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|Year : 2014
: 16 | Issue : 70 | Page
|Hearing and hearing conservation practices among Australia's professional orchestral musicians
Ian O'Brien1, Bronwen J Ackermann1, Tim Driscoll2
1 Discipline of Biomedical Sciences, School of Medical Sciences, The University of Sydney, Lidcombe, NSW, Australia
2 Sydney School of Public Health, University of Sydney, Camperdown, NSW, Australia
Click here for correspondence address
|Date of Web Publication||20-Jun-2014|
Orchestral musicians are an at-risk population for noise-induced hearing loss. Following strategic approaches to mitigate exposure, many must use earplugs to safeguard their hearing, although reported usage rates are poor. Australia has progressive hearing conservation programs within many of its orchestras, yet little is known of earplug usage rates, abilities with earplugs or self-perceived hearing loss in this population. To help direct and inform future approaches to hearing conservation in Australia's orchestras a questionnaire assessing hearing conservation behaviors and the prevalence of self-perceived hearing loss was distributed. A total of 580 musicians across eight professional orchestras were surveyed, with 367 completed surveys (63%) returned. Eighty percent of respondents reported a risk of hearing damage in the orchestra, 64% used earplugs of some type at least some of the time and 83% found this use difficult/impossible. Forty-three percent reported a hearing loss, including 54% in pit orchestras and 46% of those ≤50 years of age. Brass players were least likely to use earplugs, most likely to report usage difficulties and most likely of those ≤50 years of age to report a hearing loss. While earplug usage rates in Australia are encouraging and may be linked to hearing conservation measures in the orchestras, the widespread difficulty reported with the use of these earplugs, the prevalence of self-reported hearing loss and the continued vulnerability of those most at-risk indicate improvements in both earplug design and further education for musicians are required to progress hearing conservation options for this population.
Keywords: Music, noise induced hearing loss, orchestra, sound exposure
|How to cite this article:|
O'Brien I, Ackermann BJ, Driscoll T. Hearing and hearing conservation practices among Australia's professional orchestral musicians. Noise Health 2014;16:189-95
| Introduction|| |
In a professional orchestra musicians constantly strive to produce highly nuanced timbres across a wide dynamic range. Unfortunately, the moderately high levels of sound produced by these musicians over time have been shown to be potentially harmful to their hearing. , Protecting an orchestral musician's hearing without interfering with the balance, acoustics or the acuity they require is a vexing issue for researchers and musicians alike.
While questions have been raised regarding orchestral noise exposure assessment procedures and calculations used to measure sound levels in the orchestral environment-particularly due to the highly variable nature of sound levels in orchestral music and the limitations of using periodic assessment methodologies  - it is broadly accepted that sound levels may be hazardous depending upon key variables such as instrument played, repertoire, venue, and orchestral set-up. Those in particularly high exposure areas are players of brass instruments ,, and musicians who work predominantly in orchestra pits. ,
There have been many audiological investigations into noise-induced hearing loss (NIHL) among professional orchestral musicians, all relying upon data from volunteer cohorts. Some have found limited evidence of hearing loss, ,,,[ but many have found professional orchestral musicians exhibit greater incidence of noise-related hearing pathologies (including permanent threshold shift, tinnitus, and hyperacusis) than the general population. ,,, In terms of studies relying on self-reported hearing loss, one investigation of professional orchestral musicians found around 25% reported at least some hearing impairment,  while another found these rates to be 31%.  Both figures are higher than rates of hearing loss due to any reason in the broader population, which have been estimated to be around 13%. 
In addition to these findings, professional orchestras are generally bound by workplace health and safety regulations that oblige them to provide a safe working environment that conforms to the restrictions stipulated in this legislation. To comply with these regulations and to ensure the musicians progress through their careers with intact hearing, workplace hearing conservation measures and noise risk management strategies are necessary. Developing and maintaining a successful hearing conservation strategy within a professional orchestra is a complex task involving a fine balance of legislative requirements, control measures, exposure assessment, audiological monitoring, and educational programs that must integrate with artistic, financial, and political concerns.
Similar to approaches in other industrial settings, a successful hearing conservation strategy initially aims to control or modify the level of risk to which a worker is exposed through a range of measures designed to minimize the need for personal protective equipment (PPE) like earplugs, which are seen as the final control measure. Several organizational approaches to exposure management in this setting have been suggested, including a series of measures proposed initially by the Association of British Orchestras  and then expanded in a series of British Broadcasting Corporation guides.  While these approaches detail administrative and engineered controls, each acknowledge that inevitably PPE are required at least some of the time, particularly among musicians playing in more exposed positions in the orchestra. Acceptance and utilization of this final control measure is essential in cases where factors such as artistic or financial demands or the acoustic properties of the venue may lead to an inability to reduce the risks to an acceptable level.
As traditional hearing protectors such as earmuffs and disposable foam earplugs introduce occlusion and a high-degree of spectral distortion, which severely impedes musicians' ability to play their instrument and communicate with their colleagues,  researchers in the late 1980s developed a hearing protector specifically for musicians. This device was an earplug custom-molded to the ears incorporating a filter providing 15 or 25 dB (and subsequently 9 dB) of attenuation, which the developers claimed would cause minimal spectral distortion up to 8 kHz.  Since their commercial release relatively few objective investigations have been conducted into the impact of custom-molded earplugs on the aural perception and musical output of musicians wearing them. While two studies suggest these earplugs have little effect on auditory perception, , sound localization difficulties have been identified.  In one study, the use of these earplugs has been shown to potentially alter the spectral characteristics and sound levels produced by musicians (most significantly the brass) while playing in ensemble.  Despite ongoing debate as to their performance, these earplugs have become widely used in the music industry in preference to other styles of earplug, and there are now various manufacturers producing a range of filtered custom-molded earplugs specifically for musicians.
Although these earplugs are widely available there appears to be ongoing resistance to their use by professional orchestral musicians. This is evidenced by several reports dealing directly with this topic [Table 1], with similar take-up rates and difficulties reported among tertiary music students. ,,
Based on the findings summarized in [Table 1], it is apparent that the use of earplugs among orchestral musicians is poor. The studies indicate that these musicians believe they are unable to carry out their craft at the level required while wearing earplugs due to a range of factors, with main barriers identified including:
- Inability to hear other players clearly,
- Issues associated with occlusion, such as the predominance of one's own instrument,
- Inability to adequately assess the sonority of their own instruments,
- Difficulties with insertion/removal of earplugs, and
- Inability or unwillingness to adapt to the altered perception of sound expeienced while wearing earplugs.
A recent investigation by the current authors into organizational approaches to hearing conservation within eight Australian professional orchestras  found relatively active hearing conservation programs in Australia - several orchestras have active education programs run by audiologists and 50% regularly monitor noise levels. In all of these orchestras, musicians' custom-molded earplugs are offered as part of employment conditions. In addition, six orchestras in the study group supply wrap-around absorbent personal acoustic screens, two orchestras supply small Perspex personal acoustic screens and one orchestra supplies both styles. Seven of the orchestras also use larger acoustic screens from time to time in their orchestral set-up. There have been no studies on the uptake or use of acoustic screens, earplugs or any other earplug type among Australia's musicians, nor has there been a survey of self-perceived hearing loss in this population.
The aim of the current study was to determine in Australia's professional orchestral musicians: Their self-perceived hearing health; the use of currently available acoustic screens and PPE such as earplugs; and difficulties associated with earplug use that may impact upon the use or non-use of earplugs in the orchestra. Together with previous investigations, the findings will lay the groundwork for further research into the development of a national approach to hearing conservation in Australia's orchestras, assist in addressing barriers to the use of earplugs and help to direct and inform future approaches to education for these musicians, their managers and audiologists.
| Methods|| |
Eight professional orchestras were engaged for this investigation as part of a national orchestral occupational health study. Following research by the current authors into these orchestras' approaches to hearing conservation management  a questionnaire was distributed to all musicians covering perceived hearing health; perceived risk of NIHL during orchestral performance and private practice; use of acoustic screens; facility with earplugs; earplug use and motivation for this use; history of earplug use; type of earplugs used and difficulties experienced while wearing earplugs.
The questionnaire was kept as brief as possible to allow completion within a few minutes prior to orchestral rehearsals, with the aim of extracting the information necessary for this investigation whilst maximizing the response rate. A pilot study using a sample of six orchestral musicians indicated the questionnaire could be easily understood and completed and had good face validity. Distribution of the questionnaire occurred during visits to each orchestra by the principal researcher and was distributed to the musicians together with instructions that the questionnaire pertained to hearing conservation practices both within the orchestra and while playing their instrument in private practice.
The questionnaire used assumes that there are three main earplug styles being used when discussing earplug type. The first is the custom-molded "musicians" earplug supplied by all orchestras in the study group as part of employment conditions. The second style is the ER-20 type "generic" earplug that all orchestras except one were providing on demand, and the third-readily available in every Australian orchestra - is the disposable foam earplug also used in many industrial settings. 
Some questions were not answered by a small number of subjects and reported percentages exclude these individuals unless otherwise stated. Logistic regression was used to examine predictors of the main outcomes of interest. All analyses controlled for age and orchestra type unless otherwise stated. For the purposes of analysis, instruments were arranged into five groups: Upper strings (including harp for the purposes of this study), lower strings, woodwind, brass, and percussion (including timpani). In addition, to determine whether the type of orchestral activity impacted on hearing conservation practices and/or self-reported hearing loss, orchestras were grouped into three types based on the main activity: Pit only, stage only and both. A very high correlation was found between age and length of service (0.91), and this meant that only one of these two variables could be included in each analysis. In an attempt to reduce the obfuscating effect of age-related hearing loss, the responses of those aged ≤50 years were independently examined for some analyses. Analysis of the data was undertaken using Stata (StataCorp, College Station, TX, USA) and SAS statistical software (SAS Inc., Cary, NC, USA).
This study was part of the Sound Practice Project, which received ethical approval from the University of Sydney's Human Research Ethics Committee (Approval #11356).
| Results|| |
From a population of 580 musicians there were 367 respondents (63%). The cohort had a mean age of 42.7 years (SD 10.5 years), 47% were male, and 55% had been professional musicians for >20 years. Forty-three percent of subjects were upper string players (including harp for the purposes of this study), 14% lower strings, 17% woodwind, 18% brass, and 5% percussion.
Twenty-eight percent of respondents were employed in the pit-based orchestra ensembles providing services for opera and ballet companies, 30% performed mostly on the concert stage, and 42% played in orchestras that performed in both environments regularly.
Reported hearing problems
Forty-three percent of respondents reported a hearing loss, 39% reported no hearing loss and 18% did not know whether or not they had a hearing loss. Nine percent of those surveyed experienced tinnitus "all the time" and 42% "sometimes". There was a clear relationship between reports of tinnitus and reported hearing loss, with 79% of those who reported tinnitus all the time also reporting a hearing loss, compared to 27% who reported no tinnitus reporting a hearing loss (P < 0.0001).
Reported hearing loss was significantly associated both with age (P = 0.0009) and orchestra type (P = 0.001), with musicians playing in pit orchestras almost four times more likely to report hearing loss compared with orchestras playing on stage (odds ratio [OR] = 3.8, 95% confidence interval [95% CI] 1.8-8.2) [Table 2]. Gender, section, and individual instrument were not significantly associated with reported hearing loss.
In those aged 50 years or less (n = 237) the prevalence of reported hearing loss was 46%, with those in the brass section significantly more likely to report a hearing loss than those in other instrument sections (P < 0.05) [Table 3].
|Table 3: Hearing and hearing conservation practices by instrument section|
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Overall, 89% of those who reported a hearing loss also reported a perceived risk of NIHL in the orchestra, with self-reported hearing loss highly significantly related to perceived risk of NIHL, controlling for age and orchestra type (P = 0.0001).
Perception of risk in the orchestra and private practice
Eighty percent reported feeling that they were exposed to potentially damaging sound levels during orchestral playing, while only 20% believed they were at risk of harmful noise exposure during solitary practice. Musicians playing in stage-based orchestras were less likely to consider they had a risk of NIHL from noise exposure playing in the orchestra (P < 0.05) as well as in the practice room (P < 0.001) [Table 2].
There was no statistically significant relationship between instrument section and perception of risk during orchestral playing, although players in the lower strings (cello and basses) were much less likely to report they were at risk during private practice than other players (P < 0.001) [Table 3].
Earplug and acoustic screen use
Sixty-four percent (236) of subjects reported at least some earplug use and 29% of these used more than one style of earplug. The most popular style were the custom-molded musicians' earplugs, with 60% of earplug wearers using these at least some of the time (38% used these exclusively), 39% using disposable foam earplugs (17% exclusively) and 39% using one-size fits-all musicians' filtered earplugs (16% exclusively). Across the eight orchestras, the use of custom-molded earplugs ranged from 42% to 86%, with the musicians in the orchestra demonstrating the highest amount of use significantly more likely to wear this style (P = 0.006).
The greatest motivation for earplug use was in response to discomfort or pain (65%). Thirty-seven percent of subjects felt they used them "when needed," while very few musicians wore their earplugs in response to a directive from the employer (3%). Brass players were the least likely to be earplug users and those in the percussion section were most likely (P < 0.01) [Table 3]. Comparing specific instrument types, trumpet players were the least likely to use earplugs (36%) and percussionists - excluding timpani - the most likely (100%, P = 0.02). Among musicians ≤50 years of age brass players were also least likely to wear earplugs (56%, P = 0.02).
Those musicians who believed they were at risk of NIHL in the orchestra were more likely to use earplugs or acoustic screens, with 70% using earplugs at least some of the time compared with 41% who did not perceive a risk (P < 0.0001) and 67% using acoustic screens some or all of the time compared with 31% who did not perceive a risk (P = 0.003).
Those reporting a hearing loss were significantly more likely to use earplugs (73%) compared to those not reporting a hearing loss (57%, P = 0.006), and 50% of all earplug users reported a hearing loss, compared to 32% of those who reported not wearing earplugs (P = 0.006).
Acoustic screens were used at least some of the time by 62% (224) of respondents, with woodwind players more likely than other players to use acoustic screens some or all of the time (78%, P = 0.001). Eighty-two percent of screen users were also earplug users. Twenty-one percent of the cohort used neither acoustic screens nor earplugs.
Ability and problems with earplugs
Fifty-seven percent of those surveyed claimed difficulty playing their instrument with earplugs in place, 26% found it impossible, 13% had mild difficulties, and 3% reported no difficulty. The most common problems reported with earplugs among all surveyed were players hearing themselves (79%) or hearing others (72%), intonation (57%), and balancing with other players (50%).
Those with comfort problems were more likely to have problems with insertion of earplugs than those without comfort problems, and those with problems balancing their instrument with others were also more likely to have intonation problems compared with those without problems balancing their instruments (both P < 0.001). Females had greater problems than males hearing themselves while using earplugs (82% vs. 65%, P = 0.001). Instrument section was also a factor in capability with earplugs, with brass players most likely to report problems using earplugs (P < 0.01) [Table 2].
Users of the disposable foam variety of earplug were significantly more likely to experience problems with their use (93%, P = 0.01) than users of other earplug types; however, 81% of generic musicians' earplug users and 75% of users of the custom-molded variety still found it difficult or impossible to play while using them.
| Discussion|| |
The majority of Australia's orchestral musicians recognize aspects of their work environment contain risks for NIHL, and many believe they have a hearing loss. While these musicians seem to accept the need to use earplugs or acoustic screens at least some of the time, most feel it is difficult or impossible to do their job effectively while wearing earplugs. This is generally due to difficulties hearing themselves or others and is particularly true of those in the brass section.
Reported hearing loss is prevalent among these musicians, with only 38% of the cohort believing they have undamaged hearing. While signs of hearing loss associated with age typically become apparent after 50 years of age,  the high prevalence of reported hearing loss in those at or below this age is a compelling indication that previous findings of hearing loss in orchestral musicians due to sound exposure should not be dismissed. ,, Across the entire sample, the greater prevalence of reported hearing loss among those who work exclusively in the orchestra pit correlates with the higher sound levels observed in this environment. ,
The use of earplugs - particularly the custom-molded variety - in Australian orchestras seems substantially more prevalent than that reported in various European populations, , possibly in response to Australia's relatively active orchestral hearing conservation measures.  While the purpose of this study was not to investigate hearing conservation strategies employed by individual orchestras, the orchestra that demonstrated significantly higher uptake of custom-molded musician's earplugs (as well as the lowest use of the inferior disposable foam earplugs) also had the most active hearing conservation measures in place.  These measures included compulsory annual audiological assessment, regular contact with audiologists, systematic risk assessments with the week-to-week publication of risk levels for each position, compulsory annual education sessions for the musicians, implementation of administrative and engineered controls and ongoing administration of these strategies by a dedicated group including management, operations, artistic staff, and musicians. While the assumption that these measures led to greater usage of these earplugs appears reasonable, further investigation is required to confirm this. It is important to note that despite increased use, these musicians' experiences and abilities with these earplugs were similar to their colleagues in other orchestras.
With this study finding that 17% of musicians used disposable foam earplugs exclusively despite the availability of more appropriate hearing protectors it is clear further education is required regarding the usability of correctly fitting and attenuating musicians' earplugs. Further to this, the predominant motivation for earplug use in all orchestras (in response to pain) suggests that musicians are failing to understand that hearing loss from orchestral music exposure is more often than not cumulative rather than as a result of a single event and points to a need for improved education approaches. Such approaches should highlight the mechanisms of NIHL and illustrate that while a single episode of exposure to moderately intense sound can appear benign, it is these episodes repeated regularly over the course of years that significantly increase the risk of suffering a permanent hearing injury.
This study found that brass players - one of the highest exposed groups of musicians , - were least likely to wear hearing protection, most likely to report difficulty using earplugs and of all musicians ≤50 years of age were most likely to report a hearing loss. The reason for poor earplug uptake among these players is clearly not ignorance of risk (83% of brass reported they believed they are at risk of NIHL in the orchestra), but more likely an inability, real or perceived, to function at the required level while wearing earplugs.
More generally, results of both this and previous investigations strongly suggest that many musicians are still risking permanent hearing damage and turning to hearing protection only after a hearing loss is perceived, rather than adopting the currently available devices. It is difficult to accept that this population - particularly those most at-risk-is rejecting earplugs solely due to poor education or training or due to long adaptation periods. In fact, 88% of those who had been using custom-molded earplugs for 10-20 years still found them difficult or impossible to use. This is contrary to previous speculation that insufficient perseverance on the part of the musicians may be responsible for poor usage levels  and suggests that part of the problem lies with the available PPE. Possible contributing factors to the difficulties experienced with earplugs include: Poorly made earplug molds (not fitting deeply enough to reduce occlusion or made from unsuitable material); inappropriate earplug type; or unsuitably high levels of prescribed attenuation. As difficulty hearing others while using earplugs is one of the most common reasons noted for not using earplugs in this and other studies, it is clearly important that attenuation levels are not unnecessarily excessive. Based on sound levels reported in the more comprehensive surveys of orchestral noise exposure combined with observed durations , it is evident that for most orchestral musicians 9 dB of attenuation (the lowest commercially available attenuation) is sufficient to safeguard their hearing while maximizing contact with their colleagues. However, due to the highly variable nature of orchestral sound exposure, each orchestral musician should base their attenuation levels upon estimates of sound exposure for their unique position and durations and should discuss this with their audiologist.
An orchestra is often required to play repertoire that is both loud and lengthy, and may be required to play in less than ideal acoustic settings. As an exposure control measure, current acoustic screens - either the smaller personal screens or larger acoustic screens have certain limitations. They can interfere with sight lines between musicians and the conductor, may alter the sound quality within the orchestra, can cause an increase in exposure to some musicians through reflected sound, and have shown only between 3 and 6 dB of attenuation in previous investigations. ,, As such, PPE in one form or another will remain an essential part of orchestral playing. While it is extremely important that all in the industry understand the range of control measures that should always be considered for implementation before PPE is used, it is also essential that current earplugs are improved as much as possible in order to be functionally usable when required. A recent investigation by the current authors into newly available level-dependent earplugs has shown promise in addressing at least some of the issues identified in this study  and future research will focus upon refining such devices as well as improving education and training methods for orchestral musicians.
This study was limited by several factors. Due to a desire to maximize participation rates the questionnaire was necessarily brief and targeted to main areas of interest and as such did not cover all aspects of NIHL. In addition, although the musicians in this study may be expected to be reasonably aware of their hearing status due to regular audiometric testing - particularly those in orchestras with compulsory annual hearing tests-this study was limited by the measure of the prevalence of hearing loss relying on self-report. A comprehensive review of objective hearing loss in these musicians using audiometric measures is required. In order to more fully assess the impact of controls and education activities in place, further study should also assess these objectively. Finally, although the characteristics of the participants compared to the entire orchestra population suggest that the sample is representative, participation was voluntary. It is possible those who did not participate have different perceptions and behaviors relevant to risks of NIHL and the use of hearing protection compared to those who did participate.
Compared internationally, a number of Australia's orchestras have some of the most proactive orchestral hearing conservation strategies in place.  Despite this, some form of PPE will remain essential, both from a legal and physiological point of view. It is clear from reported difficulties and usage rates that alternative solutions and/or design improvements focusing on improving the musicians' ability to hear themselves and others are essential. Until such technology is perfected the current offerings must also be more broadly accepted if musicians are to effectively protect what is arguably their most valuable sense. While improved education for the musicians is critical, it is also the audiologist's role to recommend and supply well made, properly fitting and not over-attenuating PPE appropriate to the instrument played. These measures will ultimately help to ensure that earplugs are in the ears when needed rather than in the instrument case.
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Discipline of Biomedical Sciences, School of Medical Sciences, University of Sydney, Lidcombe, NSW
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]
|This article has been cited by|
||Description and Evaluation of a Hearing Conservation Program in Use in a Professional Symphony Orchestra
| ||I. OæBrien,T. Driscoll,B. Ackermann |
| ||Annals of Occupational Hygiene. 2014; |
|[Pubmed] | [DOI]|