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Voice disorders in teachers: examining the problem and evaluating prevention.

INTRODUCTION

TEACHERS FREQUENTLY STRAIN THEIR VOICES in the classroom, placing them at increased risk of developing vocal dysfunction, or dysphonia. Vocal dysfunction is an occupational risk for all teachers; however, it is an especially important concern for teachers of singing. (1) Miller and Verdolini established that teachers of singing experience more episodes of dysphonia during their career and are more likely to seek medical intervention for vocal dysfunction compared with nonteachers. (2) When compared with teachers of other subjects and grade levels, performing arts teachers are affected more often by chronic voice dysfunction. Chronic vocal stress can lead to serious, permanent health problems that affect a teacher's ability to teach and quality of life. (3)

Teachers account for the majority of the 5-10% of the United States workforce described as "heavy occupational voice users." (4) Recent large cohort studies have revealed that high effort and high volume voice use in the classroom places all teachers at increased risk for developing vocal dysfunction. In a study of over 1,000 teachers, nearly 60% experienced vocal dysfunction that interfered with the ability to communicate. (5) Another large study found teachers to be disproportionately affected by dysphonia compared with nonteachers, suggesting voice disorders in teachers are widespread. (6)

A voice disorder is present whenever a voice does not function, perform, or sound as it usually does, interfering with communication. Symptoms of voice disorders include hoarseness, breathiness, weakness, strain, pain, tightness, ache, discomfort, dryness, and other symptoms. Such symptoms can be caused by various abnormalities that include chronic laryngitis, vocal fold nodules, other benign and malignant masses, laryngoesophageal reflux, paresis, endocrine or pulmonary dysfunction, voice abuse or misuse, glottal insufficiency, and hyperkinesias, among others. Persistent vocal strain can lead to damage of vocal tissue, adversely affecting professional voice users, including teachers. (7)

Despite the fact that dysphonia is not life threatening, Smith et al. found the impact of voice dysfunction to be similar to that of an individual with a severe medical condition. (8) Quality of life questionnaires compared with previously published data revealed that vocally disordered patients suffered equally or more than patients with rheumatoid arthritis, hemodialysis treatments, or a prior bone marrow transplant. (9) Such a significant impact warrants a complete understanding of dysphonia.

This information is especially useful to all education professionals. Improving awareness of voice disorders will increase identification of developing vocal dysfunction and encourage teachers to access effective care crucial to preventing permanent damage. This review presents the current understanding of vocal dysfunction in teachers by defining the frequency of voice disorders, uncovering specific risk factors and patterns associated with the development of voice disorders, and evaluating potential preventive and treatment strategies.

FREQUENCY AND SIGNIFICANCE OF VOICE DISORDERS IN TEACHERS

Vocal dysfunction has long been reported as an occupational hazard for teachers. Compared to the general population, voice disorders affect teachers more often due to excess vocal strain and lack of vocal training. (10) Two controlled studies reported that teachers were nearly twice as likely to experience vocal dysfunction over the course of their career compared with nonteachers. (11) In another report comparing dysphonia in teachers and nonteachers, the former were more likely to experience vocal weakness, fatigued voice, and forced or increased effort. These symptoms led to a higher incidence of scratchy, achy, and uncomfortable phonation. (12) Long periods of high effort phonation and lack of vocal hygiene knowledge are associated with increased incidence of dysphonia. (13)

In a study of teachers with self-identified dysphonia, intense vocal demand was reported by over 80% of teachers, and more than half felt vocal dysfunction negatively impacted their job performance. Ten percent of vocally stressed teachers were limited in their ability to teach, and 39% were forced to reduce their teaching activities in response to vocal dysfunction. The majority of teachers were affected for less than one month; however, 13% were restricted in their ability to teach for over two years. (14)

RISK FACTORS ASSOCIATED WITH DYSPHONIA IN TEACHERS

Teachers speak for long periods of time over noisy classrooms without vocal rest. (15) Speaking with greater effort and incorrect phonation technique predisposes teachers to develop voice dysfunction. (16) Interestingly, although physical education teachers speak with more effort than traditional classroom teachers, they do not have an increased risk of developing voice dysfunction. This observation was explained by vocal rest experienced by physical education teachers between periods of high intensity voice use, suggesting that limited voice rest may be a risk factor for developing occupational dysphonia. (17)

Several large sample studies have identified risk factors associated with the development of dysphonia in teachers. Female gender and older age have been identified consistently as risk factors. (18) Across all age groups, women have higher lifetime prevalence and are more likely to experience chronic vocal dysfunction compared with men. (19) Prevalence of voice disorders also increases in both genders with older age. (20) The greatest risk occurs between the fourth and sixth decades of life. (21) The subsequent decrease in vocal dysfunction frequency may be due to retirement of vocally disordered teachers and the selection of more vocally fit teachers choosing to remain in the workforce. (22)

Lack of physical activity impacts the vocal health of teachers. Questionnaires distributed to over 3,000 teachers in Brazil identified a correlation between physical exercise and decreased prevalence of dysphonia. Of the teachers meeting symptom-based criteria for dysphonia, 47.52% did not exercise regularly, 31.25% exercised less than twice a week, and 21.23% exercised three or more times a week. A significant decrease in vocal dysfunction was found among teachers exercising at least three times a week. (23)

Other identified risk factors include using a loud voice, singing, Caucasian race, and specific subjects taught. (24) Teachers of performing arts and chemistry were found to be at greater risk of developing chronic vocal disorders. Conversely, special education and vocational teachers were found to have reduced risk of vocal dysfunction due limited use of high volume and stressful phonation. Smaller class size and implementation of student-led activities also provide potential explanations of the reduced risk of vocal dysfunction in this group of teachers, as the environment is less demanding vocally. (25)

Teachers with insufficient resources and limited access to technology were also at greater risk of developing vocal dysfunction. The same study revealed that dysphonic teachers failed to see their primary care physician regularly for annual examinations. (26) Teachers with vocal dysfunction are also more likely to have experienced upper respiratory tract infections, stress, anxiety, and concomitant diseases when compared with nondysphonic populations. Variation in vocal fold structure was suggested as a potential predisposing factor, suggesting the possibility of a heritable trait being associated with dysphonia. (27)

IMPACT OF DYSPHONIC TEACHERS

Vocal dysfunction in teachers results in increased absenteeism, diminished quality of life, and general difficulty communicating. (28) Remarkably, few teachers are exposed to proper vocal hygiene education despite demonstrating an interest in preventive care education and treatment. (29) Data suggest an increased rate of attrition of teachers with dysphonia, while vocally healthy teachers remain in the field longer. (30)

Vocal dysfunction occurs over the course of a teacher's career; however, the highest prevalence of vocal complaint occurs during the first five years. Although complaints decrease, vocal dysfunction and absenteeism due to dysphonia increase over the course of a teacher's career. (31) Van Houtte et al. found that teachers experienced more vocal dysfunction than other professionals. Of the vocally disordered teachers, few sought medical treatment and even fewer had been provided with any vocal hygiene information, increasing the impact of dysphonia. The authors recommend implementation of vocal education during teacher's training to help prevent this problem. (32)

Practicing teachers compared with prospective teachers perceived their voices to be in worse condition. Symptoms listed most commonly were dry throat, hoarseness, inability to sing, loss of voice control, and vocal fatigue. Teachers experiencing dysphonia were more likely to feel sad and distressed as a result of vocal dysfunction. This group also felt negatively about their social life, job, and ability to communicate. Few teachers sought medical treatment. Instead, the majority treated themselves with hydration, vocal rest, and herbal remedies. (33)

Vocally disordered teachers impacted student learning negatively. Students taught by severely dysphonic teachers failed to perform as well as those taught by instructors with healthy voices. A study by Rogerson and Dodd examined three classes of elementary school students answering multiple choice questions after listening to prerecorded passages. The three randomly ordered passages were read by a healthy voice, a mildly dysphonic voice, and a severely dysphonic voice. Afterwards students answered six multiple choice questions. In all three classrooms, students performed best when responding to questions read by the healthy voice compared to the dysphonic voices. A clear association was established linking student performance and the vocal health of teachers. (34)

TREATMENT FOR VOCAL DISORDERS IN TEACHERS

Vocal Hygiene and Prevention

Prevention strategies and treatments have been identified for teachers with dysphonia. (35) Preventive measures are low cost and relatively easy to implement, and they have demonstrated efficacy. (36) Bovo et al. studied a group of vocally taxed, at-risk female elementary school teachers. The study group completed a one-time vocal hygiene seminar and small group therapy session; a matched control group received no instruction. After three months, measures of voice quality including Voice Handicap Index (VHI), mean phonation time (MPT), and grade, roughness, breathiness, asthenia, and strain (GRBAS) were all improved significantly in the vocally disordered teachers compared with the untreated control group. Twelve month follow-up revealed persistent improvement, however, not as pronounced. (37) Similar studies have revealed that vocal hygiene education is an effective, low cost intervention to prevent voice dysfunction in teachers. (38)

Voice Amplification

Teachers who have developed vocal dysfunction already can be treated effectively with a variety of techniques. Roy et al. examined the use of voice amplification in the classroom to address dysphonia in two studies. Vocally disordered teachers were sorted into to three treatment groups: voice amplification, vocal hygiene, and a non-treatment control group. Outcomes were assessed based on VHI, self-rating, and audio recordings analyzed by speech-language pathologists. Voice amplification led to significant vocal improvement compared with vocal hygiene. Control subjects became more dysphonic compared with voice amplification and vocal hygiene cohorts. (39) Voice amplification was demonstrated to be superior when compared to resonance therapy and resonant muscle training among other treatment modalities. (40)

Voice Training

The efficacy of resonant voice therapy (RVT) was assessed studying a group of female teachers. Therapy was comprised of weekly small group RVT sessions for eight weeks. Vocal fold pathology, vibration pattern, and voice quality improved after therapy. Improvements agreed with self-perceived voice changes. (41) Roy et al. produced similar data citing improvement with resonance therapy. Compared with respiratory muscle training (RMT), resonance therapy produced superior voice improvement based on VHI scores and a voice severity self-rating scale. Participant dropout disproportionately affected the resonance therapy group. (42)

Combination Treatment

Multiple studies have examined combination therapies to treat dysphonia in teachers. A prospective randomized case control study of middle school teachers in China found that voice training and voice care education were associated with improved voice function and quality. The treatment group was provided with a four-week vocal exercise and voice hygiene program, while the control group received no treatment. Voice Handicap Index (VHI), maximum phonation time (MPT), and noise-to-harmonic ratio (NHR) were used as outcome indicators. All three measures improved significantly for the treatment group compared with the control. (43)

A similar investigation examined dysphonic female teachers and revealed slightly incongruent results. Subjects completed questionnaires, acoustic assessment, and videostroboscopic evaluation before and after treatment. The treatment group received voice training while the control group did not. Both groups received voice hygiene education. Significant reduction in hoarseness and voicelessness was observed in the treatment group. These improvements were not seen in the control group. While this study supports the efficacy of combination therapy, there were significant inconsistencies with subject compliance. (44)

DISCUSSION

The studies evaluated in this review provide education professionals with important information concerning voice disorders in teachers. Integrating this data, the following conclusions can be made: (1) many teachers suffer from vocal dysfunction. Dysphonia in teachers is appreciably more prevalent than in almost any other occupation and can lead to significant restraints on job performance. (2) Teachers speak commonly with increased effort and have limited rest, leading to the development of vocal dysfunction. Other risk factors include older age, female gender, lack of technology resources, and limited exercise. Performing arts teachers are at increased risk, while teaching special education or vocational courses appears less hazardous vocally. (3) The impact of dysphonia is substantial. Dysphonic teachers are more likely to become stressed or anxious, miss days of work, and leave the field of education. Student performance worsens when teachers suffer from voice disorders. (4) Treatments exist for dysphonia. Preventive education is a low cost and highly effective strategy to avoid voice disorders. Voice amplification, voice training and voice therapy are successful interventions. Combinations of voice education and vocal training have been shown to be effective.

These data are encouraging and provide important information for teachers and administrators. Current research findings should prompt school leadership, especially performing arts departments, to inform practicing teachers of the potentially devastating consequences of chronic dysphonia. Schools would benefit from incorporating voice training opportunities for teachers, either as departmental or school-wide professional development workshops. Providing teachers with resources and exercises that might prevent the development of vocal dysfunction permits the development of healthy, effective educators.

While myriad treatments have been developed, weaknesses in measures as well as shortcomings in study design have led to difficulty determining treatment efficacy. Few studies define the term "voice disorder" or "vocal dysfunction." Without a consistent definition, inherent ambiguity is introduced when analyzing results from different sources. Defining and classifying voice disorders clearly and consistently will improve data quality and facilitate the identification of more effective treatments. Similar discrepancies were found in studies examining vocal hygiene education.(45) Differences in the format and content of preventive education likely produce varying results. Further study leading to greater standardization would provide greater guidance for teachers.

The current body of literature investigating vocal dysfunction in teachers exposes the issue as an important health concern, especially for teachers of singing, and demonstrates the need for continued research. Teachers are at significant risk of developing vocal dysfunction making the need for identification, intervention, and prevention especially important. There exists a growing body of literature investigating voice disorders in teachers; however, additional investigation is clearly needed to elucidate fully the prevalence of the problem in various settings, impact of this important health issue, approaches to treatment, and most importantly strategies for prevention.

NOTES

(1.) S. L. Thibeault, R. M. Merrill, N. Roy, S. D. Gray, and E. M. Smith, "Occupational Risk Factors Associated with Voice Disorders among Teachers," Annals of Epidemiology 14, no. 10 (November 2004): 786-792.

(2.) M. K. Miller and K. Verdolini, "Frequency and Risk Factors for Voice Problems in Teachers of Singing and Control Subjects," Journal of Voice 9, no. 4 (December 1995): 348-362.

(3.) E. Van Houtte, S. Claeys, F. Wuyts, and K. Van Lierde, "The Impact of Voice Disorders among Teachers: Vocal Complaints, Treatment-Seeking Behavior, Knowledge of Vocal Care, and Voice-Related Absenteeism," Journal of Voice 25, no. 5 (September 2011): 570-575.

(4.) I. R. Titze, J. Lemke, and D. Montequin, "Populations in the U.S. Workforce Who Rely on Voice as a Primary Tool of Trade: A Preliminary Report," Journal of Voice 11, no. 3 (September 1997): 254-259.

(5.) N. Roy, R. M. Merrill, S. Thibeault, R. A. Parsa, S. D. Gray, and E. M. Smith, "Prevalence of Voice Disorders in Teachers and the General Population," Journal of Speech, Language, and Hearing Research 47, no. 2 (April 2004): 281-293.

(6.) J. Preciado-Lopez, C. Perez-Fernandez, M. Calazada-Uriondo, and P. Preciado-Ruiz, "Epidemiological Study of Voice Disorders Among Teaching Professionals of La Rioja, Spain," Journal of Voice 22, no. 4 (July 2008): 489-508.

(7.) E. Smith, J. Lemke, M. Taylor, H. L. Kirchner, and H. Hoffman, "Frequency of Voice Problems among Teachers and Other Occupations," Journal of Voice 12, no. 4 (December 1998): 480-488.

(8.) E. Smith, K. Verdolini, S. Gray, S. Nichols, J. Lemke, J. Barkmeier, H. Dove, and H. Hoffman, "Effect of Voice Disorders on Quality of Life," Journal of Medical Speech-Language Pathology 4 (1996): 223-244.

(9.) Ibid.

(10.) Titze, Lemke, and Montequin; Smith, Lemke, et al.

(11.) Van Houtte et al.; Roy et al.

(12.) E. Yiu, "Impact and Prevention of Voice Problems in the Teaching Profession: Embracing the Consumers' View," Journal of Voice 16, no. 2 (June 2002): 215-228.

(13.) L. Amorim Alves, M. L. do Carmo Cruz, M. H. Palucci Marziale, and C. da Conceicao Romano, "Healthy Disorders and Teachers' Voices: A Workers' Health Issue," Revista Latino-Americana de Enfermagem 17, no. 4 (July-August 2009): 566-572.

(14.) Smith, Lemke, et al.

(15.) J. Mattiske, J. Oates, and K. Greenwood, "Vocal Problems among Teachers: A Review of Prevalence, Causes, Prevention, and Treatment," Journal of Voice 12, no. 4 (December 1998): 489-499; Titze et al.

(16.) Ibid.

(17.) Thibeault et al.

(18.) A. Russell, J. Oates, and K. M. Greenwood, "Prevalence of Voice Problems in Teachers," Journal of Voice 12, no. 4 (December 1998): 467-479; A. A. Assunccao, I. B. Bassi, A. M. de Medeiros, C. de Souza Rodrigues, and A, Gama, "Occupational and Individual Risk Factors for Dysphonia in Teachers," Occupational Medicine 62, no. 7 (October 2012): 553-559; Thibeault et al.; Roy et al., "Prevalence of Voice Disorders in Teachers and the General Population"; Smith, Lemke, et al.; Amorim et al.

(19.) Roy et al., "Prevalence of Voice Disorders in Teachers and the General Population."

(20.) Ibid.; Thibeault et al.; Smith, Lemke, et al.

(21.) Roy et al., "Prevalence of Voice Disorders in Teachers and the General Population."

(22.) P. Kooijman, G. Thomas, K. Graamans, and F. de Jong, "Psychosocial Impact of the Teacher's Voice Throughout the Career," Journal of Voice 21, no. 3 (May 2007): 316-324.

(23.) A. A. Assuncao, A. M. de Medeiros, S. M. Barreto, and A. Gama, "Does Regular Practice of Physical Activity Reduce the Risk of Dysphonia?" Preventive Medicine 49, no. 6 (December 2009): 487-489.

(24.) Thibeault et al.

(25.) Ibid.

(26.) Assunccao et al., "Occupational and Individual Risk Factors."

(27.) S. H. Chen, S. Chiang, Y. Chung, L. Hsiao, and T. Hsiao, "Risk Factors and Effects of Voice Problems for Teachers," Journal of Voice 24, no. 2 (March 2010): 183-192.

(28.) Van Houtte et al.; Yiu.

(29.) I. B. Bassi, A. A. Assuncao, A. M. de Medeiros, L. N. de Menezes, L. C. Teixeira, and A. C. Gama, "Quality of Life, Self-Perceived Dysphonia, and Diagnosed Dysphonia Through Clinical Tests in Teachers," Journal of Voice 25, no. 2 (March 2011): 192-201; Kooijman et al.; Yiu.

(30.) Kooijman et al.

(31.) Ibid.

(32.) Van Houtte et al.

(33.) Yiu; Bassi et al.

(34.) J. Rogerson and B. Dodd, "Is There an Effect of Dysphonic Teachers' Voices on Children's Processing of Spoken Language?" Journal of Voice 19, no. 1 (March 2005): 47-60.

(35.) N. Roy, B. Weinrich, S. D. Gray, K. Tanner, S. W. Toledo, H. Dove, K. Corbin-Lewis, and J. C. Stemple, "Voice Amplification Versus Vocal Hygiene Instruction for Teachers with Voice Disorders: A Treatment Outcome Study," Journal of Speech, Language, and Hearing Research 45, no. 4 (August 2002): 625-638; N. Roy, B. Weinrich, S. D. Gray, K. Tanner, J. C. Stemple, and C. M. Sapienza, "Three Treatments for Teachers with Voice Disorders: A Randomized Clinical Trial," Journal of Speech, Language, and Hearing Research 46, no. 3 (June 2003): 670-688; R. Bovo, M. Galceran, J. Petruccelli, and S. Hatzopoulus, "Vocal Problems among Teachers: Evaluation of Preventive Voice Program," Journal of Voice 21, no 6 (November 2007): 705-722.

(36.) O. M. Duffy and D. E. Hazlett, "The Impact of Preventive Voice Care Programs for Training Teachers: A Longitudinal Study," Journal of Voice 18, no. 1 (March 2004): 63-70; Bovo et al.

(37.) Bovo et al.

(38.) Roy et al., "Voice Amplification Versus Vocal Hygiene."; Bovo et al.

(39.) Roy et al., "Voice Amplification Versus Vocal Hygiene."

(40.) A. Ziegler, A. I. Gillespie, and K. Verdolini-Abbott, "Behavioral Treatment of Voice Disorders in Teachers," Folia Phoniatrica et Logopaedica 62, no. 1-2 (January 2010): 9-23; Roy et al., "Three Treatments."

(41.) S. H. Chen, T. Y Hsiao, L. C. Hsiao, Y. M. Chung, and S. C. Chiang, "Outcomes of Resonant Voice Therapy for Female Teachers with Voice Disorders: Perceptual, Physiological, Acoustic, Aerodynamic, and Functional Measurements," Journal of Voice 21, no. 4 (April 2007): 415-425.

(42.) Roy et al., "Three Treatments."

(43.) J. Duan, L. Zhu, Y. Yan, T. Pan, P. Lu, and F. Ma, "The Efficacy of a Voice Training Program: A Case-Control Study in China," European Archives of Otorhinolaryngology 267, no. 1 (January 2010): 101-105.

(44.) E. Niebudek-Bogusz, B. Sznurowska-Przygocka, M. Fiszer, P. Kotylo, A. Sinkiewicz, M. Modrzewska, and M. Sliwinska-Kowalska, "The Effectiveness of Voice Therapy for Teachers with Dysphonia," Folia Phoniatrica et Logopaedica 60, no. 3 (March 2008): 134-141.

(45.) Ibid.; Duan et al.; Bovo et al.

Adam R. Szymanowski, MS is a medical student at Drexel University College of Medicine in Philadelphia. He was formerly a middle school science teacher with the New York City Department of Education. Mr. Szymanowski holds an undergraduate degree from the University of North Carolina at Chapel Hill in biology and a master's degree in teaching from Pace University in New York City, New York.

Katherine S. Borst, MS is a medical student at Drexel University College of Medicine in Philadelphia. Ms. Borst received her BS and MS in Biobehavioral Health at Pennsylvania State University, University Park.

Der Nebel stieg, das Wasser schwoll,
Die Move flog hin und wieder;
Aus deinen Augen liebevoll
Fielen die Tranen nieder.

Ich sah sie fallen auf deine Hand,
Und bin aufs Knie gesunken;
Ich hab' von deiner wei[B]en Hand
Die Tranen fortgetrunken.

Heinrich Heine
"Am Meer," Franz Schubert
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Title Annotation:CARE OF THE PROFESSIONAL VOICE
Author:Szymanowski, Adam R.; Borst, Katherine Streitel; Sataloff, Robert T.
Publication:Journal of Singing
Article Type:Report
Geographic Code:1USA
Date:Nov 1, 2014
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