For professional voice users

By Jason Mosheim

When Sherry Washington, MS, CCC-SLP, joined Cedars-Sinai Medical Center, in Los Angeles, CA, as the coordinator for speech-language pathology services 11 years ago, she felt that a certain local population was being underserved.

Legions of singers, actors, broadcasters, comedians and other performers reside in or around the entertainment capital of the world. While some thrive and some struggle, many have at least one thing in common: they don't always know how to take care of their voice. Preventative measures can help to keep their voices healthy.

When working with performers, the clinical staff of Voice and Speech Services, an outpatient program of the Cedars-Sinai Department of Rehabilitation, first tries to understand how they think, said Washington, who spearheaded the effort. "We take the judgmental aspect out of it. We look at what they need to do to keep working and try to understand the demands they face."

The speech-language pathologists on staff start out with a keen advantage. Most have backgrounds in singing and performing and have worked or continue to work as voice instructors.

"It's helpful if you have a performance background or knowledge in singing to provide care for this population. You have an appreciation there," said Washington, who has a background in singing.

An estimated 55 percent to 60 percent of the clients who visit the clinic are professional voice users. They generally fall into two categories, Joanna Cazden, MFA, MS, CCC-SLP, told ADVANCE.

"One consists of folks who have overuse or misuse issues that relate either to their singing or the demands of their day job. The other category includes people whose vocal techniques would be fine except for some medical issue that has affected their throat, such as thyroid surgery," said Cazden, who has a background in music, singing and theater arts.

Nodules are the most ubiquitous problem for performers. Other disorders include edema of the vocal cords, polyps and acid reflux.

Many vocalists also experience muscle tension from trying to compensate for other problems. "They try to sound good even though their vocal cords aren't working the way they should be," she said.

When Washington began looking into creating the Voice and Speech Services program, she formed an alliance with the Otolaryngology Department. Today, interdisciplinary collaboration remains the backbone of the program.

In addition to otolaryngology, the speech-language pathology staff works closely with the gastroenterology motility program to treat laryngopharyngeal reflux, a common ailment in singers and performers. Depending on their individual needs, patients also may be referred to physical therapy or neurology. Biofeedback therapy is provided under the guidance of a psychologist when stress management is a major contributor to the voice problem.

Another important professional to stay in touch with is the voice coach or singing teacher. This allows the clinician to balance treatment with the demands of the patient's performance or rehearsal schedule.

When a laryngologist initially diagnoses a professional voice patient in the Cedars-Sinai voice lab, the speech-language pathologist is typically available for consultation during the examination.

"It gives us the opportunity to collaborate right then in terms of the plan of care and get on the same page," said Washington. "We work with physicians who understand and appreciate the role of therapy and are not too quick to do procedures or recommend surgery."

Clinicians also discuss specific cases and research in quarterly laryngology and dysphagia meetings.

However, collaboration doesn't always exist everywhere outside the walls of Cedars-Sinai, said Karen Kochis-Jennings, MA, CCC-SLP, a staff clinician who has her own singing studio. "I wish there was more. Singing teachers are sometimes protective of their domain and perhaps a little fearful. Some of the research I'm doing involves laryngeal mechanics during singing. I want to pull the singing teachers into voice science so the patients get the best care."

In order to evaluate patients, voice clinicians at Cedars-Sinai perform an acoustic assessment as well as a videostroboscopic exam, which allows clinicians to analyze the vocal folds, examine laryngeal function and supraglottic compression, and interpret the characteristics of the vocal fold vibrations.

"I also take a good look at other aspects of the person's technique," said Cazden. "I'll look below the neck to see how they're breathing and standing. There may be a neck, shoulder or back problem that hasn't been addressed. I try to look at all the aspects and not just what's going on in their throat."

Speech-language pathologists need to determine whether a voice problem is related to the speaking voice, singing voice or both. It's important to obtain a thorough voice history and to observe individuals while they're singing and speaking to see if they are using proper breath support techniques, if any.

"Sometimes you run into problems where they have no vocal technique or breath support," said Kochis-Jennings, who specializes in non-classical voice. "Or maybe they've had inadequate training. For example, they may have been trained classically, but they sing hard rock, and the training is not crossing over."

The type of treatment that is provided depends on the diagnosis as well as the factors that contributed to the problem.

"Is it because of their schedule? Is it because of their day job? Is it because they haven't actually learned a technique that's adequate for the demands that they're under as a singer?" asked Cazden. "I try to look at what led up to the problem."

If the patient has not received proper training, the speech-language pathologist will work on basic techniques such as easy onset, relaxation and breath techniques. Even advanced singers may need to be rescued from the bad habits they've developed over time.

Professional voice users also need to develop good vocal health habits, including hydration and the avoidance of eating before bed, which can contribute to reflux. Smokers, drinkers and partiers may have to drastically curb their lifestyle.

"They need to warm up, tend to their diet and sleep schedule, and keep their body healthy while they're on the road," said Cazden. For example, performers who fly to engagements may benefit from taking a long shower when they arrive at their hotel to help recuperate from the dehydration effects of travel.

Most of the recommendations that speech-language pathologists have for performers regarding vocal hygiene are preventative, said Kochis-Jennings. "How can we change things and prevent problems from developing? We try to change usage patterns, improve hydration, control reflux, and tell them to get enough sleep. If someone has poor breath support, we want to optimize it before it becomes a problem."

The program places a strong emphasis on breath support techniques, Washington noted. "A lot of effort is put on exercises that deal with pitch and resonance; but as a foundation, there has to be a lot of work done on breath support and how to support the voice effectively in different types of vocal situations."

Working on breath support is not that easy, she acknowledged. Vocalists may have heard contradictory opinions about the "best way" to breathe, and patients without prior performance training can feel clumsy making changes in a process that seems so basic and instinctual.

"We are fortunate to have clinicians who have specialized, in-depth training in breathing approaches, such as the Fitzmaurice and Pavone methods, and who can offer a wide range of techniques to address each patient's individual needs," said Washington.

Vocal hygiene is almost always an issue in vocal fold nodules, which appear from improper vocal use. There are many ways to treat this problem, including relaxation exercises and laryngeal massage to release muscle tension.

"We can teach patients a voice technique like using resonant voice, which is bringing up the voice into the face or mouth," said Kochis-Jennings. "That reduces the impact stress of the vocal cords colliding."

If swelling is apparent but no nodules have developed yet, voice conservation is the next step. She has patients use e-mail more than the phone and asks them to avoid unnecessary talking.

Performers often have to play in less-than-perfect environments with inadequate sound systems or rehearse in small rooms where it is difficult to hear themselves. Both can result in vocal straining. Problems can revolve around how they use their voice, the conditions of the environment in which they use their voice, and how long they use their voice.

Still other performers use their voice for parts that aren't appropriate for them.

"A good voice therapist needs to realize that people can sing non-classical [styles] like rock, pop and jazz without harming their voice," said Kochis-Jennings. "People once thought that singers would ruin their voice if they sang those styles. That's not true. I've done it all my life."

Clinicians should not tell performers to change their style of singing because that's their "money maker." They are hired for sessions because they can do it. Therefore, the clinician either has to know how to do rehabilitative singing techniques with them or refer them so they can be taught how to do it safely.

The most important preventative measure for professional voice users is to take their instrument seriously, said Cazden. "They can't think that they can use it up and then go get a shot and get it fixed."

While she spent 10 years doing general speech-language pathology in hospital and university clinic settings, her current job allows her to keep working with artists and to fulfill an "intellectual curiosity." For clinicians who are singers and want to work in the voice field, she recommends a broad background in speech-language pathology.

"Don't be too quick to get a CFY if it's just in a voice clinic. Someday you'll be working with a singer who has a head injury, and you might want to have some background in that," she said.

Interested clinicians also should take singing or acting lessons in order to become familiar with the demands that are placed on individuals who use their voice for a living, Kochis-Jennings suggested. "If you're going to work with the professional voice population, immerse yourself in some of it because some of the therapy techniques, such as feeling the voice in the neck and breathing and relaxation exercises, come directly out of singing and theater."

Cazden stressed the importance of having an open mind.

"The subculture that a classical singer works in is very different than the lifestyle, subculture and terminology of a jazz or gospel singer or someone who recites Persian poetry in a formal setting," she said. "I'm honest with them in regards to what I do or don't understand about their background. It's like any other kind of cross-cultural communication."

In order to work successfully with professional voice users, clinicians need to have a good ear, Washington believes. "You have to be able to hear subtleties."

Is that a little more strain in the voice? What might be causing it? Where in the appropriate range are these individuals starting to feel tension in their voice? Are there smooth register transitions, or are they tense or have gaps? Are they carrying their chest voice too high?

"Technology has transformed the field of voice therapy; but to be comfortable with voice, you still have to be comfortable with your ear," she said.

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