THE VOICE: The Role of Rehabilitative Voice Pathology in the life of the Teacher, Conductor, Singer and Student Rebecca Miles Risser, M.M.,M.A., CCC-SLP Clinical Speech Pathologist, Voice Specialist Performance Voice Solutions Old Meridian, Suite 255 Carmel, IN

The Voice Care Team The Primary Care Physician (PCP) The Primary Care Physician (PCP) –Family Practitioner, Pediatrician, Internist The Otolaryngologist (ENT) or Laryngologist The Otolaryngologist (ENT) or Laryngologist Speech Language Pathologist (specialized in voice) Speech Language Pathologist (specialized in voice) Voice Scientist (Researchers) Voice Scientist (Researchers) Voice Teachers (Private, choral directors, etc.) and voice coaches (private) Voice Teachers (Private, choral directors, etc.) and voice coaches (private)

Our Group Performance Voice Solutions is a division of Northside ENT, Inc., and together consists of one slp and four ENTs. Performance Voice Solutions is a division of Northside ENT, Inc., and together consists of one slp and four ENTs. Model of Care reflects strong autonomy and respect between clinician/physician with frequent, nearly daily, consultation re: patients and current research. Model of Care reflects strong autonomy and respect between clinician/physician with frequent, nearly daily, consultation re: patients and current research.

“Voice Specialist”?? ASHA does not formally recognize the distinction of voice specialist or the additional training required for a “voice specialist”, as it does for swallowing or for dysfluency, for example. ASHA does not formally recognize the distinction of voice specialist or the additional training required for a “voice specialist”, as it does for swallowing or for dysfluency, for example. Additional training includes training in the use of videostroboscopy, training in normal vs. abnormal anatomy, and therapy techniques. Additional training includes training in the use of videostroboscopy, training in normal vs. abnormal anatomy, and therapy techniques. My background: My background: –Masters of Music (1990) in Performance and Pedagogy – NIU, –Masters of Arts (2000) in Speech Language Pathology – IU –National Boards (2000) = Certificate of Clinical Competency in Speech Language Pathology (CCC- SLP) from ASHA –State Boards(2000) – licensed to practice in Indiana

“What do you do, anyway”? Voice Evaluation Indexes to baseline issues of reflux (Reflux Symptom Index), the Voice-Related Quality of Life (V-RQOL) and the Voice Handicap Index (VHI), or the Singer’s Voice Handicap Index (S- VHI). Indexes to baseline issues of reflux (Reflux Symptom Index), the Voice-Related Quality of Life (V-RQOL) and the Voice Handicap Index (VHI), or the Singer’s Voice Handicap Index (S- VHI). Acoustic evaluation, using PRAAT software to evaluate Fundamental frequency, Relative Average Perturbation, Intensity, and MPT and s/z ratio. Acoustic evaluation, using PRAAT software to evaluate Fundamental frequency, Relative Average Perturbation, Intensity, and MPT and s/z ratio.

“What do you do, anyway”? Videostroboscopy Slow motion photography of the vocal folds, as they are vibrating. Slow motion photography of the vocal folds, as they are vibrating. Immediate, magnified imaging for presence or absence of pathology. Immediate, magnified imaging for presence or absence of pathology. Allows clinician to view even very small changes in the vibratory capacity of the vocal folds Allows clinician to view even very small changes in the vibratory capacity of the vocal folds Gives the patient immediate feedback and opportunity to view their vocal folds – great educational tool. Gives the patient immediate feedback and opportunity to view their vocal folds – great educational tool.

Videostroboscopy Once strobe obtained, then complete the Reflux Finding Score (Belafsky, Kouffman, et al.) Once strobe obtained, then complete the Reflux Finding Score (Belafsky, Kouffman, et al.)

The most common diagnostics noted with teachers, choral directors, singers and voice students. At Performance Voice Solutions, the top four diagnostics associated with teachers, including singing teachers, choral directors, singers (professional and non- professional) and voice students include : At Performance Voice Solutions, the top four diagnostics associated with teachers, including singing teachers, choral directors, singers (professional and non- professional) and voice students include : Singers nodules Singers nodules Polyps/cysts Polyps/cysts Hyperfunctional dysphonia (depending on the type of singing) Hyperfunctional dysphonia (depending on the type of singing) Laryngopharyngeal Reflux Disease Laryngopharyngeal Reflux Disease

Occupational Risks for Voice Problems (Verdolini and Ramig, 2001) In the United States, roughly 3-9% of the general population has some type of voice abnormality at any given moment. In the United States, roughly 3-9% of the general population has some type of voice abnormality at any given moment. With the advent of information age, voice has assumed an increasingly important role in job function. With the advent of information age, voice has assumed an increasingly important role in job function. Conservative estimates indicate that over 25% of the working population (i.e. 28,000,000 people) list voice as a critical aspect in their job. Conservative estimates indicate that over 25% of the working population (i.e. 28,000,000 people) list voice as a critical aspect in their job.

Occupational Risks for Voice Problems (Verdolini and Ramig, 2001) The occupational risk factors for voice disorder in US and Sweden: The occupational risk factors for voice disorder in US and Sweden: Singer Singer Counselor/social worker Counselor/social worker Teacher Teacher Lawyer Lawyer Clergy Clergy Telemarketer Telemarketer Ticket sales Ticket sales Health care Health care

Occupational Risks for Voice Problems (Verdolini and Ramig, 2001) Let’s talk teachers… Let’s talk teachers… –Various studies have been completed, with a range of responses, but in general at the time of the study, 32%-47.5% of the teachers responded that they were currently hoarse. –20-30% indicated they had missed work the previous school year because of voice problems. –38% reported negative effect of teaching on voice –39% were currently reducing work (reducing teaching activities) due to voice.

Occupational Risks for Voice Problems (Verdolini and Ramig, 2001) “Considering only lost work days and treatment expenses, the societal cost of voice problems in teachers alone may be…about $2.5 billion annually in the U.S.” “Considering only lost work days and treatment expenses, the societal cost of voice problems in teachers alone may be…about $2.5 billion annually in the U.S.”

Occupational Risks for Voice Problems (Verdolini and Ramig, 2001) More on teachers… More on teachers… –Female teachers reported voice problems more frequently than males (38% vs. 26%). –Physical education teachers presented highest risk, independent of gender, hours of teaching per day, number of years teaching or age

Occupational Risks for Voice Problems (Verdolini and Ramig, 2001) Other studies: Other studies: –55% of respondents indicated dry throat; –45% had vocal fatigue –36% had scratchy sensation; –32% had throat discomfort –31% had to make an effort to talk after teaching.

Occupational Risks for Voice Problems (Verdolini and Ramig, 2001) Now, singing teachers… Now, singing teachers… 125 singing teachers with 49 control subjects completed questionnaires. 125 singing teachers with 49 control subjects completed questionnaires. 21%of singing teachers had voice dysfunction (18% of controls) = not a significant difference 21%of singing teachers had voice dysfunction (18% of controls) = not a significant difference HOWEVER, 64% of singing teachers had voice problem in past (33% of controls)…SIGNIFICANT HOWEVER, 64% of singing teachers had voice problem in past (33% of controls)…SIGNIFICANT A history of voice dysfunction in the past increased likelihood of current voice problem by a factor of FIVE. A history of voice dysfunction in the past increased likelihood of current voice problem by a factor of FIVE.

Occupational Risks for Voice Problems (Verdolini and Ramig, 2001) Singing teachers continued… Singing teachers continued… The current use of dehydrating medications increased the likelihood of current voice problem by THREE. The current use of dehydrating medications increased the likelihood of current voice problem by THREE. Hmmmm….an increase in the estimated hours of LOUD singing per day appeared to have a protective effect; an increase in the number of loud hours of singing inversely predicted the likelihood of a current voice problem by a factor of three. (authors interpreted this as an effect of healthy voice not a cause of a healthy voice). Hmmmm….an increase in the estimated hours of LOUD singing per day appeared to have a protective effect; an increase in the number of loud hours of singing inversely predicted the likelihood of a current voice problem by a factor of three. (authors interpreted this as an effect of healthy voice not a cause of a healthy voice).

Occupational Risks for Voice Problems (Verdolini and Ramig, 2001) Singing voice teachers… Singing voice teachers… –Congratulations! Large proportion of singing teachers with current (56%) or past (83%) voice problems sought professional help. Large proportion of singing teachers with current (56%) or past (83%) voice problems sought professional help. –HOWEVER…in this study, no singer or control respondent with a current voice problem had received voice therapy for it. Only 4% of respondents with a past voice problem had received therapy.

Occupational Risks for Voice Problems (Verdolini and Ramig, 2001) Choral singers: Choral singers: –National Convention of Gospel Choirs and Choruses (NCGCC) and American Choral Directors Association (ACDA) were polled. –Most of the NCGCC members were African American; most of the ACDA members were Caucasian.

Occupational Risks for Voice Problems (Verdolini and Ramig, 2001) 50% of gospel singers reported current perceived hoarseness in comparison to 35% of classical singers 50% of gospel singers reported current perceived hoarseness in comparison to 35% of classical singers Hoarse AA singers were neutral about seeking voice treatment; hoarse Caucasian singers were “likely” to seek treatment or “intended” to seek treatment. Hoarse AA singers were neutral about seeking voice treatment; hoarse Caucasian singers were “likely” to seek treatment or “intended” to seek treatment.

Occupational Risks for Voice Problems (Verdolini and Ramig, 2001) For AA respondents, others’ opinions about treatment appeared to predict the likelihood of seeking treatment for current voice problem. In other words, a cultural bias influenced them. For AA respondents, others’ opinions about treatment appeared to predict the likelihood of seeking treatment for current voice problem. In other words, a cultural bias influenced them. For Caucasian respondents, one’s own opinion or “feelings” about seeking treatment predicted the likelihood of seeking treatment. In other words, a personal bias influenced them. For Caucasian respondents, one’s own opinion or “feelings” about seeking treatment predicted the likelihood of seeking treatment. In other words, a personal bias influenced them.

So how can we fix the problem?

Novel thought #1… Let’s start talking with each other!

Thoughts from my choral director/patients “I wish someone had told me about the connection between my singing voice and my speaking voice.” “I wish someone had told me about the connection between my singing voice and my speaking voice.” –What’s this about? How do we achieve vocal rest in a healthy functional way apart from “shutting down”? How do we achieve vocal rest in a healthy functional way apart from “shutting down”? “Tell them that the speaking voice requires a warm-up before the teaching day begins.” “Tell them that the speaking voice requires a warm-up before the teaching day begins.”

Thoughts from my choral director/patients “Talk about female teachers demonstrating for male choirs” “Talk about female teachers demonstrating for male choirs” –Recording parts on “smart music” and ing the parts to the students; –Having a high school male record the singing parts for extra credit. –For noisy groups: visual cues mounted on craft sticks.

Novel thought #2… It IS possible to use a healthy voice to teach, sing, AND even have a voice that’s as good or better at the end of the day!

Vocal Fold Wound Healing In 2003, Branski, et. al found that low levels of dynamic, biomechanical stress inhibited IL-1Beta (associated with inflammation) in injured tissue. In 2003, Branski, et. al found that low levels of dynamic, biomechanical stress inhibited IL-1Beta (associated with inflammation) in injured tissue. Vocal tissue from rabbits were exposed to variable levels of cyclic tensile strain (repetitive rotating vibratory movement similar to vocal cord vibrations). Vocal tissue from rabbits were exposed to variable levels of cyclic tensile strain (repetitive rotating vibratory movement similar to vocal cord vibrations).

Results 1. CTS reduced inflammation by inducing the increase of “collagen synthesis” (i.e. a marker for healing of injured tissue) in the presence of IL-1Beta. 2. Therefore, low-levels of biomechanical stress induced wound healing by decreasing the time it took to move from inflammation to tissue rebuilding.

Results Another Branski study compared two groups of performers, one with vocal fold nodules and one with healthy larynxes. Another Branski study compared two groups of performers, one with vocal fold nodules and one with healthy larynxes. –Both groups were able to produce a resonant voice as compared to a pressed, a normal, and a breathy voice. –“resonance” approximated the configuration in Branski’s study, in which low-level biomechanical stress induced wound healing faster.

The missing link… “Resonant voice” also corresponded to easy, clear resonance advocated by Lessac Madsen Resonant Voice Therapy, and to the “mask” resonance advocated by singing teacher of solo singers. “Resonant voice” also corresponded to easy, clear resonance advocated by Lessac Madsen Resonant Voice Therapy, and to the “mask” resonance advocated by singing teacher of solo singers.

Voice therapy or tissue re-engineering? Therefore, voice therapy techniques enhance biological phases of wound healing in recurrent, acute phonotrauma.

So, what should I look for? Let’s start with your students…

“How do I know if my student needs to see a voice specialist?” 1. Speaking voice and singing voice should both be smooth and easy, with no roughness, no breathiness. 1. Speaking voice and singing voice should both be smooth and easy, with no roughness, no breathiness. 2. If they become hoarse, it should last no more than two weeks, and this should be no more than 1-2 times each YEAR. 2. If they become hoarse, it should last no more than two weeks, and this should be no more than 1-2 times each YEAR. 3. Extroverted individuals will likely have vocal fold nodules; introverted will likely have muscle tension dysphonia. 3. Extroverted individuals will likely have vocal fold nodules; introverted will likely have muscle tension dysphonia.

But what if it’s not the student !?! Now let’s take a look at YOU

“That ain’t right” 1. Hoarseness is not normal. 1. Hoarseness is not normal. 2. Breathiness is not normal. 2. Breathiness is not normal. 3. The “Monday-Friday effect” is not normal. 3. The “Monday-Friday effect” is not normal. 3. Missing whole sections of your voice? NOT NORMAL. 3. Missing whole sections of your voice? NOT NORMAL.

What can we do? 1. Amplify. Get a microphone system either through your school (no, really, they sometimes do this…) or rig something up at Radio Shack (not a paid, promotional advertisement). 1. Amplify. Get a microphone system either through your school (no, really, they sometimes do this…) or rig something up at Radio Shack (not a paid, promotional advertisement). 2. Warm up your speaking voice before your first class (Vocal Function Exercises). 2. Warm up your speaking voice before your first class (Vocal Function Exercises).

What can we do? 3. When you teach, it’s better to speak 10 minutes “on” then 10 minutes “off” throughout your day. 3. When you teach, it’s better to speak 10 minutes “on” then 10 minutes “off” throughout your day. 4. Restore your voice through easy, resonant glides to regain focus and reduce effort 4. Restore your voice through easy, resonant glides to regain focus and reduce effort 5. Listen to your body – where it is tight? 5. Listen to your body – where it is tight?

The “Take Home” Let’s learn a fantastic warm up together…

Vocal Function Exercises (Joseph C. Stemple, Ph.D.) In our current climate of self- improvement, voice improvement is not only for the disordered voice but also for those who want to enhance vocal health and image. In our current climate of self- improvement, voice improvement is not only for the disordered voice but also for those who want to enhance vocal health and image. Voice is one part of the physical, emotional and life-style status of an individual. Voice is one part of the physical, emotional and life-style status of an individual.

Wellness Line Disordered voice Outstanding voice ________________________________ Normal voice

The program 1. Sustain “ee” vowel for as long as possible on F3 for adult males, F4 for adult females and children 1. Sustain “ee” vowel for as long as possible on F3 for adult males, F4 for adult females and children –Goal: should be equal to sustained /s/ in terms of time. Vocal quality is forward but not quite nasal. Voice should be engaged and not breathy. (I encourage a “twang” sound to narrow the AES)

The program 2. Glide from lowest note to highest on “whoop”. 2. Glide from lowest note to highest on “whoop”. –Goal: no voice breaks. It engages all the laryngeal muscles, and encourages a slow engagement of the cricothyroid muscles. 3. Glide from highest note to lowest note on “boom” 3. Glide from highest note to lowest note on “boom” –Goal: no voice breaks. By keeping an open throat, it encourages the engagement of the thyroarytenoid muscles without the presence of a back-focused “growl” – No Growling!

The program 4. Sustain musical notes (C-D-E-F-G) for as long as possible (for lower voices, A-B-C-D-E) on the word “knoll” or “moe” or “no”. 4. Sustain musical notes (C-D-E-F-G) for as long as possible (for lower voices, A-B-C-D-E) on the word “knoll” or “moe” or “no”. –Goal: should be equal to sustained /s/ in terms of time. Vocal quality is forward but not quite nasal. Voice should be engaged and not breathy. This is considered a low impact, adductory power exercise.

Program “Notes” All exercises are done as softly as possible, per the author’s notes. In keeping with other literature, it should be kept as soft as possible, while maintaining a clear tone. All exercises are done as softly as possible, per the author’s notes. In keeping with other literature, it should be kept as soft as possible, while maintaining a clear tone.

Let’s keep our conversation going… GO FORTH AND PHONATE!

Bibliography Blaylock, Thomas R., Effects of Systematized Vocal Warm-Up on Voices With Disorders of Various Etiologies. Journal of Voice. Vol. 13, No. 1, pp Blaylock, Thomas R., Effects of Systematized Vocal Warm-Up on Voices With Disorders of Various Etiologies. Journal of Voice. Vol. 13, No. 1, pp Branski R.C., Verdolini, K., Sandulache, V., Rosen, C.A., and Hebda, P.A. Vocal Fold Wound Healing: A Review for Clinicians. Journal of Voice 20(3): September Branski R.C., Verdolini, K., Sandulache, V., Rosen, C.A., and Hebda, P.A. Vocal Fold Wound Healing: A Review for Clinicians. Journal of Voice 20(3): September Branski, RC, Verdolini, K, Rosen, CA, Hebda, PA. Markers of wound healing in vocal fold secretions from patients with laryngeal pathology. The Annals of Otology, Rhinology, & Laryngology 113 (1): , Branski, RC, Verdolini, K, Rosen, CA, Hebda, PA. Markers of wound healing in vocal fold secretions from patients with laryngeal pathology. The Annals of Otology, Rhinology, & Laryngology 113 (1): , 2004.

Bibliography Branski, R, Perera, P, Verdolini, K, Rosen, CA, Hebda, P, Agarwal S. Dynamic Biomechanical Strain Inhibits IL-1β-induced Inflammation in Vocal Fold Fibroblasts. Journal of Voice, 21(6): Branski, R, Perera, P, Verdolini, K, Rosen, CA, Hebda, P, Agarwal S. Dynamic Biomechanical Strain Inhibits IL-1β-induced Inflammation in Vocal Fold Fibroblasts. Journal of Voice, 21(6): Branski R, Verdolini K, Rosen, CA, Hebda, PA. Acute vocal fold wound healing in a rabbit model. The Annals of Otology, Rhinology & Laryngology 114(1): Branski R, Verdolini K, Rosen, CA, Hebda, PA. Acute vocal fold wound healing in a rabbit model. The Annals of Otology, Rhinology & Laryngology 114(1): Ford, J.K., Preferences for Strong or Weak Singer’s forman Resonance in Choral Tone Quality. International Journal of Research in Choral Singing, Vol. 1(1) Ford, J.K., Preferences for Strong or Weak Singer’s forman Resonance in Choral Tone Quality. International Journal of Research in Choral Singing, Vol. 1(1) 2003.

Bibliography Jiang, J. Vocal Fold Impact Stress Analysis. Journal of Voice, 15(1): Jiang, J. Vocal Fold Impact Stress Analysis. Journal of Voice, 15(1): Johns, MM, Update on the etiology, diagnosis,and treatment of vocal fold nodules, polyps and cysts. Laryngology and bronchoesophagology, Current opinion in Otolaryngology & Head & Neck Surgery. 11 (6): , December Johns, MM, Update on the etiology, diagnosis,and treatment of vocal fold nodules, polyps and cysts. Laryngology and bronchoesophagology, Current opinion in Otolaryngology & Head & Neck Surgery. 11 (6): , December Krishna, P, Rosen, CA, Branksi, R, Wells, A, Hebda P, Primed fibroblasts and exogenous decorin: Potential treatments for subacute vocal fold scar. Otolaryngology-Head and Neck Surgery, 135(6): Krishna, P, Rosen, CA, Branksi, R, Wells, A, Hebda P, Primed fibroblasts and exogenous decorin: Potential treatments for subacute vocal fold scar. Otolaryngology-Head and Neck Surgery, 135(6):

Bibliography Li, NYK, Verdolini K, Clermont G, Mi Q. Rubinstein EN, et al. (2008) A Patient-Specific in silico Model of Inflammation and Hearing Tested in Acute Vocal Fold Injury. PLoS ONE 3(7): e2789. doi: /journal.pone Li, NYK, Verdolini K, Clermont G, Mi Q. Rubinstein EN, et al. (2008) A Patient-Specific in silico Model of Inflammation and Hearing Tested in Acute Vocal Fold Injury. PLoS ONE 3(7): e2789. doi: /journal.pone Ruotsalainen JH, Sellman J., Lehto L, Jauhiainen M, Vrbeek JH. Interventions for preventing voice disorders in adults. Cochrane Databse of Systematic Reviews 2007, Issue 4 Art No:CD DOI: / CD006372; pub2. Ruotsalainen JH, Sellman J., Lehto L, Jauhiainen M, Vrbeek JH. Interventions for preventing voice disorders in adults. Cochrane Databse of Systematic Reviews 2007, Issue 4 Art No:CD DOI: / CD006372; pub2.

Bibliography Thomas, L., Stemple, J.C., Voice Therapy: Does Science Support the Art? Communication Disorders Review. Volume 1, Number 1, pp Thomas, L., Stemple, J.C., Voice Therapy: Does Science Support the Art? Communication Disorders Review. Volume 1, Number 1, pp Verdolini, K, Drucker, D, Palmer, P, Samawi, H., Laryngeal Adduction in Resonant Voice. Journal of Voice, 12(3): , Verdolini, K, Drucker, D, Palmer, P, Samawi, H., Laryngeal Adduction in Resonant Voice. Journal of Voice, 12(3): , Verdolini, K., Ramig, L.O., Review: Occupational risks for voice problems. Log. Phon Vocol 2001; 26: Verdolini, K., Ramig, L.O., Review: Occupational risks for voice problems. Log. Phon Vocol 2001; 26: