To You and Your Students’ Good Health: Q & A Column 2023

Compliments of the CMS Committee on Musicians’ Health

The Musicians’ Health Committee, comprised of medical professionals and music faculty, all strong advocates for musicians’ health, is happy to bring you a Q & A column for this month's CMS Newsletter. If you like this idea, please send us your musicians’ health-related questions which we will direct to our committee members, or other professionals with whom we have contact, to be answered in future newsletters. Linda Cockey and, Heather Malyuk Committee Co-Chairs.

June 2023

Q: “How can I help a student monitor their vocal load to ensure vocal longevity?” 

Answered by Theresa Brancaccio, M.M. Northwestern University. As a recognized “Master Teacher” of singing by the National Association of Singers of Teaching, Theresa Brancaccio (she/her) has over 40 years of teaching experience and 30 years as a performer. She has been a member of Northwestern University’s Voice and Opera faculty since 1999, where she teaches voice, vocal pedagogy and oversees the Voice Lab. Passionate about vocal health maintenance, she created a voice-budgeting system, Singer Savvy (SingerSavvyApp.com) in 2017 and is currently developing the first wireless dosimeter and app system which gives real-time feedback, tracking and notifications. Her team’s article, Closed-loop network of skin-interfaced wireless devices for quantifying vocal fatigue and providing user feedback was recently published in The Proceedings of the National Academy of Sciences. 

A: There are many ways both teachers and students can monitor vocal load to ensure vocal longevity. Outlined below are areas for both the teacher and student to consider in monitoring vocal overloads along with a list of tips to lighten vocal loads as well tracking tools with newly developed apps to use.

FOR THE TEACHER:

VOCAL LOAD - Vocal load is the cumulative stress on the vocal fold tissue caused by vibration in speaking, singing, coughing, throat-clearing, etc. High vocal doses can result in vocal fatigue and/or injury as well as negative muscular compensatory behaviors. Symptoms of high dose stress include reduced endurance or flexibility, breathy or husky tone, vocal instability, loss of range and throat discomfort in and around the larynx. 

FIRST GET THEIR HISTORY - Before training a student, it’s important to establish a good sense of who they are and what influences have shaped them and their instrument to date. By having them fill out a questionnaire and discuss their history and habits (see below), the teacher can identify issues that may need to be addressed.  

The student’s responses regarding their vocal health, personality, lifestyle, and activities will give the teacher clues about whether they are an infrequent, occasional or frequent “heavy vocal loader”. Additionally, the student’s health history and habits will indicate whether they are more susceptible to the negative effects of heavy vocal use. 

Students need not disclose their medications to the teacher, but should be encouraged to explore the NCVS website to check for potential interactions with the voice: https://ncvs.org/prescriptions/

Vocal Health History

• Vocal Fatigue
• Vocal fold lesions
• Laryngitis
• Reflux
• Asthma
• Allergy
• Sinus issues
• Throat/neck pain
• Pre-menstrual syndrome intensity
• Other medical issues (if they wish to disclose)

Lifestyle

• Hydration
• Caffeine
• Alcohol
• Smoking
• Vaping

Personality

• Talkative- outgoing
• Quiet- introverted
• Partygoer
• Sorority/Fraternity member
• Response to stress

Past and Present Musical Activities

• Choir
• Solo practice
• Musicals/Opera
• Contemporary singling (pop/rock band, etc.)
• Theatrical plays
• Acapella groups

Other Past and Present Activities

• Sports
• Clubs
• Cheerleading
• Teaching
• Jobs

FOR THE STUDENT: 

DAILY SELF ASSESSMENT - Do “swell checks” each morning and evening to assess how your voice is functioning. Vocal Cord Swelling Checks Laryngopedia by Dr. Robert Bastian is a good resource.  

Performing two easy exercises (see below) can expose abnormalities in the mucosa of your vocal cords. In addition, softly practicing ascending and descending glides can help you determine your typical vocal range on “good days” and identify when something is concerning. If you notice your ceiling pitch is lower than usual, take note of how many half-steps it has decreased and adjust your vocal load accordingly. It’s best to be cautious and decrease your vocal load more significantly if you notice a decrease of one whole step or more in your ceiling pitch. 

Swell Check Part 1- In your upper voice range, sing only the first phrase of “Happy Birthday” as softly and as legato as you can. Do not “make it work” by getting louder. Repeat the phrase at progressively higher pitches by ½ steps and keep going up until the note at which you experience delays in onset of sound, air escaping, or you just can’t go higher without singing louder. This note is your *ceiling pitch.  

Swell Check Part 2- Sing short, quiet staccato tones use the descending figure so-so-so-so-so-fa-mi-re-do, on any vowel attacking each note buoyantly.  Repeat the phrase at progressively higher pitches by ½ steps and keep going up until *the note at which you experience delays in the onset of sound, air escaping, or you just can’t go higher without singing louder. This note is your *ceiling pitch. 

HOW TO LIGHTEN YOUR VOCAL LOAD: 

• Scan and Plan: Scan your calendar by day, week, and month to note when unavoidable voice events are scheduled close together.
• Spread Things Out When vocal commitments are stacking up (performances, choir rehearsals, opera rehearsals, voice lesson, coaching, teaching, practice sessions, social events) arrange and rearrange events, when possible, to allow for space in between. For example, don’t schedule your voice lesson on the same day as your choir rehearsal. 
• Speak Well Speak with engaged support, resonance, varied pitch, and varied dynamics. 
• Don’t Scream unless someone’s life is in danger. 
• Reduce speaking to essential conversations. 
• Eliminate Extras For instance, consider if it’s truly necessary for you to participate in the extra-curricular acapella group.  
• Voice Naps Schedule at least 15-20 minutes of total quiet multiple times throughout the day. 
• Take a Raincheck Decline social events after a day of heavy voice. 
• Avoid Loud Environments They can cause you to strain your voice in an attempt to speak loudly enough to be heard. 
• Mark Don’t sing at full volume/full voice all the time in rehearsals.  
• Chunk It Practice in 2-4 smaller sessions instead of one long session. 
• Don’t Push Through Illness When illness has affected your vocal folds and throat, pulling back voice use as soon as symptoms of swelling appear can save you from a longer recovery time. 
• Avoid Coughing Hard When ill, try a non-voiced “huff” to expel mucous. 
• Avoid Extended Whispering Prolonged whispering is fatiguing to the muscles in and around the larynx and not good for vocal fold posture.
• Write Instead For complete vocal rest, use a small whiteboard instead of talking. 
• Text Instead Type messages instead of talking. 
• Use Amplification When teaching or lecturing large groups, use a personal amplification system. 
• Technical Adaptability For instance, request help from your teacher to learn how to transition from singing in a healthy operatic style to producing a healthy straight-tone, as may be necessary for some choral literature.  
• Weightlifters Those who do weight training need to valve with the lips, teeth and/or tongue, instead of grunting. 
• Warmups Stretch vocal folds early in the day with SOVT exercises, humming and glides. 
• Cool Down At the end of the day, try SOVT exercises such as gentle, descending glides and blowing bubbles with a straw into a water bottle while lightly phonating. 

Mindfulness is key to maintaining vocal health and a skill that should be instilled early in a singer’s training. Habit tracking is a proven method toward increasing mindfulness and inspiring positive behaviors.

TRACKING TOOLS:

Journaling daily activities is one way for a singer to develop awareness of how much they are using their voice and under what circumstances they notice fatigue or voice changes. 

Singer Savvy App: singersavvyapp.com is a free web-app I designed. It guides the singer in assessing their vocal condition, calculates a daily budget and has them log every voiced event in their day. Vocal task points are reflected in a “budget bar” for the singer’s reference. The app shows trends in their vocal condition and other tracking statistics in 8 graphs over days, weeks and months. It can help connect the dots between knowing what’s good for them and doing what’s good for them.  

In Development: A wireless dosimeter-app system is currently in development at Northwestern University. This novel system uses a soft, small, wireless dosimeter worn at the top of the sternum and connected by Wi-Fi to a smartphone app. This application will give real-time visual feedback on the user’s vocal load split into two categories: speaking and singing. It will display the total amount of vocal load accumulated daily and weekly, along with other qualitative vocal measurements. The app will enable the user to calibrate their voice budget each day and reminds them to pace their voice appropriately with haptic notifications when they approach specific thresholds. 

April 2023

Q: “What should performing arts clinicians and instructors know about Black or Indigenous People of Color (BIPOC / IPOC) [1] performers and some of the challenges they face?”

Answered by Dr. Sims (pronouns: he/him).

Dr. Sims (pronouns: he/him) is the director of the Chicago Institute for Voice Care at the UIC Medical Center in Chicago. He is a board-certified laryngologist who chose a career in professional voice care as an extension of his two passions, medicine and singing. A graduate of the Yale University School of Medicine, H. Steven Sims, MD completed a clinical fellowship at the Vanderbilt Voice Center and is a current appointee of the National Institute on Deafness and Communication Disorders Advisory Council with the National Institutes of Health. He is also an accomplished musician who plays trombone, bassoon, and piano. While an undergraduate at Yale University he was a choir member and is an experienced vocalist as well.

A: The awareness of differences suggests that we already understand the crux of the issue. Whether we like it, agree with it, or not, we have all grown up in a system that views the societal construct of race as an important determinant.  People have developed identities around race that are very real, even though the concept has no genetic basis.  It is important to recognize that even though performers are a part of the culture of performing arts, they also bring their racial and ethnic identities to their respective fields.  Bias and discrimination are also witnessed in these fields, and we need to recognize this influence and face the fact that the same systems that plague people of color most visibly also affect everyone, regardless of race.

A few basic points to consider:

1. Race is a social construct with no logical basis and inherent contradictions.  It is not entirely real.  However, racism and bias promotes a system designed to advantage some while disparaging and denigrating others and it is excruciatingly real.
2. Racism is not the shark in the water, it’s water–Kyle ‘Guante” Tran Myhre
3. Racism has an inertial force so challenging it, according to the laws of physics, requires oppositional force and energetic action.  We cannot change things by watchful waiting and serendipity. 

Basic Background about Race and Racism:

Zinzi Bailey explains structural racism as the totality of ways in which our society nurtures and perpetuates discrimination based on the social construct of race.[1] She notes the mutually reinforcing systems of housing, education, employment, wages and wealth, criminal justice, and healthcare.  Historical and current patterns, practices, policies, and metrics in turn, reinforce discriminatory beliefs and this belief system dictates the allocation of resources, our value system, and all of this sustains disparate outcomes. 

Some examples for the general population disparities:

• Higher infant mortality [2, 3]
• Higher instances of primary school discipline (pipeline to prison) [4-7]
• Lower school funding (property tax bases, disparities based upon property values)
• Redlining and deprivation of communities with the consequence of lower property values (Homeowners Loan Corporation-HOLC) [8, 9]
• Lower high school graduation rates (often related to disciplinary events)
• Lower college matriculation (often related to socio-economic status tied to property values)
• Lower college graduation rates
• Less hiring and viable job opportunities
• Lower salaries
• Less access to healthcare and employment benefits (even social security initially was not meant to apply to service workers which was the primary industry of African Americans at the time)

Specific examples of disparities in the Performing Arts field:

• Disparities in college degrees [10]
• Disparities in hiring that is related directly to educational background
• Disparities in available acting roles (this includes actual acting roles, but also roles in the industry such as composers, directors, costume designers, stage management, tour management) See the Asian American Performers Action Coalition:  Visibility Report from 2021
• Disparities in opportunities: Artists are often narrowly defined by musical genres and not considered for roles deemed to be outside of that classification.
• Disparities in access to healthcare: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” —MLK

In my capacity as a musician, vocalist, songwriter, and physician, I witness these disparities in practice.  I often see artists who have been advised that they need to “give up” a musical style like Gospel, or Blues if they want to be a “serious” performer.  I lament our current system of healthcare when I prescribe an appropriate medication, but the patient’s insurance doesn’t cover it, so we must find some sort of alternative because it always feels like there is a compromise of care.  When I see a patient who is working gig-to-gig, I am always mindful that they may not be able to afford follow-up, so I need to be as complete in the information and a plan as possible.  Each encounter I have can feel like a moral injury because I know that patients deserve a better healthcare enterprise.  I always appreciate it when a patient thanks me for really listening to them, but I also lament that this is particularly noteworthy, rather than the norm.  Everyone desires to be completely seen and heard.

So, music pedagogues and general advocates with an appreciation of the depth and breadth of systemic bias may help clients maintain both their sanity and their resolve. A comprehensive acknowledgement of structural, systemic, historical, and current bias is a beginning of well-being for its victims.

In my work with MusiCares (the philanthropic program run by the National Academy of Recording Arts and Sciences to help fund struggling artists), I have seen a number of patients who, otherwise, would not have had access to any healthcare.  Many are paid by the gig and have limited access to sick days, paid time off and health insurance.  It is much more likely that a performer of color will make a living outside of Actor’s Equity of SAG/AFTRA and that they will have less access to the insurance programs sponsored by these organizations. The systems were often conceived in privilege (whether intentional or implicit), and often function to perpetuate disparities.

Some tips to help level the circumstances (See Figure 1). The level is multidimensional and requires a balance of perspectives.

Listen to the voices of others with humility and a sincere attempt to gain perspective. We can all benefit from one another, building authentic community.  When your clients or students share their narratives, become an active listener, not a judge.

Evaluate our spaces, particularly the case of casting directors, committees, and other decision-making bodies, for diversity. Does the makeup of the group, committee, or cast reflect the population it is representing or seeking to engage?  Are we considering diverse performers for all available roles?  

Vocalize when we recognize that our spaces lack diversity. When we see auditions posted, we can ask, "who will be represented _______ in this performance?”  The voice of a cis-gendered, White, Christian, heterosexual male is absolutely valued and necessary.  However, we must simultaneously understand and embrace the inherent benefits of diverse perspectives for decision-making, leadership, and creativity.

Emancipate our minds: identify and begin to consciously choose different thought patterns.  If we can begin to free our minds, much of the rest will follow.

Learn to recognize systemic barriers which contribute to the current lack of diversity in the performing arts field.  This short piece is meant to raise awareness and to prompt inquiry and investigation.

Figure 1.

References

1. Bailey, Z.D., et al., Structural racism and health inequities in the USA: evidence and interventions. Lancet, 2017. 389 (10077): p. 1453-1463

2. Kirby, R.S., The US Black-White Infant Mortality Gap: Marker of Deep Inequities. Am J Public Health, 2017. 107 (5): p. 644-645

3. Cote-Gendreau, M. and K. Donnelly Moran, Geographic heterogeneity in Black-white infant mortality disparities. Front Public Health, 2022. 10: p. 995585

4. Sabol, T.J., et al., A window into racial and socioeconomic status disparities in preschool disciplinary action using developmental methodology. Ann N Y Acad Sci, 2022. 1508 (1): p. 123-136

5. Davison, M., et al., School Discipline and Racial Disparities in Early Adulthood. Educ Res, 2022. 51(3): p. 231-234

6. Barnes, J.C. and R.T. Motz, Reducing racial inequalities in adulthood arrest by reducing inequalities in school discipline: Evidence from the school-to-prison pipeline. Dev Psychol, 2018. 54 (12): p. 2328-2340

7. Hemez, P., J.J. Brent, and T.J. Mowen, Exploring the School-to-Prison Pipeline: How School Suspensions Influence Incarceration During Young Adulthood. Youth Violence Juv Justice, 2020. 18 (3): p. 235-255

8. Namin, S., et al., Persistence of mortgage lending bias in the United States: 80 years after the Home Owners' Loan Corporation security maps. J Race Ethnicity, 2022. 3(1): p. 70-94

9. Nelson, R.K., et al., Mapping inequality: redlining in New Deal America. 2015, University of Richmond. Digital Scholarship Lab: Richmond, VA

10. Cabrera, N.L., J.D. Franklin, and J.S. Watson, Whiteness in higher education: the invisible missing link in diversity and racial analyses. ASHE higher education report. 2017, Hoboken, NJ: Wiley Subscription Services, Inc. 136 pages

Additional Resources:

Kyle Guante Tran Myhre, "How to Explain White Supremacy to a White Supremacist” https://www.youtube.com/watch?v=DbwcXDunxA8
Asian American Performer Coalition:  The Visibility Report 2018-2019. http://www.aapacnyc.org/2018-2019.html
MusiCares  https://www.musicares.org/

February 2023

Q:“What is World Voice Day and how can teachers get students involved so they can be educated on the benefits of maintaining good heath?”

Answered by Rachael Gates, DMA, Singing Health Specialist and Sri Nandamudi, Ph.D., CCC-SLP, FNAP

Soprano, Opera Director and Singing Health Specialist, Dr. Rachael Gates has sung in Germany, Russia, Italy and throughout the United States. She has taught at Northwestern University, The Hartt School of Music, Yale University, Michigan State University, and currently teaches Voice and Pedagogy at Grand Valley State University. She is the voice specialist for the College Music Society Committee on Musicians' Health and is published in the NATS Journal of Singing. Her book, The Owner’s Manual to the Voice (Oxford) is available on Amazon and at The Metropolitan Opera Shop. Srihimaja Nandamudi, is Assistant Professor in Speech-Language Pathology in the Department of Communication Sciences and Disorders at the College of Health Professions, Grand Valley State University, and specializes in voice, upper airways, and swallowing disorders. She is an ASHA certified speech-language pathologist (CCC-SLP). She completed her PhD in Communication Sciences and Disorders with a specialty area in voice and speech science at Bowling Green State University. Her dissertation focused on acoustics and aerodynamics of vocal vibrato in Western classical singing. She has over 8 years of clinical-pedagogical experience working and collaborating with vocal performers on interprofessional voice intervention.

World Voice Day is a global annual event which occurs on April 16th to acknowledge and celebrate the phenomenon of voice. The goal is to create awareness, prevent voice problems, seek help and training, and support research on voice. Singers, actors, voice instructors, speech-language pathologists, laryngologists, audiologists, psychologists, acousticians, body mapping technicians, biomechanical engineers, pulmonologists, neurologists, and oncologists come together all over the World to share talents, concerns, and disseminate information.

A group of Brazilian voice teachers, scientists, and medical professionals with a shared interest in growing the public’s awareness of voice issues and research celebrated the first “Brazilian National Voice Day” on April 16, 1999. Professional voice users and clinicians in other countries quickly followed suit and April 16 became “International Voice Day”. Then, in 2002, the American Academy of Otolaryngology – Head and Neck Surgery officially recognized the growing initiative and renamed the event “World Voice Day”. Now, every April 16, free interdisciplinary vocal events are scheduled and offered through voice clinics, universities, conservatories, and other venues. A WVD program may include a Shakespeare soliloquy and traditional Indian singing, followed by a free hearing check. Another might feature video footage of vocal adduction captured in real time with high-speed imaging, or healthy techniques for Public Speaking, Broadway Belting, Country Twang and Opera Coloratura. Many even offer a complimentary scope of the larynx (voice box) to those who attend.  

As professors of applied voice and speech-language pathology at Grand Valley State University in Western Michigan, we collaborated on our first annual virtual conference on Friday, April 17, 2020. About 142 learners from seven healthcare disciplines and the Department of Music, Theatre and Dance attended several 1-hour virtual interactive lectures and performances offered by professionals in acting, audiology, singing health, music, and speech-language pathology. The topics focused on interprofessional approach while working with vocal performers and occupational voice users through integrating training approaches and rehabilitation using evidence-based practice. Over 90% of the post-survey respondents agreed that the content helped them to learn one or more core competencies of interprofessional education and collaboration. This project was supported by a “teaching innovation grant” sponsored by GVSU’s Pew Faculty Teaching and Learning Center.

Additional participants attended from different regions of the country and a few live streamed internationally. For our 2021 and 2022 virtual conferences, we collaborated and invited speakers from otolaryngology, exercise physiology, as well as a Professional Broadway Singer and a Professional Opera Singer. Participation in WVD contributed significantly to our students’ understanding the role of an interdisciplinary voice team, the demand of a variety of vocal arts and livelihoods, the prevention of voice disorders, and importance of patient-centered voice habilitation/rehabilitation.

As professors, we regret that WVD does not fall in autumn. The day arrives too late for many who would benefit most. April 16 is the busiest time of the U.S. academic year. Students and professors reach peak-stress as finals, clinical practicums, juries’ approach, and degree recitals fill up every venue and available time slot until little resources are left to take advantage of this learning opportunity. Additionally, opera companies are in the throes of final dress rehearsals and teachers are already experiencing vocal wear and tear from illness and their heavy vocal load all school year.

Even so, as a professional singer and professor of singing who devoted three years to study with a voice surgeon and speech-language pathologists, I am grateful for this unique opportunity to unite people across all voice-related disciplines.

Each year the Voice Committee of the American Academy of Otolaryngology – Head and Neck Surgery focuses on a WVD motto such as “Educate your voice” (2014), “Share your voice” (2017) and more recently, “Lift your voice” (2022). This year’s theme will be:

Visit the links below to find WVD events happening near you!

https://voicefoundation.org/events/world-voice-day/

http://world-voice-day.org/

https://www.entnet.org/about-us/campaigns/world-voice-day/

https://pavavocology.org/ (scroll down for calendar)

https://dysphonia.org/ (list of events)

http://www.britishvoiceassociation.org.uk

PEVOC - Pan-European Voice Conference - Host Site