Voice Problems of Group Fitness Instructors:

Diagnosis, Treatment, Perceived and Experienced

Attitudes and Expectations of the Industry
Anna F. Rumbach, Brisbane, Australia

Summary: Objectives. To determine the anatomical and physiological nature of voice problems and their treatment
in those group fitness instructors (GFIs) who have sought a medical diagnosis; the impact of voice disorders on quality of
life and their contribution to activity limitations and participation restrictions; and the perceived attitudes and level of
support from the industry at large in response to instructor’s voice disorders and need for treatment.
Study Design. Prospective self-completion questionnaire design.
Methods. Thirty-eight individuals (3 males and 35 females) currently active in the Australian fitness industry who
had been diagnosed with a voice disorder completed an online self-completion questionnaire administered via
SurveyMonkey.
Results. Laryngeal pathology included vocal fold nodules (N ¼ 24), vocal fold cysts (N ¼ 2), vocal fold hemorrhage
(N ¼ 1), and recurrent chronic laryngitis (N ¼ 3). Eight individuals reported vocal strain and muscle tension dysphonia
without concurrent vocal fold pathology. Treatment methods were variable, with 73.68% (N ¼ 28) receiving voice ther-
apy alone, 7.89% (N ¼ 3) having voice therapy in combination with surgery, and 10.53% (N ¼ 4) having voice therapy
in conjunction with medication. Three individuals (7.89%) received no treatment for their voice disorder. During treat-
ment, 82% of the cohort altered their teaching practices. Half of the cohort reported that their voice problems led to
social withdrawal, decreased job satisfaction, and emotional distress. Greater than 65% also reported being dissatisfied
with the level of industry and coworker support during the period of voice recovery.
Conclusions. This study identifies that GFIs are susceptible to a number of voice disorders that impact their social and
professional lives, and there is a need for more proactive training and advice on voice care for instructors, as well as
those in management positions within the industry to address mixed approaches and opinions regarding the importance
of voice care.
Key Words: Professional voice use–Aerobics instructor–Group fitness instructor–Vocal hygiene–Voice disorder–
Treatment–Education–Training.

INTRODUCTION physiological changes at the level of the glottis may actually

Since the introduction of prepackaged fitness programs de-
signed to inspire masses to exercise together, group fitness in-
structors (GFIs; known then as aerobics instructors) have
reported voice difficulties that appear to be the result of an in-
teraction between both environmental and physiological
stresses placed on the voice that are encountered when speaking
and vigorous exercise occur simultaneously.1–4 Thirty years
later, the world of group fitness is radically different, with
better sound technology and voice amplification and a myriad
of group fitness experiences available, yet the current waves
of professionals continue to experience the same problems
faced by their former colleagues. One study that compared
vocal problems of instructors and participants found
a significantly higher incidence of vocal nodules, hoarseness,
and voice loss among the instructor cohort.1 Other small cohort
studies (N ¼ 48–54) have confirmed vocal nodules in up to 10%
of instructors.2,3 Although vocal nodules might be the ‘‘go-to’’
diagnosis, it is hypothesized that a variety of anatomical and
Accepted for publication March 26, 2013.
From the Division of Speech Pathology, School of Health and Rehabilitation Sciences,
The University of Queensland, Brisbane, Australia.
Address correspondence and reprint requests to Anna F. Rumbach, Division of Speech
Pathology, School of Health and Rehabilitation Sciences, The University of Queensland, St
Lucia, Brisbane 4072, Australia. E-mail: a.rumbach@uq.edu.au
Journal of Voice, Vol. 27, No. 6, pp. 786.e1-786.e9
0892-1997/$36.00
Ó 2013 The Voice Foundation
http://dx.doi.org/10.1016/j.jvoice.2013.03.012
contribute to perceptual voice difficulties. Furthermore,
previous research has largely failed to elucidate if, after
diagnosis, instructors sought treatment, whether teaching
continued during the treatment period, and how the voice
disorder affected their overall quality of life (QOL) and their
ongoing participation in their occupation.
The World Health Organization’s International Classification
of Functioning5 can be useful in recognizing the impact a voice
disorder can have on all aspects of an individual’s life. In rela-
tion to voice disorders, ‘‘impairment’’ is defined as an abnor-
mality in physical function (eg, abnormal laryngeal function
represented perceptually through hoarseness). ‘‘Activity limita-
tion’’ refers to the limitation in performance caused by the im-
pairment (eg, inability to produce a voice with clear quality so
cannot be easily heard) whereas ‘‘participation restriction’’ is
defined as a loss of role function because of the impairment
or disability (eg, no longer able to perform the job as required).
Newman and Kersner3 reported that of the five instructors who
reported a diagnosis of vocal nodules (impairment), two re-
ceived surgical treatment and had been forced to reduce teach-
ing hours and take time off (participation restriction) as a result.
Increased hoarseness, lower pitch, weaker voice, and increased
vocal discomfort because of the voice disorder were the chief
complaints,3 all of which may constitute an activity limitation
when the vocal demands of the profession are considered. In-
structors must use their voices to get participants where they
Anna F. Rumbach Voice Problems of Group Fitness Instructors
need to be. A lack of vocal clarity might inhibit the instructors’
ability to do so. Anecdotal reports from the author’s personal
communications with instructors indicate that vocational dys-
phonia is accepted, and to some extent expected, in the group
fitness industry. Seventy percent of GFIs currently working in
the Australian fitness industry report chronic voice symptoms,
with as little as one in seven instructors actually seeking a med-
ical opinion.4 Could this industry perception and expectation
also be a factor contributing to the problem?
The aim of this article was to explore and describe the ana-
tomical and physiological nature of voice problems and their
treatment in those GFIs who have sought a medical diagnosis,
the impact of voice disorders on QOL and their contribution
to activity limitations and participation restrictions, and the per-
ceived and experienced attitudes and level of support from the
industry at large in response to instructor’s voice disorders and
need for treatment.
METHODS
During a 5-month period (December 2011–May 2012), social
media (Facebook and Twitter) and advertisements issued by in-
dustry gatekeepers were used to disseminate the link to an anon-
ymous online survey conducted via SurveyMonkey. A total of
361 instructors were recruited to participate in a 65-item ques-
tionnaire consisting of dichotomous (eg, yes/no), multiple
choice, and open-ended response questions investigating voice
use and abuse in the fitness industry. Data presented in this ar-
ticle represent the responses to questions 46 and 50 to 62 of the
original questionnaire (see Appendix) provided by the 38 indi-
viduals (3 males and 35 females; age range, 23–63; mean,
38.32; standard deviation [SD], 10.88) who reported receiving
a formal diagnosis of a voice disorder.4 The data represented in
this study have been included as part of a study of prevalence of
self-reported voice symptoms in the GFI population, and fur-
ther biographical details of the cohort and the original question-
naire can be found there.4 As determined by self-report, no
participants had a history of voice problems before starting
work in the fitness industry. All instructors reported that they
were actively teaching at least one type of group fitness pro-
gram on a weekly basis. Participants were required to give con-
sent before they could access the online questionnaire, and all
data were collected in a deidentified manner to encourage par-
ticipation. In an attempt to minimize data bias, recruitment was
nationwide and called for anyone active in the group fitness
industry.
All responses gathered via SurveyMonkey were downloaded
into a Microsoft Excel file and analyzed using descriptive statis-
tics with Stata software (Statacorp LP, version 10.0, 2007).
Qualitative data were analyzed by two researchers. For ques-
tions that required open-ended responses, broad concepts and
categories were inductively generated using content analysis.6,7
Analyses were compared and where discrepancies occurred,
a consensus was reached on the main themes as they emerged
most frequently during the analysis. Not all individuals
completed all questions that allowed for open-ended responses;
therefore, the main themes that emerged during analysis are
786.e2
representative of only part of the cohort. Ethical approval to
conduct this research was granted by The University of Queens-
land’s Behavioural and Social Sciences Ethics Committee.
RESULTS
The total participant cohort had been teaching a mean of 3.69
(range, 1–9; SD, 1.91) different group fitness programs for an
average of 12.71 years (range, 2–34; SD, 8.91). Please note
that the term ‘‘group fitness program’’ denotes the type of exer-
cise being undertaken (eg, strength training, cardiovascular
training, interval training, etc.). GFIs taught an average of
nine classes per week (range, 2–23; SD, 5.35; Table 1), with
each class lasting approximately 60 minutes (89.47%; range,
45–90 minutes). Greater than half of the participants (57.89%)
reported teaching consecutive classes at least once a week, rang-
ing anywhere from two consecutive classes once a week up or
every working day (5 days) to three to four consecutive classes
three times a week. For 42.11% (n ¼ 16) of the respondents,
group fitness was their primary occupation and source of income
(Table 1). The remaining individuals (57.89%, N ¼ 22) were
largely employed in occupations that rely heavily on voice use
(educators—primary, secondary, and tertiary, N ¼ 10; health
professionals, N ¼ 5; personal trainer, N ¼ 3; police officer,
N ¼ 1; retail assistant and managerial roles, N ¼ 3).
Diagnosis and treatment of voice disorders
(impairment; questionnaire items 52–54)
Those who independently sought a medical diagnosis via oto-
rhinolaryngology for their voice difficulties reported deficits
attributable to both functional and organic changes at the level
of the glottis. Biographical data for this specific subset of re-
spondents (N ¼ 38) including diagnosis and subsequent man-
agement are detailed for each participant in Table 1. Eight
individuals (21.05%) reported vocal strain and muscle tension
dysphonia without concurrent vocal fold pathology. The re-
mainder of those participants who admitted seeking a formal di-
agnosis reported the presence of laryngeal pathology consisting
of vocal fold nodules (N ¼ 24, 63.16%), vocal fold cysts (N ¼ 2,
5.26%), vocal fold hemorrhage (N ¼ 1, 2.63%), and recurrent
chronic laryngitis (N ¼ 3, 7.89%). Treatment methods were
variable (Table 1), with 73.68% (N ¼ 28) receiving voice ther-
apy alone, 7.89% (N ¼ 3) having voice therapy in combination
with surgery, and 10.53% (N ¼ 4) having voice therapy in con-
junction with medication (ie, a short course of steroids to help
reduce inflammation or antireflux medication). Four individuals
(10.53%) mentioned that they were currently seeing a speech-
language pathologist for remediation of their voice problem
at the time the survey was completed. Three individuals
(7.89%) received no treatment for their voice disorder.
Symptoms—perceptual and sensory (impairment;
questionnaire items 46 and 50)
Despite 92% (N ¼ 35) of participants having sought and re-
ceived medical and speech pathology management for their
voice problem, all respondents reported one or more of the fol-
lowing permanent sensory or perceptual voice changes: in-
creased hoarseness, tired voice, weak voice, strained voice,
786.e3 Journal of Voice, Vol. 27, No. 6, 2013

TABLE 1.
Biographical Information for 38 GFIs Who Reported Formal Diagnosis and Treatment of a Voice Disorder
GFI as Primary Years in Permanent GFI
Occupation Voice Diagnosis Voice Treatment Gender Age Industry Classes/Week Number
Yes Nodules Nil M 24 2 17 1
Nodules Nil F 40 6 10 2
Nodules Voice therapy F 26 8 8 3
Nodules Voice therapy M 27 4 20 4
Nodules Voice therapy F 49 15 20 5
Nodules Voice therapy M 36 2 12 6
Nodules Voice therapy F 59 34 8 7
Nodules Voice therapy F 48 22 8 8
Nodules Voice therapy F 34 5 15 9
Nodules Voice therapy F 28 4 4 10
Nodules Voice therapy + medication F 35 18 10 11
Vocal strain Voice therapy F 55 24 4 12
Vocal strain Voice therapy F 45 12 12 13
Vocal strain Voice therapy F 47 4 23 14
Chronic laryngitis Medication only F 46 7 4 15
Cyst Voice therapy + surgery F 49 18 4 16
No Nodules Nil F 26 4 12 17
Nodules Voice therapy F 23 4 4 18
Nodules Voice therapy F 27 7 11 19
Nodules Voice therapy F 35 12 4 20
Nodules Voice therapy F 29 8 10 21
Nodules Voice therapy F 48 5 10 22
Nodules Voice therapy F 46 20 6 23
Nodules Voice therapy F 28 10 10 24
Nodules Voice therapy F 48 22 2 25
Nodules Voice therapy F 34 10 4 26
Nodules Voice therapy F 27 4 10 27
Nodules Voice therapy + medication F 37 16 10 28
Nodules Voice therapy + surgery F 46 27 4 29
Vocal strain Voice therapy F 55 29 2 30
Vocal strain Voice therapy F 27 5 10 31
Vocal strain Voice therapy F 37 17 4 32
Vocal strain Voice therapy F 63 32 8 33
Chronic laryngitis Voice therapy F 32 13 4 34
Chronic laryngitis Voice therapy F 45 23 19 35
Cyst Voice therapy + surgery F 28 12 6 36
MTD Voice therapy F 26 4 8 37
VF hemorrhage Voice therapy + medication F 41 22 10 38
Abbreviations: F, female; GFI, group fitness instructor; M, male; MTD, muscle tension dysphonia; VF, vocal fold.

difficulties with high or low notes, low or high speaking voice,
limited singing range, loudness decay, and the experience of
voice/pitch breaks (Figure 1). Another common complaint
included uncomfortable throat sensations, particularly the fre-
quent experience of a dry or sore throat (Figure 2).
Effect of voice disorder diagnosis on QOL (activity
limitation and participation restriction;
questionnaire items 55–60)
During the period of voice treatment, some individuals with-
drew from instructing aerobics classes altogether (N ¼ 9,
23.68%), whereas others decreased the number of classes being
taught on a regular basis (daily or weekly; N ¼ 12, 31.58%),
continued to teach the same amount of classes under different
conditions (eg, extra voice care, decreased volume of music
with increased volume of microphone; N ¼ 13, 34.21%), or
chose to continue to teach the same number of classes (per
day or week) under the same conditions (N ¼ 4, 10.53%).
Since receiving a formal diagnosis of their voice problem,
81.58% (N ¼ 31) of respondents have adjusted their methods
of voice use during teaching. Methods of adjustment included
reduction of overall class hours (N ¼ 12, 31.58%), altering
the work program (ie, discontinuing some programs of exercise
because of the added demands on the vocal system), (eg, no lon-
ger teaching classes that use weights or those that involve high-
intensity cardiovascular exercise; N ¼ 4, 10.53%), increasing
nonverbal cueing (N ¼ 17, 44.74%), and improving general vo-
cal hygiene (N ¼ 29, 76.32%).
Anna F. Rumbach Voice Problems of Group Fitness Instructors
FIGURE 1. Self-reported/perceived experience of sensory-
perceptual voice characteristics in a group of 38 group fitness instruc-
tors with diagnosed voice disorders (questionnaire item 50).
Generalized vocal fatigue (N ¼ 21, 55.6%), feelings of dis-
comfort when speaking (N ¼ 19, 50%), difficulties being heard
(frequent need to repeat statements; N ¼ 17, 44.74%), periods
of complete voice loss (N ¼ 17, 44.74%), and pain on speaking
(N ¼ 5, 13.16%) were frequently reported; however, only
17 participants (44.74%) reported that their voice problem
affected their ability to communicate in everyday situations.
When asked whether their voice problems impacted signifi-
cantly on their overall QOL and emotional status, 19 respon-
dents (50%) highlighted experiencing periods of emotional
distress. Emotions that were expressed included frustration,
sadness, and concern with regard to the longevity of their
teaching career. Instructors also noted that, due to their voice
disorder, they had become increasingly withdrawn from
social aspects of life because of the necessity of voice preser-
vation for work and/or severity and nature of the voice prob-
lem. Specific comments made by participants are provided in
Table 2.
FIGURE 2. Self-reported experience of throat symptoms in a group
of 38 group fitness instructors with diagnosed voice disorders (ques-
tionnaire item 46).
786.e4
Perceived industry attitudes and experienced levels
of support (questionnaire items 61 and 62)
A large proportion of instructors (>65%; N ¼ 25) reported be-
ing dissatisfied with the level of industry and coworker support
during the period of their voice recovery. ‘‘It is just an accepted
part of the industry,’’ ‘‘It was all up to me really,’’ and ‘‘I made
people aware that I was having difficulties but it was difficult to
decrease my workload and get people to understand what I
needed during the treatment period’’ are examples of the com-
mon feelings identified. Inadequate levels of education and
training regarding voice care at the instructor, facility, and an
industry level was highlighted (refer to Table 3 for specific
comments). All but one respondent (97.37%) thought that voice
education and training should be a mandatory component of in-
structor training. Lack of amplification was also frequently
mentioned as causing conflict between instructors and manage-
ment (eg, ‘‘The club I was teaching at has had ongoing issues
with the microphone for 2 years. I have complained regularly
but it’s still not 100%. I have also filed an incident report.
They are still experiencing issues’’—GFI7). One respondent
even reported that inadequate voice amplification technologies
led her to end her employment at certain fitness facilities. De-
spite these negative reports, only half (48%, N ¼ 12) of those
displeased with the industry attitudes and level of support to-
ward voice difficulties expressed an overall change of opinion
on the profession (refer to Table 3 for specific comments).
Conversely, the remaining 35% (N ¼ 13) of respondents re-
ported positive experiences. One respondent stated that co-
workers ‘‘understood’’ and were accommodating; however,
management was ‘‘unconcerned’’ and attributed the difficulty
‘‘to illness rather than the facilities and occupation.’’ Another
three respondents mentioned that management offered time
off teaching, alternative teaching schedules (eg, changing
a class of high-intensity cardiovascular activity to a flexibil-
ity/strength program), and other assistance if required.
DISCUSSION
Previous research has identified that GFIs are at a high risk of
developing both acute and chronic voice difficulties.1–4 Group
fitness instruction places heavy demands on the phonatory
system. Thus, impairments have the potential to contribute to
both activity limitations and participation restrictions. Vocal
nodules have previously been reported as the exclusive
diagnosis in this population.1,3 However, the results of this
study confirm that voice disorders in the GFI population are
attributable to a number of different anatomical and
physiological origins. Although the mechanism by which the
voice becomes damaged is unique to its own physiological
makeup, a common denominator to all diagnoses reported in
this study was vocal hyperfunction. These hyperfunctional
behaviors may be the result of habitual voicing patterns,
postural misalignment and breathing patterns, issues with
work environment, and the adoption of compensatory voicing
behaviors.8
Most GFIs (N ¼ 35, 92.11%) visited a speech pathologist for
voice therapy after obtaining an official diagnosis. Furthermore,
786.e5 Journal of Voice, Vol. 27, No. 6, 2013

TABLE 2.
Instructor Comments Regarding Impact of Voice Disorders on Quality of Life (Questionnaire Item 60)
‘‘This is a period of great upset and concern. It made me re-think my priorities and the amount of GFI work I was
doing.’’—GFI37
‘‘It does frustrate me as I can’t communicate like I would like to. My partner thinks I sound like a man, and I’m worried I’m
causing permanent vocal damage to the point of no return.’’—GFI3
‘‘Before and during my treatment I couldn’t talk for long periods and felt uncomfortable out in noisy places, eg, football
games, parties, restaurants. I cannot get my point across. Having to repeat myself makes me frustrated. There is a loss
of control with no voice and I cannot use my voice how I’d like to in a class.’’—GFI16
‘‘I could not talk to colleagues at work, leaving me feeling very isolated.’’—GFI21
‘‘I felt exhausted, frustrated, and anxious about my job—quite sad.’’—GFI23
‘‘I’m not upset with the job but am upset that I can’t be as social as I used to be as I need to save my voice for work and
teaching.’’—GFI32
‘‘It was frustrating—it affects your ability to earn an income and it is just as bad as a sprained ankle, or muscle in your
leg.’’—GFI38

seven (18.42%) of these individuals also received medication or
surgery in addition to voice therapy. It is assumed that this was at
the recommendation of the ear, nose, and throat (ENT) special-
ist. However, 7.89% (N ¼ 3) obtained a diagnosis of vocal nod-
ules, yet did not receive or seek treatment. The reasons for this
are unclear. GFIs may accept vocal attrition as part of the profes-
sion and an inconvenience that they must compensate for and
live with. It is also possible that GFIs are unaware of the benefits
of voice therapy and the services that are available to them.
Moreover, GFIs may choose to not seek intervention for their
voice problems because of the expenses and time involved as
well as the reluctance (perceived or real) for colleagues and
management and/or health insurance companies to compensate
for these. Research such as this, and other studies cited herein,
should help support a case for why time and resources should
be allocated to help prevent and treat voice problems in the fit-
ness industry.
The participants reported a number of chronic voice symp-
toms, all of which appear to be commensurate with their voice
diagnoses. It would be expected in those who received or are
receiving therapy that symptoms would lessen and hopefully
resolve over time. However, the data obtained in the survey
fail to discern the recency of treatment, perceived level of
success of treatment, and severity of any ongoing symptoms.
Moreover, effective and efficacious treatment requires the indi-
vidual’s cooperation throughout the course of the treatment. No
enquiry regarding compliance during therapy was made in this
survey. In addition to voice symptoms, instructors indicated that
dryness in their throats was common (71.05%). This sensation
may be attributable to poor voice care, with instructors not
being adequately hydrated before, during, and after exercise.
Although voice education may dictate that instructors should
continue to drink throughout a class, the industry designs
prechoreographed programs to have continuous transitions be-
tween tracks/different exercises and recommends that instruc-
tors ‘‘press play and go,’’9 which potentially means teaching
a 60-minute class without taking any drink breaks. In addition
to having to work within tight time constraints within gym

TABLE 3.
Instructor Comments in Response to How Opinions on Working in the Fitness Industry Have Been Altered Since Obtaining
the Diagnosis of a Voice Disorder (Questionnaire Item 62)
‘‘I knew it was a possibility as I know many instructors who have poor vocal quality/hoarse voices. I think I’ve picked up
bad habits in how I project my voice. I do think there needs to be a lot more coaching for instructors on using their voice
and not straining it.’’—GFI3
‘‘It is essential to have proper microphones and sound systems—it is not good enough to only have them
sometimes.’’—GFI5
‘‘Is it financially worth it for what it has done to my voice?’’—GFI24
‘‘Not a lot of care or concern is given to the GFI’s health and well-being. It is left up to the individual to do something about
it. Even as an older instructor who has had speech problems and resultant therapy, I have sat through other young
instructor’s classes and given them advice about their voice[s]. I can hear the changes/see them doing the same thing I
did. But they don’t take my advice. It should be a compulsory part of our education.’’—GFI25
‘‘. [company] recently gave a directive that you have to keep teaching your class without a microphone if it breaks down.
Luckily my voice is mostly better now, but if it wasn’t, this directive would be extremely stressful for me. On the plus
side, [company] have replacement microphones and are on the ball with getting microphones fixed—so better than
most other clubs I have worked for in the past. All clubs should take this extremely seriously as it can put the in
structor’s health/well-being at risk.’’—GFI31
‘‘I think this problem is a lot more common than we think. We really do not get much education on how to keep our voices
safe. We need this.’’—GFI37
Anna F. Rumbach Voice Problems of Group Fitness Instructors
settings, with prechoreographed classes running back to back, it
is possible that, unless experiencing thirst, instructors may for-
get to drink sufficient amounts of water throughout the day
(Rumbach, manuscript in preparation). This is just one of the
many areas that instructors, and the industry at large, require
more education.
Impairments can increase exposure to ongoing activity limi-
tation and participation restriction, impacting not only on the in-
dividual’s role as a GFI but also personal, social, and other
professional settings. It is important to remember that neither
objective measures of laryngeal examination nor results of la-
ryngeal examination can reflect the level of activity limitation
and participation restriction that a person has or perceives as a re-
sult of a voice disorder and/or its treatment. Similarly, traditional
methods of voice assessment (acoustic, perceptual, endoscopic,
and aerodynamic measures) do not necessarily correlate with the
severity of the voice disorder as it relates to voice use in both oc-
cupational and social realms. In this study, GFIs reported a num-
ber of perceptual and sensory symptoms attributable to their
voice diagnosis, with discomfort and pain, vocal fatigue, and pe-
riods of voice loss being mentioned. Similar to results found by
Long et al2 as well as Newman and Kersner,3 these chronic
symptoms have the potential to impact on work performance
and influence personal identity. Indeed, research studies have re-
ported that hoarseness and voice loss can significantly impact
performance and work efficiency.10,11 One GFI indicated that
her full-time occupation was as a member of the police force.
A police officer needs to be heard over high noise levels and
have a clear and stable voice so that intelligibility over the radio
system remains high. Inability to do so may cause undue harm to
others. Other professions represented in this cohort (eg, educa-
tors) also require stable and well-controlled voices and the abil-
ity to speak for extended periods to be deemed successful in their
professional pursuits. Inability to perform vocational tasks as
a consequence of voice difficulties is reflected in the responses
gathered, with 89.5% (N ¼ 34) either ceasing or altering their
work program and their instruction approach to compensate
for their impairment. Impairments may also contribute to other
occupational and economic problems, as most of the cohort’s
(N ¼ 22; 57.89%) income came from jobs outside the fitness in-
dustry and were found to rely heavily on their voice as part of
their primary occupation (eg, educators, health professionals,
police officer). For those working as GFIs in a full-time capacity
or who are unable to perform their primary occupations as a re-
sult of a chronic voice condition, long periods of absenteeism
from work or withdrawal from employment for the duration of
treatment may cause significant financial strain. Ceasing work
as a GFI in an attempt to remediate the impairment may poten-
tially lead to an enforced career change, which would encom-
pass the additional financial and personal burdens associated
with retraining. Forty-four percent of the cohort (N ¼ 17) re-
ported that their impairment impacted on their ability to commu-
nicate in everyday situations. Fifty percent (N ¼ 19) reported
experiencing emotional distress in response to the activity lim-
itations and participation restrictions created by the impairment.
Voice is a reflection of a speaker’s identity and allows unique
expression of personality, intention, and emotion.10 Altered per-
786.e6
ceptual features of voice (eg, ‘‘My partner thinks I sound like
a man’’—GFI31) attributable to impairment can lead to inflex-
ibility and inability to communicate verbally as desired across
all environments (eg, ‘‘There is a loss of control with no voice
and I cannot use my voice how I’d like to .’’—GFI16). A con-
siderable body of research evidence indicates that this may lead
to increased stress, frustration, and depression,11–14 which in
themselves can be significant stressors leading to participation
restriction across social and occupational domains.
To prevent disruption to overall QOL, it is important that in-
structors take the steps necessary to prevent the development
of voice disorders. Prevention of occupational voice disorders
requires a proactive and systematic approach that involves in-
dustry leaders, workplace management, health professionals,
and the instructors, with the roles and responsibilities of all
stakeholders being clearly defined. In addition to this, all people
involved in the fitness industry need to be cognizant of the
potential risks associated with high-intensity voice use during
exercise. Inadequate voice education and training has been
previously highlighted as a major concern,1–4 and the results
from this study indicate that this may be occurring at both the
facility and industry level. Industry leaders and employers
routinely provide instructors with information, instruction, and
training on how to do their job safely. A high incidence of
self-reported chronic disorders (44–70%) and diagnosed voice
disorders (10%) in the GFI population2–4 highlights a new
direction for training, one that encompasses voice education
and training. Industry training is dedicated to achieving whole
body fitness, and a large proportion of the time in training is
dedicated on how to achieve perfect execution of moves to
prevent injury. Poor technique and health leads to less efficient
and effective movement, allowing the muscles to be
increasingly susceptible to strain, fatigue, and injury. This
principle also applies to the voice. There are a number of
general postural misalignments that may result in concomitant
voice problems. These include slumping of the spine, raising
of the shoulders, exaggerated position of the pelvis, spinal
asymmetry, and torso rotation.15,16 Furthermore, inappropriate
and inefficient breathing patterns may contribute to laryngeal
hyperfunction. For example, talking with excessively high
airflow rates that results from the need to exercise and speak
simultaneously10,17–19 and the practice of ujjayi breathing,
commonly used in yoga, that requires deliberate and audible
constriction near the soft palate may be potentially damaging
if constriction is incorrectly placed within the pharynx.20
Although introducing voice education and training packages
to the industry may not eradicate the voice problems experi-
enced by those working in the industry, increased awareness
of risk for voice problems may contribute to more positive
attitudes regarding voice care. Furthermore, it may encourage
more instructors to seek a medical opinion when they encounter
difficulties with their voices. There currently appears to be no
uniform approach to voice education and training in this indus-
try,3,4 with respondents experiencing both positive and negative
reactions to their voice problem and need for treatment. In the
present study, the notion of ‘‘vocational dysphonia’’ being
considered by management as an acceptable consequence of
786.e7
the occupation leads to respondents being dissatisfied with
the level of support granted by their coworkers and industry at
large. However, the onus for education and training cannot be
placed solely on employers, fitness organizations, and the
industry at large. It is acknowledged that instructors need to
be responsible for following company policies, acknowledging
and investigating voice symptoms early, and following
any necessary treatment guidelines prescribed by health
professionals.
LIMITATIONS AND FUTURE DIRECTIONS
This is the first study of its kind to explore the diagnoses and
treatment pathways of voice disorders in a cohort of GFIs.
The responses from the study also provide insight into the per-
ceived and experienced attitudes and expectations of the fitness
industry as they relate to an Australian GFI cohort with diag-
nosed voice problems. However, in addition to those design
limitations discussed by Rumbach,4 data collection relied on
accurate self-report of voice symptoms as well as ENT diagno-
sis and treatment. Furthermore, the small sample size and gen-
der bias toward females may prevent these results being
extrapolated to the GFI population at large. Research in this
population is currently in its infancy. Future studies that use
acoustic, laryngoscopic, and physiological measures to exam-
ine voice use and acute and chronic voice symptomatology of
GFIs before, during, and after periods of exercise are required.
Furthermore, studies that track long-term changes in vocal per-
formance over time in groups of new instructors entering the
profession are required. Furthermore, formal voice education
packages that are tailored to the instructor and industry manage-
ment need to be developed, trialed, and evaluated to determine
whether they may act as a successful preventative measure and
lead to changes in industry opinion regarding voice care.
CONCLUSION
This study confirms that GFIs are at risk of developing both
functional and organic voice problems that are severe enough
to warrant behavioral and/or medical management. Further-
more, these impairments can influence an individual’s emo-
tional well-being and job satisfaction, thus creating activity
limitations and participation restrictions that must be overcome.
It is likely that the vocational dysphonia in the population is be-
cause of an interaction between habitual and compensatory
voice patterns, lack of education and training on voice care,
and the heavy demands placed on the phonatory system when
speaking and exercising simultaneously. Industry perception
that hoarseness is part of the normal experience for the profes-
sion, coupled with lack of education, may prevent instructors
from obtaining satisfactory support and assistance during the
treatment of their voice difficulties. This study highlights that
the instructor cohort and the industry at large need to be edu-
cated regarding the importance of voice conservation. Informed
and effective voice education and training packages targeted to
the fitness industry need to be developed and evaluated over
time to assess efficacy and efficiency in changing the preva-
Journal of Voice, Vol. 27, No. 6, 2013
lence of reported voice difficulties and the industry’s response
to, and management of, such issues.
Acknowledgments
Appreciation is extended to the gatekeepers of this project:
Australian Fitness Network and Les Mills Asia Pacific. Kind
thanks also to Mr Glen Stollery for promoting this research
through his blog. Thank you to Alexia Rohde for her assistance
with data analysis and Dr Anne Hill for her suggestions during
the drafting of this manuscript. Finally, to the instructors who
took time to fill out the questionnaire, thank you for your valu-
able contribution, without which this research would not be
possible.
REFERENCES
1. Heidel SE, Torgerson JK. Vocal problems among aerobic instructors and
aerobic participants. J Commun Disord. 1993;26:179–191.
2. Long J, Williford HN, Scharff Olson M, Wolfe V. Voice problems and risk
factors among aerobics instructors. J Voice. 1998;12:197–207.
3. Newman C, Kersner M. Voice problems of aerobics instructors: implica-
tions for preventative training. Logoped Phoniatr Vocol. 1998;23:177–180.
4. Rumbach AF. Vocal problems of group fitness instructors: prevalence
of self-reported sensory and auditory-perceptual voice symptoms and
the need for preventative education and training. J Voice. 2013;27:
524.e11–524.e21.
5. World Health Organization (WHO). International Classification of Func-
tioning, Disability and Health, ICF. Geneva, Switzerland: World Health
Organization; 2001.
6. Creswell JW. Research Design: Qualitative, Quantitative, and Mixed
Methods Approaches. 3rd ed. Thousand Oaks, CA: Sage; 2009.
7. Graneheim UH, Lundman B. Qualitative content analysis in nursing re-
search: concepts, procedures and measures to achieve trustworthiness.
Nurse Educ Today. 2004;24:105–112.
8. Williams N, Carding P. Occupational Voice Loss. New York, NY: Taylor &
Francis Group; 2005.
9. Les Mills International Limited. Creating fitness magic. In: Program Man-
ual—Secrets to Changing the World One Class at a Time. Auckland, New
Zealand: Les Mills International Limited; 2008.
10. Sapir S, Atias J, Shahar A. Symptoms of vocal attrition in women army in-
structors and new recruits: results from a survey. Laryngoscope. 1990;100:
991–999.
11. Sapir S, Keidar A, Mathers-Schmidt B. Vocal attrition in teachers: survey
findings. Eur J Disord Commun. 1993;28:177–185.
12. Mathieson L. The Voice and Its Disorders. 6th ed. London, UK: Whurr Pub-
lishers; 2001.
13. Smith E, Verdolini K, Gray SD, et al. Effects of voice disorders on patient
lifestyle: preliminary results. NCVS Status Prog Rep. 1994;4:1–17.
14. Smith E, Taylor M, Mendoza M, Lemke J, Hoffman H. Functional impact
of nodules: a case comparison study. J Voice. 1998;12:551–558.
15. Smith E, Taylor M, Mendoza M, Barkmeier J, Lemke J, Hoffman H. Spas-
modic dysphonia and vocal fold paralysis: outcomes of voice problems on
work-related functioning. J Voice. 1998;12:223–232.
16. Smith E, Verdolini K, Gray S, et al. Effect of voice disorders on quality of
life. J Med Speech Lang Pathol. 1996;4:223–244.
17. Lieberman J. Chapter 6. In: Harris T, Harris S, et al, eds. The Voice Clinic
Handbook. London, UK: Whurr Publishers; 2000.
18. Oates J. Chapter 7. In: Freeman M, Fawcus M, eds. Voice Disorders and
Their Management. London, UK: Whurr Publishers; 2000.
19. Colton RH, Casper JK, Leonard R. Understanding Voice Problems: A Phys-
iological Perspective for Diagnosis and Treatment. 4th ed. Baltimore, MD:
Lippincott Williams & Wilkins; 2011.
20. Freeman M, Fawcus M. Voice Disorders and Their Management. London,
UK: Whurr Publishers; 2000.
Anna F. Rumbach Voice Problems of Group Fitness Instructors 786.e8

APPENDIX 55. Select the appropriate response. During the period of

treatment I:
Select questions from the original questionnaire4 , Stopped teaching aerobics
relevant to this manuscript , Decreased the number of classes I was teaching each
day or week
46. Select the words that describe your throat symptoms: , Continued to teach the same amount of classes under
, Burning the same conditions
, Aching , Continued to teach the same amount of classes under
, Tickling different conditions (eg, extra voice care, decreased
, Dry volume of music, etc.)
, Tight , Other, please specify
, Irritable
, Sore ___________________________________________
, Lump in the throat ___________________________________________

50. Please select all the voice properties that you feel apply to 56. Have you adjusted your teaching method due to your cur-
you from the list below and whether they have lasted in rent or previous voice problems?
excess of 3 weeks:
, Yes , No
Lasted >3 wk
57. Please indicate the way you adjusted your method of
, Breathiness , teaching. Select those that are applicable.
, Tired voice , , Reduce teaching hours
, Weak voice , , Talk less in class, that is, increase nonverbal cueing
, Strained voice , , Alter work program, that is, change the programs that
, Difficulty with low notes , you teach
, Difficulty with high notes , , Improve voice care/vocal hygiene
, Voice/pitch breaks , , Other, please specify
, Low speaking voice ,
, High speaking voice , __________________________________________
, Limited singing range ,
, Loudness decay (voice becomes quieter , 58. Have your voice problems affected your ability to com-
at the end of a sentence, or municate on a daily basis?
as a conversation progresses)
, Other, please specify , , Yes , No

52. Have you ever been officially diagnosed as having a voice 59. Please select any that apply to your situation. I have had:
problem? , Feelings of discomfort when speaking
, Feelings of pain when speaking
, Yes , No , A reduced ability to speak for long periods
, Periods of complete voice loss
53. What was the diagnosis? , Difficulty being heard/getting my message across
(frequent need to repeat statements)
____________________________________________ , Other, please specify
____________________________________________ ___________________________________________
___________________________________________
54. What treatment did you undergo?
, No treatment 60. Have your voice problems affected your emotions and
, Voice therapy quality of life (eg, make you upset, concerned, unsatisfied
, Surgery with your job performance, unsatisfied with the job)?
, Combination of voice therapy and surgery
, Other, please specify , Yes , No
If yes, please detail:
___________________________________________ __________________________________________
___________________________________________
786.e9
61. In your opinion, did you receive an appropriate level of
support from your coworkers and fitness facilities during
the period of your voice treatment?
, Yes , No
Please detail any support given by coworkers and fitness
facilities.
___________________________________________
___________________________________________
Journal of Voice, Vol. 27, No. 6, 2013
62. Have you changed your opinion on the GFI profession
due to your voice problems?
, Yes , No
If yes, please explain how your opinion of the profession
has changed.
___________________________________________
___________________________________________