Factors Affecting Voice Therapy Completion in Singers

Understanding Performers' Perspectives on Access to Care and Support for Voice Injuries: A Survey Study

INTRODUCTION

Previous studies show that performers face higher risk of voice injury and experience greater impairment compared to nonperformers. Understanding the factors influencing support for performers is important for improving outcomes.

METHODS

An anonymous online survey was distributed to a target audience of performers with past voice injury, inquiring about their understanding of voice injury "red flags," access to voice care support resources, treatment adherence, and comfort discussing injury with others. Responses were analyzed considering various clinicodemographic factors and aspects related to care and treatment.

RESULTS

The survey was completed by 151 performers with self-reported history of voice injury, representing multiple performance genres. Participants commonly sought help from a general otolaryngologist (52; 34.44%), laryngologist (41; 27.15%), or voice teacher (40; 26.49%) and treatments included voice therapy, rest, medication, and surgery, with a majority reporting high treatment adherence (129; 87.16%), a statistically significant factor in resolving symptoms. Those with partial or nonadherence cited financial/insurance barriers, scheduling/availability conflicts, or treatment dissatisfaction. Participants reported high awareness of voice injury "red flags" (mean 86.80; SD 18.87%), and moderate access to voice care tools/resources (mean 74.76; SD 29.1) and a voice team (mean 71.23; SD 36.52), but low support from management/production teams (mean 50.69; SD 37.23). Several expressed a desire for better education about preventive care (mean 70.06; SD 37.78). Comfort levels in discussing voice injuries varied across social contexts, but those working with voice teachers were more comfortable discussing their voice problems with colleagues and peers.

CONCLUSION

This study explores performers' perspectives on accessing care for voice injuries and emphasizes the importance of increased preventive education to address the ongoing stigma surrounding voice injuries and to foster a supportive environment for performers seeking help. Additionally, the study highlights the role of voice professionals in both providing and advocating for support systems for performers with voice injury.

LEVEL OF EVIDENCE: 4

Population characteristics and self-assessment of speaking and singing voice in Polish contemporary commercial music singers-an exploratory, cross-sectional study

Background

The domination of the Contemporary Commercial Music (CCM) industry in music markets has led to a significant increase in the number of CCM performers. Performing in a wide variety of singing styles involves exposing CCM singers to specific risk factors potentially leading to voice problems. This, in turn, necessitates the consideration of this particular group of voice users in the Occupational Health framework. The aim of the present research was threefold. First, it sought to profile the group of Polish CCM singers. Second, it was designed to explore the prevalence of self-reported voice problems and voice quality in this population, in both speech and singing. Third, it aimed to explore the relationships between voice problems and lifetime singing involvement, occupational voice use, smoking, alcohol consumption, vocal training, and microphone use, as potential voice risk factors.

Materials and methods

The study was conducted in Poland from January 2020 to April 2023. An online survey included socio-demographic information, singing involvement characteristics, and singers' voice self-assessment. The prevalence of voice problems was assessed by the Polish versions of the Vocal Tract Discomfort Scale (VTDS) and the Singing Voice Handicap Index (SVHI). Also, a self-reported dysphonia symptoms protocol was applied. The perceived overall voice quality was assessed by a Visual Analogue Scale (VAS) of 100 mm.

Results

412 singers, 310 women and 102 men, completed the survey. Nearly half of the studied population declared lifetime singing experience over 10 years with an average daily singing time of 1 or 2 h. 283 participants received vocal training. For 11.4% of respondents, singing was the primary income source, and 42% defined their career goals as voice-related. The median scores of the VTDS were 11.00 (0-44) and 12.00 (0-40) for the Frequency and Severity subscales, respectively. The median SVHI score of 33 (0-139) was significantly higher than the normative values determined in a systematic review and meta-analysis (2018). Strong positive correlations were observed between SVHI and both VTD subscales: Frequency (r = 0.632, p < 0.001) and Severity (r = 0.611, p < 0.001). The relationships between most of the other variables studied were weak or negligible.

Conclusion

The examined CCM singers exhibited substantial diversity with regard to musical genre preferences, aspirations pertaining to singing endeavors, career affiliations, and source of income. Singing voice assessment revealed a greater degree of voice problems in the examined cohort than so far reported in the literature, based on the SVH and VTDS.

Relationships Among Stimulability Testing, Patient Factors, and Voice Therapy Compliance

OBJECTIVE

Voice stimulability testing to determine voice therapy efficacy and prognosis is commonly used during the voice evaluation, but little is known about how patient factors (eg, voice diagnosis, dysphonia severity) can influence stimulability outcomes. The predictability of voice therapy success with different stimulability facilitating techniques (eg, hums, pitch glides) is also unknown. The goals of this study were to identify relationships between patient factors, voice therapy compliance, and stimulability testing.

METHODS

A retrospective chart review was conducted on 50 patients who were seen for their initial voice therapy evaluation at the UT Southwestern Clinical Center for Voice Care. Chart review included documentation of the stimulability tasks that yielded/did not yield voice changes, level of stimulability, voice diagnosis, clinician-rated auditory-perceptual analysis of vocal quality, therapy attendance, and compliance with voice therapy recommendations. Statistical analysis was conducted to determine whether the types of facilitating techniques, voice diagnosis, and dysphonia severity could predict how stimulable patients were and whether any stimulability techniques could predict voice therapy attendance and compliance.

RESULTS

Patients diagnosed with functional voice disorders (eg, muscle tension dysphonia) were 11 times more likely to be stimulable for voice improvements than patients with neurological voice disorders (eg, vocal fold paralysis). Patients with lower dysphonia severity were more likely to be stimulable than patients with high dysphonia severity. Specific facilitating voice tasks did not predict the level of stimulability. Stimulability level was not predictive of therapy attendance or compliance with therapy recommendations.

CONCLUSIONS

Voice diagnosis and severity of dysphonia influenced stimulability levels. However, voice stimulability was not predictive of voice therapy attendance or compliance, and no specific facilitative task predicted the level of stimulability. Future investigations should focus on other means of measuring a patient's motivation for change and on the predictive power of stimulability testing on voice therapy outcomes.

Performers With History of Voice Injury: A Survey Study of Treatment Outcomes and Vocal Function

INTRODUCTION

Past studies show that performers are more susceptible to voice injury, have higher incidence of injury, and experience greater vocal impairment than non-performers. Despite literature demonstrating otherwise, there remains fear and stigma that voice injury is a career-ending circumstance. Much of this is due to a lack of information about post-treatment vocal function.

METHODS

An anonymous online survey was distributed via email, flyer, and social media to a target audience of performers with a history of voice injury. It inquired about occupation, vocal symptoms, professionals consulted, and treatment adherence. Outcome measures included ability to perform, resolution of symptoms, and attitudes about their voices after voice injury. Findings were analyzed descriptively with statistical analysis to determine factors that may be related to favorable outcomes.

RESULTS

The survey was completed by 151 performers representing a range of genres, including musical theatre, classical, and popular genres. The most reported vocal symptoms were decreased range, singing voice quality changes, increased singing effort, and vocal fatigue. Most initially sought care from an otolaryngologist, laryngologist, or voice teacher. Diagnoses and recommendations varied, but those who adhered to treatment were more likely to report resolution of voice symptoms (P = 0.025). Those with symptoms for 2-4 weeks reported greater vocal confidence than those with a longer symptom duration (P = 0.0251). Performers working with a voice teacher were more likely to find treatment helpful (P = 0.0174). Those with neurogenic voice conditions reported less vocal reliability than participants with other pathologies (P = 0.0155).

CONCLUSION

The majority of participants continued to perform, reported resolved or improved voice symptoms after treatment, and reported positive attitudes about their voices, regardless of their injury or current presence or absence of pathology on exam. Findings of this study highlight a need for continued outreach to voice teachers, education programs, and production teams about vocal function after voice injury.

LEVEL OF EVIDENCE: 4

Amateur choir singers - Does good vocal health matter?

BACKGROUND

Many amateur singers enjoy singing in choirs. They are likely to lack the training and expertise of professional singers and this may have an impact on their vocal health.

AIMS

To assess the experiences of amateur singers, their use of warm-up and cool-down sessions, their vocal health, their sources of help and advice and their reactions to receiving a diagnosis and treatment.

METHODS AND PROCEDURES

A questionnaire was sent to amateur choir singers. Quantitative data on their use of warm-up and cool-down activities were collected and the singers rated how frequently they experienced adverse voice symptoms after singing. Qualitative data were collected from singers who had sought advice about their voice and from those who had received a diagnosis and treatment.

OUTCOME AND RESULTS

Most choirs used warm-up sessions but few used cool-down. Singers who participated in choir warm-ups experienced significantly less vocal symptoms. Individual warm-ups were ineffective. Singers who had previously had a diagnosis continued to have significantly higher symptom scores. A quarter of the singers who had neither sought help nor had a diagnosis had high scores. Singers appeared uncertain about who to consult for help. Those who saw a speech and language therapist were much more likely to receive a diagnosis and treatment either by the therapist or by referral to an ear, nose and throat specialist. Those receiving treatment were mainly positive about it and likely to complete a course of therapy.

CONCLUSIONS AND IMPLICATIONS

Warm-up sessions performed by choirs are helpful in avoiding voice symptoms and are recommended. The presence of singers who are unaware of potential damage to their voices is a concern. A simple rating system, as used in this research, may act to alert them to the dangers. Choir leaders could be more active in advising singers and refer them to professionals where necessary. Speech and language therapists appear more sensitive to their problems and could be a first point of contact.

WHAT THIS PAPER ADDS

What is already known on this subject Poor vocal health may occur in amateur singers and lead to voice disorders which will reduce the demonstrated benefits of regular singing. They may be less aware than professional singers of potential hazards and may not know how to sing in a way that ensures good vocal health. There has been less research on the extent of voice problems in amateurs or of the actions they may take to resolve the vocal difficulties they encounter. What this paper adds to the existing knowledge This survey demonstrates that choir warm-ups were effective in helping to avoid common symptoms associated with voice problems. A large minority of singers who had not sought help for voice problems had high symptom scores on our assessment. Singers frequently turned to a singing teacher for help. Those who consulted a speech and language therapist were much more likely to be referred for further investigation and treatment. What are the potential or actual clinical implications of this work? We present a simple subjective measure of symptom severity which succeeds in distinguishing between singers who warm up their voices and those who do not and between singers who have received a past diagnosis and those who have not. There are a number of indications in this research that amateur singers are unsure if they need help and are uncertain who can offer it. In these circumstances the use of a simple measure of the severity of vocal abuse may be useful.

The role of patient perceptions and hyperfunctional voice disorders in predicting voice therapy attendance

OBJECTIVES/HYPOTHESIS

Attendance is essential to voice therapy's effectiveness in the treatment of voice and laryngeal disorders. With such high rates of drop-out and non-attendance, it is important to understand the factors that influence this behavior. This study sought to identify potential predictors of attendance to voice therapy at an interdisciplinary voice clinic.

STUDY DESIGN

Single-institution retrospective cohort study.

METHODS

In this retrospective cohort study, patients evaluated at an interdisciplinary voice clinic who received a referral for voice therapy were identified. Age, gender, voice-related diagnoses, Voice Handicap Index-10 scores, Reflux Symptom Index scores, and measures of patient perceptions (self-rated severity, importance of voice in one's life, and "feelings about voice therapy") were recorded to evaluate associations with attendance to at least one therapy session. Standard statistical analysis and logistic regressions were performed.

RESULTS

Of 168 subjects included, 111 (66.1 %) attended at least one session of voice therapy. Patients diagnosed with primary hyperfunctional voice disorders had a significantly higher attendance rate than other groups. Attenders had higher self-ratings of severity and more positive "feelings about voice therapy" compared to non-attenders. Regression models found three significant predictors of therapy attendance: primary diagnosis of hyperfunctional voice disorder, self-rated severity, and "feelings about voice therapy."

CONCLUSION

In this cohort, patients with more positive feelings about voice therapy, higher self-rated severity, and a diagnosis of primary hyperfunctional voice disorder were more likely to attend voice therapy.

LEVEL OF EVIDENCE: 3

Singing Voice Concern in Tertiary Laryngology Practice

OBJECTIVES

To determine the prevalence and characteristics of patients who identify singing voice as a primary concern when presenting with general voice complaints to a voice clinic.

METHODS

Data were collected from medical records on demographics, medical history, laryngoscopy exam, diagnosis, and subsequent treatments; and from self-report questionnaires including the Voice Handicap Index-10 (VHI-10) and clinical voice questionnaire.

RESULTS

A total of 17% of patients presenting to a voice clinic with general voice problems who completed a VHI-10 identified singing voice as a primary concern. Compared to the reference cohort, patients concerned about singing voice report greater handicap on several questions of the VHI-10, particularly in personal and social life impact, loss of income, unpredictability of vocal clarity, subjective upset, and subjective handicap. Those concerned with singing voice were also more concerned about their vocal problem, and both more likely to be recommended voice therapy and participate in voice therapy despite no statistical differences in categorical diagnoses.

CONCLUSIONS

When considering both professional and recreational singers, voice concerns occurred in 17% of the cohort under study. Patients with singing voice concerns are accounted for largely by recreational singers, who remain poorly characterized in the literature. We underscore the importance of sensitivity and responsivity to the needs of this group of patients.

Voice Therapy Expectations for Injured Singers

OBJECTIVES/HYPOTHESIS

Voice therapy is a mainstay treatment modality in the management of phonotrauma in singers. However, the typical duration of therapy an injured singer undergoes is unknown. The primary aims of the study were to determine (1) the number of therapy sessions preceding a decision for surgery and (2) the number of sessions and length of time to achieve improvement in singers who did not undergo surgery. Whether specific singer factors were associated with the length of therapy was also investigated.

STUDY DESIGN

Retrospective.

METHODS

Records of singers with phonotraumatic vocal fold lesions seen over a 9-year period at a tertiary care voice center were reviewed.

RESULTS

Sixty singers who underwent surgery and 183 singers who did not undergo surgery were included in the final analysis. In nearly ¾ of the surgical patients, five or fewer voice therapy sessions were completed prior to the decision for surgery. Singers who did not undergo surgery required on average 3-4 sessions before noting improvement. Over 60% of the non-surgical singers improved within 3 months and 84% were judged to be improved by 6 months. Lesion type, professional/amateur status, formal voice training, and having a current voice teacher/coach were not associated with the length of voice therapy.

CONCLUSIONS

The length of voice therapy prior to decision for surgery was limited, and so was the length of therapy leading to initial improvement in singers who did not require surgery. These findings provide a framework for voice therapy expectations and could be reassuring for this unique population.

Clinical characteristics of singers attending a phoniatric outpatient clinic

Purpose: Studies suggest that singers are over-represented in voice clinics and present a high risk of developing voice disorders. This retrospective study aims to describe the characteristics of 78 singers consulting a phoniatrician.Methods: In their medical files, data related to age, gender, occupational status, singing training, musical style, voice complaint, diagnosis, voice-quality grading (GRBAS) and treatment were gathered.Results: The patients were mostly female singers (87%). Non-professional singers (semi-professional included) represented 64%, professional singers 25% and students of singing 11%. The majority of singers were choristers (27%) and 22% were classical-style/oratorio-style singers. Two-thirds of the population had intensive vocal activity in speech or singing. Vocal endurance, somatosensory signs and difficulties with high pitches were the most frequent symptoms. Among the patients, 79% presented with singing-voice disorders with 85% of these having vocal fold lesions. Generally, their speaking voices were preserved. Vocal-folds nodules were the most prevalent pathology (37%) followed by sulcus (26%) and voice therapy was the main treatment.Conclusions: This study emphasizes the fact that singers have specific voice complaints related to their voice usage. The high occurrence of sulcus and other congenital-lesion suspicions, unusual in the general population consulting an ENT phoniatrician, seems to be rather specific for singers in agreement with the literature.

Predictors of Voice Therapy Initiation: A Cross-Sectional Cohort Study

OBJECTIVES/HYPOTHESIS

To determine predictors of voice therapy initiation.

STUDY DESIGN

Cross-sectional cohort study.

METHODS

All patients were evaluated in an interdisciplinary model at the University of Wisconsin Voice and Swallow Clinics between June 2016 and October 2017. Patients were eligible if they were diagnosed with a voice disorder and recommended for voice therapy as the only treatment. The dependent variable was attendance in at least once voice therapy session. Independent variables included therapeutic alliance, measured using the Session Rating Scale, and patient- and disease-related factors. These factors included gender, age, distance to the clinic, education level, household composition, occupational voice demand, Voice Handicap Index score, auditory-perceptual dysphonia severity (Grade, Roughness, Breathiness, Asthenia, Strain), and medical voice diagnosis.

RESULTS

Ninety-five patients were enrolled in the study. Voice therapy initiation rate was 70%. Having fewer school-aged children (5-18 years) in the household was significantly different between the group that initiated voice therapy and the group that did not (P = 0.048). There was no difference between groups for all other factors.

CONCLUSIONS

This investigation suggests that household composition, specifically having fewer school-aged children in the household, may predict initiation of voice therapy. This study confirms in a prospective fashion the absence of relationship between voice therapy initiation and most patient- and disease-related factors. Therapeutic alliance should be further investigated for its ability to predict voice therapy initiation using a measure that is validated for the population of patients with dysphonia.