How responsible are we relative to the hearing health of students enrolled in music programs? The UNT model is designed to provide students with knowledge about retaining their musicians’ ears for their careers and their quality of life. The National Association of Schools of Music (NASM) has reviewed the program and an outline is being prepared for national dissemination.

Music is always implicated as an important causal factor for noise-induced hearing loss (NIHL). Preventing this problem should include an educational strategy that targets those that teach and perform music. Through the Texas Center for Music & Medicine, the College of Music at the University of North Texas is developing various educational strategies directed at college music students. The purpose of this article is to describe one new approach that uses the music performance ensemble to inform students about NIHL.

We Enthusiastically Promote Music Education, But…
Music permeates American culture. Individuals have numerous opportunities to learn about and study music. Trained and certified music educators are teaching music in public schools and private settings. The National Association for Music Education (MENC) reports nearly 120,000 active members. At any time, roughly 100,000 college students are enrolled as music majors in over 600 music programs accredited by the National Association of Schools of Music (NASM).

Unfortunately, these pervasive educational activities do not yet include an educational agenda that informs individuals about the risks for NIHL. If hearing conservation was added to the general curriculum, the level of current concern and action within the music community would eventually transform due to increased awareness, knowledge, and perceptions of responsibility. Such an educational agenda could impact both professional musicians and teachers.

Initiating and developing such an agenda is challenging. With a basic message that school music helps children and society in real and substantial ways, one common goal of music education is to increase the awareness of the importance of music and to promote public support for school music. Acknowledging an inherent risk from music might be perceived as conflicting with the longstanding tradition of this advocacy.

Concerns are increased when the actual exposure levels produced during an educational activity are questioned and considered risky to participants. It is one thing to acknowledge that music listening may be hazardous to hearing and quite another to acknowledge that participation in a school-based activity puts a child or young adult at risk due to high exposure levels when practicing or performing music. At a minimum, these concerns should raise serious questions regarding disclosure and liability.

The University of North Texas hosted a national conference, “Health Promotion in Schools of Music” (HPSM) (for information, visit www.unt.edu/hpsm). The aim of this conference was to link health care experts to those involved with the education of musicians. In addition to recognizing the importance of educating college music students, delegates declared an urgent need to consider broad societal implications related to how music is taught to children.

The HPSM delegates recognized noise-induced hearing loss and its link to music as a widespread and serious public health issue. A high-priority strategy was generated that integrates health-related information into various educational activities so that all music students—including those preparing to become teachers—develop the knowledge, skills, and attitudes necessary to make positive contributions to this problem.

The UNT Model
The College of Music at the University of North Texas (UNT) is one of the largest music schools in the United States. With over 40 performance groups, daily sound exposures for most students include two or more periods of ensemble participation together with many other sound producing activities, including individual practice time, directed listening, and attendance to recitals, concerts, etc. Combined exposures should be considered in establishing and minimizing risk, rather than the individual effect of each or any one specific event. Acknowledging that the overall exposure levels produced during ensemble participation constitute an at-risk instructional activity dictated the use of an existing UNT Policy for Safety in Instructional Activities.

UNT policy for safety in instructional activities (Classification No. 15.2.4) assures a safe teaching environment at UNT. Based on dosimeter data, task-based assessment modeling derived from this data, and consensus among both internal and external experts, all performance ensemble classes offered by the College of Music were rated as Category 2 in a rating scale consisting of three levels. This designation recognizes that students in these instructional settings are exposed to some significant hazards and are not likely to suffer serious bodily harm.

Implementation of Policy
The UNT policy for safety in instructional activities states that the faculty member teaching a Category 2 level class is responsible for explaining applicable safety considerations at the beginning of each term and to reiterate such considerations as appropriate throughout each term.

Ensemble instructors were encouraged to consider personal values and behaviors regarding hearing loss and pedagogy. They were instructed that this may involve some self-reflection about beliefs, values, habits, and educational culture. Faculty were told that the idea of prescribing one specific approach for explaining these safety considerations has the capability to diminish the long-term impact because teaching by rote limits the potential for creative and reflective educational practices. Innovative and varied approaches were encouraged and considered necessary for engendering positive attitudes toward hearing loss prevention among the diverse music student population.

A document containing the following educational objects was designed to help the ensemble instructor deliver credible information and recommendations. The information and associated recommendations were developed by leading audiologists and hearing conservationists on behalf of UNT and are consistent with the National Institute for Occupational Safety and Health (NIOSH) Publication No. 98-126.

Periodic changes to the program details are expected as additional information and resources are gathered. Educational objectives—as stated in the program which is quoted below—have three clear goals:

GOAL 1: Promotion of Hearing Health and Concern for Hearing Loss
Goal 1 is to promote an awareness of and concern for hearing loss among music students participating in music ensembles. Students must be told that, under certain conditions, participation in music ensembles represents a risk for hearing loss, and that music-induced hearing loss can be prevented. Instructing faculty should provide the following information:

Characterization of Noise-Induced Hearing Loss (NIHL). When an individual is over-exposed to excessive sound levels, sensitive structures of the inner ear can be damaged. This damage can result in permanent hearing loss. These structures can be injured by exposure to a brief but intense sound, such as an explosion, or from regular exposure to loud sound levels over time. Risk for this type of hearing loss can be minimized through routine annual audiologic evaluation, moderation of exposure levels and exposure durations, resting between excessive exposures, and proper use of hearing protection devices such as earplugs.

Description of measurements that determine risk for hearing loss. Sound pitch or frequency is measured in Hertz (Hz). Although the human ear collects sounds up to 20 kHz, the 2-5 kHz frequency range is where most of the spectral cues for speech are found. Sound pressure levels are measured in decibels (dB). Normal conversation is measured at a moderate sound level of 50-70 dB, while the sound level within a music ensemble might be measured at 100-120 dB. Prolonged exposure to sounds above 85 dB (A-weighted, or dBA) can cause permanent hearing loss.

Characterization of the effects of hearing loss. Over-exposure to sound is the leading cause of damage to sensory (“hair”) cells in the inner ear. When damage first occurs, it usually affects the part of the ear corresponding to the mid-frequency range of 3-6 kHz. On an audiogram, this type of hearing loss configuration is commonly referred to as a “noise-notch.” These frequencies are particularly important for understanding speech, because they contain the consonant information needed for distinguishing speech sounds. Hearing loss in this region makes speech sound like it’s muffled. Conversing is difficult, especially when there is background noise present. For instance, the phrase “take the fast car” may be misheard as “rake the backyard.” It is common for individuals with this type of hearing loss to report “I can hear you; I just can’t understand you.” This is because the louder, lower frequency vowels are audible, but the softer high frequency consonants are difficult to hear, due to reduced hearing sensitivity in that spectral region.

Hearing loss may or may not be accompanied by tinnitus—a ringing, buzzing, or fluttering in one or both ears. While people with normal hearing may also have tinnitus, it is very common in people with NIHL. Sometimes, short duration exposure to sound may cause temporary hearing loss called a temporary threshold shift. A temporary threshold shift usually disappears within 14-16 hours after overexposure to loud sounds, and hearing gradually returns to pre-exposure levels. Cumulative overexposure to loud sounds will eventually result in a permanent hearing loss that will not recover over time.

GOAL 2: Promotion of Healthy Beliefs About Hearing Loss Prevention
Goal 2 is to promote healthy beliefs about hearing loss and positive attitudes toward hearing loss prevention and risk reduction practices among students, faculty, and staff. For most students, information about risk to hearing will be new, unusual, and challenging. In order to be effective, students must believe they are at risk and they must believe that the benefits of performing any recommended protective behavior outweigh the costs of risk-taking behavior. To fulfill this goal, instructing faculty should:

Underscore the importance of hearing. Address the importance and sophistication of the sense of hearing for musicians (speech understanding, pitch perception, localization, etc). Hearing loss permanently changes a musician’s capacity to hear and can diminish capability to perceive changes in timbre, pitch, dynamics, and localization.

Give them the facts of risk. Characterize prevalence rates for problems with hearing loss among musicians and assert that the risk occurs across all music genres and is not restricted to particular types of music, instruments, or venues.

Experts agree that 30%-50% of musicians have problems with hearing loss. Proportions are related to many factors including the instrument played, the genre of music performed, and the performance venue.

 TABLE 1. Exposure limits (TWA) and maximum exposure times. The chart reflects the premise that, for every 3 dB increase in sound level, the time exposure should be cut in half.

Characterize safe sound levels. Risk for injury is based on both sound intensity and duration (Table 1). The exposure limit is 85 dBA (TWA) for 8 hours in 1 day. Even brief exposures to extremely loud sounds have the same potential for hearing damage as longer exposures to lower intensity sound sources. For every 3 dB increase in sound level, decrease the time of exposure by half, as shown in Table 1.

Characterize potential sound levels generated by the music ensemble. The average sound levels produced within certain music ensembles can be very high and are dependent on many factors including an individual’s location within the ensemble, size and kind of ensemble, the selected literature, choices regarding dynamic levels, the acoustical environment, and individual playing styles.

GOAL 3. Educate on How to Reduce Risk
The third goal is designed to inform students about how to reduce the risk and prevent hearing loss. Experts agree that proactive strategies can contribute significantly to the prevention of hearing loss due to overexposure. To fully realize these benefits, students should be continuously encouraged to take individual responsibility, including making the use of free opportunities and resources available at school.

To fulfill this goal, instructing faculty should encourage students to:

Obtain an objective baseline audiogram. Encourage students to get a baseline audiological evaluation when they first enroll in the program and to have subsequent annual checkups. Evaluations on many campuses are free through the Department of Speech and Hearing. Annual test results should be compared to the baseline test and monitored for change.

Understand your baseline. Instruct students to learn about the audiogram from an audiologist and the importance of maintaining a baseline audiogram for future comparison.

Know the warning signs. Describe warning signs of overexposure, such as temporary threshold shifts, ear discomfort during or after exposure, ringing and buzzing sensation in the ears, and difficulty hearing in noise.

Have access to a sound-level meter. Encourage the use of a sound level meter and/or a personal dosimeter for estimating the amount of sound generated in a particular ensemble or for an entire day, including out of school sound exposures.

Supply sound advice. Provide tips for reducing risk. In particular, encourage students to:

  • Moderate loudness levels.
  • Reduce exposure time to sounds greater than 85 dBA.
  • Reduce repeated or cumulative exposures.
  • Avoid hazardous sound environments.
  • Give ears a periodic rest after exposure to loud sounds.
  • Monitor sounds in excess of 85 dBA.

The Future of Hearing Conservation in Schools of Music
The above program was implemented at UNT this current semester. It is too early to tell if and how students and faculty respond or benefit from the program. Additional activities at UNT are being planned to reinforce these learning objectives, including the offering of a new core curriculum course that focuses on occupational health for the musician and music educator.

On a national level, the above program has been presented to the National Association of Schools of Music (NASM) and reviewed by the NASM Executive Committee. Together with other recommended Health Promoting activities, a document outlining these recommendations is currently being prepared for national distribution to all schools of music in the United States.

The program will also be presented in April 2006 to music educators attending the 80th MENC National Biennial In-service conference in Salt Lake City. Hopefully, the music education community will continue to recognize the importance of this program and consider adopting such an approach for use in all school music settings. Together, these activities represent the first steps towards influencing the next generation of musicians and music educators.

Acknowledgements
This document is an outcome of the Health Promotion in Schools of Music (HPSM) project funded by the NEA, NARAS, NAMM, IFMR, and the Scott Foundation (www.unt.edu/hpsm), and contains text from the UNT program guidelines. The objective of the project is to develop recommendations for music schools regarding medical problems associated with learning and performing music.

Partnering organizations for this project include the Performing Arts Medicine Association (PAMA) and the National Hearing Conservation Association (NHCA). The following individuals are involved with the development of this document: The HPSM Hearing Health Working Group consisting of (Chair) Miriam Henoch, Audiology, UNT; Elliot Berger, E.A.R/Aearo Corp; Marshall Chasin, Musicians Clinics of Canada; Jennifer Tufts, Audiology, University of Connecticut, and Laura Wilber, Audiology, Northwestern University. The NHCA Taskforce on Music-Induced Hearing Loss consisting of (Chair) Brian Fligor, Diagnostic Audiology, Children’s Hospital Boston and Harvard Medical School; Marshall Chasin, Musicians Clinics of Canada; Kris Chesky, University of North Texas; Lee Hager, Sonomax; Michael Santucci, president, Sensaphonics, and Laurie Wells, president, NHCA.

 Kris Chesky, PhD, is the director of research and education at the Texas Center for Music & Medicine at the University of North Texas, Denton, Tex.

Correspondence can be addressed to HR or Kris Chesky, PhD, Director of Research and Education, Texas Center for Music & Medicine; University of North Texas, Denton, TX 76203; Web site: www.unt.edu/tcmm; email: [email protected]; tel: (940) 565-4126.