8
Influences of Amplified Music
Marc Fagelson and David M. Baguley
Introduction
Occupational and recreational exposures to
amplified music of high intensity levels have
been associated with tinnitus and hearing loss
since shortly after their appearance on stages
and in recording studios in the 1930s. The
pioneering work of musicians and luthiers
such as Les Paul and Leo Fender when com-
bined with transducers and amplifiers pro-
duced by Shure, Fender, and Ampeg provided
artists new ways to control the sound of their
instruments (voice is of course considered an
instrument). Using microphones, amplifiers,
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and loudspeakers, the output from all man-
ner of traditional acoustic or new electronic
instruments could be projected over distance
in ways that were not possible in prior eras.
Artists and producers incorporated electronic
methods with an eye on increasing their audi-
ence size through both live performance at
large venues and recordings of artists’ mate-
rial. Recording equipment and the personnel
to use it evolved with the new technologies. As
decades passed, the public displayed a craving
for music experiences that were alternatively
personal, to be enjoyed in the privacy of one’s
129
Baguley, D. M. (2015). Tinnitus : Clinical and research perspectives. Plural Publishing, Incorporated.
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home or space, and shared, to be enjoyed at
public gatherings. This craving supported the
growth of a huge industry and contributed to
substantial social and cultural events, as well
as countless profound personal experiences.
If we are to evaluate the effects of damaging
sound levels associated with music, then we
must acknowledge that the line between occu-
pational and recreational exposure is blurry,
if indeed it is there at all. Exposures to music
may be addictively sought out, intentionally
avoided, commercially motivated, emotion-
ally charged, and as recreational for one person
as they are entirely occupational for another.
For our purposes, the power of music may be
thought of in two ways: its strength to produce
change in a listener’s mental and physical state
(perhaps with therapeutic intent; see Chapter
20), and its amplitude, or the physical force
with which it is delivered to the listener. Tin-
nitus may be viewed as linked to music expo-
sures through both examples of power.
The issue of music-induced damage to
the hearing mechanism is not simple, and the
population of listeners that draws the most
attention, young people, is often exposed to
other loud sounds as well. Politicians and par-
ents correctly focus on the effects of music on
 130   Tinnitus: Clinical and Research Perspectives
young ears; however, to do so should not obvi-
ate the consideration that music is not the only
potentially toxic sound to which young people
are exposed. The effects of firearms, all-terrain
vehicles, dirt bikes, chain saws, woodwork-
ing equipment, lawn mowers, and so on, are
less-often debated, yet should be recognized as
potentiating factors when damaging effects of
music are debated (see Fligor, 2010, for review).
Advances in in-the-ear monitors for
musicians, and hearing protection devices for
both musicians and audience, were spurred
by increasingly dire, albeit largely anecdotal,
reports of hearing loss and tinnitus among
artists, the audience, and in particular, the
younger members of the audience. As high-
amplitude sound systems became available to
broader segments of the population, the risk of
overexposure produced a need in many settings
for consistent use of effective hearing protec-
tion among artists and audiences. At the same
time, the delivery of high sound pressure lev-
els (SPLs) generated by personal music players
(PMPs; i.e., MP3 players) coupled to powerful
earbud speakers increased the amount of time
that listeners have access to, and are exposed
to, potentially damaging sound levels. There is
no doubt that some individuals make choices
resulting in hearing loss and tinnitus in ways
that resemble the behavior of addicts (Floren-
tine et al., 1998); they may prefer their music
loud in order to achieve a listening experience
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that cannot otherwise be obtained, and they
may be drawn to expose themselves repeatedly.
Correctly or incorrectly, the listening
public may be judged or alarmed by reports of
music’s effects even as they are marketed to as
consumers of a commodity. Our primary aim
in this chapter is to encourage readers to make
their own interpretation regarding the trade-
off between sound level, duration of exposure,
and the joy/neutrality/despair/employment
requirements associated with listening.
Music also is a well-established, if under­
utilized, sound that can foster tinnitus relief;
Baguley, D. M. (2015). Tinnitus : Clinical and research perspectives. Plural Publishing, Incorporated.
Created from universidadviu on 2023-11-07 10:34:34.
the observation that it can cause or exacerbate
tinnitus is an unfortunate occurrence, and
one that can be managed in reasonable ways.
Therefore, another objective of this chapter
is to offer strategies for music enthusiasts to
recognize the risk-benefit ratio of their unique
listening requirements and experiences. Our
hope is that, over time, individuals make opti-
mal use of sound equipment, as well as hear-
ing protectors, in order to ensure that their
experiences listening to music are as satisfying
in the short term as they are available for the
long term.
Relation Between Decibel
Level and Loudness
The notion that a perception, such as loudness,
can be expressed on a numeric scale that is ref-
erenced to a physical quantity, as is the case for
the decibel scale, is misleading and often coun-
terproductive. Loudness is the perception of a
sound’s energy, and as it is a perceptual event,
loudness should not be measured in decibels;
referencing loudness in decibels is perhaps
slightly more informative than using colors to
quantify somebody’s height. In the realm of
psychoacoustics, loudness is measured either
in units called phons or sones. In both cases,
the objective is to provide a numerical value to
the perceptual experience of the listener such
that, for example, 10 phons would be twice as
loud as 5 phons, and 20 phons would be twice
as loud as 10 (Stevens & Davis, 1938). By
comparison, the doubling of a sound’s power
increases its decibel level by 3; 43 dB is twice
as powerful as 40 dB, while 36 dB is half the
power of 39 dB.
In addition to the effects of a listener’s
hearing status, loudness is influenced by a vari-
ety of perceptual components that are related
to a sound’s spectrum, or its distribution of
energy across frequency. Distortion, defined

as energy present in the output of a system
that was not present in the input, adds spectral
components (or frequencies) to a sound, and
in doing so, creates in the sound a rough or
noisy quality, as well as additional loudness.
The difference in quality between the
guitar playing of George Benson, when com-
pared to Jimi Hendrix, illustrates the percep-
tual effects of this quality difference. Benson’s
guitar sound employs notes that are tone-like,
thin and clean-sounding, such as on Breezin’
or This Masquerade (Breezin’, 1976; Warner
Bros.) which were described at the time as
“smooth jazz.” Conversely, Hendrix’s playing
is often associated with noise that has a pitch,
thick and dirty, for example on Purple Haze,
or even his version of the “Star-Spangled Ban-
ner.” Viewing a sound spectrograph would
highlight this difference as the Benson notes
would appear as thin, well-ordered parallel
horizontal lines with equal frequency spac-
ings between the lines; these lines represent
the energy associated with the note that he
is playing, as well as the harmonics or har-
monic energy, generated by the instrument.
To picture Hendrix’s spectrogram, imagine the
ink was still wet on Benson’s, and someone
smudged it with a thumb. The clear relation
between the lines would be harder to see, and
there would be energy (represented by the
smudging) in between the harmonic frequen-
cies. The smudging is evidence of distortion.
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Although the notes Hendrix plays may be
distinguished from one another (the song still
has a tune), the addition of distortion would
for most listeners increase the apparent loud-
ness of the music. Benson and Hendrix could
play the same song, at the same decibel output
level, but Hendrix would appear to be louder.
Interestingly, if the decibel output levels were
equivalent, then the two musical passages
would have equal potential to damage hear-
ing even though their loudnesses would be
different. Musical loudness is the perception
of its spectrum, its distribution of power over
Baguley, D. M. (2015). Tinnitus : Clinical and research perspectives. Plural Publishing, Incorporated.
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Influences of Amplified Music  131
frequency, and as a perception it is influenced
by many factors such as a person’s experience,
expectation, and state. Therefore, we will in the
following chapter reference loudness values to
familiar sounds as we offer decibel values that
capture both the energy output associated with
the familiar sounds, as well as amplified music.
Compare the sound produced by a per-
son’s voice to that of familiar sound sources,
as well as that produced by a music-related
sound source, perhaps a loud, professional
touring band. Shure, the microphone manu-
facturer, reported a measurement of 135 dB
SPL when a human yelled forcefully, at the
top of his or her voice, one inch from the
microphone. In comparison, threshold of pain
(Franks, Stephenson, & Merry, 1996) occurs
at between 130 and 140 dB SPL, which also
approximates the sound level that can produce
instantaneous permanent damage or tinnitus,
depending on the listener. The vuvuzela, that
notorious soccer accessory, produces 120 dB
SPL at a distance of 1 m (Swaenpool, Hall, &
Koekemoer, 2010). The Guinness Book of World
Records cites the Who, in 1976, as producing
an output of 126 dB SPL approximately 30 m
from the stage. If a second band onstage
with the Who played exactly the same song
at exactly the same decibel output, then the
total level of sound power would be 129 dB;
the second band would double the sound’s
power, which produces a 3 dB increase. How-
ever, because sound energy interacts in a differ-
ent way with distance, we must also consider
the effect of the observer positioned closer to
the stage. The measure of 126 dB SLP at a
distance of 30 m would, at a distance 15 m
from the stage, approach 132 dB SPL, actu-
ally a fourfold increase in power, as long as all
speaker outputs that contributed at 30 m also
contributed at half that distance. The point
is that the levels of amplified music in some
concert settings are similar in force and there-
fore effect to the sound of someone scream-
ing at top volume into the ear at very close
 132   Tinnitus: Clinical and Research Perspectives
range, for a prolonged time period, and with
occasional breaks. Although such levels are
rarely produced by personal listening devices,
the amount of damage a person incurs will be
proportional to amount of time that person
listens to recorded music.
Sound and Damage
The effects of high SPLs on hearing were
established through a variety of experiments
that used veterans of the military following
World War II, and in more controlled labora-
tory conditions using animals throughout the
second half of the 20th century (Henderson,
Hamernik, Dosanih, & Mills, 1976; Hen-
derson, Subramaniam, & Boettcher, 1993;
Ward, Glorig, & Sklar, 1959). With regard
to measurements made with human listen-
ers, one of the more striking findings was that
individuals exposed to similar environmental
and occupational conditions and sound levels
did not present with similar degrees of hear-
ing loss following exposure to damaging noise
levels (Taylor et al., 1965). Although several
intrinsic and nonauditory factors such as eye
color, gender, and age have been linked to the
effects of noise, their influence cannot account
for the large differences observed across many
studies (Henderson et al., 1993).
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The lack of predictors for susceptibility
to the effects of high-intensity sound reinforces
the need for listeners who anticipate being in
the presence of amplified music to approach
with caution. If we cannot determine who is
most susceptible to the potential damage asso-
ciated with amplified music, then we must at
least identify the factors associated with the
sound and listening environments that will
most reliably predict tinnitus and hearing loss
as exposure consequences.
Damage risk criteria for hearing were
established in response to decades of industrial
and occupational noise exposures. Industrial
Baguley, D. M. (2015). Tinnitus : Clinical and research perspectives. Plural Publishing, Incorporated.
Created from universidadviu on 2023-11-07 10:34:34.
noise levels were found to be strongly cor-
related over time with increased occurrences
of tinnitus, decreased hearing sensitivity, and
hearing loss rates that exceeded expected
losses associated with aging alone (Davis &
Silverman, 1970). The criteria for exposures
requiring hearing protection and special
accommodations for workers were formalized
in the United States with the Walsh-Healy Act
of 1969. Subsequent amendments and modi-
fications of the requirements of Walsh-Healy
were implemented as Occupational Safety and
Health Administration (OSHA) guidelines,
as well as those of the National Institutes of
Safety and Occupational Health (NIOSH).
These guidelines differ somewhat; however,
their intent and message focus on the delinea-
tion of sound levels and durations that exceed
safe listening doses, and therefore require
employers to provide hearing protection and
education to at-risk workers.
A sound of 90 dBA is of sufficient energy
such that exposures to sounds of that level for
8 hr/day require that hearing protection be
provided by the employer. The dBA scale is
used to quantify occupational exposures; it
employs decibel levels accounting for the sen-
sitivity of the human ear so that low-frequency
sounds, which may contribute to a sound’s
overall energy even though they are inaudible,
do not figure in to final calculations. By com-
parison, decibel sound pressure level (dB SPL)
indicates the total sound pressure, includ-
ing energy at those frequencies that may be
inaudible to listeners. Still, the occupational
decibel levels triggering employer actions fall
substantially below those related to music
exposure mentioned above. We will specify
decibel scales when available as we reference
music levels below.
The literature on acoustic trauma indi-
cates several factors that contribute to damag-
ing sound exposures, and many of these have
relevance for amplified-music exposures. Of
course, the amplitude of the music — its over-
all energy — is proportional to the amount

of damage it can produce. The frequency, or
spectral, content of the sound will dictate the
frequency regions of the inner ear and audi-
tory pathway that are most at risk from an
exposure; high-frequency sounds typically
produce high-frequency hearing loss, and
low-frequency sounds produce low-frequency
hearing loss, while broadband sounds may pro-
duce hearing loss that spans a wide frequency
range. Consider that the inner ear’s distribu-
tion of sensory cells spans an unusual mem-
brane composed of connective tissue adequate
to produce a distinct mechanical tuning such
that different frequencies of membrane vibra-
tion peak in amplitude at specific locations.
The frequency of a sound is mapped onto a
specific membrane location. Synapsed, or con-
nected to these “hair” cells are the neurons of
the vestibulocochlear nerve, which is the nerve
for hearing. When the sensory cells are dam-
aged, the effects may influence the function
of the auditory pathway in a variety of ways.
The effects of amplification may mimic those
of drug exposures (Chapter 6), and may alter
physiology as found with animals (Chapter 3)
exposed to noise and ototoxic drugs.
The longer the duration of the sound,
or the amount of time at which the music is
present at a traumatizing level, the greater is
the ensuing damage. Duration effects related
to exposures may be complicated when the
music contains quiet, or low-level passages
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that allow some recovery from the exposure
even as the piece of music continues. Addi-
tionally, a person exposed to amplified music
at night may, during the day, experience occu-
pational or recreational noise whose effect
would exacerbate that of the music. Although
the physical attributes of amplified music are
consistent with the potential to damage, and
are complex and multifaceted, several of them
are under the control of the listener, particu-
larly when accessed in a pre-recorded format
played on a personal music player (PMP) or
device. Therefore, it is important to offer lis-
teners at risk from damage to amplified music
Baguley, D. M. (2015). Tinnitus : Clinical and research perspectives. Plural Publishing, Incorporated.
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Influences of Amplified Music  133
strategies to minimize the potential damage,
or to at least make a more informed decision
regarding the trade-off between the benefits
and the risks of such exposures. Note also
that feedback or other unexpected traumatiz-
ing sound levels unintentionally may be pro-
duced during recordings or live performances;
the effect of such exposures is addressed as a
form of acoustic shock, and is discussed in
Chapter 11.
Live Music
The higher a sound’s intensity level, the
shorter the amount of time to which a lis-
tener can be exposed without the possibility
of damage increasing to an unacceptable level.
In the United States, OSHA utilizes a trade-
off between exposure time and signal power
that follows a 5-dB rule; 95 dBA requires
a 4-hr limit, 100 dBA a 2-hr limit, and so
on. NIOSH specifies a 3-dB rule, which is
more conservative and consistent with other
industrialized nations, although it is cited less
frequently in the noise-exposure literature.
Using the OSHA standard, sounds mentioned
above, for example, the Who’s performance at
which a level of 126 dB SPL was measured
30 m from the stage, would indicate that to
avoid ear injury, exposure time in an unpro-
tected individual should be limited to about
7 min (or less than 3 min using the NIOSH
standard). It should be noted that these sound
levels are calculated based on the assumption
that they are constant. Although musical pas-
sages contain high- and low-level compo-
nents, not to mention breaks between songs,
the potential for damage from a 90 to 120 min
performance during which traumatizing lev-
els are routinely reached and sustained several
times in each song should not be underesti-
mated. Of course, any potentially damaging
sound levels encountered other than the music
would reduce the amount of time to which the
amplified music could be safely listened.
 134   Tinnitus: Clinical and Research Perspectives
Sound levels from live performances vary
widely depending on instrumentation, venue,
and location relative to the loudspeakers.
A performance of specific decibel level in a
large hall would produce higher sound levels
if presented in a smaller venue, and music per-
formed outdoors would be less damaging than
music of similar energy presented indoors.
Of course, the location of the listener must
be considered, and anecdotal stories relating
specific exposures to tinnitus and hearing loss
onset at concerts abound. Comments sections
on webs such as that referenced here (http://
www2.gibson.com/News-Lifestyle/Features/
en-us/10-Loudest-Rock-Bands.aspx) convey
among listeners expressions ranging from
pride to regret over their exposures. Many
commenters report temporary or permanent
tinnitus resulting from the exposures. Also
listed on this website (and numerous oth-
ers) are sound levels produced by some loud
performances. Although few measurement
details are offered, the levels cited range from
117 to 137 dB (scales not specified) in both
indoor and outdoor settings. These values
are consistent with, if not a bit higher than,
those reported by Clark (1999). Again, such
exposures, if lasting more than a few minutes,
would require hearing protection if similar
exposures were encountered occupationally.
The exposure levels should compel questions
related not only to the appearance of hearing
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loss and tinnitus, but should also stir debate
regarding the fact that indeed, millions of
people routinely escape live music settings
without tinnitus or hearing loss.
To address this situation, arguments have
been advanced to suggest that overexposure to
music requires different standards from over-
exposure to other loud sounds. Dey (1970)
emphasized the value of temporary threshold
shift (TTS) measurement in the calculation
of noise effects and suggested that a differ-
ent set of damage risk criteria be developed
for musicians and concert goers in order to
Baguley, D. M. (2015). Tinnitus : Clinical and research perspectives. Plural Publishing, Incorporated.
Created from universidadviu on 2023-11-07 10:34:34.
capture the unique elements associated with
such sources of occupational and recreational
music overexposures. Temporary threshold
shift is the change in hearing threshold from
which an overexposed individual will recover
over time. Although Dey’s approach did not
gain acceptance, it addressed one of the more
difficult elements of music exposures, specifi-
cally the individual susceptibility mentioned
above. The finding that repeated TTS may
result in permanent threshold shift (PTS) con-
firms that a sound producing temporary loss
of hearing or temporary tinnitus may at a later
date, and after additional exposures, produce
permanent effects.
Reports of tinnitus and hearing loss
among the artists and audience following
exposures are ubiquitous; however, they are
not unanimous. Kahari et al. (2003) examined
139 musicians who performed and rehearsed
regularly and reported 74% experienced one
or more of the following: hearing loss, tinni-
tus, hyperacusis, distortion and/or diplacusis,
the latter of which is defined as hearing the
same tone as two different pitches. The preva-
lence of hearing loss, tinnitus, and hyperacusis
were greater in the musician group than in a
reference population without the occupational
exposures. In a survey offered to musicians
and concert go-ers, the organization Hear-
ing Education and Awareness for Rockers
indicated that 86% of respondents confirmed
experiencing tinnitus following exposure at a
concert venue (Simon & Gee, 2002).
However, Axellson, Eliasson, and Israels-
son (1995) reported different results when
investigating 53 musicians with long-term
careers playing music. After 16 years of perfor-
mances, only 15% of the musicians displayed
hearing loss when assessed using standard
audiometric tests. Interviews with the test
subjects confirmed that they were exposed to
levels of music exceeding 100 dBA routinely
for longer than the damage risk criteria stan-
dard of 2 hr at a time. The lack of precise

noise dose measurements across these stud-
ies clouds an easy or clear interpretation; it
reminds us that the relation between music
as a toxic sound source and its potential to
damage is more complex than would be indi-
cated by a strict reading of occupational noise
criteria. It is interesting and perhaps unex-
pected that in most references and reviews, a
minority of individuals experience the effects
that would be predicted for similar exposures
encountered by industrial workers.
When music exposure, subsequent tin-
nitus, and NIHL are linked with regret or self-
recrimination, the combination can be very
burdensome. An audiologist dealing with such
a patient many not feel confident that he or
she has the skill set to manage the patient’s
needs, and while there is not specific evidence,
it may be that some form of acceptance-based
psychological approach would be of value (see
Chapter 19).
Another clinical issue has been the com-
monly given advice that “taking a break” from
listening to amplified music reduces the risk of
adverse auditory effects. Recent work has indi-
cated that while taking a short break in a club
chill-out room or similar quiet space reduces
exposure duration, and hence risk, it does not
reduce the likelihood of temporary threshold
shifts (Helleman & Dreschler, 2015).
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Music Recording
The advent of digital recording technology has
allowed musicians and producers to manipu-
late aspects of the sound that previously were
inaccessible other than by playing technique.
An example is the ability to manipulate attack
times, particularly in some dance music genres
in which attack times are purposefully short-
ened in order to give a sense of excitement or
“rush.” Other transients, particularly of drum
sounds, are increased in volume to give the
sound more “snap.” While successfully cre-
Baguley, D. M. (2015). Tinnitus : Clinical and research perspectives. Plural Publishing, Incorporated.
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Influences of Amplified Music  135
ating music that is exciting and compelling,
the effect of exposure to such sound upon the
human auditory system, often at very high
intensity, is presently unknown. The concern
has to be that endogenous oto-protective,
and specifically cochlear-protective mecha-
nisms found in humans will have evolved in
response to the characteristics of sounds found
in nature, and the use of faster transients may
render them inadequate.
Recorded Music and
Personal Music Players
Personal music player (PMP) output levels, in
most instances, do not reach those indicated
above, as measured during live performances;
however, their exposures may last far longer
than those associated with live performance.
The PMP exposures are determined by the
device output, the earbud or earphone fre-
quency response, and the fit of the earphone or
earbud on the listener. Another consideration
for the use of PMPs relates to the sound level
in the background, as well as the earpiece’s
sound attenuation characteristics. Breinbauer
et al. (2012) reported that listeners increase
the output of their PMP when listening in
background noise present at levels exceeding
conversational speech.
The output level of PMPs may exceed
120 dBA, depending on the device and ear-
phones used (Fligor & Cox, 2004). To achieve
such a level, the device would need to be turned
nearly to full volume, but of course, such SPLs
may be achieved. Breinbauer et al. (2012) also
indicated that musical styles will be associated
with different outputs. Perhaps as expected,
classical music produces lower outputs at simi-
lar device settings when compared to genres
such as heavy metal. Additionally, when spe-
cific listeners and their associated listening
levels were assessed, those listeners preferring
classical music, folk, or Latin-pop favored
listening levels lower than those for metal or
 136   Tinnitus: Clinical and Research Perspectives
hip-hop. Whenever studied, however, device
and earphone combinations provide doses of
sound exposure exceeding allowable occupa-
tional limits.
The preferred level for listeners increased
in a predictable manner when background
noise was introduced into the environment.
Largely independent of earphone type (supra-
aural, in-ear, and earbuds were tested), the
addition of background noise levels of 90 dBA
compelled listeners to adjust their PMPs to
levels exceeding damage-risk criteria. When
70 dBA background noise was added, the ear-
buds, and to a lesser extent the in-ear speakers,
were raised to damaging levels. In all, earbud
users compensated for background noise with
the greatest increases in output for the three
transducer types. With respect to device type,
the differences were not as strong; however, the
trend for raising output level as background
sound level increases suggests that PMP users
should exercise particular caution when listen-
ing in places such as on buses, trains (above
and underground), and other vehicles.
Additionally, the effects of long-term
exposures at moderate levels have recently
been investigated using physiologic markers
for inner ear hair cell and related nerve dam-
age. Kujawa and Liberman (2015) described
the process by which hair cells may be spared;
however, nerve fiber activation is disrupted
due to swelling of terminal endings at the syn-
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apse between inner hair cell and primary audi-
tory fiber. Synaptic swelling may be observed
immediately postexposure, and may be associ-
ated with TTS; as the swelling decreases over
time, thresholds are recovered. Repeated or
long-term exposures increase the risk that the
swelling will not diminish and will result in
PTS and functional problems for listeners.
The process by which synapses are damaged
even as hair cell integrity is maintained is
termed synaptopathy.
Sound levels associated with synaptopa-
thy are lower than those required to produce
Baguley, D. M. (2015). Tinnitus : Clinical and research perspectives. Plural Publishing, Incorporated.
Created from universidadviu on 2023-11-07 10:34:34.
hair cell damage. After reporting 40 dB TTS
following 105 dB SPL broadband noise expo-
sure, Kujawa and Liberman (2015) deter-
mined that hearing returned to normal, and
synapses regenerated if the experimental ani-
mals survived for 4 weeks following exposure.
Also investigated by this group were the effects
of longer-term moderate exposure levels on
mice, and they employed a week-long 84 dB
SPL noise focused in the 8 to 16 kHz region,
which is in the middle of the mouse’s audible
range. This level was chosen in an attempt
to mimic the exposure levels encountered by
humans in industrial settings. Although the
reported TTS was less severe (on average <12
dB) as many as 22% of the synapses were
affected (Maison, Usubuchi, & Liberman,
2013). The cumulative effects of several simi-
lar and repeated exposures would most likely
exacerbate the damage.
Roberts et al. (2010) suggested that tin-
nitus and hyperacusis may arise, and persist,
from exposures that only caused TTS, expo-
sures that were similar to those later employed
by Kujawa and Liberman (2015). If the theo-
ries stipulating that central adaptation occurs
in response to peripheral damage are relevant
to Kujawa and Liberman’s findings, then cen-
ters in the auditory pathway upstream from
the peripheral areas of damage should display
relatively normal responses even when lower
areas appear impaired. Indeed, Hickox and
Liberman (2014) reported that exposures
causing a decrease in amplitude of Wave I of
the auditory brainstem response (ABR) did
not produce similar change to the amplitude
of Wave V when 3 weeks elapsed post expo-
sure. As Wave I is associated with auditory
nerve activity, and Wave V with higher cen-
ters, the system’s apparent recovery of neural
activity would be consistent with theories of
central compensation for peripheral damage.
The significance of this finding for amplified
music exposures relates to the possibility that
tinnitus might arise as a by-product of the

central pathway’s adjustment (see Chapter 2),
although an alternate finding to theories of
central gain is offered in relation to findings
from drug studies in Chapter 6. Changes in
auditory function that lead to tinnitus and
hearing loss may follow mild TTS or long-
term exposures to moderate levels that appear
innocuous and fail to meet damage risk cri-
teria (Gu, Halpin, Nam, Levine, & Melcher,
2010; Schaette & McAlpine, 2011).
Other Considerations
Additive Factors
The factors of duration and intensity of music
exposure strongly influence potential adverse
effects on hearing and tinnitus, and another
factor that has been discussed in the literature is
that of recreational drugs. Intoxication leads to
disinhibited behavior, and hence less care with
music exposure, and there is emergent evi-
dence that some recreational drugs may also in-
crease vulnerability to auditory harm from
music exposure. In raising this issue we wish to
avoid any moral approbation of the use of drugs;
the issues around which substances are legal/
illegal and acceptable/unacceptable in various
cultures and at various ages are highly complex.
The association between cigarette smok-
Copyright © 2015. Plural Publishing, Incorporated. All rights reserved.
ing and noise-induced hearing loss (NIHL) has
long been noted (Zelman, 1973), and specifi-
cally, NIHL has been considered (Sung et al.,
2013, for example). The causality of the asso-
ciation is complex and may involve other
factors such as gender, age, and social class,
and these are under investigation. The overall
picture indicates that a person is more at risk
of NIHL if he or she smokes cigarettes, and
that the more that person smokes, the more
risk he or she has (Mehrparvar et al., 2015;
Sung et al., 2013). Smoking cannabis may
involve a tobacco component and may have
Baguley, D. M. (2015). Tinnitus : Clinical and research perspectives. Plural Publishing, Incorporated.
Created from universidadviu on 2023-11-07 10:34:34.
Influences of Amplified Music  137
an associated risk. While there is little in the
way of published evidence regarding cannabis
use, NIHL, and tinnitus, some clinical cases of
tinnitus onset or exacerbation have been seen
with the use of modern extra-strong cannabis
variants. Han et al. (2010) noted associations
between length of hallucinogen use and risk of
tinnitus, and of inhalant use and risk of tinni-
tus, but did not include noise exposure in the
analysis. In animal experimentation the use
of the drug “ecstasy” (3,4-methylenedioxy-N-
methamphetamine [MDMA]) was indicated
to increase the risk of NIHL, but no assess-
ment of tinnitus behaviors was made (Church
et al., 2013). This is an area in which further
research is needed.
Addictive Behavior
Despite the ubiquitous warnings and evidence
that overexposure to amplified music may
damage hearing and cause tinnitus, it is still
the case that listeners of all ages consider the
endeavor worth the risk. Such an occurrence,
the persistence of listening behavior in the face
of evidence confirming its negative outcome,
has been related to addiction experienced by
substance abusers (Florentine et al., 1998).
The authors suggested that music, similar to
other addictive agents, could produce mood
changes, alter levels of arousal, and “elicit
the experience of craving.” Music also might
reduce or create negative or positive frame
of mind (depending on the performer or lis-
tener’s objective) and has been shown to alter
listeners’ mood to the extent that shopping
behaviors may be affected (see Brunner, 1990,
for review).
The links between loud music and addic-
tive behavior were supported by observations
such as listeners’ ability, or desire, to listen to
music at levels producing the perception of
loudness that exceeded their own tolerance lev-
els for other noises such as traffic, construction,
 138   Tinnitus: Clinical and Research Perspectives
and speech (Kuwano, Namba, Florentine,
Zheng, & Hashimoto, 1992). Other inves-
tigators have demonstrated that a person’s
preference for a specific musical passage or
style of music was associated with his or her
preference for louder presentations than those
assigned to other music (Cullari & Semanch-
ick, 1989). Fucci et al. (1993) reported that
preferred musical selections may be presented
at an identical level to those less preferred with
the effect that the latter would be perceived as
louder than the former. These findings when
taken together indicate that music listen-
ing, and in particular loudness of the music,
does not adhere to many expectations associ-
ated with other listening experiences. Salim-
poor et al. (2013) found that when listeners
expressed their music preference with respect
to purchasing such music, activity increased in
neural structures associated with reward and
addictive behavior such as the striatum and
nucleus accumbens. Others have focused on
aspects of craving displayed by some listen-
ers for specific music and made the argument
that if music were not craved, in an addictive
manner, the recording industry would not
have developed and grown as it did; if music
did not evoke a “need to re-experience” then
music on the radio, or in live settings would
suffice, and there would be no need for the
mass distribution of recorded music that the
industry spawned (Lacher & Mizerski, 1994).
Copyright © 2015. Plural Publishing, Incorporated. All rights reserved.
Perhaps the most interesting develop-
ment linking music to the brain in manners
consistent with addiction relate to music’s use
as a complimentary treatment for addiction.
Although effects have not been quantitatively
or definitively reported, many rehabilitation
programs feature music therapy as options
for their patients. A review by Mays, Clark,
and Gordon (2008) indicated that although
consensus has not yet been reached in the lit-
erature regarding the efficacy of music’s effect
on individuals with alcohol and substance
addictions, music may offer a noninvasive
Baguley, D. M. (2015). Tinnitus : Clinical and research perspectives. Plural Publishing, Incorporated.
Created from universidadviu on 2023-11-07 10:34:34.
and inexpensive option for some patients.
The inference is clear; if addictive behaviors
drive some individuals to risk hearing loss and
tinnitus through repeated exposures, then the
same neural mechanisms might allow other
individuals to substitute music for a different
addictive agent. Still, the probability that the
brain is “rewarded” through loud music lis-
tening, combined with our lack of knowledge
regarding individual susceptibility reinforces
the listener’s need for caution.
Caution and Reason
We often counsel patients regarding realistic
expectations when we discuss outcomes for
hearing aid fittings, communication strategies,
and tinnitus interventions. Exposure to ampli-
fied music in its many forms played through
a variety of devices clearly requires knowledge
of realistic expectations as well. Patients can
be counseled regarding the risks of music, but
they should also be counseled regarding the
mechanisms by which music can attract and
enchant. Listeners may understand that they
prefer music loud, and enjoy listening to songs
or artists repeatedly, but they may not under-
stand why. Improving a person’s understand-
ing should improve their decision making.
In particular, patients who express listening
habits that include some of the loud sound
sources listed above (i.e., dirt bikes, guns, and
chainsaws) must be informed of the potentiat-
ing influence that the sound sources exert on
each other.
The most obvious way to minimize the
possibility of damage is to lower the sound
level of a device’s output, or to stand farther
from sound sources at concerts. With respect
to PMPs, the device’s output is entirely under
the control of the listener. The external factors
that appear to influence listeners to raise the
device level to damaging levels center on the

levels of background noise in the environment.
Therefore, listening in noisy places should be
monitored most closely by listeners, and it
may be that devices can be muted, with the
earphones then acting as hearing protectors.
Sound levels at live performances will be
more difficult to manage, as the output levels
are beyond the control of the attendees. The
availability of musician earplugs of course is
not limited to musicians. Enthusiasts of many
different types of music understand the value
of purchasing custom protection devices that
attenuate sound levels across frequency such
that the performance sound is faithfully passed
to listener, but at a substantially lower level.
More and more often, musicians and sound
engineers use ear level monitors that provide
control over sound quality unavailable in past
decades. It is clear that there is no stigma asso-
ciated with the use of hearing protection that
would preclude its widespread use.
Hearing protection devices and noise
canceling headphones continue to improve.
As their intent is to protect, the nature of
improvements in protective equipment relates
primarily to the fidelity of the music that is
ultimately passed to the listener. All manner
of occlusion has been utilized by attendees at
high-sound pressure concerts, from fingers, to
cigarette filters, tissue, and clothing to com-
mercial plugs. Earplugs for live music may be
custom-made, fitted specifically for the user’s
Copyright © 2015. Plural Publishing, Incorporated. All rights reserved.
ears, or bought over the counter as one-size-
fits-all. The use of such protection is well
intended but not always effective.
However, we can consider an example of
hearing protection use as it would apply to live
music listening. Suppose a person attended
a concert at which the sound level averaged
120 dB SPL. If that person wore earplugs that
provided 20 dB attenuation, then the expo-
sure level would approximate 100 dB SPL.
The amount of time that a person can be
exposed occupationally to 100 dB is 2 hr by
OSHA standards, whereas the allowable time
Baguley, D. M. (2015). Tinnitus : Clinical and research perspectives. Plural Publishing, Incorporated.
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Influences of Amplified Music  139
for 120 dB is about 7.5 min, or one eighth
the duration. If the protection provided even
more attenuation, say 30 dB, then the amount
of exposure time could be increased by a fac-
tor of four, to 8 hr. Using hearing protec-
tion provides the means by which duration
of exposure may be increased while damage
risk is managed. The implications for sound
engineers and the artists is clear: their expo-
sure times invariably exceed those of the audi-
ence; hence, their need for hearing protection
is proportionately greater.
The amount of protection provided by
different earplugs or earphones obviously var-
ies, and unfortunately so does the susceptibil-
ity to noise effects across listeners. Given the
obstacles to ensuring safe listening environ-
ments for artists and audience, hearing con-
servationists have advocated for, and created
important public awareness campaigns aimed
at educating listeners regarding sound and
its effects. Dangerous Decibels (http://www​
.dangerousdecibels.org/) has as its mission
the provision of information, disseminated
instructional videos, literature, and hands-on
demonstrations at schools, academic confer-
ences, and other outlets stressing the relation
between noise exposures and music listening
habits to the potential for inner ear damage.
Programs such as Dangerous Decibels and
the aforementioned Hearing Education and
Awareness for Rockers will be as successful as
the listening public allows; we encourage indi-
viduals to consider the resources available for
frank and accurate discussions of music and
its effects and these two organizations, among
others, provide that valuable opportunity.
Case Study: Music and Tinnitus
Mr. B was 56 years old at his initial contact in
the tinnitus clinic at the Mountain Home Vet-
eran’s Affairs Medical Center in March 2005.
 140   Tinnitus: Clinical and Research Perspectives
He had been followed in the Audiology sec-
tion since 2003, and his hearing test results
revealed a severe bilateral high-frequency
hearing loss affecting frequencies at 3000 Hz
and up. The patient had long-standing tin-
nitus, first observed in 1968 the direct result
of combat-related noise. Tinnitus increased in
level gradually over the years, reaching its “cur-
rent” level in approximately 1995. Tinnitus
was reportedly reactive, and the patient would
notice an increase in tinnitus loudness when
hearing high-pitched “screechy” sounds, as
well as impact noises such as doors slamming
or loud machinery. He also reported that the
effects of such sounds were more pronounced
when they were unexpected. The patient was
diagnosed previously with post-traumatic
stress disorder (PTSD). His primary com-
plaint regarding symptoms associated with
tinnitus and PTSD related primarily to the
effect the tinnitus was having on his ability to
play and enjoy music.
Mr. B played several instruments, and
had played in bands both prior to and follow-
ing his active service in the military. The onset
of tinnitus in the military did not pose sub-
stantial problems related to music enjoyment
when first discharged from the army; however,
over time the effects related to tinnitus became
more pronounced. At his initial appointment,
he focused specifically on the barriers tinnitus
exerted on his enjoyment of music, indicating
Copyright © 2015. Plural Publishing, Incorporated. All rights reserved.
that such problems were more distressing than
difficulties he experienced related to sleep,
communication, and concentration problems.
The patient had declined hearing aid fittings
in the past.
At his initial appointment, intake infor-
mation was obtained, and the patient was
administered several questionnaires, with the
tinnitus handicap inventory score of 32 indi-
cating mild tinnitus disruption. As there were
no questions on the THI or other intake forms
regarding music specifically, our assumption
was that the tinnitus was likely more handi-
Baguley, D. M. (2015). Tinnitus : Clinical and research perspectives. Plural Publishing, Incorporated.
Created from universidadviu on 2023-11-07 10:34:34.
capping to this patient than identified on stan-
dardized forms, a common, but unavoidable
shortcoming of subjective intake forms. As
he had declined hearing aids, so he declined
a bedside masker at this appointment. His
rationale for declining such recommendations
related to his disdain for adding noise to an
already bothersome noise.
Regarding his concerns related to guitar
tuning and singing, he was encouraged to try
using an earplug in one ear, and switching
the ear routinely, in order to monitor his own
voice more effectively. This recommendation
was made after the patient confirmed that use
of a plug did not exacerbate tinnitus loudness.
He was encouraged to determine whether
listening with one ear facilitated guitar tun-
ing. After a few weeks, his singing reportedly
improved, guitar tuning did not.
One year later, after one follow-up
appointment focused on counseling, sound
therapy options were again discussed, and on
this date, a pair of ear level masking devices were
again demonstrated. Unlike prior attempts,
the patient appreciated the devices’ sound
and indicated that the masking produced was
pleasant. He was instructed regarding their use
and ordered a pair. He was encouraged to use
the maskers whenever possible. Although the
ear level devices provided some benefit, he still
reported difficulty tuning the guitar; he lacked
confidence that at all times he would be play-
ing in tune. He was urged again to consider
hearing aid fitting, and this recommendation
was made several times over the course of a few
years. Finally, at an appointment in 2010, he
relented and completed a hearing aid selection
appointment.
He received his first set of hearing aids
in 2010, and the differences in his music lis-
tening and playing were immediately obvious.
Indeed, he has questioned many times since
then his faulty logic relating to potential for
hearing aid benefit; he reportedly knows sev-
eral musicians who have struggled with hear-

ing aids, and he said, not without a sad shake
of the head, that he was following their advice.
The devices were programmed with reference
to Searchfield’s suggestions (see Chapter 12);
open fit devices providing the patient access to
low-level environmental sounds and contain-
ing a program intended to process music effec-
tively. In addition to communication benefits,
we have found that hearing aids provide vary-
ing degrees of tinnitus relief in more than half
our patients. With the hearing aids, Mr. B.
found that tuning and singing were substan-
tially improved. Further, his tendency in the
past of being “dragged by [his] tinnitus” to
incorrect notes was negated when the hearing
aid input was available. His use of maskers had
been helpful at the outset; however, his move
to hearing aids cemented for the patient the
idea that he would be able to manage tinnitus
effects and continue to make music.
Although his tinnitus was not caused pri-
marily by amplified music, the tinnitus inter-
fered with his ability to enjoy music. The value
of well-fit hearing aids for this patient was
obvious, and his ability to enjoy music pro-
vided, in the words of this patient, additional
opportunities for masking. The maskers, in
this patient’s case, probably provided some
relief at a time he needed it the most — when
he was having difficulty playing music, but
before he was ready to try hearing aids. As
mentioned in Chapter 12, one of the benefits
Copyright © 2015. Plural Publishing, Incorporated. All rights reserved.
of using ear level maskers is the potential for
immediate relief provided for some patients
by the devices. Additionally, this patient was
more open to hearing aid fitting after masker
use than he had been prior to masker use.
Although he was ultimately fit with combina-
tion devices, he rarely uses masking anymore,
focusing instead on the optimal hearing aid
setting to facilitate communication, and music
enjoyment. When he is active, communicat-
ing, and playing music, the patient does not
notice tinnitus. This objective could not have
been met without the clinician and patient’s
Baguley, D. M. (2015). Tinnitus : Clinical and research perspectives. Plural Publishing, Incorporated.
Created from universidadviu on 2023-11-07 10:34:34.
Influences of Amplified Music  141
careful analysis of tinnitus effects, as well as
the patient’s growing acceptance of hearing
aids as an option. The value of maskers as an
intermediate step for this patient also should
not be overlooked.
Conclusion
Several factors urge caution regarding expo-
sure to amplified music. Individual suscepti-
bility cannot reliably be predicted; therefore,
listeners should not assume invincibility. The
possibility that music rewards listeners psy-
chologically, in a form similar to that of an
addictive drug, increases the probability of
risky behavior. The loosening of inhibitions
related to recreational drug and alcohol use
may cloud a listener’s judgment regarding
prudent sound levels. Combinations between
other recreational, or other occupational expo-
sures during the course of a listener’s routine
can exacerbate damage from music exposures.
Listening levels should be controlled whenever
it is possible to do so, and to facilitate listeners
to do so, balanced counseling and information
regarding risks should be presented.
Balance in the presentation of damage
risk considerations is essential. Music’s abil-
ity to generate activity in reward centers of
the brain, as well as many association areas,
confirms that individuals will be personally
invested in their listening experience. A little
tinnitus after a night at a club may be endured
as a badge, a reminder of a fun evening similar
to the sore ankle that a person might experi-
ence after a weekend playing soccer. In both
cases, repeated exposure to a physical stressor
can have accumulating effects, and in both
cases, the effects of the aging process will
limit the capability to enjoy such experiences.
As a weekend athlete may need to stay in
shape by working out on off days, so should
music enthusiasts monitor activity associated
 142   Tinnitus: Clinical and Research Perspectives
with risk to their ears. This suggestion is not
.
intended to compel overuse of hearing pro-
tection. Rather, exposure to loud nonmusic
activities should be assessed, particularly if
such exposures result in tinnitus or exacerba-
tion of prior tinnitus.
As enjoyable and transformative as music
is for some people, so the loss of the ability to
enjoy music may be a terrible event, equally
transformative. Patients with tinnitus often
comment that the loss of silence is something
that people without tinnitus cannot under-
stand. Similarly, patients whose tinnitus
interferes with their ability to listen to and/or
perform music express profound anger, regret,
and remorse regarding the listening habits that
they associate with tinnitus. The difficult les-
son they have learned can be offered to sub-
sequent generations of listeners, but it will
probably be digested most easily when pre-
sented in a balanced and reasonable manner
by hearing health care professionals who are
sensitive to the many aspects associated with
music exposures.
References
Axelsson, A., Eliasson, A., & Israelsson, B. (1995).
Hearing in pop/rock musicians: A follow-up
study. Ear and Hearing, 16(3), 245–253.
Copyright © 2015. Plural Publishing, Incorporated. All rights reserved.
Breinbauer, H. A., Anabalon, J. L., Gutierrez, D.,
Carcamo, R., Olivares, C., & Caro, J. (2012).
Output capabilities of personal music players
and assessment of preferred listening levels of
test subjects: Outlining recommendations for
preventing music-induced hearing loss. Laryn-
goscope, 122, 2549–2556.
Brunner, G. C. (1990). Music, mood, and market-
ing. Journal of Marketing, 54, 94–104.
Church, M. W., Zhang, J. S., Langford, M. M., &
Perrine, S. A. (2013). “Ecstasy” enhances noise-
induced hearing loss. Hearing Research, 302,
96–106
Baguley, D. M. (2015). Tinnitus : Clinical and research perspectives. Plural Publishing, Incorporated.
Created from universidadviu on 2023-11-07 10:34:34.
Clark, W. W., & Bohne, B. A. (1999). Effects of
noise on hearing. Journal of the American Medi-
cal Association, 281(17), 1658–1659.
Cullari, S., & Semanchick, O. (1989). Music pref-
erence and perception of loudness. Perceptual
and Motor Skills, 68, 186.
Davis, H., & Silverman, S. R. (Eds.). (1970).
Hearing and deafness (3rd ed.). New York, NY:
Holt, Rinehart, and Winston.
Dey, F. (1970). Auditory fatigue and predicted
permanent hearing defects from rock and
roll music. New England Journal of Medicine,
282(9), 467–470.
Fligor, B. J. (2010). Recreational noise. In M. Cha-
sin (Ed.), Hearing loss and noise (pp. 49–74).
Sedona, AZ: Auricle Inkg.
Fligor, B. J., & Cox, L. C. (2004). Output levels
of commercially available portable compact disc
players and the potential risk to hearing. Ear
and Hearing, 25(6), 513–527.
Florentine, M., Hunter, W., Robinson, M., Bal-
lou, M., & Buus, S. (1998). On the behavioral
charateristics of loud-music listening. Ear and
Hearing, 19(6), 420–428.
Franks, J. R., Stevenson, M. R., & Merry, C. J.
(Eds.). (1996). Preventing occupational hearing
loss — A practical guide. Cincinnati, OH: U.S.
Department of Health and Human Services.
Fucci, D., Harris, D., Petrosino, L., & Banks, M.
(1993). The effect of preference for rock music
on magnitude-estimation scaling behavior in
young adults. Perceptual and Motor Skills, 76,
1171–1176.
Gu, J. W., Halpin, C. F., Nam, E. C., Levine, R.
A., & Melcher. J. R. (2010). Tinnitus, dimin-
ished sound-level tolerance, and elevated audi-
tory activity in humans with clinically normal
hearing sensitivity.Journal of Neurophysiology,
104(6), 3361–3370.
Han, B., Gfroerer, J. C., & Colliver, J. D. (2010).
Associations between duration of illicit drug
use and health conditions: Results from the
2005–2007 National Surveys on drug use and
health. Annals of Epidemiology, 20(4), 289–297.
Helleman, H. W., & Dreschler, W. A. (2015).
Short-term music-induced hearing loss after
sound exposure to discotheque music: The
effectiveness of a break in reducing temporary

threshold shift. International Journal of Audiol-
ogy, 54(Suppl. 1), S46–S52.
Henderson, D., Hamernik, R. P., Dosanjh, D. S.,
& Mills, J. H. (Eds.). (1976). Effects of noise on
hearing. New York, NY: Raven Press.
Henderson, D., Subramaniam, M., & Boettcher,
F. A. (1993). Individual susceptibility to noise-
induced hearing loss: An old topic revisited. Ear
and Hearing, 14(3), 152–168.
Hickox, A. E., & Liberman, M. C. (2014). Is
noise-induced cochlear neuropathy key to the
generation of hyperacusis or tinnitus? Journal of
Neurophysiology, 111, 552–564.
Kahari, K., Zachau, G., Eklof, M., Sandsjo, L., &
Moller, C. (2003). Assessment of hearing and
hearing disorders in rock/jazz musicians. Inter-
national Journal of Audiology, 42, 279–288.
Kujawa, S. G., & Liberman, M. C. (2015). Synap-
topathy in the noise-exposed and aging cochlea:
Primary neural degeneration in acquired senso-
rineural hearing loss. Hearing Research. Retrieved
from http://dx.doi.org/10.1016/j.heares.2015​
.02.009
Kuwano, S., Namba, S., Florentine, M., Zheng,
D., & Hashimoto, T. (1992). Factor analysis of
the timbre of noise — Comparison of the data
obtained in three different laboratories. Proceed-
ings of the Acoustical Society of Japan, N92-4-3,
559–560.
Lacher, K. T., & Mizerski, R. (1994). An explor-
atory study of the responses and relationships
involved in the intention to purchase new
rock music. Journal of Consumer Research, 21,
366–380.
Maison, S. F., Usubuchi, H., & Liberman, M. C.
Copyright © 2015. Plural Publishing, Incorporated. All rights reserved.
(2013). Efferent feedback minimizes cochlear
neuropathy from moderate noise exposure.
Journal of Neuroscience, 33, 5542–5552.
Mays, K. L., Clark, D. L., & Gordon, A. J. (2008).
Treating addiction with tunes: A systematic
review of music therapy for the treatment of
patients with addictions. Substance Abuse,
29(4), 51–59.
Mehrparvar, A. H., Mirmohammadi, S. J., Hash-
emi, S. H., Davari, M. H., Mostaghaci, M.,
Mollasadeghi, A., & Zare, Z. (2015). Concur-
Baguley, D. M. (2015). Tinnitus : Clinical and research perspectives. Plural Publishing, Incorporated.
Created from universidadviu on 2023-11-07 10:34:34.
Influences of Amplified Music  143
rent effect of noise exposure and smoking on
extended high-frequency pure-tone thresh-
olds. International Journal of Audiology, 54(5),
301–307.
Roberts, L. E., Eggermont, J. J., Caspary, D. M.,
Shore, S. E., Melcher, J. R., & Kaltenbach, J. A.
(2010). Ringing ears: The neuroscience of tinni-
tus. Journal of Neuroscience, 30, 14972–14979.
Salimpoor, V. N., Van Den Bosch, I., Kovacevic,
N., Mcintosh, A. R., Dagher, A., & Zatorre,
R. J. (2013). Interactions between the nucleus
accumbens and auditory cortices predict music
reward value. Science, 340(6129), 216–219.
Schaette, R., & McAlpine, D. (2011). Tinnitus
with a normal audiogram: Physiological evi-
dence for hidden hearing loss and computa-
tional model. Journal of Neuroscience, 31(38),
13452–13457.
Simon, H., & Gee, L. (2002). H.E.A.R. research
study survey preliminary findings released. Re-
trieved from http://www.hearnet.com/features/
feature_articleresearch.shtml
Stevens, S. S., & Davis, H. (1938). Hearing: Its psy-
chology and physiology. New York, NY: Ameri-
can Institute of Physics.
Sung, J. H., Sim, C. S., Lee, C. R., Yoo, C. I., Lee,
H., Kim, Y., & Lee, J. (2013). Relationship of
cigarette smoking and hearing loss in workers
exposed to occupational noise. Annals of Occu-
pational and Environmental Medicine, 25(1), 8.
Swanepoel, D. W., Hall III, J. W., & Koekemoer,
D. (2010). Vuvuzela — Good for your team,
bad for your ears. South African Medical Jour-
nal, 100(4), 99–100.
Taylor, W., Pearson, J., Mair, W., & Burns, W.
(1965). Study of noise and hearing in jute weav-
ing. Journal of the Acoustical Society of America,
38, 113–120.
Ward, W. D., Glorig, A., & Sklar, D. L. (1959).
Temporary threshold shift from octave-band
noise: Applications to damage-risk criteria.
Journal of the Acoustical Society of America, 31,
522–528.
Zelman, S. (1973). Correlation of smoking history
with hearing loss. Journal of the American Medi-
cal Association, 223, 920.
Copyright © 2015. Plural Publishing, Incorporated. All rights reserved.

Baguley, D. M. (2015). Tinnitus : Clinical and research perspectives. Plural Publishing, Incorporated.
Created from universidadviu on 2023-11-07 10:34:34.