ARTICLE IN PRESS

The Effect of Hydration on the Voice Quality of Future

Professional Vocal Performers
Liezl van Wyk, Mariaan Cloete, Danel Hattingh, Jeannie van der Linde, and Salome Geertsema, Pretoria, Gauteng,
South Africa

Summary: Objectives. The application of systemic hydration as an instrument for optimal voice quality has been
a common practice by several professional voice users over the years. Although the physiological action has been de-
termined, the benefits on acoustic and perceptual characteristics are relatively unknown. The present study aimed to
determine whether systemic hydration has beneficial outcomes on the voice quality of future professional voice users.
Study Design. A within-subject, pretest posttest design is applied to determine quantitative research results of female
singing students between 18 and 32 years of age without a history of voice pathology.
Methods. Acoustic and perceptual data were collected before and after a 2-hour singing rehearsal. The difference
between the hypohydrated condition (controlled) and the hydrated condition (experimental) and the relationship between
adequate hydration and acoustic and perceptual parameters of voice was then investigated.
Results. A statistical significant (P = 0.041) increase in jitter values were obtained for the hypohydrated condition.
Increased maximum phonation time (MPT/z/) and higher maximum frequency for hydration indicated further statis-
tical significant changes in voice quality (P = 0.028 and P = 0.015, respectively).
Conclusion. Systemic hydration has positive outcomes on perceptual and acoustic parameters of voice quality for
future professional singers. The singer’s ability to sustain notes for longer and reach higher frequencies may reflect
well in performances. Any positive change in voice quality may benefit the singer’s occupational success and subse-
quently their social, emotional, and vocational well-being. More research evidence is needed to determine the parameters
for implementing adequate hydration in vocal hygiene programs.
Key Words: Professional voice users–Vocal performers–Systemic hydration–Voice quality–Vocal hygiene.

INTRODUCTION
The need to rely on the voice as a professional tool is impor-
tant and may affect an individual’s social, emotional, and
vocational well-being.1,2 Some professional voice users, specif-
ically performers, are appraised for having optimal voice quality.
Elite vocal performers seek medical treatment for functional voice
problems, more often than individuals with a vocally less de-
manding lifestyle.3 The slightest alteration in voice quality might
have a negative influence on future job prospects.1
The art of professional performance is a field that successful
singers dedicate their lives to. The singer’s voice can be com-
pared with a musical instrument, such as a violin or a flute.
Damage to a musician’s instrument will adversely affect the per-
formance and future career of an individual. Vocal health and
maintaining optimum vocal quality is thus critical for the optimal
functioning of the instrument in the long run.4 The vocal demand
of professional singers is unique, as excessive variation in pitch
and intensity is required for long durations of time. Vocal fatigue
is therefore prevalent among this group.5,6 Like any muscle in
the body, the voice needs adequate rest and care to function op-
timally and to prevent voice hyperfunction.7,8
Professional vocal performers that are educated in vocal
hygiene are usually aware of the necessity to prevent damage
Accepted for publication January 4, 2016.
From the Department of Speech-language Pathology and Audiology, University of Pre-
toria, Corner of Roper and Lynnwood Road, Pretoria, Gauteng, South Africa.
Address correspondence and reprint requests to Jeannie van der Linde, Speech-language
Pathology and Audiology, University of Pretoria, Corner of Roper and Lynnwood Road,
Pretoria, Gauteng, South Africa. E-mail: jeannie.vanderlinde@up.ac.za
Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■
0892-1997
© 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jvoice.2016.01.002
to the vocal mechanism. Some singers are more prone to develop
voice problems because of ignorance and neglect of care for their
“instruments.”6 To maintain vocal health, hygiene programs
include the elimination of abuse and misuse of the voice. Hy-
dration has always been included in hygiene programs, but the
impact thereof on voice quality has been underemphasized and
the application lacks evidence.9 Previous studies show that vocal
rest, in combination with hydration, can be used as an interven-
tion strategy to restore vocal function or improve voice quality.10–13
The maintenance of vocal fold hydration is achieved by the
contribution of several physiological systems.14 Systemic hy-
dration refers to oral water intake and absorption at cellular level.
Vocal fold fluid composition is regulated by internal vascula-
ture, whereas superficial hydration relies on the humidity of
inhaled air.15 Superficial hydration is referred to as the fluid com-
position of the surface lumen of the vocal folds.14
The relationship between hydration and vocal fold physiol-
ogy is of increasing interest and importance.14,16,17 For professional
singers, heat dissipation and an increase in vocal fold friction
due to prolonged periods of phonation can result in alterations
of the fluid composition in the vocal mechanism. This may lead
to increased stiffness and decreased viscosity of the vocal folds,
resulting in fatigue and effortful movement.15,18,19 Water also func-
tions as a lubricant and shock absorber in the vocal folds to
ameliorate the effects of vocal misuse or abuse.20
Previous studies on systemic hydration and voice quality mainly
focused on phonation effort, measured as Phonation Threshold
Pressure.21,22 A meta-analysis conducted in 2009 aimed to de-
termine the magnitude and consistency of the effect of vocal fold
hydration on vocal function. It has been concluded that consid-
erable variability has been reported across the studies.23 Acoustic
 ARTICLE IN PRESS
2 Journal of Voice, Vol. ■■, No. ■■, 2016

and perceptual voice parameters can be used as an alternative gastroesophageal reflux (GER), caffeine intake, sinusitis, and so
outcome measurement. There are limited studies that verify the forth, were not regarded as exclusion criteria, but were taken into
exact effect of hydration on these parameters on voice quality.24 consideration.
Possible correlations between acoustic results and the percep- Participants were asked to indicate smoking habits, as a sig-
tual characteristics of both hydrated and hypohydrated conditions nificant reduction of the DSI is observed in female smokers in
have been reported.25,26 However, more research should be con- a study by Awan.37 A decrease in fundamental frequency and a
ducted to support the relationship.25,26 The effect of systemic reduced MPT are often observed in smokers and should there-
hydration on voice quality in different occupational groups has fore be taken into consideration for low DSI values.
been studied by several researchers.1,27–31 Studies on profession-
al voice users with vocal training, such as vocal performers, are Description of participants
often neglected. Scientifically based knowledge is essential to Case histories indicated that all participants generally practice good
improve the performance and the long-term occupational health vocal hygiene habits. All participants receive weekly vocal train-
of this group.5 ing and reported that they rehearse on an average of 8 hours (standard
The popular notion to use systemic hydration for vocal hygiene deviation [SD] = 4.7) per week. The average age of participants
is widely accepted by many professionals and singers.4,10,24,32,33 was 21.75 years (SD = 4.18). The participants reported that the
However, controversy still exists on the topic,34 and more re- average daily water intake is five glasses (1.5 L; SD = 2.09), whereas
searched knowledge is needed to support evidence-based the average caffeine intake exceeds half a litre per day (Mean = 2.58;
practice.24 From the existing literature, it is therefore evident that SD = 1.62). Only one participant is a smoker. Two participants
the following research question should be posed: What is the take antihistamines for hay fever and allergy-related conditions.
effect of systemic hydration on voice quality of future elite vocal Participant 1 takes Epitec for epilepsy and Altosec for GER. This
performers? participant also drinks alcohol on a daily basis. Participant 8 takes
Central Nervous System (CNS) stimulants (Conserta), whereas
METHOD participant 10 takes selective serotonin reuptake inhibitors.
Aim
The present study aimed to determine the effect of systemic hy- Voice assessment protocol
dration on the voice quality of future vocal performers. It was Perceptual analysis
hypothesized that an increase in systemic hydration will improve The listeners’ panel for perceptual measurements consisted of
the perceptual and acoustic characteristics of voice. five listeners; all with normal hearing. Two of the five were qual-
ified speech-language pathologists with more than 2 years of
clinical experience, whereas the remaining three listeners were
Research design
student researchers. A study by Bele38 showed that inter-rater re-
A within-subject, quasi-experimental, comparative, pretest posttest
liability remains high, even when a smaller number of listeners
design was applied.35 Numerical, objective, and instrumental data
are used. A blind perceptual analysis was conducted to improve
were collected.
the reliability of the interpretation.39
The Japanese Society of Logopeadics and Phoniatrics and the
Participants European Research Group recommend the GRBASI perceptu-
The participants were students enrolled in singing as a study area al rating scale in clinical and research settings (Table 1). The
from the Music Department at the University of Pretoria, South rating scale is internationally utilized, recognized, and most fre-
Africa. All participants had to be registered undergraduates or quently used.41
postgraduate Baccalaureus music students at university level. Only
females between the ages of 18–32 years were asked to partic-
ipate. Limiting the gender of the participants allowed for the TABLE 1.
elimination of confounding variables related to gender-based dif- GRBASI 4-point Rating Scale40
ferences in fundamental frequencies of voice range profiles Perceptual
(VRPs). The use of a homogeneous population promotes exter- Quality Description Rating Scale
nal validity and therefore trustworthiness of research outcomes.
G Grade Degree of hoarseness 0 = Normal
The youngest students accepted by the university are 18 years of the voice. 1 = Slight
of age, hence the minimum age selected. The dysphonia sever- R Roughness Impression of 2 = moderate
ity index (DSI) is significantly influenced by an increase in age; irregularity of vocal 3 = Severe
therefore, a maximum age of 32 years was set.36 fold movement
Participants with a history of voice disorders as diagnosed by B Breathiness Degree of escaping air
an otolaryngologist were excluded. Any predetermined voice heard.
pathology would influence the perceptual and acoustic results. A Asthenia Degree of weakness
Other criteria used to exclude participants were the presence of S Strain Degree of strain or
current infection or disease that may affect vocal fold function- hyperfunction
I Instability Changes in voice
ing such as laryngitis, upper respiratory tract infection, colds,
quality over time
or flu. Factors that may influence voice quality such as allergies,
 ARTICLE IN PRESS
Liezl van Wyk et al The Effect of Hydration on Voice Quality 3

TABLE 2.
Acoustic Parameter Description
Vocal Parameter Description
Highest frequency Refers to the highest number of vibratory cycles per second measured in Hertz (Hz).
This was obtained by phonation of the /a/ sound at comfortable loudness level.42
Lowest intensity Perceived as loudness level (dB). It can be defined as sound pressure presented by
amplitude on a spectrogram. This was obtained by phonation of the /a/ sound at a
comfortable pitch.42
Maximum phonation time (MPT) Can be referred to as the longest possible phonation of the /a/ sound, (measured in
milliseconds) after maximum inspiration given two attempts.43
Jitter (%) Defined by variation in frequency (number of cycles per unit of successive cycles).18
Shimmer (%) Defined as short-term, cycle-to-cycle variability in vocal fold vibration amplitude.18,44
S/Z ratio (s/z) A measurement for measuring respiratory and phonatory efficiency.45
Fundamental frequency (F0) The lowest tone of harmonics heard in voice production known as the habitual
frequency (Hz).42

Acoustic analysis
Analysis and feedback of acoustic measurements were com-
pleted by means of the Computerized Speech Lab (CSL) 4300
hardware system. The CSL includes the Multi-Dimensional Voice
Program (MDVP) by Kay Elemetrics, as well as the VRP.
The MDVP is a widely available software program used for
quantitative acoustic analysis of voice quality with analog input
and output channels. The MDVP has a frequency response of
between 5 Hz and 22 Hz (KayPENTAX). The software is de-
signed to calculate, analyze, and graphically display numerous
voice parameters during sustained phonation. This includes jitter,
shimmer, fundamental frequency, and harmonic ratio (Table 2).
The VRP is used to graphically compare the vocal intensity range
and the fundamental frequency (F0) on a two-dimensional graph.
The VRP is a useful measurement or technique often used during
clinical examination of voice behavior and is a sensitive indi-
cator of an individual’s vocal function.46 Both the VRP and the
MDVP measurement results were recorded on the voice assess-
ment protocol document.47
A standardized microphone was used at a distance of 15 cm
from the participants’ mouth.18 Voice signals were recorded in
a seated position of 45–90°. The recordings include ambient noise
in the room.
The DSI is a multiparametric instrument designed to estab-
lish a purely objective measurement of perceived vocal quality
in quantitative format.48 The following set of voice measure-
ments were taken into consideration when calculating the DSI
(as per the equation below); lowest intensity (I—low in dB),
highest frequency (F0 high in Hz), MPT (seconds), and jitter (%).
Acoustic parameters, such as the DSI were obtained by means
of the MDVP and the VRP (KayPENTAX).
DSI = 0.13× MPT + 0.0053× F0 (high)
− 0.26 × I (low) −1.18× Jitter (%) + 2.4
4 allowed drink water 30 minutes prior to testing. They were re-
Procedures
Ethical clearance was obtained from the Research and Ethics
Committee of the Department of Speech-language Pathology and
Audiology in the Faculty of Humanities, University of Preto-
ria, South Africa. Three music lecturers were further contacted
regarding the participation of lectured singing students. All stu-
dents participated voluntarily based on prior explanation of the
potential benefits of the outcomes. Informed consent was ob-
tained from each participant, and inclusion depended on certain
selection criteria and case history information. Case histories,
adapted from Wicklund,49 were used to record and document
background information. This information included age, level
of voice training, general heath (reflux and allergies), medical
history, and vocal habits (smoking, alcohol consumption, and
vocal abuse).
Pre- and posttest were conducted for each participant in control
(hypohydration) and experimental (systemic hydration) condi-
tions. During the pretest, perceptual and acoustic voice parameters
were measured. The participants were then required to carry out
a 2-hour routine singing rehearsal after the posttest was con-
ducted. The average rehearsal time (1.9 hours), as reported by
participants, were used to determine the singing duration fol-
lowed in the study. The participants were all expected to follow
an identical hydration schedule, stipulating the systemic hydra-
tion procedure for each condition. Preceding both conditions,
the participants were required to refrain from carbonated and
caffeinated drinks including coffee, tea, and energy drinks. They
were allowed to eat their regular breakfast, but not within 2 hours
prior to testing. For the control condition, the participants were
not allowed to ingest any fluids 2 hours prior to testing, nor during
the 2-hour rehearsal.
The hydration schedule was adapted for the experimental con-
dition. Previous research studies poorly defined the exact amount
of systemic hydration and the duration of time before the voice
is affected.18,24,34 Yet, in a pharmacokinetic analysis, it has been
reported that complete absorption of water in the plasma and
blood cells occurs within 75–120 minutes after ingestion.50 In
the schedule, it was stipulated that the participants were only
quired to drink 750 mL of water during the 2-hour rehearsal,
focusing on drinking approximately 250 mL/30 minutes of
singing. This notion is supported by previous research that re-
ported significant improvement in voice parameters when
ingesting water during rehearsal.10 The testing of voice quality
for experimental conditions was conducted on a separate day
 ARTICLE IN PRESS
4 Journal of Voice, Vol. ■■, No. ■■, 2016

within 2–5 days after the control conditions. The same pre- and
posttest procedures were consistently followed.
Data analysis
Data were captured by using formulas in Excel, from which all
descriptive statistics were obtained. Statistical software (STATA)
was used in all analyses. The Student’s t tests were used to de-
termine the significant associations for normal distributed pre-
and post-, as well as hydrated and hypohydrated test results.
Similarly, Wilcoxon-paired rank tests were used to identify sig-
nificant differences in not normally distributed variables.
Correlations between the acoustic and perceptual measure-
ments were evaluated by means of Spearman’s rank correlation
coefficient. The degree of dysphonia, as measured by the DSI,
corresponded with the G-component of the GRBASI scale.48,51
To observe the mean change in values pre- and posttesting, a
percentage change was calculated for each condition. This was
achieved by using the following equation:
⎛ ⎡ Posttest mean ⎤ ⎞⎟
⎜⎜ ⎢ ⎥ −1 ×100
⎜⎝ ⎢⎣ Pretest mean ⎥⎦ ⎟⎟⎠
RESULTS
According to the questionnaire, 83% (n = 10) of the partici-
pants reported experiencing a change in voice quality before and
after their weekly routine rehearsals. All participants reported
vocal fatigue as a result of vocal training.
Perceptual results
The only perceptual significant difference observed between the
pre- and posttest results of hypohydrated and hydrated condi-
tions were that of the G value (grade of hoarseness) for
hypohydration, according to the GRBASI scale (Table 3). Three
participants (25%; n = 3) presented with slight hoarseness, and
one participant (8%; n = 1) presented with moderate hoarse-
ness after testing. According to the Spearman’s rank correlation
coefficient, there was no statistically significant correlation
between the perceptual and acoustic measurements.
Acoustic analysis
Values obtained during acoustic analysis were recorded for pre-
and posttests of hypohydrated and hydrated conditions (Table 4).
The Wilcoxon rank and t tests confirmed that there was no sig-
nificant difference between all pretests of both hydrated and
hypohydrated conditions, which implies that both conditions were
similar at the start of each pretest.
When comparing the change between pre- and posttest of MPT/
z/ measures of both hypohydrated and hydrated conditions, a
significant positive change in duration was noted in the hy-
drated condition (P = 0.015) (Table 4). The mean MPT/z/
measures for the posttest were measured as 18.88 seconds for
hypohydration and 21.34 seconds for hydration. Therefore a sig-
nificant difference was observed in the post-MPT/z/ scores for
the two conditions (P = 0.028) (Table 5). All other postdifferences
between the conditions were not statistically significant. The per-
centage change from pre- to posttest for MPT/z/ and MPT/a/ for

TABLE 3.
Frequency Distribution of GRBASI Scores (n = 12)
GRBASI Condition Normal (Score = 1) Slight (Score = 2) Moderate (Score = 3)
Grade of Hoarseness Hypohydration Pretest 93% (n = 11) 8% (n = 1) 0% (n = 0)
Posttest 58% (n = 7) 33% (n = 4) 8% (n = 1)
Hydration Pretest 83% (n = 10) 17% (n = 2) 0% (n = 0)
Posttest 75% (n = 9) 25% (n = 3) 0% (n = 0)
Roughness Hypohydration Pretest 93% (n = 11) 8% (n = 1) 0% (n = 0)
Posttest 83% (n = 10) 17% (n = 2) 0% (n = 0)
Hydration Pretest 67% (n = 8) 33% (n = 4) 0% (n = 0)
Posttest 75% (n = 9) 25% (n = 3) 0% (n = 0)
Breathiness Hypohydration Pretest 75% (n = 9) 25% (n = 3) 0% (n = 0)
Posttest 83% (n = 10) 17% (n = 2) 0% (n = 0)
Hydration Pretest 58% (n = 7) 42% (n = 5) 0% (n = 0)
Posttest 83% (n = 10) 17% (n = 2) 0% (n = 0)
Asthenia Hypohydration Pretest 100% (n = 12) 0% (n = 0) 0% (n = 0)
Posttest 100% (n = 12) 0% (n = 0) 0% (n = 0)
Hydration Pretest 100% (n = 12) 0% (n = 0) 0% (n = 0)
Posttest 100% (n = 12) 0% (n = 0) 0% (n = 0)
Strain Hypohydration Pretest 93% (n = 11) 8% (n = 1) 0% (n = 0)
Posttest 93% (n = 11) 8% (n = 1) 0% (n = 0)
Hydration Pretest 100% (n = 12) 0% (n = 0) 0% (n = 0)
Posttest 100% (n = 12) 0% (n = 0) 0% (n = 0)
Instability Hypohydration Pretest 100% (n = 12) 0% (n = 0) 0% (n = 0)
Posttest 100% (n = 12) 0% (n = 0) 0% (n = 0)
Hydration Pretest 100% (n = 12) 0% (n = 0) 0% (n = 0)
Posttest 100% (n = 12) 0% (n = 0) 0% (n = 0)
 ARTICLE IN PRESS
Liezl van Wyk et al The Effect of Hydration on Voice Quality 5

hydration increased with 12.3% and 13.8%, respectively (Table 4).

Change (P Value)
Significance of
Furthermore, significant increases between the pre- and posttests
within the hydrated condition were also observed in MPT/a/

0.015*

0.015*
(P = 0.012) and MPT/s/ (P = 0.024) (Table 4).

0.581
0.298

0.256
0.272
0.388

0.497
0.991
When comparing pre- and posttest results within the
hypohydrated condition, significant differences were observed
in the jitter (P = 0.041), shimmer (P = 0.050), and s/z ratio
(P = 0.041) scores (Table 5). Both the average jitter score and
s/z ratio deteriorated from pre- to posttest, but the average shimmer
Change (%)

improved from 2.74% to 2.27% (Table 4). Jitter demonstrated

+13.8
+18.4
+12.3
+5.6
−10.1
+1.7
+3.0
+1.5
+14.4
the greatest percentage change, from pre- to posttest when
comparing all hypohydrated and hydrated conditions. The cycle-
Hydration

to-cycle variation in frequency increased with 138.4% from

pre- to posttest in the hypohydrated condition, whereas a 10.3%
1021.25 (233.78)

decrease was observed between pre- and posttest in the hy-

27.94 (11.69)
15.71 (3.88)

21.34 (8.75)
1.32 (0.34)
0.89 (0.58)
3.05 (1.71)

64.25 (4.63)
2.22 (1.21)
Mean (SD)

drated condition (Table 4).

Posttest

Although no statistically significant correlation was found

between acoustic and perceptual data, the increase in jitter per-
centage for the hypohydrated condition can be clinically associated
with the G value (hoarseness) of the GRBASI scale (Table 1).
This was observed in four participants during perceptual analysis.
When highest frequency (Hz) values for the two conditions
991.36 (243.82)
Mean (SD)

were compared, it was observed that the highest frequency de-

13.81 (3.92)
23.60 (8.97)
19.01 (5.59)
1.25 (0.33)
0.99 (0.39)
3.00 (1.15)

63.33 (6.17)
1.94 (1.56)
Pretest

creased by 10.3% within the hypohydrated condition and

increased by 3.0% within the hydrated condition (Table 5). Thus,
the negative change in hypohydration (pre- to posttest) was greater
than the positive change observed in hydration. This negative
change in the highest frequency scores were found to be sig-
nificantly lower (P = 0.015) in the hypohydrated condition
Change (%)
+9.9
+7.7
−2.3
+22.0
+138.4
−17.2
−10.3
−1.0
+14.9

(Table 4).

DISCUSSION
This study examined the effect of systemic hydration on the voice
quality of a population (n = 12) of future professional singers.
991.74 (238.97)

For perceptual analysis, the grade of hoarseness indicated that

Mean (SD)
Hypohydration

15.45 (4.75)
24.16(8.59)
18.88 (7.46)
1.33 (0.40)
2.67 (7.48)
2.27 (1.34)

64.75 (2.70)
2.16 (1.27)

the level of hydration had a significant effect on voice quality

Posttest

(P = 0.046). Four of the participants were perceptually hoarser

Acoustic Parameter Outcomes and Percentage Changes

after the singing rehearsal in the hypohydrated condition. This

decline in perceptual voice quality may be an indicator of vocal
fatigue.10 During lengthy singing rehearsals, prolonged phona-
tion influences vocal fold fluid composition and viscosity.18 Hence,
1105.87 (180.60)

without adequate hydration, the vocal fold vibration and sub-

14.06 (3.49)
22.44 (7.49)
19.33 (4.57)
1.09 (0.23)
1.12 (0.57)
2.74 (0.81)

65.42 (5.33)
1.88 (1.72)
Mean (SD)

sequently the voice quality of the singer may be adversely

Pretest

affected.15
The noteworthy association between the grade of hoarse-
ness and the elevated jitter values, as seen in the hypohydrated
condition, has been previously reported in literature.52 This in-
* Statistical significance P ≤ 0.05.

crease in perturbation of frequency may originate from laryngeal

muscle control that decreases as a result of vocal fatigue. Per-
Highest frequency (Hz)
Lowest intensity (dB)
Acoustic Parameters

ceptual characteristics related to this acoustic measure can be

MPT/a/ (seconds)

perceived as hoarseness. This variation in frequency from cycle-

MPT/s/ (seconds)
MPT/z/ (seconds)

to-cycle (jitter) may be clinically relevant for singers who aim

Shimmer (%)

to achieve optimal stability in voice quality.53 A significant in-

crease in jitter percentage (P = 0.041) was observed in the
Jitter (%)
TABLE 4.

hypohydrated condition, demonstrating an elevation in the average

DSI

perturbation in frequency without adequate hydration. In con-

s/z

trast, jitter decreased in the hydrated condition from pre-to posttest

 ARTICLE IN PRESS
6 Journal of Voice, Vol. ■■, No. ■■, 2016
TABLE 5.
P Values for All Tests of Significant Differences
Hypohydrate Pre- Vs. Hydrate Pre- Vs.
Acoustic Parameters Posttest Posttest
MPT/a/ 0.136
MPT/s/ 0.245
MPT/z/ 0.530
s/z 0.041*
Jitter 0.041*
Shimmer 0.050*
Highest frequency 0.086
Lowest intensity 0.662
DSI 0.869
* Statistical significance.
(10.1%), which is a positive indicator of improved voice quality
when a hydration schedule was implemented. These changes in
jitter were in agreement with values described in a population
of amateur singers after continuous singing without adequate water
intake and rest.10,54
MPTs were presented with significant results that support the
hypothesis. The ability to prolong phonation time is an impor-
tant component in singing on a highly technical level.55 In contrast,
short MPT times are often used as an indicator of vocal
pathology.43 The MPT scores were within the normal range for
female adults, thus indicating the absence of vocal pathology
in participants.56 MPT/a/ and MPT/z/ scores both yielded a sig-
nificant increase in duration within the hydrated condition
(P = 0.012 and P = 0.024, respectively). For the /z/-sound, the
participants were able to increase phonation from an average of
18.88 seconds for the hypohydrated condition to 21.34 seconds
for the hydrated condition (P = 0.028).
The results indicated that the singers’ ability to sustain the
/s/-sound (MPT/s/) increased with hydration during the 2-hour
rehearsal. Even though this sustainment does not measure pho-
nation, it gives an indication of a possible warm-up effect that
was also observed in recent literature on speech-language
pathologists.57 The latter study reported research evidence that
support the phenomena of the warm-up effect on the voice. This
prominent occurrence caused an increase in voice quality after
30 minutes of vocal exercises and stretching. Vocal warm-up thus
indicated beneficial outcomes for acoustic analysis of singers
and nonsingers alike.58 Another study investigated the effects of
a vocal warm-up program implemented in young choir girls,
which indicated positive adjustment of the vocal folds and in-
creased glottal closure.59 For future research on the effect of
hydration on voice quality, it is recommended that participants
all follow a similar warm-up program before testing in both con-
ditions to eliminate the possible voice quality changes as a result
of the warm-up effect.
The s/z ratios were obtained by using the MPT scores. This
numerical ratio is often used as a clinical indicator of vocal func-
tion, and glottic disturbances may result in a s/z ratio of more
than one.60 A significant increase in the s/z ratio (P = 0.041) was
observed in the hypohydrated condition as expected. This in-
crease indicated a possible decline in phonation efficiency after
Hypohydrated Pre- Vs. Dehydrate Post- Vs.
Hydrate Pretest Hydrate Posttest
0.012* 0.681 0.753
0.024* 0.567 0.115
0.117 0.727 0.028*
0.583 0.138 0.695
0.136 0.246 0.347
0.910 0.209 0.117
0.441 0.064 0.389
0.197 0.384 0.844
0.509 0.928 0.901
a rehearsal without adequate hydration.60 Although the s/z ratio
also increased in the hydrated condition, the decline in phona-
tion efficiency was less when hydration was implemented.54 The
singer’s ability to sustain long notes partly depends on glottal
efficiency. Thus, the better the glottal efficiency, the longer notes
the singer can produce with good voice quality.61
The results for maximum frequency are in agreement with
others that indicated a decrease in the maximum frequency value
after prolonged phonation.61 Maximum frequency changes are
an important variable to identify early vocal fatigue in profes-
sional voice users.15 These frequency values decreased from pre-
to posttest for hypohydration and increased for hydration. The
significance between the two conditions (P = 0.015) marks the
possible effects of fatigue on the vocal folds. This occurrence
may be a reflection of a decline in elasticity and viscosity of the
vocal fold mechanism.5 When vocal fatigue is then combined
with the lack of adequate hydration, additional decline in vocal
fold viscosity and elasticity can be expected. For a singer to reach
high frequencies, optimal elasticity is required for reaching the
notes comfortably and without strain. The increase in maximum
frequency (highest pitch) for the hydrated condition clinically
manifested as a larger voice range, which is beneficial for the
singer’s performance.
It was expected that shimmer, similar to jitter, would in-
crease in the hypohydrated condition, as with acoustic
measurements indicated in previous studies.24 Shimmer values
were, however, significantly better (P = 0.050) within this con-
dition, thus the cycle-to-cycle variation in intensity decreased
without hydration. Other studies have reported that for the mea-
surement of perturbation, jitter has been proven to be more
accurate in synthesized speech signals than shimmer.62
It is recommended that future research studies consider a variety
of occupational groups that may benefit from the results. A limited
sample size (n = 12) was used, and it is therefore recom-
mended that future research should be conducted on a larger
sample.32 Systemic hydration is a complex variable to control
due to differences in bodily fluid balance from participant to par-
ticipant. Rigorous measures to control the intake of fluids and
food before testing may allow for more reliable research
outcomes.1 The amount of water intake needed to change sys-
temic hydration of a body is poorly defined in literature.34,63 It
 ARTICLE IN PRESS
Liezl van Wyk et al The Effect of Hydration on Voice Quality
is recommended that more research evidence should guide these
variables.
In a professional environment where optimal voice quality is
essential, any improvement in voice quality contributes to an im-
provement in the overall performance of the professional singer.
Improvement may be a higher maximum frequency, less cycle-
to-cycle variation in pitch, or longer phonation time, depending
on the individual. From the results, we infer that systemic hy-
dration has an effect on various parameters (acoustic and
perceptual) of voice quality. The results portray clinically rel-
evant data that can be beneficial in vocal hygiene programs as
they provide an easy and cost-effective way to improve voice
quality. Hydrated vocal folds allow for optimal vibration, which
assists in effortless singing and increased ease of phonation.
Singers can thus concentrate on performance value, without the
additional stress of the perceptual voice quality.
CONCLUSION
Over the years, many professionals have been advocating sys-
temic hydration as an important component of vocal hygiene.
However, more published literature is required to determine the
exact relationship between systemic hydration and voice quality,
as well as the clinical application thereof.16 In this study, it was
confirmed that the use of systemic hydration had positive out-
comes on the acoustic and perceptual parameters of voice quality
of future professional singers.
The results obtained can be applied to vocal hygiene pro-
grams as a potential preventative intervention measure. This
implementation may benefit professional vocal performers who
rely heavily on voice production as the primary tool for occu-
pational success. Secondary benefits may include improved social,
emotional, and vocational well-being. The results obtained from
the acoustic analysis indicated an increase in MPT values, im-
provement in jitter values, and an increase in highest frequency
values in the hydrated condition. Furthermore, the change in s/z
ratio was greater in the hypohydrated condition. The results dem-
onstrated a clinically significant increase in the beneficial qualities
of the voice with adequate hydration. In conclusion, this study
aims to encourage future research on the nature of, and the re-
lationship between, contributing factors and voice quality of
professional vocal performers.
REFERENCES
1. Timmermans B, De Bodt MS, Wuyts FL, et al. Poor voice quality in future
elite vocal performers and professional voice users. J Voice. 2002;16:372–
382.
2. Vilkman E. Occupational safety and health aspects of voice and speech
professions. Folia Phoniatr Logop. 2004;56:220–253.
3. Herrington-Hall BL, Lee L, Stemple JC, et al. Description of laryngeal
pathologies by age, sex, and occupation in a treatment-seeking sample. J
Speech Hear Disord. 1988;53:57–64.
4. Sataloff RT. Professional Voice: The Science and Art of Clinical Care.
Singular Publishing Group; 1997.
5. Welham NV, Maclagan MA. Vocal fatigue: current knowledge and future
directions. J Voice. 2003;17:21–30.
6. Dayme MB. Dynamics of the Singing Voice [Internet]. Vienna: Springer
Vienna; 2009 Available at: http://link.springer.com/10.1007/978-3-211-
88729-5. Cited October 1, 2015.
7
7. Carding P, Wade A. Managing dysphonia caused by misuse and overuse.
BMJ. 2000;321:1544–1545.
8. Vilkman E. Voice problems at work: a challenge for occupational safety
and health arrangement. Folia Phoniatr Logop. 2000;52:120–125.
9. Behlau M, Oliveira G. Vocal hygiene for the voice professional. Curr Opin
Otolaryngol Head Neck Surg. 2009;17:149–154.
10. Yiu EML, Chan RMM. Effect of hydration and vocal rest on the vocal fatigue
in amateur karaoke singers. J Voice. 2003;17:216–227.
11. Colton RH, Casper JK, Hirano M. Understanding Voice Problems: A
Physiological Perspective for Diagnosis and Treatment. Williams & Wilkins;
1996.
12. van der Merwe A. The voice use reduction program. Am J Speech Lang
Pathol. 2004;13:208–218.
13. Prater RJ, Deem JF, Miller L. Manual of Voice Therapy. PRO-ED; 2000.
14. Sivasankar M, Leydon C. The role of hydration in vocal fold physiology.
Curr Opin Otolaryngol Head Neck Surg. 2010;18:171–175.
15. Leydon C, Sivasankar M, Falciglia DL, et al. Vocal fold surface hydration:
a review. J Voice. 2009;23:658–665.
16. Hartley NA, Thibeault SL. Systemic hydration: relating science to clinical
practice in vocal health. J Voice. 2014;28:652.e1–652.e20.
17. Miller-Keane Encyclopedia & Dictionary of Medicine, Nursing, and Allied
Health. Wikipedia, the free encyclopedia [Internet]. 2014. Available at:
https://en.wikipedia.org/w/index.php?title=Miller-Keane_Encyclopedia
_%26_Dictionary_of_Medicine,_Nursing,_and_Allied_Health&oldid
=613392963. Cited October 1, 2015.
18. Titze IR. Principles of Voice Production. Prentice Hall; 1994.
19. Judelson DA, Maresh CM, Anderson JM, et al. Hydration and muscular
performance: does fluid balance affect strength, power and high-intensity
endurance? Sports Med. 2007;37:907–921.
20. Jéquier E, Constant F. Water as an essential nutrient: the physiological basis
of hydration. Eur J Clin Nutr. 2010;64:115–123.
21. Roy N, Weinrich B, Gray SD, et al. Voice amplification versus vocal hygiene
instruction for teachers with voice disorders: a treatment outcomes study.
J Speech Lang Hear Res. 2002;45:625–638.
22. Solomon NP, DiMattia MS. Effects of a vocally fatiguing task and
systemic hydration on phonation threshold pressure. J Voice. 2000;14:341–
362.
23. Leydon C, Wroblewski M, Eichorn N, et al. A meta-analysis of outcomes
of hydration intervention on phonation threshold pressure. J Voice.
2010;24:637–643.
24. Franca MC, Simpson KO. Effects of hydration on voice acoustics. Contemp
Issues Commun Sci Disord. 2009;36:142–148.
25. Martens JWMAF, Versnel H, Dejonckere PH. The effect of visible speech
in the perceptual rating of pathological voices. Arch Otolaryngol Head Neck
Surg. 2007;133:178–185.
26. Ng ML, Wong RK, Wei WI, et al. Acoustic changes in Chinese patients
with cancer-related unilateral vocal fold paralysis after medialization
thyroplasty. 2008 Available at: http://hub.hku.hk/handle/10722/83200. Cited
October 1, 2015.
27. Williams NR. Occupational groups at risk of voice disorders: a review of
the literature. Occup Med. 2003;53:456–460.
28. Yiu EML. Impact and prevention of voice problems in the teaching
profession: embracing the consumers’ view. J Voice. 2002;16:215–228.
29. Villanueva-Reyes A. Voice disorders in the Metropolitan Area of San Juan,
Puerto Rico: profiles of occupational groups. J Voice. 2011;25:83–87.
30. Lerner MZ, Paskhover B, Acton L, et al. Voice disorders in actors. J Voice.
2013;27:705–708.
31. Titze IR, Lemke J, Montequin D. Populations in the U.S. workforce who
rely on voice as a primary tool of trade: a preliminary report. J Voice.
1997;11:254–259.
32. Franca MC. Effects of Hydration on Voice Performance. ProQuest; 2006.
33. Hazlett DE, Duffy OM, Moorhead SA. Review of the impact of voice
training on the vocal quality of professional voice users: implications for
vocal health and recommendations for further research. J Voice.
2011;25:181–191.
34. Valtin H. “Drink at least eight glasses of water a day.” Really? Is there
scientific evidence for “8 × 8”? Am J Physiol Regul Integr Comp Physiol.
2002;283:R993–R1004.
 ARTICLE IN PRESS
8 Journal of Voice, Vol. ■■, No. ■■, 2016
35. Leedy PD, Ormrod JE. Practical Research Planning and Design [Internet].
Harlow, Essex: Pearson; 2014 Available at: http://lib.myilibrary
.com?id=526969. Cited October 1, 2015.
36. Hakkesteegt MM, Brocaar MP, Wieringa MH. The applicability of the
dysphonia severity index and the voice handicap index in evaluating
effects of voice therapy and phonosurgery. J Voice. 2010;24:199–
205.
37. Awan SN. The effect of smoking on the dysphonia severity index in females.
Folia Phoniatr Logop. 2011;63:65–71.
38. Bele IV. Reliability in perceptual analysis of voice quality. J Voice.
2005;19:555–573.
39. Fink A, Kosecoff J, Chassin M, et al. Consensus methods: characteristics
and guidelines for use. Am J Public Health. 1984;74:979–983.
40. Yamauchi EJ, Imaizumi S, Maruyama H, et al. Perceptual evaluation of
pathological voice quality: a comparative analysis between the RASATI and
GRBASI scales. Logoped Phoniatr Vocol. 2010;35:121–128.
41. Carding PN, Horsley IA, Docherty GJ. The effectiveness of voice therapy
for patients with non-organic dysphonia. Clin Otolaryngol Allied Sci.
1998;23:310–318.
42. Raphael LJ, Borden GJ, Harris KS. Speech Science Primer: Physiology,
Acoustics, and Perception of Speech. Wolters Kluwer Health/Lippincott
Williams & Wilkins; 2011.
43. Maslan J, Leng X, Rees C, et al. Maximum phonation time in healthy older
adults. J Voice. 2011;25:709–713.
44. Wertzner HF, Schreiber S, Amaro L. Analysis of fundamental frequency,
jitter, shimmer and vocal intensity in children with phonological disorders.
Braz J Otorhinolaryngol. 2005;71:582–588.
45. Shipley K, McAfee J. Assessment in Speech-language Pathology: A Resource
Manual [Internet]. Cengage Learning; 2008 Available at: http://
books.google.co.za/books?id=2evSMjy8_ogC.
46. Titze IR. Acoustic interpretation of the voice range profile (phonetogram).
J Speech Hear Res. 1992;35:21–34.
47. Barsties B, De Bodt M. Assessment of voice quality: current state-of-the-art.
Auris Nasus Larynx. 2015;42:183–188.
48. Wuyts FL, De Bodt MS, Molenberghs G, et al. The dysphonia severity index:
an objective measure of vocal quality based on a multiparameter approach.
J Speech Lang Hear Res. 2000;43:796–809.
49. Wicklund K. Singing Voice Rehabilitation: A Guide for the Voice Teacher
and Speech-language Pathologist. 1st ed. Clifton Park, NY: Cengage
Learning; 2009.
50. Péronnet F, Mignault D, du Souich P, et al. Pharmacokinetic analysis of
absorption, distribution and disappearance of ingested water labeled with
D2O in humans. Eur J Appl Physiol. 2012;112:2213–2222.
51. Timmermans B, De Bodt M, Wuyts F, et al. Voice quality change in future
professional voice users after 9 months of voice training. Eur Arch
Otorhinolaryngol. 2004;261:1–5.
52. Petrovic-Lazic M, Jovanovic N, Kulic M, et al. Acoustic and perceptual
characteristics of the voice in patients with vocal polyps after surgery and
voice therapy. J Voice. 2015;29:241–246.
53. Staes FF, Jansen L, Vilette A, et al. Physical therapy as a means to optimize
posture and voice parameters in student classical singers: a case report. J
Voice. 2011;25:e91–e101.
54. Gelfer MP, Pazera JF. Maximum duration of sustained /s/ and /z/ and the
s/z ratio with controlled intensity. J Voice. 2006;20:369–379.
55. Yanagihara N, Koike Y. The regulation of sustained phonation. Folia
Phoniatr (Basel). 1967;19:1–18.
56. Goy H, Fernandes DN, Pichora-Fuller MK, et al. Normative voice data for
younger and older adults. J Voice. 2013;27:545–555.
57. Van Lierde KM, Haeseleer ED, Baudonck N, et al. The impact of vocal
warm-up exercises on the objective vocal quality in female students training
to be speech language pathologists. J Voice. 2011;25:e115–e121.
58. Amir O, Amir N, Michaeli O. Evaluating the influence of warmup on singing
voice quality using acoustic measures. J Voice. 2005;19:252–260.
59. Falcão LMG, Masson MLV, Oliveira G, et al. Spectrographic analysis of
the effect of vocal warm-up on the voice of choir girls. Audiol Commun
Res. 2014;19:380–386.
60. Eckel FC, Boone DR. The S/Z ratio as an indicator of laryngeal pathology.
J Speech Hear Disord. 1981;46:147–149.
61. Stemple JC, Glaze LE, Gerdeman BK. Clinical Voice Pathology: Theory
and Management. Cengage Learning; 2000.
62. Teixeira JP, Gonçalves A. Accuracy of jitter and shimmer measurements.
Procedia Technol. 2014;16:1190–1199.
63. Verdolini K, Min Y, Titze IR, et al. Biological mechanisms underlying voice
changes due to dehydration. J Speech Lang Hear Res. 2002;45:268–281.