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

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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. 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.  “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 lowpitched sound.  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) 45-55 60-70 75-85 80 90 92-95 95 105-120 120-137 140 150  Sound source Normal conversation at arm’s length Piano played at moderate levels Chamber music in a small auditorium Telephone dial tone Train whistle at 150 meters away Piano played loudly Subway train at 60 meters away Amplified rock music at 1-2 meters away Symphonic music peak Jet engine at 30 meters away 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 Trombone Piccolo Flute French horn Clarinet Violin Piano Oboe Xylophone Cello String Bass  Typical sound levels (dBA) 85-114 95-112 85-111 90-106 92-103 84-103 92-95 80-94 90-92 84-92 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.hearit.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.  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).  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! Table 4: Average noise exposure of various bar staff (accumulated results) Task/ occupation DJ  Number of measurements 53  Bar staff  204  Floor staff  32  Security (bouncers)  10  Average Average hours Time per day permitted dB(A) per week at this sound level 96.3 16.5 • 36 minutes/day • 3 hours/week 92.3 15.7 • 1.5 hours/day • 7.5 hours/week 92.9 Not given • 1.3 hours/day • 6.5 hours/week 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., nonclassical) (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 Which instruments are likely play? to affect my hearing? Reeded woodwind The brass section (to the rear) Flute Flute section Small strings Small strings Large strings Brass section Brass Brass section (or percussion) Percussion Percussion Vocalist (solo) Soprano singers Vocalist (non-solo) Other instruments Amplified instruments Amplifiers  What plug should I use? ER-15 (vented/tuned) ER-15 (vented/tuned) ER-15 Vented/tuned Vented/tuned ER-20/Hi-Fi Vented/tuned ER-15 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 ER15, 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-er20fittingguide.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. Miskolczy-Fodor (1960). "Pure-tone thresholds of professional pianists." Archives of Otolaryngology 71(June): 938-947. Axelsson, A. and F. Lindgren (1981). "Hearing in Classical Musicians." Axelsson, A. and D. Prasher (2000). "Tinnitus induced by occupational and leisure noise." Noise and Health 8: 47-54. Axelsson, A. and A. Ringdahl (1989). "Tinnitus - a study of its prevalence and characteristics." British Journal of Audiology 23: 53-62. Behroozi, K. B. and J. Luz (1997). "Noise-related Ailments of Performing Musicians: A Review." Medical Problems of Performing Artists 12(1): 19-22. Bray, A., M. Szymanski, et al. (2004). "Noise induced hearing loss in dance music disc jockeys and an examination of sound levels in nightclubs." Journal Of Laryngology And Otology 118(2): 123-128. Chasin, M. and J. Chong (1991). "An in situ ear protection program for musicians." Hearing Instruments 42(12): 26-28. Chasin, M. and J. Chong (1992). "A Clinically Efficient Hearing Protection Program for Musicians." Medical Problems of Performing Artists 7(2): 40-43. Chasin, M. and J. Chong (1995). "Four Environmental Techniques to Reduce the Effect of Music Exposure on Hearing." 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American Journal of Industrial Medicine 31(1, Grant No. T42-CCT-210425): 75-79. Hall, J. W. I. and M. Santucci (1995). "Protecting the professional ear: conservation strategies and devices." Hearing Journal 48(3): 37-45. Hart, C. W., C. L. Geltman, et al. (1987). "The Musician and Occupational Sound Hazards." Medical Problems of Performing Artists 2(1): 22-25. Henoch, M. A. and K. Chesley (2000). "Sound exposure levels experienced by a college jazz band ensemble - Comparison with OSHA risk criteria." Medical Problems Of Performing Artists 15(1): 17-22. Ising, H., W. Babisch, et al. (1997). "Loud music and hearing risk." Journal of Audiological Medicine 6(3): 123-133. Jansson, E. and K. Karlsson (1983). "Sound Levels Recorded Within The SymphonyOrchestra And Risk Criteria For Hearing-Loss." Scandinavian Audiology 12(3): 215221. 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-tone thresholds 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  Axelsson  1981  Hearing in classical 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  1997  Noise related ailments 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  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  club music  NIHL  Noise and Hearing Loss in Musicians  Author  Year  Page 23 of 39  Title  Study Group  Study design  Noise source  Health outcome  Purpose  Results  Chesky  2000  Instrumentspecific reports of HL: Differences between classical and non-classical musicians  3292 musicians of varying types who filled in an online questionnaire  crosssectional  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 noiseinduced 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  Dey  1970  Auditory fatigue and 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  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; 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.)  crosssectional  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  Author  Year  Page 24 of 39  Title  Study Group  Study design  Noise source  Health outcome  Purpose  Results  Fearn  1976  Hearing loss caused by different exposures to amplified pop music  leisure listeners of pop music; although this is a comment on another study  crosssectional  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  Griffiths  1995  Hearing Sensitivity 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  musicians  review  different types of 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 nontreated 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  review  music  NIHL, etc.  review  Ising 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  Author  Year  Title  Study Group  Page 25 of 39  Study design  Noise source  Health outcome  Purpose  Results  exposures in mind  did not  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 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  Jaroszewski & Rakowski  1994  Loud music induced thresholds shifts and damage risk prediction  4 musicians using high powered electronic equipment  cross sectional  rock/jazz music  Jaroszewski et al  1998  Hearing damage from exposure to music  musicians, people listening to loud music  review  rock/ classical music  NIHL, TTS  to review the literature on various components of hearing impairment in club goers, rock/classical musicians  Johnson et al  1985  Effects of instrument type and orchestral position on hearing sensitivity for 0.25 to 20 kHz in the orchestral musician  musicians  cross sectional  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  pannists  controlled cross 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  Author  Year  Page 26 of 39  Title  Study Group  Study design  Noise source  Health outcome  Purpose  Results  Kahari  2003  Assessment of hearing and hearing disorders in rock/jazz musicians  rock/jazz musicians  crosssectional  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  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;  higher pure tone threshold  Noise and Hearing Loss in Musicians  Author  Year  Page 27 of 39  Title  Study Group  Study design  Noise source  Health outcome  Purpose  Results  Meyer-Bisch  1996  Epidemiological evaluation 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  Ostri  1989  Hearing impairment in orchestral musicians  96 Danish orchestral musicians  crosssectional  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  Palin  1994  Does ClassicalMusic 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  Author  Year  Page 28 of 39  Title  Study Group  Study design  Noise source  Health outcome  Purpose  Results  Steurer  1998  Does choir singing 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  Teie  1998  symphony orchestra musicians  review  classical music  NIHL  to put forth suggestions for monitoring and protecting the professional ear  Westmore & Eversden  1981  Noise-induced hearing loss and symphony orchestra musicians: risk factors, effects, and management NIHL and orchestral musicians  orchestral musicians  cross sectional  classical music  NIHL  to make a connection between sound pressure levels and NIHL  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; 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  musical instruments  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)  Early  1996  Noise Exposure to Musicians during Practice  marching bands, concert bands (7 different types of arrangements)  Fisk  1997  Sound pressure levels 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  Henoch  2000  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  Jansson  1983  Sound exposure levels experienced by a college jazz band ensemble Comparison with OSHA risk criteria Sound levels recorded 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  Author  Year  Page 30 of 39  Title  Study Group  Study design  Noise source  Health outcome  Purpose  Results  Laitinen  2003  Sound exposure among 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  Lee  2003  Noise exposure of opera 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  Mikl  1995  Orchestral music: 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  Author  Year  Page 31 of 39  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 mannequin)  background at work + headset noise  NIHL (though the paper is exposurefocused)  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 of symphony 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 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 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)  Axelsson & Prasher  2000  Tinnitus induced by occupational and leisure noise  Axelsson & Ringdahl  1989  Tinnitus - a study of its prevalence and characteristics  3600 residents of GothenburgSwede n, randomly chosen by age  surveillance  varied  Tinnitus  to estimate the prevalence of tinnitus in this population  Lockwood  2001  Tinnitus and the performer  Performers of all types  General review of tinnitus etiology and therapy  Various; music, environmental  Tinnitus  to encourage prevention, 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 onetime exposure to loud music  Risk of permanent hearing loss is low compared to tinnitus. Rheologic therapy helped with hearing loss.  Rosanowski  1996  External auditory canal 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 induced permanent tinnitus (NIPT)  Noise and Hearing Loss in Musicians  Page 33 of 39  Table 4: Controls and preventive measures Author  Year  Title  Purpose  Results  Chasin  1995  Four environmental techniques 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  Author  Year  Page 34 of 39  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  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  Assessment of health risks in musicians of the Slovene Philharmonic Orchestra, Ljubljana, Slovenia 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  Author  Year  Page 36 of 39  Title  Study Group  Study design  Noise source  Health outcome  Purpose  Results  Gittens  1986  Entertainment noise  many groups  review  many different leisure noises  NIHL  to review studies of leisure exposure to live rock music, classical music, earphones, fireworks, guns  Harper  2002  Workplace and health: 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  Hellstrom  1998  Temporary threshold shift induced by music  Teenagers using personal cassette players  -  -  -  -  -  Henoch  1999  Hearing loss and aging: Implications for the professional musician  musicians  online 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  -  -  -  -  -  -  Hoppmann  2001  Effects on hearing caused by PCPs, concerts, and discotheques and conclusions for hearing conservation in Switzerland Instrumental musicians' hazards  instrumental musicians  review  orchestral instruments  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  Author  Year  Page 37 of 39  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.  Liebel  1996  Measurement of noise 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  Author  Year  Title  Study Group  Page 38 of 39  Study design  Noise source  Health outcome  review  Purpose  Results  to review some of the med. problems (noise not included)  -  Lockwood  1989  Medical problems of musicians  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  music  n/a (only area exposure 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  McCann  1992  Occupational Hazards in the Arts and Professions  visual & performing artists, TV production  n/a  musical instruments  NIHL  very broad review of hazards of many types of artists  None- suggests ear plugs and plastic shields to limit exposure  Merry  1995  Historical assessment 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  Okada  1991  MorphologicalChanges 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  Author  Year  Page 39 of 39  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  Progress in industrial 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  2004  Occupational disorders in instrumental musicians  musicians  review  HL  to determine the frequency of occupational disorders in instrumental musicians; compensation issues too  Mostly based on MSI/neuropathies  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"  Wallis & Marsh  1978  -  

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