ISSN:2240-2594

Background: Professional singers must become aware of their vocal behaviour so that they can prevent the occurrence of problems likely to  negatively interfere with their profession.
 
Objectives: The aim of our study is the prevention of occupational dysphonia.
 
Methods: The sample was subjected to phoniatric visit, fiber optic laryngoscopy, MSHI (Modern Singer Handicap Index) and CSHI (Classical Singer Handicap Index) questionnaires, MDVP (Multidimensional Voice Program).
 
Results: The analysis of the data obtained makes it possible to quantify the awareness of the singer on the risk associated with the vocal effort required by his profession.
 
Discussion and Conclusion: Integration of phoniatrician, speech pathologist and voice teacher skills cooperate toward a common objective for the prevention of disorders related to professional singing.


Background
Professional singers, during their professional activities, do not always put attention to risk factors for vocal effort that can often be responsible for diseases that may affect voice hence their vocal performance.
 
Objectives
The aim of our study is the prevention and treatment of occupational dysphonia. The survey is aimed at sensitizing the professional on the importance to undergo periodic inspection by the physician and speech pathologist for integration of medical counseling and progress of singing exercises.
 
Materials and Methods
The study has been developed at the Complex Operative Unit of Phoniatrics of the Policlinico Umberto I University Hospital in Roma.
 
Firstly an informative questionnaire was elaborated and distributed to 84 professional singers.
 
The questionnaire is divided into 4 principal areas containing specific questions regarding:
v  General data on the performer;
v  Information on his/her health;
v  Information on the vocal behaviour;
v  Extra-professional activities.
 
The questionnaire was sent by email to Conservatories, Music Academies and singing teachers.
We enrolled 84 singers, of which 30 males and 54 females; 43 singers were under 35 years, 41 were over.
Genres found are as follows (Table 1) (1):
 

Table 1 - Vocal classification of the sample.
 

VOCAL CLASSIFICATION	RESULT	RATE
SOPRANO	24	28,5%
MEZZO-SOPRANO	13	15,5%
ALTO	17	20%
TENOR	16	19%
BARITONE	9	11%
BASS	5	6%

 
 
v  Lyrical;
v  Classical/polyphonic;
v  Jazz, Soul, Gospel;
v  Pop;
v  Rock.
 
We have also administered Classical Singer Handicap Index (CSHI) and Modern Singer Handicap Index (MSHI) (2), to value self-perception by singers.
68 singers completed these questionnaires, 16 failed to the compilation.
We proposed phoniatric control, fibrolaryngoscopy and spectroscopic analysis of the voice with MDVP (Multi-Dimensional Voice Program) (3, 4) to all singers that completed the questionnaires.
 
Results
50 out of the enrolled 84 professional singers underwent phoniatric visit.
We consider as risk factors respiratory diseases, allergies and GERD and we observed that (graphic 1):
v  29 singers were affected by respiratory disorders;
v  27 singers were affected by allergies;
v  20 presented GERD (GastroEsophageal Reflux Disease)
Singer’s life style is also important (5) and other risk factors considered were smoke and alcohol (graphic 2):
v  22 singers smoked regularly;
v  13 drank alcohol.
 
 
Graphic 1- Respiratory disorders, allergies and GERD in the sample


Graphic 2- Smoking and alcohol used in the sample.

 
Regarding their vocal training, 79 singers attended regular singing lessons, 5 described themselves as self-taught.
33 singers referred to be joining sessions of vocal efforts shorter than 1 hour; 37 referred vocal efforts longer than 1 hour; 14 could not  quantify the duration of their exercises (graphic 3), 73 subjects used to accustom gradually to vocal efforts before the vocal training sessions. Only 9 singers performed cool-down after the exercises.
47 singers perceived a vocal change after their vocal exercise, qualifying in positive and negative effects.
 
Positive effects are:
v  Full and clear voice ;
v  Improved timbre of voice;
v  Voice with more harmonics;
v  Greater ability to diversify the dynamics of the song;
v  Enhanced voice.
 
Negative effects are:
v  Decreased voice;
v  Hoarse voice;
v  Muffled voice;
v  Falling tones;
v  Falsetto.
 
 
Graphic 3- Singing lessons, vocal rest and cool-down exercises in the sample.
 
 
33 subjects perceived shortened breath and needed to refuel often inspired air; 51 perceived breathing enhanced enough to carry on long sentences.
50 patients referred hoarse and muffled voice after the performance.
Among singers, 44 believed to be accustomed to speak at high vocal volume and 45 affirmed to be forced to talk in noisy and large environments.
Results refers that 15 singers were subjected at least to one  phoniatric visit and 12 of these required a speech therapy.
 
Regarding results of the MSHI and CSHI, subdivided into 3 areas (functional, emotional and physical) we can report the findings (Table 2-3).
16 singers haven’t completed these questionnaires.
 
 
Table 2 - Number of singers, divided according to the scores obtained for each partial area MSHI and CSH.
 

SUBSCORES	FUNCTIONAL AREA	EMOTIONAL AREA	PHYSIC AREA
0	22	25	19
1-5	36	31	27
6-10	7	8	10
11-15	3	2	5
16-20	0	1	2
21-25	0	1	2
≥ 26	0	0	3

 
 
Table 3 - Number of singers divided by the total MSHI and CSHI score.
 

TOTAL SCORE	SINGERS
0	10
1-5	18
6-10	17
11-15	10
16-20	4
21-25	3
≥ 26	6

 
 
Discussion
Analysis of the questionnaire data makes it possible to clarify how a singer becomes aware of  his/her occupational risk and of the effort associated with speech.
It should be emphasized that almost all of the subjects in the sample have another work so as to rely on a stable source of income, besides the gain resulting from their artistic profession.
Risk factors, such as respiratory disorders present in 34.5% of the sample, allergies in 32%, GERD in 24%, smoking in 26% and use of beverages with alcohol content in 15%, are often associated and simultaneously present in some subjects, exacerbating the framework of risk.
Almost the entire sample, (94% of subjects), continues to attend singing lessons, ensuring continued didactic support to the profession. Only 6% self-described as autodidact and deals with the profession without a personalised preparation. The daily time devoted to the study of vocal technique, was less than 1 hour for 39% of the sample, for 44% equal to or greater than 1 hour. For the remaining 17% the time length of their exercise varied without the possibility to be more accurate.
It was also difficult to quantify an average daily exposure to the use of the voice including performances and study, as the variation of  commitments or salary changes like the duration of vocal use does.

Vocal training, in 87% of the sample, is preceded by specific warm-up exercises, important to:
 
v  improve phonation;
v  increase elasticity of the vocal fold mucosa;
v  reduce effort and vocal tract constriction;
v  contribute to a broader resonance.
 
Only 11% of the sample started the exercise of voice training without any warm-up, important to promote a faster recovery after an overdrive.
Considering that dysphonia can depend also on daily speech, it was reputed important to pay attention to the sample responses about their habits in daily talk. 52% reported of using a high volume of voice during speech for reasons related to the type of work or for personal habits which would exclude underlying causes. 53.5% daily attended large and/or noisy environments inducing to this attitude. The habit of turning up the voice volume is an attitude characterized by a vocal effort which, added to the vocal stress due to their profession, exposes the subject to a greater risk than the vocal pathologies.
Another fact which highlights the importance for vocal professionals to be sensitized to the prevention, is the observation that only 18% of the sample had  at least once  a phoniatric visit and 14% of these were followed by a Speech Therapist.
This study confirms that  MSHI and CSHI questionnaires are appropriate for assessing self-perception and provide a significant contribution to the diagnosis.  MSHI and CSHI questionnaires have not been completed by the whole sample. Singers who completed the compilation of these surveys were 68. 81%. This is important since it allows us to deduce that a percentage of the sample showed no ability to quantify self-perception of their voice in the artistic context.
Analysis of the scores obtained by completing MSHI and CSHI questionnaires, reports that the prevalent score is between 1 and 5 points. This fact does not show any particular tendency to think that their voice would be compromised. This score was obtained from 18 singers (26%). The partial scores are included between 1 and 5 points in every area of the questionnaires. The emotional area has the lower score (ie equal to 0), that shows how the condition of singer’s voice is experienced without any emotional / psychological tension. These data are present in 25 subjects (37%). On the contrary, the score that showed a significant impairment, equal to or greater than 26 points, is present in the physic area in 3 subjects, equal to 4.4% of the sample.
The scarcity of the scores, however, is explained by considering that these questionnaires assume a problematic voice, absent in the singers observed.
Concerning the phoniatric visits, we did not observe any pathological findings. It should be underlined, however, that during the examination in fibro-laryngoscopy,  in almost all singers, and mostly in those of younger age, it was demonstrated  a neglect of the vocal apparatus, and the need for further information and clarification.
Let us now consider the information emerged from vocaligrams, taking into account  parameters considered indicative.
The parameter most affected appears to be the Shimmer. It was altered in 23.8% of vocaligrams. The average value found was 4.569%, compared to the threshold value of  3.810%. Value of the parameter vF ° was found to be altered in 4.7% of the total vocaligrams carried out, with an average value of 1.426%, compared to the threshold value of  1.1%.
The value of the ShbD was  found to be altered in 19% of vocaligrams, with an average value of 0.413 dB, compared to the threshold value of 0.350 dB.
Either values of the parameter Jitter, the value of the parameter NHR, were found to be perfectly within the limits of the threshold values.

Conclusions
It is required a combination of medical knowledge and teaching skills for health protection . Professional singers must necessarily become aware of their vocal behaviour so that they can prevent the occurrence of problems that may negatively interfere with their profession, and the risk of vocal effort is certainly among the most important.
It is therefore essential that the support given to professional singers from the medical speech pathologist and the speech therapist is not experienced as an interference in the singing teaching process, but as a support that would allow the reliability of voice as an instrument of personal gratification and as a tool of professionalism.
It is essential that the medical intervention is  considered important not only in the treatment of any disease, but in preventing its occurrence, in the management of the singer's voice and driving towards a more conscious management that allows the enhancement of individual skills.
It is therefore necessary that the knowledge of teaching and medicine are united one to the other, so singers will always be able to adapt their voice in different situations. It is indispensable to eliminate the conflict between the singing pedagogy and medicine; conflict that is based on the concept of intrusion into different fields, so as to reach the necessary and indispensable cooperation. The intervention of the physician and speech pathologist will be aimed at guiding the professional singer towards:
• a use of an as economical as possible mode proportionate to the commitment required;
• a respect for rules of vocal hygiene towards a protection from abuse;
• a vocal attitude  minimizing the risks of overwork;
• a self-awareness of voice control;
• a self-perception of effort/vocal abuse and self-protection.
The desirable prospect is an interaction between voice teachers, speech therapists and phoniatricians so as to boost interest and attention for singers, which make of voice their only instrument of expression.
 
 

References

1. Thalen M, Sundberg J. Describing different styles of singing: a comparison of a female singer’s voice source in Classical, Pop, Jazz and Blues. Logoped Phoniatr Vocol 2001; 26 (2): 82-93.
2. Fussi F. La voce del cantante III volume. Omega Edizioni, Torino, 2005.
3. Di Nicola V, Bellotti R, Fiorella ML, et al. Multi-Dimensional Voice Program (MDVP). Introduzione e metodologia. Acta Phoniatrica Latina 2002; 24: 94-104.
4. De Colle W. Voce & Computer- Analisi acustica digitale del segnale verbale (Il sistema CLS-MDVP). Omega Edizioni, Torino, 2001.
5. Fussi F, Magnani S. L’arte vocale-fisiopatologia e riabilitazione della voce artistica. Omega Edizioni, 2000.

 
 

Corresponding Author: Mario Fabiani
Department of Sense Organs, “Sapienza” University of Rome, Italy
e-mail: info@preventionandresearch.com 
 

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