For Those About to Rock Loud music and noisy hobbies are part of our cultural landscape. These activities can be enjoyed with minimal risk to hearing if a few commonsense guidelines are followed. Educating clients about risks and protective strategies will empower them to make informed decisions about their hearing health that best reflect their ... Article
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Article  |   December 2012
For Those About to Rock
Author Affiliations & Notes
  • Jennifer Tufts
    Department of Speech, Language, and Hearing Sciences, University of Connecticut, Storrs, CT
  • Disclosure: Jennifer Tufts serves as Board Member of the National Hearing Conservation Association (2012–2014).
    Disclosure: Jennifer Tufts serves as Board Member of the National Hearing Conservation Association (2012–2014).×
  • © 2012 American Speech-Language-Hearing Association
Article Information
Hearing & Speech Perception / Acoustics / Hearing Disorders / Articles
Article   |   December 2012
For Those About to Rock
SIG 8 Perspectives on Public Health Issues Related to Hearing and Balance, December 2012, Vol. 13, 29-35. doi:10.1044/hcoa13.1.29
SIG 8 Perspectives on Public Health Issues Related to Hearing and Balance, December 2012, Vol. 13, 29-35. doi:10.1044/hcoa13.1.29

Loud music and noisy hobbies are part of our cultural landscape. These activities can be enjoyed with minimal risk to hearing if a few commonsense guidelines are followed. Educating clients about risks and protective strategies will empower them to make informed decisions about their hearing health that best reflect their values and priorities. In this article, the author covers essential information to avoiding noise-induced hearing loss, writing in easily accessible language to better help clinicians convey this information to their clients.

Many of the pleasures of life have an insidious underbelly that only shows itself over time. The beautiful summer tan turns into wrinkled, leathery skin; the nicotine buzz turns into a nagging cough and shortness of breath.
Music listening, too, has a dark side. Listening to music is a pleasurable activity for people of every culture. When shared with others, music listening (often in combination with dancing or other activities) promotes social cohesion. But exposing your ears to loud music for a prolonged period of time can, ironically enough, lead to socially isolating hearing loss. It can also lead to other disorders and sequelae including tinnitus, hyperacusis, diplacusis, distortion of sound quality, impaired figure-ground perception, and recruitment (Einhorn, 2006; Rawool, 2012). This article provides a glimpse into why loud music is here to stay, and how we can educate and empower our clients to protect themselves from noise- and music-induced hearing loss.
Loud Music is Here to Stay
Think about the 4th of July parade in your hometown. When the fire engines go by at the end, sirens blaring, what do very young children do that most adults do not? They cover their ears! Very young children are naturally averse to or afraid of loud sounds. Why does this natural reaction disappear in older children and adults? It doesn’t completely. Adults can be distressed or frightened by very loud noise or music, especially if it is unfamiliar or perceived to be threatening in some way. In fact, loud music has been routinely used as a weapon of torture in many cultures. In everyday life, though, adults usually recognize the sources of loud sounds and have the experience to know that those sources are not going to cause bodily harm. In other words, the loud sounds occur within a safe and familiar context. In fact, teenagers and adults often choose to expose themselves to loud sounds and music. Assuming that most people know that loud music can cause hearing loss, why would they voluntarily put themselves at risk?
Behar (2012), in an editorial in the National Hearing Conservation Association’s Spectrum, asks this very question. He writes that there is no shortage of publicly available information on the dangers of loud noise and music. Despite this, the warnings are largely ignored, and hearing conservationists are “left to preach to the converted.” Behar concludes that we will direct our hearing conservation efforts more successfully if we understand why people love noise in the first place.
One of the reasons why people love loud sounds is that they grab our attention and stimulate us. Blesser (2007)  points out that until the advent of amplification, loud sounds were created by dynamic events of obviously great raw power—think of thunder, the noise of a waterfall, or the energetic pounding of drums. Displays of power can be exciting or even awe-inspiring to experience. Today, extremely loud sounds can be created with the flick of a switch and the stroke of a pick. The power necessary to create such sounds is invisible to us. Nevertheless, the connection between loudness and power is hard-wired in our brains. Interestingly, loud dance and rock music, with its low-frequency-weighted spectra, has just the right acoustic characteristics to stimulate the saccule, a vestibular end organ that retains some vestigial acoustic sensitivity to high-amplitude sound in humans (e.g., Todd & Cody, 2000). Sounds of sufficient intensity to stimulate the saccule may be associated with a pleasure response in some people (Todd, 2001). Such sounds provide vibrotactile sensations, too, and these can also be pleasurable.
Loud sounds and music are part of many rituals, celebrations, and social activities. Music, especially, can promote social cohesion and feelings of inclusion and well-being. Fireworks, parades, parties, dances, concerts, movies, and weddings all involve loud sounds or music. The sounds at these events are often experienced by participants as pleasurable or exciting. The same sounds can be unpleasant to nonparticipants, who by definition are not part of the “in group.” We all know that the noise of a party is enjoyable if you belong to the group of merrymakers, but can be extremely annoying if you do not.
These social rituals become more and more important as a person moves from childhood into adolescence and adulthood. Everyone wants to “belong.” Not surprisingly, children’s preferences regarding exposure to loud music change as they reach adolescence. Knobel and Lima (2012)  surveyed 740 Brazilian children 6–14 years of age. They showed that a liking of loud music was positively correlated with age, with older children liking loud music to a much greater degree than younger children.
The rock group Kiss, in their single “I Love It Loud,” sang, “I love it loud, I wanna hear it loud … Turn it up, got me hypnotized / Rock on, I won’t be tranquilized … Turn it up, this is my attitude …” (Simmons & Cusano, 1982). The original video for the song features a teenaged boy drawn into a trancelike state by watching Kiss perform the song on television. He leaves the house to join a crowd of teenagers outside, all in a similar trancelike state. They are experiencing what Blesser (2007)  calls the social synchronization of brain states brought about by the shared experience of loud music. Although music styles have changed since 1982, the social and emotional response to loud music has not. An article in the October 2011 issue of The Atlantic  titled “I Gave My Ears to Rock and Roll” begins with the synopsis, “Wearing earplugs could have saved the author’s hearing, but at the cost of his soul.” The author and former rock guitarist Jon Fine describes his hearing loss and tinnitus acquired from years of playing highly amplified music:

For me, it stays loud when things are quiet … . I hear one everlasting tone, which generally hovers around A … . I have to lean in, far in, to hear people in noisy rooms … . Here is where I’m supposed to say I’m sorry … . Here is where I beg, in cloying tones, that we teach the children to learn from these mistakes [italics in original]. Screw it. I don’t regret a thing. [Loud] sound transported [me] to places most people never get to see … . The old basketball star walks gingerly on aching knees. Me? My ears ring. I can’t hear a thing you’re saying in this noisy bar … . But I’m okay enough. If not, I accept the physical penalty without complaint. For now, at least.

The rewards of cranking the music to earsplitting levels were so great for Fine that, at least in the near term, he is accepting of the disability it caused. His case is more extreme than some, but hardly unique. Exhorting people to keep the volume turned down all the time is like telling people to give up all chocolate for the rest of their lives—the advice may be well-intentioned, but it is unnecessarily restrictive and will most likely not be followed anyway. Fortunately, most hearing conservationists (some of whom have been sighted at live-music clubs) advocate a less prescriptive and more nuanced approach.
Education is Important
The connection between loud music listening and risk to hearing is not straightforward or intuitive. Other public health risks, such as obesity, seem to be better understood by the general public. For example, while most people would be hard-pressed to define just what a “calorie” is, they know that you gain weight if you take in more calories than you burn. They also know that if they succumb to temptation and eat that delicious slice of strawberry rhubarb pie with lunch, they are going to have to cut back at dinnertime. By way of contrast, how many people have heard of a noise dose, or know when they are reaching their noise exposure limit for the day?
People can make informed decisions about exposure to loud music and other noisy activities only if they have good information at their disposal. Thus, it is critical that we educate our clients and the public at large about risks and protective behaviors in ways that they can understand and apply to themselves and their families. In that spirit, here are some basic concepts about noise and music exposure that you and your clients should know.
Essential Concepts Regarding Exposure to Loud Music and Noise
The Big Three: How Loud, How Long, and How Often
Picture starting the day with an empty cup underneath a faucet. As long as you are exposed to quiet or moderate sounds, the faucet does not run. But every time you are exposed to a sound that exceeds a certain level (say 80 dBA, which roughly equates to a moderate to moderately loud sound), the faucet turns on and starts to fill the cup. As long as the noise is above 80 dBA, the faucet continues to run—slowly for sound levels near 80 dBA and much faster for higher-level sounds. At some point during the day, the cup fills to the brim. At that point, you’ve reached your noise exposure limit for the day. In theory, if you do not exceed your limit each day, you will not incur a permanent hearing loss from noise, but this is not always a reality.
In this analogy, the physical volume of the cup represents the amount of acoustic energy that an individual can be exposed to in a day without risk of hearing loss; the rate at which water runs through the faucet represents the level of the sound. Clearly, the faster the water rushes through the faucet, the faster the cup is going to fill (i.e., the faster the noise exposure limit is going to be reached). Here we have the how loud and how long aspects of exposure to sound. This tradeoff between how loud and how long is known as a time-intensity trade or an exchange rate. The Occupational Safety and Health Administration (OSHA) stipulates a 5-dB time-intensity trade. That is, for every 5-dB increase or decrease in intensity of the noise (how loud), the allowable exposure time (how long) is halved or doubled, respectively. For example, OSHA stipulates that a 100% daily noise dose is reached with exposure to 90 dBA for 8 hours. According to the 5-dB trading rule, a 100% dose would also be reached with exposure to 95 dBA for 4 hours, 100 dBA for 2 hours, and so on. (Note: Many other agencies in the United States and internationally use or recommend a more conservative 3-dB exchange rate, coupled with a 100% daily dose that is defined as an 8-hour exposure at 85 dBA.)
One important thing to remember about the how loud and how long tradeoff is that it is not linear. The following example illustrates this concept. According to Fligor (2010)  and Portnuff (2012), when personal music players (PMPs) are used with generic earbuds or earphones, it is safe to listen for 90 minutes per day at 80% of the maximum volume (known as the 80-90 rule). Imagine that the volume control on your PMP is clearly marked from 1 to 10. According to the 80-90 rule, you could set the volume at 8 and listen safely for an hour and a half. Turn the volume up just two notches to the maximum of 10, however, and you would be able to listen safely for only about 5 minutes! (For an interesting and informative discussion on the use of direct pressure values—a linear measure—rather than decibels to quantify noise exposures, see Drott & Bruce, 2010).
Keep in mind that a 100% noise dose, as defined by a governmental agency, is not a magic quantity. Most people should be safe from incurring noise-induced permanent hearing threshold shifts if their exposures do not exceed a 100% dose on a regular basis, and exceeding a 100% noise dose certainly does not mean that hearing loss is inevitable. Even those of us who do not work noisy jobs or rehearse for hours a day exceed a 100% noise dose at one time or another—often several times—without incurring material hearing impairment. However, those individuals in the population who are most susceptible to noise- or music-induced hearing loss could be at risk even if their exposures do not exceed a 100% dose.
How often is the third aspect of sound exposure to consider. Damage to the inner ear accumulates over time. Thus, exposure to hazardous sound levels on a regular basis is far more risky than exposure on an occasional basis. It is even riskier if the ears do not get an adequate rest break between exposures. Fortunately, risk can be managed by balancing the three aspects of how loud, how long, and how often.
The foregoing discussion is largely conceptual. Very few people have access to instruments that can measure the decibel level of sound or provide a noise dose. Practically speaking, most people will have to use “rules of thumb” and common sense to decide how to best mitigate their risk while still enjoying the activities and hobbies they love.
With that in mind, how can you tell if the music or noise in your environment is potentially hazardous? Do not try to judge hazard based on loudness. Judgments of loudness can be influenced by personal tolerance for loudness, previous exposures, and opinions about how pleasurable the sound is or how much control the listener has over it. Loudness judgments can also be influenced by acoustical characteristics of the sound, such as its frequency content. The best rule of thumb is this: if you have to raise your voice to be heard by someone about an arm’s length away (2–3 ft), then you are in an environment that is loud enough to be hazardous to hearing (i.e., the faucet is running and the cup is filling). Another handy rule of thumb is if you leave an environment with your ears ringing and/or feeling muffled, then the music or noise was intense enough to be hazardous.
Some excellent practical advice on balancing the three aspects of how loud, how long, and how often for particular noisy hobbies and recreational activities can be found in Fligor (2010) . This chapter excerpt, published in The Hearing Review, covers such topics as exposure to noise from firearms, woodworking, motor sports, toys, and music. In the same vein, Chasin (2001)  provides practical advice on managing risk that is geared specifically to performing artists. It also may be seen as commonsense to have your hearing evaluated by an audiologist if you know that you are continually exposed to hazardous music or noise (see “Not All Ears Are Created Equal,” below) so that you can take additional action to preserve your hearing if necessary.
Bottom line for the patient: The level of sound is potentially harmful if (a) you have to raise your voice to have a conversation with someone an arm’s length away, or (b) your ears ring and/or feel muffled after exposure. Manage your risk by balancing how loud, how long, and how often you are exposed. Remember that as the sound gets louder, the amount of time you can be safely exposed decreases very rapidly. (So, turn up that great tune in the car—but turn it back down to a more moderate level when it’s over. If you absolutely insist on rehearsing in a garage with corrugated metal walls at full volume three times a week [definitely not recommended], at least follow the other advice in this article—and have your hearing evaluated from time to time by an audiologist. Your hearing may become more important to you as the years go by.)
Some Sounds can Destroy Hearing in a Single Blow
Impulsive sounds—such as firecrackers, gunfire, cap guns in close proximity to the ears, or highly amplified music emanating from a loudspeaker at very close range over the course of a concert—can and do cause acoustic trauma, an immediate insult to the inner ear that leaves a person with permanent hearing loss. In rare cases, the hearing loss will be debilitating; more likely, it won’t be debilitating in the short run, but will contribute significantly to a lifetime of insults that will eventually present a handicap to the individual.
Bottom line for the patient: Always avoid, or protect yourself from, sounds that are painfully loud, and sounds that cause your ears to feel muffled immediately. Never put someone else’s ears at risk, either.
Ears Need Breaks
Loud sounds can cause physical damage to middle- and inner-ear structures. They can also increase the production of reactive oxygen species (ROS) in the cochlea. ROS are harmful molecules that are produced as a normal byproduct of metabolism. They can continue to cause damage even after the noise exposure ceases. Therefore, it is very important that ears get a long break in relative quiet (preferably 65 dBA or less) between exposures to allow them to recover sufficiently.
Bottom line for the patient: If your ears take a beating, they are at increased vulnerability for some time afterward. Let them recover for at least 16 hours (or more if possible). Keep noise in your vicinity at or below a level at which you can converse very comfortably with someone 3 feet away.
Not All Hearing Damage Shows Up on an Audiogram
Once upon a time, the story went, if hearing thresholds returned to normal after an exposure, then no lasting damage from noise had occurred. However, recent groundbreaking work by Kujawa and colleagues (e.g., Kujawa & Liberman, 2009) has thrown that belief into question, if not out the window. In their experiments, laboratory mice were exposed to noise that caused a temporary elevation in thresholds of the auditory brainstem response (ABR; Wave I), cochlear nerve compound action potentials, and distortion product otoacoustic emissions (DPOAEs). Growth functions of the ABR and DPOAEs were also measured and showed reduced amplitudes. Over time, the ABR and DPOAE thresholds returned to normal. The DPOAE growth function also recovered to normal amplitudes. However, the ABR growth function continued to show reduced amplitudes, even at 8 weeks post exposure. Upon post-mortem examination, the mice were found to have intact outer and inner hair cells, but a reduced number of inner hair cell synaptic elements, with the most acute losses occurring in the region corresponding to the greatest temporary threshold shift. Losses in spiral ganglion cells were noted to occur at even longer post-exposure intervals. If similar injuries occur in humans—and it is reasonable to speculate that they do—then the way we think about noise damage will need to change. Neural damage, if severe enough, could lead to difficulty with suprathreshold processing (e.g., difficulty understanding speech in noisy environments) and could potentiate tinnitus or hyperacusis, even in the absence of hearing threshold shifts. The aging of the auditory system could be affected, too, since neuronal loss is also a hallmark of aging. Thus, seemingly innocuous noise exposures could have long-term perceptual consequences.
Bottom line for the patient: If you experience a muffled feeling in your ears following an exposure, but your hearing returns to normal after a few hours, it is no longer safe to assume that your ears have completely healed. Unseen damage to neural structures in the inner ear and auditory nerve may have occurred. Damage of this kind, if severe enough, could potentially affect the ability to understand speech in noise, could contribute to ringing in the ears or sensitivity to loud sounds, or could even affect the way the auditory system ages.
Not All Ears are Created Equal
Expose two people identically to damaging noise or music, and one is going to develop hearing loss faster than the other. The “tough” ears in a population can withstand exposures greater than a 100% dose day after day without incurring hearing loss. But the “tender” ears will incur hearing loss with repeated exposure at or below the “safe” limit of 100%. The difference in susceptibility could be due to medical factors (such as high cholesterol), environmental factors (such as exposure to ototoxic chemicals or medication), and/or structural or genetic factors. Unfortunately, at this time there is no way to know if someone has tough or tender ears until they start to lose their hearing.
Bottom line for the patient: Protect your ears, no matter who you are. If you are continually exposed to hazardous noise or music, get your hearing evaluated by an audiologist.
Hearing can be Protected
If we are in the sun and we want to protect our skin from premature aging or cancer, we have three options: (a) get out of the sun, (b) limit the amount of time we are in the sun, and/or (c) wear sunscreen or protective clothing. Likewise, if we are in loud music or noise, and we want to protect our hearing, we have three analogous choices: (a) get away from the sound source; (b) limit the amount of time we are in noise (as discussed above); and/or (c) turn the volume down or wear hearing protectors.
Getting away from the noise source does not just mean removing oneself completely from a noise-hazardous area. It may mean simply moving away from loudspeakers in a venue. In an ideal, empty field with no obstacles to reflect sound, sound levels decrease by 6 dB with every doubling of distance from the sound source. In a room, the 6-dB rule does not hold because sound waves reflect from the walls, ceiling, and floor. Nevertheless, even a small decrease in dB can translate into significantly reduced risk.
Turning the volume down reduces the risk for obvious reasons. Wearing hearing protection can be effective in reducing risk as well. Earmuffs are generally easier to wear correctly and are useful in situations where hearing protection needs to be donned and doffed quickly. For concert-goers or people at noisy spectator events, earplugs will usually be the preferred choice for cosmetic reasons. Both styles, but especially earplugs, require careful attention to instructions for wearing. A thorough discussion of hearing protection could fill a large textbook. For a short and accessible article containing practical tips for wearing earplugs and earmuffs, see Berger (1988) . It is also important to know that the effectiveness of hearing protectors decreases dramatically if they are only worn for part of the exposure time. For maximum effectiveness, hearing protection should be worn for the entire duration of the exposure.
Bottom line for the patient: If you are in a noise-hazardous area where you cannot control the level of sound, do one of three things to protect your ears: (a) increase the distance between yourself and the sound source, (b) limit the amount of time you are in the area, and/or (c) wear hearing protectors. Pay close attention to the instructions on the hearing protector packaging and wear the protectors for as much of the exposure as you can.
Vulnerable Populations
The advice covered in this article assumes that individuals are in control of the sound in their environments or, at least, are at liberty to choose their responses to sound they cannot control. However, not everyone can control his or her acoustic environment or make clear judgments about risk. Young children surveyed by Knobel and Lima (2012)  were much less likely to control the volume of music in the home or automobile than were older children, even though there was no statistical difference between the two groups in terms of exposure to loud music in these environments. Besides children, other vulnerable populations include music students, noise-exposed workers, and those who experience an addiction-like compulsion to listen to loud music (Florentine, Hunter, Robinson, Ballou, & Buus, 1998). For these populations, advocacy, oversight, and/or legislation is called for; however, these are topics that are outside the scope of this article.
Final Words
Ultimately, the person who is able to recognize when his or her hearing is at risk, who fully understands the potential consequences of exposure to that risk, and who knows how to protect him- or herself is in the driver’s seat. He or she can make informed decisions about hearing health that reflect his or her values and priorities, whatever they may be. Fortunately, loud music and noisy hobbies can be enjoyed with minimal risk to hearing if a few commonsense guidelines are followed.
References
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