hearing loss among classical musicians range from 4-43%, however these losses are usually slight (Arnold and Miskolczy-Fodor 1960; Axelsson and Lindgren 1981; Westmore and Eversden 1981; Hart, Geltman et al. 1987; Behroozi and Luz 1997; Chesky and Henoch 2000). ?Hearing loss? can be defined in many ways, but it is usually measured using audiometry, which tests at what sound pressure level a certain frequency (or pitch) of sound is barely audible to the person being tested. This is recorded as an ?audiogram?, which is a graph of frequency (pitch) against sound level (measured in dB). The audiograms of a musician being tested can be compared to an average audiogram for that person?s age and sex, and differences can be assessed for their relation to noise. Usually, a downward ?notch? in an audiogram (meaning it takes a higher sound pressure level for the person to hear) around 4000 Hertz (between the notes B7 and C8, if middle C is C4) indicates that noise might have caused some damage.   The most important factors in assessing the hearing of classical musicians is what instrument you play and where you sit in the orchestra. Some typical sound levels by instrument type, when performing solo, are presented in Table 3. The values in the table are given as a range, and this reflects sound levels produced during varying musical compositions (i.e. ? piano versus fortissimo).  Table 3: Sound levels by instrument type (adapted from (Hart, Geltman et al. 1987; Sataloff and Sataloff 1991; Teie 1998)).   Instrument  Typical sound levels (dBA) Trombone 85-114 Piccolo 95-112 Flute 85-111 French horn  90-106 Clarinet 92-103 Violin 84-103 Piano 92-95 Oboe 80-94 Xylophone 90-92 Cello 84-92 String Bass  75-83  Noise and Hearing Loss in Musicians    Page 10 of 39   In particular, brass musicians and certain woodwind players showed an increased risk of hearing loss (Axelsson and Lindgren 1981), although Karlsson reported that double bass and flute players are at increased risk (Karlsson, Lundquist et al. 1983). For French horn players, but also for some others, sound levels come from the instruments around them rather than their own instruments (especially from drums, which are usually right behind the horn section). What about rock musicians?  Estimates of the number of rock and pop musicians with some level of hearing loss range from 13 to 30% (Axelsson and Lindgren 1981; Hart, Geltman et al. 1987; Jaroszewski and Rakowski 1994; Chesky and Henoch 2000). Indeed, there are many anecdotal reports of hearing loss in rock and pop musicians, brought to attention by rockers like Pete Townsend, Eric Clapton, and Sting (http://www.youth.hear-it.org/page.dsp?forside=yes&area=782). The sound pressure levels measured in rock music venues are often especially high and fairly constant, such that ears aren?t offered any break. The performers themselves also spend time in practice, and attending other rock concerts, and therefore may receive substantial doses of loud music on a regular basis.  Dey reported that about 16% of young men exposed to 2 hours of rock music at a sound pressure level of 110 dBA experienced ?unusually severe? temporary threshold shift (Dey 1970). It seems that hearing damage from rock music may lead to more severe hearing losses than the ?slight? ones mentioned above for most classical musicians. One study found that 51.1% of their cohort had hearing threshold deficits of 20 dB or greater (Fearn 1993). This study also revealed that most of this hearing loss occurs at the pitch of 6000 Hz (between F6# and G6, if middle C is C4), and may occur in one ear only (on the side closest to amplifier/speaker, or cymbal/drums) (Sataloff 1991; Fearn 1993). Sataloff cited the results of a study by Speaks (1970), where temporary threshold shifts occurred in about half of the rock musicians studies, and permanent threshold shifts existed in one quarter (Sataloff 1991). Twenty-five percent of the subjects in Axelsson & Lindgren?s study were also affected by hearing loss (greater than 20 dB) attributable to their pop music exposures, and the largest notch in the audiogram was at 6000 Hz (also cited in (Sataloff 1991).   Given the measured sound levels in bars and the substantial body of evidence (both in scientific and popular sources), there is ample reason to believe that rock and pop musicians are at risk of hearing loss, beginning at the 6000 Hz frequency, and perhaps in one ear more than the other.         Noise and Hearing Loss in Musicians    Page 11 of 39  What about other people who work around music, like bar and club staff?  According to Meyer-Bisch (Meyer-Bisch 1996), the sound level on a typical dance floor ranges from 95-110 dBA, and rock concerts almost always fall between 100 and 115 dBA. Given that many people are employed in these venues and would be expected to be exposed to these levels for several hours during a shift, the potential for hearing loss could be quite high.  A comprehensive review of the exposures of bar and club staff was conducted at the Health and Safety Executive in the United Kingdom in 2002 (Smeatham 2002), and this report should be consulted for specific questions.   The following table (Table 4) summarizes the results of all the studies reviewed by Smeathem with regards to noise exposure of bar staff, by occupation. These sound exposures are loud enough to cause permanent noise damage to the average person, based on calculations presented in the report (Smeatham 2002); the longer a person is exposed, the higher the risk! Many studies in these venues test what is called ?temporary threshold shift?, or TTS, where some sensitivity in hearing is lost right after a loud concert, but returns after a rest. Hearing loss can be thought of as a ?permanent threshold shift?; it has been suggested that experiencing TTS 5 times a week for 10 years can cause a permanent hearing loss of that level (Jaroszewski and Rakowski 1994). However, the relationship between TTS and PTS is not clear at this point (Gunderson, Moline et al. 1997; Smeatham 2002).  Table 4: Average noise exposure of various bar staff (accumulated results)  Task/ occupation Number of measurements Average dB(A) Average hours per week Time per day permitted at this sound level DJ 53 96.3 16.5 ?  36 minutes/day ?  3 hours/week Bar staff  204  92.3  15.7  ?  1.5 hours/day ?  7.5 hours/week Floor staff  32  92.9  Not given  ?  1.3 hours/day ?  6.5 hours/week Security (bouncers) 10 96.2 Not given ?  36 minutes/day ?  3 hours/week   Noise and Hearing Loss in Musicians    Page 12 of 39  What factors increase the risk of noise-induced hearing loss in musicians?  There are several risk factors for noise-induced hearing loss (NIHL) in musicians of all types. Some are quite obvious, such as playing music that is consistently loud (i.e., non-classical) (Chesky and Henoch 2000; Kahari, Zachau et al. 2004), or playing music with high intensity at high frequencies (as in some symphonies). Perhaps equally obvious is the observation that being exposed for longer periods of time, whether over a period of one day or over a lifetime, poses a higher risk for developing hearing loss (Kahari, Axelsson et al. 2001). Playing some of the ?louder? instruments (such as bassoon, French horn, trumpet, double bass, flute, and trombone) has also been associated with poorer hearing (Axelsson and Lindgren 1981; Karlsson, Lundquist et al. 1983; Eaton and Gillis 2002). In many cases, this may also be related to the musician?s position in the orchestra, with those sitting in front of the brasses or percussion section reporting worse hearing (Westmore and Eversden 1981). Violinists and flautists may also be at increased risk for developing worse hearing losses in their left and right ears, respectively, due to the placement of their instruments (Ostri, Eller et al. 1989).   Many researchers have noted that male musicians tend to have more pronounced hearing losses than females; whether this has a biological cause, or is a function of men playing louder instruments is not clear (Axelsson and Lindgren 1981; Steurer, Simak et al. 1998; Kahari, Axelsson et al. 2001; Kahari, Zachau et al. 2003). Musicians who have had a longer career are also at increased risk of hearing loss. In older people the natural loss of hearing with age (called ?presbycusis?) seems to be worsened with increasing noise exposure (Kahari 2001). Since musicians and entertainment professionals often spend a great deal of their leisure time partaking in the music of others, it is important that they use hearing protection during these times to give their ears a rest (DeLay, Hiscock et al. 1991). If they do not, they increase their risk of hearing loss in the long run (Bray, Szymanski et al. 2004). Poor acoustic design of venues, especially important for rock music, may pose a greater risk for musicians? hearing as well (Hart, Geltman et al. 1987).   What do we recommend that you do to protect your hearing?  There are many different options and methods to reduce the risk of noise-induced hearing loss depending on your instrument type, or your job. An interesting observation is that many of today?s ?innovations? to make music ?better? might actually hinder a musician?s ability to monitor the sounds that they produce. For example, you might have seen or used baffles or overhangs to dampen the sound in your orchestra pit or on stage. While these may help in some situations, they can also make it hard for the musician to get a feel for their tone, and how loud they are playing (Chasin and Chong 1995). Overcompensation is common, and the musician is more likely to play louder so that they can hear themselves properly. This creates a situation that may be dangerous to hearing, as well as to the wrists and hands, resulting in ergonomic problems .  For example, they  Noise and Hearing Loss in Musicians    Page 13 of 39  reported a drummer who used inappropriate earplugs that blocked too much sound; he ended up overplaying and developing sore wrists.  In general, the use of baffles, sound shields, transparent shields and the like is rather limited. This appears to be because not enough research has been done on their effectiveness in preventing hearing loss among musicians, and doubt about preserving the quality of the music if they are used (Hart, Geltman et al. 1987; Daum 1988; Teie 1998; Eaton and Gillis 2002).   Following are suggestions from the literature for preventing hearing loss in musicians: Changes to the environment or to technique  Since it is not often possible to reduce the intensity of music at its source, here are some features that can be changed about the way your band or orchestra is organized that may help reduce noise exposure.   1.  Elevate speakers and amplifiers off of the floor (Chasin and Chong 1995) When these instruments are set on the floor of the stage, low frequency sound is absorbed by the floor, causing the sound engineer to turn up the volume to create the feeling of ?loudness?. This creates a potentially dangerous situation for excessive noise exposure. If the speakers are elevated, less low-frequency noise is lost to the floor, and the desired sound can be delivered at less intensity.  2.  Make sure that the small strings (violin/viola) do not have any overhangs above them (for at least 2 meters of unobstructed space) (Chasin and Chong 1995) It is common, especially in orchestra pits, to place the small stringed instruments underneath an overhang. This usually dampens the sound in the higher frequencies. While this may appear to be a positive development, because we know that the higher frequencies are most damaging to the ear, this is not the case. If the musician can?t properly monitor the tone of their instrument, they tend to play louder, with negative effects on themselves (strain injuries, higher noise exposure) and their neighbours.  3.  Make sure that there is at least 2 meters of unobstructed space between the front of the orchestra and the audience (Chasin and Chong 1995) Having floor space in front of the orchestra creates a surface for shorter sound wavelengths (higher frequency) to reflect off of, allowing these notes to be better monitored by the musicians. When the musicians can hear the full tonal quality of their music, they are not required to overcompensate and risk overuse injuries and louder sound exposures.  4.  Place the treble brass instruments on risers (Hart, Geltman et al. 1987; Daum 1988; Chasin and Chong 1995) The treble brass instruments produce high intensity sounds at high frequencies, making them especially hazardous to hearing. In addition, these instruments produce a sound that is highly directional, so that people sitting in front of brass  Noise and Hearing Loss in Musicians    Page 14 of 39  musicians are at highest risk for hearing damage. By directing the treble brass sounds out and over the heads of those musicians, less sound will reach their ears.  5.  Do not stand or sit directly in front of speakers (for rock musicians) ? move slightly to the side (Sataloff 1991; Hall and Santucci 1995) Amplifiers and speakers project their sound outwards. Standing behind the speakers is not feasible, as too much sound quality is lost, but standing slightly to the side of the equipment will reduce the intensity of the music without losing too much in the way of quality.  6.  Avoid overcrowding of musicians whenever possible (Hart, Geltman et al. 1987) Having a smaller distance between musicians increases the sound delivered to the ear, especially when the instrument?s sound is highly directional (like trumpets) (Kahari 2001). In addition, the increased sound levels from neighbouring players may reduce the individual?s ability to monitor their own sound, which may encourage louder playing.  7.  Let your ears rest (Fearn 1993) for at least 12 hours after a loud concert, and wear ear protection during your leisure noise exposures.    Hearing protection devices  The use of hearing protection devices (earplugs) by musicians has been historically undesirable or even somewhat taboo (Chasin and Chong 1992). It has been undesirable for 2 main reasons: 1) the occlusion effect, which causes the user to feel stuffed-up or ?echoey?, and 2) the stronger attenuation of high frequency sounds relative to low frequency (Killion and Stewart 1988; Chasin and Chong 1991). It has been considered taboo because a musician doesn?t want their peers or their audience to perceive them as having less-than-perfect hearing (Ostri, Eller et al. 1989).  Luckily, hearing protection devices (earplugs) have come a long way, and there are several commercially available models specially designed for use by musicians. Table 5   gives a recommended earplug by instrument type; the earplugs are described in more detail below. Most of the research on the protection of musicians? hearing has been undertaken by two research teams led by Marshall Chasin, as well as Michael Santucci.  Also note that more specialized earplugs are available today (Chasin and Santucci made their recommendations in 1991). Etymotic Research (ER) makes ?filter buttons? that fit into plugs that you have made by an earmold lab. Therefore, it is easy to substitute in a button that provides a different amount of attenuation if the musician requires it. Currently, ER makes buttons with 9, 15, and 25 dB uniform attenuation, as well as their non-custom ER-20 (all described below, and at www.etymotic.com).  Noise and Hearing Loss in Musicians    Page 15 of 39   Table 5: Optimal earplug by instrument type (Chasin and Chong 1991)  What instrument do I play? Which instruments are likely to affect my hearing? What plug should I use? Reeded woodwind  The brass section (to the rear)  ER-15 (vented/tuned) Flute  Flute section  ER-15 (vented/tuned) Small strings  Small strings  ER-15  Large strings  Brass section  Vented/tuned Brass  Brass section (or percussion)  Vented/tuned Percussion Percussion  ER-20/Hi-Fi Vocalist (solo)  Soprano singers  Vented/tuned Vocalist (non-solo)  Other instruments  ER-15 Amplified instruments  Amplifiers  ER-15   The ER-15 earplug  This custom-made earplug (developed by Etymotic Research) has an acoustic amplifier built right inside it. Since higher frequencies are inherently attenuated more strongly, this device pre-emphasizes this range, and the net result is uniform attenuation of about 15 dB (Killion and Stewart 1988; Santucci 1990; Chasin and Chong 1991). What this means in practical terms is that all frequencies of the music are reduced in intensity at the ear by 15 dB, with no change in the fundamental or harmonic structure of the music (see Figure 1). The sound filter is purchased from Etymotic Research, but a mold of the ear must be taken at a registered lab, so these plugs can be costly (about $150-$200).  Figure 1: Response of the unprotected ear versus an ear protected by the ER-15 (from http://www.etymotic.com/pdf/erme-er20-fittingguide.pdf)    The ER-20/HI-FI earplug  Noise and Hearing Loss in Musicians    Page 16 of 39   This is a non-custom (one-size-fits-most) earplug (pictured in Figure 2) that aims to match the fundamental and harmonic structure of music at the ear, only at a sound pressure level of about 20 dB lower than at the unprotected ear (Chasin and Chong 1991). Because of the non-custom fit, there is a slightly higher attenuation at higher frequencies (called ?roll-off?). The ER-20 is a lower-cost (less than $20 a pair) alternative to the ER-15, and works well for percussionists whose highest-risk sound exposure comes from the high-hat cymbals. The slight high-frequency roll-off helps to prevent damage at a frequency of 6000 Hz (mostly from the cymbals). The sound attenuation provided by the ER-20 is shown in Figure 3, as compared to 2 common foam earplugs. If required, it is possible to make a custom version of the ER-20 is with the help of an earmold lab.  Figure 2: Diagram of the ER-20/Hi-Fi earplug (from http://www.etymotic.com/pdf/erme-er20-fittingguide.pdf)    Figure 3: The real-ear attenuation of the ER-20/Hi-Fi as compared to 2 types of regular foam earplugs. Note the preservation of high frequency sounds.   The Vented/Tuned earplug  This type of plug was also developed by researchers specifically for musicians. It consists of a swimmer?s earplug with a tuneable vent or ?Select-A-Vent? drilled through the center (Chasin and Chong 1991). When the hole is at its largest (about 3mm), the earplug is ?transparent? up to about 2000 Hz, but has about 30 dB of high frequency attenuation. By varying the diameter of the hole, this acoustic signature can be altered, depending on the type of sound being filtered. This is a highly specialized earplug that is especially useful for musicians who don?t require much attenuation at lower frequencies (because  Noise and Hearing Loss in Musicians    Page 17 of 39  their instrument is not capable of producing very loud noises at these pitches), and also don?t need to bother much with high frequency sounds to monitor their tone.  An example of this is the large stringed instruments.   In summary, there are many feasible options for the at-ear protection of musician?s hearing. Those interested are encouraged to visit the websites for Etymotic Research at www.etymotic.com, and Sensaphonics, another designer and developer of hearing protection for music venues and musicians (www.sensaphonics.com).   Conclusions and Recommendations  Based on this comprehensive literature review, it is evident that all types of musicians are at increased risk of developing hearing loss as a result of their exposure to music. Some factors that may increase this risk include playing louder instruments (brass or drums, for example), position in the orchestra or on stage, longer career length (regardless of age), and playing in acoustically unsuitable venues. Despite these risks, however, there are many techniques that can be used to control exposure and help to prevent hearing loss. These may be behavioural (such as avoiding loud noises outside of work), engineering (such as modifying the seating positions of loud instruments), or varying techniques for protection at the ear (such as the ER-15 earplug).    Acknowledgements We would like to acknowledge the guidance and advice provided by Ms. Linda Kinney of SHAPE. Noise and Hearing Loss in Musicians    Page 18 of 39  References Arnold, G. and M. D. 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"Sound Levels Recorded Within The Symphony-Orchestra And Risk Criteria For Hearing-Loss." Scandinavian Audiology 12(3): 215-221. Jaroszewski, A., T. Fidecki, et al. (1998). "Hearing damage from exposure to music." Archives of Acoustics 23(1): 3-31. Jaroszewski, A. and A. Rakowski (1994). "Loud music induced thresholds shifts and damage risk prediction." Archives of Acoustics 19(3): 311-321. Johnson, D. W., R. E. Sherman, et al. (1985). "Effects of instrument type and orchestral position on hearing sensitivity for 0.25 to 20 kHz in the orchestral musician." Scandinavian Audiology 14: 215-221. Juman, S., C. S. Karmody, et al. (2004). "Hearing loss in steelband musicians." Otolaryngology-Head And Neck Surgery 131(4): 461-465. Kahari, K., G. Zachau, et al. (2004). "The influence of music and stress on musicians' hearing." Journal of Sound and Vibration 277(3): 627. Kahari, K., G. Zachau, et al. (2003). "Assessment of hearing and hearing disorders in rock/jazz musicians." International Journal Of Audiology 42(5): 279-288. Kahari, K. R. (2001). "Hearing assessment of classical orchestral musicians." Scandinavian Audiology 30(1): 13-23. Kahari, K. R., A. Axelsson, et al. (2001). "Hearing development in classical orchestral musicians. A follow-up study." Scandinavian Audiology 30(3): 141-149. Karlsson, K., P. G. Lundquist, et al. (1983). "The hearing of symphony orchestra musicians." Scandinavian Audiology 12(4): 257. Killion, M. C. and J. Stewart (1988). "An earplug with uniform 15-dB attenuation." Hearing Journal 41(5): 14-17. Laitinen, H. M., E. M. Toppila, et al. (2003). "Sound exposure among the Finnish National Opera personnel." Applied occupational and environmental hygiene 18(3): 177-182. Lebo, C. P. and K. P. Oliphant (1968). "Music as a source of acoustic trauma." Laryngoscope 78: 1211-18. Lee, J., A. Behar, et al. (2003). "Noise exposure of opera orchestra players." Canadian Acoustics 31(3): 78. Lockwood, A. H., R. J. Salvi, et al. (2001). "Tinnitus and the performer." Medical Problems Of Performing Artists 16(4): 133-135. McBride, D. (1992). "Noise And The Classical Musician." British Medical Journal 305(6868): 1561-1563.  Noise and Hearing Loss in Musicians    Page 20 of 39  Metternich, F. U. and T. Brusis (1999). "Acute hearing loss and tinnitus related to strongly amplified music." Laryngo-Rhino-Otologie 78(11): 614-619. Meyer-Bisch, C. (1996). "Epidemiologic evaluation of hearing damage related to strongly amplified music (personal cassette players, discotheques, rock concerts) - High definition audiometric survey on 1364 subjects." Audiology 35: 121-142. Mikl, K. (1995). "Orchestral music: an assessment of risk." Acoustics Australia 23(2): 51. Nodar, R. H. (1993). "Hearing Loss in a Professional Organist: A Case Study." Medical Problems of Performing Artists 8(1): 23-24. Ostri, B., N. Eller, et al. (1989). "Hearing impairment in orchestral musicians." Scandinavian Audiology 18(4): 243. Palin, S. L. (1994). "Does Classical-Music Damage The Hearing Of Musicians - A Review Of The Literature." Occupational Medicine-Oxford 44(3): 130-136. Patel, J. A. and K. Broughton (2002). "Assessment of the noise exposure of call centre operators." Annals of Occupational Hygiene 46(8): 653-661. Royster, J. D., L. H. Royster, et al. (1991). "Sound exposures and hearing thresholds of symphony orchestra musicians." Journal of the Acoustical Society of America 89(6): 2793. Sabesky, I. J. and R. E. Korczynski (1995). "Noise Exposure of Symphony Orchestra Musicians." Applied Occupational and Environmental Hygiene 10(2): 131-135. Santucci, M. (1990). "Musicians Can Protect Their Hearing." Medical Problems of Performing Artists 5(4): 136-138. Sataloff, R. T. (1991). "Hearing Loss in Musicians." American Journal of Otology 12(2): 122-127. Sataloff, R. T. (1997). "Hearing loss in singers and other musicians." Medical Problems Of Performing Artists 12(2): 51-56. Schmidt, J. M., J. Verschuure, et al. (1994). "Hearing-Loss In Students At A Conservatory." Audiology 33(4): 185-194. Smeatham, D. (2002). "Noise levels and noise exposure of workers in pubs and clubs - a review of the literature." Research Report 026: 91. Steurer, M., S. Simak, et al. (1998). "Does choir singing cause noise-induced hearing loss?" Audiology 37(1): 38-51. Szymanski, K. (1983). "The sound of music [noise levels in concerts]." Noise & Vibration Control Worldwide 14(2): 54. Teie, P. U. (1998). "Noise-induced hearing loss and symphony orchestra musicians: risk factors, effects, and management." Maryland Medical Journal 47(1): 13-18. Westmore, G. A. and I. D. Eversden (1981). "Noise-Induced Hearing Loss and Orchestral Musicians." Archives of Otolaryngology 107(12): 761-764.    Noise and Hearing Loss in Musicians    Page 21 of 39  Appendix 1: Literature Search Strategy  Four bibliographic databases were used to identify the literature for this review: PubMed, CCINFOWeb, Compendex, and Web of Science.  PubMed, produced by the U.S. National Library of Medicine, specializes in health literature. CCINFOWeb, produced by the Canadian Centre for Occupational Health and Safety, specializes in occupational health and safety literature. Compendex contains information on engineering, and some noise measurement papers were located using this database. The search was conducted in February 2005 and employed combinations of the following keywords: noise, hearing, hearing loss, noise-induced hearing loss, tinnitus, audiometry, dosimetry, TTS, PTS, hearing conservation program and musicians, classical, rock music, pop music, musical instrument, symphony, orchestra, orchestral music, hearing protection devices. In addition, a significant portion of the literature cited within this review was identified through pearling, or hand searching of references found within other papers.  We included all accessible scientific literature relating to noise exposure and hearing loss in musicians in general, but excluded articles which were written in languages other than English and French.       Noise and Hearing Loss in Musicians  Page 22 of 39  Appendix 2: Literature Review Summary Tables   Table 1: Epidemiology Papers: Exposure and Health Outcome Papers  Author Year Title Study Group Study design Noise source Health outcome Purpose Results Arnold       1960 Pure-tonethresholds of  professional  pianists (30) pianists who volunteered cross sectional piano music NIHL to examine whether  piano music can  cause hearing loss in  professionals SPL measured on the pianos were up to 95 dB; the group of pianists were all over the age of 60, and actually had better hearing than might be expected for their age group; however the SPLs were high enough that susceptible individuals might be expected to  experience deleterious effects Axelsson1981 Hearinginclassical musicians 139 musicians & 19 retired musicians cohort classical music NIHL & tinnitus To assess hearing damage among musicians using  hearing tests  combined with exposure measurements Audiograms for all musicians indicated a slight hearing impairment; women had better hearing than men (but small # of women); sound levels ranged between 40 and 100 dBA; also mentions rehearsal time @ home, as well as tutoring as other exposures; highest Leq (5 hour) was 88 dBA; brass musicians had the most hearing  loss Behroozi &  Luz 1997Noise relatedailments in  performing  musicians: a  review musicians review   to review the influence of noise on  hearing and the CV system of musicians Evidence for auditory/non-auditory deleterious effects of loud music Bray et al 2004 NIHL in dance music disc jockeys and an examination of  sound levels in  nightclubs 23 DJs (audiometry and exposure measurements) cross sectional club music NIHL to assess exposure and NIHL among DJ's (maybe only study of this kind??) 3/23 DJs had clear NIHL; most were concerned about hearing loss but did not wear HPD; non occupational exposures are particularly important for this group; tinnitus and TTS were common; Leq of 96.1 dB  Noise and Hearing Loss in Musicians  Page 23 of 39  Author Year Title Study Group Study design Noise source Health outcome Purpose Results Chesky  2000 Instrument-specific reports of  HL: Differences  between classical and non-classical  musicians 3292 musicians of varying types who filled in an online  questionnaire cross-sectional all different  types of music (jazz, rock, classical, etc.) NIHL "to examine the incidence of hearing  problems reported from ? musicians of  both? performance area and ?primary instrument" 21.7% of respondents reported hearing loss problems; highest in  rock/alternative/rap/pop group; church & gospel music had the lowest reported problems; among musicians on the same instrument, those playing in nonclassical settings were more likely to report HL Daum 1988 Hearing loss in musicians musicians review music NIHL, etc. review; basics of hearing loss,  measurement,  controls Nice introduction and format for the layperson; describes many forms of noise-induced hearing problems, regulations (current as of 1988), how the ear works, etc. Delay et al 1991 The effects of music technology on hearing: a  case study of St. John's bars bar patrons, employees, and managers (15 popular bars in St. John's) cross sectional rock music NIHL (measured by opinion survey) to see whether sound levels exceeded  regulations, and to gauge opinions on the sound levels 12 bars exceeded the ACGIH 1 hr. exposure limit (); average level measured was 102 dBA (safe unprotected exposure time = 49 minutes); 60% of patrons report tinnitus after leaving a bar; 70% of employees experienced ringing after their shifts, but 78% didn't think that noise could cause permanent damage; 60% of employees were positive about more strict noise regs., but patrons and managers were not as receptive;  Dey1970 Auditory fatigueand predicted  permanent  hearing defects  from rock-and-roll music  rock and roll listeners clinical trial rock music TTS, NIHL to find out how many people are likely to experience adverse and/or permanent ear damage under a damage-risk criterion of a 40 db TTS 2 hours of music at 110 dB (not uncommon at a bar/concert/disco) may leave an "unusually severe" TTS in about 16% of young men exposed, but if the noise level were reduced to 100 dB, only 2 would be affected in this manner Fearn 1993 Hearing loss in musicians many groups (volunteers exposed to pop music, student musicians, etc.) cross-sectional orchestral  music, big  band music,  amplified  music NIHL, TTS To examine hearing loss among young musicians of varying types, and also those who listen to amplified music TTS has a large individual variation; older musicians had worse audiograms; people don't get hi exposure from their own instrument but from others around them (except for percussionists); sound levels in the orchestra are potentially harmful; 12 hours is a good time to wait between concerts;   Noise and Hearing Loss in Musicians  Page 24 of 39  Author Year Title Study Group Study design Noise source Health outcome Purpose Results Fearn           1976 Hearinglosscaused by different  exposures to  amplified pop  music leisure listeners of pop music; although this is a  comment on another study cross-sectional pop music NIHL To highlight that frequency of visits to a music venue might  not be a valid  measure of exposure Variability in exposure, variation in noise level, length of attendance, and different individual sensitivity to hearing loss would camouflage any effect that increased exposure has. Fearn 1989 Hearing level of young subjects  exposed to  gunfire noise gunfire exposed young adults cross sectional gunfire noise NIHL To compare the hearing of young people who were exposed to gunfire as compared to those who weren't The percentages of gunfire exposed subjects with hearing loss are 3-4 times higher than for the control group Griffiths1995 HearingSensitivity among Professional  Pannists steel pan players case-control steel drums NIHL & tinnitus To compare the hearing of pannists with non-exposed people Used questionnaire & hearing test + dosimetry; 72% of pannists had abnormal audiograms (and was worse than in regular orchestras); mean exposures as high as 110 dBA Hart 1987 The musician and occupational  sound hazards musiciansreview differenttypesof music  tinnitus & NIHL Review of hearing problems in  musicians There are real risks to musicians and rock concert-goers (some researchers have measured over 150 dB); acoustically non-treated rooms and reverberations in the venue can also contribute to noise exposure (especially for rock music); definition of what constitutes "HL" is important; clarinetists  can't wear HPD; mention of a company called Sensaphonics making HPD for musicians  Smeathem  (HSE) 2002 Noise levels and noise exposure of workers in pubs and clubs: A  review of the literature all workers in pubs and clubs reviewmusicNIHL, etc.reviewIsing et al 1997 Loud music and hearing risk 569 teenagers exposed to discotheque noise and  Personal Cassette  Players (PCP) cross sectional loud music  to assess the average exposure times and noise intensities of PCP use and disco  visits, and to make a prognosis of hearing risk with these 2 Researchers had the kids set their desired volume level on their PCPs and then measured it; about 5% of the group adjusted to 110 dBA (loudest group was the 13-yr olds); kids who had attended discos or other musical venues were 1.3 times more likely to have hearing loss than those who  Noise and Hearing Loss in Musicians  Page 25 of 39  Author Year Title Study Group Study design Noise source Health outcome Purpose Results exposures in mind did not Jaroszewski & Rakowski 1994           Loud musicinduced  thresholds shifts  and damage risk prediction 4 musicians using high  powered electronic equipment cross sectional rock/jazz music  to measure sound pressure distribution during performance, followed by hearing thresholds Direct measures oscillated between 90 and 120 db; if an exposure producing a TTS @ 2 minutes is repeated 5 times a week for 10 years, a PTS of that TTS level can be expected; median TTS reached 30 dB at 1 kHz, and just above 40 dB @ 4 and 6 kHz for both ears; but as high as 70 dB @ 6kHz for one subject Jaroszewski et al 1998Hearing damagefrom exposure to music musicians, people  listening to loud music reviewrock/classical music NIHL, TTS to review the literature on various components of  hearing impairment in club goers,  rock/classical musicians Problems include decrease in sensitivity leading to distorted frequency discrimination, loudness perception; early changes that may not affect the musician should not be expected to stop, and may lead to more severe impairment later on; in their tested sample of 214 people, 68% had permanent threshold shifts of 10 dB or more Johnson et  al 1985Effects ofinstrument type and orchestral  position on  hearing sensitivity for 0.25 to 20 kHz in the orchestral  musician musicianscrosssectional orchestral  music NIHL to relate hearing sensitivity to musician instrument type, years of playing and orchestral stage  position Average hearing sensitivity in musicians was similar to the hearing of control group; no greater hearing loss in one type of instrumentalist vs. others, also no significant  association with placement in the orchestra Juman et al. 2004 Hearing loss in steelband  musicians pannistscontrolledcross sectional  steel drums NIHL/tinnitus to determine the difference in hearing between pannists and a control group Pannists had significantly worse hearing than controls, except the young musicians (<30); 4/10 platers for 10-19 yrs. Had HL, and 9/12 players for >20 yrs. Had HL (66%!!)  Noise and Hearing Loss in Musicians  Page 26 of 39  Author Year Title Study Group Study design Noise source Health outcome Purpose Results Kahari   2003 Assessmentofhearing and  hearing disorders in rock/jazz musicians rock/jazz musicians cross-sectional rock/jazz music hearing loss,  tinnitus,  hyperacusis (age related hearing loss)  to assess hearing  disorders among the musicians Hearing loss & tinnitus were more common among men, 74% of the group had hearing disorders Kahari et al 2001 Hearing assessment of  classical orchestral  musicians orchestral musicians cross sectional classical music HL to examine hearing loss among classical  musicians No severe hearing losses attributable to music exposure; may be important later in life (additive effect with aging) Kahari et al 2004 The influence of music and stress  on musicians'  hearing 279 classical & rock/jazz musicians cross sectional music of  varying types audiometry and questionnaire  used to assess HL to evaluate hearing disorders, and  explore psychosocial factors in musicians Overall, hearing thresholds were well preserved; although woodwind and brass players had worse hearing; rock and jazz musicians had worse hearing than classical musicians; all thresholds had a "notch" configuration, indicating NIHL; 74% of musicians suffered from different hearing disorders; more men than women; no convincing connection between social factors and hearing Karhari et al 2001 Hearing development in  classical orchestral  musicians: a  follow-up study classical musicians (56 total) follow-up of x-sect (by Axelsson &  Lindgren,  79-80) classical music  to investigate hearing development in  classical musicians, to look at female/male  differences and to compare thresholds w/ control groups Pure-tone thresholds did not decrease faster than normal; men had worse hearing, but also played the loudest instruments (in this study) Karlsson 1983 The hearing of symphony orchestra  musicians 417 symphony orchestra musicians (123  measured twice over 6 yrs.) cohort classical music higher pure tone threshold To investigate  whether the pure tone thresholds of  symphony musicians are higher than an unexposed group (using a relatively  large sample size) From the audiograms, they found that there was no increased risk of impaired hearing for musicians; when grouped by instrument, the double bass players and flute players had very slight NIHL though; former military musicians had worse hearing than others;  Noise and Hearing Loss in Musicians  Page 27 of 39  Author Year Title Study Group Study design Noise source Health outcome Purpose Results Meyer-Bisch           1996 Epidemiologicalevaluation of  hearing damage related to strongly amplified music? 1364 volunteers who underwent audiometric testing and  questionnaires case control rock music, discotheque  noise, PCP NIHL to assess whether leisure exposures cause hearing  damage (separated by each exposure) Disco patrons presented no hearing losses; people who use PCPs had significantly worse hearing, as did those who attended a rock concert at least twice a month Nodar 1993 Hearing Loss in a Professional  Organist: A Case Study 1 professional organist case study organ music hearing loss the woman had complaints that she  was playing too loud, and actually couldn't hear herself play Measurement of hearing showed that she had moderate to severe hearing loss Ostri1989 Hearingimpairment in  orchestral  musicians 96 Danish orchestral musicians cross-sectional symphonic music hearing loss to assess the hearing of musicians Has results of hearing self-assessment  (interesting); musicians do have increased hearing thresholds compared to the general population Palin1994 Does Classical-Music Damage  The Hearing Of Musicians - A Review Of The Literature classical musicians review orchestral instruments NIHL To assess whether classical music damages the hearing of musicians Poor design of many studies makes generalizations harder Sataloff 1991 Hearing loss in musicians review-----Sataloff 1997 Hearing loss in singers and other musicians musicians/singers review all types of music HL to do a thorough review of the subject of hearing loss in  musicians Review (n/a) Schmidt 1994 Hearing loss in students at a  conservatory 79 students at the Rotterdam conservatory case control (med  students as  controls) orchestral  music NIHL to test the hearing of musicians at the start of their career, and assess possible  damage caused by music High percentages of audiometric noise dips (16%) and Hi-f losses (20%), and extended hi-f losses (72%); however, no different (and sometimes less) than the control group  Noise and Hearing Loss in Musicians  Page 28 of 39  Author Year Title Study Group Study design Noise source Health outcome Purpose Results Steurer    1998 Does choirsinging cause  noise-induced  hearing loss? 62 opera choir singers cross sectional  measured  hearing loss choir singing hearing threshold impairment to investigate hearing  impairment in choir  singers (major lack of  studies in the  literature) Hearing loss was greater in all female groups (compared to reference group) with few exceptions; older men had worse hearing for their age, but younger showed no differences; women hear better at high frequencies than men Teie1998 Noise-inducedhearing loss and  symphony orchestra  musicians: risk factors, effects, and management   symphony orchestra musicians review classical music NIHL to put forth suggestions for  monitoring and  protecting the  professional ear NIHL can make it difficult or impossible to hear some musical tones; balance of tones  is hard to accomplish (especially important for singers and sound engineers); reducing sound levels at the ear may be the most appropriate; deep insertion plugs (ER) can help reduce the occlusion effect;  Westmore & Eversden 1981NIHL andorchestral  musicians orchestral musicians   cross sectional classical music NIHL to make a connection between sound pressure levels and  NIHL Short term measurements >120 dB; sound levels depend on type of music (i.e. the composer); substantial # of people had NIHL (~50% of woodwinds)      Noise and Hearing Loss in Musicians  Page 29 of 39  Table 2: Exposure assessment papers  Author Year Title Study Group Study design Noise source Health outcome Purpose Results Early 1996 Noise Exposure to Musicians during Practice marching bands,  concert bands (7 different types of arrangements)       musicalinstruments    TTS, NIHL Determine the noise exposure of musicians at practice Many musicians' exposures are above the OEL of 85 dBA, even if they only practice for 1-3 hours per day; also considers determinants (including time of year) Fisk1997 Sound pressurelevels during  amplified orchestra  rehearsals and  performances  professional  orchestral musicians exposure assessment orchestral music  + country & pop NIHL, but complaints of tinnitus & dulled hearing after performances too To assess noise exposure of an orchestra at their request Sound levels ranged from 70 - 89 dBA, with a max of 100 dBA; sound levels were lower during rehearsals as compared to performances (more breaks) Gunderson et al 1997 Risks of developing noise-induced  hearing loss in  employees of urban music clubs employees of live music clubs (not  musicians  themselves) cross sectional live music performed in urban clubs NIHL (using  audiometry and exposure meas.) to determine whether a hazard of NIHL exists for music club  employees other than musicians  themselves Range of average sound level (over performance and intermission times) was 91.9 to 99.8 dB, which is above the OSHA standard of 90. sound levels varied by music type, with hard rock being the loudest, closely followed by blues; sound levels were usually too high, although they did have a small sample size Henoch2000 Sound exposurelevels experienced  by a college jazz band ensemble - Comparison with OSHA risk criteria college jazz band members exposure assessment jazz music (rehearsal) NIHL To measure sound levels for different  instruments in the jazz band 10 out of 15 measurements had mean exposures over 100 dBA, and lead musicians in each section had the highest exposures Jansson1983 Sound levelsrecorded within the symphony orchestra and risk criteria for  hearing loss classical musicians cohort classical music NIHL To map sound levels and spectra within the symphony orchestra   Noise and Hearing Loss in Musicians  Page 30 of 39  Author Year Title Study Group Study design Noise source Health outcome Purpose Results Laitinen    2003 Sound exposureamong the Finnish National Opera personnel  personnel of an  opera (conductors, dancers, musicians, singers) exposure assessment musical  instruments and  singing hearing loss to evaluate exposure to noise by all types of musicians and workers Most of the personnel were exposed to noise levels that were hazardous to hearing; rehearsals and performances had high levels; recommends HPDs and motivation to wear them Lebo &  Oliphant 1969 Music as a source of acoustic trauma musicians (rock and symphony) exposure assessment rock music, compared to  symphonic music - to map out the acoustical properties  of symphony music to compare to rock music Rock groups were usually louder than 95 db in the lower frequencies, while the symphony rarely achieved such levels; the highest noise levels of the rock groups were at and below 500Hz, while symphonies were higher than this Lee2003 Noise exposureofopera orchestra players   73 Opera orchestral musicians in an orchestra pit exposure assessment opera music not measured to examine noise exposure during rehearsal and  performance of 2 operas Measured exposure with noise dosimeters; determinant of exposure was proximity to the brass section (which also had the  highest noise measurements) McBride 1992 Noise And The Classical Musician 63 of 89 City of Birmingham  Symphony Orchestra exposure assessment symphonic music NIHL to test the hypothesis that noise exposure may cause hearing loss in classical musicians Half of rehearsal measurements were above 85 dB; high risk group was woodwind and brass, strings were low-risk, but comparison of hearing showed no difference between the groups; however potential exists for hearing loss in  the orchestra according to measured noise levels Mikl1995 Orchestralmusic:an assessment of  risk  orchestral musicians  in an opera pit  opera music NIHL To do area measurements of noise during  rehearsal and  performance in an orchestra pit over an entire musical  season Audience and conductors are not at risk; the tight performance schedule and pit placement are risk factors  for NIHL  Noise and Hearing Loss in Musicians  Page 31 of 39  Author Year Title Study Group Study design Noise source Health outcome Purpose Results Patel 2002 Assessment of the noise exposure of call centre operators 150 call centre  operators cross-sectional  (measurements done with a man-nequin) background at  work + headset noise NIHL (though the paper is exposure-focused) To see if either  background noise or  headset noise  exceeds OEL Mean personal exposures were unlikely to exceed 85 dBA Royster et al 1991 Sound exposures and hearing  thresholds of  symphony orchestra musicians symphony orchestral musicians (Chicago S. O.) cross sectional symphonic music NIHL to assess the risk of NIHL in the Chicago symphony orchestra (using dosimetry and audiology) Mean Leq 89.8 dB; peak 125 dB; 68 measurements; small amount of NIPTS risk for average musician, but high for susceptible individuals Sabesky & Korczynski 1995  Noise exposure ofsymphony orchestra musicians classical musicians (Winnipeg S.O.) surveillance classical music only measured exposure to see if noise  exposure was within Manitoba standards (testing 3 playing events) Noise exposure was in excess of all provincial standards Szymanski 1983 The sound of music n/a exposure assessment orchestral music NIHL to see whether participants at  symphonies are exposed to  unacceptable noise  levels (as people at  discotheques are) Data presented by musical piece, the loudest of which was 85.3 dBA Leq; also considered the effect of audience applause, which was very loud, but too short to exact any risk; overall, there was no danger of NIHL to concertgoers    Noise and Hearing Loss in Musicians  Page 32 of 39  Table 3: Disorders other than noise-induced hearing loss  Author Year Title Study Group Study design Noise source Health outcome Purpose Results Axelsson &  Prasher 2000          Tinnitus inducedby occupational and leisure noise noiseinducedpermanent  tinnitus  (NIPT)   Tinnitus usually develops slowly (not as the result of one high exposure); tinnitus is commonly reported after a rock concert; basic message: more research needed Axelsson &  Ringdahl 1989 Tinnitus - a study of its prevalence  and  characteristics 3600 residents of GothenburgSweden, randomly chosen by age surveillance varied Tinnitus to estimate the prevalence of  tinnitus in this  population 66% response rate; 14% of respondents reported tinnitus "often" or "always"; it was more often reported in the left ear, especially in males; tinnitus was more severe in older vs. younger females, but there was no such difference in the men; tinnitus was generally more common in those with other hearing loss (subjective measure though) Lockwood 2001 Tinnitus and the performer Performers of all types General review of tinnitus etiology and therapy Various; music, environmental Tinnitusto encourageprevention, as the treatment isn't very good To conserve musician's hearing: change in seating, addition of risers, sound shields between players, HPD Metternich 1999 Acute hearing loss and tinnitus  related to strongly amplified music 24 patients with music-related acoustic trauma retrospective  cohort 67%: rock concert; 17%: discotheque; 12%: parties; 4%: walkman Hearing loss  & tinnitus to look at the risk of  hearing loss from a short term or one-time exposure to loud music Risk of permanent hearing loss is low compared to tinnitus. Rheologic therapy helped with hearing loss. Rosanowski1996 External auditorycanal in situ  measurement of  sound pressure in a professional  violinist suffering from bilateral  tinnitus 1 violinist case study Vuillaume & Carcassi violins, up to 90 dB bilateral tinnitus to see if the different sound spectra of the 2 violins was the cause of the  musician's enhanced tinnitus It is possible that the different violin sound spectra caused the enhanced tinnitus, but it couldn't be verified    Noise and Hearing Loss in Musicians  Page 33 of 39  Table 4: Controls and preventive measures  Author Year Title Purpose Results Chasin  1995 Four environmentaltechniques to reduce the effect of music exposure on hearing to describe 4 methods that may help to reduce hearing loss (also outlined in the Ontario Min. of Labour document- Live Performance Industry (1) Elevate speakers & amps (such that low freq. sounds are not absorbed and technicians don't turn up the volume to compensate); (2) Put treble brass on risers (to protect those directly in front of them); (3) ensure 2m of unobstructed floor in front of the orchestra; and (4) ensure small strings have 2m above them (so that they don't overcompensate and risk HL & other injury Chasin & Chong 1992 A clinically efficient hearing protection program for musicians to review clinically efficient HPP's for musicians Problems with HP: 1) occlusion effect (causes hearer's voice to sound loud and hollow); 2) non-uniform attenuation (more at high freq.); HPD options: 1) acoustic attenuator inserted into custom earplugs, the net result is flat attenuation @ the eardrum; 2) tuned or adjustable vent --> allows lower frequencies to pass unattenuated but filters the high freq. Chasin & Chong 1991 An in situ ear protection program for musicians to showcase a few earphones that may be useful for musicians' hearing protection; also separated by instrument Three plugs are the ER-15, the ER-20, and vented/tuned; variability among instruments and musicians is important for choosing the right earplug; broken down individually in this paper Eaton & Gillis 2002 A review of orchestral musicians' hearing loss risks   to determine exposure levels; evaluate risk; evaluate HL; examine effectiveness of controls   Engineering controls may be counterproductive to the musical experience  Groothoff 1999 Incorporating effective noise control in music entertainment venues? Yes, it can be done to see whether noise control is viable in an industry that sells loud noise; follow up with venues where excessive noise was a problem 14 venues were followed up; all surveyed sites exceeded 85 dB regulation; owners knowledge had increased re: obligations to health and safety Hall & Santucci 1995 Protecting the professional ear: conservation strategies and devices to present some case studies of the range of experiences of music professionals re: hearing loss; to outline some strategies for  prevention Hearing loss in musicians is a very different problem than in industrial workers because hearing is so important for their livelihood; high-fidelity hearing protection as well as in-ear monitoring may be able to help  Noise and Hearing Loss in Musicians  Page 34 of 39  Author Year Title Purpose Results Killion et al 1988 An earplug with uniform 15 dB attenuation to highlight the use of the ER-15 earplug (how it works, why it may be the best solution) Normal earplugs muffle the sound too much (give too much attenuation at higher frequencies than lower); the ER-15 better matches the natural frequency response of the open ear, but at a reduced level Santucci 1990 Musicians can protect their hearing to outline a method for an HCP for musicians (including case history, education, testing) Important in HCP: case history; audiology; sound measurements; preventive measures (good part on HPD's); education      Noise and Hearing Loss in Musicians  Page 35 of 39  Table 5: Papers not used for this review  Author Year Title Study Group Study design Noise source Health outcome Purpose Results Berger & Killion 1989 Comparison of the noise attenuation of three audiometric earphones, with additional data on masking near  threshold n/a  testing attenuation  props. Of  audiometric  earphones any loud noises none to compare noise attenuation of a  few earphones that are used to give hearing tests The purpose of the earphones is to block a good deal of outside noise, and so they are not likely to be appropriate for musicians; Crnivec  2004 Assessmentofhealth risks in  musicians of the  Slovene  Philharmonic  Orchestra, Ljubljana,  Slovenia  70 philharmonic  musicians case control orchestral instruments MSI mostly, but minor hearing  impairment too to compare  Slovenian and  German musicians' health  problems Mostly MSI reported; 22.8% of Slovenian musicians had "minor  performance-related hearing impairments" Dibble 1995 Hearing loss and music review - loud music hearing impairment to ascertain the relationship  between exposure to loud music and  hearing  impairment Rock and roll "does not work" below about 96 dB; weight of evidence suggests that music is  not as big of a risk as  occupational noise because it is  "wanted noise" Fearn 1976 Hearing loss caused by amplified pop music 50 pop music  event attendees cross sectional pop music NIHL - Not measuring occupational exposures of musicians Galbraith 1977 Rock music and NIHL: The British scene n/a - - - - Not measuring occupational exposures of musicians  Noise and Hearing Loss in Musicians  Page 36 of 39  Author Year Title Study Group Study design Noise source Health outcome Purpose Results Gittens                      1986 Entertainmentnoise many groups review many different leisure noises NIHL to review studies of leisure  exposure to live rock music, classical music, earphones,  fireworks, guns  Harper2002 Workplaceandhealth: A survey of classical orchestral musicians in the United Kingdom and Germany  musicians questionnaire music NIHL, but many others to identify the health concerns  of musicians Noise was ranked high by the most people, and woodwind players were frequently more susceptible Hellstrom1998 Temporary thresholdshift induced by  music  Teenagers using personal cassette  players -----Henoch 1999 Hearing loss and aging: Implications for the professional musician musiciansonline survey(self-reported) orchestral  instruments, but more  focused on  age hearing loss (NIHL and age-related) to review knowledge on age-related hearing loss  among musicians hearing loss may occur earlier in life among musicians than the  general population Hohmann 1999 Effects on hearing caused by PCPs, concerts, and  discotheques and  conclusions for  hearing conservation in Switzerland ------Hoppmann2001 Instrumentalmusicians' hazards instrumental  musicians revieworchestralinstruments mostly MSI largely looking at MSI, but a small  part on NIHL Only a brief description of NIHL; not useful for this review  Noise and Hearing Loss in Musicians  Page 37 of 39  Author Year Title Study Group Study design Noise source Health outcome Purpose Results Jaroszewski 2000 The extent of hearing damage from exposures to music Discotheque  attendees &  musicians/music  students review       ----Kahari et al. 2003 Associations between hearing and psychosocial working conditions in rock/jazz musicians 139 rock/jazz  musicians  (volunteers that  filled out a  questionnaire) cross sectional stress, loud music no exposure measured  (questionnaire only) to explore associations  between psychosocial work conditions, mental load, and  hearing disorders Assessed such stressors as work, family, sleep-related, mood. Musicians were compared with white-collar workers for stress levels based on these stressors. Liebel1996 Measurementofnoise effects in a  discotheque by means of  otoacoustic  emissions  disco visitors cross sectional dance music TTS  to investigate the difference in  techniques for  assessing TTS The threshold shift occurred @ 4000 Hz in the group exposed for 1 hr @ 105 dBA, and was spread over all frequencies when the time increased; after 2 hours of exposure, the threshold shift was 10.1 dB  Lipscomb 1976 Hearing loss of rock musicians young people potentially exposed to loud  music (total people measured = 7179) cross sectional rock music NIHL to use hearing screening tests to  map the high  frequency hearing  impairment with age (from 6th grade to first year of college) 32.9% of college freshmen had HFI (high frequency impairment); boys were worse off than girls; exposure was not assessed, so these results are only postulated to be explained by loud music; besides all this, rock musicians seem to have low hearing loss overall- protective mechanism? Lipscomb 1969 Ear damage from exposure to rock and roll music Guinea pigs - - - - Talks about the destruction of hair cells in the cochlea resulting  from 122 db; irreversible damage in nearly 20% of cells  Noise and Hearing Loss in Musicians  Page 38 of 39  Author Year Title Study Group Study design Noise source Health outcome Purpose Results Lockwood 1989 Medical problems of musicians  review   to review some of the med.  problems (noise  not included) - MacPherson 1991 A method for assessing and  controlling noise  exposure of employees and patrons in  entertainment  (music) venues patrons and  employees @ live band  performances, clubs, and the  theatre surveillance          musicn/a (only areaexposure measurements) to validate an  assumption made  in a previous  study (that "room loss' was constant from  one performance to the next) "room loss' was generally consistent for a venue McCann1992 OccupationalHazards in the Arts and Professions visual &  performing  artists, TV production n/amusicalinstruments NIHL very broad review of hazards of  many types of artists None- suggests ear plugs and plastic shields to limit exposure Merry1995 Historicalassessment and  future directions in  the prevention of occupational hearing  loss review - - - - Has some info about different hearing conservation programs and hearing protection, but is really about occupational hearing loss in general Okada1991 Morphological-Changes Of The Spiral Vessel After Rock-Music Exposure Guinea pigs animal study; case control rock music dilation/constriction of the spiral vessels to investigate  potential  physiological causes of  temporary threshold shifts At sound levels of ~115 dB, there was no change in the spiral vessel; results convoluted  Noise and Hearing Loss in Musicians  Page 39 of 39  Author Year Title Study Group Study design Noise source Health outcome Purpose Results Okamoto 1986 Hearing loss after exposure to musical sounds not clear not clear Musical sounds hearing loss to look at hearing loss caused by music (rock, discotheque,  headphones) Not given Peters     1999 Progressinindustrial noise  control review - - - - Industrial noise control not useful to this reveiw Prince 2002 Distribution of risk factors for hearing loss: Implications for  evaluating risk of occupational NIHL - - - - - Not specific to musicians Schuele &  Lederman 2004Occupationaldisorders in  instrumental  musicians musicians review  HL to determine the frequency of occupational  disorders in  instrumental  musicians;  compensation  issues too Mostly based on MSI/neuropathies Wallis & Marsh 1978 Control of noise in places of  entertainment - - - - - Focused on reducing noise for the neighbours of clubs because people on the inside "are there because they enjoy it"    


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