Ask the Expert
CSD - Preventing Voice Injury : Katherine Verdolini. PhD
We’ve all experienced the extreme discomfort that comes from using our voices too much. For years the conventional remedy for an overused voice has been rest; like the cures to many injuries. The thinking went, immobilization would lead to recovery. But research by Dr. Kittie Verdolini , professor, Department of Communication Science and Disorders , is beginning to suggest that, in some cases, a more counterintuitive approach may work best to promote healing. Rather than rest the voice, Verdolini’s research is showing that the best healing may sometimes come through use.
Verdolini offers insights into what people can do to prevent voice injury and describes the paradigm shifting research that she and others in the department have conducted that can help heal a wounded voice.
Q: What are some of the most common steps – aside from the obvious – that people can take to avoid injuring their voice?
A: One of the most important things people can do is to not “push” their voice beyond what is generally comfortable – and certainly not for extended periods of time. This principle is relevant for both speech and singing, and it’s importance increases when people have a cold or other upper respiratory tract condition. Having said this, there are ways to learn to use the voice so the range of what is comfortable and safe increases.
Many of these approaches to using the voice safely have come to us through the performing arts. One approach that we’ve studied extensively is “resonant voice,” a technique that involves vibratory sensations in the front of the mouth while talking or singing.
Q: How can people with careers that are highly demanding on their voice reduce the impact of overuse?
A: There are several steps that can be taken to avoid damaging the voice. First, it is important to take into consideration the acoustic environment in which they are producing voice. Is it noisy? Does sound project well or is it damped by carpet or other materials? Is it dry? People who consistently work in a given environment may be able to take steps to optimize it for long-term voice use but the first thing is to know their environment. For teachers, one effective option is to amplify their voices.
Another principle is one we mentioned above: Pay attention to the “comfort level” of your voice. If you are feeling physically uncomfortable, try changing something such as pitch, loudness, or quality – even if only slightly – to see if the discomfort improves.
If necessary, seek professional evaluation and training by an ear-nose-throat specialist and speech-language pathologist or, if there is no concern about an obvious challenge and the individual just wants to prevent one from occurring, I would advise to work with a theatre or singing voice and speech trainer to develop techniques that can work well on a case-by-case basis for the individual.
Q: Your most recent research centers on the premise that some forms of vocal stimulation may be more effective healing mechanisms for voice injury compared to rest. How did you and your team of researchers reach this initial hypothesis?
A: As occurs often in research, the hypothesis was originally generated entirely by chance. I had been working clinically and intensively with numerous patients with Parkinson’s disease and part of their recommended treatment involves training to speak “loudly.” In doing so, I was speaking loudly for hours every day. This, compounded by the fact that I also often taught three-hour lecture courses in large lecture halls in the evenings, lead to vocal loading, a condition that results from overuse. I was hoarse and had swelling in my vocal folds. At the same time I was scheduled to have a classical singing lesson that night. Unable to cancel, I went to the class and despite a slow start, as the lesson progressed my voice progressively improved. I was amazed! By the end of the lesson I was not only completely recovered, my voice was crystal clear and my high notes were soaring. After several weeks of this, I realized the initial result was more than just a fluke. After anecdotally sharing the experience with a biologist friend, I realized that the mobilization had led to the reduction in inflammation and not soon after we began to prepare and conduct our research.
Q: What types of studies did you conduct to confirm that your suspicions about voice stimulation as a remedy for voice injury were true?
A: The study we conducted that lead to most of our key findings started with the examination of throat (vocal fold) secretions before and after a period of “vocal loading,” or loud voice use. Specifically, we had our test subjects go through what would be the equivalent of an hour-long lecture and then we broke down the sample group into three post-lecture treatments randomly assigned: one that allowed subjects to speak at-will, another that forced them to remain silent and a third that engaged them in resonant voice exercises voice drills derived from classical singing.
We found that while the group that rested their voices improved at 24 hours compared with immediately post loading, those who participated in the resonant voice exercises recovered 100 percent and then some – they actually showed improvement in the health of their vocal folds compared to baseline, before they even engaged in the vocal loading. Specifically, those who engaged in voice rest had reduced inflammatory mediator concentrations in the their vocal fold secretions compared to concentrations right after loading, although at 24 hours they had not yet recovered to baseline values. Those who did resonant voice exercises had inflammatory mediator concentrations that were not only improved compared to post loading, they were even better than before they used their voices strongly in the first place! Subjects who spoke normally during the recovery period were generally still inflamed 24 hours later.
Q: How has this new approach to voice therapy been received by your peers and has it begun to be adopted by practitioners in the industry?
A: Initially, I believe there was some skepticism. But the skepticism was largely limited to just within the speech-language pathology community. Performing artists generally nodded their heads and said, “Absolutely. That’s the cool-down effect. You have to cool down after performing by doing these kinds of exercises.” However, voice clinics around the country are being run more and more by speech-language pathologists (and otolaryngologists) who have background in the vocal performing arts. In addition, they are generally not shy about training people to use their voices loudly, and now, with our new data, they are getting more excited about the prospect of using certain voice exercises as part of an actual treatment program.
However, one important caution is that not just any voice use will do, as we saw in our experiment. The key to success seems to be voice exercises that involve large-amplitude but small-impact vocal fold oscillations, as generally occurs in resonant voice. Also, we don’t currently have a sense of what the ideal “dosing” of the treatment should be. We’re working to get answers to this question, but we’re not there yet.
Q: How do you see this new approach impacting people with careers that put great stress on their voice, such as teachers and professional vocalists?
A: Both our data and clinical experience suggest the value of using resonant voice exercises in the treatment of existing voice problems in teachers and others who use their voices professionally. Interestingly, some of our very recent data suggest that more general “vocal education” or “voice hygiene measures” such as not smoking, drinking plenty of water, avoiding spicy foods, not yelling with a cold or flu and others, may be sufficient to prevent voice problems in young teachers with resonant voice training adding little to the protective effect especially in the beginning of teaching. However, those data are preliminary, involving only about 30 subjects followed over a maximum of just a few months. We’ve submitted a grant to the National Institutes of Health (NIH) to examine whether the same results are obtained in a larger series, with two-year follow-up. That study would be conducted in Pittsburgh and Hong Kong.
Q: What other research have you been working on that ties into this new line of thinking about voice therapy?
A: One area is the piece I pointed out above – looking at the value of these exercises for prevention of voice problems. Another area of interest is related to an NIH grant involving vocal fold wound healing using physical models of phonation, high-speed imaging, and computational modeling of vocal fold inflammation. We are very excited about that series and we hope it will generate meaningful results that will make a serious contribution to clinical knowledge. We’re working with some very well known researchers for this study, among them Dr. Luc Mongeau from McGill University, Dr. Thomas Siegmund from Purdue University, Dr. Yoram Vodovotz from the University of Pittsburgh, Dr. Clark Rosen and Dr. Tom Carroll from the University of Pittsburgh Voice Center and Nicole Li from my lab who will soon receive her doctorate.