Voice Disorders and Related Risk Factors among Music Therapists: Survey Findings and Strategies for Voice Care

Voice Disorders and Related Risk Factors among Music Therapists: Survey Findings and Strategies... Abstract The purposes of this article are to: (a) describe the prevalence of voice disorders among professional and student members of the American Music Therapy Association (AMTA); (b) highlight the risk factors associated with voice disorders among music therapists; (c) report on the types of education received by music therapists regarding voice care; and (d) present practical strategies to music therapists for preserving vocal health. The authors distributed an online survey that was completed by 561 AMTA members. Results indicated that 43% of respondents reported having a voice disorder at some point in their lives while 7.8% reported having an existing voice disorder. Over 84% of respondents reported at least one vocal health risk factor, the most frequent of which included seasonal allergies (66.5%), acid reflux (29.1%), and missing at least one day of work because of a voice issue (29.1%). Additionally, using the Voice Handicap Index-10 as a screening tool, 15.8% of respondents met criteria for a referral to a medical voice specialist. Around 4% of respondents indicated that they had not received education regarding voice care, while the most common means of vocal health education involved the integration of voice care into pre-clinical training coursework or continuing education. Results suggest that not only are music therapists at an elevated risk compared to the general population for the development of voice disorders, but the availability and types of educational resources related to vocal health are quite variable. Thus, more education regarding the care and handling of the voice is needed. music therapy, voice disorder, vocal health, self-care, risk factors The ability to use our voices to communicate is an often underappreciated gift, until that ability becomes compromised. Voice use is considered a primary tool of the trade for many professions, and it is well established that professional voice users such as singers and teachers are at a higher risk for the development of voice disorders (Mori & Song, 2014; Titze, Lemke, & Montequin, 1997; Williams, 2003). One commonly utilized definition of a voice disorder has been “any time the voice does not work, perform, or sound as it normally should, so that it interferes with communication” (Roy, Merrill, Thibeault, Gray, & Smith, 2004). Voice disorders are typically broken down into three broad categories: neurologic (i.e., vocal fold paralysis), organic (i.e., carcinoma), or functional (i.e., vocal nodules) (Boone, McFarlane, Von Berg, & Zraick, 2014). Functional voice disorders are especially relevant for professional voice users, as these particular disorders typically stem from either misuse or overuse of the voice. According to the American Academy of Otolaryngologists, more than half of all teachers develop a voice disorder during their lifetime, 20% report missing work due to a voice issue, and 1 in 10 teachers are forced to leave the profession because of voice problems (Roy et al., 2004). Although vocal complaints among teachers and singers have been well documented, little is known about the prevalence of voice disorders among other presumably high-risk groups, such as music therapists. Boyle and Engen (2008) made this point in their review of the potential risk factors by describing music therapy as a “vocally demanding profession” (p. 46). And while acknowledging that no evidence of lifetime or point prevalence for voice disorders among music therapists existed, they recommended that educational programs and preventive health mechanisms (e.g., voice screenings and evaluations) be put into place. More recently, Gooding (2016) identified voice problems as one of many occupational risks faced by practicing music therapists. Further reiterating the need for empirical evidence on the risks and lifetime occurrence for voice disorders, Gooding provided a number of ameliorative voice care strategies, including vocal warm-ups, hydration, vocal rest, and voice amplification. Others have studied the perceived impact of voice problems among music therapists. Murray (2014) explored the shared experiences of music therapists diagnosed with vocal health problems. Using a phenomenological approach, Murray found that the challenges associated with having a voice disorder impacted occupational, interpersonal, emotional, and physical aspects of music therapists’ lives. Moreover, these music therapists experienced a shift in how they approached their clients and the music therapy profession. One respondent found that she developed an appreciation for her clients with communication disorders: “I’ve seen what it feels like to be able to not communicate… It was a very isolating experience so its [sic] given me good perspective for the clients I work with” (p. 34). In a study of factors related to music therapist occupational burnout, Murillo (2013) reported that approximately 12% of respondents identified vocal health as a concern. As part of the analytic approach, Murillo identified two emergent themes. The first theme centered around vocal injury and was characterized by responses such as “I believe that vocal health skills are undervalued at the academic level, resulting in injury that could be avoided due to lack of proper training,” and “I’ve had issues with vocal health because of overuse and lack of self-care” (p. 106). Statements constituting a second theme about the importance of vocal health serve as a cautionary tale to those entering the profession: “Vocal care is an important issue that is sometimes overlooked,” “You need to take care of your voice, how to sing and how not sing,” and “Warming up vocally and instrumentally is highly important” (p. 118). These findings suggest that education and training prior to entering the field are undervalued or ignored. As music therapists are required to not only speak but also sing for prolonged periods of time, this particular occupational group would seemingly be at risk for potential voice overuse common to both singers and teachers. Since voice disorders are often preventable given access to adequate information about how to care for the voice, it also becomes important to ascertain the degree of continuing education that music therapists might currently be receiving regarding vocal health. Other risk factors beyond voice overuse (i.e., smoking, acid reflux, allergies, alcohol) have not been thoroughly studied in this occupational group. Survey Purposes To better elucidate the prevalence of and risk factors related to voice use among music therapists, the author distributed a survey to American Music Therapy Association (AMTA) members to: 1. Estimate the prevalence of voice problems among professional and student members of AMTA; 2. Identify the presence of risk factors associated with voice problems among professional and student members of AMTA; and 3. Determine whether vocal health or the development of voice problems are addressed through continuing education, vocal training (at the pre-professional level), or the workplace. Methods The researchers used a non-experimental, survey approach to address the study’s purposes, which involved both descriptive and comparative design features (McMillan & Schumacher, 2009). QuestionProTM, an online survey platform, was used to create and distribute a researcher-designed questionnaire to professional and student members of AMTA. The researchers selected QuestionProTM because of its use in recent music therapy–related studies (Waldon, 2015a; Waldon & Wheeler, 2017); ease and flexibility of use; survey distribution, data organization, and respondent management features; and familiarity to the first author. Participants All methods and procedures, including those involved in participant selection, used in this study were approved by the researchers’ Institutional Review Board. Following their policies for purchasing the names and e-mail addresses, the AMTA provided a listing of contact information for student and professional-level members. During this process, it was also noted that the contact information for AMTA members opting out of third-party mailings was not included in the listing. This suggests that the available population (i.e., the members identified in the list) may not accurately represent the membership by not including those members choosing not to be contacted by third parties. In all, the authors distributed the survey via e-mail to 1752 potential participants on February 1, 2017, which was followed by two survey reminders to those who had not yet responded. Instrumentation The researcher-designed questionnaire1 included three parts and items about participants’ background and training, current voice use, and a standardized self-report measure. The first part, background and demographic information, included 19 items, many of which served to define the study’s independent variables: years since training/in practice, educational attainment, work setting, occupational role, history of formal voice training, and primary instrument/voice part studied. Part two of the questionnaire consisted of items inquiring about respondents’ vocal practices, health status, and other behaviors, particularly those that may place a person at greater risk for developing a voice disorder (e.g., alcohol, caffeine, and tobacco use) (Roy, Merrill, Gray, & Smith, 2005). The final part of the questionnaire included two items related to current and past voice disorders. The first item was the Voice Handicap Index 10 (VHI-10; Rosen, Lee, Osborne, Zullo, & Murry, 2004), a 10-item self-report questionnaire designed to assess the psychosocial impact of a voice disorder on an individual’s well-being. The VHI-10 is a standardized voice-specific quality of life scale, and it is the most frequently used measure to gauge the psychosocial impact of a voice disorder (Franic, Bramlett, & Bothe, 2005). Participants respond to each item on a 5-point scale, with total scores ranging from 0 (no voice handicap) to 4 (worst possible voice handicap). An abbreviated form of the 30-item Voice Handicap Index (VHI; Jacobsen at el., 1997; Rosen et al., 2004) studied the VHI-10 alongside the full index and confirmed the presence of convergent-related evidence (r = .90) claiming that both tools were equivalent measures. In a separate study, Deary, Webb, Mackenzie, Wilson, and Carding (2004) found that the VHI-10 possessed adequate internal consistency (Cronbach’s alpha = .89) and, using principal components analysis, that the tool measured a single construct: perceived functional impact of voice disorder symptoms. As a final question in the voice disorders portion of the questionnaire, respondents were asked to identify whether they currently or previously had been diagnosed with a voice disorder using a definition provided by the researchers. Results Respondent Characteristics Of those invited to participate, 561 responded, which represents a response rate of 32%, considered acceptable by Saldivar (2012). The majority of the respondents were professional members (88.71%), while others included undergraduate student (1.25%), graduate student (8.6%), and honorary life (1.08%) members.2 Retired and inactive status members each comprised less than 1% of the sample. Regarding regional representation, the majority of the respondents were from the Great Lakes (23.8%) and Mid-Atlantic (21.7%) regions, followed by the Western (17.8%), South Eastern (12.2%), Mid-Western (11.2%), South Western (7.0%), and New England (6.0%) regions. Less than 1% of the respondents were from outside the United States. Using region of residence as an independent variable, respondent regional representation was proportionately similar to those reported in the 2016 AMTA Member Survey and Workforce Analysis, χ2(7, N = 517) = 0.42, P > .05, ns. Table 1 includes additional survey respondent characteristics related to gender, age category, educational attainment, occupational role, and clinical setting. Table 1 Respondent Characteristics   n  %  Gender (n = 560)   Female  504  90.0%   Male  54  9.64%   Other (non-binary, transgender)  2  0.36%  Age Category (n = 559)   18 to 29 years  148  26.48%   30 to 39 years  126  22.54%   40 to 49 years  108  19.32%   50 to 59 years  96  17.17%   60 to 69 years  69  12.34%   70 or more years  12  2.15%  Educational Attainment (n = 531)   Undergraduate Degree  230  43.31%   Master’s or Specialist-level Degree  246  46.33%   Doctoral-level Degree  55  10.36%  Occupational Role (n = 509)   Clinical  420  80.0%   Administrative  38  7.24%   Academic Teaching and/or Research  51  9.71%  Clinical Setting (n = 510)   Corrections  7  1.37%   Education/School Setting (pre, K–12)  77  15.09%   Hospice  55  10.78%   Inpatient/Outpatient Medical  50  9.80%   Inpatient/Outpatient Psychiatric  64  12.54%   Military (including Veteran’s Affairs)  7  1.37%   Private Practice/Contractual  113  22.15%   Rehabilitation (physical, speech, occupational)  9  1.76%   Skilled Nursing/Older Adult Setting  56  10.98%   Adults with Intellectual Disabilities  25  4.90%   University/College (Academic Teaching/Research)  47  9.21%    n  %  Gender (n = 560)   Female  504  90.0%   Male  54  9.64%   Other (non-binary, transgender)  2  0.36%  Age Category (n = 559)   18 to 29 years  148  26.48%   30 to 39 years  126  22.54%   40 to 49 years  108  19.32%   50 to 59 years  96  17.17%   60 to 69 years  69  12.34%   70 or more years  12  2.15%  Educational Attainment (n = 531)   Undergraduate Degree  230  43.31%   Master’s or Specialist-level Degree  246  46.33%   Doctoral-level Degree  55  10.36%  Occupational Role (n = 509)   Clinical  420  80.0%   Administrative  38  7.24%   Academic Teaching and/or Research  51  9.71%  Clinical Setting (n = 510)   Corrections  7  1.37%   Education/School Setting (pre, K–12)  77  15.09%   Hospice  55  10.78%   Inpatient/Outpatient Medical  50  9.80%   Inpatient/Outpatient Psychiatric  64  12.54%   Military (including Veteran’s Affairs)  7  1.37%   Private Practice/Contractual  113  22.15%   Rehabilitation (physical, speech, occupational)  9  1.76%   Skilled Nursing/Older Adult Setting  56  10.98%   Adults with Intellectual Disabilities  25  4.90%   University/College (Academic Teaching/Research)  47  9.21%  View Large Table 1 Respondent Characteristics   n  %  Gender (n = 560)   Female  504  90.0%   Male  54  9.64%   Other (non-binary, transgender)  2  0.36%  Age Category (n = 559)   18 to 29 years  148  26.48%   30 to 39 years  126  22.54%   40 to 49 years  108  19.32%   50 to 59 years  96  17.17%   60 to 69 years  69  12.34%   70 or more years  12  2.15%  Educational Attainment (n = 531)   Undergraduate Degree  230  43.31%   Master’s or Specialist-level Degree  246  46.33%   Doctoral-level Degree  55  10.36%  Occupational Role (n = 509)   Clinical  420  80.0%   Administrative  38  7.24%   Academic Teaching and/or Research  51  9.71%  Clinical Setting (n = 510)   Corrections  7  1.37%   Education/School Setting (pre, K–12)  77  15.09%   Hospice  55  10.78%   Inpatient/Outpatient Medical  50  9.80%   Inpatient/Outpatient Psychiatric  64  12.54%   Military (including Veteran’s Affairs)  7  1.37%   Private Practice/Contractual  113  22.15%   Rehabilitation (physical, speech, occupational)  9  1.76%   Skilled Nursing/Older Adult Setting  56  10.98%   Adults with Intellectual Disabilities  25  4.90%   University/College (Academic Teaching/Research)  47  9.21%    n  %  Gender (n = 560)   Female  504  90.0%   Male  54  9.64%   Other (non-binary, transgender)  2  0.36%  Age Category (n = 559)   18 to 29 years  148  26.48%   30 to 39 years  126  22.54%   40 to 49 years  108  19.32%   50 to 59 years  96  17.17%   60 to 69 years  69  12.34%   70 or more years  12  2.15%  Educational Attainment (n = 531)   Undergraduate Degree  230  43.31%   Master’s or Specialist-level Degree  246  46.33%   Doctoral-level Degree  55  10.36%  Occupational Role (n = 509)   Clinical  420  80.0%   Administrative  38  7.24%   Academic Teaching and/or Research  51  9.71%  Clinical Setting (n = 510)   Corrections  7  1.37%   Education/School Setting (pre, K–12)  77  15.09%   Hospice  55  10.78%   Inpatient/Outpatient Medical  50  9.80%   Inpatient/Outpatient Psychiatric  64  12.54%   Military (including Veteran’s Affairs)  7  1.37%   Private Practice/Contractual  113  22.15%   Rehabilitation (physical, speech, occupational)  9  1.76%   Skilled Nursing/Older Adult Setting  56  10.98%   Adults with Intellectual Disabilities  25  4.90%   University/College (Academic Teaching/Research)  47  9.21%  View Large Study Purpose #1: Prevalence of Voice Problems Provided with a standard definition of a voice disorder,3 43.02% (n = 222) of respondents reported having had a voice disorder at some point in their lives (lifetime prevalence), a rate that exceeds the general lifetime prevalence of 29.9% (Roy, Merrill, Gray, & Smith, 2005). Additionally, the percentage of respondents currently reporting a voice disorder (point prevalence, 7.75%; n = 40) exceeded that in the general population (6.6%) (Roy et al., 2005). Study Purpose #2: Voice Disorder Risk Factors Regarding risk factors, 84.12% (n = 434) of respondents reported at least one vocal health risk factor, the most frequent of which included seasonal allergies (66.5%; n = 343), acid reflux (29.1%; n = 150), and missing at least one day of work because of a voice issue (29.1%; n = 150). Figure 1 includes a complete list with corresponding frequencies for the risk factors explored in the survey. Additionally, using the VHI-10 total score as a diagnostic measure, 15.8% (n = 82) of respondents met criteria (at the time of the survey) that would justify a referral to a laryngologist. Figure 1. View largeDownload slide Reported frequency of vocal health risk factors explored in this survey (n = 516 valid responses). Figure 1. View largeDownload slide Reported frequency of vocal health risk factors explored in this survey (n = 516 valid responses). Study Purpose #3: Vocal Health Education and Training Of the 402 respondents answering questions related to vocal health maintenance and education, 4.13% (n = 17) indicated that they had never received training or education about the voice. For those who had reportedly received such instruction, respondents indicated that voice education was required as part of their academic training (n = 157); came after entry into the field (e.g., through private instruction, continuing education; n = 103); occurred prior to academic training (n = 102); and/or was an elective during academic training (n = 33). Survey Discussion Results suggest that not only are music therapists at an elevated risk for the development of a voice disorder, but the availability and types of training and educational resources related to vocal health may not be consistent. Results from the current investigation found that 7.8% of respondents reported experiencing a current voice disorder. This percentage is well above the data culled from the general population, which indicates a 1.7% yearly prevalence rate of voice disorders in the United States (Benninger, Holy, Bryson, & Milstein, 2017). This would suggest that music therapists are more likely to experience a voice disorder as compared to those in other occupations. However, caution should be used when comparing these figures, as the 1.7% general prevalence was based on national medical databases where patients actively sought medical attention. Some individuals with voice problems may not seek out a physician’s care due to a variety of factors (i.e., lack of insurance, distance to clinic). Those in the general population who might experience voice disorders but choose not to seek medical care were not reflected in the results of the recent Benninger et al. study. Regarding risk factors, the majority of study respondents reported having at least one risk factor associated with developing a vocal health problem (Roy et al., 2005). Additionally, findings from the VHI-10 suggest that over 15.8% of respondents met criteria for a referral to a laryngologist. The cutoff value utilized for potential referral was 7.5 or above on the VHI-10 (Behlau et al., 2016). These findings combined with the point and lifetime prevalence of voice disorders among respondents would seem to substantiate Boyle and Engen’s (2008) assertion that music therapists should be concerned about vocal health. Finally, this survey sought to identify whether (and what types of) vocal health education had been available to survey respondents. While a minority indicated never having received such education (4.13%), that only 39% of respondents indicated that vocal health training was included (or required) in their academic programs is alarming given the apparent risk. Therefore, the authors would suggest reexamining the AMTA Professional Competencies and having academic programs review curricula and take considerable note of the extent to which vocal health is addressed for all developing and entry-level clinicians. It may also be beneficial to study the specific types of education available to music therapists, how instruction is delivered (e.g., in groups versus individual settings), and when information on vocal health is being offered (e.g., at the beginning/end of training or following entry to the field). As in all survey research, there are two limitations that should be considered when interpreting findings. The first involves respondent recruitment and survey participation. While the 32% response rate is considered acceptable given the online nature of the survey, it is unknown whether those who chose not to participate are in some way substantially different from those who did. Additionally, because AMTA members are permitted to “opt out” of being contacted by third parties, the sample may not be fully representative of the AMTA membership at the time of the survey. In this same regard, not all practicing music therapists are members of AMTA, with some estimates suggesting that only a third of Board-Certified Music Therapists (MT-BCs) are members (Waldon, 2015b). Therefore, it may be advisable to conduct a similar study by recruiting MT-BCs through the Certification Board for Music Therapists. The second limitation concerns the use of self-report measures. Whenever a research participant is directed to report about or reflect on a personal belief or behavior, there is a possibility that they will respond in a way that does not reflect their lived experience, that is, they may provide answers viewed as “socially desirable” or that conform to the perceived expectation of the researcher(s). Although unlikely to eliminate this bias completely, research approaches that minimize this threat (e.g., using face-to-face interviews and measures with low face validity; Nederhof, 1985) or verify the veracity of respondent answers could be used. Strategies for Voice Care The term “vocal hygiene” is used among medical speech-language pathologists to refer to the ways in which healthy voicing is maintained (Boone et al., 2014). Vocal hygiene also often involves the purposeful elimination of harmful behaviors that hinder vocal fold healing. Medical Evaluation Before delving into general vocal hygiene recommendations, an important point should be made. If a change in vocal quality and/or pain in the laryngeal area persists for greater than two weeks, it is critical that a person see a physician. More specifically, the advice of a laryngologist (an otolaryngologist, commonly referred to as an ENT with specialized training in the voice) should be sought, as this is a specialist who is trained to diagnose voice disorders. The reason for this disclaimer is that serious medical conditions (i.e., laryngeal carcinoma) might be responsible for the change in voice quality. Even benign lesions can significantly impair vocal function, and a thorough medical evaluation is warranted (Sataloff, 2005). After visualizing the vocal folds, a laryngologist will diagnose the problem and set forth a treatment plan. Depending on the diagnosis, treatment may be medical (i.e., medication, surgery), behavioral (e.g., voice therapy with a speech-language pathologist), or both. Vocal Load The amount of time an individual uses his/her voice is referred to as vocal load. Because the vocal folds collide on average approximately 225 times/second for women and 125 times/second for men (Boone et al., 2014), it is important for professional voice users to be aware of their vocal load. In many cases, hyper-functional voice disorders such as nodules are the result of overuse of the vocal mechanism. Therefore, a key component of vocal hygiene involves a conscious awareness of the ways in which an individual uses the voice both in and out of the workplace. Cutting back on vocally strenuous activities and/or rearranging schedules to accommodate breaks for voice rest are often indicated. Hydration Hydration is also critical for professional voice users such as music therapists. This can either involve systemic hydration (i.e., ingestion of liquid), superficial hydration (i.e., nebulizer, humidifier), or ideally a combination of both. Vocal professionals need to maintain higher levels of hydration because singing and prolonged speaking result in the evaporation of moisture via the oral cavity. Because individual variability is a factor (i.e., exercise level, body mass, etc.), there are no established guidelines regarding the amount of water that should be consumed daily. However, a general water recommendation for professional voice users is either a minimum of 64 ounces (Sataloff, 2005) or a more specific amount based upon a person’s own body weight (e.g., body weight divided in half equals the amount of water to be consumed in ounces; Shaw, 2009). Superficial or external hydration can be accomplished in different ways. Often a humidifier is placed in the bedroom at night and in the office during the day to increase the ambient level of moisture in the surrounding air. Facial steamers commonly purchased at drugstores offer a more direct means of hydrating the vocal fold mucosa. More recently, the use of ultrasonic saline nebulizers administered orally have been shown to help maintain vocal fold moisture and decrease phonation threshold pressure, which results in less perceived vocal effort (Tanner et al., 2010, 2016). The finer particles of the nebulized saline are thought to better reach the level of the vocal folds, as compared to the larger boiled molecules from vaporizers. Tanner and colleagues recommend nebulizing 3–9 ml of a 0.9% sterile saline solution twice daily for approximately 15 minutes. Ultrasonic nebulizers are recommended, as it is believed that the air compressor–powered nebulizers could potentially be drying. The ultrasonic variety uses high-frequency vibrations to aerosolize the medication into a fine mist. These small, often battery-powered portable nebulizers are quiet in operation and can be used virtually anywhere. Single-use plastic vials of 0.9% saline solution can be easily purchased online, but Tanner and colleagues stress that physician approval should be obtained before embarking on a nebulizing protocol. Hydration is important because hydrated vocal folds are able to vibrate using less subglottal pressure and phonatory effort (Sivasankar & Leydon, 2010; Verdolini, Titze, & Fennell, 1994). In other words, well-hydrated vocal folds require less air pressure and effort for either speaking or singing. Reduced phonatory effort and increased vocal endurance translates to a voice that is less tired at the end of the day. Hydration also plays a role in vocal fold healing for patients who are recovering from benign lesions such as nodules (Verdolini-Marston, Sandage, & Titze, 1994). Furthermore, caffeine and alcohol are only recommended in moderation for professional voice users, due in part to their drying effect on vocal fold mucosa and their role in triggering acid reflux (Sataloff, 2005). Reflux and Medications Acid reflux has been associated with the development of a host of voice disorders, including laryngeal cancer (Schneider, Vaezi, & Francis, 2016; Tae et al., 2011). When gastroesophageal reflux (GERD) rises to the level of the vocal folds, a phenomenon known as laryngopharyngeal reflux (LPR) occurs. LPR is particularly harmful to the delicate mucosa of the vocal folds, as stomach acid and digestive enzymes were not designed to come into contact with the vocal folds. Unbeknownst to some, LPR can occur at night due to horizontal body positioning during sleep. Even in the absence of a burning sensation, simply having a persistent lump in the throat, chronic throat clearing, or excessive mucus can all be signs of what is known as “silent reflux” (Dresden, 2016). LPR can sometimes be controlled behaviorally by avoidance of food 2–4 hours before bed, eating smaller and more frequent meals, raising the head of the bed slightly during sleep, and avoiding certain triggers like alcohol, caffeine, chocolate, fatty/acidic foods, carbonated beverages, and gum (Nowak et al., 2005). In more severe cases, medication can be used in the form of either H2-receptor antagonists or proton pump inhibitors (Savarino et al., 2017). Only a physician can decide which medication might be best as well as the duration of treatment. Although certain medications like those for reflux might be prescribed with the aim of helping the voice, there are a host of medications that are contraindicated due to their drying effects. Most over-the-counter decongestants (e.g., pseudoephedrine, phenylephrine), certain allergy medications (e.g., diphenhydramine, chlorpheniramine), and asthma-control agents can negatively impact vocal fold hydration (Simpson, 1996). Certain corticosteroid inhalers (e.g., beclometasone) for asthma are more harmful to the voice than others, so it is imperative that professional voice users such as music therapists consult with their physicians to ascertain if a change in medication might protect the voice to a greater degree. Common colds cannot always be avoided, but rather than reaching for multi-symptom over-the-counter medications (with decongestants that can be drying), a safer alternative is to opt for mucolytic agents such as those that only contain guaifenesin. Guaifenesin thins the thickened secretions often associated with the common cold but does not dry the mucosa. Mucinex® and Robitussin® are two common brands, but it is important to find the specific variety that lists guaifenesin as the only active ingredient on the label. Voice Exercises and Training If a voice disorder is diagnosed by an otolaryngologist and therapy with a speech-language pathologist (SLP) is recommended, it is important that the patient adhere to the individualized treatment plan. However, if an individual has no current vocal complaints and simply wants to keep his/her voice healthy and/or increase range and stamina, one established vocal warm-up technique involves the use of semi-occluded vocal tract exercises (SOVT). These SOVT exercises developed by Titze (2006) often involve a plastic straw and/or lip trills, which add back pressure to the vocal folds, decrease laryngeal tension, and encourage anterior resonant vibrations. For more information on SOVT exercises, readers are referred to http://www.voicescienceworks.org/sovt-exercises.html. Videos of Dr. Titze demonstrating the SOVT exercise of straw phonation are available online. For those music therapists for whom singing is a common practice, formal voice lessons from an experienced teacher of singing is extremely important. Unhealthy singing practices such as singing with excess strain/tension or vocalizing outside an individual’s natural range may pose serious problems. A brief summary of both helpful and harmful strategies for voice care is provided below in Table 2. Table 2 Example Behaviors and Factors That Support or Harm Vocal Fold Health Helpful Behaviors/Factors  Harmful Behaviors/Factors  Hydrating (superficial and systemic)  Excessive caffeine use  Allowing breaks for voice rest  Use of alcohol  Using *SOVT exercises  Inadequate sleep  Using portable amplification  Speaking/singing excessively  Using mucolytic medications  Smoking  Controlling acid reflux (diet or medication)  Exposure to airborne irritants  Using resonant voice  Laryngopharyngeal reflux  Engaging in formal voice training  Drying medications (e.g., antihistamines)  Decreasing laryngeal tension (through stretches or voice treatment)  Chronic throat clearing    Dehydration    Loud phonation for extended periods  Helpful Behaviors/Factors  Harmful Behaviors/Factors  Hydrating (superficial and systemic)  Excessive caffeine use  Allowing breaks for voice rest  Use of alcohol  Using *SOVT exercises  Inadequate sleep  Using portable amplification  Speaking/singing excessively  Using mucolytic medications  Smoking  Controlling acid reflux (diet or medication)  Exposure to airborne irritants  Using resonant voice  Laryngopharyngeal reflux  Engaging in formal voice training  Drying medications (e.g., antihistamines)  Decreasing laryngeal tension (through stretches or voice treatment)  Chronic throat clearing    Dehydration    Loud phonation for extended periods  *Semi-Occluded Vocal Tract Exercises View Large Table 2 Example Behaviors and Factors That Support or Harm Vocal Fold Health Helpful Behaviors/Factors  Harmful Behaviors/Factors  Hydrating (superficial and systemic)  Excessive caffeine use  Allowing breaks for voice rest  Use of alcohol  Using *SOVT exercises  Inadequate sleep  Using portable amplification  Speaking/singing excessively  Using mucolytic medications  Smoking  Controlling acid reflux (diet or medication)  Exposure to airborne irritants  Using resonant voice  Laryngopharyngeal reflux  Engaging in formal voice training  Drying medications (e.g., antihistamines)  Decreasing laryngeal tension (through stretches or voice treatment)  Chronic throat clearing    Dehydration    Loud phonation for extended periods  Helpful Behaviors/Factors  Harmful Behaviors/Factors  Hydrating (superficial and systemic)  Excessive caffeine use  Allowing breaks for voice rest  Use of alcohol  Using *SOVT exercises  Inadequate sleep  Using portable amplification  Speaking/singing excessively  Using mucolytic medications  Smoking  Controlling acid reflux (diet or medication)  Exposure to airborne irritants  Using resonant voice  Laryngopharyngeal reflux  Engaging in formal voice training  Drying medications (e.g., antihistamines)  Decreasing laryngeal tension (through stretches or voice treatment)  Chronic throat clearing    Dehydration    Loud phonation for extended periods  *Semi-Occluded Vocal Tract Exercises View Large Job-Related Accommodations for Voice If a music therapist is experiencing voice problems on the job, it is important to note that voice disorders are considered a disability under the law (Americans with Disabilities Act, 1990). The Job Accommodation Network (JAN, www.askjan.org) offers a host of job-related accommodations that might prove helpful for various work settings. A sample of accommodations suggested for those experiencing voice disorders can be found in Table 3. Table 3 Sample Accommodations for Individuals with Voice Disorders According to the Job Accommodation Network 1.  Allow increased use of text-based communication such as e-mail, instant messaging, and texting  2.  Modify employee’s schedule to allow breaks to manage condition by eating, drinking water, using stress reductions techniques or vocal exercises, or resting voice  3.  Allow flexible use of leave time when symptoms are exacerbated or to pursue treatment  4.  Relocate workstation away from sources of background noise  5.  Allow use of a telephone voice amplification device  6.  Allow use of a portable voice amplifier or a more powerful amplifier such as a PA (public address) system  7.  Reduce background noise by installing noise reduction panels in meeting areas  8.  Change meeting etiquette so only one person speaks at a time  9.  Be prepared to use alternate means of communication such as pen and paper, typing, or an AAC device in cases of extreme vocal fatigue  10.  Modify policies to allow employee to eat or drink at workstation  11.  Allow use of assistive devices such as electrolarynx or AAC devices for employees who use these as a primary means of communication  1.  Allow increased use of text-based communication such as e-mail, instant messaging, and texting  2.  Modify employee’s schedule to allow breaks to manage condition by eating, drinking water, using stress reductions techniques or vocal exercises, or resting voice  3.  Allow flexible use of leave time when symptoms are exacerbated or to pursue treatment  4.  Relocate workstation away from sources of background noise  5.  Allow use of a telephone voice amplification device  6.  Allow use of a portable voice amplifier or a more powerful amplifier such as a PA (public address) system  7.  Reduce background noise by installing noise reduction panels in meeting areas  8.  Change meeting etiquette so only one person speaks at a time  9.  Be prepared to use alternate means of communication such as pen and paper, typing, or an AAC device in cases of extreme vocal fatigue  10.  Modify policies to allow employee to eat or drink at workstation  11.  Allow use of assistive devices such as electrolarynx or AAC devices for employees who use these as a primary means of communication  View Large Table 3 Sample Accommodations for Individuals with Voice Disorders According to the Job Accommodation Network 1.  Allow increased use of text-based communication such as e-mail, instant messaging, and texting  2.  Modify employee’s schedule to allow breaks to manage condition by eating, drinking water, using stress reductions techniques or vocal exercises, or resting voice  3.  Allow flexible use of leave time when symptoms are exacerbated or to pursue treatment  4.  Relocate workstation away from sources of background noise  5.  Allow use of a telephone voice amplification device  6.  Allow use of a portable voice amplifier or a more powerful amplifier such as a PA (public address) system  7.  Reduce background noise by installing noise reduction panels in meeting areas  8.  Change meeting etiquette so only one person speaks at a time  9.  Be prepared to use alternate means of communication such as pen and paper, typing, or an AAC device in cases of extreme vocal fatigue  10.  Modify policies to allow employee to eat or drink at workstation  11.  Allow use of assistive devices such as electrolarynx or AAC devices for employees who use these as a primary means of communication  1.  Allow increased use of text-based communication such as e-mail, instant messaging, and texting  2.  Modify employee’s schedule to allow breaks to manage condition by eating, drinking water, using stress reductions techniques or vocal exercises, or resting voice  3.  Allow flexible use of leave time when symptoms are exacerbated or to pursue treatment  4.  Relocate workstation away from sources of background noise  5.  Allow use of a telephone voice amplification device  6.  Allow use of a portable voice amplifier or a more powerful amplifier such as a PA (public address) system  7.  Reduce background noise by installing noise reduction panels in meeting areas  8.  Change meeting etiquette so only one person speaks at a time  9.  Be prepared to use alternate means of communication such as pen and paper, typing, or an AAC device in cases of extreme vocal fatigue  10.  Modify policies to allow employee to eat or drink at workstation  11.  Allow use of assistive devices such as electrolarynx or AAC devices for employees who use these as a primary means of communication  View Large If an employer is unwilling to accommodate an individual experiencing a voice disorder, the Equal Employment Opportunity Commission (www.eeoc.gov) can be a valuable resource. The EEOC acts as an intermediary between individuals with disabilities and their employers. Conclusion Studies that examine the prevalence of voice disorders among specific occupational groups are an important first step in addressing a potential underlying need. If, as the present data suggest, music therapists are more prone to the development of voice problems, future studies might examine the best ways in which to prevent voice problems before they begin. Since the majority of respondents reported having received voice care education outside their clinical programs, a more systematic means of addressing vocal hygiene education might be warranted. This education could not only be geared toward prevention, but also involve the steps for proper treatment and accommodations should voice problems arise. Future studies might examine the use of the Singing Voice Handicap Index (Cohen et al., 2007) as a self-report tool used to identify voice problems among music therapists. Newer technologies such as ambulatory voice monitoring using dosimeters and accelerometers allow researchers to quantify the amount of speaking/singing a person experiences on a daily basis (Mehta, Van Stan, Masson, Maffei, & Hillman, 2017). These devices, which are even able to monitor vocal loudness and pitch, would permit researchers to objectively quantify how music therapists are using their voices on the job. Stress management and mindfulness programs are gaining ground across the helping professions (Christopher & Maris, 2010). Therefore, in line with other self-care initiatives, perhaps a greater understanding of the vocal mechanism can help ensure that music therapists are able to deliver quality services while enjoying long, productive careers. Eric G. Waldon, PhD, MT-BC, Associate Professor of Music Therapy at the University of the Pacific, is involved with the education and training of music therapists at the undergraduate and graduate level. 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Nordic Journal of Music Therapy , 26, 395– 410. doi: https://doi.org/10.1080/08098131.2017.1284889 Google Scholar CrossRef Search ADS   Williams, N. R. ( 2003). Occupational groups at risk of voice disorders: A review of the literature. Occupational Medicine (Oxford, England) , 53( 7), 456– 460. Google Scholar CrossRef Search ADS PubMed  Footnotes 1 Available from the authors upon request. 2 Given the small number of undergraduate and graduate student participants, only respondents who reportedly have been working in the profession (e.g., which included some graduate student members) were included in subsequent analyses. 3 Anytime your voice does not work, perform, or sound as you feel it normally should, so that it interferes with communication (Roy et al., 2004). © American Music Therapy Association 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Music Therapy Perspectives Oxford University Press

Voice Disorders and Related Risk Factors among Music Therapists: Survey Findings and Strategies for Voice Care

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Abstract

Abstract The purposes of this article are to: (a) describe the prevalence of voice disorders among professional and student members of the American Music Therapy Association (AMTA); (b) highlight the risk factors associated with voice disorders among music therapists; (c) report on the types of education received by music therapists regarding voice care; and (d) present practical strategies to music therapists for preserving vocal health. The authors distributed an online survey that was completed by 561 AMTA members. Results indicated that 43% of respondents reported having a voice disorder at some point in their lives while 7.8% reported having an existing voice disorder. Over 84% of respondents reported at least one vocal health risk factor, the most frequent of which included seasonal allergies (66.5%), acid reflux (29.1%), and missing at least one day of work because of a voice issue (29.1%). Additionally, using the Voice Handicap Index-10 as a screening tool, 15.8% of respondents met criteria for a referral to a medical voice specialist. Around 4% of respondents indicated that they had not received education regarding voice care, while the most common means of vocal health education involved the integration of voice care into pre-clinical training coursework or continuing education. Results suggest that not only are music therapists at an elevated risk compared to the general population for the development of voice disorders, but the availability and types of educational resources related to vocal health are quite variable. Thus, more education regarding the care and handling of the voice is needed. music therapy, voice disorder, vocal health, self-care, risk factors The ability to use our voices to communicate is an often underappreciated gift, until that ability becomes compromised. Voice use is considered a primary tool of the trade for many professions, and it is well established that professional voice users such as singers and teachers are at a higher risk for the development of voice disorders (Mori & Song, 2014; Titze, Lemke, & Montequin, 1997; Williams, 2003). One commonly utilized definition of a voice disorder has been “any time the voice does not work, perform, or sound as it normally should, so that it interferes with communication” (Roy, Merrill, Thibeault, Gray, & Smith, 2004). Voice disorders are typically broken down into three broad categories: neurologic (i.e., vocal fold paralysis), organic (i.e., carcinoma), or functional (i.e., vocal nodules) (Boone, McFarlane, Von Berg, & Zraick, 2014). Functional voice disorders are especially relevant for professional voice users, as these particular disorders typically stem from either misuse or overuse of the voice. According to the American Academy of Otolaryngologists, more than half of all teachers develop a voice disorder during their lifetime, 20% report missing work due to a voice issue, and 1 in 10 teachers are forced to leave the profession because of voice problems (Roy et al., 2004). Although vocal complaints among teachers and singers have been well documented, little is known about the prevalence of voice disorders among other presumably high-risk groups, such as music therapists. Boyle and Engen (2008) made this point in their review of the potential risk factors by describing music therapy as a “vocally demanding profession” (p. 46). And while acknowledging that no evidence of lifetime or point prevalence for voice disorders among music therapists existed, they recommended that educational programs and preventive health mechanisms (e.g., voice screenings and evaluations) be put into place. More recently, Gooding (2016) identified voice problems as one of many occupational risks faced by practicing music therapists. Further reiterating the need for empirical evidence on the risks and lifetime occurrence for voice disorders, Gooding provided a number of ameliorative voice care strategies, including vocal warm-ups, hydration, vocal rest, and voice amplification. Others have studied the perceived impact of voice problems among music therapists. Murray (2014) explored the shared experiences of music therapists diagnosed with vocal health problems. Using a phenomenological approach, Murray found that the challenges associated with having a voice disorder impacted occupational, interpersonal, emotional, and physical aspects of music therapists’ lives. Moreover, these music therapists experienced a shift in how they approached their clients and the music therapy profession. One respondent found that she developed an appreciation for her clients with communication disorders: “I’ve seen what it feels like to be able to not communicate… It was a very isolating experience so its [sic] given me good perspective for the clients I work with” (p. 34). In a study of factors related to music therapist occupational burnout, Murillo (2013) reported that approximately 12% of respondents identified vocal health as a concern. As part of the analytic approach, Murillo identified two emergent themes. The first theme centered around vocal injury and was characterized by responses such as “I believe that vocal health skills are undervalued at the academic level, resulting in injury that could be avoided due to lack of proper training,” and “I’ve had issues with vocal health because of overuse and lack of self-care” (p. 106). Statements constituting a second theme about the importance of vocal health serve as a cautionary tale to those entering the profession: “Vocal care is an important issue that is sometimes overlooked,” “You need to take care of your voice, how to sing and how not sing,” and “Warming up vocally and instrumentally is highly important” (p. 118). These findings suggest that education and training prior to entering the field are undervalued or ignored. As music therapists are required to not only speak but also sing for prolonged periods of time, this particular occupational group would seemingly be at risk for potential voice overuse common to both singers and teachers. Since voice disorders are often preventable given access to adequate information about how to care for the voice, it also becomes important to ascertain the degree of continuing education that music therapists might currently be receiving regarding vocal health. Other risk factors beyond voice overuse (i.e., smoking, acid reflux, allergies, alcohol) have not been thoroughly studied in this occupational group. Survey Purposes To better elucidate the prevalence of and risk factors related to voice use among music therapists, the author distributed a survey to American Music Therapy Association (AMTA) members to: 1. Estimate the prevalence of voice problems among professional and student members of AMTA; 2. Identify the presence of risk factors associated with voice problems among professional and student members of AMTA; and 3. Determine whether vocal health or the development of voice problems are addressed through continuing education, vocal training (at the pre-professional level), or the workplace. Methods The researchers used a non-experimental, survey approach to address the study’s purposes, which involved both descriptive and comparative design features (McMillan & Schumacher, 2009). QuestionProTM, an online survey platform, was used to create and distribute a researcher-designed questionnaire to professional and student members of AMTA. The researchers selected QuestionProTM because of its use in recent music therapy–related studies (Waldon, 2015a; Waldon & Wheeler, 2017); ease and flexibility of use; survey distribution, data organization, and respondent management features; and familiarity to the first author. Participants All methods and procedures, including those involved in participant selection, used in this study were approved by the researchers’ Institutional Review Board. Following their policies for purchasing the names and e-mail addresses, the AMTA provided a listing of contact information for student and professional-level members. During this process, it was also noted that the contact information for AMTA members opting out of third-party mailings was not included in the listing. This suggests that the available population (i.e., the members identified in the list) may not accurately represent the membership by not including those members choosing not to be contacted by third parties. In all, the authors distributed the survey via e-mail to 1752 potential participants on February 1, 2017, which was followed by two survey reminders to those who had not yet responded. Instrumentation The researcher-designed questionnaire1 included three parts and items about participants’ background and training, current voice use, and a standardized self-report measure. The first part, background and demographic information, included 19 items, many of which served to define the study’s independent variables: years since training/in practice, educational attainment, work setting, occupational role, history of formal voice training, and primary instrument/voice part studied. Part two of the questionnaire consisted of items inquiring about respondents’ vocal practices, health status, and other behaviors, particularly those that may place a person at greater risk for developing a voice disorder (e.g., alcohol, caffeine, and tobacco use) (Roy, Merrill, Gray, & Smith, 2005). The final part of the questionnaire included two items related to current and past voice disorders. The first item was the Voice Handicap Index 10 (VHI-10; Rosen, Lee, Osborne, Zullo, & Murry, 2004), a 10-item self-report questionnaire designed to assess the psychosocial impact of a voice disorder on an individual’s well-being. The VHI-10 is a standardized voice-specific quality of life scale, and it is the most frequently used measure to gauge the psychosocial impact of a voice disorder (Franic, Bramlett, & Bothe, 2005). Participants respond to each item on a 5-point scale, with total scores ranging from 0 (no voice handicap) to 4 (worst possible voice handicap). An abbreviated form of the 30-item Voice Handicap Index (VHI; Jacobsen at el., 1997; Rosen et al., 2004) studied the VHI-10 alongside the full index and confirmed the presence of convergent-related evidence (r = .90) claiming that both tools were equivalent measures. In a separate study, Deary, Webb, Mackenzie, Wilson, and Carding (2004) found that the VHI-10 possessed adequate internal consistency (Cronbach’s alpha = .89) and, using principal components analysis, that the tool measured a single construct: perceived functional impact of voice disorder symptoms. As a final question in the voice disorders portion of the questionnaire, respondents were asked to identify whether they currently or previously had been diagnosed with a voice disorder using a definition provided by the researchers. Results Respondent Characteristics Of those invited to participate, 561 responded, which represents a response rate of 32%, considered acceptable by Saldivar (2012). The majority of the respondents were professional members (88.71%), while others included undergraduate student (1.25%), graduate student (8.6%), and honorary life (1.08%) members.2 Retired and inactive status members each comprised less than 1% of the sample. Regarding regional representation, the majority of the respondents were from the Great Lakes (23.8%) and Mid-Atlantic (21.7%) regions, followed by the Western (17.8%), South Eastern (12.2%), Mid-Western (11.2%), South Western (7.0%), and New England (6.0%) regions. Less than 1% of the respondents were from outside the United States. Using region of residence as an independent variable, respondent regional representation was proportionately similar to those reported in the 2016 AMTA Member Survey and Workforce Analysis, χ2(7, N = 517) = 0.42, P > .05, ns. Table 1 includes additional survey respondent characteristics related to gender, age category, educational attainment, occupational role, and clinical setting. Table 1 Respondent Characteristics   n  %  Gender (n = 560)   Female  504  90.0%   Male  54  9.64%   Other (non-binary, transgender)  2  0.36%  Age Category (n = 559)   18 to 29 years  148  26.48%   30 to 39 years  126  22.54%   40 to 49 years  108  19.32%   50 to 59 years  96  17.17%   60 to 69 years  69  12.34%   70 or more years  12  2.15%  Educational Attainment (n = 531)   Undergraduate Degree  230  43.31%   Master’s or Specialist-level Degree  246  46.33%   Doctoral-level Degree  55  10.36%  Occupational Role (n = 509)   Clinical  420  80.0%   Administrative  38  7.24%   Academic Teaching and/or Research  51  9.71%  Clinical Setting (n = 510)   Corrections  7  1.37%   Education/School Setting (pre, K–12)  77  15.09%   Hospice  55  10.78%   Inpatient/Outpatient Medical  50  9.80%   Inpatient/Outpatient Psychiatric  64  12.54%   Military (including Veteran’s Affairs)  7  1.37%   Private Practice/Contractual  113  22.15%   Rehabilitation (physical, speech, occupational)  9  1.76%   Skilled Nursing/Older Adult Setting  56  10.98%   Adults with Intellectual Disabilities  25  4.90%   University/College (Academic Teaching/Research)  47  9.21%    n  %  Gender (n = 560)   Female  504  90.0%   Male  54  9.64%   Other (non-binary, transgender)  2  0.36%  Age Category (n = 559)   18 to 29 years  148  26.48%   30 to 39 years  126  22.54%   40 to 49 years  108  19.32%   50 to 59 years  96  17.17%   60 to 69 years  69  12.34%   70 or more years  12  2.15%  Educational Attainment (n = 531)   Undergraduate Degree  230  43.31%   Master’s or Specialist-level Degree  246  46.33%   Doctoral-level Degree  55  10.36%  Occupational Role (n = 509)   Clinical  420  80.0%   Administrative  38  7.24%   Academic Teaching and/or Research  51  9.71%  Clinical Setting (n = 510)   Corrections  7  1.37%   Education/School Setting (pre, K–12)  77  15.09%   Hospice  55  10.78%   Inpatient/Outpatient Medical  50  9.80%   Inpatient/Outpatient Psychiatric  64  12.54%   Military (including Veteran’s Affairs)  7  1.37%   Private Practice/Contractual  113  22.15%   Rehabilitation (physical, speech, occupational)  9  1.76%   Skilled Nursing/Older Adult Setting  56  10.98%   Adults with Intellectual Disabilities  25  4.90%   University/College (Academic Teaching/Research)  47  9.21%  View Large Table 1 Respondent Characteristics   n  %  Gender (n = 560)   Female  504  90.0%   Male  54  9.64%   Other (non-binary, transgender)  2  0.36%  Age Category (n = 559)   18 to 29 years  148  26.48%   30 to 39 years  126  22.54%   40 to 49 years  108  19.32%   50 to 59 years  96  17.17%   60 to 69 years  69  12.34%   70 or more years  12  2.15%  Educational Attainment (n = 531)   Undergraduate Degree  230  43.31%   Master’s or Specialist-level Degree  246  46.33%   Doctoral-level Degree  55  10.36%  Occupational Role (n = 509)   Clinical  420  80.0%   Administrative  38  7.24%   Academic Teaching and/or Research  51  9.71%  Clinical Setting (n = 510)   Corrections  7  1.37%   Education/School Setting (pre, K–12)  77  15.09%   Hospice  55  10.78%   Inpatient/Outpatient Medical  50  9.80%   Inpatient/Outpatient Psychiatric  64  12.54%   Military (including Veteran’s Affairs)  7  1.37%   Private Practice/Contractual  113  22.15%   Rehabilitation (physical, speech, occupational)  9  1.76%   Skilled Nursing/Older Adult Setting  56  10.98%   Adults with Intellectual Disabilities  25  4.90%   University/College (Academic Teaching/Research)  47  9.21%    n  %  Gender (n = 560)   Female  504  90.0%   Male  54  9.64%   Other (non-binary, transgender)  2  0.36%  Age Category (n = 559)   18 to 29 years  148  26.48%   30 to 39 years  126  22.54%   40 to 49 years  108  19.32%   50 to 59 years  96  17.17%   60 to 69 years  69  12.34%   70 or more years  12  2.15%  Educational Attainment (n = 531)   Undergraduate Degree  230  43.31%   Master’s or Specialist-level Degree  246  46.33%   Doctoral-level Degree  55  10.36%  Occupational Role (n = 509)   Clinical  420  80.0%   Administrative  38  7.24%   Academic Teaching and/or Research  51  9.71%  Clinical Setting (n = 510)   Corrections  7  1.37%   Education/School Setting (pre, K–12)  77  15.09%   Hospice  55  10.78%   Inpatient/Outpatient Medical  50  9.80%   Inpatient/Outpatient Psychiatric  64  12.54%   Military (including Veteran’s Affairs)  7  1.37%   Private Practice/Contractual  113  22.15%   Rehabilitation (physical, speech, occupational)  9  1.76%   Skilled Nursing/Older Adult Setting  56  10.98%   Adults with Intellectual Disabilities  25  4.90%   University/College (Academic Teaching/Research)  47  9.21%  View Large Study Purpose #1: Prevalence of Voice Problems Provided with a standard definition of a voice disorder,3 43.02% (n = 222) of respondents reported having had a voice disorder at some point in their lives (lifetime prevalence), a rate that exceeds the general lifetime prevalence of 29.9% (Roy, Merrill, Gray, & Smith, 2005). Additionally, the percentage of respondents currently reporting a voice disorder (point prevalence, 7.75%; n = 40) exceeded that in the general population (6.6%) (Roy et al., 2005). Study Purpose #2: Voice Disorder Risk Factors Regarding risk factors, 84.12% (n = 434) of respondents reported at least one vocal health risk factor, the most frequent of which included seasonal allergies (66.5%; n = 343), acid reflux (29.1%; n = 150), and missing at least one day of work because of a voice issue (29.1%; n = 150). Figure 1 includes a complete list with corresponding frequencies for the risk factors explored in the survey. Additionally, using the VHI-10 total score as a diagnostic measure, 15.8% (n = 82) of respondents met criteria (at the time of the survey) that would justify a referral to a laryngologist. Figure 1. View largeDownload slide Reported frequency of vocal health risk factors explored in this survey (n = 516 valid responses). Figure 1. View largeDownload slide Reported frequency of vocal health risk factors explored in this survey (n = 516 valid responses). Study Purpose #3: Vocal Health Education and Training Of the 402 respondents answering questions related to vocal health maintenance and education, 4.13% (n = 17) indicated that they had never received training or education about the voice. For those who had reportedly received such instruction, respondents indicated that voice education was required as part of their academic training (n = 157); came after entry into the field (e.g., through private instruction, continuing education; n = 103); occurred prior to academic training (n = 102); and/or was an elective during academic training (n = 33). Survey Discussion Results suggest that not only are music therapists at an elevated risk for the development of a voice disorder, but the availability and types of training and educational resources related to vocal health may not be consistent. Results from the current investigation found that 7.8% of respondents reported experiencing a current voice disorder. This percentage is well above the data culled from the general population, which indicates a 1.7% yearly prevalence rate of voice disorders in the United States (Benninger, Holy, Bryson, & Milstein, 2017). This would suggest that music therapists are more likely to experience a voice disorder as compared to those in other occupations. However, caution should be used when comparing these figures, as the 1.7% general prevalence was based on national medical databases where patients actively sought medical attention. Some individuals with voice problems may not seek out a physician’s care due to a variety of factors (i.e., lack of insurance, distance to clinic). Those in the general population who might experience voice disorders but choose not to seek medical care were not reflected in the results of the recent Benninger et al. study. Regarding risk factors, the majority of study respondents reported having at least one risk factor associated with developing a vocal health problem (Roy et al., 2005). Additionally, findings from the VHI-10 suggest that over 15.8% of respondents met criteria for a referral to a laryngologist. The cutoff value utilized for potential referral was 7.5 or above on the VHI-10 (Behlau et al., 2016). These findings combined with the point and lifetime prevalence of voice disorders among respondents would seem to substantiate Boyle and Engen’s (2008) assertion that music therapists should be concerned about vocal health. Finally, this survey sought to identify whether (and what types of) vocal health education had been available to survey respondents. While a minority indicated never having received such education (4.13%), that only 39% of respondents indicated that vocal health training was included (or required) in their academic programs is alarming given the apparent risk. Therefore, the authors would suggest reexamining the AMTA Professional Competencies and having academic programs review curricula and take considerable note of the extent to which vocal health is addressed for all developing and entry-level clinicians. It may also be beneficial to study the specific types of education available to music therapists, how instruction is delivered (e.g., in groups versus individual settings), and when information on vocal health is being offered (e.g., at the beginning/end of training or following entry to the field). As in all survey research, there are two limitations that should be considered when interpreting findings. The first involves respondent recruitment and survey participation. While the 32% response rate is considered acceptable given the online nature of the survey, it is unknown whether those who chose not to participate are in some way substantially different from those who did. Additionally, because AMTA members are permitted to “opt out” of being contacted by third parties, the sample may not be fully representative of the AMTA membership at the time of the survey. In this same regard, not all practicing music therapists are members of AMTA, with some estimates suggesting that only a third of Board-Certified Music Therapists (MT-BCs) are members (Waldon, 2015b). Therefore, it may be advisable to conduct a similar study by recruiting MT-BCs through the Certification Board for Music Therapists. The second limitation concerns the use of self-report measures. Whenever a research participant is directed to report about or reflect on a personal belief or behavior, there is a possibility that they will respond in a way that does not reflect their lived experience, that is, they may provide answers viewed as “socially desirable” or that conform to the perceived expectation of the researcher(s). Although unlikely to eliminate this bias completely, research approaches that minimize this threat (e.g., using face-to-face interviews and measures with low face validity; Nederhof, 1985) or verify the veracity of respondent answers could be used. Strategies for Voice Care The term “vocal hygiene” is used among medical speech-language pathologists to refer to the ways in which healthy voicing is maintained (Boone et al., 2014). Vocal hygiene also often involves the purposeful elimination of harmful behaviors that hinder vocal fold healing. Medical Evaluation Before delving into general vocal hygiene recommendations, an important point should be made. If a change in vocal quality and/or pain in the laryngeal area persists for greater than two weeks, it is critical that a person see a physician. More specifically, the advice of a laryngologist (an otolaryngologist, commonly referred to as an ENT with specialized training in the voice) should be sought, as this is a specialist who is trained to diagnose voice disorders. The reason for this disclaimer is that serious medical conditions (i.e., laryngeal carcinoma) might be responsible for the change in voice quality. Even benign lesions can significantly impair vocal function, and a thorough medical evaluation is warranted (Sataloff, 2005). After visualizing the vocal folds, a laryngologist will diagnose the problem and set forth a treatment plan. Depending on the diagnosis, treatment may be medical (i.e., medication, surgery), behavioral (e.g., voice therapy with a speech-language pathologist), or both. Vocal Load The amount of time an individual uses his/her voice is referred to as vocal load. Because the vocal folds collide on average approximately 225 times/second for women and 125 times/second for men (Boone et al., 2014), it is important for professional voice users to be aware of their vocal load. In many cases, hyper-functional voice disorders such as nodules are the result of overuse of the vocal mechanism. Therefore, a key component of vocal hygiene involves a conscious awareness of the ways in which an individual uses the voice both in and out of the workplace. Cutting back on vocally strenuous activities and/or rearranging schedules to accommodate breaks for voice rest are often indicated. Hydration Hydration is also critical for professional voice users such as music therapists. This can either involve systemic hydration (i.e., ingestion of liquid), superficial hydration (i.e., nebulizer, humidifier), or ideally a combination of both. Vocal professionals need to maintain higher levels of hydration because singing and prolonged speaking result in the evaporation of moisture via the oral cavity. Because individual variability is a factor (i.e., exercise level, body mass, etc.), there are no established guidelines regarding the amount of water that should be consumed daily. However, a general water recommendation for professional voice users is either a minimum of 64 ounces (Sataloff, 2005) or a more specific amount based upon a person’s own body weight (e.g., body weight divided in half equals the amount of water to be consumed in ounces; Shaw, 2009). Superficial or external hydration can be accomplished in different ways. Often a humidifier is placed in the bedroom at night and in the office during the day to increase the ambient level of moisture in the surrounding air. Facial steamers commonly purchased at drugstores offer a more direct means of hydrating the vocal fold mucosa. More recently, the use of ultrasonic saline nebulizers administered orally have been shown to help maintain vocal fold moisture and decrease phonation threshold pressure, which results in less perceived vocal effort (Tanner et al., 2010, 2016). The finer particles of the nebulized saline are thought to better reach the level of the vocal folds, as compared to the larger boiled molecules from vaporizers. Tanner and colleagues recommend nebulizing 3–9 ml of a 0.9% sterile saline solution twice daily for approximately 15 minutes. Ultrasonic nebulizers are recommended, as it is believed that the air compressor–powered nebulizers could potentially be drying. The ultrasonic variety uses high-frequency vibrations to aerosolize the medication into a fine mist. These small, often battery-powered portable nebulizers are quiet in operation and can be used virtually anywhere. Single-use plastic vials of 0.9% saline solution can be easily purchased online, but Tanner and colleagues stress that physician approval should be obtained before embarking on a nebulizing protocol. Hydration is important because hydrated vocal folds are able to vibrate using less subglottal pressure and phonatory effort (Sivasankar & Leydon, 2010; Verdolini, Titze, & Fennell, 1994). In other words, well-hydrated vocal folds require less air pressure and effort for either speaking or singing. Reduced phonatory effort and increased vocal endurance translates to a voice that is less tired at the end of the day. Hydration also plays a role in vocal fold healing for patients who are recovering from benign lesions such as nodules (Verdolini-Marston, Sandage, & Titze, 1994). Furthermore, caffeine and alcohol are only recommended in moderation for professional voice users, due in part to their drying effect on vocal fold mucosa and their role in triggering acid reflux (Sataloff, 2005). Reflux and Medications Acid reflux has been associated with the development of a host of voice disorders, including laryngeal cancer (Schneider, Vaezi, & Francis, 2016; Tae et al., 2011). When gastroesophageal reflux (GERD) rises to the level of the vocal folds, a phenomenon known as laryngopharyngeal reflux (LPR) occurs. LPR is particularly harmful to the delicate mucosa of the vocal folds, as stomach acid and digestive enzymes were not designed to come into contact with the vocal folds. Unbeknownst to some, LPR can occur at night due to horizontal body positioning during sleep. Even in the absence of a burning sensation, simply having a persistent lump in the throat, chronic throat clearing, or excessive mucus can all be signs of what is known as “silent reflux” (Dresden, 2016). LPR can sometimes be controlled behaviorally by avoidance of food 2–4 hours before bed, eating smaller and more frequent meals, raising the head of the bed slightly during sleep, and avoiding certain triggers like alcohol, caffeine, chocolate, fatty/acidic foods, carbonated beverages, and gum (Nowak et al., 2005). In more severe cases, medication can be used in the form of either H2-receptor antagonists or proton pump inhibitors (Savarino et al., 2017). Only a physician can decide which medication might be best as well as the duration of treatment. Although certain medications like those for reflux might be prescribed with the aim of helping the voice, there are a host of medications that are contraindicated due to their drying effects. Most over-the-counter decongestants (e.g., pseudoephedrine, phenylephrine), certain allergy medications (e.g., diphenhydramine, chlorpheniramine), and asthma-control agents can negatively impact vocal fold hydration (Simpson, 1996). Certain corticosteroid inhalers (e.g., beclometasone) for asthma are more harmful to the voice than others, so it is imperative that professional voice users such as music therapists consult with their physicians to ascertain if a change in medication might protect the voice to a greater degree. Common colds cannot always be avoided, but rather than reaching for multi-symptom over-the-counter medications (with decongestants that can be drying), a safer alternative is to opt for mucolytic agents such as those that only contain guaifenesin. Guaifenesin thins the thickened secretions often associated with the common cold but does not dry the mucosa. Mucinex® and Robitussin® are two common brands, but it is important to find the specific variety that lists guaifenesin as the only active ingredient on the label. Voice Exercises and Training If a voice disorder is diagnosed by an otolaryngologist and therapy with a speech-language pathologist (SLP) is recommended, it is important that the patient adhere to the individualized treatment plan. However, if an individual has no current vocal complaints and simply wants to keep his/her voice healthy and/or increase range and stamina, one established vocal warm-up technique involves the use of semi-occluded vocal tract exercises (SOVT). These SOVT exercises developed by Titze (2006) often involve a plastic straw and/or lip trills, which add back pressure to the vocal folds, decrease laryngeal tension, and encourage anterior resonant vibrations. For more information on SOVT exercises, readers are referred to http://www.voicescienceworks.org/sovt-exercises.html. Videos of Dr. Titze demonstrating the SOVT exercise of straw phonation are available online. For those music therapists for whom singing is a common practice, formal voice lessons from an experienced teacher of singing is extremely important. Unhealthy singing practices such as singing with excess strain/tension or vocalizing outside an individual’s natural range may pose serious problems. A brief summary of both helpful and harmful strategies for voice care is provided below in Table 2. Table 2 Example Behaviors and Factors That Support or Harm Vocal Fold Health Helpful Behaviors/Factors  Harmful Behaviors/Factors  Hydrating (superficial and systemic)  Excessive caffeine use  Allowing breaks for voice rest  Use of alcohol  Using *SOVT exercises  Inadequate sleep  Using portable amplification  Speaking/singing excessively  Using mucolytic medications  Smoking  Controlling acid reflux (diet or medication)  Exposure to airborne irritants  Using resonant voice  Laryngopharyngeal reflux  Engaging in formal voice training  Drying medications (e.g., antihistamines)  Decreasing laryngeal tension (through stretches or voice treatment)  Chronic throat clearing    Dehydration    Loud phonation for extended periods  Helpful Behaviors/Factors  Harmful Behaviors/Factors  Hydrating (superficial and systemic)  Excessive caffeine use  Allowing breaks for voice rest  Use of alcohol  Using *SOVT exercises  Inadequate sleep  Using portable amplification  Speaking/singing excessively  Using mucolytic medications  Smoking  Controlling acid reflux (diet or medication)  Exposure to airborne irritants  Using resonant voice  Laryngopharyngeal reflux  Engaging in formal voice training  Drying medications (e.g., antihistamines)  Decreasing laryngeal tension (through stretches or voice treatment)  Chronic throat clearing    Dehydration    Loud phonation for extended periods  *Semi-Occluded Vocal Tract Exercises View Large Table 2 Example Behaviors and Factors That Support or Harm Vocal Fold Health Helpful Behaviors/Factors  Harmful Behaviors/Factors  Hydrating (superficial and systemic)  Excessive caffeine use  Allowing breaks for voice rest  Use of alcohol  Using *SOVT exercises  Inadequate sleep  Using portable amplification  Speaking/singing excessively  Using mucolytic medications  Smoking  Controlling acid reflux (diet or medication)  Exposure to airborne irritants  Using resonant voice  Laryngopharyngeal reflux  Engaging in formal voice training  Drying medications (e.g., antihistamines)  Decreasing laryngeal tension (through stretches or voice treatment)  Chronic throat clearing    Dehydration    Loud phonation for extended periods  Helpful Behaviors/Factors  Harmful Behaviors/Factors  Hydrating (superficial and systemic)  Excessive caffeine use  Allowing breaks for voice rest  Use of alcohol  Using *SOVT exercises  Inadequate sleep  Using portable amplification  Speaking/singing excessively  Using mucolytic medications  Smoking  Controlling acid reflux (diet or medication)  Exposure to airborne irritants  Using resonant voice  Laryngopharyngeal reflux  Engaging in formal voice training  Drying medications (e.g., antihistamines)  Decreasing laryngeal tension (through stretches or voice treatment)  Chronic throat clearing    Dehydration    Loud phonation for extended periods  *Semi-Occluded Vocal Tract Exercises View Large Job-Related Accommodations for Voice If a music therapist is experiencing voice problems on the job, it is important to note that voice disorders are considered a disability under the law (Americans with Disabilities Act, 1990). The Job Accommodation Network (JAN, www.askjan.org) offers a host of job-related accommodations that might prove helpful for various work settings. A sample of accommodations suggested for those experiencing voice disorders can be found in Table 3. Table 3 Sample Accommodations for Individuals with Voice Disorders According to the Job Accommodation Network 1.  Allow increased use of text-based communication such as e-mail, instant messaging, and texting  2.  Modify employee’s schedule to allow breaks to manage condition by eating, drinking water, using stress reductions techniques or vocal exercises, or resting voice  3.  Allow flexible use of leave time when symptoms are exacerbated or to pursue treatment  4.  Relocate workstation away from sources of background noise  5.  Allow use of a telephone voice amplification device  6.  Allow use of a portable voice amplifier or a more powerful amplifier such as a PA (public address) system  7.  Reduce background noise by installing noise reduction panels in meeting areas  8.  Change meeting etiquette so only one person speaks at a time  9.  Be prepared to use alternate means of communication such as pen and paper, typing, or an AAC device in cases of extreme vocal fatigue  10.  Modify policies to allow employee to eat or drink at workstation  11.  Allow use of assistive devices such as electrolarynx or AAC devices for employees who use these as a primary means of communication  1.  Allow increased use of text-based communication such as e-mail, instant messaging, and texting  2.  Modify employee’s schedule to allow breaks to manage condition by eating, drinking water, using stress reductions techniques or vocal exercises, or resting voice  3.  Allow flexible use of leave time when symptoms are exacerbated or to pursue treatment  4.  Relocate workstation away from sources of background noise  5.  Allow use of a telephone voice amplification device  6.  Allow use of a portable voice amplifier or a more powerful amplifier such as a PA (public address) system  7.  Reduce background noise by installing noise reduction panels in meeting areas  8.  Change meeting etiquette so only one person speaks at a time  9.  Be prepared to use alternate means of communication such as pen and paper, typing, or an AAC device in cases of extreme vocal fatigue  10.  Modify policies to allow employee to eat or drink at workstation  11.  Allow use of assistive devices such as electrolarynx or AAC devices for employees who use these as a primary means of communication  View Large Table 3 Sample Accommodations for Individuals with Voice Disorders According to the Job Accommodation Network 1.  Allow increased use of text-based communication such as e-mail, instant messaging, and texting  2.  Modify employee’s schedule to allow breaks to manage condition by eating, drinking water, using stress reductions techniques or vocal exercises, or resting voice  3.  Allow flexible use of leave time when symptoms are exacerbated or to pursue treatment  4.  Relocate workstation away from sources of background noise  5.  Allow use of a telephone voice amplification device  6.  Allow use of a portable voice amplifier or a more powerful amplifier such as a PA (public address) system  7.  Reduce background noise by installing noise reduction panels in meeting areas  8.  Change meeting etiquette so only one person speaks at a time  9.  Be prepared to use alternate means of communication such as pen and paper, typing, or an AAC device in cases of extreme vocal fatigue  10.  Modify policies to allow employee to eat or drink at workstation  11.  Allow use of assistive devices such as electrolarynx or AAC devices for employees who use these as a primary means of communication  1.  Allow increased use of text-based communication such as e-mail, instant messaging, and texting  2.  Modify employee’s schedule to allow breaks to manage condition by eating, drinking water, using stress reductions techniques or vocal exercises, or resting voice  3.  Allow flexible use of leave time when symptoms are exacerbated or to pursue treatment  4.  Relocate workstation away from sources of background noise  5.  Allow use of a telephone voice amplification device  6.  Allow use of a portable voice amplifier or a more powerful amplifier such as a PA (public address) system  7.  Reduce background noise by installing noise reduction panels in meeting areas  8.  Change meeting etiquette so only one person speaks at a time  9.  Be prepared to use alternate means of communication such as pen and paper, typing, or an AAC device in cases of extreme vocal fatigue  10.  Modify policies to allow employee to eat or drink at workstation  11.  Allow use of assistive devices such as electrolarynx or AAC devices for employees who use these as a primary means of communication  View Large If an employer is unwilling to accommodate an individual experiencing a voice disorder, the Equal Employment Opportunity Commission (www.eeoc.gov) can be a valuable resource. The EEOC acts as an intermediary between individuals with disabilities and their employers. Conclusion Studies that examine the prevalence of voice disorders among specific occupational groups are an important first step in addressing a potential underlying need. If, as the present data suggest, music therapists are more prone to the development of voice problems, future studies might examine the best ways in which to prevent voice problems before they begin. Since the majority of respondents reported having received voice care education outside their clinical programs, a more systematic means of addressing vocal hygiene education might be warranted. This education could not only be geared toward prevention, but also involve the steps for proper treatment and accommodations should voice problems arise. Future studies might examine the use of the Singing Voice Handicap Index (Cohen et al., 2007) as a self-report tool used to identify voice problems among music therapists. Newer technologies such as ambulatory voice monitoring using dosimeters and accelerometers allow researchers to quantify the amount of speaking/singing a person experiences on a daily basis (Mehta, Van Stan, Masson, Maffei, & Hillman, 2017). These devices, which are even able to monitor vocal loudness and pitch, would permit researchers to objectively quantify how music therapists are using their voices on the job. Stress management and mindfulness programs are gaining ground across the helping professions (Christopher & Maris, 2010). Therefore, in line with other self-care initiatives, perhaps a greater understanding of the vocal mechanism can help ensure that music therapists are able to deliver quality services while enjoying long, productive careers. Eric G. Waldon, PhD, MT-BC, Associate Professor of Music Therapy at the University of the Pacific, is involved with the education and training of music therapists at the undergraduate and graduate level. 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For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Published: May 29, 2018

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