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Readings

McCoy(2004).YourVoice:AnInsideView.Chapter12(pp.158174) Miller(1996).TheStructureofSinging.Chapter17(pp.218240) Shewell(2009).VoiceWork.Chapter27&28(pp.415460)

Vocal Health & Voice Care


Objectives:
1. Discussissuespertainingtovocalhealth 2. Brieflyexaminevocaldisordersresultingfrommisuseofthevoice 3. Reviewpositivelivingpracticesthatenhanceoverallvocalhealth.

Outcomes:
Thismoduleendeavourstohighlighttheeverpresentchallengeofthesingeristheirinstrument.Atthe endofthissession,thestudentshouldbemoreawareofthenecessityforvoicecareandtheimpactsof environmentandlifepracticeontheirgeneralvocalhealth.

1. Vocal Health
I have been presenting on the topic of Vocal Health & Voice Care for nearly twenty years and it still amazesmehowmanysingersrolltheireyeswhenIstresstheimportanceofthetopic.Allowmetostate upfront,Iamnotavocalhypochondriac!IdonotseevocaldamageeverywhereIlook(orhear),nordoI believe every contemporary vocal sound is detrimental to the health of the voice. This being said, singers embody their instrument. Everywhere the singer goes, everything (and I mean everything) the singer does and all that the singer is has a bearing on the singers vocal health. Allan Dawson (2005) states it quite simply: Vocal health is an occupational concern for all singers (p. 14). Notsomebutallsingers! Beforecontinuing;adisclaimer:Thematerialinthis[module]isintended toproviderudimentaryinformationabout[vocalhealthandvoicecare].It is not meant for use as a diagnostic or therapeutic tool, nor as a substitute for consultation with an otolaryngologist or voice therapist (McCoy,2004,p.158).
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NormalVoice
Banktellersareeducatedtoidentifycounterfeitmoneybycarefullystudyinggenuinecurrency.Andthat iswhereweshouldstartwiththehumanvoice:Whatdoesnormalvoicelookandsoundlike?1 Firstly, it is important to allow for some variance in what we consider normal. There are far too many exceptions to the rule to categorically state fixed rules of normality. For example, the human voice is anatomically capable of three to three and a half octaves of phonatory range (Thurman, Theimer, Grefsheim, & Feit, 2000, p. 773), but there are singers who exceed these so called normal limits. Brisbane (Australia) based singer Adam Lopez currently holds the Guinness world record for the highest note sung by a male voice: C sharp in the 8thoctave (one note above the range of a piano!). Wow! Thatsnotnormal. Havingacknowledgedsomewriggleroomwhendiscussingnormalvoice,letsbrieflydefinehownormal voiceshouldtypicallypresent: Normal Voice Pathology: The healthy voice, when viewed under fixed or flexible scope, should present as a free (unobstructed) airway. The vocal folds should be lightpink or pearlywhite in colour with no observable lesions or dysfunction. There should be relative symmetry to the glottispositioninaccordancewiththepositioningofthearytenoidsandthemannerinwhichthe arytenoidsactivate.2Themajorityofthetruevocalfoldlengthshouldbeclearlyvisible. Normal Voice Phonation: The healthy voice should present as a clear tone. Phonatory dysfunctionmightexhibithighlevelsofaspiration(breathiness)orraspysound,reducedcapacity for increasing volume and inconsistent phonatory patterns (e.g. the sound cutting in and out). It is important to note however that the presence of these characteristics does not automatically indicatereducedhealthorfunction.ChristinaShewell(2009)remindsusthat,
No voice practitioner can ever reliably identify the nature of the voice disorder by the sound of the voice. The sound of a voice may give clues about vocal tract and fold function, but it cannot specify the pathology that is creating that sound. Highlevel laryngeal examination is essential, and there are frequentlysurprises.(p.416)

Vocal longevity will be achieved by attending to vocal health through healthy voice production, following a vocal hygiene program, and avoiding vocal injury and not losingsightoftheimportanceofgeneralhealth.(Harvey&Miller,2006,p.108)

For a more detailed review of vocal anatomy the interested reader is encouraged to read Vocal Anatomy 101 (Robinson, 2013). 2 There is currently some debate about the impact of asymmetry of the arytenoids and whether or not this actually has any detrimental effect on phonatory patterns. Without seeking to solve the issue here, perhaps this is another area where normalhasawidescopeofvariance.Furtherresearchmayyetshedlightonthisongoingdiscussion. Page2 VocalHealth&VoiceCare 2013DrDanielK.Robinson
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TheDisorderedVoice
Of course, maintaining clear normal voice function is a challenge to the professional voice user; just as maintaininghealthyfunctionalphysiologyistheeverpresentchallengefortheprofessionalathlete.But things do go wrong. A professional singer can perform successfully for decades without complaint, but thenoneday(usuallythroughaseriesofcollidingevents)noticesthattheirvoiceisnotperformingwith itsusualrigororagility. Shewell(2009)identifiesthedifferencebetweenavoicedisorderandageneralvoiceproblem(p.415) bynominatingthreegroups:3 1. Impairment: temporary alteration to the normal function which might exhibit with some breathinessorsoreness. 2. Disability:prolongedchangestovocalsoundandfunction;oftenprecededbyimpairment. 3. Handicap:thedisabledvoicewhenexposedtodisadvantagerelativetoothers. Clearly, a vocal impairment, if left unattended, may develop into a vocal disability. The disabled professional voice is most definitely exposed to disadvantage when seeking income arising from the regular and sustained use of their voice. Thus, the professional singer with a damaged voice can be thoughtofashandicapped! When identifying voice disorders practitioners typically classify the conditions into two groups: Organic andFunctional.4
Traditionally, organic pathologies are those for which a specific lesion, disease, or malfunction can be identified in some organ of the body relevant to voice production. Functional pathologies usually are defined as those for which there is no identifiable lesion, but voice production is somehow abnormal. (Titze&Abbott,2012,p.51)

Letsnowlookatthevariousvoicedisordersgroupsunderthesetwoheadings. 1. Organic:thesevocaldisordersoftenrequiresurgicalintervention,butthisisgenerallyconducted after the patient has adequately (to the surgeons satisfaction) addressed their vocal hygiene elements(e.g.hydration,alcohol,acidreflux),adjustedtheiroverallvocaloutputandvocalloads (e.g. relative and/or complete vocal rest), and attended speech therapy for 510 sessions (Bastian,Klitzke,&Thurman,2000). Laryngitis: The term laryngitis is used synonymously for a range of vocal ailments including short term viral infection (leading to acute inflammation of the vocal folds and surrounding tissues) and chronic longterm inflammation which is often caused by irritants(reflux,smokingetc.).

ShewellhasderivedtheselabelsfromtheWorldHealthOrganisation(Shewell,2009,p.415). Itisimportanttonotethatthelinethatseparatesorganicandfunctionalcanoftenbeblurredbecauseattimesitisdifficult toidentifywhatiscauseandwhatiseffect.


4 3

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Vocal Fold Cysts: Small sacs of fluid can randomly appear anywhere in the body, including the larynx. Deceptive little critters5, vocal folds cysts (mucus retention cysts; Figure1)willoftenswellwithvocaluseandthenreducein size with vocal rest, leaving the voice user believing theyre voice has healed. This type of cyst occurs more commonly just below the leading edge of a foldwhen cysts become large enough, they can impact on the other fold and can cause a nodular tissue reaction there (Bastian,Thurman,&Klitzke,2000,p.533).

Figure1:CystonRightVocalFold

Papillomas: Believed to originate from a wartlike virus, papillomas can occur suddenly, and in chronic cases can be life threatening (especially in small children) due to the manner in which they grow and obstruct the airway. The wartlike growths may need to be surgically managed; that is, removed regularly to ensure an unobstructed airway. Oftenthepapillomasresolvethemselvesanddiscontinuegrowing;again,notdissimilarto thecommonwart. Vocal Fold Paralysis and Paresis: The vocal folds and their surrounding musculature are driven by the right and left recurrent laryngeal nerve. If either (or both) of these nerves becomes damaged, paresis (partial) or paralysis (complete) can be sustained either temporarily or permanently. Vocal fold paralysis can be obtained during times of trauma to the neck (e.g. thyroid surgery). Vocal fold paralysis is generally treated with voice therapyand/orsurgicalintervention. Spasmodic dysphonia/laryngeal dystonia: An intermittent disorder of the vocal folds, spasmodic dysphonia is evidenced by irregular and abrupt closure and/or opening of the glottis. This rare condition is often treated by injections of botulinum toxin (botox) into thevocalfolds,toweakentheirclosurepatterns(Shewell,2009,p.435). Laryngeal Cancer: Cancer of the larynx is a relatively uncommon occurrence. Typically found in older people with a history of heavy smoking and alcohol consumption, presenting symptoms may include voice change, chronic sore throat with or without swallowingdifficultyandoccasionally,asenseofbreathingrestriction(Bastian,Klitzke, et al., 2000, p. 629). Treatment of laryngeal cancer is dependent on the size and type of thecancerousgrowth.

Ofcourse,vocalfoldcystsarenotcrittersImwritingcolloquially. Page4 VocalHealth&VoiceCare 2013DrDanielK.Robinson

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2. Functional:typically,thesevocaldisorderscanbeshowntooriginatefromthefunctionalactivity of the voice the manner in which the vocalist has been using their voice. Again, it is important to note that the line that separates organic from functional is often blurred by the multiplicity effect of many contributing factors. That is, vocal disorders can (and often do) onset because of both organic and functional matters: e.g. the singer with nodules (functional) may have developedthembecausetheychosetosingonavoicewithchroniclaryngitis(organic). a) Primarilyderivedfrommuscletension Muscle Tension Dysphonia (MTD): Usually related to speech patterns, MTD is the hypo adduction of the vocal folds.6 Muscle Tension Dysphonia is generally evidenced by a large posterior glottal chink, which produces a breathy voice with much air leakage (Titze & Abbott, 2012, p. 85). MTD requires therapeutic intervention designed to assist complete symmetrical adduction (closure) of the vocal folds along the full line of the glottis.Ifleftuntreated,MTDcandevelopsecondaryconcernssuchnodules. Vocal Fold Swelling (oedema7): Like all muscles, the vocalis muscle (the muscular body of the true vocal folds) swells with use; i.e. the muscle is supplied with extra blood flow duringheighteneduse.However,underextremeuseand/orwhenthehealthofthevoice is compromised (e.g. laryngitis) the natural levels of heightened blood flow can move beyond a tippingpoint, and become detrimental to healthy phonatory patterns. This compensatory response of the bodys physiology may distribute additional fluid to the lamina propria (second layer of the true vocal fold) in order to provide protection and healing. Pitch can be altered by fluid engorgement (edema). The usual explanation for pitch drop in edema cases is that greater mass creates lower natural frequencies (Scherer,2006,p.90).Oftenthebesttreatmentforacuteoedemaiscompleteorrelative vocalrest. Reinkes oedema: The labelling of this form of vocal fold swelling is socalled because it occurs in the Reinkes space (the second layer of the true vocal fold). Not actually a cavernous space, Reinkes space is a gelatinous layer that allows the epithelium (outer layer) to move freely (oscillate) over the top of it. An extreme and prolonged (chronic) case of vocal fold swelling (often observed in older people with a history of smoking or heavy alcohol consumption) is referred to as Reinkes oedema. In some cases, Reinkes oedema may be alleviated by voice therapy and/or the removal of excess fluid via surgery.Reinkesoedemamightalsobeobservedinsuffersofchronicreflux. Nodules: Striking fear into the heart of most vocalists, nodules have earned widespread renown,butaremostlymisunderstoodbyvoiceusers.Nodulesgenerallyoccurasaresult ofpoormuscularfunction(e.g.MTD)orbyusingthevoiceduringatimeofcompromised

TitzeandAbbott(2012)highlightthatinsomecasesofMTDthevocalfoldsarehyperadductedovertheirlength,although thisistheexception.(p.85) 7 TheAmericanspellingofoedema(Englishspelling)isedema. Page5 VocalHealth&VoiceCare 2013DrDanielK.Robinson

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health (e.g. laryngitis). Similar to small calluses on the outer edge of the vocal folds, nodulesaresmallbenignswellings(typicallybilateral)thatinterruptthevocalfoldripple wave. Soft nodules (early in development) are often resolved with voice therapy, but if the swellings have been allowed to persist and harden, and if time is pressing (i.e. if a singer is on tour and the show must go on), then surgical removal might be entertained as a quickfix solution. Leading Otolaryngologist, Dr Robert T. Sataloff (2006) writes, Vocal nodules resolve with proper voice use and should be treated with voice modification and relative voice rest, including avoidance of vocally abusive activities (p. 255). Even when surgery is the chosen option, voice therapy (both spoken and singing) is highly recommended as the remedial route for learning new vocal habits designed to diminishthechanceofthenodulesredevelopment. Polyps:Occurringasaprotrusionanywherealongthevocalfold,polypsgenerallydevelop as a singular mass lesion (unlike nodules which typically occur bilaterally) and may vibrate with the vocal fold oscillation. Sometimes described as a nodule with a stalk (Dayme, 2009, p. 163), these lesions rarely respond well to voice therapy in the first instance; and typically require surgical removal followed by remedial voice therapy. These functionally derived growths onset due to vocal abuse (often preceded by vocal fold haemorrhage) and can occur suddenly; whereas nodules are often seen developing overprolongedperiodsofmisuse. VocalFoldHaemorrhage:Perhapsoneofthemoredebilitatingfunctionaldisordersofthe voice (in the acute stage) is the vocal fold haemorrhage (Figure 2). McCoy (2004) points out that, a person who experiences a vocal fold haemorrhage will almost certainly realise something is wrong with his or her voice (p. 164). As the name suggests this disorder, typically occurring due to highlevel vocal abuse8, is the rupture of capillaries (blood vessels) either within the lamina propria (second layer) or the epithelium (outer layer) causing bruising of the vocal fold. The bleeding impedes normal vocal fold oscillation and if left untreated can lead to significant scarring. Immediate and complete vocal rest is generally prescribed,and in rarecases, due to continuous bleeding, surgery may be required. Again, voice therapy (speech and singing) is highly recommended following a vocal fold Figure2:VocalFoldHaemorrhage(LeftVocalFold) haemorrhage.

Vocal fold haemorrhage can also be caused by coughing and crying. Shewell (2009) notes that Sataloffs (1997) says that aspirin and the premenstrualperiod make them more likely in women singers who sing hard and strongly (p.424).It is also importanttonotethatdrugscontainingibuprofenhavebeenshowntoheightentheriskofvocalfoldhaemorrhage. Page6 VocalHealth&VoiceCare 2013DrDanielK.Robinson
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Vocal Fold Sulcus: Observed as a groove along the vocal fold tissue, a sulcus vocalis runs parallel to the vocal fold margin (Titze & Abbott, 2012, p. 57). One of the least understood vocal fold disorders (in regards to its origin), the vocal fold sulcus can be aggravatedbyheavyvoiceuseandinseverecasesthebiomechanicaloscillatorbecomes a double oscillator, with upper and lower tissues moving independently (p. 58). Resulting in a highly fatigued voice with thin and reedy phonation, vocal fold sulcus may respondtovoicetherapy,butgenerallyrequiressurgicalinterventioninordertoimprove vocalfoldoscillation. Vocal Process Granulomas & Ulcers: The vocal process granuloma (raised granulation tissue) and the vocal process ulcer (embedded abrasion) typically occur on the cartilaginous portion of the vocal folds which are attached to the vocal processes of the arytenoid cartilages (the rear twofifths of the vocal folds) (Bastian, Thurman, et al., 2000, p. 532). It is thought that granulomas precede the development of contact ulcers, and are actually the part of the healing process (McCoy, 2004, p. 168). Often observed in suffers of reflux disease and in voice users who expose the mechanism to extreme vocal loads, these formations can be experienced as painfully intrusive sensations that develop over time. Treatment is often directed at the cause (e.g. alleviating reflux through diet and medication), and while some granulomas may mature and spontaneouslydetach,othersmayrequiresurgicalremoval. VocalFoldBowing:Causedbytheinabilityofthevocalfoldstoadduct(close)tothemid lineoftheglottis,thecharacteristicbowingofthevocalfoldsprovidesthisdisorderwith its namesake. Considered by some to be caused by extended use of forced falsetto (McKinney, 1994; Titze & Abbott, 2012), this vocal disorder create[s] a leaky voice, whichsoundsasthenic(weak),eventhoughthereisconsiderableefforttoproducevoice (Titze & Abbott, 2012, p. 85). Ongoing research is required for suitable therapys for suffers of vocal fold bowing, but it is currently thought that focused muscular exercise can lead to a strengthening of the vocalis muscle, and the subsequent more complete adductionoftheglottis.

Vocal folds are very strong, resilient structures. While they can take a lot of punishment, they are living tissue and there are limits to the number of impact and shearing forces they can take before they begin to defend themselves or break down. Recovery from these conditions can occur with help from one or more members of a team of voice professionals including laryngologist, a speech/voice therapist,andaspecialistvoiceeducator.(Bastian,Thurman,etal.,2000,p.535)
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b) Primarilyderivedfrompsychogenicfactors Puberphonia: Also known as mutational dysphonia, puberphonia is typically observed during and/or directly after the mutational transformation of the voice during puberty. This condition, generally treated with voice therapy, displays with the matured larynx (postmutational) continuing to perform premutational phonatory patterns. While commenting on mutational dysphonia, IngoTitze(2000) further explains, the pitch of the voice and the general pattern of vibration of the vocal folds assume the characteristicsoftheoppositesexmutationaldysphoniaistreatablewithvoicetherapy, especiallyifitiscombinedwithsomekindofpsychologicalcounselling(p.361). Transgender/Transsexual Voice: Typically listed under psychogenic voice disorders, the transgendered/transsexualvoicediffersfromothervocaldisordersinsomuchasthevoice user is intentionally seeking to alter their phonatory patterns. Often assisted with hormone therapy, the transgendered voice user is strongly advised to undergo voice transformation with the assistance of a qualified speech therapist experienced in this highly specialised field. During therapy, it is important that vocal fold strain be avoided because muscle tension voice problems can result if the client constricts in [his/]her attemptstoreachhigher[/lower]pitches(Shewell,2009,p.430).

2. Voice Care
Ingo Titze and Katherine Verdolini Abbott (2012) define voice disorders according to the World Health Organisations classification summarising, the relative health status of an individual involves three domains: (1) body and mind, (2) an individuals activities, and (3) an individuals participation in society. Bothenvironmentandpersonalfactorscomeintoplayineverydomain(p.39). UsingScott McCoys(2004)twelveheadings(pp.158160)letsnowoutlinearangeofareasthatmight improveyourchancesofpreservingyourvocalhealth(p.158). 1. Speak Well: As stated at the commencement of this module, the challenge facing every professionalvoiceuseristhattheyaretheirvoice.Predominantly,thevoiceisusedforspeech. Evenprofessionalsingersutilisetheirvoiceforspokencommunicationfarmorethansinging.Itis therefore necessary to ensure that the voice is used expertly during this dominant activity. Plainly, if your voice is being fatigued and damaged with poor speech patterns, then it will most probablyperformpoorlywhenitisemployedforsinging. As with all things associated with phonation, well managed breathing is essential to healthy spokenvoice. Leon Thurman and his colleagues note that active exhalation is required during skilledspeakingandsinging,butinwidelydifferentdegreesdependingonthevocalvolumelevel needed for the expressive purposes at hand. (Thurman, Theimer, Welch, Grefsheim, & Feit, 2000, p. 349). Vocal expression is generally driven by alteration to the biofunctional patterns of thelarynxandthemannerinwhichthevocaltractshapesthesoundasittravelsalongthehighly
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mouldable pathway. Vocal actions such as glottal attacks, aspirate tone and overtalking (in order to be heard in loud environments) can all contribute to the wear and tear of the voice for both speaking and singing. Scott McCoy (2004), while recommending habitually clear tone and resonant voice qualityalso suggests finding an optimum speaking range, which might be higher orlowerthanyouusuallyspeak(p.158). It is also important to note the deleterious effect of clearing the throat on the general wellbeing of the voice. Heuer et al. (2006) state that clearing the throat is generally out of habit, rather than need (p. 235). Stating the traumatic impact of throat clearing on the vocal folds, their article, Voice Therapy, recommends replacing the throat clear with a dry swallow, takingsmallsips ofwater,lighthummingand,forsingers,vocalis[ing] lightlyonfivenotescales in a comfortable range on //, or slide up on [an] octave softly on //, and crescendo (get louder)(p.235). 2. Sing Well: It will surprise no one to read here that I strongly advocate for the necessity of qualified technical instruction when it comes to acquiring a healthy singing voice. Sataloff(2006) highlights the need for singing lessons when he aptly states, singing skills are to speaking as running skills are to walking (p. 25). When the voice is being operated during the heightened activity of singing, many challenges present themselves. McCoy (2004) provides a helpful list of considerationswhenonedesirestosingwell(p.158): a) Maintaineffectivebreathsupportandcontrol; b) Keep extrinsic laryngeal, tongue and jaw muscles free fromexcesstension; c) Avoidexcessiveglottalonsetsandoffsetsoftone; d) Avoid air pushing during tone initiation, between consecutivetones,andatphraseterminations; e) Singinyouroptimumtessitura9; f) Singwithproperbodyalignmentandcorrectlaryngeal position(neithertoohighnortoolow). Thefinalkeytosingingwellisregular(45timesperweek) disciplined and structured practice. There are many excellent exercise compilations for developing the singing voice;includingDrDansVoiceEssentialsCD(Figure3).10

Figure3:DrDan'sVoiceEssentials(CDCover)

Tessitura(It.).Termusedtodescribethepartofavocal(orinstrumental)compassinwhichapieceofmusicpredominantly lies.Thetessituraofapieceisconcernedwiththepartoftherangemostused,notbyitsextremes(Sadie,1994,p.813). 10 DrDansVoiceEssentialsvocalexerciseCDisavailableviathedjartsonlinestore(www.djarts.com.au)orthroughiTunes. Page9 VocalHealth&VoiceCare 2013DrDanielK.Robinson


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3. Moderation: The human body is not designed (some would say, unfortunately) to keep going and goingand going. So too with the voice. It is important to monitor the amount of use the voice receives. Importantly, like most muscular systems in the body, the voice can develop increased stamina with regular exercise; but even this will have a limit. Of course, your voice is unique and will perform at its optimum for different lengths when compared to other vocalists; so it is important to establish your own personal limits and stick to them (allowing for development/improvement of vocal stamina). JohannSundberg(1987) submits, It is a rarely realized fact that an indispensable side of a singers career is to learn not only how but also how muchtosingunderwhatconditions(p.185). Muscularfatigueisobservedduringandafterprolongedmuscularexercise.Vocalfatigue,similar (in part) to general muscle fatigue limits vocal endurance by reducing the pliability of the vocal folds required for healthy oscillation. Titze (2000) offers five observations of the fatigue voice in histext,PrinciplesofVoiceProduction(p.362): a) Fatigue of laryngealmuscles that normally provide tension in the vocal folds and stability ofthelaryngealconfiguration. b) Strainingofnonmuscularlaryngealtissue(ligaments,joints,membranes). c) Increase in tissue viscosity of the vocal folds, making it harder to maintain vibration because of increased internal friction. This may be the result of dehydration or chemical changesinfluidcomposition. d) Loss of blood circulation due to the constricted blood vessels in phonation. This may impede regenerative processes and reduce the systems capacity to transfer heat away fromthevocalfoldstosurroundingtissue. e) Lossofsubglottalpressurecausedbyfatigueoftherespiratorymuscles. 4. Rest: The answer to general vocal fatigue is rest. Plain and simple!? Actually, achieving times of vocal rest for the professional voice user is not always plain and simple. Sometimes finding the opportunitiestorestthevoicecanbedifficult.Forexample,agiggingsingerwhohasafivenight run of shows may start to experience vocal fatigue by the middle of the 2nd or 3rd nights. They cant simply cancel the remaining shows. But they can clear their schedules of other, less pressing events; such as the Saturday BBQ with friends where talking will be the main activity. Itsatthesetimesthatthejoboftheprofessionalsingerbecomesworkrequiringdisciplineand agooddoseofdelayedgratification.Remember:novoice=nowork. Itsnotonlythelarynxthatrequiresrestthewholeinstrument(theentirebody)needstimesof recuperation also. It is important therefore to ensure that adequate amounts of sleep are obtained and maintained. Sataloff (2006) indicates that that the functions of a number of body systems are optimized with approximately 8.25 hours of sleep (p. 124). And as Jaime Babbit (2011) writes, The singer who gets enough sleep will always feel more confident, be more productiveandgenerallysoundwaybetterthanthesingerwhodidnt(p.24).
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5. Hydration: Most singers know that drinking 23 litres of water a day is important. Equally, most singers dont do it! Beyond the many health benefits of the wellhydrated body, the well hydrated voice is advantaged by consistent lubrication of the vocal folds. Additionally, Judith Wingate (2008), in her text, Healthy Singing, advises that whenthesingeriswellhydrated,theairpressureneeded beneath the vocal folds to set them into vibration is reduced, giving the singer a feeling of reduced effort to sing (p. 21). This is another case of work smarter, not harderandallyouhavetodoisdrinkwater! Its important to state here that there are beverages that work in opposition to good hydration by actively dehydrating the body. Specifically, caffeinated and alcoholicbeveragesareknowndiuretics;i.e.theypromote thebodysproductionofurine.Earlysignsofdehydration include headache, fatigue, loss of appetite, flushed skin, heat intolerance, lightheadedness, dry mouth and eyes, burning sensation in the stomach, and dark urine with a strongodor(Kleiner,1999,p.201). 6. UseGoodHygiene:Practicinggoodhygieneisanabsolutemustforsingers.Iliketotravelwitha small bottle of antibacterial hand gel because viruses often infect our bodies through hand contact with mouth, nose and eyes. Washing the hands frequently (especially after exposure to public articles such as hand rails and door knobs) helps reduce the risk of viral and bacterial transfer(McCoy,2004,p.159). 7. Avoid Unnecessary Drug Use: Pharmaceuticals are a normal part of western society living. The wonder of modern medicines supports our bodies in the fight against everything from the commoncoldtocancer.Thesedrugs,forthemostpart,arenotwithouttheirsideeffectsonthe voice.TitzeandAbbott(2012)identifytheiraffectonthenervoussystem,thebloodsupply,the muscles,andparticularlythetissuesinvibration(p.105).Thedetrimentaleffectsofmedication, and their impact on the voice can include: dry mouth, Candida, cough, hoarseness, muscular tremor, reflux and slurred speech. Many drugs have a drying effect on the throat and larynx. When medications are prescribed, particularly antihistamines and decongestants, it is important toreplenishthebodysgeneralhydrationwithextrawaterintake. Of course, for all the wellknown reasons, illicit drugs (narcotics, stimulants, depressants (sedatives), hallucinogens, and cannabis) should be avoided by the professional voice user not only because they are typically illegal to purchase and consume; but they generally leave the voicesusceptibletoheightenedwearandtear.
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8. StayPhysicallyFit:Gonearethedayswhenthearchetypalsingerwaspicturedasanoverweight (obese)personsinginganoperaticnumber.Therigorsoftodaysprofessionalworldrequiresthe modernsinger(classicalandcontemporary)tobephysicallyfit(andmentallyalso).Thephysically fit singer is able to maintain harsh schedules and is less likely to succumb to sickness. McCoy(2004) also notes that good physical appearance aids in winning competitions and getting roles (p. 159). Harsh, but true! The realities of todays industry are the better you lookthebetteryousound! Furthermore,JohnLyon(1993)statesthatSingerssingbetterandmoreonpitchwhentheyare alertphysicallyandmentally(p.21).Beingphysicallyalertrequiresstamina;staminaincreases withgeneralfitness. 9. Practice Safe Sex: Remember that I stated at the beginning of the module (Page 1) Everywhere the singer goes, everything (and I mean everything) the singerdoesandallthatthesingerishas a bearing on the singers vocal healthandthatincludessex!Without explicitly stating where your mouth might go during sex, it is important to note what your mouth (and throat) might be exposed to during sex. Specifically, herpes and gonorrhoea are easily transmitted to the mouth, pharynx and larynx through unprotected oral sex with an infectedpartner(McCoy,2004,p.159).Amomentofpassion,canleadtomonthsofdiscomfort, pain,andinsomecases,reducedvocalcapacity.Yoursexualactivitiesdohaveabearingonyour vocalhealth. 10. WearYourSeatbelt:ThismightappeartobeselfexplanatorybutinAmericaitisestimatedthat 1 in 7 people dont buckle up! Your voice (the whole body) and you larynx are at high risk of extremedamageeveninthelightestofbingleswhenyoudontwearacarrestraint.Thisheading alsoremindsus,yetagain,thateverythingyoudoyourvoicedoestoo! 11. DontSingifYouAreIll:Singingwhenyouaresickistobeavoidedatallcosts.Andinsomecases thiswillmeancancellinga(ormany)gig.Remember,youcanseriouslydamageyourvoiceinone set of singing! And you voice is extremely vulnerable to damage when you are ill. Meribeth BunchDayme(2009)leavesnoroomfornegotiationwhenaddressingthesicksinger.Shewrites, Clearly with a severe cold all singing must cease. Singing with a voice made hoarse by swollen mucous membranes has produced many vocal cripples by leading to chronic hoarseness (p. 160). There will be times when a judgement call needs to be made. Assessing the level of risk in thesecircumstancesisanimportantconsiderationinthedecisionmakingprocess.
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12. KnowaGoodENT:Ittakesavillagetoraiseachildandittakesavocalteamtoraiseasinger.It is important, early in the career of the developing singer, to establish a trusted team of voice care professionals including an ENT (Otolaryngologist) who specialises in voice, a Speech Therapist and Singing Voice Specialist. McCoy (2004) recommends a well visit [to the ENT] so thedoctorcanestablishabaselineanddocumentlaryngealappearancewhenhealthy(p.160). Some singers baulk at the idea of visiting the ENT, but this hesitation is generally driven by fear andshould beaddressedwithsupportive(andassertive)instructionconcerningthebenefitsand thepossiblerisksassociatedwithavoidance. Importantly, prevention is always better than cure. The developing singer is well advised to address their technical prowess in support of a healthy voice, in addition to practicing many of thelifestyledisciplineslistedinthismodule.Whendoingso,thesmartsingersavesthemselvesa lotoftime,money,andagreatdealofstressbyinsuringagainstthedifficultandlengthyroadof vocalremediation.

Who is Dr Daniel K. Robinson? Daniel is a freelance artist and educator. In 2011 Daniel completed his Doctor of Musical Arts degree at the Queensland Conservatorium Griffith University. He has served as National Vice President (200911) and National Secretary for the Australian National Association of Teachers of Singing (200611). Daniel is the principal Singing Voice Specialist for Djarts (www.djarts.com.au) and presents workshops to singers across Australia and abroad. Over the past two decades, while maintaining his own performance career, Daniel has instructed thousands of voices. This vast experience enables Daniel to effortlesslyworkwithvoicesofallskilllevels:beginnerstoprofessionals.

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References
Babbit,J.(2011).Workingwithyourvoice:Thecareerguidetobecomingaprofessionalsinger.VanNuys, CA:AlfredMusicPublishing. Bastian,R.,Klitzke,C.,&Thurman,L.(2000).Vocalfoldandlaryngealsurgery.InL.Thurman&G.Welch (Eds.), Bodymind and voice: Foundations of voice education (Vol. 3, pp. 620631). St. John's University,MI:TheVoiceCareNetwork. Bastian, R., Thurman, L., & Klitzke, C. (2000). Limitations to vocal ability from userelated injury or atrophy. In L. Thurman & G. Welch (Eds.), Bodymind and voice: Foundations of voice education (Vol.3,pp.527537).St.John'sUniversity,MI:TheVoiceCareNetwork. Dawson, A. (2005). Voice training and church singers: The state of vocal health of church singers of contemporary commercial styles in charismatic evangelical churches. Unpublished Masters Dissertation,QueenslandConservatorium,GriffithUniversityBrisbane,QLD. Dayme,M.B.(2009).Dynamicsofthesingingvoice(5thed.).Austria:SpringerWienNewYork. Harvey, P. L., & Miller, S. H. (2006). Nutrition and the professional Voice. In R. T. Sataloff (Ed.), Vocal health and pedagogy: Advanced assessment and treatment (2nd ed., Vol. 2, pp. 99120). San Diego,CA:PluralPublishingInc. Heuer, R. J., Rulnick, R. K., Horman, M., Perez, K. S., Emerich, K. A., & Sataloff, R. T. (2006). Voice Therapy. In R. T. Sataloff (Ed.), Vocal health and pedagogy: Advanced assessment and treatment (2nded.,pp.227251).SanDiego,CA:PluralPublishingInc. Kleiner, S. M. (1999). Water: An essential but overlooked nutrient. Journal of the American Dietetic Association,99(2),200206. Lyon,J.T.(1993).Teachingallstudentstosingonpitch.MusicEducatorsJournal,80(2),2059. McCoy,S.(2004).Yourvoice:Aninsideview(2ed.).Princeton,NJ:InsideViewPress. McKinney, J. C. (1994). The diagnosis & correction of vocal faults: a manual for teachers of singing and forchoirdirectors(2nded.).Nashville,USA:GenevoxMusicGroup. Robinson, D. K. (2013). Vocal anatomy 101. 15. Retrieved 21 August 2013 from http://www.djarts.com.au/articles/voiceanatomy101/ Sadie,S.(Ed.)(1994)Thegroveconcisedictionaryofmusic.London,UK:TheMacmillanPressLtd. Sataloff, R. T. (Ed.). (2006). Vocal health and pedagogy: Advanced assessment and treatment (2nd ed. Vol.2).SanDiego,CA:PluralPublishingInc.
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Scherer, R. C. (2006). Laryngeal function during phonation. In R. T. Sataloff (Ed.), Vocal health and pedagogy:Scienceandassessment(2nded.,Vol.1,pp.85102).SanDiego,CA:PluralPublishing Inc. Shewell,C.(2009).Voicework:Artandscienceinchangingvoices.WestSussex,UnitedKingdom:Wiley Blackwell. Sundberg,J.(1987).Thescienceofthesingingvoice.Dekald,IL:NorthernIllinoisUniversityPress. Thurman, L., Theimer, A., Grefsheim, E., & Feit, P. (2000). Classifying voices for singing: Assigning choral partsandsololiteraturewithoutlimitingvocalability.InL.Thurman&G.Welch(Eds.),Bodymind & voice: Foundations of voice education (2nd ed., Vol. 5, pp. 772782). St. John's University, MI: TheVoiceCareNetwork. Thurman, L., Theimer, A., Welch, G., Grefsheim, E., & Feit, P. (2000). Creating breathflow for skilled speaking and singing. In L. Thurman & G. Welch (Eds.), Bodymind & voice: Foundations of voice education(2nded.,Vol.2,pp.339355).St.John'sUniversity,MI:TheVoiceCareNetwork. Titze, I. R. (2000). Principles of voice production (2nd Printing ed.). Iowa City, IA: National Center for VoiceandSpeech. Titze,I.R.,&Abbott,K.V.(2012).Vocology:Thescienceandpracticeofvoicehabilitation.SaltLakeCity, UT:NationalCenterforVoiceandSpeech. Wingate,J.(2008).Healthysinging.SanDiegoCA:PluralPublishing.

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