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Year : 2008  |  Volume : 10  |  Issue : 38  |  Page : 14-26
Employment and acceptance of hearing protectors in classical symphony and opera orchestras

Freiburg Institute for Musicians' Medicine, Faculty of Medicine, University of Freiburg, Germany

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  Abstract 

Objectives: Prior to this study, it was not clear how familiar orchestral musicians were with the various insertable models of hearing protectors. The present study focuses on musicians and entertainers and proposes the maintenance of a noise exposure limit through the use of a hearing protector. Materials and Methods: This study was conducted by distributing a questionnaire to musicians ( n = 429) in nine orchestras in order to obtain information on the use of hearing protection and the musicians' hearing sensitivity. Results: Hearing protectors were found to be seldom used by orchestral musicians. During orchestral rehearsals, <1/6 of the test persons used Type 1 (individually fitted) hearing protectors although >80% of the respondents indicated that they knew about them. A gap emerged between what seemed most important to musicians in hearing protectors and what was provided by the manufacturers. Conclusions: The subject of hearing protection in orchestral musicians should be investigated with a multidimensional approach which considers the following in equal measure: legal regulations, the requirements and limits of the music sector and the individual characteristics of the musicians involved.

Keywords: Hearing impairment, hearing protectors, hearing symptoms, musicians, usage

How to cite this article:
Zander MF, Spahn C, Richter B. Employment and acceptance of hearing protectors in classical symphony and opera orchestras. Noise Health 2008;10:14-26

How to cite this URL:
Zander MF, Spahn C, Richter B. Employment and acceptance of hearing protectors in classical symphony and opera orchestras. Noise Health [serial online] 2008 [cited 2020 Nov 27];10:14-26. Available from: https://www.noiseandhealth.org/text.asp?2008/10/38/14/39004

  Introduction Top


Sustained noise of >85 dB(A) may induce permanent hearing impairment. While neither the eardrum nor the ossicles of the middle ear may be damaged, the highly sensitive hair cells in the inner ear may die off - first with high frequencies around 4 kHz and, later on, in the principal speech range as well. Early studies were conducted in the 1960's to examine the danger presented by instruments to the hearing ability of musicians. [1]

It was ascertained that acoustic pressure levels in classical symphony orchestras lie above the upper limits even for individual instruments so that the permissible exposure level of 87 dB(A) is exceeded in the case of instrument groups. [2],[3],[4]

A number of studies have described the risk of suffering hearing damage due to high acoustic pressure levels without documenting the actual impairment of musicians' hearing by means of audiometric measurements. [5],[6],[7],[8],[9],[10]

Actual audiometric evidence for impairment induced by music is quite equivocal. [11] A number of investigations confirming hearing impairment induced by loud music [12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22] among classical orchestral musicians is countered by equally weighty evidence denying such impairment due to noise. [1],[23],[24],[25],[26],[27],[28],[29],[30] Comparability of the studies is considerably restricted by various methodological imprecisions such as heterogeneous criteria for inclusion and exclusion especially those concerning age, the interval between the exposure to noise and the time of measurement, the number of subjects etc. Moreover, most of the studies had only one measurement point, permitting no statements regarding the progression of audiometrically established impairment across time. Only the investigation conducted by Kahari et al. [29],[30] in 2001 can make a limited statement as the musicians in question had already been examined in 1981. No significant worsening of the musicians' hearing was found during this period.

Reduction of acoustic pressure levels by means of an individual hearing protector along with other technical and organizational measures is one way of minimizing risk of hearing impairment. Laitinen [31] demonstrated that a mere 6% of the musicians in Finnish orchestras regularly use hearing protection. There was however a greater tendency to use hearing protectors when hearing impairment was already present. Laitinen [31] also placed considerable weight on musicians' perception of loudness. Nevertheless, causal relationships between hearing impairment and the use of hearing protectors remained unclear. Moreover, Laitinen's study failed to mention what types of hearing protectors were used and how the musicians evaluated the types of protection at their disposal.

Types of individual hearing protectors

At present, the following nonelectronic types of individual hearing protectors can be described:

  1. Hearing protection stoppers fitted individually to the auditory canal equipped with a linear filter. By virtue of their protective effect due to insulation, their frequency response as well as their capacity for exact fitting, these stoppers would seem to be best suited for musicians.
  2. Prefabricated noise protection stoppers also equipped with a filter which muffles high and low frequencies as homogeneously as possible.
  3. Mass-produced foam stoppers which block the auditory canal well but distort sound as they have no linear frequency response and muffle particularly high frequencies.
  4. Stoppers fabricated from cotton or paper by the musicians themselves. While these makeshift, protective measures may bring relief from subjective distress, they fail to block the auditory canal securely and also distort sound by muffling high frequencies more strongly than low ones [Figure - 1].


The use of individual hearing protection is of particular significance for two reasons:

  1. While until now, the contradictory state of current research has not yet allowed an exact assessment of the degree to which musicians' hearing is endangered, the "noise" level of an orchestra could very well pose a danger to musicians.
  2. The European Union (EU) Directive that is directed not only to industry workers but also to musicians has to be taken into account by employers as well as the employees in an orchestra. The regular use of individual hearing protection remains a feasible method of minimizing noise-induced danger to musicians' hearing.


The new EU regulation is focused explicitly on persons active in the music and entertainment sector, calling for, among other things, the maintenance of a noise exposure limit and taking into account the insulating effect of a hearing protector (Directive 2003/10/EC, page 40). {The present study is an investigation commissioned by the Federal Ministry of Labour and Welfare, conceived as accompanying research for the implementation of the EC guidelines for occupational health and safety regarding "Noise" [Directive 2003/10/EC of the European Parliament and of the council of February, 6th, 2003 on the minimum health and safety requirements regarding the exposure of workers to the risks arising from physical agents (noise): http://europa.eu.int/eur-lex/pri/en/oj/dat/2003/1 042/1 04220030215en00380044.pdf]:
"1. For the purposes of this Directive, the exposure limit values and exposure action values in respect of the daily noise exposure levels and peak sound pressure are fixed at:

(a) exposure limit values: Lrxsn = 87 dB(A) [... ];

(b) upper exposure action values: Lrxsn = 85 dB(A) […];

(c) lower exposure action values: Lrxsn = 80 dB(A) […]"


Objectives

The goals of the present study were:

  1. To gain knowledge regarding the use and acceptance of individual hearing protectors in Germany.
  2. To derive recommendations for developing and promoting practical hearing protection for musicians in the future.


In addition to this generally formulated goal, the following questions for research were also identified:

  1. How well known are hearing protectors among orchestral musicians and to what extent are they actually employed?
  2. How do orchestral musicians evaluate the types of currently available hearing protectors?
  3. How is the wearing of hearing protectors in the orchestra valued?
  4. What are the feelings of orchestral musicians regarding the loudness of the orchestra?
  5. To what extent is hearing impairment already present among orchestral musicians?
  6. Are there differences between the various groups of instrumentalists in the orchestra?
  7. Are there differences between the various types of orchestras?
  8. Are there connections between the use of hearing protectors, the subjective perception of noise and hearing symptoms?



  Materials and Methods Top


By means of a questionnaire, quantitative data regarding hearing protection and hearing were gathered from 429 orchestral musicians in nine different orchestras.

Participants

It was possible to obtain 429 musicians from nine different orchestras for the study, thus providing a responder quota of 63% of the musicians contacted. Out of the nine orchestras, six were predominantly opera orchestras, i.e ., the musicians (N opera = 260) play mainly in the orchestra pit. The other three of the nine orchestras were predominantly concert orchestras, i.e ., the musicians (N concert = 169) play mainly onstage. The average age (M age ) of the total sample was 42.13 years (standard deviation, SD age = 10.45; minimum age, Min age = 22; maximum age, Max age = 65); the average number of years spent playing in a professional orchestra was M years = 17.41 (SD years = 10.79; Min years > 1; Max year = 47). Of the 429 participants, 263 (61.3%) were male and 156 (36.4%) were female (significantly fewer women than men are employed in orchestras). Ten persons (2.3%) omitted to provide this information on the questionnaire. On an average, the women were 3.77 years younger than the men and had 4.65 fewer years of professional practice.

Questionnaire

Psychometric measurement of various relevant matters was based on a battery of tests entailed in the "Questionnaire on Hearing Protection in the Orchestra." The questionnaire comprised three sections with a total of 79 items (including four items for the evaluation of the questionnaire itself).

Sociodemographic data

The questionnaire requested information concerning sex, age, family status, principal instrument, function in the orchestra, nationality, position in the orchestra etc.

Questions on individual use and evaluation of the available hearing protectors customary among musicians.

Information on the use of the four most common types of hearing protectors in musical work situations (practising, rehearsing and performing) was requested.

In addition to reporting on subjective experience, the subjects rated various aspects in connection with the wearing of hearing protectors (wearing comfort, handling, sonority, agogics/dynamics, aesthetics/optics) using a five-level Likert scale. The subjects differentiated these aspects according to their importance and practicality. Information regarding sensations of loudness (emanating from the musician's own instrument, neighboring instruments and the entire orchestral body) and subjective fears (worry about hearing impairment) was also sought. We also asked about the extent to which hearing protection is discussed in the orchestra and the players' reactions to the wearing of hearing protectors.

Individual hearing impairments

Subjective stress due to hearing impairment was clarified on the basis of defined criteria such as hearing impairment in conversations with single and/or several persons (5-level Likert scale).

Prior to the initiation of the study, the questionnaire was sent to the members of an existing committee (for establishing guidelines for the music and entertainment sectors) with a request for expert evaluation. It was also possible to improve the suitability of the questionnaire by means of a trial run with particular orchestral musicians. A comprehensive pretest (according to the concurrent think-aloud method) was carried out with N = 22 orchestral musicians of the local opera orchestra. The final version of the questionnaire was submitted to the `Buehnenverein' (Association of Stage Performers), which subsequently recommended that its orchestras participate in the study.

Procedure

Written requests were sent to 30 orchestras to ask them to participate in the research project. None of these orchestras refused participation so that the final choice of orchestras for the study was mainly determined by organizational criteria. In making the definitive choice of the nine orchestras for the study, care was taken to include both opera and concert orchestras.

Time points for gathering of the data during rehearsals were determined with the help of the orchestra managers. The questionnaires were placed on the music stands before the rehearsals began. At the beginning of the rehearsals, the background of the study was explained to the musicians. The conductors of the test were present at the rehearsals and were available to answer the musicians' questions during the breaks and after the rehearsals. Many of the completed questionnaires were gathered directly; the remaining ones were collected and sent in by the appropriate administrators.

Statistical analysis

Large portions of the evaluation of the questionnaires were conducted on a descriptive level. Mean deviations were tested in the framework of nonparametric procedures (Kruskal-Wallis-place variance analysis, rank variance analysis, Wilcoxon Test, Mann Whitney U-Test). These procedures are not only some of the strongest nonparametric tests in terms of statistical power but are also strong compared to parametric variance analysis. [32]

Correlations (no causal statements possible) and linear structure equation models (statements on causality possible) were calculated to try to explore the connections between relevant variables. Linear structure equation models integrate and expand two fundamental statistical approaches:

  1. Factor analysis (structuring of empirical data and establishment of common latent factors influencing the magnitude of the variables tested) and
  2. Multiple regression analysis (ascertaining an optimal model for the prediction of one dependent variable - the criterion - out of a number of predictor variables).


With this method, it is possible to differentiate relationships between a number of predictors and criteria and to scrutinize both observed and unobserved variables. The most commonly employed software solution for calculating such models is the program package AMOS from the SPSS family. [33]


  Results Top


Questions regarding hearing protection and the use of various types of hearing protectors

[Table - 1] depicts the actual employment of hearing protector types 1-4 in various relevant situations (codes: never: 0, rarely: 1, occasionally: 2, often: 3, very often: 4).

This study shows that while 82.6% of the participating musicians knew about the Type 1 (individually fitted) hearing protector, 17.4% did not know about it.

[Table - 1] shows that between 6.6 and 15.6% of the participating musicians use Type 1 individually fitted hearing protection very often, often or occasionally when practising or at orchestra rehearsals. It is used most frequently - as is also the case with other types of hearing protectors-during rehearsals and used least during practising. A total use score can be put together from the scaled items: with a maximum rating of 12 (situation (3) x frequency (4)), the mean score of Type 1 is M Type 1 = 1.52 with a standard deviation of SD Type 1 = 2.61.

Between 0.9 and 3.5% of the musicians questioned use Type 2 (a preformed protective stopper with a filter) hearing protector on occasion or frequently depending on the situation. The total use score of Type 2 is M Type 2 = 0.36 with a standard deviation of SD Type 2 = 1.23.

Depending on the situation, 2.1-9.6% of the musicians questioned used the Type 3 hearing protector (mass-produced stoppers) at least occasionally. Here, the total use score is M Type 3 = 0.91 with SD Type 3 = 1.59.

Improvized hearing protectors such as cotton, cigarette filters, paper tissues etc (Type 4 hearing protectors) are known to 77.1% of the musicians participating in the study (unknown: 22.9%). Depending on the situation, between 2.4 and 9.9% of the participants use this hearing protection occasionally or frequently. The total use score for Type 4 is M Type 4 = 0.93 with a standard deviation of SD Type 4 = 1.93.

The Wilcoxon pair comparison was performed to compare the mean total use scores for individual hearing protector types as the data comes from joint samples (ideally, one person gives information regarding all of the hearing protectors).

[Table - 1] shows that there are obviously significant differences between the employment of the various types of hearing protectors (n.s. = not significant, * P < 0.05, ** P < 0.01, *** P < 0.001).

Taken together with the descriptive data, the significant differences observed in this study clearly show that the individually fitted Type 1 hearing protector is used most frequently within the sample investigated. This is followed by Types 3 (mass-produced protectors) and 4 (improvized protectors), which are used with approximately equal frequency. It is clear that the preformed, musician-specific Type 2 hearing protector is the least used among the various types.

Evaluation of the various types of hearing protectors

Detailed evaluation of the various hearing protectors was facilitated by the questions pertaining to wearing comfort, handling, sonority of the musician's own instrument, sonority of the other instruments, agogics/dynamics, aesthetics/optics. It was possible to assess both the importance of various aspects and the extent to which they influenced actual use. Thus, it was possible to calculate use scores weighted to the aspect plane as well as a total evaluation score of the individual types of hearing protection. On the plane of individual aspects, the highest obtainable rating was 25 (optimal putting into practice (5) × very significant aspect (5)). As six different aspects were rated, the highest possible total score was 150 (minimum: 6). [Table - 2] shows the ratings of Types 1-3 with regard to the various aspects of wearing hearing protectors and the total evaluation score. As Type 4 hearing protectors are not a standardized means of hearing protection and these variables are too heterogeneous, it was necessary to omit their evaluation.

It can be seen from [Table - 2] that comparison of the detailed evaluations of the various types of hearing protectors yields diverse results. As differentiated evaluation by the participants referred only to the single type of hearing protection chosen by each individual participant, the Mann-Whitney U-Test for pair comparison was used to test the deviance of disjoint samples for significance ( one participant evaluated one means of hearing protection). As a nonparametric procedure, it is not bound to any prerequisites (n.s. = not significant, * P < 0.05, ** P < 0.01, *** P < 0.001).

No significant differences were shown between the individual aspects or total evaluation scores of type 1 (individually fitted) and 2 (prefabricated) hearing protectors. At the same time, Type 2 is the least used hearing protector [Table - 1]. Compared with the mass-produced type 3 hearing protector, Types 1 and 2 are shown to be clearly superior with Type 1 being rated higher than Type 3 in all relevant aspects [Table - 2].

Aspects of wearing hearing protectors

A ranking list of the various wearing aspects was made independently of the different hearing protector types. In [Table - 3], the aspects are depicted according to their importance in the order of their medianized rankings (the higher the rank, the more important the aspect). This ranking list is juxtaposed to aspects concerning actual use.

[Table - 3] shows that the importances of the individual wearing aspects are inverse for the first three ranks. The participants ( n = 351 for valid ratings) indicated that the most important aspect for them was the general sonority (or the distortion) of their own instruments while the least significant aspect was the aesthetics/optics. However, this aspect was rated as the one that turned out to be the least satisfactory for all hearing protectors ( n = 296 for valid ratings).

Information on sensations of loudness

The descriptive responses to questions on sensations of loudness are summarized in [Table - 4]. The participants were asked to evaluate the extent to which they felt the volume of their own instruments, of neighboring instruments and of the entire orchestral body to be too high.

The results show that >75% of musicians frequently feel that the entire orchestral body and, above all, the instruments in their immediate vicinity are too loud. On the other hand, only a little more than 25% of the artists feel that their own instrument is too loud.

Worries regarding one's own hearing

Almost seventy per cent of the participants in the study (325 or 65.8%) also indicated that they worried-at least on occasion-that their hearing might suffer due to their work in the orchestra with 57 (13.3%) actually feeling permanently worried. As many as 23 persons (5.4%) continually feared that they might someday be unable to practise their profession due to excessive strain on their hearing. Two hundred and fourteen musicians (49.9%) stated that they fear this at least occasionally.

Presence of the theme in the orchestra

Questioned as to whether the wearing of hearing protection is a topic discussed in the orchestra, 15 persons (3.5%) answered, "Yes, all the time"; 99 (23.1%) replied, "very often"; 211 (49.2%) said "occasionally"; 84 (19.6%) responded with "rarely," and 12 (2.8%) with "never." Interestingly, a large majority of 325 musicians (75.8%) stated that the wearing of hearing protectors is repeatedly discussed in the everyday life of the orchestra. Positive and negative reactions to the wearing of hearing protectors in the orchestra were approximately equal (38.5%:40.6%) with 20.8% reporting ambiguous reactions.

Information on the musicians' own hearing: Impairments and symptoms

Twenty five percent (25.2%, 108) of the persons agreed at least partially with the general statement that their hearing was impaired (generally agree: 27 or 6.3%; agree completely: 21 or 4.9%). [Table - 5] presents the information given regarding particular situations in which hearing impairment becomes noticeable. It is shown that hearing impairment among orchestral musicians is clearly recognizable in conversations with a group of people. Twenty nine musicians (6.7%) indicated that they occasionally notice insecurity of pitch due to hearing impairment.

Of the six scaled items on hearing impairment, a total impairment score was put together (valid ratings of n = 410): With a maximum score of 24, the mean value was M impairment = 4.37 with a standard deviation of SD impairment = 4.37 (Min impairment = 0, Max impairment = 20).

No tested and standardized questionnaires are available for measuring hearing impairment and symptoms. Nonetheless, various hearing symptoms were established by means of items we constructed ourselves [Table - 6] and a total symptom score was calculated.

Almost 16% (15.8%, 68 persons) indicated that they were hampered by tinnitus to a moderate/strong degree. By comparison, the Deutsche Tinnitus-Liga e.V. (German Tinnitus League, www.tinni.net) ca. speaks of approximately 2.9 million German adults with subjective symptoms (about 4.7%, assuming that there are 61.1 million adult Germans). According to the Tinnitus League, 800000 persons (1.3%) are suffering from massive impairment. In our study of orchestral musicians, 2.1% complained of strong impairment.

The prevalence rates for considerable to severe hearing loss at high frequencies and excessive sensitivity to noise are 17.5% (75 persons) and 5.3% (237 persons), respectively. With a maximum score of 12, the total mean symptom score is M symptoms = 2.88 with a standard deviation of SD Symptoms = 2.50 (Min symptoms = 0, Max symptoms = 12).

Differences between the groups of instrumentalists

Strings (59.2%), woodwinds (17.5%) and brass (14.7%) were the largest groups of instrumentalists within the total sample studied. The keyboard instrumentalists (0.7%) thus played only a subordinate role in the orchestra. As diverging cell sizes become problematic for parametric procedures when a certain imbalance is reached, group differences were tested by Kruskal-Wallis rank variance analysis on the plane of the five instrumentalist groups (strings, woodwinds, brass, percussion and plucked instruments).

The use and evaluation of the types of hearing protection among the various groups of instrumentalists

The total use scores of the four different types of hearing protection revealed differences between the groups of instrumentalists. The mean ratings are shown in [Table - 7] (maximum score of 12).

Maximum use of hearing protectors (individually fitted Type 1) was found among the percussionists.

Rank variance analysis evinces significant to highly significant differences with regard to the use of Type 1 (χ2 Type 1 = 31.81; df = 4; P < 0.001), Type 2 (χ2 Type 2 = 11.74; df = 4; P < 0.05) and Type 3 (χ2 Type 3 = 19.51; df = 4; P < 0.01). The extent of the use of Type 4 does not differ between the groups of instrumentalists.

[Figure - 2] depicts the statistical comparison with regard to the use of Type 1 protectors. The parentheses refer to the significant Mann-Whitney pair comparisons of the mean ratings (* P < 0.05; ** P < 0.01; *** P < 0.001) [Figure - 2]. [Figure - 2] shows that percussionists are the most frequently users of the individually fitted Type 1 hearing protector, showing significantly higher scores for the use of Type 1 as compared to all the other groups of instrumentalists. The next frequent users of individually fitted Type 1 hearing protectors were the strings.

When using the Mann-Whitney Test, we determined that percussionists used prefabricated Type 2 hearing protectors significantly more than the strings (Z = -2.79; P < 0.01) and the woodwinds (Z = -2.55; P < 0.05) did.

The mass-produced hearing protectors (Type 3) were significantly used most by the female players of plucked instruments as compared with the strings (Z = -2.99; P < 0.01), woodwinds (Z = -2.06; P < 0.05) and brass (Z = -2.65; P < 0.01) musicians.

Differentiated evaluation of the various wearing aspects showed that percussionists followed by the strings, have the highest opinion of individually fitted Type 1 hearing protectors (Kruskal-Wallis Test: χ2 total evaluation: Type 1 = 15.04; df = 3; P < 0.01). This positive evaluation was based principally on a corresponding assessment of the aspect "sonority of the musician's own instrument"(χ2 own sonority: Type 1 = 24.82; df = 3; P < 0.001).

Hearing impairments and hearing symptoms in the various instrumentalist groups

[Table - 8] presents the total scores for "hearing impairment" (maximum score = 24) and "hearing symptoms" (maximum score = 12) within the various groups of instrumentalists.

Significance tests of hearing impairment (χ2 impairment = 10.42; df = 4; P < 0.05) and hearing symptoms (χ2hearing symptoms = 10.95; df = 4; P < 0.05) show considerable differences between the median group ratings. Strings and brass players show the highest degree of hearing impairment whereas the strings also show the highest degree of hearing symptoms. The percussionists and players of plucked instruments tend to describe fewer hearing impairments, the percussionists having the lowest total score for hearing symptoms without diverging significantly from the other groups in the pair comparison. Within the Mann-Whitney pair comparisons, the strings (Z = -2.87; P < 0.01) and the brass (Z = -2.43; P < 0.05) showed significantly higher hearing impairment ratings than did the woodwinds. The strings also described more hearing symptoms than the woodwinds (Z = -2.50; P < 0.05) and the brass (Z = -2.40; P < 0.05).

Differences between the types of orchestras: Use and evaluation of the types of hearing protection

In general, the individually fitted Type 1 hearing protectors seem to be better known in opera orchestras (85.2%) than in concert orchestras (78.4%). At the same time, Types 3 (mass-produced) and 4 (improvized) were better known in concert orchestras (Type 3: 94.6%; Type 4: 82.8%) than in opera orchestras (Type 3: 88.5%; Type 4: 73.3%). Accordingly, it has also been shown that the fitted Type 1 hearing protector was used more frequently in opera than in concert orchestras (Mann-Whitney Test; Z = -1.91; P = 0.06). On the other hand, the greater frequency of the use of improvised (Type 4) hearing protectors in concert orchestras was highly significant (Z = -2.84; P < 0.01). The mean ratings can be seen in [Table - 9].

Characteristically, the musicians in opera orchestras (valid: No = 106) evaluated Type 1 hearing protectors less positively than their colleagues (valid: Nc = 50) in concert orchestras (Mtotal evaluation: Type1-o = 78.97; SDtotal evaluation: Type1-o = 26.99; Mtotal evaluation: Type 1-c = 87.49; SDtotal evaluation: Typel-c = 23.64; Z = -1.96; P = 0.05) particularly with regard to the "sonority of their own instrument" and "wearing comfort."

Hearing impairments and hearing symptoms in opera and concert orchestras

There were significantly more measurements of hearing impairment in opera orchestras than in concert orchestras (Z = -2.17; P < 0.05, cf. [Table - 10] for mean values). There was also a tendency towards more frequent hearing symptoms in opera orchestras (Z = -1.72; P = 0.07).

Connections

A number of bivariate correlations can be found between the different variables, some of which are presented below (r = correlation coefficient, * P < 0.05; ** P < 0.01; *** P < 0.001).

Basically, it may be stated that hearing impairment ( n = 400; r = 0.300***) and hearing symptoms ( n = 384; r = 0.141**) increase slightly in direct correlation with the number of years of activity in professional orchestras. Moreover, the use of fitted Type 1 hearing protection correlates negatively with the number of years in professional orchestras; in other words, the older the musicians are, the less they use Type 1 hearing protectors ( n = 355; r = 0.139**). There is also a highly positive correlation between the extent of the use of Type 1 hearing protectors and their differentiated total evaluation ( n = 275, r = 0.482***).

In general, the use of hearing protection is connected to the subjective sensation of the loudness of both the musician's own instrument and that of neighboring instruments. The greater the sensation of loudness, the more frequent is the use of hearing protection ( e.g , use of the individually fitted Type 1 hearing protector and loudness of the musician's own instrument; n = 359; r = 0.335***) and the greater is the fear of severe damage to hearing ( e.g , employment of type 1 protectors and worry about damage; n = 358; r = 0.318***). Accordingly, increased severity of hearing symptoms corresponds to greater use of hearing protection ( e.g. , Type 1 and hearing symptoms; n = 338, r = 0.250***). Therefore, it may be assumed that the use of hearing protection can be seen as a consequence of sustained and frequently occurring situations placing any kind of strain on hearing. Conversely, it would appear that most orchestra members see no reason to protect their own hearing prophylactically. The connections observed up to this point leave the question open regarding the extent to which hearing symptoms causally influence the use of hearing protectors. The assumption that the use of hearing protection tends to be a reaction to hearing symptoms rather than a preventive measure on the part of the musicians, should be confirmed within a linear structure equation model. Expressed concretely, it was assumed in this study that increased sensitivity to noise results in hearing problems, the outbreak of which leads in turn to increased use of hearing protectors. [Figure - 3] shows the standardized solution of the corresponding model.

The global dimensions of the model fit are highly satisfactory suggesting that the model indeed fits well: normed χ2 (CMIN/DF = 2.29), RMSEA = 0.05 (PCLOSE = 0.31), NFI = 0.919, TLI = 0.908, CFI = 0.951. [34],[35] Alternative explanatory models were also examined. Dimensions for model comparison such as AIC (Aikaike Information Criterion) or PNFI (Parsimonious Normed Fit Index) confirm that the model presented in this report had the best fit.


  Discussion Top


The questionnaire used in this study sought to determine how widespread and how accepted available hearing protectors are in the everyday work of orchestral musicians. In particular, hearing impairment and hearing symptoms were to be placed under scrutiny in this context.

All in all, the present study was able to reduplicate and expand the results obtained by Laitinen [31] on the frequency with which hearing protection is used by German orchestral musicians: Hearing protectors are seldom used by orchestral musicians with only about 1/6 of them using individually fitted Type 1 hearing protectors in orchestral rehearsals although they were known to >80% of the participants. One of the reasons for this lack of use would appear to be the mediocre evaluation of the available hearing protectors. Discrepancies can be discerned between the aspects of the hearing protectors considered most important to musicians and those aspects which they deem to have been put into practice. The most important factor for the musicians is the sonority of their own instruments but they see it as the aspect least featured in current hearing protectors. Although individually fitted Type I hearing protectors have been evaluated as "the least poor," they do not seem to be decisively better than prefabricated Type 2 protectors, which are more economical. Above all, the most important wearing aspect-"one's own sonority"-is evaluated similarly with both types. Of all of the hearing protectors, Type 2 is the least known and the least used. The potential of this type of hearing protector would thus seem to have not yet been exhausted and should continue to be taken into consideration.

This study focuses on the extent to which orchestra musicians deal with the topic of hearing protection; those who use hearing protectors seem to also value them more highly. Interestingly enough, in spite of the evident desire to use hearing protection, there was no connection between the extent of use and the musicians' evaluation of the prefabricated Type 2 protector. This absence of correlation may be attributed to the relative obscurity and very slight use of this type of hearing protector.

Do musicians who have valued and used hearing protection tend to use it more frequently? Younger musicians often seem more open to the use of hearing protection; percussionists stand out especially as active users of individually fitted Type 1 hearing protectors. Although string players use hearing protectors more often than other groups of instrumentalists, they also indicated a greater degree of hearing impairment. It may thus be inferred that while strings tend to "react," percussionists tend to "pro-act." The use of hearing protection both when practising and rehearsing seems to have been inculcated in percussionists from the onset of their musical activity and is thus, beyond a doubt, more widely accepted. Percussionists seem to profit by their early use of hearing protectors (percussionists have the fewest hearing symptoms). In general, the extent of the use of hearing protectors is closely connected with the sensations of loudness experienced by members of the orchestra. The more sensitive they are to loudness and the more strained their hearing is, the more they protect themselves. These connections can also be understood causally: the use of hearing protection is to be seen largely as a reaction to strains placed on hearing rather than as a preventive step. Hearing symptoms are caused by excessive sensitivity to noise. This is an important starting point for further treatment of the subject. It is thus evident that exhaustive education on the preventive advantages of hearing protection is necessary. Regular audiometric examinations of all musicians could help early diagnosis of excessive sensitivity to noise. Persons at risk could thus be identified and guided towards the use of hearing protectors. At the moment, it would seem as though musicians are only rarely urged to use hearing protectors.

Hearing symptoms are very prevalent among musicians. [3],[19],[27] It has been observed until now that musicians account for more than twice as many cases of tinnitus than the general adult population in Germany. Among musicians, those in opera orchestras are under greater strain than their colleagues in concert orchestras. It may be assumed that frequent playing in the orchestra pit and rehearsing in partially inadequate rooms lead to the observed physical symptoms.

The total validity and/or significance of the results are suitable to be central criteria for the quality of the study. As a matter of principle, the subcriteria of interior and exterior validity can be differentiated. [36]

In part, the external validity of this study must be evaluated critically for its instrumental validity. Good instrumental validity is characterized by the predominant use of standardized, well-tested measuring instruments. As no standardized questionnaires based on hearing protection in orchestras are available which would be adequate in the sense of classical test theory, we had to construct the questionnaires ourselves. The questionnaire was continually refined and improved during preparations for the study by means of pretests and consultations with experts.

It may also be concluded that based on the high responder quota (63%), a relatively precise impression of the basic total is given making a sample error quite improbable. As the study was conducted under natural field conditions (during rehearsals at the place of work), the experimental reactivity of the participants was observed to be slight. The number of missing values is moderate. The construct validity (an important part of external validity) can be considered satisfactory based on the state of research presented, the construct explications, and operationalizations.

The internal validity of the study is still satisfactory but perhaps reduced by selection effects stemming from the fact that the majority of the orchestras questioned were from southern Germany. In general, external influences and diverse context conditions were either slight or taken into account in the evaluation ( e.g , type of orchestra).

Little research has been performed on other factors which might result in the decision for hearing protection, e.g ., the subjective sensation of loudness, the musician's emotional attitudes towards his/her own instrument, the neighboring instruments and the compositions performed. Identical strain seems to induce a lesser degree of hearing impairment among musicians who have positive emotional associations with the music they are performing. [16] As the repertoire of most orchestras is very broad and individual music preferences vary radically, this factor offers no insight into the practical use of hearing protectors. However, the different development of efferent nerval suppression mechanisms and their moderating effects on the function of the exterior hair cells may provide a possible anatomical-physiological correlative for the capacity of musicians to protect their hearing more than nonmusicians. [37]

The prevalence of hearing damage among orchestral musicians should be investigated more precisely in the framework of further epidemiological examinations with objective audiometric data. It is imperative that contradictory data reported in earlier literature should be duplicated and/or controlled. In particular, audiological data on conditions at the onset of professional practice and prospective subsequent data should be included in all studies.

Cooperation should be promoted between industry and other nonindustrial organizations so that basic audiological studies can optimize and further develop the available hearing protectors in the framework of research assignments.


  Conclusions Top


Musicians are understandably very easily alarmed about the health of their hearing making the subject of hearing protection important even in the everyday life of professional musicians. Nevertheless, only few musicians use hearing protectors probably because only limited optimal professional practice is possible when using the hearing protectors.

In addition to preventive behavioral measures ( i.e. , communication of information, practising with hearing protectors, urging others to use hearing protection), preventive environmental measures are indispensable. This means having acoustically appropriate working conditions in rehearsing rooms, heeding breaks in rehearsal schedules and including aspects of hearing protection when determining the performing schedule. Care must be taken with all these operations that hearing protection should not govern or hinder artistic practice; it should rather be appropriately integrated into artistic practice.

The topic of hearing protection in the orchestra should be approached multidimensionally by considering legal regulations as well as idiosyncracies, requirements and limitations of the music sector and the musicians involved.

 
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Correspondence Address:
Mark F Zander
Freiburger Institut für Musikermedizin, Hansastr. 3, 79104 Freiburg
Germany
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1463-1741.39004

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    Figures

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    Tables

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