Let’s break the TABOO of ‘voice problems’ - you are not alone!
The research tells us there is incidence and risk of vocal injury in Elite Voice Users:
The professional singer is required to dedicate themselves to maintaining their vocal
strength and health. How a singer uses their vocal mechanism differs from standard speech throughout the Power, Source, Filter System (Taylor and Reby, 2010).
Differences in breathing, sub-glottic and phonation pressure levels, laryngeal positioning, vocal fold contact, and the placement and shaping of sounds have been noted (Dimon, 2011). These changes in phonation levels and the creation of ‘qualities’ in the voice have been of continual interest to those in voice research (Beaud et al, 2017). These differences, alongside stringent vocal care routines, allow singers to operate at high levels of vocal, physical, and mental output for extended periods of time in high stress environments. However, it is these demands that put them at such a high risk of phono trauma (Guss et al,2014). Therefore, vocal health and understanding of the importance of self care is extremely important!
Professional singers and other ‘elite voice users’ are the second highest rated group seen in voice clinics in the UK for voice disorder management (Beaud et al 2017).
Guss et al (2004) found phono traumatic lesions (nodules, polyps and cysts) were significantly more common in singers (63.5%) than the general population (28.6%). More recent results (Andrea, 2021) showing increasing incidence in ‘Sulcus Vocalis’ could be reflective of changes to the vocal demands of the modern day performer, with cast sizes getting smaller, and more performers needing to learn multiple roles. This may create more pressure to perform through illness or vocal change (Donohue & Patterson, 2020). Another more recent challenge for Voice Specialist SLT’s has
been the effects of COVID-19 on the singing community. Le Borgne’s (2020) recent study revealed complex after-effects for singers diagnosed with COVID-19, such as vagal neuropathy and vocal fatigue from the virus, (which is known from other upper respiratory tract viral infections) (Milar, 2001). IF you’ve had COVID and you notice your voice is ‘altered’ please see ENT :)
Further difficulties in singers voices have also been previously documented by Tepe (2002) in which singers reported: hoarseness (43%), fatigue (24%), and loss of range (19%). Phyland et al (1999) previously reported that 44% of singers observed one or more vocal difficulties within the last year, with 27% not being able to perform. Other studies have examined the prevalence of self-reported vocal problems in singers (Donahue et al, 2013., Pestana et al, 2017., Campagnolo et al, 2021, Franco, 2007., Cohn, 1995., Lundy, 1999., Koufman, 1988), as well as investigations into singers adherence to vocal health (Wyl et al, 2016., Flynn, A, 2020., Searle et al, 2020, Emerion, 2002., Donahue, 2014., Broaddus Lawrence, 2000., Timmerman, 2005., Murray, 2000., Berham, 2008).
Flynn (2020) found that many undergraduate programs included vocal health as part of their curriculums, though it was unclear how much education was received throughout the training, how and when it was delivered, and its regularity. Students reported the delivery of the training was in lecture format, or ‘as and when’ it came up, and mostly in the first year of study, with 31% vaguely stating they were taught vocal health on ‘multiple occasions’. There appears to be no regulation or precedent for this in UK institutions, with no official body stipulating what singers should be taught with regard to vocal physiology and health care.
This confused picture of vocal education delivery mirrors the picture created by Griffin’s
(1995) earlier study which revealed singers perceptions of supported singing were not
contingent with physiological measures. This was furthered by Myint et al’s (2015) study
which displayed findings of frequent disparity between singer’s awareness of vocal function and clinically diagnosed voice disorders.
High risks are associated within the singing community with a diagnosis of a voice disorder, including declining opportunities for future employment, as well as poor emotional and mental health outcomes (Beaud et al, 2021).
Guss et al (2014) discovered most singers declared their voice was vital to them, however, only 43% said they were likely to seek medical help. Gilman et al’s (2007) study uncovered a lack of awareness of voice care services among CCM singers in Washington, USA. Petty (2012) revealed that 50% of the singers in their study sought vocal advice from singing teachers (who have no formal clinical training), and previously, Gilman (2007) found that singers were more likely to seek medical help for a non-voice problem. Quite shocking isn’t it?!
This behaviour could be due to apprehension about the voice appointment, what might be found, anxiety around examinations, seeing a vocal expert, being made to feel like a ‘bad singer’. Guss et al (2014) showed that 70% of participants waited for up to a year before their initial clinic visit, and only 12% took action within a week of vocal change or difficulties.
So lets reflect on alllll of that:
The thing is, as a professional singer YOU are an athlete in your own right. Dancers are injured all the time, they have their physio, do their exercises to get back to the fitness level they need. THAT is voice therapy, that is your link to SLT in the performing world, we are your vocal physios. The likelihood is you will or have already had a vocal injury, whether you know it or not…..
Do these ring a bell: Vocal fold swelling / Haematoma / Reflux induced voice loss / Laryngitis, etc… All of these are common and they are all vocal injuries and should be treated as such, they all present with similar symptoms, how do you know what has happened? Does your GP know…. Lets take a punt on .. nope.
Lessons :
Notice a change in your voice - get it checked out - SLT / ENT who specialise in elite voice user rehabilitation (Clinics at the bottom of this document)…. Do not sing on an infection is you can possibly help it!
So the benefits of educating singers on the early warning signs of vocal disorders is pretty dam important, does it happen, not really.
These benefits of building knowledge in singers around vocal fold swelling have been formerly highlighted many many years ago by Bastian et al (1990), with several suggestions being made to increase vocal education and help prevent injury, as well as bolster knowledge of the clinical voice pathway (Emerich, 2002., Sataloff, 2005., Murray, 2000., Timmermans, 2005). Therefore, the need for multidisciplinary care of professional singers (Baker, 2002., Gates, 1998., Sataloff, 2006) alongside SLT’s, ENT and educational institutions is of even greater importance.
References:
Zuim AF et al. (2021) “Associations of Education and Training with Perceived Singing Voice Function among Professional Singers,” Journal of voice : official journal of the Voice Foundation, 35(3), pp. 17–500. doi: 10.1016/j.jvoice.2019.10.003.
DeVore, E. K. et al. (2020) “Can Voice Disorders Matter As Much As Life-Threatening Comorbidities to Patients’ General Health?,” The Laryngoscope, 130(10), pp. 2405–2411. doi: 10.1002/lary.28417.
Franca, M. C. and Wagner, J. F. (2015) “Effects of Vocal Demands on Voice Performance of Student Singers,” Journal of Voice, 29(3), pp. 324–332. doi: 10.1016/j.jvoice.2014.07.004.
Sapir. S, (1993) “Vocal Attrition in Voice Students: Survey findings” Journal of the Voice, 7(1), pp. 69-74. doi.org/10.1016/S0892-1997(05)80113-4.
Harris, T. (1998) The voice clinic handbook. London: Whurr.
Dejonckere, P. H. (2001) Occupational voice : care and cure. Hague, the Netherlands: Kugler Publications.
Gilman, M. et al. (2009) Performer's Attitudes Toward Seeking Health Care for Voice Issues: Understanding the Barriers, Journal of Voice, 23(2), pp. 225–228. doi: 10.1016/j.jvoice.2007.08.003.
Zimmer-Nowicka.J, Januszewska-Stańczyk.H. (2011) Incidence and Predisposing Factors of Common Upper Respiratory Tract Infections in Vocal Students During Their Professional Training, Journal of Voice, 25 (4), pp. 505-510.
Prebil, N., Hočevar, B., Bahar Maja, I., Bahar Maja, S. (no date) Risk Factors for Voice Problems in Professional Actors and Singers, Slovenian Journal of Public Health, 59(2), pp. 92–98. doi: 10.2478/sjph-2020-0012.
Curtis, J.N. (2019) The mental health of musical theatre students in tertiary education: A pilot study, Studies in Musical Theatre, 13 (3), DOI: https://doi.org/10.1386/smt_00011_1
Martin, E., Battaglini, C. (2019) Health Status of Live Theater Actors: A Systematic Literature Review, Science and Medicine, 34 (2), pp. 108-117. doi: https://doi.org/10.21091/mppa.2019.2010
Marion Beaud, Benoît Amy de la Bretèque, Claire Pillot-Loiseau & Nathalie Henrich Bernardoni (2021) Clinical characteristics of singers attending a phoniatric outpatient clinic, Logopedics Phoniatrics Vocology, DOI: 10.1080/14015439.2021.1924853
Ebersole, B., Soni, R.S., Moran, K., Lango, M., Devarajan, K. and Jamal, N., 2018. The role of occupational voice demand and patient-rated impairment in predicting voice therapy adherence. Journal of Voice, 32(3), pp.325-331.
Braun-Janzen, C. and Zeine, L., 2009. Singers' interest and knowledge levels of vocal function and dysfunction: survey findings. Journal of Voice, 23(4), pp.470-483.
Gilman, M., Merati, A.L., Klein, A.M., Hapner, E.R. and Johns, M.M., 2009. Performer's attitudes toward seeking health care for voice issues: understanding the barriers. Journal of Voice, 23(2), pp.225-228.
Kwak, P.E., Stasney, C.R., Hathway, J., Minard, C.G. and Ongkasuwan, J., 2014. Knowledge, experience, and anxieties of young classical singers in training. Journal of Voice, 28(2), pp.191-195.
Adessa, M., Stadelman-Cohen, T., Zipse, L., Guarino, A.J. and Heaton, J.T., 2018. Factors affecting voice therapy completion in singers. Journal of Voice, 32(5), pp.564-571.
Guss, J., Sadoughi, B., Benson, B. and Sulica, L., 2014. Dysphonia in performers: toward a clinical definition of laryngology of the performing voice. Journal of Voice, 28(3), pp.349-355.
Curtis, J.N., 2019. The mental health of musical theatre students in tertiary education: A pilot study. Studies in Musical Theatre, 13(3), pp.333-348.